AGE - SYSTEMS Flashcards
Name 3 changes in the heart muscle with age:
- ventricular myocytes hypertrophy (increased afterload)
- fibrous tissue deposited
- amyloid deposits
- LV cavity slight enlargement
- LA hypertrophy
What happens to the heart valves as we age?
-thicker, calcified, less flexible
Suggest how/why conduction of electrical impulses in the heart are affected with age.
- less pacemaker cells
- fibrous/fat/amyloid infiltrates
- hypertrophy means slower propagation of impulses
- intrinsic HR reduces
Less cardiac contractility, max HR and less blood vol. in LV with ageing leads to what?
- lower CO reserve
- CO cant increase upon stress/exercise as much
- orthostatic hypotension and activity intolerance
How are vessels affected with age? NO? Atherosclerosis? Compliance?
- less NO from endo (NO=protective from atheroma)
- endo. dysfunction -> ath.sclerosis
- arteries get stiffer, less elastin -> less compliant
- collagen & calcifications increase stiffness
What is lipohyalinosis that can occur in ageing vessels due to microvascular damage to them?
-narrowing of vessels by wall thickening, eventually block off supply (e.g. to eye/brian/kidney)
Because of changes in the CVS with age, HT, CHD, MI, Stroke…are more common. Name 3 modifyable risk factors that affect these?
- BP
- Diabetes
- Dyslipidaemia
- Smoking, alcohol
- PA, stress
Give 2 reasons the chest wall stiffness increases with age:
- less elastin
- calcification
- more Conective Tissue
- muscle stiffness
How is the thorax compressed with age lowering FEV1 and FVC?
-degenerative narrowing of IV disc spaces -> kyphosis
How does the cough reflex change with age?
- less sensitive reflex
- weaker muscles
Why does mucociliary clearance decrease with age?
- less no. cilia
- cilia are slower. less efective, take longer to recover post-insult
Less elastic recoil of alveoli cause small airways to collapse, any other alveoli changes?
- reduced elastic tissue -> thinner and shalllower
- less SA for exchange
How does the diameter of respiratory bronchioles and alveolar ducts dilating with age affect air/inflation? (aka senile emphysema)
- get premature closing of small airways during normal breathing
- airtrapping and hyperinflation occurs
What pathology can vascular remodelling of vessels within lungs, more pulmonary stiffness/pressure/resistance contribute to?
- more pressure on R-Heart
- Right sided HF
What is homeostenosis? E.g. in response to insult
-an insult withstood in younger people pushes elderly beyond their functional capacity - > decompensation, disease and death
Give 2 ways in which the kidney ages structurally?
- less renal mass,
- more fat and fibrosis
- tubular atrophy
Give 2 ways in which the kidney ages functionally?
- less compliance (as intimal fibrosis) less blood flow
- sclerosis of cortical nephrons -> non-functioning
- less renin, aldosterone, lower GFR
- poorer concentrating capacity (poor Na+ excretion)
What contributes to the poorer ability to maximally dilute urine and excrete water load with age?
- decreased max. urine osmolality
- decreased total body water
- decreased response to thirst
What do the 5 Is of Presentation of unwell Older people stand for?
- Immobility
- Instability
- Intellectual Impairment
- Incontinence
- Iatrogenic
List 2 consequences of immobility in older unwell people:
- pressure ulcers
- pneumonia
- dependence, death
List 2 consequences of instability in older unwell people:
- fractures
- immobility
- fear of falling
- traumatic intercranial haemorrhage, dependency
Delerium is a common syndrome characterised by what? (presentation, onset, course)
- disturbed conciousness, cognition or perception
- an acute onset
- fluctuating course
What are the 4 types of urinary incontinence?
- urge
- stress
- mixed
- functional
What is the response to cold? List receptors, and 2 responses
- central&periph thermal receptor send info to hypothal
- shivering
- More thyroid, catecolamine, adrenal activity
Shivering produces heat and increases what 3 things in the body?
- metabolism
- ventilation
- CO
What is “cold diuresis” why does it happen?
- cold induced increased urination to preserve heat
- vessel constriction to have less BF to skin, more to internal organs causes more fluid volume in core -> urine
Give 4 reasons the elderly are at an increased risk of developing hypothermia and its complications:
- less subdermal fat
- less shivering (sarcopaenia)
- social isolation, cognitive impairment
- chronic endocrine disease
- reduced physiologival reserve
- medications
What are some possible causes of an Osborn/J wave on an ECG? (as well as a normal physiological variant..)
- low temperature
- hypercalcaemia
- medications
- neuro insults (nitercranial HT, subarach haemorr.)
What growth factor made by osteocytes causes less vit D activation? What efefct does this GF have on phosphate levels?
FGF-23
Causes phosphate excretion
What do osteoblasts differentiate from?
Mesenchymal stem cells
What are osteoclasts derived from?
Heamatopoetic Stem Cells
What cell controls the balance of osteoblast:osteoclast activity? What are these cells terminal derivations of?
Osteocytes
-derived from osteoblasts
Via what network do osteocytes communicate with eachother and with surface cells and systemic circulation?
The Lacunar-Canaliculi Network
Give an example of facotrs favouring bone reabsorption and what favours formation?
- unloading favours resorption (bed-rest)
- loading like weight-exercise favours formation
Name 3 actions of PTH. e.g. stimulates bone remodelling (both ana & cata -bolic)
- released when Ca2+ is low
- stimulates 25-OH D3 to active vit D3 in kidney via 1-a hydroxylase
- stimulates Ca absorption in renal tubule, (phos. excretion)
Give 2 actions of vit D in terms of bone remodelling
- more Ca and phos. absorption from gut
- promotes osteo-clast/blast differentiation
- inhibits PTH release and 1-a hydroxylase
What is the action of Calcitonin??
- decreases Ca2+ when high
- inhibits osteoclast function
What effect does oestrogen have on the lifecycle of osteoclasts and osteoblasts?
- osteoclasts: promotes apoptosis
- osteoblasts: protects vs. death so more bone made
What effect does oestrogen have on oesteoclast differentiation?
Indirectly inhibits it
Receptor Activator of Nuclear Factor Kappa-B (RANK) is a surface receptor on which cells? Stimulating..?
- receptor on pre-osteroclasts
- stimulates osteoclast differentiation
RANK-ligand is made by: pre-osteoblasts, osteoblasts and osteocytes. What does it stimulate when bound to RANK?
-osteoclast differentiation
Osteoprotogerin (OPG) is released by osteocytes, what is its effect in binding to RANK-ligand?
- its a decoy receptor
- by binding to RANK-ligand it competes for RANK so downregulates osteoclasts
Sclerostin prevents the activation of the Wnt pathway, what effect does this have on osteoblast formation?
- sclerostin inhibits osteoblast formation
- as o.blast differentiation involves Wnt pathway
Osteomalacia is a loss of bone mineralisation. What is osteoporosis?
-loss of mineral and organic bone mass and density
List 3 causes of osteoporosis…age-related, endocrine…
- malignant bony metastasis
- systemic PTH-related hormone releasing tumour
- drug induced (glucocorticoids)
- end stage kidney disease
- inadequate nutrition
List 3 endocrine causes of osteoporosis:
- hypogonadism (/oestrogen deficiency)
- excess glucocorticoids (endo/exo.genous)
- hyperparathyroidism - benign PT tumour secreting
- hyperthyroidism
How is osteoporosis diagnosed?
- Bone Mineral Density (BMD) measured
- DEXA of e.g vertebrae, NOF
- T score -2.5 or lower
Risedronate and alendronate are examples of what class of drugs used to treat osteoporsis by inhibiting osteoclasts?
-Bisphosphonates
Denosumab is a mab against what? (used to treat osteoporosis by inhibiting osteoclasts)
-mab vs. RANK-ligand
Before pharmacological treatments of osteoporosis, what 2 things should be checked/confirmed?
- adequate calcium and vit D intake
- sufficient/appropriate exercise
What are the guidlines for HRT for menopause?
-short term (3-5yrs) to treat vasomotor symptoms at lowest effective dose is good
A “fall” is
unintentional/unexpected loss of balance
Give 2 most common causes of a fall in the elderly
- incorrect shifting of weight
- trip/stumble
What does the pneumonic ACE stand for in factors contributing to an elderly falling?
A-Age related changes
C-Comorbidiities
E-Environment
What age-related neurological changes occur that contribute to the risk of falling?
- loss of neurones, brain weight decreases
- neurones shrink, less connections
- more demyelinated neurones (slower)
- sensory impairment esp. extremities
- impaired vestibular system
What age-related muscular change occurs that contributes to the risk of falling?
- sarcopaenia (loss of muscle strength and mass)
- more loss in legs vs arms
What age-related postural changes occur that contribute to the risk of falling?
- CT becomes less elastic
- weaker muscles
- changes C.o.G. so harder to maintain postural stability when walking
What age-related gait changes occur that contribute to the risk of falling?
- reduced speed from 70yrs
- stride length shortens as calf muscles weaker and double support phase longer than swing
- reduced hip flexion/extension
- wider based gait
What are some co-morbidities for falling?
- stroke, arthritis, anaemia
- visual impairment
- dementia, delirium
- othostatic hypo, post prandial hypo
- incontinence (going at night)
List some class of drugs that may increase the risk of falls:
- benzodiazepines
- hypnotics, sedating anti-depressants
- opiates
- anti-epileptics
- diuretics
- alpha, beta-blockers
- antihistamines
List 3 extrinsic factors that may increase the risk of falls:
- lighting
- rails, mobility aids
- headroom
- rugs/carpets
- clothing/footwear
Falls can cause injuries and 2dry disease like infections, pressure sores, pain..what psychosocial consequences can falls cause?
- fear of falling
- decreased confidence
- loss of independence
- low mood, social isolation
To prevent falls we need to identify those at risk, assess the risk, reduce it and maintain this. Suggest ways to do these things..
..routinely ask, do a multifactorial risk assessment
- make an individualised intervention plan
- strenth/balance excercise program
- home hazard assessment
- eyesight and medication reviews
1 in 3 hip fractures die within the yr. 50% permanently disabled. Where is a hip fracture anatomically?
-break in upper quarter of proximal part of femur
What is a frailty fracture? A common one/site?
Fractures that occur as a result of normal activities (fall from standing height) Colles fracture (radius)
Hip fracture presentation on examination is usually..
- shortened and ext. rotated leg
- pain on movement
- cant weight bare
An intracapsular hip fracture is the neck of femur. repaired by hemiarthoplasty. What are 2 extracapsular hip fractures, what surgery?
- Trochanteric - dynamic hip screw
- Sub-trochanteric - Intramedullary nail
List 4 post. hip operation complications in the elderly:
- infection (pneumonia, wound)
- reduced mobility, pressure sores
- prosthesis failure
- delerium (1 in 2)
- heart disease, thromboembolism
What is the somtopause in regards to the ageing endocrine system?
- general decrease in protein syn., less GH
- decrease muscle mass and M.Rate (less IGF-1)
- more adipose deposition
- reduced BMD, more osteoporosis risk
- general decline in immune function
How does thyroid hormones secretion change with age? Effect?
- less T4 secretion, also less T4 hepatic excretion
- serum T3 and TSH decline so reduced BMR
- more autoimmune pathologies
What co-morbidities or medication affect thyroid hormones?
- HT, COPD, Diabetes
- Steroids, Lithium
How is the endocrine pancreas affected with age?
- ageing cells less sensitive to insulin
- B cells need higher BG to trigger insulin release
- more B cell apoptosis
- more insulin excretion from liver
What happens to the ageing adrenal gland in terms of aldosterone secretion and effect?
- less aldosterone, poor controlled BP more postural hypotension
- hyponatraemia contributes to this
An adrenal crises “Addisonian-like Crises” is a triad of what? NB: this is precipitated by infection, vomiting, major surgery…
-Hypoglycaemia, Hyponatraemia, Hypotension
low sugar, low salt, low BP
How does an adrenal crises “Addisonian-like Crises” present? How is it treated?
- confusion in the elderly and rapid clinical decline
- IV fluids and hydrocortisone (+IV glucose)
Osteoporosis is often primary, more osteoclast vs blast activity. What diseases may it be 2dry to?
- parathyroid disease
- hyperthyroidism
- Cushing’s
- low testosterone
What happens to the pineal gland with age? Effect?
- it calcifies
- melatonin changes -> sleep disturbance and cognitive impairment
What does the adropause refer to?
Less testosterone with age so lower libido, BMD, muscle strength
Testosterone can be given to improve the symptoms of the adropause, when is it contraindicated?
Prostate Cancer
How does the epidermis change with age? Consequence?
- less sebum produced
- epidermis thins and dermo-epidermal junction flattens
- more risk of infection
What factors cause older adults to have poorer ability to thermoregulate? More heat retention and quick dehydration?
- dermal thinning
- reduced moisture retention
- decreased ability to vasodilate capillary bed
- hypothalamic dysregulation making higher thirst threshold
How does pain and touch sensation change with age in the skin?
- less nerve endings due to dermal thinning so less sensation
- more neuropathic pain esp. if diabetes/micronutrient defieciencies
How does the endocrine (vit D, melanin) function of the skin change with age?
- less ability to make both vit D and melanin so more skin cancers
- less vit D so more fracture risk
How does the cycle of deconditioning with falls leading to incontince go..
- fall -> fear of falling -> altered gait
- limit world, walk less, less able, risk of immobility
- > more pressure injuries, cant get to toilet
- incontinence and more skin irritation here
What is a pressure injury?
-ischaemia/necrosis of soft tissue thats compressed between a body prominence and a hard surface occluding the blood supply
An ulcer is a “cone” injury, what does this mean?
-the wide base of cone is next to bone, tip is on surface what you see (injury worse than looks)
What are moisture lesions? (NB: treat with barrier creams)
- v. red/irritable lesions on skin surface often due to urine/stools or between skin folds
- only superficial, no necrosis
As moisture and pressure sores indicate immobility, poor nutrition or unmet care needs, what should be done?
Hollistic review
What is xerosis and why does it occur in older adults v commonly?
- dry skin
- less moisture retention and less sebum
What is xerosis worsened by in older adults? any conditions?
- AC, sitting by fire, soaps, rough clothing
- hypothyroidism, CKD, malnutrition, dermatisis
What is itchy skin often associated with? As such what is the first step in treatment…
-associated with dry skin-so treat the dryness first
Itchy skin can arise from what haematological conditions?
- IDA (iron deficient anaemia)
- polycynthaemia
- leukaemia
- lymphoma
What medication can cause skin itchiness?
-opiods
Small vessel vascuilitis presents how? Diagnosis by histoliogy showing..?
- “purpura” - raised palpable purple areas
- inflamed vessels on histology
What is pemphigoid on the skin? Consequences?
- intense dense large blisters from dermal layer
- can -> dehydration, hypothermia, pain
How are pemphigus and pemphigoid treated? What are the risks of the medication..
Steroids
- e.g. DM: can they check sugars? Administer med? Recognise hypos? Call for help?
- can you adjust dose?
- do they need to be an inpatient
What is cellulitis skin infection associated with? Onset? Presentation?
-associated with fevers and sepsis
-rapid onset, unilateral progressive redness
(NB: bilateral v.v.v. rare)
As cellulitis is often caused by a pathogen gaining entry beneath skin, what questions are important to ask?
- check between toes, ensure good foot care
- ask about skin breaks
- insect bites
- adequate moisture barrier?
What is the inflammatory condition “Lipodermatosclerosis” of the lower limbs usually due to?
Chronic Venous Insufficiency
Presentation of Lipodermatosclerosis (due to chronic venous insufficiency)?
- deep red colour
- acute flares -> red, painful, scaly, bilateral
- if chronic, brown haemosiderin may be deposited on insides of leg
Name 4 causes of swollen legs?
- fluid overload
- dependent oedema
- low-protein states
- lymphodema
- drugs
Fluid overload-> leg swelling is a consequence of what? Presentation? Treat underlying cause.
- HF (history important)
- swelling of skin with sub-cut. fluid
- bilateral and pitting
Dependent oedema looks similar to fluid overload, whats the difference? Where does it present?
- seen where gravity is, no relation to HF
- reduces with elevation above heart level
- doesnt ~go above knees
Low protein states -> nephrotic states, severe protein malnutrition..where will oedema be? What will urine dipstick show?
- all extremities, inc. hands, face, arms
- dipstick protein = +++
Drugs can cause fluid retention by interupting lymphatic drainage, give an example of a drug that may do this?
-antihypertensives e.g. amlodipine
Lymphodema causes swelling of legs, can be 1ry or 2dry. How does it present?
- chronic, thick skin, cracked skin
- squaring of the toes
Give 3 conditions which may lead to 2ndry Lymphodema?
- lymph node surgery
- severe cellulitis
- inflam. conditions (RA, exzema)
- venous disease -> overflow of fluid to lymph system
What changes occur in the oesophagus with age?
- slower peristalsis
- oesophageal sphincters lose tension so less contraction
There are many links between poor mouth care and systemic diesease. Name some signs of an unhealthy mouth:
- ulcers
- thrush
- bleeding/swolllen gums
- tooth decay
- dry mouth (xerostomia)
Give 3 ways to manage xerostomia (dry mouth)?
- frequent sips of cold water
- sugar free chewing gum
- water based moisturising sprays
- sugar intake control
- daily thrush check
Enteric NS neurodegenerates with age but gut transit time is unaffected. What is gut transit time v. sensitive to changes in?
- Thyroid hormone concentrations
- can be clinically prolonged transit time even in sub-clinical hypothyroidism
What changes lead to more foecal incontinence in older adults?
- reduced rectal wall elasticity
- tonic activity of ext. sphincter is lost at a smaller volume
- max. resting anal pressure and max. squeeze pressure decrease with age
Nutrition support is for malnourished patients, how are these defined?
- BMI<18.5, >10% unintentional weight loss in 3-6m
- eaten little/nothing in last 5+ days
- poor absorpative capacity
- sepsis as increased catabolism…
How does appetite change in older adults?
- eat less, usually only 1/2 the plate
- eat more from high contrast colour plates
If an older adult has lost a lot of weight, what 3 questions are important to ask?
- was it intentional
- how much have you lost
- since when?
What are common causes of unintentional weight loss?
- malignancy (20%)
- psychiatric disorder
- GI disease
- Hyperthyroidism (10%)
- CV
- nutritional/alcohol
How is constipation defined?
- hard stool more than once every 3 days
- difficulty initiating evacuation
- feeling of incomplete evacuation
How is constipation managed in older adults?
- more dietary fibre
- enough water intake
- maintain mobility where poss
- regular toiletting (use gastro-colic reflex)
How do Bulk forming Laxatives e.g. Fybogel work?
NB: cant take with opiods
- enable fluid to be retained in faeces
- increase peristalsis
- useful in patient with decreased ano-rectal tone
How do osmotic laxatives e.g. lactulose, macrogels and phosphate enemas work?
-soften stool by increasing water in bowel from elsewhere
NB: lactlulose -> bloating
How do stimulant laxatives e.g. Bisacodyl and Senna work?
- stimulate nerves that control muscles lining GIT
- causes muscle in large bowel wall to squeeze harder
How do stool softener laxatives work e.g. Docusate?
-“surface wetting agent” so surface of stools is permeable and water can be absorbed to increase the water content
What are 3 possible complications of constpation?
- urinary retention (as bladder neck compressed)
- overflow diarrhoea
- bowel obstruction and perforation
How may constipation impact someones quality of life?
-significantly interferes with many aspects of daily life..
- mood
- mobility
- normal work
- recreation
- enjoyment of life
Give structural and neurological abnormalities that may lead to Foecal Incontinence?
- Structure: anorectal abnormalities (sphincter trauma, rectal prolapse), congenital abnormalities
- Neuro: MS, stroke, pudendal neuropathy
Management of Foecal Incontinence depends on the cause, suggest some ways?
- gastro colic reflex and regular toilleting
- stool sample to rule out infection
- sigmoidoscopy if doesnt settle
- pelvic floor exercises
- laxatives e.g. loperamide, enema for overflow
