aging Flashcards
define aging *
it is the process of growing older - biological, psychological/cognitive, social
the biological process of growing old, with associated changes in physiology and increased susceptibility to disease and increased likelihood of dying.
define life expectancy *
a statistical measure of how long a person is expected to live
can define at different points eg LE at birth and LE at 65 might differ because of the things that have influenced your health
LE for baby girl in england is 83
describe the trend of age in the population *
worldwide population is aging - increasing LE and falling fertility rates
because of better nutrition, better public health, reduced violence, advances in medicine and better education
improved public health is the main factor
advance in medicine is one of the smaller contributers
describe the changing natyre of the older population *
Increasing numbers of BAME older people (ethnic minority)
Increasing education of older people - people reaching older age are better educated now - protective against dementia, predictions of high levels of dementia with aging pop hasnt happened
Reduction in poverty
More people are working for longer
More complex/nuanced retirement process - people leave and come back, come back part-time/to a different job
what are the 2 theories of aging *
programmed aging
damage or error theories
describe programmed aging *
aging is built into DNA - influenced by genetic, hormonal and immunological changes
cells in vitro divide for a certain time then stop - this is the hayflick limit - ie the number of times a cell divides before it stops
it is because of telomeres
cells count the number of times they divide and age, then cant make new cells - this is to protect them against cancer
if we could alter genes, improve telomerase or stop degradation of telomers could in theory increase LE
describe damage or error theories *
cells accumulate damage from radiation. radicals, DNA damage and misrepair and loss of telomeres
if we could stop DNA damage - could stop aging
mice on calorie restricted diets produce less free radicals = longer lives
summarise the theory of aging *
there are no proven anti-aging therapies in humans
people age at different rates - have the chronological and biological age - chronological is the actual age, biological is the age because of health behaviours - if unhealthy you will have a higher biological age than chronological age
unhealthy people more likely to die younger
both programmed and damage/error theories of aging probably contribute
20-20% of age is genetic - if have relatives that live until old age you will probably age slower - appear younger and have better organ function
can we prevent aging *
by stopping smoking, drinking excessively, doing more exercise and eating healthily
can stop protein glycation and free radical production
what challenges does population aging cause society *
- 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
describe the working life/retirement balance problem *
as a society we are not saving enough for retirement
there is autoenrolement when people get jobs into government pesion scheme but this is underfunded
pension was set at 65 because that was the LE - therefore pension was affordable for the government because they were only paying to 50% population
now people are living longer so people have to work longer - not unreasonable because people are more healthy at 65 - influences the complex move into retirement eg people working part time
what is the dependancy ratio *
the number of dependants (children, students and retired) compared to people of working age
describe the problem of extending healthy old age not just LE *
there has been an increase in LE for people of all classes - this is tailing off - perhaps because of austerity and the cut in social care and pension poverty - there is a decrease in LE in the most deprived women
we have been doing life extension - ie increasing LE but not affecting the onset of health problems so people are living longer in poor health - implications on the health service
we want to compress morbidity so people are living longer healthy lives
what effects health in old age *
genetic inheritance
where we live - noise/air pollution, job and stress
health behaviour
access to health care
the more well off = longer healthy LE
describe the problem of caring for older people *
social care budgets are cut - most councils have reduced the amount that they are spending in social care
3% of >65s are in care homes
care workers are paid minimum wage and do skilled jobs - many people who do these jobs are immegrants - people in UK dont want these jobs - therefore heathcare will be effected by effects on immegration
social care is means tested - if have assets or >£23000 asked to pay for your social care - people dont want to/cant afford it so they sell homes/go without
there is market fragility - care services are private and are commissioned by councils - they are going out of business because they cant afford it - council give less money to care businesses so people paying private subsidise it so that the care homes dont make a loss
there is disjointed care - delayed transfer of care and lack of integration with health
postcode lottery
what is meant by care home
nursing home - nurses present all the time - pts are bedbound and need tube feeding etc
residential homes - have carers that are less trained than nurses - the pts have dementia and need prompting etc but physically more capable than in nursing homes
what is the sandwich generation *
people who care for an older relative and bring up children <16yrs
1.25million in UK
68% women
78% also in paid work
88 000 (84% women) provide more than 35h of care/week
describe the problem with the design of the NHS for the aging population *
it was designed for single acute diseaes
not for people with multiple comorbidities
there are projects in primary care to improve care for older people - however have to think about the payment system for GP and hospital - this doesnt help us with reform
what are the implications of the aging population on the health service *
- Increasing demand for primary, secondary and tertiary health care - tertiary care because older people who wouldnt have been healthy enough for specialised care are now
- 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
can have mild frailty - still see people and are independant but need a bit of help
moderately frail
severe frailty - in care homes or are bed bound, very dependant
what are the factors that lead to frailty *
genetic and env factors linked by epigenetic mechanisms, lead to molecular and cellular damage
this reduces physical reserve in organ systems, influenced by physical activity and nutritional factors that causes frailty
what is the effect of frailty *
small stressor event is more likely to have severe effects of illness - push body over the edge
lost so much reserve that the mild stressor can push them into dependancy - they cant compensate and do the things they normally do
have falls, delerium, fluctuating disability = increased care needs, admission to hospital and long term care
4-5x more likely to die then healthy older people
can we prevent frailty *
yes - stop smoking, drinking, do exercise and eat healthy
can we treat frailty *
yes but difficult
through exercise which increases muscle mass and prevents loss of BMD, nutrition and possibly drugs
difficult because people who are frail need walking aidand are dependant on people
need very motivated person and support network
prevention is better than cure
what are the non-specific presentations of frailty *
called the geriatric giants - symptoms, not diagnoses
- Falls
- Reduced mobility
- Recurrent infections
- Confusion
- Weight loss
- “Not coping”
- Iatrogenic harm
how do older people present *
either non-specifically or with non-textbook symptoms
eg for an MI - less likely to have chest pain more likely to have SOB
for PE less likely pleuritic chest pain or haemoptysis, more likely syncope
this means that the correct diagnosis and treatment can be delayed = pt gets worse
what is multimorbidity *
2 or more chronic conditions
what is the problem of multi-mobidity *
Conditions impact on one another - more likely to have episodes of each condition
Treatment for one condition may impact on another
Negative impacts
- Worse QoL, more likely to be depressed
- Increased functional impairment
- Burden of treatment
- Polypharmacy - drugs will interact with each other
why do older people take more drugs *
Multimorbidity
Guidelines/QOF (quality outcomes framwork)/NICE - drive increase in prescription because each condition has a framework that doesnt consider other conditions
Undetected non adherence - people not adhering = unchanged symptoms on follow up so people are given more drugs (whether they take them is a different matter)
Infrequent review - deprescribing is becoming important - eg BP increases until about 80yrs so then need to remove antihypertensives
Poor communication
describe potentially innappropriate polypharmacy (PIP)*
Up to 40% of prescriptions are inappropriate
eg taking long term agents for insomnia (zopiclone), long term antipsychotics for dementia, long term opiates for non-cancer pain
Polypharmacy is associated with bad outcomes eg for long term antipsychotics and opiates for pain
- Falls
- Increased length of stay
- Delirium
- Mortality
give an example of iatrogenic harm form PIP *
high BP so given amlodipine - causes ankle swelling so pt given furosemide for HF
this causes postural hypotension = a fall and Colles fracture
this is the prescribing cascade - drugs given to treat the SE when actually the 1st drug should be removed and replaced
what can be iatrogenic harm *
it is medical care associated harm - older people are more suseptible - include mistakes in providing care, and known complications of treatment.
- adverse reactions to med
- nosocomial conditions - hospital acquired
- deconditioning
- Infections
- Pressure sores
- Constipation
- Delirium - acute delusion
- Malnutrition - hospital meals not enough
- Incontinence
- falls
- psychological/cognitive damage
describe with constipation is a problem *
people are frail so have less reserve so doesnt take much to push them into problems
they dont eat or drink so at risk of renal failure and are becoming weaker
describe deconditioning *
people stay in bed without moving - loss muscle mass and BMD
can lose 1Kg of muscle mass with 1 wk of bed rest
describe why incontinance is a problem *
increase dependancy - need carers to change pads
skin at risk
what is the problem with adverse drug reactions and why are older people more at risk *
- Up to 17% of hospital admissions are due to drug reactions
- The more medications taken, the greater the risk
older people more at risk:
- Reduced physiological reserve
- Impaired compensation mechanisms
- Comorbidities
- Polypharmacy
- Cognitive impairment
what drug is most likely to be the cause of hospital admin *
NSAIDS - GI bleeding, HF, renal failure
so rarely use NSAIDs in older people
what are the benefits of comprehensive geriatric assessments *
CGA in the community
- Reduce admissions to institutional care
- Reduce falls
- Most benefit in mild or moderate frailty
CGA for frail inpatients
- Reduces inpatient mortality up to 6months after discharge
- Reduces functional and cognitive decline
- Reduces admission to institutional care
what is involved in a comprehensive geriatric assessment *
MDT assessment - medical, functional, social, psychological/psychiatric
make a problem list of everything that is wrong with the pt
plan
describe rehabilitation *
aim is to restore or improve functionality
MDT
rehab alongside acute illness - preventing deconditioning
prehabilitation - get people as fit as possible before operation
what are the physical changes in the aging brain *
atrophy - reduction in grey and white matter
lose microglia and supportative structures
lose connections
ventricle size increase and can see the gyri (gaps between the gyri enlarge)
the volume of cerebral spinal fluid within the surrounding brain increases with age
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
what are the normal cognitive changes in older people *
processing speed slows - general speed that you do things - this is the white matter
working mem is slightly reduced
simple attention ability is preserved but reduction in divided attention eg driving and talking
executive functions are generally reduced
no change in nondeclarative mem ie implicit ability to be able to do things
no change in visuospatial abilities
no overal change in language (some reduction in verbal fluency - probably to do with the reduced processing speed)
what is dementia *
decline in all cognitive functions, not just memory
impairment of function
chronic
progressive
degenerative
irreversible
can we stop dementia *
yes - with stopping smoking, drinking, better food and exercise
what are the key types of dementia *
vascular - problem with processing speed
alzheimer’s - memory change and orientation problems
mixed
are we diagnosing all dementia cases *
no
screening tests - cognitive assessments *
AMT (10 point test), clock drawing test (get them to draw a clock and a time), 4AT, GP COG, 6CIT
mini mental state examination (MMSE) - not used clinically because it was designed for alzhiemer’s
Montreal cognitive assessment (MOCA) - replaced MMSE
diagnostic tests for cognitive assessments *
addenbrooke’s cognitive assessment (ACE) - 100 point test, take 20mins
detailed neuropsychometric testing - takes hours, delivered by psychologist
what are the advantages of MOCA *
covers a variety of domains of cognitive function
brief to administer - 10mins
validated in range of pop
available in translated versions
widely used so can compare and track change
what are the disadvantages of MOCA *
education level will effect the results - add 1 point if you have <12 yrs education but in reality lack of education will reduce the score more than 1 point
language level will effect results
floor and ceiling effects - very educated people will score high even if have dementia
can be poorly administered - invented as a free test so can be performed by untrained people
possibly practice/coaching effects
problems with cognitive assessments in general *
- Hearing and visual impairment may limit testing
- Physical problems may limit testing eg if cant hold pencil
- 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
eg of when drugs would be given for opposite effects *
this is potentially inappropriate polypharmacy
antihypertensive drugs and fludrocortisone to stop postural hypertension (ie to raise BP)
why can drug treatments be more like to cause people harm *
there are changes in pharmacokinetics and pharmacodynamics
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.
why have diagnosises of dementia been low
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.
what is mild cognitive impairment *
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.
what is delerium *
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.
