HNS57 When We All Become Methuselah

Question 1

Factors for global aging

Answer 1

1. Increase longevity
   - measured by Life expectancy (LE)
   —> Average number of years an individual of a given age is expected to live if current mortality rates continue to apply
   —> Life expectancy at birth: average number of years a newborn is expected to live if current mortality patterns at the time of birth remain constant
   —> Universal improvement in LE except some African countries due to AIDS
   —> Exponential increase with average annual income (***level off eventually)
   —> HK LE increasing
2. Decreasing newborn
   - measured by Fertility rates
   —> Average number of children that would be born to a woman over her lifetime
   —> Sharp decrease in fertility rates observed around the world
   —> ***Lower than Replacement rate (average fertility rate of 2.1 children per woman) in recent years

Question 2

Projected scenario of global population aging

Answer 2

Between 2000 and 2050:

• proportion of >60 around the world: from 11% —> 22%
• absolute number of people >60 from 605 million —> 2 billion
• number of people >80 quadrupled to 395 million

No similar historical precedent

Question 3

Low and middle income countries

Answer 3

Population aging particularly serious problem in Low + Middle income countries
Because:
- experiencing most **rapid and dramatic demographic change (esp. countries with large population)
- similar disease pattern / **double burden (CD + NCD)
- poor accessibility to ***affordable health care

Question 4

Problem of population aging in HK

Answer 4

Hong Kong is undergoing a demographic transformation with significant increase in both number + proportion of older people in population

From 2011 to 2039:

• > =65: 0.9 million —> 2.5 million
• > =85: more than double, fastest-growing age group

Implications:
1. Working population reducing (↓ proportion of working population aged 15-64 to one elderly person >=65)

Question 5

Implication of population aging in clinical practice

Answer 5

Increase demand for healthcare services (outpatient, inpatient, chronic care etc.)

Question 6

Health issues in elder population

Answer 6

1. Physiological changes and multiple concomitant health problems
   - NCDs
   - Dementia, Alzheimer’s disease
2. Long-term care (quadruple by 2050)
   - Nursing, community care and assisted living, residential care and long stays in hospitals
3. Vulnerability
   - Maltreatment (4-6% in developed countries)
   - During crisis and emergency situations

Question 7

Functional capacity over life course

Answer 7

e.g. Ventilatory capacity, Muscular strength, Cardiovascular output

Increases in childhood
—> Peaks in early adulthood
—> followed by decline

Rate of decline depends on:
—> Risk factors exposed during whole life course e.g. diet, smoking, alcohol, physical activity, external and environmental factors
—> Life course approach of disease prevention is important
—> changes in environment can lower disability threshold —> ↓ number of disabled people in a given community

Question 8

Increasing physiological heterogeneity

Answer 8

• Increasing physiological heterogeneity on aging e.g. CVS endurance, lung capacity, cognitive ability
• Widened definition of “normality” in elderly
• However, Common finds =/ Normal
  —> e.g. hypertension, osteoarthritis, dementia
• Importance of understanding patients’ understandings and expectations about aging
• Same disease can present very differently

Example:

• 90 yo with dementia who develops pneumonia —> may present with delirium
• 90 yo with OA and neuropathy who develops pneumonia —> may present with fall
• 90 yo with no “weak link” who develops pneumonia —> may present typically

Question 9

Geriatric disorders

Answer 9

Usually disabilities rather than discretely defined diseases

Assessment:

1. ADL: dressing, eating, walking, going to bathroom, bathing —> Severe functional disabilities and define dependency
2. Instrumental ADL: shopping, housekeeping, accounting, meal preparation, travel —> Less severe than ADL but clearly cause dysfunction and lead to dependency

Normally:
65-69: <10% need help with ADL/IADL
>85: 60% need help with IADL, 40% need help with ADL

Question 10

Dementia as problem of population aging

Answer 10

Dementia: syndrome that affects memory, thinking, behaviour and ability to perform everyday activities

Can present with large variations
Stages of dementia and common presentations:

• Early stage: memory loss with decreased ability to think
• Intermediate stage: easily get lost, mood changes and behavioural problems, need assistance with daily activities
• Late stage: language impairment, cannot recognise relatives, may become incontinent and totally dependent

Question 11

Causes of dementia

Answer 11

1. Alzheimer’s disease (most common, 65%)
   - cause unknown
   - moderately strong hereditary component
   —> ***APOE (Apolipoprotein E gene) polymorphism —> Odds ratio: 3.57
2. Vascular dementia
   - due to multiple minor strokes
   - affect about 30% of elderly with dementia
3. Other causes
   - brain tumour
   - head injury
   - vit B12 deficiency
   - drug / alcohol abuse
   - hypothyroidism
   - depression

Question 12

Epidemiology of dementia

Answer 12

• Mainly older people
  —> growing awareness of cases before 65
• Worldwide prevalence growing with population aging
• Much of increase will be in ***developing countries
  —> 62% people with dementia live in developing countries (by 2050 71%)

Question 13

Situation of dementia in HK

Answer 13

• Prevalence of dementia >70: 9.3% (Female: 15.3%, Male: 8.9%)
• Incidence of dementia increased with age and approximately doubled for every 5 years
• Affecting approximately 1 in 4 by 90
• Alzheimer’s account for 64.6%, Vascular dementia 29.3%

Question 14

Diagnosis and treatment gap of dementia

Answer 14

Diagnosis usually made at relatively late stage

• Most people currently living with dementia have ***NOT received formal diagnosis
  —> NO access to treatment, care, organised support

—> Globally: 28 out of 36 million unrecognised
—> High income countries: only 20-50% cases recognised and documented
—> Low, Middle income countries: much worse (~90% remain unidentified in India)

Question 15

Common clinical presentations of dementia patients

Answer 15

Rather subtle esp. in early stage, not easy to recognise
—> need to go through details of health history
—> compare present and past

1. Impaired ability to acquire and remember new information
   - repetitive questioning / conversations
   - misplacing personal belongings
   - forgetting events and appointments
   - getting lost on a familiar route
2. Impaired reasoning and handling of complex functional tasks to an extent it interferes with everyday activities
   - inability to manage finances
   - poor decision-making ability
   - inability to plan complex / sequential activities
3. Language impairment
   - having difficulty thinking of common words while speaking
   - hesitations
   - speech, spelling, writing errors
4. Decline in emotional control / motivation
   - emotional lability
   - irritability
   - loss of empathy
   - loss of drive
   - social withdrawal
   - decreased interest in previous activities
5. Change in personality and behaviour
   - coarsening of social behaviours
6. Impaired visual-spatial abilities
   - inability to recognise faces / common objects
   - inability to find objects in direct view despite good visual acuity
   - inability to operate simple instruments / orient clothing to body

Question 16

Screening of dementia

Answer 16

• No programme of routine screening in whom cognitive impairment is not otherwise suspected
• Opportunistic screening in primary health care settings using currently accepted cognitive and memory tests
  1. MMSE (max score 30, test 5 areas: Orientation, Registration, Attention/Calculation, Recall, Language)
  2. Abbreviated mental test (AMT): 10-question test to screen for cognitive impairment in geriatric patients, test include Short term memory, Long term memory, Attention, Orientation —> Less time-consuming (Sensitivity 96%, Specificity 94%)
• Should be suspected when:
  —> impairment in memory
  —> + impairment of >=1 other area of higher cognitive functioning (e.g. judgment, abstract thinking, complex task performance, agnosia, apraxia, visuospatial awareness, personality change in context of deficits) that interferes with normal social and executive functioning in an otherwise alert person

Question 17

Management of dementia

Answer 17

Seek early medical advice / treatment if there is suspicion of dementia —> however no cure for dementia

1. Medications for improving memory / cognitive functions in early AD
2. Medications for non-cognitive symptoms such as depression, psychotic features, sleep problems
3. Behavioural therapy for improving memory and cognitive function
4. Education, counselling, support groups to patients and carers

Question 18

Public health impact of dementia

Answer 18

• Impact on patients as well as their families and caregivers
• Most caregiving is provided by informal caregivers
  —> e.g. spouses, adult children, other family members, friends
  —> themselves prone to mental disorders (e.g. depression, anxiety)
  —> themselves often in poor physical health
  —> economical impact on work flexibility
• Lack of awareness and understanding of dementia in most countries
  —> Stigmatisation
  —> Physical, Psychosocial, Economical impacts on caregivers, families and societies

Question 19

Cost of dementia in society

Answer 19

1. Informal care (unpaid care by family / others)
2. Direct cost of social care (community care professionals, residential home settings)
3. Direct cost of medical care (costs of treating dementia, other conditions in primary and secondary care)

About 70% of costs occur in Western Europe and North America (availability and affordability of services)

Informal care + Direct cost of social care: Similar proportions
Direct cost of medical care: Much lower

However, in low and middle income countries
—> Informal care cost: Majority of total costs
—> Direct cost of social care and medical care: Negligible (availability and affordability of services)

Question 20

Economic impact of dementia

Answer 20

Total estimated worldwide cost of dementia in 2010:

• US $604 billion
• ~1% of world’s GDP

Question 21

Summary

Answer 21

Dementia is a public health priority

• closely related to population aging problem
• make dementia a public health and social care priority everywhere
• promote dementia friendly society to improve attitudes to and understanding of dementia
• invest in health and social systems to improve care and services for people with dementia and their caregivers
• increase research on dementia

—> reduce stigmatisation, improve diagnosis of potential cases