Acute ischaemic stroke is common in older people and is associated with a higher morbidity and mortality compared with younger patients. Intravenous thrombolysis with recombinant tissue plasminogen activator (r-tPA) has become the mainstay of treatment and is the only evidence-based specific treatment for acute ischaemic stroke. However, little data are available on the safety of thrombolysis in the over-80 years age group due to under-representation of this group in trials and the upper age limit for licensing of the drug. In this review, we look at the pathophysiology of stroke and recent advances in neuroimaging techniques. We also look at the evidence base for use of thrombolysis in stroke and in particular analyse the trials that include the very elderly as subjects. Finally, issues around ongoing trials and future research are discussed.

Urinary incontinence is a common and under-reported symptom, affecting one in five people, with a higher prevalence in women and those who are elderly. It can have a major impact on physical health and social activity. Initial assessment to categorize symptom type is the key to guiding further therapy. Non-pharmacological (NP) options are preferred as first-line intervention, and if unsuccessful, are followed by anticholinergics, often in combination with NP options. Surgical intervention must be sought where appropriate. However, NP interventions are often not considered due to uncertainty about the evidence-base, perceived difficulty of application and perhaps a lack of awareness of or access to specialist continence services. This article addresses the first of the barriers, summarizing the evidence for various NP interventions, including lifestyle interventions, physical therapies, behavioural therapies and containment options, enabling the reader to formulate an evidence-based opinion and a pragmatic view on the feasibility, efficacy and applicability of the various NP interventions, without automatic recourse to anticholinergic medication in the first instance.

In this review, we analyse original research articles in English and Spanish in which fear of falling (FoF) as a long-term syndrome defines the participants, or is the main outcome, or in cases where FoF is a secondary outcome, falls or activity are the main outcomes.

FoF is difficult to measure. Attempts are made to do so by use of single questions or scales. Restriction in activity due to FoF is a secondary outcome and can be an important influence on a person's quality of life. There are also various methods of measuring it by use of single questions or scales, and general questions in basic or instrumental activities of daily living (ADL) indices are frequently used. Other scales or questionnaires about quality of life (such as the SF-36) or activity (such as the Survey of Activity and Fear of Falling Scales (SAFE), or the Groningen Activity Restriction Scale (GARS)) are also used. The varying objectives of the analysed articles explain some of the variations in measures used. Further work is required to reach a consensus on definition and standardized measurement of FoF and its effect on quality of life and activity.

An important protective function of the brain's innate immune system is to detect the presence of proteins such as amyloid and to remove them before they become neurotoxic, as is thought to occur in Alzheimer's disease (AD). Ageing affects the immune system response to infection and can influence the systemic response to vaccination and other potential immunotherapeutic agents. The generation of systemic antibodies is a vital component of the immune response, facilitating the identification and clearance of pathogens from the central nervous system (CNS). Experimental evidence using transgenic animal models of AD has shown successful clearance of amyloid from the CNS following vaccination with an amyloid peptide, and consequently a trial of amyloid beta peptide (Aβ) vaccination was undertaken in older people with AD. This produced some unexpected results, as not only was there evidence for amyloid plaque removal, but also a small number of cases developed encephalitis. A detailed review of the response to vaccination and the neuropathology findings are discussed, showing that the findings are understandable given the effects of ageing upon the innate immune system in the brain. Finally, the therapeutic potential of manipulating the regulatory components of the ageing innate immune system in order to inhibit brain inflammation and reduce cognitive decline is outlined.

Sleep problems in older adults are common and disturbance in sleep is associated with increased mortality. These problems are more pronounced in the care home population because of institutional factors and a high prevalence of frailty and co-morbidity. This article reviews the randomized controlled trials undertaken to address sleep problems in care homes. These suggest that stand-alone therapies – oral melatonin and light therapy – have no effect on sleep but that combination treatments – physical exercise plus sleep hygiene, physical exercise plus sleep hygiene plus light and melatonin plus light – may have positive effects. These effects are more marked for daytime arousal than nocturnal sleep. Practical considerations for care homes are how to maximize light exposure, incorporate exercise into daily routines and minimize night-time disruption for residents. Trials undertaken so far are compromised by small sample size and inappropriate randomization strategies and further research is therefore required.

Malnutrition is common in older people and is associated with a number of adverse outcomes. We review the evidence for the effectiveness of nutritional supplementation for older people in the community, in institutional care and following discharge from hospital. Studies in these settings are scarce, often include only small numbers of participants and are of variable quality. The interventions used are heterogeneous and difficult to directly compare. Oral nutritional supplements (sip feeds), dietary fortification, educational programmes, exercise, flavour enhancement and meal setting have all been studied. Evidence for use of oral nutritional supplements as sip feeds in undernourished community-dwelling and institutionalized older people and in those discharged from hospital is currently insufficient to recommend routine use. Flavour enhancement and more sociable meal environments may be beneficial. Further, more methodologically robust research is needed to clarify the effect of these interventions.

Stroke is a leading cause of disability worldwide and patients with stroke frequently require prolonged periods of in-patient rehabilitation prior to discharge. This poses a large economic strain on health services, and the cost-effectiveness of this system has been questioned. However, in implementing changes in the delivery of post-acute stroke care it is important that patient outcome is not compromised. Early supported discharge (ESD) was introduced approximately 15 years ago and allows suitable patients to be discharged home early with increased support from a well co-ordinated, multi-disciplinary rehabilitation team in the patient's own home. This paper focuses upon the evidence available from multiple international studies of ESD over the last decade, including both clinical benefit and cost-effectiveness. Findings from these trials are largely positive resulting from a reduction in bed days, therefore overall cost, and an improvement in function and independence reported in many studies. Suitable patient selection, careful discharge planning and continuity of care by the ESD linked to a stroke unit are essential components of the success of this service.

Collecting outcome measures by patient or proxy-completed postal survey in stroke research offers a pragmatic and cost-effective alternative to interview-based assessments. The psychometric properties of outcome measures cannot be assumed to be equivalent across methods of questionnaire administration. Many stroke outcome measures have variable or unproven psychometric properties when administered by post. The validity of stroke research that uses postal surveys may be improved through the adoption of questionnaires with acceptable postal psychometric properties. This review identifies 60 reports of quantitative stroke studies using one or more of 36 instruments to collect stroke outcome data by postal survey. Three of these instruments have acceptable psychometric properties for postal administration in stroke populations (the Frenchay Activities Index (FAI), Subjective Index of Physical and Social Outcome (SIPSO) and the EuroQoL (EQ5D)). Two further instruments lack evidence to support proxy reliability (Nottingham Extended Activities of Daily Living and London Handicap Score), but have otherwise acceptable properties.

This paper reviews the limited evidence on the causes of homelessness in old age and on the circumstances and problems of older homeless people, and it describes the few services dedicated to the group. Health care and social care professionals rarely encounter homelessness among the many problems of older people that present to them, but in many developed countries there is evidence that the number of older homeless people has recently been growing. Some among them have been homeless intermittently or continuously for years, but many became homeless for the first time in later life. The reasons for becoming homeless and the problems and needs of the group are exceptionally diverse. Many have been estranged from their family or have no living relatives, and they have a high prevalence of health problems and functional limitations. Although services for homeless people in general have improved since the early 1990s, few have targeted the needs of older people.