Elderly Care Medicine E-Book

Claire G. Nicholl

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Serie: Lecture Notes
• Sprache: Englisch

Seitenzahl: 591

Veröffentlichungsjahr: 2012

Beschreibung

Elderly Care Medicine Lecture Notes provides all the necessary information, within one short volume, for a sound introduction to the particular characteristics and needs of elderly patients.

Presented in a user-friendly format, combining readability with high-quality illustrations, this eighth edition has been thoroughly revised to reflect advances in knowledge on how disease presents in elderly people, and changes in management practice, particularly regarding stroke, dementia, delirium, and cancer.

New for this edition, Elderly Care Medicine Lecture Notes also features:

• More treatment tables and boxes throughout for rapid access and revision
• Expansion of material on polypharmacy and prescribing
• Discussion of emotional support, counselling and spirituality
• Advice for doctors on breaking bad news and end-of-life care
• Consideration of ethical and legal issues

A companion website at www.lecturenoteseries.com/elderlycaremed features appendices which can be used as guidelines in a clinical setting, key revision points for each chapter, further reading suggestions, and extended content for specialty training in geriatrics.

Not only is this book a great starting point to support initial teaching on the topic, but it is also easy to dip in and out of for reference or revision at the end of a module, rotation or final exams. Whether you need to develop or refresh your knowledge of geriatrics, Elderly Care Medicine Lecture Notes presents 'need to know' information for all those involved in treating elderly people.

Leseprobe

Contents

Cover

Title Page

Copyright

Preface

Abbreviations

Chapter 1: The World Grows Old

Introduction

Population Trends

Ageing in India

Ageing in Africa

Ageing in Brazil

Global Warming

Global Poverty

Inter-Generational Strife

Social Aspects of Ageing

Loss of Wealth

Retirement

Some Myths of Ageing

References

Further Information

Chapter 2: Health and Social Care for Elderly People in the UK

How Many Older People are There?

Is Life Expectancy Still Increasing?

What is Your Life Expectancy When you are Old?

Does Living Longer Mean More Suffering in Old Age?

What are the Characteristics of the Older Population?

Income

Where do Elderly People Live?

Sheltered Housing

Institutional Care

What Types of Institutions are There?

Who Provides Institutional Care?

How is Institutional Care Paid for?

How is Care for Older People Organized?

Health Care for Older People

Mental Health Services for Older People

Intermediate Care

Day Hospitals

Social Care for Older People

When the Person Stays in their Own Home What Types of Care can be Provided?

Regulation of Health and Social Care

Who Cares?

Strategies to Improve Care of Older People

References

Further Information

Chapter 3: Special Features of Medicine in the Elderly

The Ageing of Populations

The Ageing Process

Immunity and Ageing

Unifying Hypothesis

Declining Function

Special Features of Illness in Older Patients

Ethical Problems

Examination of the Aged Patient – Things to Look out for

Pharmacological Treatment: Special Considerations

Surgery in Elderly Patients

References

Further Information

Chapter 4: Old Age Psychiatry

Age Changes

Sleep

Problem Drinking

Anxiety

Late-Onset Delusional Disorder

Depression

Acute and Chronic Confusion

Delirium

Dementia

Alzheimer's Disease

Transient Global Amnesia

Self-Neglect

References

Further Information

Chapter 5: Falls and Immobility

Falls

References

Further Information

Chapter 6: Bones, Joints and Muscles

Bones

Joints

Muscle Weakness

Further Information

Chapter 7: Stroke Made Simple

Importance

Definitions

Outcome of Stroke

Aetiology and Pathology

Presentation

Transient Ischaemic Attacks

Management of Carotid Disease

The Established Stroke

Multi-Infarct Disease (Dementia)

Cerebellar Infarct or Haematoma

Spinal Cord Infarction

Subarachnoid Haemorrhage

Central Venous Thrombosis

Investigation of Stroke

Management of the Established Ischaemic Stroke

Dispersing the Thrombus

Vasodilatation and Cerebral Oedema

Neuroprotection

Management of Haemorrhagic Stroke

Hydration and Nutrition

Information for the Family and Patient

Palliative Care

Rehabilitation

Primary and Secondary Prevention

Indicators of Poor Outcome

Driving After a Stroke

Information on Discharge From Hospital

References

Further Information

Chapter 8: Other Diseases of the Nervous System

Age Changes and Clinical Examination

Symptomatic Classification of Neurological Disease in the Elderly

Aetiological Classification

Further Information

Chapter 9: Cardiovascular Disorders

Age Changes

Manifestations (Figure 9.1)

References

Further Information

Chapter 10: Respiratory Disease

Age Changes

Upper Respiratory Tract Infection

Acute Breathlessness

Airway Obstruction

Pneumonia

Pulmonary Tuberculosis

Pleural Effusion

Bronchiectasis

Chest Trauma

Carcinoma of the Bronchus

Pleural Plaques

Malignant Mesothelioma

Interstitial Lung Disease

Carbon Monoxide Poisoning

Further Information

Chapter 11: Gastrointestinal Disease and Nutrition

Age Changes

Unintentional Weight Loss

Dysphagia

Dyspepsia

GI Bleeding

The Acute Abdomen

Bowel Ischaemia

Acute Diarrhoea

Constipation

Change in Bowel Habit

Faecal Incontinence

Absorption

Coeliac Disease

Diverticular Disease

Endoscopy in the elderly

CT Abdomen

Jaundice

Chronic Liver Disease

Clinical Nutrition

References

Further Information

Chapter 12: Disorders of Homeostasis and Metabolism

Age Changes

Endocrine Changes

Fluid and Electrolyte Imbalance

Diabetes Mellitus

Thyroid Disease – Function Tests

Adrenal Disease

Autonomic Nervous System

Accidental Hypothermia

Other Dangers of Extreme Weather

References

Chapter 13: Genitourinary Disease

Age Changes

Acute Kidney Injury (AKI) in Old Age

Chronic Kidney Disease (CKD) in The Elderly

Intrinsic Renal Disease

Urinary-Tract Infection (UTI)

Presentations of Urosepsis in Old Age

Obstructive Nephropathy

Bladder Outflow Obstruction

Cancer of the Prostate

Drugs and the Kidneys

Blood Pressure and the Kidneys

Haematuria

Renal Cell Carcinoma

Bladder Carcinoma

Urinary Incontinence

Vaginal Bleeding

Vaginal Prolapse

Disease of the Vulva

Sex in Old Age

References

Further Information

Chapter 14: Blood and Bone Marrow

Age Changes

Anaemia

Myeloproliferative Disorders

Leukaemias

Myeloma

Monoclonal Gammopathy of Unknown Significance (MGUS)

Lymphoma

Coagulation Disorders

Further Information

Chapter 15: Eyes, Ears, Mouth and Skin

Eyes

Ears

The Mouth and its Contents

Skin

Pruritus

Other Important Skin Conditions in Geriatric Medicine

Malignant Diseases of the Skin

Hair and Nails

Further Information

Chapter 16: Legal and Ethical Aspects of Medical Care of Elderly People

Driving in Later Life

Confidentiality

The Mental Capacity Act (MCA) 2005

Lasting Power of Attorney

Independent Mental Capacity Advocates (IMCA)

Consent

Testamentary Capacity

Emergency Symptomatic Treatment of the Incompetent Patient

Restraints

Deprivation of Liberty

The Mental Health Act (Table 16.1)

Ethical Issues Relating to Life-Supporting Interventions

Age Discrimination

Elder Abuse

Euthanasia

Death Certification and the Role of the Coroner

Her Majesty's Coroner

Coroners and Death Certification Bill

References

Further Information

Chapter 17: Palliative Care

Age and Place of Death

Recognizing the Last Year of Life

Advanced Care Planning (ACP)

Advanced Decision to Refuse Treatment (ADRT)

Hospice Care

Symptom Control

Diagnosing Dying

The Liverpool Integrated Care Pathway for the Dying Patient (LCP)

Syringe Drivers

Spiritual and Religious Support

Considerations for People of Different Faiths

Emotional Support

Enabling People to Die at Home

Care After Death

Bereavement

Further Information

Index

Companion Website

This book is accompanied by a companion website:

www.lecturenoteseries.com/elderlycaremed

The website includes:

Key revision points for each chapterAppendices:

1. Standards for long-term care

2. The Barthel Scale

3. CAGE questionnaire for alcohol problems

4. The Abbreviated Mental Test (AMT)

5. The Geriatric Depression Score (GDS)

6. Fitness to fly

7. Respiratory function in the elderly

8. Malnutrition Universal Screening Tool (MUST)

9. The Waterlow Score for pressure sores

Extended content for specialty traineesFurther reading

This edition first published 2012 © 2012 by John Wiley & Sons, Ltd.

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Library of Congress Cataloging-in-Publication Data

Nicholl, Claire.

Lecture notes. Elderly care medicine / Claire Nicholl, K. Jane Wilson. – 8th ed.

p. ; cm.

Elderly care medicine

Includes bibliographical references and index.

ISBN 978-0-470-65454-5 (pbk. : alk. paper)

I. Wilson, K. Jane (Kathryn Jane) II. Title. III. Title: Elderly care medicine.

[DNLM: 1. Geriatrics. WT 100]

618.97–dc23

2011049097

A catalogue record for this book is available from the British Library.

Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not be available in electronic books.

Preface

Unless you are planning to be a paediatrician or an obstetrician, this book is for you. 2011 was the year that the world population topped 7 billion (UN). Whilst population growth is still very rapid in some areas, in industrialized countries it is the ageing of the population that is having most effect on health and social needs. Because of the size of their populations, the greatest numbers of old people already live in China and India. By the end of the century it is estimated that the world population will be falling so the challenges of ageing will dominate worldwide.

Whatever career choice you make, with a few exceptions, the patients you look after during your career will be increasingly elderly and increasingly frail. Even in surgical specialties the majority of patients are old. A good understanding of the basics of managing this group with their fragile homeostatic mechanisms, multiple diseases and drugs, high prevalence of dementia and risk of delirium will make a difference to the outcome for your patient. Knowledge of the ways in which the multidisciplinary team can work with the patient and family and a grasp of the complexities of the social care system will also help you to put together the best package of care for an older person. This will reduce their length of stay in hospital, the risks of hospitalization and money wasted on inefficient care.

In the community, the limited time available for a GP consultation makes good medical management of older people with complex health problems difficult to achieve. If a specialist opinion is needed, frail older people are not easily managed by single-organ specialists, but elderly care medicine as a specialty remains poorly developed in much of Europe and North America. In the UK it is recognized that frail old people are the greatest users of the NHS and geriatric medicine is now the biggest specialty within the Royal College of Physicians. However, academic departments of medicine for the elderly have been in decline and the medicine of old age is often taught by non-specialists as an integrated part of medicine in the life cycle. This has the advantage that ageing is seen in the context of human development, but the time allocated to older people is not proportionate to what the student doctor will need to know as soon as they are qualified.

If you are still not convinced that a grasp of medicine for the elderly is essential, have a look at the medical or surgical ‘take’ list for the hospital where you are working. At Addenbrooke's the average age of the patients admitted on the medical take sometimes exceeds 75 years and the average age of the patients under the physicians here who specialize in elderly care is 86 years.

This book is aimed at medical students and junior doctors who may have had relatively little specialist teaching about older people. Therefore since the last edition, the content has been expanded as well as updated, particularly the chapters on dementia, stroke, falls and ethical issues. We hope that it is written in an approachable manner which would make it accessible to nurses and allied health professionals. The accompanying website gives key points for revision and more details particularly about health care provision, dementia and stroke. It also forms an initial refresher for trainees approaching their specialty examination to identify gaps in knowledge for appropriate supplementation from longer textbooks and papers.

You will need to learn the basics of medicine for the elderly – we are hoping to make it easier and to convince you that medicine for older people is interesting, varied and challenging. There is great scope for clinical acumen and decision making as the complexity of the patients makes guideline-driven medicine less relevant. Over recent years, geriatricians have expanded into orthopaedics, stroke medicine, acute medicine and community services and there is now demand for input into general surgery. As other specialties contract, a career in medicine for the elderly is well worth considering.

Claire G. NichollK. Jane Wilson

Abbreviations

AAAttendance allowanceAADCaromatic amino acid decarboxylaseAAFBacid and alcohol fast bacilliABGarterial blood gasACAanterior cerebral arteryACEangiotensin-converting enzymeACEiACE inhibitorAChEacetylcholinesteraseAChEiacetylcholinesterase inhibitorACPadvanced care planningACSacute coronary syndromeACTHadrenocorticotrophic hormoneADAlzheimer's diseaseADHantidiuretic hormoneADLactivities of daily livingADRadverse drug reactionADRTadvance decision to refuse treatmentADsadvance decisionsAEDanti-epileptic drugAFatrial fibrillationAFOankle-foot orthosisAIDPacute inflammatory demyelinating polyradiculoneuropathyAIPacute interstitial pneumoniaAKIacute kidney injuryALDalcoholic liver diseaseALLacute lymphoblastic leukaemiaALPalkaline phosphataseALSamyotrophic lateral sclerosisAMLacute myelocytic leukaemiaAMPAα-amino-3-hydroxy-5-methylisoxazole-4-propionic acid receptorAMTAbbreviated Mental TestANHartificial nutrition and hydrationANSautonomic nervous systemAPantero-posteriorallyAPPamyloid precursor proteinARBangiotensin receptor blockerAMDage-related macular degenerationASAlzheimer's SocietyATNacute tubular necrosisAVatrioventricularAVParginine vasopressinAXRabdominal X-rayBAFTABirmingham Atrial FibrillationTreatment of the Aged studyBCCbasal-cell carcinomaBMABritish Medical AssociationBMDbone mineral densityBMIbody mass indexBNFBritish National FormularyBNPbrain natriuretic peptideBOOPbronchiolitis obliterans organizing pneumoniaBPblood pressureBPHbenign prostatic hyperplasiaBPPVbenign paroxysmal positional vertigoBPSDbehavioural and psychological symptoms of dementiaCAAcerebral amyloid angiopathyCADcoronary artery diseaseCADASILcerebral autosomal dominant arteriopathy with subcortical infarcts and leucoencephalopathyCAPDcontinuous ambulatory peritoneal dialysisCBDcorticobasal degenerationCBTcognitive behavioural therapyCCFcongestive cardiac failureCCUcoronary care unitCDADClostridium difficile associated diarrhoeaCFHcomplement factor HCHARMThe Candesartan in Heart failureAssessment of Reduction in Morbidity and Mortality studyCHARTcontinuous hyperfractionated accelerated ratioCHFcongestive heart failureCIconfidence intervalCIDPchronic inflammatory demyelinating polyradiculoneuropathyCKcreatine kinaseCKDchronic kidney diseaseCLLchronic lymphocytic leukaemiaCMLchronic myeloid leukaemiaCNScentral nervous systemCOHbcarboxyhaemoglobinCOMTcatechol-O-methyltransferaseCOPcryptogenic organizing pneumoniaCOPDchronic obstructive pulmonary diseaseCOX-2cyclo-oxygenase-2CPAPcontinuous positive airways pressureCPNCommunity psychiatric nurseCPRcardiopulmonary resuscitationCQCCare Quality CommissionCRPC-reactive proteinCSFcerebrospinal fluidCTcomputerized tomographyCTPAcomputerized tomography pulmonary angiogramCTZchemoreceptor trigger zoneCVAcerebrovascular accidentCVPcentral venous pressureCXRchest X-rayDANdiabetic autonomic neuropathyDBSdeep brain stimulationDCdirect currentDFLEdisability-free life expectancyDGHDistrict General HospitalDHDepartment of HealthDICdisseminated intravascular coagulationDIPdistal interphalangeal jointsDLBdementia with Lewy bodiesDMdiabetes mellitusDMARDsdisease-modifying anti-rheumatic drugsDNA CPRdo not attempt cardiopulmonary resuscitationDNRdo not resuscitateDOLSDeprivation of liberty safeguardsDPLDdiffuse parenchymal lung diseaseDPPdipeptidyl peptidaseDSPNdiabetic sensorimotor polyneuropathyDVLADriver and Vehicle Licensing AuthorityDVTdeep vein thrombosisDXAdual-energy X-ray absorptiometryECGelectrocardiogramECTelectroconvulsive therapyEDEmergency departmentEEGelectroencephalographyeGFRestimated glomerular filtration rateELISAenzyme-linked immunosorbent assayEMAendomysial antibodiesEMGelectromyogramEOFADearly-onset familial Alzheimer's diseaseERCPendoscopic retrograde cholangiopancreatographyESRerythrocyte sedimentation rateETessential tremorEVARendovascular aneurysm repairFASTFace Arm Speech Time scoreFBCfull blood countFDGfluorodeoxyglucoseFEV1forced expiratory volume in 1 sFRAXFracture Risk Assessment toolFSHfollicle stimulating hormoneFTDfrontotemporal dementiaFTLDfrontotemporal lobar degenerationFVCforced vital capacityGARSglycyl-tRNA synthetaseGBSGuillain–Barré syndromeGCAgiant-cell arteritisGDNFglial cell-line derived nerve growth factorGDPgross domestic productGDSGeriatric Depression ScoreGFRglomerular filtration rateGIgastrointestinalGLP-1glucagon-like peptide 1GMCGeneral Medical CouncilGORDgastro-oesophageal reflux diseaseGPgeneral practitionerGSFGold Standards FrameworkGTNglyceryl trinitrateGUgenitourinary tractHCMhypertrophic cardiomyopathyHLEhealthy life expectancyHOOFHome oxygen order formHRCThigh resolution computerized tomography scanHSMNhereditary motor and sensory neuropathyHUThead-up tiltIBSirritable bowel syndromeICintermediate careICAinternal carotid arteryICHintracerebral haemorrhageICSinhaled corticosteroidsIHDischaemic heart diseaseILDinterstitial lung diseaseIMintramuscularIMCAIndependent Mental Capacity AdvocateINRinternational normalized ratioIPFidiopathic pulmonary fibrosisITUintensive therapy unitIVintravenousIVUintravenous urogramJVPjugular venous pressureLABAlong-acting beta2 agonistLacIlacunar infarctLAMAlong-acting muscarinic antagonistLBBBleft bundle branch blockLCPLiverpool Care Pathway for the dying patientLDHlactate dehydrogenaseLElife expectancyLFTliver function testLHluteinizing hormoneLHRHluteinizing hormone-releasing hormoneLMNlower motor neuronLMWHlow molecular weight heparinLOADlate-onset Alzheimer's diseaseLOCloss of consciousnessLPlumbar punctureLPALasting Power of AttorneyLTOTlong-term oxygen therapyLUTSlower urinary tract symptomsLVleft ventricularLVFleft ventricular failureLVHleft ventricular hypertrophyMAO-Bmonoamine oxidase BMARMedicines Administration RecordMCAMental Capacity ActMCAmiddle cerebral arteryMCCDMedical Certificate of Cause of DeathMCImild cognitive impairmentMCVmean corpuscular volumeMDRDmodification of diet in renal diseaseMDSmyelodysplastic syndromeMDTmultidisciplinary teamMGUSmonoclonal gammopathy of unknown significanceMHAMental Health ActMImyocardial infarctionMIBItechnetium 99 2-methoxy isobutyl isonitrileMMSEMini-Mental State ExaminationMNAMini-Nutritional AssessmentMNDmotor neuron diseaseMPTP1-methyl-4-phenyl-1,2,3,4-tetrahydropyridineMRmagnetic resonanceMRCMedical Research CouncilMRCPmagnetic resonance cholangiopancreatographyMRImagnetic resonance imagingMRSAmethicillin-resistant Staphylococcus aureusMSmultiple sclerosisMSAmultiple system atrophyMSUmidstream urineMTPmetatarso-phalangeal jointNAD+nicotinamide adenine dinucleotideNAFLDnon-alcoholic fatty liver diseaseNBMnil by mouthNCSnerve conduction studiesNCSEnon-convulsive status epilepticusNGnasogastricNHS CCNHS continuing careNHSNational Health ServiceNIA-AANational Institute on Aging and the Alzheimer's Association (new criteria for diagnosis of AD)NICENational Institute for Health and Clinical ExcellenceNIHSSNational Institutes of Health Stroke ScaleNIVnon-invasive ventilationNMDAN-methyl-D-aspartateNOFneck of femurNPHnormal pressure hydrocephalusNSAIDnon-steroidal anti-inflammatory drugNSCLCnon-small cell lung cancerNSF OPNational Service Framework for Older PeopleNSIPnon-specific interstitial pneumoniaNSTEMInon-ST-elevation myocardial infarctOAosteoarthritisOGDoesophago gastro duodenoscopyOSAHSobstructive sleep apnoea/hyponoea syndromeOTCover-the-counterPApernicious anaemiaPACIpartial anterior circulatory infarctPAFparoxysmal atrial fibrillationPBCprimary biliary cirrhosisPBRpayment by resultPCIpercutaneous coronary interventionPCRpolymerase chain reactionPCTPrimary Care TrustPDParkinson's diseasePDEphosphodiesterasePEpulmonary embolismPECpercutaneous endoscopic colopexyPEFRpeak expiratory flow ratePEGpercutaneous endoscopic gastrostomyPETpositron-emission tomographyPICCperipherally inserted central catheterPIPproximal interphalangeal jointsPMRpolymyalgia rheumaticaPoCIposterior circulatory infarctPOPplaster of ParisPPARγperoxisome-proliferator-activated receptor gammaPPIproton pump inhibitorPPSpost-polio syndromePSAprostate-specific antigenPSPprogressive supranuclear palsyPTCApercutaneous transluminal coronary angioplastyPTHparathyroid hormonePUVApsoralen + UVA treatmentPVpolycythaemia veraPVSpersistent vegetative stateQOFquality and outcomes frameworkRArheumatoid arthritisRANKLreceptor activator of nuclear factor kappa-B ligandRASrenal artery stenosisRCPRoyal College of PhysiciansRCTrandomized controlled trialRDWred cell distribution widthRGSCRegistrar General's socio-economic classROSIERRecognition of Stroke in the Emergency Room scaleRoSPARoyal Society for the Prevention of AccidentsRPEretinal pigment epitheliumrt-PArecombinant tissue-type plasminogenSABAshort-acting beta2 agonistSAHsubarachnoid haemorrhageSAMAshort-acting muscarinic antagonistSBOTshort-burst oxygen therapySCCsquamous-cell carcinomaSCLCsmall-cell lung cancerSDstandard deviationSEstatus epilepticusSERMselective estrogen modulatorSHAStrategic Health AuthoritySIADHsyndrome of inappropriate antidiuretic hormoneSIGNScottish Intercollegiate Guidelines NetworkSITS-MOSTSafe Implementation of Treatments in Stroke Monitoring StudySIVDsubcortical ischaemic vascular diseaseSLEsystemic lupus erythematosusSNsubstantia nigraSNRIserotonin and norepinephrine reuptake inhibitorSOLspace-occupying lesionSPAstate pension ageSPECTsingle-photon emission computerized tomographySSRIselective serotonin reuptake inhibitorSTEMIST-elevation myocardial infarctTACItotal anterior circulatory infarctTAVItranscatheter aortic valve insertionTBtuberculosisTCCtransitional cell carcinomaTDPtransactive response DNA-binding proteinTEDSthromboembolic-deterrent stockingsTENStranscutaneous electrical nerve stimulationTFTthyroid function testTGAtransient global amnesiaTHtyrosine hydroxylaseTIAtransient ischaemic attackTLOCtransient loss of consciousnessTOEtransoesophageal echocardiographytPAtissue plasminogen activatorTSHthyroid stimulating hormonetTGAtissue transglutaminase antibodiesTUIPtransurethral incision of the prostateTUMTtransurethral microwave therapyTUNAtransurethral needle ablationTURPtransurethral resection of the prostateTVTtension-free vaginal tapeU&Eurea and electrolytesUIPusual interstitial pneumoniaUKPDSUnited Kingdom Prospective Diabetes StudyUMNupper motor neuronUTIurinary tract infectionVAvisual acuityVaDvascular dementiaVEGFvascular endothelial growth factorVGCCvoltage-gated calcium channelsVTEvenous thromboembolismWBCwhite blood cellYAGyttrium aluminium garnet laser

Chapter 1

The World Grows Old

Introduction

The Western world turned grey in the 20th century and much of the rest of the world will follow this century. Improvements in housing, sanitation, nutrition and education, and smaller family size, higher incomes and public health measures such as immunization were the major factors driving this epidemiological transition. In many developed countries, this shift started in the mid-19th century and life expectancy increased as infant and maternal mortality and deaths from infectious diseases in children and young adults fell. Over the last 30 years, gains in life expectancy are also being made in middle age. In countries such as Japan the transition started later but proceeded more quickly. In many developing countries, the transition started even later and is still in progress.

In the West, the impact of an ageing population on the retirement age, pensions and the cost and practicalities of service provision has become an important issue. An increasingly small number of people of working age cannot fund the pensions of older people with ever longer retirements. Most older people are independent, but if they need help, family care is often not available; many of their daughters will be working, families are scattered geographically and options for care are less well developed than child care.