The Exarchate of Ravenna has usually been seen as peripheral to Carolingian Italy because of its ’alien’ character, stemming from its position as a province of the eastern empire up to 751. This chapter first argues that, while the area retained many distinctive ‘Roman’ institutions that were quite distinct from the those of the old Lombard kingdom, it is unhelpful to regard these as ‘Byzantine’, and that enduring links with Constantinople were limited. The chapter goes on to argue that the area came to play an increasing role in the political and ecclesiastical life of Carolingian Italy, for a number of reasons, including the archbishops’ conflicts with the papacy and the attractiveness of Ravenna’s heritage to rulers keen to enhance their claims to imperial authority. Also, by the late ninth century various factors led to the settlement in the Exarchate of several powerful families of Lombard and Frankish descent.

Introduction

Nutrition plays a key role in later life health and wellbeing. Older people face a high risk of nutrient deficiencies and malnutrition that can lead to sarcopenia, loss of skeletal muscle mass and strength. A recent review identified that sarcopenia was associated with functional decline, higher rate of falls, higher incidence of hospitalisations and increased mortality (Beaudart et al, 2017). Understandably severe sarcopenia is extremely disabling as it prevents independent living and places an increasing burden on care providers.

Avoiding late life malnutrition is dependent on a number of factors including physical, mental and cognitive health. However, the relative impact of each of these factors and the relationships between them are not well understood. Physical factors, such as problems with chewing, swallowing and impaired mobility, all contribute towards nutritional decline (Hickson, 2006). Mental health status also plays a part, particularly depression, which has been identified as a predictor of poor appetite in older adults (see Engel et al, 2011). Treating depression can be an effective way of increasing appetite and improving nutritional status, but it is commonly under-diagnosed and under-treated among older people (Allan et al, 2014).

There is also growing evidence of associations between diet and cognitive function. Older people with dementia or cognitive decline have a poorer nutritional status than those without (Atti et al, 2008), with increasing dementia severity related to poorer nutritional status (Riccio et al, 2007). The potential for diet to protect against cognitive decline in older people is not currently well understood as much of the epidemiological research has not been supported in trials, and more research is needed to confirm the impact of changing whole diets on cognitive measures (Smith and Blumenthal, 2016).

To explore the associations and interactions between mental and physical health and diet, new intervention and prospective cohort studies are needed (Psaltopoulou et al, 2008). Such research is challenging to complete with older adults, as both ageing itself and the accompanying cognitive and physical decline are progressive and dynamic. Existing tools for measuring diet, cognition and physical activity typically provide snapshots of the situation and cannot identify rate of decline nor readily distinguish cause and effect.

The use of psychological treatments for patients presenting with physical health problems has a long history. A Persian physician used exploratory psychotherapy over 1200 years ago to successfully treat a patient's psoriasis, by linking it to conflict with his father (Shafi & Shafi, 1979). Alexander (1950) was one of the great pioneers of psychosomatic medicine of the 20th century. Although he recognised that the aetiology of disease was multifactorial, he speculated that in a number of diseases (including hypertension, rheumatoid arthritis, peptic ulcer and asthma) psychological factors might be of aetiological importance. The notion that psychological factors may be relevant to either the genesis or the progression of physical illness persists. We now know that there is a strong association between most chronic diseases and psychiatric disorder, especially depression (Katon & Sullivan, 1990). Increasing awareness of this has led to an upsurge in the literature assessing psychological interventions in this area.

Even though only a minority of patients with physical illnesses meet criteria for psychiatric disorder, psychologically determined consequences of physical illness are common, clinically significant and potentially treatable. Indeed, it has been argued that psychological skills are essential in the management of all physical disorders (Mayou, 2005). Psychological treatments are not only useful for patients who have psychiatric disorder in addition to physical illness but are also beneficial in patients without psychiatric disorder who have difficulties arising from problematic illness beliefs, illness behaviour or adjustment to illness. Not infrequently these distinctions overlap, such as non-epileptic attacks in a patient who has epilepsy, or breathlessness secondary to panic attacks in a patient with asthma.

Psychological therapy has been particularly neglected in older patients, who are most at risk of physical illness and often require longer periods of treatment. However, there is no evidence that they do not respond to psychological treatment and many may benefit (Evans, 2007). The focus of this chapter is on psychological treatments for patients who are physically ill and those who present with medically unexplained symptoms. It will not cover treatments in other areas of liaison psychiatry such as self-harm, substance misuse, eating disorders or perinatal psychiatry, which have been addressed in the relevant chapters in this book.