Ageing Flashcards
Define ageing
Ageing is the process of growing older Biological Psychological/cognitive Social Ageing or senescence is the biological process of growing old, with associated changes in physiology and increased susceptibility to disease and increased likelihood of dying.
What is meant by life expectancy
Life expectancy is a statistical measure of how long a person can expect to live
By 2050, what percentage of the population is expected to be >60 in the u.K
30%
Currently, the number is between 10 and 30%
Summarise the changing nature of the older population
Increasing numbers of BAME 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 theories for ageing based on
Programmed ageing: based on Hayflick limit - whereby cells in culture will divide a certain number of times before stopping; results from telomere shortening on replication; ageing results from cells stopping dividing - and those with more active telomerase repair telomeres to live longer
Damage/error theories: cells accumulate damage over lifespan e.g. From radiation, toxins, free radicals, DNA damage - and these errors lead to ageing
Describe the damage or error theory of ageing
Damage or error theories describe the accumulation of damage to DNA, cells and tissues, for example loss of telomeres or oxidative damage, as the cause for ageing. Damage theories implicitly hold that if we could prevent or repair this damage then we could prevent ageing.
Describe the programmed theory of ageing
Programmed ageing theories describe how genetic, hormonal and immunological changes over the lifetime of an organism lead to the cumulative deficits we see as ageing. Programmed ageing theories tend to suggest this is part of an inescapable biological timetable, just as growth and puberty are programmed to occur.
What is important to remember about the different theories for ageing
No single theory explains all that we know about ageing, and there is widespread, active research into ageing from molecular to societal levels.
What does population ageing refer to
Population ageing refers to the increasing age of an entire country, due to increasing life spans, and falling fertility rates.
Population ageing reflects the successes of public health policies, education and socioeconomic development, but brings big challenges for societies as they try to adapt. The costs alone are a major challenge to all societies.
Describe how people age at different rates
No proven specific anti-ageing therapies in humans
People age at different rates
Chronological age vs biological age
Describe the changes in life expectancy
§ Life expectancy – the expected number of years a person can expect to live.
o 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.
o It is predicted there will be SMALL increases in the number of young people but the largest increase will be in the elderly.
Summarise how we can prevent ageing
No clinical treatments/prevention Positive health behaviours Exercise Stop smoking Drink less Eat well
The Khaw study showed that the people who practiced all 4 of these behaviours were more likely to live longer.
Summarise the different challenges that society faces as a result of population ageing
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
Identify the issue with the ageing population in terms of morbidity
Although life expectancy has increased, the healthspan has not increased, therefore we have more people with morbidities living in society.
For optimal longevity we need to increase the health span and compress the morbidity in a patient’s life expectancy
Describe the factors that influence health in older age
Not random
We age differently because of genetic inheritance and as a result of who we are. Depends on where we live, the healthcare that we have access to and our health behaviour.
Social economic class plays a big role
Years of healthy life increases linearly as the IMD deprivation score decreases (i.e the more affluent you are, the greater number of years of healthy life you live).
What is meant by the sandwich generation
1.25m sandwich carers in the UK caring for an older relative whilst bringing up children 68% women 78% also in paid work 88 000 (84% women) provide more than 35h of care/week
Describe the issues with social care
means-testing- it’s not like the NHS
Catastrophic costs- selling homes to pay for care
unmet need- people going without the support and care that they need
quality of care- 15-minute care visits and neglect
workforce pay and conditions:- underpaid, overworked staff
market fragility: care home companies going out of business
disjointed care: delayed transfers of care and lack of integration with health
the postcode lottery: unwarranted variations in access and performance
Describe the implications of the ageing population for the NHS
Increasing demand for primary, secondary and tertiary health care
Increasing complexity
Navigating the health and social care divide
Define frailty
Loss of biological reserve across multiple organ systems, leading to vulnerability to physiological decompensation and functional decline after a stressor event
Describe how frailty can precipitate to morbidity
Genetic and environmental factors interact via epigenetic mechanisms.
This leads to cumulative molecular and cellular damage
This leads to reduced physiological reserve in:
Brain
Endocrine
Immune
Skeletal Muscle
Cardiovascular
Respiratory
Renal
Physical and nutritional factors interact with this loss of physiological reserve to lead to frailty
A stressor event then takes place
Fraility leads to falls, delirium and fluctuating disability- which furthermore can reduce physiological reserve
the falls, delirium and fluctuating disability can lead to increased care needs, admission to hospital nd admission to long-term care
describe the relationship between frailty score and probability of survival and avoidance of institutional care
higher frailty score (out of 7) is associated with a lesser probability of survival and a reduced probability of avoiding institutionalised care
How can we prevent frailty
Have a healthy lifestyle- see the 4 big health behaviours
Describe how we can treat frailty
Exercise - improve bone density, lung capacity
Nutrition- increase protein intake
Drugs (possibly)
Prevention is better than cure
What are the ‘geriatric giants’ of non-specific presentations in the elderly
Falls Reduced mobility Recurrent infections Confusion Weight loss “Not coping” Iatrogenic harm
Describe how the presentation of diseases can differ in the elderly
Older people are less likely to have common, “textbook” symptoms of disease ACS Less likely to have chest pain PE Less likely to have pleuritic chest pain Less likely to have haemoptysis More likely to have other symptoms ACS More likely to have shortness of breath PE More likely to have syncope
Describe the issue with non-specific presentations in the elderly
Can often mean we miss the diagnosis :
80M with falls, mild confusion Depressed, hyponatraemia due to citalopram but actually Cryptococcal meningitis due to undiagnosed AIDS 85F with reduced mobility UTI but actually Staphylococcal osteomyelitis/discitis 90M with confusion and fever UTI but actually herpes simplex encephalitis
What is meant by multi morbidity
Multimorbidity is two or more chronic conditions
Why does multi morbidity exist
Conditions impact on one another- effect of heart failure on COPD and lung infections
Treatment for one condition may impact on another- can’t take beta blockers for heart failure if they have peripheral vascular disease
Describe the negative impacts of multi-morbidity
Negative impacts Worse QoL, more likely to be depressed Increased functional impairment Burden of treatment Polypharmacy
Describe the issue with polypharmacy in the elderly
20% of >65s take 10 or more drugs
Why is polypharmacy such an issue in the elderly
Multimorbidity
Guidelines/QOF/NICE
Undetected non adherence- patient given anti-hypertensives but doesn’t take them, so BP stays high, doctor prescribes more to lower BP- communication essential.
Infrequent review- not deprescribing drugs when condition improves
Poor communication
Describe potentially inappropriate polypharmacy
Up to 40% of prescriptions are inappropriate
Polypharmacy is associated with bad outcomes
Falls
Increased length of stay
Delirium
Mortality
Give an example of iatrogenic harm
79F with high blood pressure Amlodipine Ankle swelling as a result of amlodipine Furosemide Postural hypotension Fall and Colles fracture
Describe the different causes of iatrogenic harm
Adverse reactions to medications Nosocomial conditions Infections Pressure sores Constipation Deconditioning- lose muscle mass due to being bed bound Delirium Malnutrition Incontinence Falls Psychological/cognitive damage
Describe the impact of adverse drug reactions in the elderly
Up to 17% of hospital admissions are due to drug reactions
The more medications taken, the greater the risk
Particularly with NSAIDs- increased MI risk ,stroke risk and risk of GI bleeding
Why are older people at an increased risk of adverse drug reactions
Reduced physiological reserve Impaired compensation mechanisms Comorbidities Polypharmacy Cognitive impairment
Describe the comprehensive geriatric assessment
CGA in the community1 Reduce admissions to institutional care Reduce falls Most benefit in mild or moderate frailty CGA for frail inpatients2 Reduces inpatient mortality Reduces functional and cognitive decline Reduces admission to institutional care
Summarise the comprehensive geriatric assessment
Multidisciplinary assessment Medical Functional Social Psychological/psychiatric Problem list Plan
What is the role of the emergency department
Diagnosis Fall Fractured humerus Plan M obilise Collar and cuff Fracture clinic
What is the role of the CGA
Problem list Fall, cause currently unclear Unsteady gait Fractured humerus ?Osteoporosis Cognitive impairment, likely dementia Poor medication compliance
Plan ECG Lying and standing BP Collar and cuff Fracture clinic Calcium/vit D Alendronate Collateral history re cognition MOCA …
Describe the use of rehabilitation
Aim is to restore or improve functionality
Multidisciplinary
Rehabilitation alongside acute illness
Preventing deconditioning
Prehabilitation- before major surgery to improve outcomes
Describe the anatomical changes in the elderly brain
Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) scanning in healthy elderly people has shown that the volume of cerebral spinal fluid within the surrounding brain increases with age, the ventricles enlarge and the gaps between the major gyri widen. About 50% of normal elderly persons show some degree of white matter changes. The brain attains a maximum weight at about 20 years of age and remains at this weight until 40-50 years of age after which it decreases in weight at a rate of 2-3% per decade eventually reaching a value of some 10% below maximum by age of 80 years
Neural changes: number of neurones doesn’t change, but gyri enlarge as atrophy occurs when connections broken
lose both white and grey matter, supporting cells such s microglia
Ventricular enlargement
What are some of the normal cognitive changes in older people
Processing speed slows
Working memory slightly reduced
Simple attention ability preserved, but reduction in divided attention
Executive functions generally reduced
Which of the following cognitive changes are not normal in older people
No change in nondeclarative memory
No change in visuospatial abilities
No overall change in language (some reduction in verbal fluency)
What is dementia
Decline in all cognitive functions, not just memory Impairment of function Progressive Degenerative Irreversible
How can dementia be prevented
By particpating in all the health behaviours!!
What are the major subtypes of dementia
Alzheimer’s - usually presents with memory loss
Vascular - usually presents with major delay in cognitive processing
Dementia with LB
Parkinson’s
Frontotemporal
Summarise the different causes of dementia
HIV
Progressive multifocal leukencephalopathy (PML)
Neuro syphilis
Thiamine deficiency
Pellagra (niacin def)
Hypothyroidism
Alcohol
Huntingdon’s Multiple sclerosis Progressive supranuclear palsy (PSP) Corticobasal degeneration (CBD) Multisystem atrophy (MSA) Posterior cortical atrophy Creutzfeld-Jakob disease (CJD)
Normal pressure hydrocephalus
Post “insult” cognitive impairment (eg stroke, head injury, encephalitis)
Why is the diagnosis rate of dementia low
Some aspects of cognition change as a person ages, but significant impairment of cognitive function is not normal, even in the oldest old, and indicates that there is a problem. Rates of diagnosis of dementia have been low historically, due to a combination of misinterpretation (it’s normal for older people to have poor memory), fatalism (we can’t do anything about it so what’s the point in diagnosing it) and social isolation of some older people, such that they have no one to notice any problems. Locally, around 70% of those with dementia have a diagnosis
65% average in the UK
Describe the different screening tests we have for cognitive assessments
Screening tests
AMT, clock drawing test, 4AT, GP COG, 6CIT…
Mini Mental State Examination (MMSE)
Montreal Cognitive Assessment (MOCA)
Describe the different diagnostic tests we have for cognitive assessments
Diagnostic tests
Addenbrooke’s Cognitive Examination (ACE)
Detailed neuropsychometric testing
Describe the different sections of the MOCA
Visulospatial/ Executive:
Draw a 3D cube, match letters with numbers, draw a clock with time
Naming: name different animals
memory: repat list of words, 2 trials, one 5 minutes later
Attention: Read list of digits both in forward and reverse order, read list of letters- subject must tap his knee when A is read, serial 7 subtraction starting at 100
Language: repeat sentences, name maximum number of words in 1 min that begin with F
Abstraction: similarity between banana and fruit
delayed recall - -optional
orientation - where are we, what date etc
Out of 30
>26 normal
add 1 point if education <12 years
Describe the advantages of moca
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
What disadvantages of moca
Education level will affect results Language level will affect results Floor and ceiling effects Can be poorly administered Possibly practice/coaching effects
Describe problems with cognitive assessments in general
Hearing and visual impairment may limit testing
Physical problems may limit testing
Most assume numeracy and literacy
Most assume some basic cultural knowledge
Depression can masquerade as dementia
Not valid in acute illness
Normal cognitive changes (slower processing speed, slower reaction times) may affect administration
Distinguish between delirium and Alzheimer’s
It’s important to distinguish between dementia and delirium, which are both diagnoses, and terms such as confusion, cognitive impairment, being muddled etc, which are nonspecific and can refer to either.
Dementia is a chronic, progressive, degenerative disease which causes a decline in cognition. The most common types of dementia (Alzheimer’s and vascular) often start with memory problems, but over time will include all cognitive functions. Dementia is more common with increasing age. Mild cognitive impairment is a specific term used to refer to people who have mild problems which do not interfere with their day-to-day life and don’t meet the diagnostic criteria for dementia.
Delirium is an acute episode of confusion, usually with a clear precipitant such as infection or medication changes. Delirium usually resolves, but can leave some people with residual problems (ie dementia). Delirium is much more common in people who already have dementia.
Summarise management in elderly patients
Atypical and non-specific presentations can lead to delays in treatment when the underlying problem is not recognised.
Older people often present with multiple problems, which all need to be managed simultaneously. Using the example above, a young person with mild pneumonia has only one problem but the frail, older person described has three – mild pneumonia, delirium and reduced mobility. All these problems need to be managed simultaneously for a successful outcome.
For this reason, Medicine for the Elderly is a multidisciplinary specialty, involving doctors, nurses, therapists, social workers etc. Geriatricians never practice alone!
Changes in pharmacokinetics and pharmacodynamics can make drug treatments in older people more likely to cause harm. This is not a reason to deny treatment to older people, if it is indicated, but should cause doctors to think carefully before they prescribe.
Many drug trials have low numbers of older people, so the evidence for treatment is often extrapolated from younger people. In the past it was common to exclude older people from drug trials altogether.
Describe the issue with frailty
Frailty is a common problem in older people. Referring to older people as frail is common in lay language as well, but frailty has a specific meaning in medicine. It refers to the loss of functional reserve among older people which causes impairment of their ability to manage every day activities, and increases the likelihood of adverse events and deterioration when they are faced with a minor stressor. For example, a young person with mild pneumonia may need treatment with antibiotics at home, but will usually recover without any other treatment. A frail, older person with mild pneumonia may end up in hospital because the pneumonia causes delirium and reduced mobility.
Describe some of the issues with treating the elderly
Non-specific presentations can mislead both doctors and patients, when they attribute symptoms to another cause or “old age”, and lead to delays in treatment.
Iatrogenic problems are illnesses caused by receiving healthcare treatments and are more common in older people.
They include mistakes in providing care, and known complications of treatment.
What are the giants of geriatric medicine
These are the so-called the “giants of geriatric medicine” – immobility, intellectual impairment, instability, incontinence and iatrogenic problems.
