Whilst clinical psychologists and a few fellow professionals have long known the importance of psychology in rehabilitation, it has recently been formally acknowledged as an essential professional discipline in such settings. In relation to stroke care for example, the recently published National Service Framework for Older Adults, England (NSFOA) specifies (Standard Five) that multidisciplinary stroke rehabilitation teams should include clinical psychologists, a view that is echoed in the Royal College of Physicians’ ‘Guidelines for Stroke Care’. The NSF is not yet universal to all areas of the UK, however, this article will reflect the English NSF as appropriate standards for health care across the country.

The difficulty in making an accurate diagnosis of idiopathic Parkinson’s disease (PD) should never be underestimated. Just as the introduction of CT scanning and, more recently, magnetic resonance imaging has revolutionized general neurological practice and exposed the diagnostic inadequacies of the most experienced clinician, current understanding of the pathophysiology of the extrapyramidal system has advanced considerably, even in the last decade or two.

Use of the term frailty in the medical literature has increased significantly in the last 20 years. A MEDLINE search using the combined terms ‘frail’ and ‘elderly’ yielded 473 articles published between 1996 and 2001, compared with 85 between 1980 and 1985. This increasing interest in frailty has been fuelled by evidence that the ‘frail elderly’ are the group most likely to benefit from geriatric intervention programmes and by the close links between frailty and longer hospital stays, nursing home utilization and mortality.

Cognitive impairment is one of the major health problems facing elderly people in the new millennium. This does not only refer to dementia, but also to lesser degrees of cognitive deficit that are associated with a decreased quality of life and, in many cases, progress to dementia. Some studies suggest that delaying the emergence of dementia for a few years would result in a considerable decrease in the human and economic burden related to the condition.

Liaison psychiatry, a term that is sometimes used interchangeably with consultation-liaison psychiatry, refers to the interface between psychiatry and general hospital patients and specialists. It involves psychiatrists’ intervention in the care of medically ill patients who present with psychiatric symptoms whilst in a general hospital setting. It may also involve assessment of patients who have pre-existing psychiatric illness or those who develop psychiatric symptoms because of their medical or surgical illness (e.g. coping with bad news).

The term counselling is a nebulous one. For the purposes of this paper it refers to a therapeutic approach that places value on the person’s subjective experience and challenges the person to accept responsibility for his or her own life. The relationship that develops between counsellor and client can foster personal growth. The overall aim is to provide an opportunity for the client to work towards living in a way he or she experiences as more satisfying and resourceful. Counselling may be concerned with addressing and resolving specific problems, making decisions, coping with crises, working through conflict or improving relationships with others.

The National Service Frameworks for Older People and for Mental Health are setting standards for services in areas where problems are complex and solutions limited. Primary Care Trusts seeking to raise the quality of primary care for older people and commission specialist services rationally face many challenges. Specialists in old age medicine and old age psychiatry will find themselves working closely with primary care practitioners to develop services and extend professional skills, for it is uncertain that specialist services will be able to deal with the scale of the clinical and social problems unaided.

Unilateral spatial neglect is a disorder that has, for many years, intrigued and frustrated researchers and clinicians working in the area of stroke rehabilitation. A vast literature exists on the subject of neglect, much of it published by neuropsychologists and neurologists. Many of these papers aim to identify the underlying causal mechanisms, in terms of the neuroanatomical structures and cognitive processes involved. More recently, research has focused on evaluation of rehabilitation strategies to reduce the disabling effects of neglect. Various research designs have been used to examine whether a particular approach is effective or not. These range from single-case experimental designs (where the individual acts as their own control) through to randomized controlled trials (RCTs). In the latter, comparisons are made between (typically) two groups, one randomly assigned to receive the therapy approach under investigation and the other assigned to the control treatment.

The purpose of this review is to explore the evidence currently available and to identify the framework within which to consider bladder and bowel emptying problems following a stroke. The author was a member of the Intercollegiate Working Party for Stroke Continence Subgroup that reviewed the evidence for the National Guidelines. The review is based on the author’s personal knowledge of published and unpublished work. References in large textbooks and in the landmark papers were checked and a Medline search was performed using the terms stroke, cerebrovascular disease, incontinence and constipation.

Alzheimer’s disease (AD) is an international problem of enormous significance. The human and financial cost to the sufferers, their families and friends is huge, matched by the costs to health and social services in all developed countries and, increasingly, elsewhere.

It is often said that the demand for health care is growing inexorably in the UK, so that the NHS is constantly struggling to keep up. The dilemma was most famously put by Enoch Powell, who said that any health service faces the problem of infinite demand meeting finite resources. This was an economist's view, which suggests that anything that is free will be demanded infinitely.

Delirium is a common disorder in ill older patients, characterized by a fluctuating disturbance of consciousness and changes in cognition that develop over a short period of time. Studies have shown that delirium is an independent predictor of increased length of hospital stay, and is associated with increased dependency and mortality, as well as being distressing for patients and families. Much is known about the epidemiology of delirium, including predisposing factors such as pre-existing dementia and advanced age, and common precipitants such as infection, drugs and major surgery. In comparison, very little is known about the neuropathological mechanisms that lead to the development of delirium.

Stroke is particularly prevalent in older people and the effects of stroke can be profound. Not only are the abilities to stand, balance and walk affected, but also the ability to use the upper limb and hand in its diversity of functions in everyday life. Loss of independence of upper limb function contributes enormously to functional disability, affecting quality of life and independence in ‘basic’ (washing, grooming, feeding, dressing, etc.) and ‘instrumental’ activities (shopping, home/financial management, etc.) of daily living. A larger proportion of stroke patients with initial severe upper limb paresis are discharged to institutionalized care (63%) than are discharged home (37%).

For each person the experience of aging highlights special concerns: Will it be possible to be happy in later life? How can this goal be attained? Is it worthwhile striving to remain youthful, without taking advantage of the experience offered by other stages of life?

Foot problems are common in elderly people and healthy feet are recognized as a key factor in maintaining activity and independence. People aged over 75 years exhibit a greater degree of foot pathology than a younger population and foot pain is prevalent in a high percentage of elderly patients. Foot problems impair mobility in many older people and may also contribute to falls. The immobility that results from a local foot problem can have a significant impact on the patient’s ability to maintain life as a useful member of society and has been identified as a common cause of unreported disability, often accepted as an accompaniment of the aging process. With increasing age, many foot problems which may have been well compensated for earlier in life will begin to reduce an elderly person’s mobility and health-related quality of life.

Comprehensive geriatric assessment (CGA) has been defined as ‘a multidimensional, often interdisciplinary, diagnostic process intended to determine a frail elderly person’s medical, psychosocial, and functional capabilities and problems, with the objective of developing an overall plan for treatment and long-term follow-up’. Evidence from recent meta-analyses of clinical trials of the effectiveness of CGA programmes suggest that older persons may experience a variety of health benefits from these comprehensive services.

Elderly people and their carers are not homogeneous groups, but are highly diverse in terms of their age, ethnicity, income, housing, education, geographical location and access to providers of health. In planning provision, particularly respite care, we need to focus attention on the needs and preferences of those who are not currently receiving help, as well as on the satisfaction with existing services of those who are. There been evidence for some years, for instance, that those in rural areas have different needs from those in urban areas.