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Payment by Results (PbR) is a model of financial flow within the NHS, where money is paid by commissioners for clinical work carried out. It poses challenges for clinicians and necessitates changes in work practices around discharge documentation. Elderly care patients are by nature very complex, and capturing full, accurate details about their in-and-out patient journeys can be challenging.

Recognising the needs of autistic adults is now an expectation enshrined in law, but little attention has been paid to the issues affecting older people with the condition. What is certain is that a significant challenge remains to ensure that adults with autism enjoy fulfilling and productive lives as they age.

The gaming device Nintendo Wii is now recognised as a successful tool in young and elderly rehabilitation. Not just a physical therapy, €œWii-habilitation€ is helpful even in palliative patients as a means of distraction and improving concentration skills. Our review reflects current practice and discusses the varied scope of the Wii as an enjoyable therapy.

Obesity has increased dramatically in the UK because of the ageing population alongside the general secular trend for weight gain across all age groups. Obesity exacerbates all the complications of old age and has a great impact on people's lives and their ability to function and exist independently. Managing obesity in the elderly, in the context of concurrent and associated long-term conditions is important and realistic as a means of improving health, reducing risk and enhancing quality of life.

Part two of the anniversary article. First part published March 2011.

Anniversary article.

Carotid endarterectomy is the most effective strategy to prevent ischaemic strokes in patientswith haemodynamically significant symptomatic carotid artery stenosis. This article reviews thecurrent status of carotid endarterectomy in symptomatic patients with carotid stenosis.

Depression in older people differs from younger adults in causation, symptom profile and response to treatment. The efficacy of various treatment approaches vary considerably. Transcranial magnetic stimulation (TMS) is a novel treatment, and increased efficacy appears to depend on higher intensity, greater frequency, bilateral application and/or longer treatment duration.

Cancer is not synonymous with pain; however, pain is a very common and debilitating symptom. Cancer is primarily a disease of older people, who will frequently rely heavily on general practitioners and care of the elderly physicians. Inadequate knowledge of pain management by professionals has been identified as a barrier to cancer pain management. This article aims to provide an overview of the principles of cancer pain management, particularly in the elderly population.

Hypertension remains widely prevalent and a significant determinant of cardiovascular risk in the elderly population. Several large controlled trials have shown the benefits of treating hypertension in the elderly, including octogenarians. Several drugs are available and the majority need combination therapy. Management can be challenging due to side effects, polypharmacy and orthostatic hypotension.

In the UK, hypertension affects around 20% of the adult population and is particularly prevalent in the elderly population. With new clinical guidance from NICE due to be published this year, this article looks at the landmark HYVET trial that found that the use of antihypertensive treatment in people over 80 years of age reduced mortality for all causes by 21%

Delirium is a common disorder in the elderly, particularly those with previous cognitive impairment, and is associated with adverse outcomes. Early recognition and adequate management is essential but prevention is a highly effective strategy.

It has been five years since NICE published its guidance for Parkinson's disease. There have been several new developments since the publication of this guidance, including new drugs, new formulations and some controversial changes in strategy. The fundamental principles of managing Parkinson's disease have not changed but in the light of these developments, some aspects of care may need to be re-thought.

The prevalence of type-2 diabetes is rapidly increasing with up to a quarter of people over 60 years of age affected by it. To reduce the risk of the associated microvascular and macrovascular complications, national guidelines for glycaemic control recommend HbA1c targets of between 6.5€“7·5%. In recent years two novel GLP 1 receptor agonists exenatide and liraglutide have become available for clinical use.

Diabetic ketoacidosis is a presenting feature of both type 1 and type 2 diabetes mellitus in the elderly. The diagnosis and management of new onset diabetes is discussed along with the challenges in an older age group. It is important that symptoms associated with new onset in the elderly are not limited to those associated with hyperosmolar hyperglycaemic states.