Parkinson's disease is a progressive neurodegenerative condition. There is an increasing incidence and prevalence with advancing age and more cases are predicted as the population ages. Because of likely differing aetiology, genetics and pathology in individual patients, as well as confounding co-morbidities, diagnosis can be difficult even for specialists. We present an overview of the pathology, aetiology and differential diagnosis of Parkinson's disease in older people. The importance of specialist medical input in diagnosis is emphasized.

B-type natriuretic peptide (BNP) and the inactive N-terminal fragment of the precursor (NT-proBNP) are hormones predominantly produced by the cardiac myocyte. It has been shown that very high levels of circulating natriuretic peptides correlate with a diagnosis of heart failure. In view of this, the current NICE, SIGN and European Society of Cardiology guidelines on heart failure recommend the measurement of natriuretic peptides as part of the diagnostic pathway for patients with suspected heart failure in primary care. Patients should be stratified according to results, with high-risk patients referred and reviewed by specialist services within 2 weeks. There has also been interest regarding the potential use of natriuretic peptides in disease surveillance, therapeutic monitoring and in-patient discharge planning. Consequently, it is a test that we will encounter with increasing frequency in clinical practice.

Heart failure is common in older people, hence geriatricians need to have an understanding of the implications of natriuretic peptide levels. The test can be affected by both physiological and pharmacological factors and this should be taken into consideration when interpreting results.

‘Cerebral small vessel disease’ is common in older adults and is an important cause of morbidity, functional impairment and cognitive decline. Small vessel disease is a collective term used to describe a number of underlying pathological processes and neuroimaging findings, such as lacunar infarcts, white matter lesions and microhaemorrhages.

With readily available neuroimaging, diagnostic accuracy has improved; however, the management of small vessel disease and prevention of cognitive decline remains uncertain. Treatment of conventional vascular risk factors may be appropriate, but future research is required to provide definitive answers. We have conducted a comprehensive literature review of cerebral small vessel disease in older adults. This highlights the clinical sequelae and underlying pathological processes, whilst discussing novel diagnostic neuroimaging and therapeutic strategies.

Degenerative-calcific aortic stenosis is mainly a disease of old age. Patients with mild to moderate stenosis without symptoms and those with aortic valve sclerosis do not require mechanical intervention. There is no firm evidence that the rate of progression can be modified by medical therapies, though statins might have some effect. Patients who develop severe stenosis with symptoms have a very poor prognosis if managed medically. Surgical aortic valve replacement greatly improves symptoms and mortality rates and remains the treatment of choice for those fit for major surgery, even above the age of 80 years. For those not suitable for surgery, or who are unwilling to have an operation, outcomes can be significantly improved by trans-catheter aortic valve replacement, which has become an important option for frail elderly patients. Balloon aortic valvuloplasty improves symptoms and short-term survival, but has a less clear impact on mortality beyond 1 year. It is useful as a palliative treatment and as a bridging procedure for patients who are not ready for valve replacement. There is less agreement on the best approach to patients with asymptomatic severe aortic stenosis. Trials indicate that early valve replacement results in outcomes that are comparable to those seen in symptomatic patients, though guidelines advocate delaying surgery until symptoms occur or left ventricular function begins to decline rapidly. All elderly patients with severe aortic stenosis should be considered for a mechanical intervention unless there is a properly considered reason for not doing so, or they are not willing to receive such treatment.

This article reviews the research into anxiety disorders in adults aged 65 years and older that has been published over the past ten years. The topics covered include: the construct of anxiety and its disorders in this age group; epidemiology, including prevalence, incidence, course, outlook, and risk factors; assessment scales; co-morbidity and differential diagnosis (depression, dementia, physical illness); and management, both pharmacological and non-pharmacological. There has been a significant improvement in our understanding of these disorders in older adults over this period, but evidence to support their treatment and prevention is still quite sparse.

In recent years, there has been a growing understanding that organizational culture is an important characteristic that may influence the effectiveness of health care provision, not least for the growing numbers of older people needing care. The purpose of this paper is to review the literature to uncover any reliable evidence supporting the assertion that organizational culture in health care organizations is related, in terms of activity and outcome, to their performance. Searches identified 20 relevant papers published between 1993 and 2010. A number of studies reviewed claims to have uncovered evidence of a relationship in terms of activity, while others failed to find a clear relationship. None of the studies found much evidence against. In terms of outcomes, none of the studies reviewed found evidence of a relationship between culture and performance. It is clear that any relationship between culture and performance is highly unlikely to be simple: such relationships are more likely to be multiple, complex, contingent and dynamic.

The expansion of e-learning in medical education is a reflection of the inherent advantages that technology can bring to teaching and learning. Geriatric medicine has taken advantage of some of the benefits associated with e-learning in terms of undergraduate education, specialty training and interdisciplinary training. However, there are further opportunities and challenges to be met for geriatric medicine to make the very most of e-learning. This review outlines the terminology associated with e-learning, summarizes the advantages and potential problems, and considers the evidence base for the efficacy of e-learning. Current use of e-learning amongst professional groups is summarized and recommendations made for expanding the use of e-learning for all healthcare professionals working with older people.