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The same general principles apply to prescribing for elderly diabetic patients as for non-diabetic patients. In the great majority of instances the prescription of drugs and adverse reactions to them are no different, but there are a number of particular problems. The difficulties that elderly patients have with compliance with drug therapy are perhaps somewhat greater in the elderly diabetic patients, who may have to take medication for diabetes in addition to that for other conditions. There is thus an inevitable tendency towards multiple drug therapy, which is one of the main contributory factors both to the occurrence of adverse drug reactions and to the patient’s difficulty with compliance. Other common causes of the latter include poor vision (to which diabetic eye problems may contribute), poor manipulative skills in the hands, and, most important of all, intellectual impairment.

The complications of diabetes are important for two reasons: (1) many of them are, up to a point, preventable by strict control of diabetes, and (2) their consequences, such as blindness, kidney failure, and lower limb amputation, are obvious causes of major disability. This is the most important reason, apart from the control of symptoms, for attempting a strict control of diabetes in elderly diabetic patients. In the elderly patient, however, the significance of the complications may be difficult to assess because it is not easy to disentangle them from the other causes of similar states of affairs.

Two hundred and eighty elderly patients who were referred because of a principal problem of confusion were investigated by computerized tomography; 94% were suffering from a 'dementia syndrome' and unrecognized receptive dysphasia was the commonest problem in the remainder. One hundred and twenty-four patients were suffering from senile dementia of the Alzheimer type, and 79 from multi-infarct dementia. Space-occupying lesions (tumour, subdural haematoma or hygroma) were found in 32 (11%). Of the 25 with other intracranial and extracranial causes, 64% had potentially treatable lesions (PTL). In only four cases was no diagnosis made. PTL were found in 31% of 170 patients with a duration of confusion of less than a year compared with 1% of 110 patients with a longer duration. In 48 of the former group, confusion was an isolated phenomenon; 12 of these (25%) had a PTL, as had 27 of 88 with confusion and a focal neurological deficit (31%). All five patients with recognized seizures, and six of 15 of those with reduced alertness had PTL. Twenty of 37 patients with neurosurgical lesions underwent surgery.

Eight hundred and eight subjects participated in three surveys of random samples of people aged 65 years or more living in their own homes. Neurological history and examination showed the prevalence of completed stroke to be 73 per 1000. Eighty-seven subjects per 1000 gave a history of transient cerebral ischaemic attacks. These prevalence rates were unaffected by age or sex. Senile dementia was diagnosed in 24 subjects per 1000 under 75 years and 109 per 1000 over that age. The prevalence of dementia of all types was 43 per 1000 under, and 140 per 1000, over 75 years of age. Parkinsonism was diagnosed in 16 subjects per 1000, and essential tremor in 17 per 1000. The prevalence of epilepsy was four subject per 1000. Other neurological disorders were diagnosed in 36 subjects, and a similar number had neurological abnormalities to which a definite diagnosis could not be given.

A series of 111 intracranial tumours in elderly patients, investigated by modern methods, is reviewed. The clinical picture of progressive neurological deficit, and/or intellectual impairment, did not differ greatly from that of younger patients, but the manifestations of raised intracranial pressure (headache and papilloedema) were much less common in the elderly. Intermittency of symptoms appeared to be a relatively common phenomenon with meningiomas, occurring in four of 12 symptomatic cases. Operative treatment, for removal of meningiomas or relief of obstructive hydrocephalus, produced improvement in almost all cases, with a low morbidity and mortality. High-dose steroid therapy produced substantial, if temporary, benefit in 51% of hemisphere tumours.

Digoxin elimination phase kinetics have been studied in 24 hospital in-patients (mean age 79 years), six of whom showed no evidence of digoxin toxicity. The others, with suspected toxicity, have been grouped according to the nature of the drug effects observed. Renal function, digoxin elimination half-life, apparent volume of digoxin distribution, and notional body content of digoxin have been compared between the groups. Apart from two hyperthyroid patients, the volumes of distribution averaged 6.1 1/kg. Toxic patients tended to have lower creatinine clearances, longer digoxin half-lives, and higher body contents of digoxin than the nontoxic, but the highest body contents were found in those with systemic toxicity. Thyrotoxicosis increases the apparent volume of digoxin distribution in the elderly.

Twenty elderly patients with intracranial tumour were treated with high-dose steroids (beta- or dexamethasone 12--16 mg per day). Six of eight patients with primary intracranial malignancies and four of six with metastatic tumours showed a definite response of conscious level and/or neurological deficit. One of two patients with lymphoma responded but neither of two with meningioma. Six patients were able to return home. Two patients suffered serious, and three minor, side-effects attributable to steroid therapy, but this treatment has a definite place in the management of intracranial tumour in old age.

Two indices of the possibility of malnutrition were constructed from the number of nutrients (up to 10) taken in amounts below recommended levels (index A) or below specified lower levels (index B). Values for these indices were determined from nutritional data for 264 old people living at home. High values for both indices were significantly related to the amount spent on food per week, the taken ing of 7 or fewer hot meals per week, and the presence of physical disability, but not to social class, living alone, or presence of a psychiatric diagnosis. The amount spent on food per week, taking 7 or fewer hot meals per week, and physical disability, are thus possible pointers to malnutrition in the elderly at home and may be useful for screening purposes.

The skinfold thickness on the dorsum of the right hand over the second metacarpal was measured with Harpenden calipers in 276 women and 152 men aged 65 and over living at home. Mean values were higher in men than women and declined with age in both sexes. Skinfold thickness was related to body size, as estimated from lean body mass, but was unrelated to the presence of osteoporosis as assessed from bone mass of the second metacarpal or the presence of vertebral fractures. The skinfold thickness was low in those subjects who had senile purpura and also in a small group of subjects on long-term steroid therapy.

Three principal diagnostic problems were encountered in a group of 81 elderly patients with epileptic seizures: Post-ictal paresis (Todd's palsy) occurred in 13 patients (16%), of whom seven had evidence of past or present cerebral infarction, and six no such evidence. The paresis lasted up to 4 days, and could be confused with recurrent infarction or a transient ischaemic episode. Ictal and post-ictal confusional states of 24 h or more duration (up to 7-8 days) were noted in 11 patients (14%). They occurred in association with normal intellectual function as well as with pre-existing dementia, and required to be distinguished from other causes of delirium. Two patients presented paroxysmal sensory phenomena of ictal type. The differential diagnosis of episodic pain in hemiplegic limbs is discussed.

A study has been made of chronic respiratory disease among 83 men and 217 women aged 65 and over, randomly chosen from those living in their own homes. Twenty-six per cent of the men and 13% of the women had chronic bronchitis. The prevalence of chronic bronchitis was related to current cigarette smoking in both sexes, and to socio-economic status in men. Chronic bronchitis was a contributory cause of disabling dyspnoea and recurrent chest illness in half of the subjects with these symptoms. Significant radiological evidence of tuberculosis was found in 9% of men and in 4% of women, asthma in 2% of women, industrial lung disease in 4% of men, and bronchogenic carcinoma in three subjects.

Prognosis for vision has been studied in 135 patients with diabetic retinopathy and good vision and compared with that in 228 diabetics without retinopathy similarly studied. The risk of “blindness” in diabetics with retinopathy whose diabetes was diagnosed under the age of sixty was 3 per cent in five years, and 20 per cent in those diagnosed over that age. The risk of “visual impairment” also increases with age at diagnosis. Fifty per cent of a small group of diabetics with “malignant retinopathy” were “blind” in five years, and only 14 per cent preserved good vision. One third of forty-six diabetics had good vision in one eye one year and four years after their first vitreous hemorrhage. One third had “impaired vision”, and one third were “blind”.

Eleven patients with Parkinson's disease were tested for prosodic abnormality, on three tests of speech production (of angry, questioning, and neutral statement forms), and four tests of appreciation of the prosodic features of speech and facial expression. The tests were repeated after a control period of two weeks without speech therapy and were not substantially different. After two weeks of intensive domiciliary prosodic therapy, the prosodic abnormality score was improved, as were three of the four tests of recognition of the prosodic features of speech and facial expression, and two of the three tests of production (of angry and questioning forms). The apparent receptive disorder of speech in Parkinson's disease can thus respond to therapy. Possible mechanisms of improvement are briefly discussed.

Classical cardiological teaching is that valvular heart disease, except aortic stenosis, is rare in old age. That this is not so was clearly shown by pathological investigations (Friedberg and Tartakower 1931), and by clinical studies reviewed by Bedford and Caird (1960).

Sixty-six elderly subjects (mean age 77 years) whose mental state was assessed clinically and by simple psychometric tests have been studied by computerised tomography. The mean maximum ventricular area in the 17 mentally normal subjects was above the upper limit of normal for younger subjects, and there was a broad relationship between increasing ventricular dilatation and increasing intellectual impairment. No such clear relationship was demonstrable for measures of cortical atrophy.

Cardiac failure is a common problem in clinical geriatrics. Moreover, its importance is much increased because proper treatment can probably benefit the patient more than treatment for any other condition of equal severity in old age, while improper treatment can lead to disaster.

Computerized tomograms were studied of 67 adults whose lumbar pneumoencephalograms were normal or showed ventricular dilatation with or without widening of the sulci. The maximum ventricular area, measured from 80 x 80 matrix printouts, correlates well with measures of ventricular size on the pneumoencephalogram. An area of 10 cm2 is suggested as the upper limit of normal. The correlation between measures of sulcal width on computerized tomography and pneumoencephalography is less precise, but normal sulci and gross degrees of cortical atrophy can be identified.

Intakes of calcium, iron, potassium, and magnesium are reported for 77 men and 187 women aged 65 and over and living at home in N. Glasgow. Calcium intakes were below the national average. The importance of milk as a source of calcium and the relevance of calcium intake to bone disease in old age are discussed. Iron intakes were probably adequate, but those of potassium and magnesium may well be below optimum levels.

The frequency and importance of valvular heart disease in old age are now well recognized. Since the problems of pathology and surgical treatment are dealt with elsewhere in this volume, this account will concentrate on clinical features, diagnosis, and natural history. It is appropriate to consider disorders of each valve separately.

Twenty-six patients with the speech disorder of Parkinson's disease received daily speech therapy (prosodic exercises) at home for 2 to 3 weeks. There were significant improvements in speech as assessed by scores for prosodic abnormality and intelligibility' and these were maintained in part for up to 3 months. The degree of improvement was clinically and psychologically important, and relatives commented on the social benefits. The use of a visual reinforcement device produced limited benefit over and above that from prosodic exercises alone, except to patients with severe speech disorder.

Two separate studies have been carried out. In the first, measurements of the ventricular size and sulcal size in the computerised tomograms were compared with the appearances in the pneumoencephalograms of the same patients. In the second study the measurements of the ventricular size and sulcal size obtained from the computerised tomograms were used to assess the degree of atrophy, in a group of elderly patients, and the relationship between the degree of atrophy and intellectual performance was then investigated.

Eighty-one elderly patients with epileptic seizures are described, of whom 60 were investigated by computed tomography. The cause was cerebrovascular disease in 44%, tumour in 12%, extracerebral in 11%, and unknown in 16%. Partial seizures were commoner in patients with tumour than with other causes. The findings are discussed in relation to other studies and to the investigation of elderly patients presenting with seizures.

It is well established that symptoms of heart disease are often modified in the elderly. Cardiac pain, both that of angina pectoris and that of cardiac infarction, may be either greatly reduced in intensity, or overshadowed by the simultaneous development of mental confusion, presumably because of reduction in cardiac output and cerebral blood flow. The dyspnea of cardiac failure is replaced as a leading symptom by fatigue, though patients in whom this occurs appear objectively to be as breathless as those who do complain of dyspnea. This frequent relative insignificance of the major symptoms of heart disease in the elderly makes proper and detailed clinical examination and investigation the more important. There are, however, numerous problems of interpretation, both of physical signs and of the results of investigations, that are particular to the cardiology of old age. Knowledge of these problems is essential in arriving at an accurate and complete cardiological diagnosis, which is often a crucial part of the overall assessment of the elderly patient.

Twenty-three elderly patients with normal renal function were studied during digitalisation for cardiac failure or atrial fibrillation. Mean serum digoxin concentrations were in the therapeutic range from the fourth day in seven patients given digoxin 0.25 mg daily, from the second day in seven patients given 0.5 mg followed by 0.25 mg daily, and from the first day in nine patients given 0.75 mg followed by 0.25 mg daily. Toxic effects were not encountered in any patient. Serial measurement of serum digoxin concentrations in six patients recovering from digitalis intoxication, all of whom had severe renal impairment, allowed calculation of serum half-times (62 to 189 hours), and elimination constants (9 to 27% per day). The apparent volumes of distribution of digoxin were around 300 litres, and the apparent body contents of the drugs around 20-25 mug/kg body weight. Differences between these figures and those determined by others for younger patients seem mainly to reflect the consequences of renal impairment. If reasonable assumptions are made for fractional absorption, volume of distribution, and elimination constant, serum digoxin levels during digitalisation can be predicted, and are found to agree well with those observed.

Twenty eight patients with Parkinson's disease (average age 63 years, average duration of disease 8 years) and 28 normal elderly controls (average age 70 years) were tested for their ability to appreciate the prosodic aspects of their own and others' speech and facial expression. Compared with the controls the Parkinsonian subjects performed worse at these tests, though both groups could easily identify neutral statements. The Parkinsonian subjects were unable to produce statements in an angry or questioning form. These seemed to be features of early Parkinson's disease.

Nine normal elderly subjects and 81 patients with dementia have been studied by computerised tomography (CT) and electroencephalography (EEG). There was a broad relationship between slowing of the basic frequency of the EEG and the severity of mental impairment. Localised slow-wave activity was found in 19% of those with non-vascular dementia and 72% of those with dementia of vascular origin. The mean size of the ventricles, as determined from CT scans, was larger in the vascular than in the non-vascular group. Within the vascular group it was larger in those without than in those with visible infarcts. There was no relationship in either group between ventricular size and dominant EEG frequency.

The cardiac output has been determined by radionuclide angiocardiography and by impedance cardiography in 93 elderly patients. The agreement between the two methods was excellent in patients in sinus rhythm, without regurgitant valvular lesions, and without severe airways obstruction or right bundle branch block. In atrial fibrillation the lack of correlation may be due to differences in heart rate during the two measurements, in regurgitant valvular lesions to the fact that impedance cardiography measures stroke output, whether forward or backward, in airways obstruction to high values for the basal thoracic impedance, and in right bundle branch block perhaps to the abnormal impedance wave-form often present.

Postural or orthostatic hypotension is a very common phenomenon in geriatric clinical practice. If severe, it is very disabling, since at best it leads to a self-perpetuating loss of confidence, and at worst to the patient taking to bed and staying there. It is a common cause of falls, particularly on the way from bed to toilet at night or on rising in the morning. In any elderly patient with a complaint of dizziness or falls, the blood pressure must be taken both lying and standing. If orthostatic hypotension seems likely from the history, it is wise to take the blood pressure with the patient sitting before standing, as this may avoid the embarrassment of having to pick the patient up from the floor (Caird and Judge, 1974). In some patients the pressure falls progressively on walking, and if the history suggests this possibility, then it should be taken both immediately after standing and after walking 5-10 m. If these elementary clinical observations are made, ‘vertebrobasilar insufficiency’ will be very rarely diagnosed in the elderly. Indeed, the heretical speculation that this diagnosis has no real existence in old age is more than tempting.

Studies were made for evidence of heart disease on 501 people aged 65 and more living at home; 22-4 per cent had clinical and/or electrocardiographic evidence of ischaemic heart disease. The prevalence of ischaemic heart disease increased with age, and was slightly greater in men than women. The frequency of ischaemic heart disease increased with increasing current cigarette consumption and with total cigarette consumption. There was no increase in relation to any of the following possible risk factors: systolic and diastolic blood pressure, blood glucose, serum cholesterol, skinfold thickness, percentage of ideal body weight. The survival over a 5-year period of all subjects with ischaemic heart disease did not differ significantly from that of all subjects together, but the mortality of subjects with ischaemic heart disease and an abnormal electrocardiogram was 1-5 to 2 times that of subjects in whom ischaemic heart disease was diagnosed on the basis of angina pectoris or past cardiac infarction, the electrocardiogram being normal.

Study of the epidemiology of heart disease in old age can contribute to the measurement of the size of the problem. The essential sources of information are studies of mortality, which are usually based on death certification, and of the prevalence of heart disease in groups of old people who have been examined specifically with regard to the cardiovascular system.

The possibility that pregnancy may play a part in the development of diabetes was investigated. A study was made of the records of 543 diabetic women and 413 diabetic men aged 40-79 years. The individuals came from a defined population of the City of Oxford and surrounding districts and attended a diabetic clinic with newly-discovered diabetes in the years 1954-1965. Among the women the risk of diabetes increased with increasing parity. Comparison with other studies shows that between the ages of 50 and 80 years the excess risk above that of a nullipara is 20% for 1 child 45% for 2 100% for 3 200% for 4 or 5 and 400% for 6 or more children. Parous women were heavier than nulliparous but there was no increase in weight with increasing parity. The frequency of family histories of diabetes was unrelated to parity. Among the men the risk of diabetes was unrelated to civil state or to the number of children. Men have a risk almost 50% in excess of that for nulliparae a figure virtually the same as that for women with 2 children. It is suggested that perhaps the environmental influence is added to the genetic to give the increased risk of diabetes.