KNPE 335 - Midterm Flashcards
age trends and projections in canada
increasing number of people age 65 and older and decreasing number of people aged 0-14
What determines trends in senior populations in canada
- Fertility trends
- Migration
- Life expectancy
Why may seniors not inhabit NWT or Nunavut
not good access to resources that seniors need
life expectancy trends
individual life expectancy continues to increase across males and females
4 life span predictions
- decrease in infant mortality rate
- Advances in public health
- plateau of life expectancy
- adding “life to years” instead of “years to life”
Aging and quality of life
-living linger does not mean better
-decreased quality of life: decrease physical, cognitive, mental and social health & increase in common morbidities and comorbidities
what does the fact that people are living longer not better infer
we focus more attention to quantity of life rather than quality of life
gender trends in living longer
males showed more of a desire to live longer
4 things desire to live is associated with
- positive psychological wellbeing
- increase happiness, life satisfaction and purpose
- decrease risk of all cause mortality
- decrease mortality from cancer or suicide
(3 and 4 didnt look at quality of life as a mediator)
chronological age
number of years a person has lived
biological age
a description of individuals development based on biomedical markers that are determined by molecular or cellular events (can change aging progression)
Psychological age
a description of ones own experiences using nonphysical features such as experience, logic and emotion
Social psychological/subjective age
the personal subjective age of a person based on how old the individual feels and how they feel towards age
Social age
the social roles that an individual has placed on them by society that determines their age
Types of functional age
1st age: childhood
2nd age: working and parenting
3rd age: “young old” between 65-84 years
4th age: above 85 years
Functional Age
a combination of chronological, biological, and psychological age. Considered to be the wholistic picture of a persons described age
healthy aging includes a persons ability to:
-meet basic needs
-learn, grow and make decisions
-be mobile
-build and maintain relationships
-contribute to society
Rowe and Kahan 3 main points to successfully age
- Avoiding disease and disability
- High cognitive and physical function
- engagement with life
Fries (1980) compression of morbidity
how much illness has a burden on you is compressed to later in your life (QoL refers to how long you suffer for)
Strawbridge (2002)
in addition to the 3 main points, need to include the effect of chronic conditions and functional difficulties with successful aging
Riechstadt et al (2010)
qualitative interviews on successful aging in older adult perspectives: people who percieve aging as positive are more likely to successfully age
2 categories of aging theory
- Stochastic theories of aging
- programmed theories
stochastic theories of aging
-most prevalent is free radical theory
-metabolic rxns occurring continuously in the body produce unstable molecules called free radicals
-“anti-oxidant vitamins”
-age spots
-random change due to random rxns that create free radicals cause aging
FREE RADICALS -> CELL DAMAGE -> AGING
Non stochastic theories of aging (programmed)
-born with biological clock, programmed time you will die
-aging is predetermined through programmed cells and cell death
Neuroendocrine-Immunilogical theory
-tied to both programmed and free radical theory
-immunity theory of aging (by targetting immune system we can prevent aging)
General Physical Changes with Aging
-increased risk of chronic disease
-decline in lean body mass & bone density
-increased risk of fractures
-increased risk of falls
-impaired oral, eye, ear health
-changes in skin, taste, smell
-geriatric syndromes (dementia, depression …)
broad Changes during aging
-skeletal
-musculature
-vision
-hearing
-vestibular
-joint proprioception
-balance
what is the skeletal system essential for
calcium storage, movement, reduce frailty
starting at 30, progression of various issues to skeletal system such as:
-density/mass of bones begin to diminish
-bones more fragile and more likely to break
-development of osteoporosis/osteoarthritis
-stiffer/less flexible joints
-limited ROM
-collapse of vertebrae
when is bone density decline the highest in women
after menopause
peak muscle strength
-peak muscle strength occurrs at age 20-30
musculature is essential for:
-prevent weakness
-prevent fatigue
-improve ability to perform activities of daily living
-reduce risk of falls and injury
musculature after 30 and into old age
-muscle atrophy (thinning/loss of muscle tissues)
-harder to regenerate muscle
-sarcopenia (loss of muscle)
-muscle fibers cannot contract as quickly
-presence of lipofuscin
-hand and joint tissue becomes tough fibrous tissue
Visual Changes
-occur due to environment, genes, illness/disease, and socioeconomic factors
-1 in 9 canadians experience irreversible vision loss by 65
common visual diseases
-glaucoma (damage to optic n)
-dry eyes
-macular degeneration
-cataracts (cloudy lens)
-diabetic retinopathy
age related change to the pupil
resting pupil diameter decreases
age related change to the lens
lens protein precipitate (cataracts)
age related change to the macula
receptors generate and die, causing loss of central vision
age related change to vitreous humour
changes from gel to liquid, may detach from retina
hearing changes
-prebycusis
-hearing loss: sensorineural, conductive, mixed
prebycusis
-preogressive, multifaceted, age-related hearing loss
-influenced by factors like genetics, environment, trauma, ototoxic medicines
age related changes to ear canal
-potential collapse
-earwax accumulates
age related changes to ossicles
joints between calcify and become thinner
age related changes to the eustachian tube
muscles atrophy
age related changes to the pinna
enlarges with age
vestibular changes with age
-increase frailty
-decrease balance
Joint proprioception and aging
-mechanoreceptors changes, which are located in the joints, capsules, ligaments, muscles, tendons and skin
-impaired/ deterioration of proprioception leading to less accurate detection of body position
**result in increased risk for falls and degenerative joint disease
Balance and aging
-balance disorders result from steady reduction of several systems functions including musculoskeletal, CNS, & sensory system
three fundamental properties of balance
- steadiness
- symmetry
- dynamic stability
what does good balance require?
reliable sensory input form an individuals vision, vestibular system & proprioceptors
Balance disorders in the elderly
-degenerative neuropathy
-decrease nerve conduction velocity
-decrease vestibular function
-visual impairment
-degenerative spinal deformity
-decrease function of tendons/joints
-decrease thigh muscle thickness
3 most common chronic diseases in 65+ age group
- hypertension
- periodontal disease
- Osteoarthritis
10 common chronic diseases among 65+
- hypertension
- periodontal disease
- osteoarthritis
- diabetes
- Ischemic heart disease
- asthma
- mood & anxity disorders
- cancer
- COPD
- osteoporosis
prevlaence trend for chronic diseases
all increase with age except for asthma (decrease)
what is the most important risk factor for chronic disease
aging - due to decline in organ function and system function
Multimorbidity
-the co-occurrance in the same individual of two or more of ten common chronic diseases
-associated with impaired QoL, increased use of health care, institutionalization, adverse health effects, disability and premature death
prevalance of multimorbidity
with increasing age, increasing risk of multimorbidity (positive correlation)
diabetes and aging
-aging increases risk of diabetes (increase insulin resistance and decrease pancreatic repairs)
-management is more complicated in older adults
-cognitive issues
relationship between lifetime risk of cardiovascular disease and age
lifetime risk of cardiovascular disease increases with age with or without risk factors but risk factors increases rate of lifetime risk more
High Blood Pressure (Hypertension)
-most common in older adults
-due to changes in vascular system as one ages
-reduction of elastic tissues, resulting in stiff arteries
**age influences HBP independent of other risk factors
cancer and aging
-aging is a major risk factor for developing cancer
hypothesis of cancer
after 85, cancer risk decreases due to lack of cell growth
Falls
-most common cause of injury in older adults
-one of leading causes of death in older adults
-large cost to healthcare system result from falls
Post fall syndrome
creates a cycle of increasing weakness and instability through joint mobility reductions, physical deconditioning, and poor balance
Fall cycle
- Fall
- loss of balance confidence
- Fear of falling again
- Self restriction of physical activities
- Reduced muscle strength, impaired balance
- abnormal gait, more unstable on feet
- increased risk of falling
REPEAT
compensatory mechanisms walking
-cautious gait
-frozen gait
cautious gait
excessive degree of age-related changes in walking and fear of falling
(slow, wide base, reduced arm swinging)
***usually occurs right after falling
Frozen Gait
-abnormal gate pattern in which there are sudden, short temporary episodes of an inability to move the feet forward despite the intention to walk
-frustrating/annoying
-feet shuffle, then stop but still have intent to move forward so upper body leans increasing risk of falling
***usually occurs a while after falls
Frailty
-increased vulnerability to disease, disability, being dependent and death
-associated with multiple health conditions, reduced mobility & functional decline
5 ways to avoid frailty CFN
activity, vaccinate, optimize medications, interact, diet & nutrition
7 behaviours of a healthy lifestyle
- Exercising
- Eating a diet high in fruits and vegetables
- Not smoking
- Drinking alcohol in moderation
- Getting adequate rest
- Coping with stress
- Having a positive outlook
Basic activities of daily living
things needed to manage basic physical needs
ex
-dressing
-locomotion
-continence
-eating
-transferring
-walking/moving around
instrumental activities of daily living
things to take care of self/home
ex.
-using phone
-traveling
-shopping
-preparing meals
-housework
-taking medicine
**good way to measure independence
5 types of physical activity
- aerobic (endurance)
- Strength
- Flexibility
- Balance
- Functional
Aerobic (endurance) PA
-supplies O2 to brain
-walking, jogging, swimming
-20-30m / day
strength PA
-muscles work more than daily living activities
-weight training, resistance bands etc
flexibility PA
-flexability and stretching for increased freedom of movement for everyday activities and other exercise
-yoga, leg raises, swimming
Balance PA
-strengthens muscle that keeps you upright
-improve stability to prevent falls
Functional PA
-trains muscles to work together
-prepares for daily tasks by reproducing common movements
-various muscles in upper and lower body used at same time
-mimics everyday activities
examples of benefits of PA
-decrease BP
-increase strength and CV endurance
-increase balance
-increase lung and breathing function
-improve immune function
-reduce depression and anxiety
-control obesity
frailty and exercise
-can help improve physical function, minimize and delay age-related declines
-aerobic, muscle strengthening, and multi-component PA programs all demonstrate benefits to frailty
PA benefits related to frailty
-improves ability to perform tasks
-prevents weak bones and muscle loss
-improves joint mobility & sleep quality
-reduces risk of chronic conditions
-extends years of activity and independent living
-lowers risk of demetia
-reduced likelihood of falls
2 types of barriers to activity
- Intrinsic barriers
- Extrinsic barrires
intrinsic barriers
-related to beliefs, motives, and experiences
extrinsic barriers
-related to broader physical activity environment
two main avenues in overcoming barriers
- Reassurance in relation to concerns abt safety, frequency, and intensity
- education of individuals as to what is appropritate PA
controversy of master athletes
one view: can be motivating for people who CAN participate
other view: creates social comparisson because they may not be able to engage also
What is cognition?
set of all mental abilities and processes related to knowledge, attention, memory, judgement and evaluation, reasoning, problem solving, decision making, comprehension, and production of language
Cognitive Health
a brain that can perform all the mental processes that are collectively known as cognition, including learning, intuition, judgement, language and remembering
cognitive non-linear changes that occur during aging
-memory
-attention
-language
-intelligence
-brain changes
-everyday functioning
**can improve and/or decline
Brain reserve
“passive” form of capacity that is thought to depend on the structural properties of the brain. Physical/structural components (size, # neurons….)
**declines with age
Less brain reserve =
lower threshold of expression of functional impairments
Cognitive Reserve
“active” mechanism for coping with brain pathology. The brains ability to cope with damage or changes, such as aging or neurological disease, by using pre-existing cognitive processes
-helps maintain cognitive function despite brain pathology
General Aging trends
speed and memory decline the most while vocabulary declines the least
**individulals who did PA everyday declined less than those who did cognition activites everyday
Aging & Long term memory
-slower processing speed and difficulty retrieving memories, but not all memory decline is related to alzheimers
Neuroplasticity
mentally stimulating activities can help maintain long-term memory function
types of long term memory
Episodic & semantic
Episodic memory
personal experiences, tends to decline with age
semantic memory
facts and knowledge, usually remains stable longer
Hippocampus and memory
plays a crucial role with long term memory, a reduction in hippocampal volume may lead to age-related cognitive decline
Fluid Intelligence
tasks involving quick thinking, info manipulation, activities involving allocation and reallocation of attention
(biology based)
examples of fluid intelligence
testing memory, spatial relations, abstrat and inductive resoning, free recall, mental calculations
age related differences of fluid and crystallized intelligence
fluid intelligence declines with age meanwhile crystallized stays the same
crystallized intelligence
tasks that tap well-learned skills, language, and retrival of learned material
(culture-knowledge based)
examples of crystallized intelligence
verbal meaning, word association, social judegment etc
development rates of fluid and crystallized intelligence
fluid: develops quickly, declines fast
crystallized: develops slower but suffers less decline
factors affecting cognitive needs
- High BP
- Genetic predisposition to alzhimers
- High cholesterol
- Inflammation
- Myocardial Infarction
- Diabetes
- Stroke
- Depression
- Alcohol
- poor sleep quality
Dementia
-group of symptoms affecting memory, thinking and social abilities severely enough to interfere with daily life
-results in cognitive and psychological changes
-caused by damage to or loss of nerve cells and their connections in the brain
why is dementia hard to treat and diagnose
likely to have multiple comorbidities making it difficult to identify
causes of dementia
caused by neurodegeneration, which is the damage and death of brain neurons **progressive
what do you SEE in someone brain who has dementia
shrinkage of the hippocampus and enlarged ventricles
general trend in dementia statistics
expected to increase prevalence by 50% likely because people are living longer AND because we have better technology to diagnose
what populations is dementia increasing in
asian, indigenous, african, latin and central american and females
8 A’s of dementia
- Anosognosia
- Agnosia
- Aphasia
- Apraxia
- Altered perception
- Amnesia
- Apathy
- Attention deficits
Anosognosia
Ignorance of the presence of disease
agnosia
inability to recognize objects by using the senses
aphasia
loss of ability to speak or understand spoken, written or sign language
apraxia
inability to perform purposeful movements
Amnesia
memory loss
apathy
lack of interest; inability to begin activities
Acute A’s of dementia
apathy, attention deficits, and amnesia
risk factors that cannot be changed
-age
-genetics
-sex
risk factors that can be changed: EARLY LIFE
-education
(less education=greater risk of dementia)
risk factors that can be changed: MIDLIFE
-hypertension
-obesity
-hearing loss
-alcohol intake
-TBI
risk factors that can be changed: LATE LIFE
-smoking
-depression
-social isolation
-inactivity
-diabetes
-air pollution
Alzheimers Disease
-most common cause of a preogressive dementia in older adults
-occurs when proteins (plaques) and fibers (tangles) build up in the brain -> this blocks nerve signals
what does alzheimers look like
shrunken brain
S&S EARLY alzheimers
-beginning memory loss disrupting daily life
-coming up with the right word or name
-remembering names
-difficulty performing tasks
-forgetting material just read
-misplacing things
-changes in mood/personality
-increased trouble planning/organizing
S&S MODERATE alzheimers
-being forgetful of personal events
-feeling moody/withdrawn
-unable to recall info
-confusion
-need help chosing proper clothing according to season
-trouble with bowel and bladder control
-changes in sleep
-wander
-personality and behaviour changes
S&S SEVERE alzheimers disease
-around the clock assistance
-changes in physical abilities
-difficulty with or no communication
-vulnerable to infection
clinical diagnosis of alzheimers
-medical history
-physical exam
-neuro exam
-mental cognitive status exam
-brain imaging
-blood samples
-protein analysis of CSF
what percent of dementia cases could be prevented through 12 changeable risk factors
40%
Cognitive function
changes in memory, attention & processing speed
mental disorders:
depression, anxiety, cognitive impairments
well being
general sense of feeling good & being able to function
coping mechanisms
strageties used to manage stress & life changes
Resilience
ability to adapt positively to adversity or significant life events
life satisfaction
overall contentment & fufillment with life experiences
purpose and meaning
a sense of contribution & meaningful engagement in daily activities and relationships
social support
relationships with family, friends and communities
social isolation
the degree to which an inidividual lacks a sense of engagement with others
Cultural identity
the preservation and influence of ones cultural background
cultural competence
the ability to interact effectively with people from diverse cultural backgrounds
retirement
adjusting to a new phase of life with changes to ones routine, responsibilities and identity
bereavement
coping with loss and the associated grief processes
self-esteem
maintaining a positive self-image and self-worth
autonomy
maintaining independence and control over ones life decisions
life transitions
retirement and bereavement
what is mental illness
alteration in thinkin, mood or behaviour associated with some significant distress and impaired functioning
***specific diagnosed disorders
mental health
similar to QoL and well-being
mental health and aging
prevalence of mental health problems in 65+ ranges from 20-30%
most common mental health condition among older adults
depression (including undiagnosed)
what percent of deaths from suicide are from 60+
25%
external factors affecting mental health (adults)
housing, transportation & mobility, income and services
internal factors affecting mental health (adults)
physical, emotional, social and spiritual
why are mental illnesses missed in older adults
-S&S often differ from young people
-symptoms dont match criteria
-less likely to self identify
-can often stem from serious physical illness and mask mental illness
-caregiver stress and burnout
factors that contribute to compromising dignity of older adults
loneliness, ageism, stigma and discrimination, inequalities, institutionalization, neurocognitive disorders etc…..
what would happen if older adult dignity compromised
increase change of developing mental illness and less likely to get help
3 neurotransmitters associated with healthy aging
dopamine, norepenephrine & serotonin
***** decrease with age
Dopamine
-reward motivation system
-motor control ,decision making, teaching motivation and pleasure
-directly affects mood and mental health
serotonin
-boost when you feel significant and important
-mood, memory, cognition and sleep
-directly affects mood and mental health
norepenephrine
-regualted bp
-memory formation and retrival
-stress and sleep regulation
9 common mental health disorders in older adults
- depression
- suicide
- anxiety
- dementia
- loneliness and isolation
- delerium
- paraphrenia
- concurrent disorders (mental illness + substance problem)
late life depression
-may be reactive- such as after long term care admission
-beginning of old age
-affects 1 in 5 ppl
-characterized by an atypical cluster of symptoms
-challenging to distinguish from dementia
Late onset depression
often has cognitive componenet, some memory impairment, leading to decreased BF and TIA (stroke)
Symptoms of depression
-change in sleep
-lack of interest
-guilt
-concentration issues (linked to fear)
-changes in energy
-changes in appetite
-psychomotor (slowed down)
-suicide
2 screening scales for depression
- geriatic depression scale
- Hamilton rating scale for depression
Delirium
acute change in mental status causing shift in cognitive functioning, reduced environmental awareness, altered attention and behaviour changes
3 types of delirium
- Hypoactive
- Hyperactivity
- Mixed
Hypoactive delirium
abrupt symptoms, withdrawn, reduced speech and activity, apathy
hyperactivity delirium
gradual symptoms, increased activity, irritability, restlessness, combativeness
mixed delirium
flucuations in psychomotor activity
short term delirium outcomes
falls, pressure injuries, aspiration pneumonia, distress, prolonged hospital stay, long term care admission, increased risk of mortality
***these are reversible
Long term outcomes of delirium
functional and cognitive impairment, dementia, PTSD symptoms, sleep disturbances, increase risk of mortality, aspiration pneumonia, pressure sores
Factors reducing risk of delirium
- Cognitive reserve: the capacity of brain can buffer neuro disease
- Social support: regular interactions reduce cogntive impairment by frequent reorientation
- Environment: exposure to natural daylight can promote circadian rhythyms
- pain management
intersection of delirium & MH conditions
-some populations most vulnerable to delirium are older adults who have dementia, depression and acute psychiatric syndrome
-each can co-occur
when an individual with pre-existing dementia develops delirium, it is called:
delirium superimposed on dementia
Loneliness
-perception, state of mind
-typically though to be subjective, negative feeling related to deficent social relations
-more dangerous to health than smoking
high degree of lonelines precipitates:
-suicial ideation
-para-suicide
-alzheimers
-dementia
-negative effects on IS &CV systems
-increase hospitalization risk
-can cause symptoms of things to occur more rapidly
3 types of loneliness
- developmental
- internal
- situational
developmental loeliness
lack of balance between individualism and innate desire to relate to others
situational loneliness
socio-economic and cultural milieu effected by environemnt
-caused by unplesaant experiences, trauma etc
internal loneliness
-more prevalent
-perception of being alone
-associated with low self-esteem and worth
interventions of loneliness
-activity involvement
-volunteer
-quality relationships
-pharmalogical
-staying in contact
Social isolation can lead to:
-increase risk ACM
-dementia
-incease risk rehospitalization
-increase # falls
social isolation patient care
focused on assessing and improving physical, mental AND social well-being
Impacts of social isolation
1.Health behavioural
2. Psychological
3. Physiological
4. Other outcomes
health behavioural impact of social isolation
-dont have encouragement to adhere to medical treatmetn
-behaviour habits: drinking, smoking, gambling
psychological impact of social isolation
-less participation
-increase risk for cognitive decline
-increase risk suicide and depression
physiological risk of social isolation
-predictor of mortality from heart disease and stroke
-decrease infection resistance
other outcomes of social isolation
-ACM
-risk of falls
-rehospitalization and institutionalization
interventions for social isolation
-address medical and social needs
-asking what THEY want
-taking individual presepctive/experience into play
-social prescribing
-patient-centered approach
What is social healthy aging
adequate and well-functionnig:
social relationships, social support, little or no social strain, social participation, social inclusion, strong & well-functioning social networks & sexuality
Key dimensions of social well-being
presence and quality of social: relationships, networks, participation, isolation, sexuality, support, strain and environemnt
Social Ecological model- MICRO
-immediate family, friends & community significantly shape the aging process & health
-supportive social connections & interactions with family and friends are imperative
-need for belonging and reciprocity
-loneliness is influenced by social network size
-family context experiences during early years of ones life has significant influence on later-life health
MICRO social ecological model
individual & interpersonal factors
MESO social ecological model
institutional and community
social ecological model - meso
-neighbourhood, healthcare, eductional systems factors exert influence on adult health experiences
-the physical environemnt, including housing conditions, transportation, access to food, exercise, also affects health
-improved via collaborative leadership, cooperation, age-friendly communities and top down approaches
MACRO social ecological model
policy, cultural, and structural factors
social ecological model - macro
-cultural health beliefs, policies, & environemntal characteristics of a region have influence on health
-political factors shape socioeconomic determinants & can reduce health disparities
-capacity to cope with progression of disease & effects of medical intervention are infuenced by sociteal cultural values
the socioemotional selective theory
-explains progression of social networks while aging
-proportion of emotional material recalled increases with age
-as people age they become selective as to where their time is put
- older adults haev greater emotional response
why do older adults have fewer social partners
they want to spend time with people they care about most (socioemotional selective theory)
-see themselves as having less time to waste and are more risk-adverse
Disengagement theory
-as people age they naturally withdraw from responsibilities and social interactions
-theory posits both individual and society benefit
social issues of aging and psychological health
-connection is critically essential for humans
-social connection is a pillar in health
Social connection: Structure
the connection to others via the existence of relationships and their roles
social connection: Functions
a sense of connection that results from actual or percieved support or inclusion
social connection: Quality
teh sense of connection to others that is based on positive and negative qualities
Stress prevention model
Social support -> potentil stressor
stress buffering model
stress appraisals influence health behaviours and physical health outcomes
Direct Affect model
connection, esteem, control influence health behaviours and physical health outcomes
-social support can improve health even without challenges
Retirement and aging
-shown to have positive and negative association with mental health
-variations in outcomes of retirement highlight the complexity of this issue
evidence of involuntary retirement
overall increases the possibility of loneliness, isolation and mental disorders
Naturally occurring retirement communities
unplanned communities that have high proportion of older residents. integrate health, social and physical supports with a participatoey design that promotes social well being
NORC buildings
apartments, condos, co-ops with adults
social worth=
improved overall health and survival
fufilling multiple social roles=
self-efficacy and life satisfaction
benefits of having strong ties to family/friends
more likely to retain independence, a sense of meaning and purpose in life, & effective physical & phsychological functioning longer
late life changes that impact social networks & relationships
family dynamics, illnesses, retirement, admisson to LTC, death of a spouce or change in income
Marriage and aging
-those who experienced marital loss have lower positive self-perceptions of aging than those who remained marred
how do canadians classify marriage successfully aging?
found that men who were continuously married, widowed or became married between waves were more likely to successfully age than never married counterparts
Violence against older adults
aka elder abuse
-often perpetrated by family members
-includes physical, sexual, financial and emotional
-constantly increasing
social media and technology with aging
-ageist messages on SM associated with negative health outcomes including poorer mental health
-increasing # of older adults using social media
barriers to social media and aging
-lack of instruction/knowledge
-confidence
-financial
-health abilities
-trust
older population on social media are motivated by
-social support
-enjoyment and fun
-personal empowerment
-advocacy
-bridging generational gaps
intergrnerational programs benefits
support social health and combat ageism
Healthy aging definition WHO
continuous process of
optimizing opportunities to maintain and improve physical and
mental health, independence, and quality of life throughout the
life course
