All Flashcards
prep for exam (144 cards)
1
Q
Frailty triangle
A
Sarcopenia, Malnutrition, chronic Inflammation
2
Q
Malnutrition
A
Undernutrition, overnutrition, inflammation
3
Q
Greenhouse gasses
A
CO2, CH4, N20, Flourinated gasses
4
Q
Austria temperature changes
A
+2C since 1880, +1C since 1980
5
Q
Global temperature changes
A
+0.85C since 1880, +0.5C since 1980
6
Q
Greenhouse effect
A
Climate System: solar radiation from sun to earth, about half absorbed by earth’s surface and warms it, some reflected by atmosphere and earth, infrared radiation emitted from earth’s surface
Greenhouse Effect: some of the infrared radiation passes through the atmosphere but most is absorbed and re-emitted in all directions by greenhouse gas molecules and clouds (water vapor) = warms lower atmosphere and earth
7
Q
Climate change - Vulnerability - Probability
A
Condition —- Vulnerability —- Probability
Heat exposure —- High (risk groups), moderate (general population) —- High
Extreme events —- Moderate – high (depending on region) —- High
New emerging pathogens, allergens, food safety —- Less robust Assessment possible —- Low
8
Q
Classical Test Theory - psychometric properties
A
Objectivity – The result does not depend on the person who administers the instrument.
Validity – The instrument measures what it intends to measure.
Reliability – Readministration of an instrument leads to the same result, inter-rater (different raters) and intra rater (same rater twice) reliability
Sensitivity to change – the instrument measures the change produced by the intervention
9
Q
Evidence-based medicine - Sackett definition
A
integration of the best research evidence with clinical expertise and patient values
10
Q
Economic evaluation - Drummond definition
A
the comparative analysis of alternative courses of action in terms of both theirs costs and their consequences
11
Q
Types of economic evaluation
A
Type/outcome unit
Cost-minimisation: equal effectiveness and safety of interventions
Cost-effectiveness: natural units (life years, cases detected…)
Cost-utility: QALY (longevity and quality of life)
Cost-benefit: monetary valuation of outcomes
12
Q
Opportunity cost
A
the potential benefits which are sacrificed when resources are committed to one purpose rather than another; = the health benefit that could have been achieved had the money been spent on the next best alternative intervention
13
Q
economic evaluation perspective
A
affects what costs are included
individual, government, health provider, society
14
Q
Austrian finance of health expenditure (2014)
A
33% general government 45% social security 17% private out-of-pocket 5% private insurance (fairly close to EU28 average)
15
Q
Austrian health expenditure (2014)
A
11% GDP (typically 10-11% every year)
36.25 billion
16
Q
Austrian health care system
A
Bismarck type
17
Q
Austria private insurance
A
~35% of population has private insurance
direct payments, cost sharing
18
Q
Austrian hospitals (2014)
A
271 hospitals; 178 acute care
7.6 beds/1000
# beds declined 10% 2000-2010
19
Q
Austrian physicians (2009)
A
19,000
20
Q
Non-contract physician fees
A
Patients can claim reimbursement from their insurer - 80% of the relevant contract physician fee
21
Q
Long-term care allowance (1993)
A
independent of age, income level/availability of asset
care must be expected to be needed for at least 6 months
22
Q
Emission - Exposure
A
50% cars --> 62% 30% cities/homes? --> 31.5% 11% factories/industrial? --> 5.4% 9% refineries? --> 1.3% rainbow graphic
23
Q
Ecological Crisis
A
humans have always affected the ecosystem, but since the industrial revolution, anthropogenic effects on ecosystems increased quantitatively and qualitatively
population growth –> demand on resources
24
Q
Prevalence definition
A
Prevalence (P) is the number of cases (having a particular disease or health trait) in a population at a given time (Pt0 = point prevalence) or in a given time period (Pt1-tn = period prevalence). It corresponds to the sum of all cases (existing and new cases) and thus indicates the existence of a disease in a population.
Magnitude of epidemic
25
Prevalence equation
Number of persons with the illness or trait at a certain time (t0) or in a certain period (t1-tn)/Number of persons in the population at risk at a certain time (t0) or in a certain period (t1-tn)
* 100.000
26
Incidence definition
```
The incidence (I) describes the number of cases that newly occur in a defined population over a defined period of time. This "population at risk" is, strictly speaking, the sum of the individual time sequences each individual has spent under exposure (= risk) (e.g., sum of person years, if 1 year, then = number of persons). The incidence thus measures the occurrence of new cases (persons with a specific disease).
This means that at least two examinations would actually be necessary to determine the incidence: In a first step, the cases that already have the disease to be examined would have to be excluded from the study. They can not be included in either the numerator or the denominator because only persons who can get the disease (population at risk) can appear there. Then it would be necessary to determine in an observation period how many really new cases occur. Only new cases belonging to the observed population may be counted. For large populations, the incidence cases are not removed from the population under observation (denominator), as the distortion of calculated rate by them is in the decimal range and is irrelevant.
```
Danger of epidemic
27
Incidence equation
Number of persons who become ill during the observation period/Sum of the length of stay of each individual person in population at risk
* 100.000
28
Mortality
Number of deceased/Number of population
| * 1.000 or 10.000 or 100.000
29
Perinatal mortality
number of still-born, and those who died at birth and during the first week of life, relative to the number of live births in the same calendar year.
30
Infant mortality
Deceased in the first year of life, relative to the number of live births in the same calendar year.
31
Case Fatality (Lethality)
Number of persons with a certain disease who died during the observation period/Number of Persons who suffered from this disease within this time
* 100
(usually expressed as percentage)
32
relative number
E.g.: In Austria (2006) in total there are 3,360,072 men over the age of 15 years. Of these, 1,848,040 men are overweight or obese according to Statistics Austria's health survey. With these numbers (1,848,040 out of 3,360,072), the order of magnitude are not readily apparent.
This becomes much easier when calculating relative numbers: The numbers above correspond to a total of 55% of the male population over 15 years. At the same time, it also equals 550 per thousand (550 per 1000), or 5500 / 10,000, or 55,000 / 100,000 and 550,000 / 1,000,000 men. One could say so well that of one million men in Austria, 550,000 are overweight or obese.
33
rate
E.g.: In Austria in 2004 (= 1 year of observation) a total of 17,343 women were newly affected by cancer. This corresponds to a "new disease rate" (incidence) of 17,343 / 4,205,543 female-years = 412.4 / 100,000 female-years. This means that in 2004, of 100,000 (theoretically observed) women (= 100,000 person years), 412.4 had cancer.
34
Dietetic factors with convincing blood pressure lowering effects
body weight (+ visceral fat) - adverse - ++
salt (sodium chloride) - adverse - ++
60% salt-sensitive HT
potassium - protective - ++
supplementation problematic (overdose/GI issues), increase intake through food
alcohol - adverse - ++
sympathetic NS activation
DASH (dietary approaches to stop HT) diet - protective - ++
35
European guidelines on cardiovascular disease prevention in clinical practice
Characteristic of a healthy diet
➢Saturated fatty acids to account for <10% of total energy intake, through replacement by polyunsatureated fatty acids
➢ Trans-unsaturated fatty acids: as a possible, preferably no intake from processed food, and <1% of total energy intake from natural origin.
➢ <5g of salt per day
➢ 30-45g of fibre per day, from wholegrain products, fruits and vegetables
➢ 200g of fruit per day (2-3 servings)
➢ 200 g vegetabled per day (2-3 servings)
➢ Fish at least twice a week, one of which tob e oily fisch (omega 3, Vit. D)
➢ Consumption of alcoholic beverages should be limited to two glasses per day (20g/day of alcohol) for men and one glass per day (10g/day of alcohol) fo women.
36
Nurse Model
```
Naming: naming emotions
Understanding: showing understanding
Respecting: show respect for your opposite`s feelings and emotions
Supporting: offer support
Exploring: explore the background
```
37
medical pluralism
multiple medical systems/healing traditions coexist
| typically biomedicine dominant
38
hybridization
people see multiple types of care at the same time, such as TCM and biomedicine
often in places with resource shortages
39
idioms of distress
varieties of ways that people express their distress in a clinical setting
culturally-constructed but within a culture there is a wide range
40
bioculturalism
interaction between biology and culture in health and illness
pain is biological, but the expression and experience is cultural
culture/behaviour impacts infectious disease spread
41
biopower
form of social control within context of modern nation states
modern regimes of knowledge/practice --> control through dissemination of knowledge in institutionalized form
control turns into behaviour (choices are not independent - socially constructed)
M. Foucault
It relates to the practice of modern nation states and their regulation of their subjects through "an explosion of numerous and diverse techniques for achieving the subjugations of bodies and the control of populations"
42
syndemics
= synergistic epidemic
critique of treating diseases as isolated, distinct entitites, independent of social context
example: HIV and TB
the aggregation of two or more concurrent or sequential epidemics or disease clusters in a population with biological interactions, which exacerbate the prognosis and burden of disease.
43
structural violence
"suffering structured by historically given, economically driven, processes and forces that constrain agency" P Farmer
health systems reinforce political economic regimes of oppression
a form of violence wherein some social structure or social institution may harm people by preventing them from meeting their basic needs (such as institutionalized racism)
"the increased rates of death and disability suffered by those who occupy the bottom rungs of society, as contrasted with the relatively lower death rates experienced by those who are above them"
44
intersectionality
different aspects of social location are related
various forms of social stratification, such as class, race, sexual orientation, age, religion, creed, disability and gender, do not exist separately from each other but are woven together.
45
structural competency
ability of health care providers and trainees to appreciate how symptoms, clinical problems, diseases and attitudes toward patients, populations and health systems are influenced by 'upstream' social determinants of health.
46
Executive body of the most important organization in the Austrian health care system
Federal Health Commission
| Bundesgesundheitskommission
47
Which body funds public hospital care in Austria?
Health platforms of regional health funds
| Die Landesgesundheitsfonds, Gesundheitsplattform
48
Number of sickness funds in Austria
18
49
Compared to international peers, Austria stands out for what type of care?
being hospital-centered, relying less on ambulatary care
50
Compared to international peers, Austria stands out for which types of health staff?
high number of practicing physicians
| low number of nurses
51
Compared to international peers, Austria stands out for various items?
high number of day surgeries
| low number of midwives
52
Does Austria have gate-keeping?
No
53
Share of Austrian population covered by social health insurance?
99.9%
54
Austrian life expectancy (2015)
79 men
84 women
(81 average)
55
Approaches to health care financing
1) tax funded - UK (from general taxes)
2) social insurance - Germany, Austria (from employment tax) - Bismarck type
3) private insurance - USA, switzerland
56
Odds Ratio definition
The odds ratio is defined as the ratio of the odds of A in the presence of B and the odds of A in the absence of B, or equivalently (due to symmetry), the ratio of the odds of B in the presence of A and the odds of B in the absence of A. Two events are independent if and only if the OR equals 1
= RR if disease is rare
57
OR equation
AD/BC = (A/C)/(B/D)
EE*CN/CE*EN
(EE/EN)/(CE/CN)
58
Relative Risk (risk ratio) definition
the ratio of the probability of an outcome in an exposed group to the probability of an outcome in an unexposed group
RR = 1 means that exposure does not affect the outcome;
RR < 1 means that the risk of the outcome is decreased by the exposure;
RR > 1 means that the risk of the outcome is increased by the exposure.
= OR if disease is rare
59
RR equation
experimental event rate (EER) / control event rate (CER)
(EE/ES)/(CE/CS)
EE(CE+CN)/CE(EE+EN)
A(B+D)/B(A+C)
60
Selection Bias
Error from: 1) selection of participants (case-control) or 2) uneven dropout (cohort)
* Must depend jointly on exposure and disease
* systematic
61
Observation Bias
Error from the way information is obtained during the study
| *systematic
62
Recall Bias
Differential recall of information between study groups (such as based on disease status)
* Not possible in cohort studies
* systematic
63
Misclassification
error in assessment of data, such as error in confounding variable classification
1) random: towards the null (misclassification of subjects based on exposure does not depend on disease or vice versa)
2) non-random: away from the null (depends on other variables)
* systematic
64
Confounding
"mixing effect"
distortion of the effect of one risk factor by the presence of another factor
1) C must cause or be a risk factor of O
2) C must be related to E
3) C must not be on the causal pathway between E and O
stratified OR/RR are the same and/or are on the same side of the crude OR/RR
report adjusted OR/RR
65
Effect of randomization on confounding
blocks confounders from determining exposure
66
How to minimize confounding
design: restricting, matching, randomization
analysis: stratification, multivariate analysis
67
descriptive studies
case report/case series
ecological/correlation
cross-sectional
cross-sectional/assessment @ 1 point in time
68
analytic studies
```
Observational:
case-control (retrospective)
cohort (prospective)
Interventional:
RCT
```
69
Ecological Measures
aggregate measures of groups (mean, proportions)
| environmental, global measures
70
Ecological Fallacy
An ecological fallacy (or ecological inference fallacy) is a formal fallacy in the interpretation of statistical data that occurs when inferences about the nature of individuals are deduced from inferences about the group to which those individuals belong.
i.e. making inferences on the individual level using group-level data
71
Effect Modification
outcome-exposure relationship differs by level when stratified by a third variable
*different groups have different risk estimates
Want to highlight this, not bury it
stratified OR/RR are different
report stratum-specific OR/RR
72
Outcomes research definition
The study of the end results of health services that takes patients’ experiences, preferences, and values into account.
73
Outcomes - types
```
clinical signs and symptoms
intervention results
quality of life
functioning
pain, fatigue
what is most important for patients?
```
74
Rasch analysis
transform ordinal scale to metric interval scale
The probability of the response to an item is a logistic function of the ability of a person and the difficulty of an item.
75
Instrument vs. survey
instrument: to determine a specific concept, to test the ability of a person. needs to be psychometrically valid (use state-of-art instruments). designed to be used multiple times in multiple settings.
survey: develop questions based on theory. could be self-developed. designed to be used once.
76
value-based health care (Porter)
maximising the value of care for patients and reducing the cost of healthcare (patient outcomes/costs per patient)
77
research validity
intervention/therapeutic trials
RCT = best
non-randomized controlled trial
pre-post trial
78
problems with pre-post trials
Spontaneous course of the disease
Therapeutic effect of study participation
Regression to the mean („Physician‘s friend“)
79
simpson's paradox
observe no effect or the opposite effect when switching from amalgamated analysis to stratified analyses
80
PICO
Patient/Disease
Intervention
Control
Outcome
81
evidence grading
1a) systematic review or meta-analysis of RCTs
1b) at least one high-quality RCT
1c) all or none
2a) systematic review or meta-analysis of observational cohort studies
2b) at least one high quality (prospective) cohort-study or „low-quality“ RCT
3a) systematic review or meta-analysis of case-control-studies
3b) at least one high quality case-control-study
4) cross-sectional studies, uncontrolled or non-randomized interventional studies, case-series, „low-quality“ cohort- or case-control-studies
5) expert opinion, clinical reasoning
82
absolute risk reduction
personal risk * RR
| 2.2*0.6 = 1.3%
83
number needed to treat/harm
for example, per 100 people in 1 year
100/absolute risk reduction
(100/1.3 = 77)
84
cancer risk factors
smoking, unhealthy weight/low activity, alcohol, sun, genes, some infections
age!
85
carcinogens
damage genome, promote carcinogenesis
| classification structure, legal thresholds
86
harvesting
when environmental exposure causes deaths that were going to happen soon anyway - death rate returns to normal afterward
non-harvesting: causes premature deaths; death rate does not return to normal afterward
87
Effect chain of environmental agents
primary source (emission) > environmental media (immission) > incorporation (exposure) > resorption/distribution/metabolism/storage > biological effect/disease/death
88
how to observe chain of environmental agents?
emission assessment > analytics > dose assessment > biomonitoring > bioeffect monitoring, diagnostics
89
dose pathways
inhalation, ingestion, dermal, parenteral (blood)
90
key differences between inhaled agents?
for gas/vapor
is it water or lipid soluble?
water soluble - absorbed higher in lungs
lipid-soluble - goes deeper into lungs (alveols), stored in body longer
for particles/aerosols
size!
air velocity, directional change
example: danger of smog (smoke and SO2)
91
toxicokinetics
exposure > intake (absorption, distribution, toxification, resorption) > toxic product, target organ
92
consideration of half life of agent
may never go above the toxicity threshold even though the agent itself is technically toxic
OR may take some time to go over the threshold & then you stay over it
93
toxic effects of air pollution agents
```
psychovegetative
pulmonary
neurotoxic
nephrotoxic
hepatotoxic
```
94
influence of environmental contaminants on cancer
DNA - genome damage or epigenetic processes
| approx. 15%
95
carcinogenesis
main stages:
neoplastic conversion - DNA reaction, DNA damage, expression, fixation
neoplastic development - pre-neoplastic cell, promotion, progression, neoplasia
DNA change - mostly repair and/or apoptosis, if not > initiation (irreversible) leads to initiated cell - mostly apoptosis, if not > proliferation leads to pre-neoplastic focal lesion > promotion (reversible) leads to proliferation > neoplasia > more mutations, progression (irreversible) leads to malignant metastases
cancerous cell secrete growth hormone itself
96
development of cancer - cancer mechanisms
sustained proliferative signaling > evasion of growth suppression > resistance to cell death > cellular immortality > neoangiogensis > acquiring invasive properties
97
processes to prevent abnormal development
contact signals between cells, apoptosis trigger, telomerase (cell division counter), size constrained by passive nutrition
98
how does a cancerous cell circumvent the processes to prevent abnormal development?
secretion of growth hormone, blocking adhesion signal, mutation of p53 (lost ability to process apoptosis trigger), change telomerase signal path, induce growth of blood vessels to the tumor to facilitate active nutrition (secretion of VEGF), epithelial-mesenchymal-transition
99
genetic factors increasing risk of cancer
proto-oncogene > mutation > oncogene
*dominant > increased risk
tumor suppressor gene > mutation > loss of heterozygosity; haplo insufficiency
*recessive > increased risk
100
DNA damage - alkylation
formation of adducts by covalent binding of alkyl groups
destabilization of Abasic sites
101
DNA damage - adducts
formation of adducts by covalent binding of large molecules
block transcription
disturbance of DNA structure
chromosomal bridges and deletions
102
DNA damage - cross-links
covalent binding of bases across DNA strands
block translation and transcription
deformation
maybe frame-shift mutation
103
DNA damage - oxidation
oxidation of DNA bases
DNA cross-links
base mispairing
104
DNA damage - Deamination
hydrolysis of DNA bases
base loss
105
DNA damage - strand breaks
single- or double-strand breakage
breakage of chromosomes
deletions
genome instability
106
DNA damage - epigenetic processes
CpG methylation
histone modification
microRNA disturbance
107
rarity of cancer
~250 malignant transformations per day but 99.99% repaired
108
genotoxic carcinogens
Mutations
Aneuploidy
Rearrangement of chromosomes
Gene amplification
109
non-genotoxic carcinogens
* increase cell proliferation
* block apoptosis
* disrupt hormone activity
* modulate gene expression
* cause chronic inflammation
* are cytotoxic
* suppress the immune system
* cause oxidative stress
* cause epigenetic changes
110
Incremental Cost-Effectiveness Ratio (ICER)
(Cost1 - Cost2) / (Effect1 - Effect 2)
111
5 Ds
death, disease, disability, discomfort, dissatisfaction/destitution
112
what IS intersectionality?
IS:
- based on mutually constituted & intersecting social categories
- a way of understanding inequalities as dynamic relationships
- based on the understanding that power configurations are time/location dependent
- focus on structural/political factors which shape inequalities
- explores how social inequalities are shaped by power relations
- focus on implications for vulnerable/marginalized within a group
- researchers reflect upon how their own background identity shapes research process and interpretation of results
113
what ISN'T intersectionality?
- based on adding up advantages and subtracting disadvantages assuming equivalence between them
- static examination of inequalities which omit relational aspect
- group of a priori assumptions re: the importance of any one/multiple social categories
- focus on individual behaviour w/o consideration of structural/political constraints
- ignores impact of power relations on social inequalities
- focus on implications for those whose status are protected/elevated with a group
- researchers attempt to completely remove themselves from the research/analysis process
114
intersectionality wheel
1st ring: systems (politics, economics, history, education, law, etc)
2nd ring: isms, phobias (racism, sexism, homophobia, etc)
3rd ring: characteristics (social status, class, gender, education, ethnicity, work, etc)
4th ring: unique circumstances of power, privilege, and identity
115
research & intersectionality
ask questions:
who is being studied? who is being compared to whom?
who is the research for and does it advance the needs of those under study?
what is the frame of research?
116
public health action cycle
definition of the problem > defining strategy (policy) > implementation > evaluation > (circle)
117
definition of gender (Payne)
„Women ́s and men ́s identities as something „that is done“ as opposed to biological sex ascribed at birth according to external genitalia and where women and men ́s identity, behaviour and expectations placed upon them reflect socially constructed ideas about femininity and masculinity“
118
importance of gender
relational social determinant of health - alters the way we consider any of the social determinants of health, but the effectiveness of gender as a framework is dependent on how we understand it
119
gender medicine
sex-specific biology
| social construction
120
prevention and management of Type 2 diabetes (diet)
reduce: meat, esp. processed, red; sugary drinks; refined grains
eat more of: whole grains; green, leafy vegetables; coffee
121
dehydration
1-2.5% body mass: decline in performance
>3% body mass: decline in cognitive function and memory, increased heart rate, tiredness
higher: serious neurological symptoms
122
supplements
vitamin d during the winter!
vegetarians/vegans - iron (amount absorbed is much lower than amount consumed), esp for child-bearing women
B12
123
symptoms of dehydration
```
dry skin und mucosa
• fatigue und loss of concentration
• headache
• dizziness
• confusion (especially in elderly)
• obstipation
• risk for urinary tract infections and renal stones (chronic dehydration)
• rise of body core temperature
```
124
vitamin d
UV radiation is most important source; unavailable during winter months above ~50 degrees latitude
skin > liver > kidney > body
hormone-inducing genomic effects
up to 80% of calcium uptake in the upper small intestine is dependent on vitamin D
impacts muscle function - increased risk of falls, also fractures
~100 ng/ml
125
health aims for older adults
* Maintain quality of life
* Improvement independence
* Prevention of institutionalisation
* Management of chronic diseases
* Prevention of complications and co‐morbidity
126
Frailty definition
Frailty is theoretically defined as a clinically recognizable state of increased vulnerability resulting from aging‐associated decline in reserve and function across multiple physiologic systems such that the ability to cope with everyday or acute stressors is comprised.
127
SHARE frailty index
```
exhaustion (physical & mental)
loss of appetite
low physical activity
walking difficulties
slowness
weakness (grip strength)
```
```
frail = 3+
pre-frail = 1-2
```
128
weight management among elderly
improve and maintain physical function and quality of life and prevent dependence and institutionalization rather than prevention of medical problems associated with obesity.
minimize muscle and bone loss
BMI less important than other measures
activity > diet
129
activity recommendations
at least 150 minutes of moderate activity per week (or 75 minutes of high-intensity)
2x muscle strengthening
130
communication is not "being nice"
improves:
accuracy, efficiency, supportiveness
health outcomes for patients
satisfaction for patients and doctors
131
why do we need communication in medicine?
bridge between evidence-based medicine and successfully working with individual patients
```
create a collaborative partnership
collect data
provide information
establish treatment adherence
create a more effective consultation
```
132
problems in medical communication
```
bad relationship between dr. and patient
unsatisfied patients - complaints
unsatisfied doctors - work aggravation
adherence issues
"difficult patients"
lack of cooperation
```
133
Calgary guide to medical interview
1) initiate session
2) gather information
3) physical information
4) explanation and planning
5) closing the session
throughout: providing structure, building the relationship
134
core values of medical interviews
acceptance, authenticity, empathy (do not give up as if position)
135
WWSZ
warten, wiederholen, spiegeln, zusammenfassen
136
problems with information in medical communication
too much/too little information
unwanted information
incomprehensible information
137
Burger method
McDonalds - small quantity of meat
ask/listen
inform
ask/listen
138
medical anthropology definition
* Medical anthropology is the study of health, disease, illness and healing across the range of human societies
* Human experience
* Behaviors, ideas, organization of resources
* Understanding and response to challenges to their existence
* Access to or exclusion from resources health restoring and maintaining
* Social power and economic structures
139
medicalization
Process of rapid expansion of scientific medicine into various walks of human life
140
critical medical anthropology definition
political economy of health: study of inequalities
who and what is responsible for population patterns of health, disease, wellbeing - as manifested in present, past, changing social inequalities of health?
biological expressions of social inequalities
local biologies
individual sufferer's experience and macrosocial processes
141
training in old age prevents BIOLOGICAL issues
sarcopenia
falls
ADL deficits
insulin resistance
142
training in old age prevents PSYCHOLOGICAL issues
cognitive deficits
depression
fear of falls
143
training in old age prevents SOCIAL issues
social decline
reduced social participation
isolation
dependency
144
training in old age prevents BIG issues
low quality of life
frailty
morbidity
mortality
