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There is little information dealing specifically with motor neuron disease (MND) in the elderly. Given current epidemiological trends, geriatricians will be increasingly called upon to diagnose and manage this condition. We report four patients who presented within a six month period to a geriatric medical unit, and place this experience in the perspective of 229 patients from a population-based study of adult-onset MND in Scotland in 1989 and 1990. In 1990 Scotland had a crude annual incidence of MND of 2.25/100,000; the figure for those over 65 is four times greater. MND is more common in men, but the sex ratio was nearly equal over the age of 65. The risk of presenting with bulbar palsy was greater in women, and even higher in elderly women. This, together with increasing age, is the most important negative prognostic factor in MND. Problems with the diagnosis and management of MND in the elderly are highlighted.

Fourteen patients aged 66–87 years are described, in whom major psychiatric problems dominated the presentation of intracranial tumour. Six had initially been referred to psychogeriatricians and eight to geriatricians. All showed intellectual failure, developing over a few weeks or months, with failure of self-care, and a variety of disturbances of behaviour. Four had undoubted and two possible seizures. Their mental state was described as facile, or slow, with relatively unimpaired memory when it could be tested. Four were inaccessible or mute. Abnormal neurological signs were absent in two, but included unilateral or bilateral hypertonia and hyperreflexia in most; the plantar responses were flexor in seven, equivocal in three, and extensor on one or both sides in four. Computed tomographic (CT) scans shows frontal or bifrontal tumours in 13, and one occipital lobe tumour. The corpus callosum was involved in eight. Ten tumours were considered to be high-grade astrocytomas (proven by biopsy in three and autopsy in one); one patient had bifrontal metastatic tumours, and three had meningiomas, all of them successfully resected. Clinical diagnosis was difficult, but a CT scan is indicated in all patients with a short history of intellectual failure.

A retrospective study was carried out of the outcome of surgical decompression of cervical spondylotic myelopathy in 21 elderly patients. The presenting symptoms and signs were similar to those in younger patients. The indication for surgery was recent progressive neurological deficit. Assessment of pre-operative state was based on information from hospital records. Post-operative evaluation was made from a home visit in 17 cases (mean age 71) after a mean post-operative period of 19 months (3 patients had died in the interim and one had emigrated). Objective functional improvement was found in the upper limb in 58% and in the lower limb in 71%; the remainder were unchanged. Surgical decompression in cervical spondylotic myelopathy is a safe procedure, which benefits appropriately selected elderly.

People over the age of 64 constitute 15% of the population in the UK, yet they consume approximately 30% of all National Health Service drug prescriptions, and adverse drug reactions account for 10.4% of all admissions to geriatric medical assessment wards. Many published studies concerning the pharmacology of old age are seriously flawed. Problems include failure to measure the drug bio-availability and the selection of subjects with overt or sub-clinical disease. It is difficult to make general rules about the effect of ageing on drug kinetics and dynamics. Each drug has to be tested separately.

The operation over ten years of a simple and practical method of collaboration between general surgeons and geriatricians is described. This was designed, by means of a weekly ward round by geriatricians and consultant surgeons on general surgical wards (120 beds), to give geriatric medical advice and, when appropriate, to arrange transfer for geriatric assessment, medical treatment and rehabilitation, long-term care, or terminal care. Some 240 such transfers are described, comprising approximately 2% of all patients over the age of 65 admitted to the surgical units. The commonest single surgical diagnosis was of malignant disease. A total of 43% had had no operation and 18% had no medical diagnosis. 64% of those transferred for assessment etc. went home, half of them within two weeks, but nearly a third of them after more than four weeks. The system was effective, and benefited both surgeons and geriatricians, at no cost to the former and little to the latter in terms of time or increase in work load.

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.

A simple, virtually non-invasive, radionuclide method of measurement of ejection fraction has been evaluated in a study of 60 elderly patients. The causes of difficulty are described. The mean difference between duplicate measurements is 4.9%. The range of values obtained corresponds well to that found by others, as does the relationship to systolic time intervals. The method should be of value particularly for the assessment of the effects of drugs on the myocardium.

The vitamin intakes of 77 men and 187 women aged 65 and over living at home were studied using seven-day dietary records. Intakes of ascorbic acid were below 10 mg/day in 5 per cent 25 per cent of men and 33 per cent of women took less than 50 i.u./day of vitamin D. Intakes of other vitamins (vitamin A, thiamine, riboflavin, nicotinic acid, pyridoxine, and folate) were, in general, adequate, except for small numbers of subjects. The findings are compared with those of the Panel on Nutrition of the Elderly (1972).

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.

A study is reported of the religious beliefs, attitudes, and practice of old people in the West of Scotland, based on a questionnaire given to 501 people aged 65 years and over randomly selected from those living at home. Almost all had had a full range of religious instruction, and regarded their parents as religious. Weekly church attendance was commoner among Catholics (70%) than Protestants (40%), among women than men, among those whose beliefs were those of organized religion, and among those with unrestricted mobility. The pattern of participation in church organizations and social activities was similar. A firm belief in an after-life was expressed by 80% of Catholics and 60% of Protestants, and higher proportions derived comfort from religion, especially in bereavement. Over 70% expressed no fear of their own death. In this elderly population, religious beliefs and attitudes remain important considerations, which should therefore be of concern to all those involved in the care of the elderly.

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.

Measurement of serum-phenytoin concentrations in 17 elderly patients showed that levels of 40 mumol/l or more were not produced by daily doses of less than 300 mg/day, but that doses of 350 mg/day or more produced higher and potentially toxic levels. Determination of mean values for Vmax and Km for phenytoin gave values little different from those for younger patients. The implications of these findings for anticonvulsant therapy in the elderly are discussed.

The epidemiology of cataract has attracted little attention. The definition of cataract is difficult enough to make surveys of its prevalence in popu lations of doubtful value. One partial solution is to consider only cataract of a degree sufficient to be operated upon. Fuchs (1960) has published figures snowing a very wide variation in the proportions of patients with cataract admitted to various ophthal mological centres throughout the world, but the information is of little use unless the reasons for admission of patients without cataract are known. Halevi and Landau (1962) studied operations for senile cataract in Israel in 1956-57; they make comparisons with figures from Sweden and Thailand, the value of which is greatly diminished by lack of detail. Sorsby (1962) has published estimates of rates of extraction of cataract of all types in England and Wales for 1958. The purpose of the following study is to provide detailed estimates of cataract extraction rates for a clearly-defined English population.

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”.