Ischaemia of the deep subcortical white matter in the brain may be a common contributor to disability and cognitive impairment in old age. There is tremendous potential for preventing, or at least slowing, some of this damage. However, progress both in research and in clinical practice has been hampered by the confused nosology, with various diagnostic and descriptive labels applied to appearances on neuroimaging, to the underlying pathology and to clinical states (Table 1).

In their summary of changes in renal function with age, Porush and Faubert do not mention one of the most troublesome and least understood: the reversal of the circadian rhythm of water and electrolyte excretion. Young adults normally excrete the greater part of their 24-hour urine volume during the day and have a low night output. This rhythm has been shown to weaken by the age of 50 years and to be lost or apparently reversed by the eighth decade. Increased urine production is probably the principal cause of the need to get up at least once at night experienced by practically all elderly people. Together with bladder hyperreflexia, it is also an important cause of nocturnal incontinence.

The majority of patients seen in ophthalmic clinics are over the age of 60. In addition, ophthalmology is a major care provider for elderly people. In the author’s unit a recent review of patients undergoing surgery showed that 75% of them were over the age of 60 and 38% over 75. Ten years ago these proportions were 50% and 25% respectively. Much of this reflects the increasing demand for and success of cataract surgery. Age-related macular degeneration is the major cause of visual loss in the United Kingdom and elsewhere and is responsible for 48.5% of all patients registered blind or partially sighted in England and Wales.

Age is deformed, youth unkind,

We scorn their bodies, they our mind.

Thomas Bastard, 1566-1618

There is a universal acceptance in the Western world that age and arthritis are inextricably associated and that both will steam on, leaving our youthful minds wallowing in their wake. However, the danger in accepting this as a fact of life is that relatively less importance is attached to arthritis in older people, despite the often enormous impact this group of conditions may have on them. In addition, the changing demography of the Western world ensures that ever greater numbers will be afflicted by arthritis, not only due to disease arising de novo but also to the carry-through effect.

There has been much discussion about the effect of aging on routinely analysed haematological parameters. The consensus view favours a slow decline in the median value of haemoglobin, including the lower limit of the reference range, especially in the very old. This could be explained in part by the recent finding that many elderly patients with a normocytic, but not a microcytic or a macrocytic, anaemia have an impaired response to erythropoietin. In addition, the number of bony sites exhibiting active haematopoiesis decreases with age, with the marrow being replaced by fatty tissue. This involution first takes place in the long bones, particularly the femur, while the flat bones are relatively spared. The sternal marrow, for example, is one of the last bony sites to show fatty change, usually occurring after 60 years of age. Magnetic resonance imaging confirms this age-related reduction in marrow cellularity.

A person who has a dropped foot is unable to lift the toes clear of the ground during the swing phase of walking. Such a problem is seen in people who have either a peripheral nerve lesion, as a result of trauma or disease, or an upper motor neuron lesion. It is the latter that responds to neuromuscular stimulation; lesions of the lower motor neurons result in destruction of the neural pathway so that muscle contraction can be achieved only through direct stimulation of the muscle fibres.

Ramón y Cajal, the pioneer neuroanatomist, was one of the earliest Nobel laureates, sharing the 1906 physiology prize with Camillo Golgi at the height of his career. He went on to become something of an elder statesman in his field, overcoming the need, far more onerous then than now, to publish his results in foreign languages, while campaigning to bring Spain, if not to the forefront, than at least into communication with the rest of European science. In this he largely succeeded, though to date he remains the only Spaniard to have received a Nobel science award. One of that select generation whose research careers spanned the emergence of the most crucial modern technologies, he began work in total obscurity in the 1880s but lived to see his discoveries become commonplaces of the textbook, as he in person grew to be a hero of Spanish culture almost unequalled in his time and still remembered with justifiable pride.

The number of emergency admissions to hospital in the United Kingdom continues to rise despite the shift in emphasis towards care in the community. Admissions are reported to have been increasing for four decades and, although these increases span all age groups, major contributions come from older persons. The most important and immediately apparent factors contributing to this change are that people are living longer, are more likely to suffer from multiple pathologies and are therefore frequent users of hospital acute services. OECD (1994) projections indicate that the proportion of people aged 65 and over in the population will have doubled from an average of below 10% in 1950 to over 20% by the year 2050.

The problem of patients not following drug therapy has long been recognized. Having reviewed studies which attempted to quantify the problem, determine its causes and advise about its management, Sacket concluded that the magnitude of compliance as a problem in clinical and health care is matched by the extent of our ignorance of its determinants and remedies. He defined compliance as the extent to which a person‘s behaviour coincides with medical or health advice. This definition has been used widely since.