7. Ageing

Question 1

What is the life expectancy of a baby girl born in England today?

Answer 1

83 years

Question 2

Why are average ages in the world increasing?

Answer 2

People are living longer and fertility rates are falling

Question 3

What are the 2 theories for ageing?

Answer 3

• Programmed ageing

* Damage or error

Question 4

What do the theories for programmed ageing involve?

Answer 4

• Genetics
• Cells have a culture limit - Hayflick limit
• Related to telomerase
• Allows cell to reach maturity
• Benefit = prevention of cancer
• Evidence suggests more active telomerase increases lifespan

Question 5

What do the theories for damage or error involve?

Answer 5

• Free radicals (oxygen, hydrogen peroxide, nitrous oxide)
• Generated in the body - particularly by mitochondria
• Mitochondria are damaged
• Mitochondrial DNA doesn’t have good repair mechanisms
• When they die, the cell dies
• Chronic inflammatory conditions cause faster ageing
• Constant radiation exposure - DNA damage
• Protein cross-linking over time => damage/non-functional

Question 6

How is smoking related to the theory of damage/error?

Answer 6

• Smoking increases oxidative stress and free radical production
• Smokers age quickly

Question 7

What are the challenges of an ageing society?

Answer 7

• Work/retirement balance
• Caring for older people
• Extending health in old age, not just life expectancy
• Inadquate servives
• Outdated ageist beliefs/assumptions
• Medical system (designed for single acute diseases)

Question 8

Why is extended life not necessarily ideal?

Answer 8

At the moment, we have an extension of life with an extension of comorbidities - make people more impaired before they die

Question 9

What is frailty?

Answer 9

• Loss of biological reserve across multiple organ systems

* Leading to vulnerability to physiological decompensation and functional decline after a stressor event

Question 10

How do we treat frailty?

Answer 10

• Exercise
• Nutrition
• Drugs - particularly ACE inhibitors

(prevention > cure)

Question 11

What are non-specific presentations of frailty?

Answer 11

• Falls
• Reduced mobility
• Recurrent infections
• Confusion
• Weight loss
• Iatrogenic (medical) harm

Question 12

How do disease symptoms change in older people?

Answer 12

Less likely to have common symptoms, more likely to have harder symptoms to interpret e.g.
• Shortness of breath rather than chest pain for acute coronary syndrome
• Syncope rather than pleuritic chest pain and haemoptysis for PE

Question 13

Why do older people take more drugs?

Answer 13

• Multimorbidity
• Guidelines
• Undetected non-adherence
• Infrequent review
• Poor communication

Question 14

What is the term to describe uneccessary prescriptions and what are the consequences?

Answer 14

Potentially inappropriate polypharmacy (PIP)
• Up to 40% prescriptions are inappropriate
• Associated with bad outcomes e.g. falls, increased hospital stay, delirium, mortality

Question 15

What are nosocomial infections?

Answer 15

Caught in a hospital
• Infections
• Pressure sores
• Constipation
• Delirium
• Malnutrition 
etc.

Question 16

What is a comprehensive geriatric assessment?

Answer 16

Multidisciplinary assesment - medical, functional, social, psychological

In the community:
• Reduces admissions and falls

For frail inpatients:
• Reduces mortality, functional and cognitive decline, and further admission

Question 17

How does a brain CT compare in an older person?

Answer 17

• More prominent sulci and ventricles

* Lost grey and white matter (atrophy)

Question 18

Why does grey and white matter deteriorate in ageing brains?

Answer 18

• Number of connections between neurones reduced

* Neurones themselves shrink

Question 19

Is there a change in non-declarative memory (how to do things), visuo-spatial abilities or language in older people?

Answer 19

None, although they may be a reduction in verbal fluency

Question 20

What is dementia?

Answer 20

• Decline in all cognitive functions (not just memory)
• Impairement of function
• Progressive and irreversible

Question 21

What are the different types of dementia?

Answer 21

• Alzheimer’s - most common

* Vascular dementia

Question 22

Give some examples of causes of dementia

Answer 22

• HIV
• Thiamine deficiency
• Alcohol
• Hypothyroidism
• MS
• Head injury

Question 23

Compare dementia and delirium

Answer 23

Dementia
• Chronic
• Gradual
• No change in conscious level
• Irreversible

Delirium
• Acute
• Fluctuating
• Problem with alertness
• Reversible

Question 24

What cognitive screening tests can be done on someone with dementia?

Answer 24

• AMT (abbreviated mental test)
• Clock drawing test
• Montreal Cognitive Assessment (MOCA)

Question 25

What cognitive diagnostic tests can be done on someone with dementia?

Answer 25

• Addenbrooke’s cognitive examination (ACE)

* Detailed neuropsychometric testing

Question 26

What are the advantages and disadvantages of the Montreal Cognitive Assessment (MOCA)?

Answer 26

Advantages
• Covers many domains
• Brief
• Range of populations

Disadvantages
• Affected by educational level
• Affected by language level
• Floor and ceiling affects (limits to effectiveness)

Question 27

What are the problems with cognitive assesments?

Answer 27

• Limited by hearing, visual and physical impairment
• Most assume numeracy, literacy and basic cultural knowledge
• Depression can masquerade as dementia
• Not valid in acute illness
• Affected by normal cognitive changes e.g. slower reaction times

All has to be interpreted in the context of the patient