• Overview
• Definition
• Incidence, prevalence and trends
• Risk factors
• Health consequences
• Costs
• Contributors

Definition

Ageing

According to Maynard Smith, ageing is "a progressive, generalised impairment of function resulting in a loss of adaptive response to stress and an increasing probability of death." ¹

Distinguishing people on the basis of age (ie ageism) has been a common experience in health and social care. ² This is not acceptable because the outcomes of treating older people are not inferior to those of younger people when we compare groups with similar physiological function.

Successful ageing implies a positive view of old age in which there is a continuing integration between psychosocial and biomedical parameters. ³ It is more than simply a lower burden of risk factors.

Frailty

Frailty is the interaction of the ageing process and disease states at an individual level. There is no generally accepted definition. ⁴ Most definitions refer to a multidimensional (energy, physical ability, cognition, health) loss of reserve that is associated with vulnerability to minor illness such that they cause acute functional dependency (see Box 1 for the core elements of frailty).

Frailty makes it hard to reduce the crisis response pattern of health care that is associated with older people. Proactive case management may have a role but the evidence is not yet strong. ⁶ Two common clinical manifestations of frailty are falls and delirium. Both are expensive in health and social care resources, but one third could be prevented if appropriate care systems were in place.

Disability

The World Health Organization (WHO) International Classification of Functioning, Disability, and Health (ICF) states: "Disability is an umbrella term for impairment, activity limitations, or participation restrictions." ⁷ Population based surveys have used different definitions resulting in different disability estimates between surveys. More restrictive approaches use instruments such as the Barthel index that assess activities of daily living, ⁸ or the Nottingham extended activities of daily living score. ⁹

Rehabilitation

There are many definitions of rehabilitation. For older people rehabilitation has been defined by Young as "a complex set of processes usually involving several professional disciplines and aimed at improving quality of life of older people facing daily living difficulties caused by chronic disease." ¹⁰ The key purposes of rehabilitation have been summarised as ¹⁰ :

• Realisation of potential

• Reablement

• Resettlement

• Role fulfilment

• Readjustment.

Comprehensive geriatric assessment

Older people can have several conditions of varying severity, which can make providing a personalised intervention plan complicated. Doing so involves carrying out a comprehensive geriatric assessment with systems of care that can coordinate the inputs from several disciplines. There is reliable evidence that this improves outcomes for older people with multiple conditions, with the proviso that assessment is linked to targeted interventions. ¹¹

The evidence is strongest for comprehensive geriatric assessment delivered in specialist hospital elderly care departments. There is also evidence for the effectiveness of home based assessment, but only for people at low risk of death and when multidimensional assessment has been done and combined with intensive (more than nine) follow up visits. ¹²

Falls

A fall is a common clinical syndrome in older people. The most common definition that has been used in intervention studies is: "Unintentionally coming to rest on the ground, floor, or other lower level; excludes coming to rest against furniture, wall, or other structure." ¹³

Delirium

The main features of delirium – recent onset of fluctuating awareness, impairment of memory and attention, and disorganised thinking – have been formulated into the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM IV) criteria (Box 2). ¹⁴ Additional features may include hallucinations and disturbance of the sleep–wake cycle. There are three clinical subtypes of delirium: hyperactive; hypoactive; and mixed.

Urinary incontinence

Urinary incontinence is defined by the International Continence Society as: "The complaint of any involuntary leakage of urine." ¹⁵ It can develop as a complication of an acute illness or as a result of disease state of lower urinary tract structures.