Ageing

Question 1

Ageing: define ageing, health and disability; identify the main causes and theories and summarise the challenges of ageing affecting society.

Answer 1

Ageing/senescence – biological process of growing old, with associated changes in physiology and increased susceptibility to disease and increased likelihood of dying.

Why organisms age – two main categories of thought:

1. Damage or error theories – accumulation of damage to DNA, cells and tissue.
   
   • E.G. loss of telomerases or oxidative damage.
   • This theory suggests that we can prevent ageing IF we can prevent this damage.
   • Mice in low diet - (3/4) reduce production of free radicals
2. Programmed ageing theories – genetic, hormonal and immunological changes lead to the cumulative deficits we see as ageing.
   
   • These theories suggest ageing is part of an inescapable/programmed process.
   • The cells sometimes just stop dividing
   • If we could alter our genes to

No single theory explains all that we know about ageing and no proven specific anti-ageing therapies in humans

• Population ageing – increasing age of an entire country due to increasing life spans and decreasing fertility rates.
  
  • This reflects the successes of healthcare but brings extra burden to society – e.g. cost

Better public health - increases life expectancy

Aging population:

• Increasing numbers of minority groups elderly
• Increasing education of older people
• Reduction in poverty
• More people are working for longer
• More complex/ nuanced retirement process

Ageing prevention:

• EXERCISE, smoking, alcohol, fruit and vegetable

Question 2

Discuss life expectancy

Answer 2

Life expectancy: statistical measure predictive how many years someone will live – the expected number of years a person can expect to live.

• Has been rising for many years:
  
  • 83 years for a baby girl born today (79 boy).
  • 80 years for a baby girl born in 1998 (75 boy).
• The graph shows the impact of increased life expectancy.

It is predicted there will be SMALL increases in the number of young people but the largest increase will be in the elderly

What challenges does society have to face due to the aging population?

1. Working life/ retirement balance- dependency ration
2. Extended healthy old age (not only life-expectancy) - social care changes
3. Caring for older people, Sandwich generation: 68% women (78% in paid work)
4. Medical system designed for single acute diseases

Question 3

Frailty

Answer 3

Frailty (in medical language) – the loss of functional reserve among older people which leads to impairment of their ability to manage everyday activities and increases the likelihood of adverse events and deterioration when faced with a minor stressor.

• E.G. young person with mild pneumonia may need AB treatment at home but will recover fine.
• E.G. old person with mild pneumonia may end up in hospital because pneumonia causes delirium and reduces mobility.

Treatment of frailty:

• exercise, nutrition, drugs

Question 4

Disease prevention in older people

Answer 4

Disease Prevention in Older People

• Older people are more likely to have an atypical or non-specific presentation of a disease.
• Atypical – symptoms of pathology don’t immediately link to the disease – i.e. falls, delirium.
• “Giants of geriatric medicine” – immobility, intellectual impairment, instability, incontinence, iatrogenic (problems due to receiving healthcare) problems.

Non-specific presentations – symptom is attributed to another cause or “old age” -> delays in treatmentNon-specific presentations:

Falls, reduced mobility, recurrent infections, confusion, weight loss, ‘not coping’, iatrogenic harm

Older people have less specific symptoms( shortness of breath) than chest pain or hemoptysis

Disease Management in Older People

• Atypical & non-specific presentations can lead to delays in treatment.
• Older people often present with multiple problems which all need to be managed simultaneously.
  
  • For this reason, geriatrics is a multi-disciplinary speciality.
• Changes in pharmacokinetics and pharmacodynamics can make drug treatments more dangerous in older people.
• Many drug trials have low numbers of older people, so the evidence for treatment is often extrapolated from younger people which may not always be accurate.

Question 5

Outline multimorbidity and explain reasons for polypharmacy

Answer 5

Multimorbidity

• conditions impact on one another
• treatment for one condition may impact
• worse QoL - depression
• increased functional impairment
• burden of treatment

Reasons for polypharmacy:

• Multimorbidity
• Guidelines/ QOF/ NICE
• Undetected non-adherence
• Infrequent review
• Poor communication

Question 6

Iatrogenic harm

Answer 6

Iatrogenic harm:

• Adverse reactions to medication
• Nosocomial conditions
  
  • Infections
  • Pressure sores
  • Constipation
  • Deconditioning
  • Delirium
  • Malnutrition
  • Incontinence
• Falls
• Psychological congitive disease

Question 7

Ageing brain: recognise the key physical and cognitive changes associated with the ageing brain.

Answer 7

Age-related changes – assessed with MRIs and CTs:

• CSF within the surrounding brain increases.
• Ventricles enlarge.
• Gaps between major gyri widen - lost connections
• 50% of normal elderly people show a degree of white matter change.
  
  • 2-3% decrease in brain mass from age 40/50 per decade eventually reaching 10% below maximum brain mass by around age 80.
• Significant impairment of cognition is NOT normal.
• Small relative cognitive ability: loss of executive function

Rates of dementia diagnosis have been low historically due to – only 70% of those with dementia are diagnosed:

1. Misinterpretation – older people have worse memory anyway.
2. Fatalism – can’t do anything about it so no reason to diagnose it.
3. Social isolation – so no one notices it.
4. Dementia vs. delirium:
   
   • Dementia – chronic, progressive, degenerative; causing a decline in cognition.
     
     • Most common types (Alzheimer’s and vascular) start with memory problems and progress to include all cognitive functions.
     • More common with increasing age.
     • Mild cognitive impairment – people that have MILD cognitive impairment, not enough to warrant a dementia diagnosis
     • Delayed speech interpretation
   • Delirium – acute episode of confusion, usually with a clear precipitant (i.e. infection).
     
     • Usually resolves but can progress to dementia.
     • Much more common in people that already have dementia.

Question 8

Cognitive assessment: identify the key issues associated with cognitive assessment of older adults and recognise the social and MDT management of the ageing population.

Answer 8

• Types of cognitive assessment: (screening tests)
  
  • Abbreviated Mental Test (AMT) and clock drawing tests – screen for cognitive impairment.
  • Montreal Cognitive Assessment (MOCA) – detailed examination in wide general use.
  • Mini Mental State Examination (MMSE) – slightly outdated and less widely used.
  • Confusion Assessment Method (CAM) and 4AT – tools to help distinguish between dementia and delirium.

Diagnostics tests

• Addenbrooke’s cognitive examination ( 40 minutes)
• Detailed psychometric test (hours)

Disadvantages of MOCA

• Education and language level will affect results
• Floor and ceiling effects
• Can be poorly administered
• Possibly practice/ coaching effect