Introduction

Physical therapy has been found to improve sensorimotor function following stroke.–5 Early intervention might be better than late6 but even late poststroke physical therapy may be beneficial.3,7–9 Increased intensity of physical therapy may bring increased benefit,10–12 but this might not always be the case,13 as the severity of motor impairment may influence response to additional treatment.14 Not surprisingly, the content of physical therapy might also influence sensorimotor response,15 but at present, choice of treatment by physiotherapists appears to be mostly determined by the treatment approach which was prevalent during their training.16,17 As there are several different physical therapy approaches (Partridge18 describes nine), the potential for variation is extensive. Variation also arises from location of groups of therapists, e.g. the emphasis on the Movement Science Approach in Australia and the emphasis on the Bobath approach in the UK. There is a strong impression that physiotherapy practice has often been shaped by fashion, underpinned by clinical intuitions, based on uncontrolled observations and rationalized by quasi-scientific theories. An example of this is the Bobath approach, which we shall use as an illustration of the current inadequate scientific basis for commonly-used physical therapies.

Depression is the most common mental health problem in old age, presenting a significant challenge to mental health services for older adults. The high chronicity, relapse and mortality rates associated with late-life depression suggest that existing treatments for late-life depression are insufficient. Therefore, current theoretical understandings may require further development. Given the growing population of older adults, the need to improve our understanding of late-life depression is increasingly urgent.

Introduction

This paper considers the approach to decision-making on behalf of mentally incapacitated adults. It updates and revises the 1996 article Ethical Aspects of the Law Commission Report on Mental Incapacity in this journal. The Law Commission Report No. 231, Mental Incapacity, issued in February 1995, was the final outcome of a lengthy and wide-ranging process of consultation. This process resulted in four consultation papers over a period of four years. The Government did not support the Law Commission’s draft bill on mental incapacity and a further consultation period was initiated (Who Decides? Making Decisions on Behalf of Mentally Incapacitated Adults, Cm. 3803). This process culminated in October 1999 when the Lord Chancellor’s Office issued its report, Making Decisions (Cm. 4465). This policy statement sets out the Government’s proposals to improve the decision-making process for those who are incapable of making decisions for themselves or who cannot communicate their decisions.

Introduction

This is a review of recent and clinically relevant work on neuroimaging and its contribution to the diagnosis of neurodegenerative or other neurological and psychiatric diseases in older patients. Earlier research has been summarized in our previous review. We include publications on cranial computed tomography (CT) and magnetic resonance imaging (MRI), on single photon emission computed tomography (SPECT) and positron emission tomography (PET), electroencephalo-graphy (EEG), and on other methods.

Communication is integral to human life. During the communication process, an idea or concept is received by an individual either from another individual or from the physical environment. Person-to-person transmission of ideas could be through the medium of spoken/written language or through non-verbal media such as body language, gesture or facial expression. Ideas or concepts communicated from the physical environment allow the individual to function within that environment. For example, the concept of traffic must be understood, so as to allow safe and effective day-to-day functioning, whilst comprehension of the concept of a CD player could allow the individual to acquire appropriate auditory stimulation for relaxation and enjoyment.

What is spasticity?

Spasticity is a well-recognized and potentially important clinical syndrome comprising inappropriate and involuntary high muscle tone. It has been variably defined, with debate still ongoing. Currently, the most widely accepted definition is that of Lance, stating that spasticity is ‘a motor disorder characterized by a velocity-dependent increase in tonic stretch reflexes (muscle tone) with exaggerated tendon jerks, resulting from hyper-excitability of the stretch reflex.’ Unfortunately, even this description does not fully encompass the multifactorial nature of spasticity, since resistance to movement, even in the normal state, is subject to varied contributors. These include patient volition, inertia, visco-elastic muscle forces and range of joint movement, as well as true muscle activation secondary to reflex action. In the real clinical world, it is often not possible to distinguish which of these features is/are dominant. Furthermore, spastic muscle undergoes physiopathological, rheologic change with stiffness, atrophy, fibrosis and finally contracture.

Introduction

Physical therapy forms a large part of the multi-professional package of stroke care which has been shown to save lives and reduce disability, effects which may be maintained in the longer term. More specifically, physical therapy may improve performance of movement and functional ability poststroke, especially in the form of exercise-based interventions, and increased intensity of physical therapy may bring increased benefit. However, there is little evidence on which to base clinical decisions about what interventions to give to which patients, in what intensity and at what stage in the recovery process. In short, much of physical therapy practice remains based on clinical belief rather than objective evidence and robust research is needed.

Introduction

Across the world, population structures are changing, with particularly rapid growth in the numbers of very old people. For example, in the USA, the number of people aged 85 or over is now around 4.6 million, having grown at nearly 4% per annum since 1980.1 It appears that human longevity has been increasing gradually over many years, with centenarians only appearing as a relatively recent phenomenon about 1800,2 the age of 110 being reached in the mid-20th century and 115 only by 1990. There is no sign of this extension of longevity slowing down towards a presumed biological maximum. In addition to the increase in the maximum age, there is a decrease in mortality rates in almost all age groups, and there has been a considerable rise in the chances of surviving from age 60 to 80 over the last century, which will further increase the numbers of very old people. Furthermore, the death rate in England and Wales for people aged 85 or over has decreased throughout the twentieth century.3

The clinical indications and potential uses of botulinum toxin A (BtA) have steadily increased since it first became available for clinical use in the late 1980s. A pattern has emerged of anecdotal reports of possible benefit in a new indication, followed by multiple small uncontrolled or open studies, with the eventual publication of controlled and blinded trials. This process has been fastest in easily defined clinical situations such as focal dystonias - blepharospasm is a good example - and slowest in the more complex world of rehabilitation. For some indications, uncritical initial enthusiasm has created an atmosphere inhibiting adequate controlled trials.

Geriatric medicine emerged from long-term care championed by Marjory Warren and contemporaries, who focused attention on the opportunities and rewards of assessing, treating and, in particular, rehabilitating older people resident in institutional care. Then as now, people in long-term care were generally beyond the remit of hospital medicine. From this rehabilitative initiative in long-term care, geriatric medicine has continually developed and in the process has become increasingly divorced from its roots. The present evolutionary state of the specialty could be summarized by the goals of concentrating on the early detection, treatment and rehabilitation of acute and chronic ill health, in an attempt to improve quality of life and reduce dependency.

Introduction

Day hospitals for older people typically provide a multidisciplinary service for a heterogeneous group of patients based largely upon a health care model. The broad objectives of day hospital attendance are now widely accepted (Figure 1). There is wide variation, nationally and locally, in the types of service provision. Little information is available to support evidence-based day hospital practice, partly due to the lack of an established methodology to evaluate current practice and allow comparison of different types of community-based rehabilitation and support. This review will confine itself to day hospitals for older people; day care and day hospitals for psychiatry of old age will not be discussed in any detail.

Driving: a new geriatric giant?

Over the last fifty years geriatric medicine has promoted the concept that functional loss in older people is primarily a health issue. For a major loss of function, such as incontinence or immobility, we recognize the need for detection, investigation and treatment. The diagnostic / therapeutic / rehabilitation paradigm takes precedence over the prosthetic approach. Not only do we appreciate the benefits of an interdisciplinary assessment, but we are also accustomed to estimating risk and competence when making decisions about discharging frail older people back to their home environment.

The debate surrounding what has been termed in the literature as relocation stress, transplantation shock, transfer trauma, and pure relocation effect has fuelled academic interest and research over the last half century. Coffman’s review of both published and unpublished data on 26 groups of relocated individuals highlights the breadth of equivocal evidence of mortality post-relocation. Although his review found no general relocation effect, research on the effects of relocation are still found to be ambiguous and contradictory, and its causative or other link to physical and mental health and mortality measures are unclear. In the United States there have even been legal moves (i.e. O’Bannon v. Town Court Nursing Center, Inc.) to persuade courts that relocation ‘should be a legally recognized phenomenon invoking judicial protection against transfer.’

Falls are common in late life. Evidence from New Zealand, the United States and Great Britain suggest that about a third of people aged over 65 will fall each year, a proportion that rises to about half for the community-dwelling population older than 85 years. Falls are the leading cause of death from injury in older people. Although many falls do not cause serious injury, nor precipitate referral to the health services for 30–50% of fallers, those that do have major consequences. From a purely financial perspective, acute care of those with falls is estimated to cost $10 billion per annum in the United States.

Introduction

The context for the review of loneliness and social isolation in later life is that of ‘successful aging’ and ‘quality of life’. The term ‘quality of life‘ includes a broad range of areas of life and there is little agreement about the definition of the term. Models of quality of life range from identification of ‘life satisfaction’ or ‘social wellbeing’ to models based upon concepts of independence, control, and social and cognitive competence. However, regardless of how the concept of quality of life is defined, research has consistently demonstrated the importance of social and family relationships in the definition of a ‘good quality of life’.

Chronic obstructive pulmonary disease is a major cause of morbidity, disability and mortality in old age. The disease is characterized by shortness of breath, impaired ventilatory function and easy fatiguability. These are the most distressing and disabling symptoms of COPD, limiting exercise tolerance, interfering with basic activities of daily living and often, in turn, impairing quality of life.