Intro

Question 1

10 leading causes of death in 65+

Answer 1

Cardiovascular disease, Malignant neoplasms, Cerebrovascular disease, chronic lower respiratory disease, Alzheimer’s, Diabetes, Influezna/Pneumonia, Kidney disease, all other accidents, septicemia, MVA

Question 2

Most common reported chronic conditions

Answer 2

HTN, arthritis, chronic joint symptoms, coronary heart disease, cancer, vision impairment, diabetes, sinusitis, ulcers, hearing impairment, stroke, emphysema, chronic bronchitis, kidney disorders, liver disease

Question 3

Leading Causes of Hospitalization 65+

Answer 3

Heart disease, pneumonia, CVD, malignant neoplasms, fractures, OA, chronic bronchitis, septicemia, volume depletion, psychoses

Question 4

Dynamics accompanying aging

Answer 4

Loss of social role (retirement, empty nest)
Loss of income
Loss of friends and family
Often, the loss of vital health
Loss of identity?

Question 5

Cellular Supply Theory

Answer 5

The cellular supply theory of aging looks at the decreased supply of nutrients to cells and tissues due to diminished blood flow into and out of cells.
Diminished nutrient supply will eventually result in cell death, tissue atrophy and loss of tissue function.
Cell death is also related to the accumulation of intracellular and extracellular waste products and toxins.

Question 6

Free Radical Theory

Answer 6

The uncontrolled buildup of free radicals causes accumulated damage to cellular membranes and the contents of cell, including DNA and RNA.
Sufficient damage results in the eventual death of the cell.

Question 7

Calorc Restriction

Answer 7

Mice/rats fed 30%-40% less food than they would typically eat, live approximately 40% longer than freely fed animals.
Mechanism is poorly understood but CR is believed to alter response to insulin/glucocorticoids, increase resistance to oxidative injury, decrease inflammatory processes and change in stem cell self-renewal, amongst others.

Question 8

Methionine Restricted Diets

Answer 8

Rats fed a diet containing reduced levels of methionine without caloric restriction were shown to live 40% longer than rats on a standard diet.
Mechanism though to be due in part to the rate of protein turnover, changes in DNA methylation, changes in levels or distribution of glutathione, changes in insulin, glucose and IGF-1.

Question 9

Single Gene Mutations

Answer 9

There are currently six mutations in mice that have been found to increase life span.
Mechanism is thought they all lead to a decrease in levels of IGF-1 (and also possibly GGH, prolactin, thyrotropin and thyroxine).
Epigenetics? Phenotype vs genotype?

Question 10

Autoimmune theory

Answer 10

The autoimmune theory of aging, proposed by Dr. Roy Walford, hypothesizes that B and T cells of the immune system weaken with age and malfunction.
B cells lose their ability to adequately attack bacteria, viruses and cancer cells and T cells lose their ability to adequately attack cancer cells and transplant cells.
When B and T cells malfunction, they often attack normal healthy body cells.

Question 11

Telomere

Answer 11

A telomere is a structure of non-coding DNA (DNA that does not convey genetic instruction) at each end of a chromosome.
Telomeres are essential for chromosome duplication during cell division.
They function as handles to pull the dividing chromosomes apart as the original cell divides into two new cells.
However, the process of cell division permanently destroys a tiny fragment of the telomere with each division.

THEORY
Human embryonic cells in culture have a finite life span, that is, only a limited number of divisions of the cells and only a limited number of cell generations are possible.
This number is referred to as Hayflick’s limit after Dr Leonard Hayflick.
Drs Hayflick and Moorhead determined that shortening of telomeres at each cell division is responsible for limiting the number of cell divisions.

Question 12

Telomerase

Answer 12

Embryonic stem cells express telomerase, which allows them to divide repeatedly and form the individual.
In adults, telomerase is expressed only in specialized cells, specifically certain adult stem cells, precursor cells to sperm and in activated white blood cells whereas other normal human cells do not express it.

There is one type of cell known to contain telomerase in amounts that allow for that cell to continually restore the length of it’s telomere strands, thus rendering the cell capable of infinite cell divisions - cancer cells.
Does that mean that abnormal amounts of telomerase in normal cells leads to cancer?
This has not been proven.

Telomeres shorten with the normal aging process in several tissues
BUT… their reduction is also more significant in certain disease states.
There appears to be a 100-fold higher incidence of vascular dementia in people with prematurely short telomeres.

The psychological stress associated with provision of long-term care for those with chronic illness has also been associated with premature shortening of telomeres

Question 13

Mitochondria and Aging

Answer 13

Mitochondria – intracellular organelles, carrying its own DNA genome, that are responsible for generating cellular energy.

As a by-product of energy production, mitochondria are also the major source of ROS within the cell, and thus responsible for and a target of oxidative stress. Any age related increase in the fraction of damaged mitochondria is likely to contribute to a progressive decline in cell and tissue capacity for energy production.

What nutrients may be helpful in supportive mitochondrial function?

Question 14

Inflammaging

Answer 14

A summary of the physiological and molecular changes consistent with the aging process that are known to be associated with chronic activation of inflammatory pathways.

Good or bad? Inflammation is a protective response by the body that involves immune cells, blood vessels and biochemical mediators.

The purpose of inflammation is to eliminate the initial cause of cell injury, clear out dead and dying cells and damaged tissues.

Thereafter, the same inflammatory process serves to initiate tissue repair.

Many older individuals with no obvious injury/infection have ongoing activation of an inflammatory process
Activation of inflammatory pathways (IL-6, CRP)  adverse health outcomes

Question 15

Cardiovasc Health

Answer 15

Leading cause of death and serious illness in the US.
Atherosclerosis, the deposition of fatty plaque on the inner lining of our blood vessels, is a process that most begins before our teens
Dr. Ornish has promoted a model of health care based upon lifestyle changes which include but are not limited to a whole foods/ plant-based diet, smoking cessation, exercise and stress management techniques such as yoga and meditation.
The results of Ornish’s first large scale attempt at testing his recommendations was called the Lifestyle Heart Trial.
Not only did patients fare better with respect to cardiac events than those who followed standard medical advice, many of the patients revealed some reversal of their coronary atherosclerosis as documented on cardiac angiography

Question 16

CV health and telomeres

Answer 16

Further investigation into studying the effects of lifestyle changes, Ornish and co-collaborator, Elizabeth Blackburn, were able to establish that a change in gene expression can occur in only three months.
Utilizing lifestyle changes and mind-body modalities was shown to turn on disease-preventing genes and turn off genes that promote cancer and heart disease.
Further testing showed increased levels of telomerase enzyme levels within cardiac tissue
Elizabeth Blackburn at UCSF has found that telomerase activity at the site of blockages in coronary artery tissue is increased relative to other areas in the heart that were examined.
Greater telomerase activity appears to be associated with more rapid accumulation of plaque within the coronary arteries driving the growth of blockage.
Telomerase is driving the growth of the blockage

Question 17

Prescription Drugs and Nutrient depletions

Answer 17

Commonly associated deficiencies include:
SSRIs, a type of antidepressant medication, deplete the B vitamins B6, B12 and folic acid.
PPI’s and H-2 blockers – Diminished levels of B12, calcium, iron, magnesium and other minerals and nutrients that depend upon an acidic environment for optimal absorption.
Metformin and B12 deficiency
Statins and Coenzyme Q10 deficiency
Birth control pills and B5, B6, B12 deficiencies
Seizure meds and folic acid deficiency

Question 18

Body Comp

Answer 18

With age, lean body mass and total body water content decline, whereas total body fat and fat located in the upper body (visceral and subcutaneous abdominal fat) increase proportionately.
Muscles show a decreased number of muscle fibers and decreased strength.
These changes, which are linked in part to reduced physical activity, can be partially modified by continued exercise patterns
Kyphosis is increased, especially in females. There is a slight bending (flexion) at the knees and hips which leads to a shortened stature.
Increased cervical extension occurs as a compensatory mechanism.
Changes in bone mass often lead to a increased susceptibility to vertebral fractures and a decrease in height.

Question 19

Weight

Answer 19

Approximately 15% of men and 20% of women over the age of 65 are above the average weight for their height.
This tendency seems to plateau at 65-75 years of age and decreases thereafter.
Obesity in the geriatric population usually reflects weight obtained in the first 5 decades of life

Question 20

Weight Loss

Answer 20

Weight loss is a phenomena commonly associated with the aging process.
On average, there is a decrease in lean body mass of ~25% for males and ~15% for females in the U.S.
The greater loss of body mass in males is due to a larger initial muscle mass.

Question 21

Hair

Answer 21

There is a generalized decrease in total body hair.
Scalp hair thins and diminishes.
Axillary and pubic hair also thins as individuals age.
Hair production may increase at various sites (i.e. beards in men)

Question 22

Facial Features

Answer 22

Subcutaneous fat of eye sockets generally decreases as we age, often resulting in the appearance of “sunken eyes”.
This physical finding, known as enophthalmos, generally results in an average loss of ~10 mm in the depth of the eyeball as we age
Drooping of the upper eyelid or ptosis is a commonly occurring condition.
Ptosis can result in difficulty with vision, especially of peripheral vision.
Progressive resorption of bone from the mandible and maxilla results in diminished prominence of the jaw.
The nose may broaden and lengthen.
Ears lengthen.

Question 23

Skin

Answer 23

Changes in subcutaneous fat, vasculature, collagen, and skin texture in the elderly make the skin less resistant to external forces.
Diminished number and function of sweat and sebaceous glands predispose the elderly to skin trauma, infections, and decubitus ulcers.
The skin shows a thinning of cell layers with a decreased production of cells.
There are fewer melanocytes which leads to an increased risk of skin cancer.
Vitiligo becomes more common.
Vascular fragility is increased, thus hemorrhages and ecchymosis occur more readily

Question 24

Eye

Answer 24

Aging is associated with changes in lens elasticity (presbyopia) and in the physiology of the retina and vitreous humor.
Visual acuity is often decreased and adaptation to both darkness and accommodation is often impaired.
Reduction in tear formation is a common finding in the aging eye and drying of the cornea is often a precursor to corneal infections
Light response and accommodation decrease as pupil size gets smaller.
It may be more difficult to visualize the fundus in your geriatric patients.
Arcus senilis is common and does not interfere with sight nor does necessarily denote a problem in cholesterol levels.
Lessened speed of dark adaptation.
Increased minimal threshold of light perception results in difficulty seeing in dim light.
The formation of cataracts is another common cause for reduced vision and lessened visual acuity in settings of diminished light

Question 25

Cataract

Answer 25

A cataract is an opacity or haziness of the lens of the eye.
A cataract may be particularly problematic when driving at night when oncoming headlights produce glare with decreased acuity and/or eye discomfort.
Cataracts may or may not reduce the vision depending on size, density and location.

Question 26

Glaucoma

Answer 26

Glaucoma is condition in which the pressure within the eye is elevated to the point where the visual cells and nerves are affected and is a major cause of vision loss and blindness.
Glaucoma will often lead to a loss of peripheral vision before central vision is affected.

Question 27

Closed-angle Glaucoma

Answer 27

Closed-angle Glaucoma Accounts for less than 10% of glaucoma cases in the United States, but as much as half of glaucoma cases in other nations (particularly Asian countries). About 10% of patients with closed angles present with acute angle closure crises characterized by sudden ocular pain, seeing halos around lights, red eye, very high intraocular pressure (>30 mmHg), nausea and vomiting, sudden decreased vision, and a fixed, mid-dilated pupil. Acute angle closure is an ocular emergency.

Question 28

Open-Angle Glaucoma

Answer 28

Open-angle Glaucoma Accounts for 90% of glaucoma cases in the United States. It is painless and does not have acute attacks. The only signs are gradually progressive visual field loss, and optic nerve changes (increased cup-to-disc ratio on fundoscopic examination).

Question 29

Chronic Glaucoma

Answer 29

Often the patient will not notice the loss of vision until it is too late for an optimal treatment.
Chronic glaucoma becomes much more common with increasing age.
It is uncommon below the age of 40 but affects ~1 %of the population aged 40 to 65 and ~5 % of individuals over age 65.

Question 30

Macular Degeneration

Answer 30

Leading cause of vision loss.
The deterioration of the central portion of the retina.
The retina is responsible for focusing central vision in the eye.

Question 31

Hearing

Answer 31

As we age, there is an increased threshold for higher frequencies such that higher pitched sounds are not heard as well.
High frequency loss is more common in men.
It may benefit you to speak in a lower pitched voice to your patients who are hard of hearing rather than speaking more loudly

Question 32

Taste and Smell

Answer 32

The sensations of both taste and smell commonly decrease as we age.
This may be due in part be to atrophy of the parietal lobes.
The changes in ability to discriminate smells invariably leads to a diminished sensation of taste.
Several drugs will alter the sense of taste

Question 33

Taste

Answer 33

Zinc deficiency may play a role in diminished taste.
A sensory decline in taste can often result in the diminished enjoyment of food and eventual poor nutritional intake.
When this decline accompanies a problem with dentition and bite occlusion, poor nutritional intake is often worsened.

Question 34

Bone and Joints

Answer 34

After age 40 there is a shift from increasing bone mass to loss of bone.
Long bones will appear as externally enlarged but internally have less boney matrix and diminished density.
Irregular bony overgrowths may occur at joints and are usually related to trauma

Question 35

Arthritis

Answer 35

One in seven Americans–nearly 40 million–have some form of arthritis.
That number will climb as the baby boomers age.
By 2020, about 60 million Americans will have arthritis, according to The National Arthritis Data Workgroup.

Question 36

OA

Answer 36

A principal mechanism of injury in osteoarthritis, breakdown of cartilage such the bones of a joint will rub together.
The joint then loses shape and alignment.
Bone ends thicken, forming bony out growths also known as bone spurs.
Bits of cartilage or bone often “float” in the joint space, causing increased crepitus, possible increased pain and possible decreased range of motion.

Risk Factors: Risk factors for osteoarthritis include:
Increasing age
Female
Heredity conditions, such as defective cartilage and malformed joints
Joint injuries caused by work or sports
Obese
Concomitant diseases that change the structure and function of cartilage, such as rheumatoid arthritis, hemochromatosis, Paget’s disease, gout or pseudogout

Question 37

RA

Answer 37

Rheumatoid arthritis is an autoimmune condition resulting in inflammation of the synovial membrane.
Inflammation at the joint lining results in cytokine and other inflammatory cell recruitment that acts to damage and eventually digest the cartilage and bone.
As the space between joints diminishes, the joint will lose shape and normal alignment.

Question 38

CVD

Answer 38

Atherosclerotic disease is the leading cause of death in the U.S.
In the U.S., approximately 40% of patients older than 65 years of age will die as a result of heart disease, 15% will die due to cerebrovascular disease, and 5% will die from complications related to renal and peripheral vascular disease.

The aging heart is prone to degenerative myocardial and vascular diseases, varying degrees of heart block, and dysfunction of the sinus node.
The fibrous skeleton and the valves of the heart show progressive changes with age, the collagen becomes more sclerotic, and calcium is deposited in areas of mechanical wear

As we age, the sinoatrial and atrioventricular nodes normally show a decrease in the number of pacemaker cells.
Ectopic beats are more frequent in the elderly.
With age, there is a progressive reduction in cardiac output, both at rest and in response to exercise.

Question 39

Pulm Changes

Answer 39

Multiple age-related changes generally occur in the lungs which result in a reduction in pulmonary function.
After age 30, the lung surface is reduced by approximately 4% per decade.
With aging, there is a decrease in the number of alveoli although the average alveolar size usually increases in a compensatory fashion.

After the 5th decade, the lungs usually increase in anterior-posterior diameter with a reduction in the base-to-apex diameter, partly due to concomitant changes in the shape of the thoracic cage.
Functional changes include an increase in the residual volume of the lung with only a modest decline in total lung capacity
Pulmonary infections occur more frequently in the elderly.
Risk factors for pneumonia in the elderly include reduced gag and cough reflexes, reduced respiratory muscle strength and diminished mucociliary cell activity

Question 40

Renal Changes

Answer 40

Advancing age generally leads to a decrease in the size of the kidneys with fewer, smaller, and more sclerotic nephrons.
In addition, there is increased basement membrane thickening of the glomeruli.
Atherosclerosis of renal vasculature can further reduce renal function.