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We continue to celebrate Age & Ageing’s 50^th anniversary with specially commissioned commentary articles that commemorate the journal’s achievements and growing success. It is particularly pleasing to see the journal’s expanding international influence and relevance. Tan highlights the special challenges, but also opportunities, that arise with an ageing population in lower and middle income countries. Most of the world’s people aged 60 or over will reside in such countries, projected to reach two-thirds of the total by 2050. Tan’s thought-provoking commentary highlights tensions that will resonate with geriatricians the world over. The roles of the state, the individuals themselves and their families and wider society must come together to meet the needs of a rapidly ageing population. The pandemic has disproportionately affected the oldest and frailest in society and variable access to vaccinations threatens to widen health inequalities. Covid has, however, brought the health and wellbeing of older people sharply into focus and provides an opportunity to reset and rethink older people’s services throughout the world. Tan argues for prevention and timely interventions and the development of geriatric medicine services in lower and middle income countries. This may involve higher income countries becoming less reliant on recruiting staff from these countries.

It may seem obvious to think geriatricians are to older people what paediatricians are to children. Yet, O’Neill points out some fascinating discrepancies in how clinicians and the speciality is perceived by those we serve and how we interact with our patients and advocacy groups. Although geriatricians rightly take pride in being holistic about their outlook to health, there remains an overly medicalised approach to our clinical work’s focus and our form of advocacy for older people. This inevitably has resulted in geriatricians being associated with only the problems of ageing. O’Neill recommends focusing much more on the richness of later life, the longevity dividend, taking a life-course approach to clinical practice and research, being more careful in our use of language and placing more importance on non-medical aspects of gerontology. I encourage all readers to reflect on his thoughtful piece.

In this issue we have a helpful summary of the implications for geriatricians of new osteoporosis guidance by the UK National Osteoporosis Guideline Group, accredited by the National Institute for Health and Care Excellence (NICE). Guidelines, or more accurately how many are injudiciously applied, have been something of a mixed blessing for older people. Although the focus on evidence-based treatment is welcome and has helped reduce unwarranted and unhelpful clinical variation, they are also a major driver of inappropriate polypharmacy and burden of investigation and treatment for older people with multi-morbidity. Nevertheless, this new guidance encouragingly recommends first-line treatment with intravenous zolendronate and use of a tweaked version of the FRAX score into routine comprehensive geriatric assessment to better stratify fracture risk and avoid over-treatment. This should prove less burdensome to older people with osteoporosis while hopefully minimising avoidable fractures, even near the end of life.

Acute geriatric units or acute frailty units have gained traction throughout the United Kingdom and beyond. It is a real shame the effects of their introduction on patient outcomes and wider health service measures have not always been well described or collated. A systematic review and meta-analysis by O’Shaughnessy et al shows for the first time evidence that they improve the chances of living at home at 3 months and of reduced functional decline at 6 months. The lack of effect on in-hospital outcomes such as length of stay comes as a big surprise and a complete contrast with the experience at my own hospital, but this should serve to encourage us all to value research and better integrate service development with robust outcome measurement that can survive scientific peer view and be properly disseminated.

One of the holy grails of gerontological research is a reliable and valid marker of senescence, or biological ageing. Many clinical decisions are influenced by estimates of longevity and life expectancy. Using chronological age is tempting for its simplicity and reasonable accuracy at the population level but ignores that individuals age at difference rates, leading to ageism. An algorithm based on deep learning of ageing-related changes on retinal photography better predicts mortality and morbidity than chronological age and other phenotypic biomarkers.

An observational study of older people in Portugal showed a better prognosis of left ventricular systolic dysfunction where there is treatment with beta-blockers and renin-angiotensin system blockers. Although the benefits of these drugs are well established in randomised trials, studies often exclude older people or the benefits are not as marked in ‘real world’ scenarios. Importantly, improved outcomes in those taking beta-blockers and RASB were observed even in very old individuals and emphasise the importance of both these groups of drugs in clinical practice.

The exclusion of older people from clinical trials is also the subject of the study by Yang and colleagues. Oncogeriatrics is a field growing in popularity as evidence grows for the benefits of the integration of geriatricians into the multi-disciplinary cancer care team. Despite this, they found less than 1% of all cancer trials were undertaken in older people specifically. Worse still, even when considering only these trials, less than 10% used outcome measures that were clinically meaningful in this age group. This shows an evidence chasm and perhaps an even bigger cultural gulf that must be bridged to improve patient outcomes and minimise harm and waste.

This issue sees the results of the ReMInDAR randomised control trial of ongoing pharmacist-led medication review in residents of 39 Australian care homes. The intervention focussed on avoiding medication related harm and anticholinergic burden. The intervention group declined cognitively significantly more slowly than the control group. The trial was underpowered, in part due to the covid pandemic restrictions causing recruitment problems, but encouragingly a whole raft of other important outcome measures favoured the intervention, even if the improvements in these domains could not be conclusively proven. An important observation is that medication-related problems arose very frequently after the initial review, highlighting how crucial it is for medication-related interventions in care homes to be undertaken on an ongoing basis, and not just as a one-off.

The value of qualitative research should not be underestimated and is neatly demonstrated by a new study on the fear of falling. The fear of falling is well known to be harmful where it leads to immobility, but it can also be protective and result in behaviours that reduce falls. Ellmers and colleagues found that individuals that perceived their fears to be within their locus of control were able to adopt protective behaviours whereas those that perceived their worry was outside their control tended to panic and adopt unhelpful behaviours leading to immobility. They urge clinicians to undertake a simple exploration of their patient’s fear of falling to help individuals adapt their behaviour to encourage mobility.

Finally, if there is one intervention that comes close to being a panacea, it is exercise. However, it can be difficult to persuade people to do more exercise and some are too frail to engage in more conventional exercise types. Inspiratory muscle training (IMT) and whole body vibration exercise (WBV) are two interventions that may be suitable even for those unable to engage in other forms of training. In a randomised controlled trial in pre-frail women aged 60–80 years, a combination of IMT and WBV over 12 weeks improved physical performance and balance over a sham intervention. It would be interesting to see if this could be replicated in a larger study and in other studies, such as inpatient rehabilitation.