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Every day clinicians rely on the results of clinical trials for prescribing and interventions, yet how are these trials conducted and what do they mean in terms of the elderly patients who regularly present in their surgeries? Dr Terence O'Neill considers the advantages and limitations of randomised trials, and the role of observational studies in determining the effectiveness and safety of medical interventions.

Myelodysplastic syndromes (MDS) are a heterogeneous group of disorders clinically characterised by peripheral cytopenia, followed by a progressive impairment of myelodysplastic stem cells. The natural history of MDS, ranging from indolent conditions spanning years to forms rapidly progressing to leukaemia, are reviewed by Dr Nabil Aly as are methods of diagnosis and available therapies.

Older people with complex needs have increasingly become the largest group to use hospital wards, but routine systems of care have been slow to reflect this. Standard 4 of the National Service Framework for Older People was designed to improve hospital care for them and 40 national pilot studies were established. Professor John Young and Deborah Sturdy review the practical strategies and what still needs to be done to enact change.  

Electroconvulsive therapy (ECT) remains one of the most controversial treatments currently used in psychiatric practice, despite its long-standing record of safety and efficacy. Drs Sreedharan Amarjothi, Murali Krishna and Richard Barnes discuss of the origins of ECT, how this form of therapy came to be incorporated in psychiatric practice and why it continues to be enigmatic to both medical practitioners and the general public.

We live in an increasingly diverse society, both culturally and religiously. Rituals surrounding dying and death differ between faiths. To provide appropriate end of life care it is essential that healthcare workers have an understanding of the practices and beliefs of patients and their families. Drs Alison South, Elizabeth Teale and Victoria Watts outline the basic principles for the major religions in the UK.

The surgical treatment of cataract has seen great advances over the past decade, revolutionising the delivery of care to patients with this condition. The prevalence of cataract is greatest among the elderly and they have much to gain from these developments. Drs Nicholas Wride and David Allen discuss some of the issues surrounding the treatment of elderly patients with cataract in the UK.

Each year the number of heart failure patients rises with an annual increase in new patients of 10 per cent. Prevention of heart failure is therefore an important goal but physicians are currently not doing enough in this regard. Every reasonable opportunity should be utilised to assess left ventricular function in populations at a high risk of heart failure. Dr Prithwish Banerjee discusses the conditions that can lead to heart failure and examines the best treatment options.

Early diagnosis and intensive treatment to maintain optimal glycaemic control reduce the morbidity and mortality associated with type 2 diabetes. To sustain glucose concentrations as near normal as possible - and make the Quality and Outcomes Framework diabetes targets achievable - generally requires use of more than one antidiabetic agent, which necessitates attention to licensing indications, as Dr Caroline Day explains.

Coagulopathies cause a predisposition to thrombosis and therefore an increased risk of ischaemic stroke. Although the frequency of coagulopathies in patients with stroke is low, the yield for diagnosing coagulopathies is typically greatest in young patients, those with family history of thrombosis, those with repeated unexplained strokes and patients with no vascular risk factors, as Omer H T Ali with Drs Bella Richard and Pradeep Khanna explain.

A consultation document is soon to be published that will give hotel-style ratings to care homes for older people. While this change is promising, Dr Eamon Fottrell illustrates by example how older people with psychiatric problems and their carers can benefit through the involvement of community mental health teams, and challenges GPs to become actively involved with such patients living in residential and nursing care.

The Better Metrics Project is supported by the Healthcare Commission and involves the development of performance measures that are of particular relevance to front line clinicians €” existing metrics specific to older people's services are reviewed and some new ones proposed. Professor John Young and Dr Paula Whitty encourages engagement from readers to enable the next phase of the work to progress even further.

The discovery of dopamine deficiency as a cause of the disability of Parkinson's disease has led to an era of successful dopaminergic therapy. Professor Jeremy Playfer provides an overview of the evolution of dopamine agonists and their use, starting from the 1960s through to what innovative new therapy options are available today and which may best suit the older patient in the early and late stages of the disease.

Fracture of the neck of femur, or hip fracture, is common in frail elderly patients with multiplecomorbidities. Collaboration between orthopaedic surgeons, geriatricians, and other members of themultidisciplinary team should be sought to assist in medical management and rehabilitation of suchpatients. Orthogeriatric leadership is as important as high-quality surgery to minimise the effect ofosteoporotic fractures on patient's quality of life.

Chronic kidney disease is a common and impending global health problem. This review discusses itsburden, its classification using an estimate of glomerular filtration rate, and how early managementparallels that of cardiovascular risk reduction. This condition can be easily managed by doctors who arenot renal specialists, such as geriatricians and general practitioners.

Self-reported back pain is common at any age; however, as a new symptom in elderly people it requirescareful assessment because it may signal a serious disorder. The challenge is to maintain clinicalvigilance for detection of cancer, infections or serious spinal disorders, since benign axial back painaffects a substantial proportion of the population. Red flags assist in obtaining key features in thehistory and examination that may relate to sinister pathology such as malignancy, infection andcauda equina syndrome. Knowing what and when to refer to a spine specialist such as an orthopaedicsurgeon or neurosurgeon is important. Spinal-cord compression and loss of the structural integrityof the spine may require specialist skills for decompression and reconstruction. Management is oftenmultidisciplinary, involving oncologists or infectious-disease specialists, and surgeons.