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.

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.

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.

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.

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.

Dementia has traditionally been viewed as a global, undifferentiated impairment of intellect and memory. The implication is that patients with dementia share a common clinical syndrome. It is, however, now recognized that different dementing diseases give rise to distinct patterns of mental change, reflecting differences in the topographical distribution of pathological change within the brain. Contrary to the traditional view, analysis of the characteristics of dementia can contribute substantially to differential diagnosis. Indeed, since many patients with a dementing illness exhibit few physical signs, evaluation of the mental changes may be critical to diagnostic accuracy. With the advent of new therapies for dementia, precise diagnosis has become increasingly important. Moreover, understanding of patients’ symptom pattern provides a rational basis for patient management and for advice to carers.

The epidemiology of hearing loss in the elderly has been well documented in the UK by Davis and in the USA by Gates. Both studies confirm that presbyacusis is common. Hearing loss results in significant disability in social communication. Davis based his conclusions on a cohort of 2910 subjects while Gates looked at 1475 subjects six years apart. Both studies carried out detailed audiological examinations.

In England there are over 100 000 elderly people registered blind and a further 80 000 registered partially sighted. Visual impairment is common in the elderly population, with approximately 10% of people of 65 years of age and over having poor vision. The prevalence of visual problems appears to be much greater among older people in institutionalized care. A study of 100 elderly people living in residential homes in London revealed that 51% had cataract and 34% had significant refractive errors. A further study of patients attending a geriatric day centre found that about one-third had unrecognized visual loss.

Unfortunately, stroke is an extremely common disease. Around 100 000 people suffer a first-ever stroke each year. Stroke is the third commonest cause of death in the western world and is a major cause of long-term disability. Many patients admitted acutely to hospital after stroke will have a transient or persistent problem with their swallowing. Impaired swallowing results in a failure to maintain nutritional status and hydration, a break-down of vital organs, increasing susceptibility to infection and an increased likelihood of dying.

As the number of elderly people in society increases then the number of those with diabetes will increase. The prevalence of diabetes varies both geographically and between different ethnic groups. The large population study NHANES 2 in the USA showed rates of 9.3% and 8.4% for diagnosed and undiagnosed diabetes, respectively, in those aged 66-74 years. These figures have been roughly corroborated, using similar diagnostic criteria, in a more recent population-based study in Italy (10% and 5% respectively). Although known risk factors for non-insulin-dependent diabetes mellitus (NIDDM) such as family history, obesity and central distribution of fat are important in the elderly, aging itself seems to be a stronger risk factor.