It is frequently observed that medical treatments are evaluated in patient populations which have characteristics significantly different from those of patients upon whom the treatments will be used once established in clinical practice. The most striking illustration of this has been the almost complete exclusion, until recently, of elderly patients from trials of new medication. Whereas clinical trials include younger adults with a single pathology, the real world of patient care is dominated by older adults with multiple pathology.

Current knowledge suggests that parental age has many influences on offspring. This topic has been exhaustively reviewed in Finch's monograph. The major maternal age-related changes in humans are increases in fetal aneuploidy later in reproductive life; Down's syndrome (trisomy 21); Kleinfelter's syndrome (XXY); Edward's syndrome (trisomy 18); and Patau's syndrome (trisomy 13). Despite a recent dramatic decrease in fetal death rates, advanced maternal age remains an important independent risk factor for fetal death.

Diabetes mellitus is a common and expensive condition which is reported to be responsible for as much as 4-5% of national health care expenditure in developing countries. It is a disease of some antiquity, although the predominant clinical presentation is not that which was described by Aretaeus in the second century AD ('a melting down of the flesh and limbs into urine').

Despite the increasing numbers of elderly subjects in society, the characteristic changes of old age such as the presence of wrinkles and grey hair still carry social stigma. This is taken advantage of by a cosmetics industry which produces enormous numbers of products to disguise aging. Contrary to popular belief, elderly people are often anxious to look attractive. Elderly patients present to dermatologists with a variety of skin problems. These may be directly related to aging (e.g. carcinogenesis) or may be common problems whose clinical expression, physical and emotional consequences and management may be altered by the age of the patient. A survey of elderly patients by Beauregard and Gilchrest revealed that two-thirds had symptoms relating to their skin and that this rose to 83% in subjects over 80 years.

Because women die at an older age than men, and marry men older than themselves, widows outnumber widowers and the average woman can expect to survive her husband by five to six years. In fact, widows make up a substantial proportion of the elderly population. In this paper the current state of our knowledge of the reaction to bereavement in the elderly will be reviewed and its implications for the provision of services considered.

A great deal of attention has been devoted to the ever-increasing incidence of fractures of the proximal femur in elderly patients and the impact which this has had upon their life expectancy and quality of life. The condition has also made heavy demands on the Health Service, and much effort has been devoted to increasing hospital throughput by effective programmes of rehabilitation. In these circumstances, it is not surprising that much less has been written about the issues involved in treating elderly patients with less serious forms of fracture. Nonetheless, closer attention to this group reveals that it also makes heavy demands on the Health Service. An example is that, in 1995, out of 1771 elderly patients admitted to the acute orthopaedic wards at Edinburgh Royal Infirmary, only 47% had fractures related to the proximal femur or displacement of a hip prosthesis (Figure 1) (CT Currie, unpublished data, 1996). Most of the remainder had fractures at other sites, while 8% had soft tissue injuries. The percentage of fractures involving more common sites in old people was 2.5% for the neck of humerus, 3% for the shaft of humerus, and 7% for the wrist. The low proportion of vertebral fractures emphasizes that this condition rarely leads to admission to an acute unit, so that the size of the problem is usually underemphasized.

The growth of the elderly population in the UK and other Western societies, as well as in the USA, Australia and Japan, has led to widespread interest in the living arrangements of this group. Although co-residence patterns within the household alone are not sufficient indicators of the strength of conjugal and intergenerational ties, they do provide a measure of potential intra-household support for the elderly. Studies have shown that children who live at home provide greater assistance to their parents (both financially and with domestic tasks) than non-co-resident children. Thus, residential patterns appear to be important for exchange relationships between the elderly and their kin.

In many developed and developing countries, life expectancy has greatly increased over the last two decades. However, this seemingly favourable change raises new questions concerning the quality of the years of life gained, particularly in the elderly. Do the individuals who escape death accumulate disabilities, sequelae of accidents or consequences of chronic diseases? The concept of disability-free life expectancy, and more widely that of health expectancy, has been developed in order to answer this question.

Urinary incontinence is a condition in which involuntary loss of urine is objectively demonstrated and results in a social or hygienic problem. A poll conducted for the Association for Continence Advice estimated that up to three million people in the UK suffer from incontinence. The incontinence may be transient, e.g. as a result of a urinary tract infection, or permanent, e.g. as a result of damage to the pelvic floor. Many sufferers may not seek medical advice for their predicament and the figures given above may be a gross underestimation of the problem.