7: prospectives on Ageing Flashcards
What is Ageing?
Ageing is the process of growing older
It has 3 different main domains:
- Biological
- Psychological/cognitive
- Social
What is Life expectancy?
Life expectancy is a statistical measure of how long a person can expect to live
Why did life expectancy increase in the past 100 years
Many factory but mainly
- better public health (sanitation, hygene etc) but also:
- better nutrition
- less violence
- adnancaes in medicine and
- better education
How does the nature of the ageing population changes?
- Increasing numbers of BAME (black asian, minority ethnicity) older people
- Increasing education of older people
- Reduction in poverty
- More people are working for longer
- More complex/nuanced retirement process
What are the two main groups of Ageing theories?
- Programmed ageing
- Damage or error theories
But:
- no know theory/application there are no anti-ageing treatments in medicine
- people age at different rates
Explain the main thesis of “programmed ageing” theory
Aged because it is programmed in DNA
- e.g. telomers get shorther
- –> cells count the number they are deviding and at some point stop deviding
Explain the “Damage of error theories” as a rationale behind ageing
In theory: could live forever but cells get damage appears that cause ageing
What are the big challanges for society in a ageing population?
- Working life/retirement balance - dependency ratio
- Extending healthy old age not just life expectancy
- Caring for older people, the sandwich generation
- Outdated and ageist beliefs/assumptions
- Medical system designed for single acute diseases
Explain the role of the dependency ration as a challenge of ageing
Working life/retirement balance - dependency ratio
- number of depemdance of people in society (older people in pansion and children)
- vs number of people that work
- being able to pay pansion to people!
Explain the role of extending healthy old age not just life expectancy in a challange of ageing
Extending healthy old age not just life expectancy
- aim: to reduce disease time and increase life expectancy
- but currently: mainly life expectancy went up but disease free time did not
Which factors influence health and (disease free) life expectancy?
- where we live (e.g. pollution)
- genetic
- health behaviour
- access to healthcare
- who we are (gender etc.)
Explain the challenge of Caring for older people, the sandwich generation
3% of over 65 live in a carehome
- is expensive for working “sandwich” generation
- caring for an older relative
- whilst bringing up children
- not paied by government for vast majority of people
- leading to
- decreased workforce and
- underpaied workers, delayed and worse care
Explain the consequences of the increased age on the healthcare system
- Increasing demand for primary, secondary and tertiary health care
- Increasing complexity
- Navigating the health and social care divide
What is frailty?
Loss of biological reserve
- across multiple organ systems
- leading to vulnerability to physiological decompensation and
- functional decline
after a stressor event
–> having decreased resources to deal with a stressor event so that a minor stressor (e.g. mild infection) have a big impact (need for care afterwards, admission to long-term care and hospital
Which factors influence Frailty?
It is dependant on
- Environmental and
- Genetic factors
- Leading to
- accumulative damage to cells and molecular damage (Ageing)
- reduced physilogical reserve (in all organ systems)
- influenced by nutritional status and exercise
What does a stressor event in a fragile person lead to?
It leads to (more) severe response/effects like
- falls
- Delirium
- Fluctuating disability
Leading to
- increased care needs
- admission to hospital
- admission to long-term care
What are the characteristics of
- mild
- severe frailty
- Mild
- living on their own, dependant on some help
- severe
- dependant on others and help of others (often living in care home)
Can frailty be prevented?
Yes, with lifestyle choices
- exercise
- nutrition
- no smoking
- no drinking
Can frailty be treated?
Yes but it is difficult
- Exercise
- Nutrition
- Drugs (possibly)
Prevention is better than cure
What are the non-specific presentations of fraiglty?
- Falls
- Reduced mobility
- Recurrent infections
- Confusion
- Weight loss
- “Not coping”
- Iatrogenic harm
–> Not diagnosis but syndromes that make people come into hospital
How does presentation of a disease in old people change?
They are less likely to have a “textbook presentation” of symptoms but are more likely to show additional symptoms
- ACS
- Less likely to have chest pain
- More Likely to have SOB
- PE
- Less likely to have pleuritic chest pain
- Less likely to have haemoptysis
- More likely to have syncope
What is the impact of multimorbidity in age?
Because: conditions of conditions impact on one another
- directly
- viat the treatment of one condition
- Leading to
- Worse Quality of Life, more likely to be depressed
- Increased functional impairment
- Burden of treatment
- Polypharmacy
Why do older people take more drugs?
- more conditions (multimorbidity)
- infrequent review
- guidelines
- only on single condition and not on multimoriditions that might be treated differently
- undetected non-adherence
- poor communication
What is the result of Potentially inappropriate polypharmacy (PIP) ?
E.g. Long-term perscription of opioids,
- Falls
- Increased length of stay
- Delirium
- Mortality
What is the iatrogenic harm?
Harm caused by the medical treatment
iatrogenic illness or death caused purposefully or by avoidable error or negligence on the healer’s part
What are the possible effects of iaterogenic harm?
- Adverse reactions to medications
- Nosocomial conditions
- Infections
- Pressure sores
- Constipation
- Deconditioning
- in hosptial e.g. moving too little in Hospital Bed
- Delirium
- Malnutrition
- Incontinence
- Falls
- Psychological/cognitive damage
Why are older people more suspectible to ADRs?
- Reduced physiological reserve
- Impaired compensation mechanisms
- Comorbidities
- Polypharmacy
- Cognitive impairment
What is a CGA?
Comprehensive geriatric assessment
How is a CGA made?
- It is a Multidisciplinary assessment of
- Medical
- Functional
- Social
- Psychological/psychiatric needs
- Then: coming up with a Problem list and a
- Treatment Plan
What are the advantages of a CGA?
In the community
- reduces hospital admissions
- and falls
- benefit in mild or moderate frailty
In hospital:
- reduces mortality
- reduced functional and cognitive decline
- reduces hospital/care home admission
What are the goals of Rehabilitation?
- Aim is to restore or improve functionality
- Multidisciplinary
- Rehabilitation alongside acute illness
- Preventing deconditioning
- Prehabilitation
What are the biological changes in the brain that occur with ageing?
- Enlargement of the ventricles
- loss of supporting matter + connection between neurons
- in grey+ white matter
What are the normally cognitive functions that decline with age?
Reduction of
- cognitive speed, working memory
- executive function e.g. probling solving abilits
- devided attention
Name some cognitive abilities that do not physiologically change with age?
No change (decline) in
- simple (on one thing) attention
- nondeclerative memory
- visuospatial abilities
- language (some reduction in verbal fluency)
What is dementia?
•Decline in all cognitive functions, not just memory
- Impairment of function
- Progressive
- Degenerative
- Irreversible
Can dementia can be prevented?
YES (at least lifestle has some influence)
- stop smoking
- exercise
- diet
- alcohol
What is the AMT?
It is a brief assessment (10 point) of cognitive function
The Abbreviated mental test score (AMTS)
What are possible screening test cognitive function?
- AMT–> 10 point questions used in clinical practice
- Clock drawing test (try the patients to show time with their fingers)
- both used tas brief screening for cognitive impairment
- MMSE (Minimal Mental Stater Examination) not used in clincal practice anymore
- MOCA (Montreal Cognitive Assessment) –> has replaced MMSC as brief screening test (screening test that is a bit more detailed thatn first two)
What are possible diagnositc test that can test cognitive function?
- Addenbrooke’s Cognitive Examination (ACE)
- 100 qestions, 20-50 mins
- Detailed neuropsychometric testing
- hours, done by psychology
Explain the process of testing the MOCA test
MOCA= Montreal Cognitive Assessment
–> normally 30 min for exam (realistically 15-20)
What are the adantages of a MOCA screeming test?
- Covers a variety of domains of cognitive function
- Brief to administer (10 mins)
- Validated in a range of populations
- Available in translated versions
- Widely used –> good comparisons available
What are the disadvantages of the MOCA test?
- Education level will affect results
- Language level will affect results
- Floor and ceiling effects
- with good education –> education but still dement and high score
- Can be poorly administered (if people don’t have the training)
- Possibly practice/coaching effects
What are general problems with cognitive tests?
Just interpret test in the context of the patient!
- Physical problems may limit testing
- also hearing + seeing
- e.g. can’t hold a pen
- Education may limit testing
- most need: numeracy and literacy
- and some basic cultural knowledge
- Depression can masquerade as dementia
- Not valid in acute illness (acute confusion)
- Normal cognitive changes (slower processing speed, slower reaction times) may affect administration
What are the implications of the two main theories of ageing on treatment?
- Damage theories
- if damage could be prevented/ repaired this could stop ageing
- Programmed ageing theories
- if genetic modification
What are the “giants of geriatric medicine”?
The reasons why old people come into hospital
- immobility
- intellectual impairment
- instability
- incontinence
- iatrogenic problems.
What are possibilities to differentiate between dementia and delirium?
Confusion Assessment Method (CAM)
4AT
are tools to help distinguish between delirium and dementia
