Vascular dementia (VaD) is common. Pure vascular disease may account for 5–20% of all cases of dementia, while mixed dementia, Alzheimer's disease (AD) with VaD, occurs at least as frequently. It is unusually heterogeneous and frequently overlapping and comorbid with other conditions such as stroke, other cardiovascular and cerebrovascular diseases and their risk factors, as well as AD. There is no specific treatment or cure for VaD, but its proximity to other conditions may make it amenable to interventions at various stages of the disease. Most recent research suggests that VaD and AD occupy ends of the same spectrum and share common risk factors. As VaD is closely related to cardiovascular disease, modifying cardiovascular risk factors may assist in its prevention. Cardiovascular risk factors such as hypertension, dyslipidaemia, obesity, smoking and diabetes are closely associated with cognitive impairment, AD, as well as VaD. Regular screening of high-risk individuals could help to detect dementia early on and enable appropriate preventive intervention. This could involve pharmacological as well as behavioural modulation of risk factors. Medication for hypertension, diabetes and hypercholesterolaemia is recommended, as treatment reduces the risk of developing cognitive impairment and dementia. Behavioural treatments include enhancing and encouraging cognitive and physical activity, social engagement, smoking cessation and healthy diet, including alcohol reduction.  It should not be forgotten that depressive illness or symptoms in old people can affect their cognitive function and worsen existing cognitive impairment.

Old age is often a time of loss: of physical health, sensory capacity, cognitive function, independence, work, income and social support. The diagnosis of anxiety and depression in older patients is difficult. There is a complex relationship between depression and physical illness, there is uncertainty regarding diagnostic criteria and the PHQ-9 should probably not be used. We are more likely to recognise late life anxiety and depression if we are aware of the risk factors and the less obvious ways in which patients can present. Antidepressants are potentially hazardous in older patients and their use should be restricted to those with more severe depression or those who have not responded to psychological treatments. One in ten people aged ≥ 65 fulfil the diagnostic criteria for at least one common mental disorder. Patients with common mental disorders are twice as likely to develop functional impairment. Older depressed patients have an increased risk of both cardiac and all-cause mortality, and there is some evidence that this risk extends to those with subthreshold depressive symptoms. Both anxiety and depression in older patients are often unrecognised and untreated, and have a poor prognosis.

The effective management of osteoporosis in older people has been enhanced by recent developments in risk assessment and an increasing number of therapeutic options to enhance adherence to therapy. Treatment should be considered strongly in older people with a history of fragility fracture, particularly if a recent fracture, without the necessity of BMD assessment. In the absence of fracture, the combination of FRAX and the NOGG guideline brings risk assessment and therapeutic decisions to a wide audience within primary care.

Almost 200 years ago, James Parkinson described a condition with ‘involuntary tremulous motion, lessened voluntary powers,' but with ‘uninjured senses and intellect' that would later be named Parkinson's disease by Charcot. Since then, it has emerged that cognitive impairment is present in a large proportion of patients with Parkinson's disease. Cognitive symptoms in patients with Parkinson's disease are associated with more rapid deterioration and eventually, a two-fold increase in mortality. Patients with cognitive impairment place a greater burden on their care givers and many such patients are admitted to nursing homes. Primary care plays a significant role in the recognition of DLB and PDD. Early recognition and referral to a specialist memory clinic can help to educate the patient about their often worrying symptoms and initiate the relevant treatment. Through the involvement of the multidisciplinary team, appropriate care networks can be set up to provide support and education for both patients and carers.

Musculoskeletal disease is the most common cause of chronic pain and disability in older people. Joint pathology may lead to reduced mobility, increased risk of falls, low energy, dependency and depression. Chronic pain itself is strongly associated with psychological distress and fatigue. The importance of correctly diagnosing and managing joint pain in the elderly is paramount and the GP is central to this process.

Brain ageing is generally thought of as atrophy, leading to cognitive deficits and functional impairment.  However,  there are also physiological reductions in cell numbers, connectivity and brain plasticity during the life span that may play an important role in the adjustment of brain function to the changing roles of the individual.

How should patients be assessed and diagnosed? What evidence-based treatments are available? Which patients should be referred?

What are the benefits of increased physical activity? What type of exercise is suitable for older people? How can GPs support and motivate patients to be more active?

How does pain present differently in older patients? How should pain be assessed in primary care? What is the key to providing adequate analgesia?

How common is depression in older people? What screening tools are recommended? Which patients are at risk of suicide?

What are the normal age-related changes to the eye? When should a patient with a cataract be referred for surgery? What new treatments are available for age-related maculopathy?

Can primary care screening for falls in the elderly make a difference? Are the NICE guidelines on falls relevant to primary care? When should GPs consider referral to a specialist falls service?

When should dementia be suspected in a patient presenting with memory problems? When should a patient with memory problems be referred to secondary care? Which patients with dementia should be started on cholinesterase inhibitors?