Multiple myeloma is a neoplastic proliferation of a plasma cell clone that produces a monoclonal immunoglobulin. It is one of the most common haematological malignancies and the incidence increases with age, with a median age at diagnosis of 65–70 years. The diagnosis of multiple myeloma requires the presence of ≥10% plasma cells in the bone marrow and an M-protein in serum and/or urine. Cytogenetic status, serum β2-microglobulin and response to therapy are the key prognostic factors. Treatment is necessary for the patient diagnosed with symptomatic multiple myeloma, with organ damage. Patients older than 65 years are ineligible for autologous transplantation. The introduction of novel agents, such as thalidomide, bortezomib and lenalidomide, have changed the management of myeloma and extended overall survival. However, in older patients the results are not as satisfactory and treatment strategies have to be individualized to improve tolerability and optimize efficacy.

Medication reviews in primary care are now an established and important part of the care of patients on multiple medications. In the current NHS this review has demonstrated that pharmacist-led medication reviews can reduce inappropriate prescribing and offer an efficient approach to ensuring reviews are completed. These reviews appear best operationalized with experienced pharmacists who are closely aligned with the patients and prescribers through joined up services. Further developments in pharmacists’ communication skills with patient and prescribers may offer greater benefits in the future.

As the mean life expectancy of the population continues to increase, the challenge for individuals is to remain healthy and fit throughout their life span. This review examines the relationships between moderate-vigorous physical activity and sedentary behaviour in relation to the fitness-frailty continuum. The association between increased physical activity and decreased adverse health outcomes is firmly established. A direct association between frailty and moderate-vigorous physical activity has been established to a lesser degree. What has some potential to undermine even these gains is the increasingly recognized relationship between sedentary behaviour and poor health. It now seems likely that sedentary behaviour can have a negative impact on an individual's health, over and above that of meeting the recommendations of moderate-vigorous physical activity. Individuals must consider both increasing their level of moderate-vigorous physical activity and minimizing their level of sedentary behaviour during all aspects of daily life.

Faecal incontinence is a disabling condition, with a high personal, social and economic cost. Whilst it may occur at any age, prevalence and severity of symptoms is higher among older people. There are many therapeutic options, ranging from non-invasive treatments to complex surgical techniques, with results that can be considered satisfactory in about 70% of individuals. A comprehensive study of the type of incontinence and its presentation and severity, together with consideration of the general condition of the patient and their environment, are the keys that will decide the best treatment option.

Evidence from England, Australia, Canada, Japan and the USA indicates that the single homeless population is ageing, and that increasing numbers of older people are homeless. This paper reviews evidence of changes in the age structure of the single homeless population, and the factors that are likely to have had an influence on the growth of the older homeless population. In many Western cities, the housing situation of older people is changing and there is a growing reliance on the private rented sector. Unemployment is also having an impact on older people who are under the official retirement age. An increasing number of older people are experiencing problems linked to alcohol, drugs, gambling and criminality, and these are all behaviours that can contribute to homelessness. Despite high levels of morbidity and disability among older homeless people, they are a relatively neglected group and receive little attention from policy makers and mainstream aged care services.

Delirium has been associated with institutionalization, increased length of hospital stay, cognitive and functional decline and mortality. Research in the last thirty years has recognized that accurate diagnostic criteria allow for targeted interventions for those suffering from delirium. However, despite the advances made in understanding delirium, adverse outcomes persist.

This article will first review how the evolution of diagnostic criteria has fostered improvements in the recognition of delirium and facilitated the development of therapeutic strategies. Second, we discuss how this foundation in approach to delirium has influenced outcomes and the evidence for causality. Finally, the candidate factors responsible for propagating adverse events are considered and future research direction outlined.

Recently, diagnostic criteria for preclinical Alzheimer's disease have been proposed. These describe and define three stages of disease. Stage I is focused on asymptomatic cerebral amyloidosis. Stage II includes evidence of synaptic dysfunction and/or early degeneration. Finally, stage III of the disease is characterized by the beginning of cognitive decline.

The transformation of human immunodeficiency virus (HIV) from a rapidly fatal disease to a chronic manageable illness has resulted in annual increases in the numbers of people living with HIV. The HIV cohort is therefore ageing, with numbers of older adults with HIV climbing, through both prolonged survival and late acquisition of the disease. Associated with ageing is an accumulation of HIV-associated non-AIDS related co-morbidities, creating a complex patient group affected by multi-morbidity along with polypharmacy, functional decline and complex social issues. With this in mind, this review seeks to explore areas where HIV (diagnosed or undetected) may impact on the work of clinical geriatricians.

Parkinson's disease (PD) is a common and costly condition affecting a predominantly older population. Physical rehabilitation has been shown to enhance motor performance and functional mobility in the short-term. However, there is limited information available about how best to design and deliver an ambulatory rehabilitation (AR) programme for this patient group. This article reviews the current evidence, aiming to provide guidance about best-practice service provision. We highlight the benefits of group therapy and techniques aimed at reducing falls. Further research is required to determine the optimal dose and intensity of AR necessary to provide sustained benefits in people with different stages of PD.

Cardiovascular disease (CVD) is a major cause of morbidity and mortality in the Western world in older people. Diet and lifestyle change can reduce CVD risk in older people, and this evidence base is reviewed. For example, diets low in trans fats can reduce CVD risk, while for saturated fats the CVD-lowering effect depends on what is substituted for the saturated fat. Diets rich in fish reduce CVD risk, although n-3 supplements have not been shown to have a consistent effect on CVD end-points. Antioxidant and B-group vitamin supplementation are unlikely to reduce CVD risk, but diets rich in these micronutrients (e.g. rich in fruits and vegetables and the Mediterranean diet) are associated with lower CVD risk, while, for the Mediterranean diet, this has been supported by randomized controlled trials. Maintaining a healthy weight and being physically active reduce CVD risk factors and CVD incidence and mortality.

Prostate cancer is the most frequent tumour diagnosed in men, especially in older people. Radical prostatectomy is the treatment of choice for this disease, but is also the main cause of stress urinary incontinence in men by iatrogenic injury. This procedure is performed far more frequently now than 10 years ago, so the incidence of post-prostatectomy incontinence (PPUI) has increased. PPUI has a detrimental impact on a patient's quality of life and is a significant problem that needs to be solved. The artificial urinary sphincter is still the gold standard treatment for PPUI. In recent years, less invasive approaches such as suburethral slings have been used with promising results. The selection criteria and most appropriate choice of device for the treatment of PPUI are not well standardized. In this review, the different forms of assessment and management of PPUI will be discussed.

The heart failure epidemic predominantly affects older people, particularly those with concurrent co-morbid conditions and geriatric syndromes. Mortality and heath service utilization associated with heart failure are significant, and extend beyond the costs associated with acute care utilization. Over time, older people with heart failure experience a journey characterized by gradual functional decline, accelerated by unpredictable disease exacerbations, requiring greater support to remain in the community, and often ultimately leading to institutionalization. In this narrative review, we posit that the rate of functional decline and associated health care resource utilization can be attenuated by optimizing the management of heart failure and associated co-morbidities. However, to realize this objective, the manner in which care is delivered to frail older people with heart failure must be restructured, from the bedside to the level of the health care system, in order to optimally anticipate, diagnose and manage co-morbidities.

Dysphagia represents a salient concern in many conditions prevalent in older people. There are direct implications for morbidity and mortality. The importance of recognizing and managing dysphagia in hospital and the community also extends to psychosocial impact and quality of life, as well as health, economic and ethical-legal issues. This review outlines reasons for the importance of recognizing and treating dysphagia. It then proceeds to look at recent developments in our understanding of the nature, assessment and management of dysphagia in older people. Whilst there are well-established practices in assessment and management, ongoing work continues to challenge the validity and reliability of many methods. These concerns are covered and directions for future developments highlighted.

Acute heart failure is a highly prevalent geriatric syndrome presenting one of the most frequent reasons for visits to the emergency department and hospital admission, and is associated with a high morbidity and mortality and acute functional impact. The present study reviews some of the features that characterize diagnosis and immediate management of acute heart failure in older people, as well as recommendations about the management of co-morbidity, risk stratification and the decisión-making process, and the design of care plans in this older age group within the setting of hospital emergency departments.

Evidence suggests that there is a greater prevalence of pain, particularly chronic pain, in the older than in the younger population. This review looks at how dementia affects older people's ability to report pain, and indicates that pain is poorly assessed and managed in people living with dementia, in particular in care and acute settings. The review also reports findings from two recent studies looking at ways of improving the assessment and management of pain in acute settings. Multi-dimensional, patient-centred approaches to assessing and managing pain in those living with dementia are required, and future research should focus on innovative and practical approaches that can be applied in care home and acute settings.

Populations are ageing worldwide. The prevalence of dementia will rise exponentially with the oldest old the most rapidly growing segment of society. Caring for this ageing population with dementia, many of whom will have multiple chronic and disabling diseases, will be a challenge to healthcare systems, particularly general hospitals. At any one time, a quarter of acute hospital beds in the UK are in use by people with dementia. Delivery of high-quality care to this growing and vulnerable population must be high on any health service agenda.

Current medical training not only generates relatively low numbers of geriatricians and specialists with interest in dementia, but also there is a lack of appropriate training in assessment and management of dementia. There remains huge need for better staff training and support to provide safe, holistic and dignified dementia care. Here we explore various key features for non-specialist assessment and management of older people with dementia in the general hospital setting.

Prescribing for older people is often complex and challenging. With age, people almost invariably develop diseases leading to the prescription of drugs and the risk of multiple prescribing increases, especially if there is strict adherence to single disease guidelines. There remains a paucity of evidence from clinical trials as to the efficacy of many drugs in patients aged over 80 years due to the gross under-representation of older people in clinical trials. Older people are also at increased risk of adverse drug events, which are an important cause of morbidity and mortality. A significant percentage of these are both predictable and potentially avoidable.

In this updated review the concept of appropriate prescribing in older people is explored, including the importance of individualized care and shared decision-making. The available tools to enhance prescribing practice are examined, including those aimed at reducing inappropriate prescriptions and under prescribing. The limitations of existing tools are discussed and areas with particular promise and scope for advancement are highlighted, including the development of integrated IT systems and software engines to aid clinicians in appropriate prescribing.

Older people are high consumers of prescription drugs and are at increasing risk of polypharmacy and adverse reactions. Pharmacokinetic and pharmacodynamic modifications due to age and co-morbidities are an important consideration, but pharmacological background evidence to guide safe and effective therapeutic approaches are often inadequate since the older population is under-represented in clinical trials. We review the pharmacokinetic and pharmacodynamic changes that are characteristic in old age and consider evidence regarding potentially safer prescription and monitoring of drugs commonly used in older patients. We also introduce the possible role of pharmacogenomics and therapeutic drug monitoring as tools to guide the individualization of drug therapy.

Hip fracture is very common among older patients, who are characterized by increased co-morbidities, including cognitive impairment. These patients have an increased risk of falls and fractures, poorer functional recovery and lower survival both in hospital and 12 months after discharge. We review the survival and functional outcomes of older patients with cognitive impairment and hip fracture managed in orthogeriatric units, and highlight the gaps in our knowledge of the efficacy and efficiency of specific orthogeriatric programmes for such patients and the future research perspectives in this field.

This study systematically reviews the published literature regarding inappropriate prescribing in frail individuals aged at least 65 years. Twenty-five of 466 identified studies met the inclusion criteria. All papers measured some surrogate indicators of frailty, such as performance-based tests, cognitive function and functional dependency. Beers criteria were used in 20 studies (74%) to evaluate inappropriate medication use and 36% (9/25) studies used more than one criterion. The prevalence of inappropriate medications ranged widely from 11 to 92%. Only a few studies reported the relationship between potentially inappropriate medication use and surrogate measures of frailty. These diverse findings indicate the need for a standardized measure for assessing appropriateness of medication in frail older individuals. Prescribing tools should address both medication and patient-related factors such as life expectancy and functional status to minimize inappropriate prescribing in frail individuals.