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 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.

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:

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.

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:

Depression in old age is common, disabling and undertreated. This review will examine recent advances in our understanding of its clinical presentation, epidemiology, management and prognosis. The relationship of depression in old age with dementia and with physical illness is also discussed, as are the links between suicides, deliberate self-harm and depression in old age.

With significant demographic changes already apparent amongst the older population, care of elderly people in the community is becoming ever more important. It is predicted that the number of elderly people aged 65 years and over will rise from 8.4 million in 1985 to 9 million by the year 2001. The most significant growth will be found amongst those aged 85 years and over, with a projected rise from 8-13% of the population by the millennium.

In his book ‘Effectiveness and Efficiency’ Cochrane drew attention to the need to evaluate the effectiveness of health service intervention. Despite his plea for more evaluative research in health services, it has been suggested that only 20% of health care interventions have been rigorously evaluated. Changes in the structure and philosophy of the NHS in the past decade have stimulated interest in the evaluation of health services interventions at both local and national levels.

The recent Royal Commission report on funding long-term care was produced following more than 100 visits and evidence from 400 organizations. It was set up following concern at the costs of long-term care for elderly people and what was seen to be the anomalous position of elderly people cared for by the NHS in long-term beds, where all costs were found by the state, albeit that elderly persons themselves lost most of their benefits. This contrasted with those in the social or independent sector, where payment has to be made unless the elderly person is poor.