Ageing

Question 1

Define ageing

Answer 1

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.

Question 2

What is meant by life expectancy

Answer 2

Life expectancy is a statistical measure of how long a person can expect to live

Question 3

By 2050, what percentage of the population is expected to be >60 in the u.K

Answer 3

30%

Currently, the number is between 10 and 30%

Question 4

Summarise the changing nature of the older population

Answer 4

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

Question 5

What are the two theories for ageing based on

Answer 5

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

Question 6

Describe the damage or error theory of ageing

Answer 6

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.

Question 7

Describe the programmed theory of ageing

Answer 7

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.

Question 8

What is important to remember about the different theories for ageing

Answer 8

No single theory explains all that we know about ageing, and there is widespread, active research into ageing from molecular to societal levels.

Question 9

What does population ageing refer to

Answer 9

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.

Question 10

Describe how people age at different rates

Answer 10

No proven specific anti-ageing therapies in humans
People age at different rates
Chronological age vs biological age

Question 11

Describe the changes in life expectancy

Answer 11

§ 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.

Question 12

Summarise how we can prevent ageing

Answer 12

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.

Question 13

Summarise the different challenges that society faces as a result of population ageing

Answer 13

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

Question 14

Identify the issue with the ageing population in terms of morbidity

Answer 14

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

Question 15

Describe the factors that influence health in older age

Answer 15

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).

Question 16

What is meant by the sandwich generation

Answer 16

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

Question 17

Describe the issues with social care

Answer 17

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

Question 18

Describe the implications of the ageing population for the NHS

Answer 18

Increasing demand for primary, secondary and tertiary health care
Increasing complexity
Navigating the health and social care divide

Question 19

Define frailty

Answer 19

Loss of biological reserve across multiple organ systems, leading to vulnerability to physiological decompensation and functional decline after a stressor event

Question 20

Describe how frailty can precipitate to morbidity

Answer 20

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

Question 21

describe the relationship between frailty score and probability of survival and avoidance of institutional care

Answer 21

higher frailty score (out of 7) is associated with a lesser probability of survival and a reduced probability of avoiding institutionalised care

Question 22

How can we prevent frailty

Answer 22

Have a healthy lifestyle- see the 4 big health behaviours

Question 23

Describe how we can treat frailty

Answer 23

Exercise - improve bone density, lung capacity
Nutrition- increase protein intake
Drugs (possibly)

Prevention is better than cure

Question 24

What are the ‘geriatric giants’ of non-specific presentations in the elderly

Answer 24

Falls
Reduced mobility
Recurrent infections
Confusion
Weight loss
“Not coping”
Iatrogenic harm

Question 25

Describe how the presentation of diseases can differ in the elderly

Answer 25

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

Question 26

Describe the issue with non-specific presentations in the elderly

Answer 26

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

Question 27

What is meant by multi morbidity

Answer 27

Multimorbidity is two or more chronic conditions

Question 28

Why does multi morbidity exist

Answer 28

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

Question 29

Describe the negative impacts of multi-morbidity

Answer 29

Negative impacts
Worse QoL, more likely to be depressed
Increased functional impairment
Burden of treatment
Polypharmacy

Question 30

Describe the issue with polypharmacy in the elderly

Answer 30

20% of >65s take 10 or more drugs

Question 31

Why is polypharmacy such an issue in the elderly

Answer 31

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

Question 32

Describe potentially inappropriate polypharmacy

Answer 32

Up to 40% of prescriptions are inappropriate
Polypharmacy is associated with bad outcomes
Falls
Increased length of stay
Delirium
Mortality

Question 33

Give an example of iatrogenic harm

Answer 33

79F with high blood pressure
Amlodipine
Ankle swelling as a result of amlodipine 
Furosemide
Postural hypotension
Fall and Colles fracture

Question 34

Describe the different causes of iatrogenic harm

Answer 34

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

Question 35

Describe the impact of adverse drug reactions in the elderly

Answer 35

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

Question 36

Why are older people at an increased risk of adverse drug reactions

Answer 36

Reduced physiological reserve
Impaired compensation mechanisms
Comorbidities
Polypharmacy
Cognitive impairment

Question 37

Describe the comprehensive geriatric assessment

Answer 37

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

Question 38

Summarise the comprehensive geriatric assessment

Answer 38

Multidisciplinary assessment
Medical
Functional
Social
Psychological/psychiatric
Problem list
Plan

Question 39

What is the role of the emergency department

Answer 39

Diagnosis
Fall
Fractured humerus
Plan
M obilise
Collar and cuff
Fracture clinic

Question 40

What is the role of the CGA

Answer 40

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
…

Question 41

Describe the use of rehabilitation

Answer 41

Aim is to restore or improve functionality
Multidisciplinary
Rehabilitation alongside acute illness
Preventing deconditioning
Prehabilitation- before major surgery to improve outcomes

Question 42

Describe the anatomical changes in the elderly brain

Answer 42

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

Question 43

What are some of the normal cognitive changes in older people

Answer 43

Processing speed slows
Working memory slightly reduced
Simple attention ability preserved, but reduction in divided attention
Executive functions generally reduced

Question 44

Which of the following cognitive changes are not normal in older people

Answer 44

No change in nondeclarative memory
No change in visuospatial abilities
No overall change in language (some reduction in verbal fluency)

Question 45

What is dementia

Answer 45

Decline in all cognitive functions, not just memory
Impairment of function
Progressive
Degenerative
Irreversible

Question 46

How can dementia be prevented

Answer 46

By particpating in all the health behaviours!!

Question 47

What are the major subtypes of dementia

Answer 47

Alzheimer’s - usually presents with memory loss
Vascular - usually presents with major delay in cognitive processing
Dementia with LB
Parkinson’s
Frontotemporal

Question 48

Summarise the different causes of dementia

Answer 48

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)

Question 49

Why is the diagnosis rate of dementia low

Answer 49

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

Question 50

Describe the different screening tests we have for cognitive assessments

Answer 50

Screening tests
AMT, clock drawing test, 4AT, GP COG, 6CIT…
Mini Mental State Examination (MMSE)
Montreal Cognitive Assessment (MOCA)

Question 51

Describe the different diagnostic tests we have for cognitive assessments

Answer 51

Diagnostic tests
Addenbrooke’s Cognitive Examination (ACE)
Detailed neuropsychometric testing

Question 52

Describe the different sections of the MOCA

Answer 52

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

Question 53

Describe the advantages of moca

Answer 53

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

Question 54

What disadvantages of moca

Answer 54

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

Question 55

Describe problems with cognitive assessments in general

Answer 55

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

Question 56

Distinguish between delirium and Alzheimer’s

Answer 56

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.

Question 57

Summarise management in elderly patients

Answer 57

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.

Question 58

Describe the issue with frailty

Answer 58

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.

Question 59

Describe some of the issues with treating the elderly

Answer 59

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.

Question 60

What are the giants of geriatric medicine

Answer 60

These are the so-called the “giants of geriatric medicine” – immobility, intellectual impairment, instability, incontinence and iatrogenic problems.