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This article reviews the leading causes of involuntary weight loss in older people. We look at the underlyingpsychiatric and neuropsychiatric causes including depression, dementia, and longstanding eating disorders.We consider the negative consequences of these conditions and suggest management strategies.

The classic triad of ataxia, dementia, and urinary incontinence is an increasingly recognised andpotentially reversible cause of dementia seen on geriatric wards. The exact pathogenesis is unknown,although many theories have been proposed that could account for the condition. Normal-pressurehydrocephalus is often missed if it is not suspected or considered. There is no medical treatment, butsurgical placement of a ventriculoperitoneal shunt can be helpful; however, as with all surgery, inherentcomplications exist. The greatest challenge is perhaps not diagnosing normal-pressure hydrocephalusbut recognising those patients who will benefit from ventriculoperitoneal shunting.

This article outlines the definition, pathophysiology, and epidemiology of osteoporosis. We describe thestructure and function of bisphosphonates, and review the history and evidence for use of bisphosphonatetherapy in osteoporosis. We also discuss the guidelines for their use in elderly patients.

In the UK, the coroner (or procurator fiscal in Scotland) will only return a verdict of suicide ifsuicidal intent can be proved beyond reasonable doubt. Suicidal intent is not a static concept andchanges with time. Among psychiatric inpatients (including older people), suicides are higher inpatients who have f luctuating suicidal intent than in those whose intent does not f luctuate. Theissue of intent becomes even more complex in elderly patients who, although not overtly expressinga desire to kill themselves, have hidden intent. This paper describes these concepts and reviewsassessment and management options.

Doctors will inevitably need to fill in a death certificate, but newly qualified doctors might not know what is expected. This article is intended as an aid to completing death certificates.

Normal-pressure hydrocephalus was first described more than 40 years ago as a syndrome of cognitive impairment, gait disturbance, and urinary incontinence affecting the older adult. It is a syndrome of symptoms and signs, which should be diagnosed clinically with the aid of radiological imaging and diagnostic tests. Dementia caused by normal-pressure hydrocephalus is potentially reversible. We report a case of a patient in which this disorder was diagnosed clinically after radiological imaging, but with some uncertainty. We emphasise the need for increased awareness of the presentation of normal-pressure hydrocephalus and the associated diagnostic challenges.

In older people, sleep disturbances are very common. Changes in sleep patterns may be a normal partof ageing, but many other factors in older people can contribute to sleep problems. Sleep disordersdecrease quality of life in older people by causing daytime sleepiness, tiredness, and lack of energy. Poorquality of sleep can also lead to confusion, difficulty concentrating, and poor performance in tasks. Inthis article, we discuss the main features of sleep disorders in older people, the causes, and the generalmanagement options.

General practitioners are at the forefront of the annual influenza vaccination, but they are not the only health workers with responsibility for vaccination. The aims of vaccination are to both protect the induvidual, and the wider community via herd immunity. In addition to vaccination, we now have antiviral drugs to treat those who did not take the vaccine, although these drugs must be given in a short window after the onset of symptoms.

Itching is a common and distressing symptom in elderly people and can disturb sleep. If no rash is present, then systemic causes of itch, such as iron deficiency, or neuropathy should be considered. The somewhat derogatory term senile pruritis is used to describe itching that has no known cause in older patients. Itch is often associated with dry skin, and good emollients can be used to moisturise the skin and even as a substitute for soap, which can contribute to irritation. Patients might find antihistamines beneficial, especially first-generation drugs that are sedating and thus aid sleep.

Type-2 diabetes is an increasing public-health problem, both in terms of treating the condition itself,and in preventing complications. Optimising clinical outcomes depends on reducing HbA1C, as seenin the Quality and Outcomes Framework and in recommendations from NICE. The recommendedfirst-line treatment is metformin, but poor adherence to this and other therapies potentially leads toworsening outcomes for patients.

Back pain is a common symptom that can indicate serious disease, particularly in elderly patients.Separation of the serious pathologies such as malignancy, infection, and cauda equina syndrome frombenign axial back pain is a challenge. The red flags have clinical use for assisting in obtaining keyfeatures in the history and examination that may relate to sinister pathology. Knowing what and whento refer to a spinal specialist, such as an orthopaedic surgeon or neurosurgeon, is important. Spinalstenosis, radicular pain, and vertebral compression fractures of the spine may require specialist skills indiscectomy, decompression, and reconstruction. This article deals with the assessment and treatment ofspinal stenosis, radicular pain, and vertebral compression fractures.

About a third of surgeries involve elderly patients; however, postoperative cognitive dysfunction is animportant adverse outcome in such patients. Doctors should be aware of this condition and consider therisk€“benefit ratio when referring elderly patients for surgery.

Morbidity from ischaemic heart disease increases as patients age, and the burden of angina in elderlyindividuals can severely reduce their quality of life. The most common interventions are angioplasty,stenting, and coronary artery bypass grafting. However, the COURAGE trial showed that medicalmanagement had similar outcomes to percutaneous intervention. Several drug options are available formedical management of angina.

Ticks are endemic in many regions of the UK and Europe. With recent mild winters, the tick populationhas been increasing and new areas affected. Tick bites can transmit infections to human beings and asubstantial number of ticks are infected with the causative agent of Lyme disease, Borrelia burgdorferi.Healthcare professionals and outdoor enthusiasts should be aware of the risks, of the precautions to takeburgdorferito avoid infection, and of the signs and symptoms of Lyme disease.

A substantial proportion of older people have problems swallowing that can inhibit effective adherenceto solid oral treatment regimens. Causes of dysphagia include reductions in gastrointestinal motilitywith age, consequences of age-related diseases, and side-effects of other treatments. Patients aresometimes advised to open capsules or to crush tablets to aid swallowing, but this practice is contraryto guidelines, largely because interfering with some formulations can alter their pharmacokinetics.Because of these compliance issues and because dysphagia is an alarm symptom, doctors should beaware of and enquire about older patients' ability to swallow as part of the standard consultation.