There is strong indirect evidence that free radical production appears to be an important mechanism of brain injury after exposure to ischaemia and reperfusion. Although significant brain damage occurs during an ischaemic episode, new cerebral damage can occur after reperfusion. One proposed mechanism for the brain damage that occurs during reperfusion involves generation of free radicals. Body defences against free radicals depends on the balance between free radical generation and the antioxidant protective defence system. Many of these protective antioxidants are essential nutrients or have essential nutrients as part of their molecule that has to be obtained from diet.

In the United Kingdom, the number of people aged 65 years and over increased from 7.4 million (13% of the total population) in 1971 to 9.2 million (16%) in 1996, and is projected to increase further to 14.5 million (24%) by 2061. Because of the strong association between aging and chronic disease, the numbers of people in the United Kingdom suffering from chronic illness and disabilities are projected to increase two to threefold by the middle of the next century. These changes in population age structure are particularly marked in the developing world, such that the greatest increases in both total numbers and proportions of older people will be experienced by Asia, China and Africa.

The last year has seen much change in Reviews in Clinical Gerontology, and this will continue over the next year.

At the beginning of last year I took over as Editor from Professor Ray Tallis, whose vision, drive and initiative were instrumental in establishing what Age Ageing has recently referred to as one of the major review journals in the field on gerontology. The year also saw a major change in the section editors, the only one remaining from l’ancien regime being Bob Baldwin, our section editor for Old Age Psychiatry. The contributions of David Barer, Ioan Davies, Emily Grundy, Jackie Oldham and Peter Overstall have been considerable, and their contribution, with Ray, to Reviews cannot be understated.

Stroke and coronary heart disease (CHD) share many risk factors, suggesting at least some similarities in pathogenesis. It is therefore surprising that the role of one of the major risks for CHD, dyslipidaemia, remains so contentious as a risk factor for stroke. Because of a lack of good clinical trials, conflicting views have been expressed on the association of lipids, primarily serum cholesterol and its subfractions, with stroke disease and the merits of preventing stroke by lowering cholesterol. Many of the issues involved are intimately related to those of managing dyslipidaemia in the elderly. If stroke occurred as commonly below the age of 65 as above this age it is likely that the necessary epidemiological and intervention studies would already have been undertaken.

Growth hormone and related growth factors are essential for normal childhood development, secretion rate then declining from early adulthood. Adults with growth hormone deficiency, e.g. after pituitary ablation, have many clinical features such as reduced muscle and bone mass which are also seen in healthy older people. In both cases, growth hormone treatment at least partly reverses these changes. This has led to the rather elegant notion that growth hormone decline may be responsible for age-related involution and death and raises the prospect of hormonal replacement therapy for aging and frailty.

The first decade of the 20th century saw a dramatic growth in knowledge of neurodegenerative disease, with new histological techniques leading to the identification for the first time of distinct clinicopathological conditions, including Alzheimer’s disease (AD). The last ten years of the century (‘the decade of the brain’) has seen similar breakthroughs in our understanding of the pathogenesis of neurodegeneration, largely due to the availability of the new techniques of molecular biology. Whilst much of the research has centred on the genetics of early-onset disease, the findings have direct relevance to the great majority of elderly patients with sporadic AD. There is now a realistic prospect, in the early part of the next century, of effective disease-slowing therapies for established disease and even preventive interventions for at-risk individuals.

Coronary artery disease is extremely common among elderly people and accounts for half of all deaths in those who are more than 65 years old. Although the condition is essentially the same as that encountered in younger patients, the management of coronary artery disease in elderly subjects can be difficult because the anticipated benefits and risks of the various treatment options are often altered by the presence of co-morbid conditions. Moreover, the results of the major outcome studies that underpin most treatment guidelines may not be relevant to the needs of many elderly patients for several reasons.

Over a lifetime, the human lung is exposed to a multitude of factors capable of altering its structure and function. The frequency of acute, self-limiting lung disease, exposure to environmental pollutants and previous tobacco consumption in elderly people makes it difficult to identify pulmonary changes that can be attributed to ‘normal aging’ alone. It is likely that all these factors may have some influence on both lung structure and function.

The term syncope has been used to describe collapse of any nature but this is not the appropriate use of the word. Syncope originates from the Greek and means ‘cessation’ or ‘interruption’. The specific application of the word syncope is a temporary loss of cerebral blood flow, resulting in loss of consciousness and postural tone, thus leading to collapse. Although other conditions resulting in collapse may be difficult to disentangle from a syncopal event, it is the broad spectrum of diagnoses resulting in syncope to which this article is dedicated.

Research carried out in the 1950s and early 1960s indicated that there was considerable unmet need amongst older people in Britain. This work prompted research into ways of meeting the health care needs of older people, a task made more important by the aging of the population at the end of this century. This focus resulted in the introduction in 1990 of a nationwide health assessment programme for older people, as a contractual obligation for general practitioners. The programme, the first in the world, remains in force but is widely ignored. This paper describes:

The accurate measurement of renal function in elderly subjects is often required, due to structural and functional changes resulting from age and diseases affecting the kidney. Structurally, with age there is progressive loss of renal mass, particularly in the cortex, leading to a decreased number of glomeruli and an increase in the proportion of sclerotic glomeruli. A decline in the glomerular filtration rate (GFR) has been observed in both cross-sectional and longitudinal studies. However, it has also been noted that about one third of subjects have stable renal function, implying that this decline is not universal, and may reflect the effects of age-associated diseases.

Stroke is a disease with which we are all too familiar; it is the leading cause of severe disability and the third most common cause of death in the developed world. Over the last few years there has been a tidal wave of literature on the subject. Not before time, the impact of stroke worldwide has been recognized and this, it is to be hoped, signals an end to the nihilism that used to be so common.

The present review, building on a previous review published in 1993, gives a general overview of a large subject. As on the previous occasion, it is primarily concerned with the assessment of risk and the improvement of outcome in the older surgical patient. However, some of the previously-discussed technical difficulties of assessing risk, which apply to a wide range of medical and surgical specialties, have not been repeated this time. Updates have been given on cardiac, respiratory and nutritional risk assessment in older surgical patients, and a section on post-operative changes in mental function has been added. The use of new outcome measures, including the measurement of quality of life, is also discussed more fully in the present review.

As the proportion of older people in the population rises, health services must continue to develop to meet their special needs. This includes accident and emergency (A&E) services which work at the interface between primary and secondary health care for individuals of all ages. This literature review aimed to answer the following questions:

1) What are the characteristics and special needs of older people in A&E?

2) Which of the current literature describes, evaluates or advocates service initiatives aimed at meeting the needs of older people in A&E?

3) What are the policy implications of the literature reviewed for British A&E services?

Hypertension is a common problem in elderly people. The actual prevalence is uncertain and depends on the diagnostic methods used. Hypertension is an important factor in the two most common causes of death in elderly patients in the UK: heart disease and stroke. Next to age, hypertension is the most important risk factor for acute stroke and an important risk factor for ischaemic heart disease and cardiac failure. There are well defined methods of diagnosis and guidelines on management such as those issued by the British Hypertension Society (BHS). A new version is in preparation. Several trials have confirmed the benefits of treatment in older patients, particularly in terms of stroke reduction. Since the last review in this journal, in 1994, the most important developments have been the publication of more outcome studies, some of which have used calcium antagonists as first-line treatment. This review again focuses on the over-65 age group. Since there are still insufficient data in older subjects, information from research on younger patients has been included to support arguments for various aspects of management.

Since the oral cavity has a specific role in maintaining wellbeing, appropriate care can help to increase quality of life by keeping the mouth free from infection, maintaining dentition - thus facilitating ‘normal’ eating - and restoring appearance. Yet, as age increases, the ability to carry out effective oral care may be jeopardized by physical and mental disability and an associated inability to manage personal care. Indeed, a significant relationship between dexterity, impaired oral hygiene and accumulation of dental plaque has been demonstrated in institutionalized older adults. Although levels of untreated dental caries, periodontal disease and tooth loss may be significant, oral care is frequently overlooked in older individuals; dental care is rarely provided in institutional settings, often being sought only when an oral health problem is identified. There is, therefore, a significant unmet dental need, associated with marked oral disease and poor levels of oral hygiene. This is often exacerbated by the effects of aging on the mouth.

The dementias which affect the elderly are chronic diseases with protracted courses, substantial morbidity, complicated presentations and serious effects on families and caregivers. The care of a patient with dementia is therefore complex, requiring a rational model of treatment including careful multidisciplinary evaluation, a treatment plan, and ongoing reassessment. The aim of this article is to provide a framework for any clinician involved in the management of patients with dementia. Dementia has been thought of as untreatable by some health professionals: however, in many ways it can be managed effectively and its consequences reversed or stabilized, even though the disease process may be irreversible. With evolving knowledge in basic research and with the development of new intervention strategies, more effective treatments will be available over the next several years. Therefore we provide a guide to the management of patients with dementia which is responsive to the introduction of future treatments.

It is widely acknowledged that ‘rewarding personal and sexual relationships promote health and well-being’, an opinion exemplified by the identification of sexually-transmitted infections (STIs) as one of the key targets for disease reduction in the Health of the Nation White Paper. Indeed, since the advent of the AIDS pandemic in the early 1980s, a substantial body of research has been undertaken in the area of sexual health.

Dementia is not a disease. It is the neuropsychological deficit which results from chronic brain disease or encephalopathy. Dementias may be nonprogressive, for example resulting from brain trauma or cerebral hypoxia, or progressive, resulting from intrinsic, extrinsic or metabolic cerebral disorder. The progressive encephalopathies, in particular those resulting from intrinsic brain disease, form the subject of this review.

It is not easy to establish with any confidence the prevalence of drug misuse in older people. The issue is confounded by variations in definition of what constitutes ‘elderly’ and ‘drug misuse’, and by the types of sample used (Tables 1 and 2). There are few large-scale studies in the UK, and much of the information has been extrapolated from the American findings. The available information can be organized into four main areas: