Involuntary movements become increasingly common with age and often lead to considerable disability, handicap and social embarrassment. Many causes of involuntary movements can be readily treated once the correct diagnosis is established. Getting the diagnosis right in older people is often challenging even for specialists. Even the identification of conditions thought easy to classify in younger people, such as Parkinson's disease, can be very difficult in older adults. This burden of movement disorder in older people reflects the increasing prevalence of neurodegenerative and vascular disease with age as well as the growing exposure to medication and the natural history of conditions such as essential tremor, which tend to worsen with age and precipitate medical presentation later in life. A complex and poorly understood relationship exists between motor control, disorders of mood and cognitive function. In older subjects involuntary movements are often associated with gait abnormalities and poor mobility and falls may be the presenting feature.

Increasingly, the term ‘dignity’ is becoming a part of contemporary discussions of health care. Phrases such as ‘respect for human dignity’, ‘treatment with dignity’, ‘death with dignity’ and the ‘right to dignity’ are so commonplace as to have almost become clichés. This is especially so in the context of older people. In the UK, the NHS Plan uses the term ‘dignity’ on a number of occasions (Chapter 15 is entitled ‘Dignity, security and independence in old age’) and the National Service Framework for Older People explicitly mentions dignity in relation to person-centred care. However, practice has often failed to measure up to this much-cited aspiration.

Most of the things done by the professionals in the health service have evolved over the years through personal experience, expert views and trial and error. Since the last World War, initially with the randomized controlled trials of TB therapy, there has been increasing interest in objectively measuring the effect of treatment on patients. The proponents of this approach suggest that, where tested, personal experience, even in those with a great deal of experience, does not always allow us to draw our evidence from sufficient numbers nor does it immunize us against unfounded enthusiasm for one treatment over another.

Oral anticoagulant therapy has become more commonly prescribed for people of 65 years and over following the widening of its clinical indications to include thromboembolic prophylaxis in atrial fibrillation. It is estimated that approximately 470 000 people in the UK, almost 1% of the population, are currently receiving oral anticoagulant therapy and this is growing. Due to its narrow therapeutic index, and the intra-individual variation in dose requirement, there is a need to monitor the level of anticoagulation in each patient. In consequence, health systems have had to invest resources into monitoring services to cope with this development.

Until recently, there has been relatively little scientific research investigating the influence of food or nutrient intake on longevity. This is partly due to the fact that most investigators have been interested in the relationship of food or nutrient intake to specific diseases i.e. communicable diseases, coronary heart disease and cancer of specific sites, rather than to overall mortality or longevity. Another significant factor is the difficulty of comparing the nutritional intake of populations, owing to the wide variability in individual intake and poor individual recall of specific food items in epidemiological studies.

Dysphagia is defined as difficulty in swallowing solids or liquids and is distinct from odynophagia, which is pain on swallowing. Dysphagia occurs in a range of conditions that affect the oral, pharyngeal and oesophageal phase of swallowing. The problem of dysphagia assumes greater importance in older persons. Some people may not be able to communicate that a problem exists. In others the lack of nutrition due to dysphagia compounds existing undernutrition, a common problem in institutionalized older persons. This paper discusses dysphagia in the context of the older person and outlines the normal mechanism of swallowing, the important clinical distinction between oropharyngeal dysphagia and oesophageal dysphagia, the aetiology of dysphagia and issues of management.

The availability of high-quality, evidence-based, clearly communicated, user-focused information is central to the new NHS. Reliable information empowers patients and their families and enables them to become more knowledgeable about their care and condition following consultation and diagnosis or before a therapeutic intervention. It is an integral part of clinical governance and the clinical risk framework.

Ethics increasingly becomes a forefront issue in health care decision-making, as health care becomes more technologically and organizationally complex. Hence, a great number of new laws on the status and rights of patients and professional codes have been adopted in Europe. However, research suggests that violation of patients’ rights of autonomy, informed consent and privacy may still be common, especially in elderly care.

Darwin described how animal populations have two adaptation strategies: natural selection based on genetic variation acting over many generations, and developmental plasticity acting within the lifetime of an individual. The contribution of these processes can be difficult to distinguish at the individual level, and the relevance of human developmental plasticity to aging and health in later life is only now being recognized. The formal definition of developmental plasticity is ‘the ability of a single genotype to produce more than one alternative form of structure, physiological state or behaviour in response to environmental conditions’. As an alternative to adaptation to changing environments through genetic diversification, living things have evolved plastic responses. This enables the production of phenotypes that are better suited to their environment than would be possible if the same phenotype was produced regardless of environmental conditions

Many doctors have the impression that elderly-onset epilepsy is uncommon. This has no basis in the recent literature. There is evidence from many countries e.g. USA, Denmark, that the incidence of seizures rises sharply in old age. The United Kingdom National General Practice Survey of Epilepsy and Epileptic Seizures (NGPSE), a prospective-based, community-based study found that 24% of new cases of definite epilepsy were in subjects over the age of 60. A study of a primary care database covering 82 practices and nearly 370 000 subjects, 62 000 of whom were over the age of 60, revealed a continuing rise in the incidence of seizures in old age, whereas the incidence for the overall population was 69 per 100 000, the incidence in the 65 to 69 age group was 87, in the 70s, 147 per 100 000, and in the 80s, 159 per 100 000. Over one-third of all incident cases placed on antiepileptic drugs (AEDs) were individuals over the age of 60.

Although a reduced liver size in elderly people has long been recognized from post-mortem studies, these studies do not allow the separation of true ‘age-related’ differences from the effects of premorbid illness, and death. An age-related effect was confirmed however by an in vivo study which measured liver size by ultrasound scanning of healthy individuals. This demonstrated a significant negative correlation between age and liver volume, with volumes being 28% lower in individuals above the age of 65 compared with those under 40 years of age.

Frailty is a term that is used often, but commonly not defined precisely. As reviewed elsewhere most definitions share several features. Typically, older adults who are frail have a greater rate of dependence on others, so-called ‘loss of physiological reserve’ and multiple diseases. A dynamic component is often included (e.g. ‘loss of reserve’ and such synonyms as ‘unstable disability’ and ‘impaired homeostenosis’) and is manifest when, over time, patients respond less well to stress, or when those with given levels of frailty have higher rates of adverse outcomes. Still, the imprecision of the term frailty has led some to question its merit, and either to develop alternative means of classification or to stay with the concept of function and disability. Alternative methods of classification are either broadly or narrowly focussed.

Coeliac disease (CD) is a syndrome caused by damage to the small intestinal mucosa caused by ingestion of gluten in wheat and other cereals in genetically susceptible people. In recent years, there is increasing recognition of the broad spectrum of clinical and histological features associated with gluten sensitivity. CD can present at any age.

It is clearly established that older people suffer a high rate of disease related to medication. Probably the major reason for this is that older patients are prescribed more drugs than younger people and the rate of prescribing appears to be increasing all the time. In the UK, data are currently collected on all prescriptions dispensed and this shows that older patients (aged over 65 years) receive 35-40% of all drugs prescribed. Between 1977 and 1988, prescription items increased by 17% overall, but by 52% in people over 65 years. compared to only 1% in adults under 65. Prescription rates are rising for a number of reasons, including new advances in therapeutics, a rapidly enlarging older population, moves to treat older patients more effectively (i.e. a less agist policy), rising patient expectations and defensive medical practice.

Disequilibrium is typically described as a feeling of dizziness when standing or walking that is not present while sitting or lying down. Since dizziness is such a common symptom in older people, the symptom may be dismissed as a normal aging phenomenon. On the other hand, the patient may be inappropriately given nonspecific treatment for dizziness such as meclizine or diazepam, which may worsen the condition, due to sedation.

Urinary incontinence has been defined by the International Continence Society as ‘the involuntary loss of urine, which is a social and hygienic problem and can be objectively demonstrated’. This is a useful definition, although due to the subjective component, prevalence can only be estimated.

Falls have always been a major health issue for older people, but over the past few years there has been an explosion of interest in their prevention. We are now at the challenging stage of incorporating best evidence into routine clinical practice. This has been recognized by the UK government in its National Service Framework for Older People in England, which has set targets to reduce the number of falls that result in serious injury, and to ensure effective treatment and rehabilitation for those who have fallen.

Little is known about the frequency of headache in the elderly population as few epidemiological studies have been carried out. In one year in the USA, 70% of the general population had a headache, 5% of whom sought medical attention. In a large population-based study carried out in East Boston, US, some 17% of patients over 65 yrs of age reported frequent headache, with 53% of women and 36% of men reporting headache in the previous year.

The incidence of deep vein thrombosis (DVT) and pulmonary embolism (PE) increases with age and it has been reported to be higher in males. The annual incidence rates per 1000 for DVT and PE are 1.3 and 1.8 respectively for people aged between 65 and 69 years, rising to 2.8 and 3.1 respectively in those aged between 85 and 89 years. Older people are about eight times more likely to develop venous thromboembolism (VTE) in hospitals, nursing homes or other chronic care facilities. About 1.7% develop PE and 8% develop recurrent PE within one year of treatment for DVT. About 3% of patients with DVT and 21% of those with PE die in hospital. One year mortality with DVT is 21% and that with PE is 39%. The diagnosis of PE is often missed in older people and it is often detected only at postmortem.

The current focus on dementia risks eclipsing other mental health problems of later life. While the National Service Framework for Older People (NSF) has highlighted depression as an important disorder meriting special consideration,1 anxiety and psychoses in older people remain difficult problems for practitioners to manage. This paper reviews the prevalence and impact, recognition, complexity and prognosis and treatment for these three clinical problems, and proposes a framework for ‘good enough practice’