Older Persons Health Flashcards
76F - Mrs B
7.5mg Zopiclone repeat presciption review
Attends annual NHS health check
PMH = hypertension - well controlled by ACEi; osteoarthritis - paracetamol on bad days
What would you ask her next?
What does a typical day look like to you?
Mrs B - Typical day
Wake up at 9am - porridge and banana
Gentle housework until lunch - made from local corner shop groceries
Eats low-quality, high sugar diet -cake, sandwiches, noodles
Would eat healthier - does not enjoy cooking and eating alone
Nearest supermarket too far for her arthritis
Dinner = similar to lunch
4-5 cups of tea a day
Whiskey on special occasions
Good relationship with son - speak on the phone to him (he’s in Manchester)
Sees no one else other than shopkeeper each week
More isolated since husband died
Arthritis makes journeys difficult, no car
Watches soaps and TV dramas for entertainment
Goes to bed at 11pm - takes zopiclone to ‘help her sleep’ - dependent on these
What are the key social determinants and lifestyle behaviours identified in this case that would be important in taking a holistic approach to this Mrs B’s health?
Exercise - difficulty with arthritis
Sleep - difficulty getting to sleep without zopiclone = dependency
Diet - v. poor, increasing CVD risks, diabetes
High caffeine intake
Why does food intake decrease as we get older?
Physiological changes:
Dereased basal mmetabolic rate
Lean body mass
Reduced sensation of taste an smell = less tasty food = less interest
What is malnutrition?
What is undernutrition VS overnutrition?
Malnutrition = diet with incorrect amount of nutrients
Malnutrition can be undernutrition (not getting enough nutrients) or overnutrition (getting too many nutrients - often leads to obesity)
Is malnutrition a normal part of ageing?
No
Although - 10% of over 65s are malnourished
What causes malnutrition?
Age related physical changes = difficult to obtain adequate nutrition
Poor dentition - dental disease, ill fitting dentures, gum disease = painful to eat
Swallowing difficulty - neurological conditions e.g. stroke
Arthritis and declining co-ordination = struggle feeding themselves
Deteriorating eyesight
Cognitive changes and poor mental health - low mood and cognitive decline = do not want to cook, do not know what to buy
Medical conditions = cancers, heart failure, kidney disease, hypothyroidism = impair appetite
Malabsorption syndromes - coeliac disease, IBS
Medications = impair appetite e.g. hypertensives
Reduced activity = weight gain
Dependency on staff / carers
What are the effects of malnutrition on health?
Impaired immune function Poor wound healing Osteoporosis Cognitive impairment Mood disturbance Joint and muscle pain
What does lack of calcium and vit D lead to?
What does lack of vit C lead to?
What does lack of vit B12 / folate lead to?
Osteomalacia - vit d / calcium
Poor wound healing - vit c
Anaemia - vit B12 / folate
What does loss of skeletal mass cause?
Sarcopenia - component of frailty syndrome
Increases morbidity and mortality
What should history taking with older persons include?
Patient And with consent - family members / carers Check for changed to weight and BMI Additional symptoms of malnutrition Social history - living situation, care and functional needs Mental health Drug history PMH Fluid and food diary
What should examination of an older person include?
Weight
BMI
Dentition
Other relevant signs - brittle nails, mouth ulcers, psychological disturbance etc.
What do investigations of older persons include?
Guided by history and examination
May include:
Blood tests - electrolytes etc.
What else should be used in a consultation?
MUST - malnutrition screening tool
Objective indication of risk of malnutrition
How can older persons be treated to help malnutrition?
MDT approach
Doctors = review medications, manage medical conditions, play co-ordinating role
Dietitians = formal nutritional assessment, implement recommendations e.g. calorie and nutrient dense supplements, texture modifications, changes to portion sizes etc.
Occupational therapists = practicalities e.g. shopping, cooking, reminding of meal times etc.
Social care = assess and provide increases support e.g. carers, meal deliveries
Speech and language therapists = unsafe swallow corrected
Dentists = address dental pain, provide better fitting dentures
What is OSA?
How does it affect sleep?
Obstructive sleep apnoea - partial or fully blocked airway, often occurs during sleep
Brain gets starved of oxygen, person must wake up to re-invigorate the musculature of the airway
Results from a partial/fully blocked airway
Tonsils too large, jaw set too far back, excess weight
Airway blocked in sleep → brain hypoxia → mini arousal → sharp intake of breath
↑ risk of CVD/stroke/type 2 diabetes/severe depression/severe COVID-19
How patients with OSA present clinically?
Often unaware they are waking up to correct their airways, therefore primarily complain of excessive daytime sleepiness
Partner complains of their snoring - as patient often unaware of this
Loud snoring, pause in breathing, large gasp of air
Excessive daytime sleepiness (EDS)!
Ideally diagnosed with PSD – expensive + resource intensive
Use STOP-Bang questionnaire
What is meant by the term somnolence?
What is meant by fatigue?
Somnolence = strong desire to sleep, can be pathological or not
Fatigue = physical and/or mental exhaustion not alleviated or facilitated by sleep
OSA increases risks of what?
CVD, stroke, T2DM, independent of weight and age
More severe depression
What do the pauses in breathing lead to in the night?
Hypercapnia = increased CO2 in the brain = cellular death
How do OSA patients experience covid-19 symptoms?
5x more severe
How is OSA diagnosed?
Ideally = PSG although expensive and resource intensive
STOP-bang questionnaire = used for differential diagnosis narrowing
Why may the airway be blocked and how can these issues be fixed?
Too large tonsils - may be removed
Wight gain - opt for weight loss
Set back jaw - opt for mandibular advancement
How does weight gain cause OSA?
More adipose tissue around base of tongue and pharynx = airway more likely to collapse when muscles relax during sleep
Risk factors for OSA/ What can increase OSA severity?
- Sleeping on the back
- Anything impacting REM sleep (muscles are paralysed) - Alcohol, some antidepressants
What is the gold standard treatment for OSA?
CPAP - continuous positive airway pressure
Mask worn at night
Keeps airway open - pneumatic splint keeps airway open
V. effective but low compliance = behaviour changes to get them to adhere to this
other treatments:
- Lose weight, quit smoking, reduce alcohol
- Always consider bed partner!
What lifestyle factors can help OSA?
Quit smoking
Lose weight
Reduce alcohol intake
What is insomnia diagnosis clinically?
ICSD-3 (international classification of sleep disorders) diagnostic criteria:
Difficulty initiating or maintaining sleep
Waking up earlier than desired and resistance going to bed
Difficulty sleeping without parent or caregiver
Daytime difficulties because of sleep
Present for 3 months = chronic
1-3months = short-term insomnia
What may cause insomnia?
Continuous elevated stress response across 24hr day - hyper arousal theory of insomnia
Why are psychotropics not recommended for insomnia?
Side effects are worse than insomnia itself
Effects short lived and can lead to dependence
What is the first line treatment for insomnia?
CBT - cognitive behavioural therapy:
other treatments: Sleep hygiene Relaxation training Paradoxical intention Sleep restriction therapy - retraining people with sleep schedule using short term sleep deprivation
What is insomnia a predictor of?
New incidence / developing depression
In an elderly person, what factors could contribute to sleeping difficulty?
x
What are hypnotics and why should they not be used long-term?
Benzodiazepines = GABA receptor agonists = anxiolytic, hypnotic and sedative effects
Zopiclone = ‘Z’ drug = removes some of the side effects of benzos
Risk of dependence, tolerance, hangover side effects (unsteady gait, drowsiness, confusion), associated with road traffic accidents
Mrs B has been using hypnotic medication long term, why is this an issue particularly in older patients?
Unsteady gait = higher fall rates in the elderly = morbidity and mortality
More susceptible to cardiorespiratory depression
Reduced social funcitoning die to effects on memory and gait disturbance
Impaired cognitive dunction - can be wrongly diagnosed as dementia
Mood disturbance = aggravation of depression, emotional blunting or anxiety
Why do patients feel drowsy during the day on zopiclone?
It can help fall to sleep - but low quality sleep - lack of deep restorative sleep
Therefore, when waking in the morning - feel unrested and groggy
Zopiclone also has sedative effects = daytime drowsiness
What are some sleep hygiene suggestions to help sleep?
Less stressful evenings
Less caffeine - herbal tea or hot chocolate instead of coffee
Screen time
Exercise during the day = help sleep better at night
Reduce alcohol intake
What worries does Mrs B have about stopping taking Zopiclone?
Cold turkey
Side effects of stopping - withdrawal symptoms
‘How will I sleep?’
How can Mrs B’s worries be tackled?
Gradually reduce zopiclone dose whilst implementing lifestyle factors
Until eventually she can sleep without zopiclone
What are some stats on loneliness and its prevalnece?
7 in 10 have a friend who is lonely
92% find it difficult to tell others they are lonely
1M >65 = lonely
8/10 feel judged negatively for feeling lonely
1/3 believe something is wrong with them
13% feel lonely all the time
1/4 know a parent who feels lonely
What is the difference between social isolation and loneliness?
Social isolation =
- Objective measure of the number of contacts that people have
- About quantity and not quality of relationships
Loneliness =
- Subjective feeling about the gap between a person’s desired levels of social contact compared to their actual level of social contact
- Perceived quality of the person’s relationships
Why is it important to distinguish between social isolation and loneliness?
Quality vs quantity: Possible to have a large social network and still feel lonely so measuring social isolation alone does not account for the quality of relationships or subjective experience of individuals
Meaningful solutions: policy makers and researchers need to ensure that solutions are focused on creating and maintaining meaningful relationships that address both social isolation and loneliness
Measurement tools: the “gold standard” measure of loneliness includes both direct (Community Life Survey single-time measure) and indirect (UCLA 3 item scale) measures
What are the direct and indirect effects of social isolation and loneliness on health?
Social connection (social isolation and loneliness) has impacts on lifestyle. psychological and medical adherence factors
Social connection can impact lifestyle factors e.g. physical activity, nutrition, sleep, smoking, risk-taking behaviours
Social connection can impact psychological factors e.g. appraisal, stress, depression, resilience, meaning / purpose, hopelessness, safety
Social connection can impact medical adherence and compliance e.g. taking medications, following diet plans, executing lifestyle changes
These impacts on lifestyle, psychological and medical adherence factors can have an effect on biomarkers e.g. inflammation, BP, gene expression, neuroendocrine functioning, adiposity, and more
These can lead to morbidities e.g. CVD, CHD, stroke, diabetes
Morbidities can lead to mortality
How does loneliness negatively effect each of the health systems below?
Cardiovascular system
Immune system
Neuroendocrine system
Cognition
Psychological health
Cardiovascular system
Immune system
Neuroendocrine system
Cognition
Psychological health
What barriers do you think older people face in seeking help for social isolation and loneliness?
1) Stigma – they might find it difficult to admit feeling lonely and may feel that they are a burden on others.
2) Fear of admitting reliance on others and consequences of ageing
3) Fear of external action due to expressing need – e.g. having to move to a nursing or care home.
4) Previous negative experiences, which has impacted their trust and expectation of services
5) Limited awareness of relevant support services
What are some examples of wider determinants of health?
Nutrition
Social networks
Physical activity
Financial well-being
What percentage of patients see their GP for social problems?
20% - e.g. education, work, housing, finance
What is social prescribing?
Way of enabling frontline healthcare professionals to refer people to a range of local, non-clinical services (e.g. community gardening to housing charities)
Way of addressing patient’s needs in a holistic manner - often at a lower cost than prescribing medications
How does social prescribing work in practice?
GP / frontline worker assesses needs to patient
Refers patient to link worker - a person with a background in health and social care who has received special training in social prescribing
Link worker signposts appropriate support and activities to patients
Patient has multiple meetings with link worker over subsequent months
follow up patients
Self care VS social prescribing?
Self care = broad term encompassing anything done to support own health and well being e.g. painkillers, mindfullness app
Social prescribing = personalised plan to help needs
How does social prescribing help?
- Increased quality of life and mental health
- Reduction in use of NHS services
What effects outcomes of social prescribing?
How well patients are signposted to the right interventions to help their needs
Compliance
How well the interventions work
What are the challenges of social prescribing (Why is it difficult to measure outcomes of social prescribing?)
Due to heterogenous (mixing together unlikely substances - like oil and water) nature of the programmes, service users, and their outcomes
- Without strong evidence to support, hard to commission social prescribing programmes
- Risk of seeming like you are trivialising the patient’s issues
What are the physical health benefits from exposure to green space?
Decreased risk of pre-term birth and small size gestational age
Decreased risk of T2DM
Decreased risk of cardiovascular mortality and all cause mortality
Reduced incidence of stroke, hypertension, dyslipidaemia, asthma, and coronary heart disease.
What are the physiological changes from exposure to green space?
Reduced salivary cortisol
Reduced diastolic BP
Reduced HR
Changes in HRV (heart rate variability)
What are the mental health benefits from exposure to green space?
Reduced feelings of stress
Reduced anxiety and depression
Improved attention and memory
Improved childhood development
What are the social benefits from exposure to green space?
Improved social cohesion and interaction
Reduced crime
Improved work productivity
Increased job opportunities
What are some additional benefits to greenspace exposure?
Less suffering from cardiovascular, musculoskeletal, mental health, respiratory, neurological, and digestive diseases
Diabetics show better blood sugar ocntrol
Associated with better cognitive development in children
Decrease in BP / hypertension
Outdoor activity improves physical and mental well being more than indoor activities
Decrease in anxiety, negative thinking and lowers levels of depression and stress
Can you think of any population groups who might not be able to access green space?
- hay fever
What is the role of physical activity in Ageing?
- Anti-inflammatory effects = delivers the greatest health benefit in two main ways - by reducing inflammatory visceral fat and releasing anti-inflammatory myokines during muscle contraction
- Effects at the mitochondrial level = increased charge in the mitochondria during sedentary behaviour increases ‘electrochemical charge’ across the mitochondrial membrane. Allows leakage of free radicals into the cell causing damage in the cytoplasm and mitochondria. This damage in the cell results in inflammation, which leads to telomere shortening and over time, cell death creating yet more inflammation. This speeds up the ageing process
Using ATP during muscle contraction reduces the charge in the mitochondria and can reverse the above process, and even lengthen telomeres. Physical activity also increases the number and size of mitochondria
- Weight loss = however, remember the benefits of being active and overweight outweigh the benefits of weight loss while being inactive
- CVD
Coronary artery disease - plaque regression
Reduces blood pressure
Can prevent re-hospitalisation after an MI - Diabetes
Aerobic/resistance exercise reduces mortality and increases insulin sensitivity
Better HbA1c/blood lipids/waist circumference/BMI
What are the 2 most common chronic diseases?
Hypertension
Diabetes
Lifestyle changes are suggested for which chronic conditions?
Hypertension
Hypercholesterolaemia
Diabetes
All to help prevent deterioration
How can meeting physical activity recommendations be achieved realistically in daily lives?
30 mins of daily exercise target can be met within a commute
2 days of strength exercises/ week can be met by carrying bags of shopping home
How does physical activity help in the management of chronic disease?
Exercise = significant reduction in systolic and diastolic BP regardless of weight
Even after cardiac event, or with established cardiac disease, exercise can help prevent subsequent hospitalisations
Aerobic / resistance exercise helps reduce mortality for T1DM and T2DM as it increases insulin sensitivity
How does physical activity help so many conditions?
It induces adaptations in multiple cells and tissues - changes can be seen in the mitochondria, cardiomyoctes and skeletal muscle myocytes
Effect on endothelia to allow for vasodilation
Effect on anti-oxidant systems and anti-inflammatory effects systemically
What would a Lifestyle Medicine Prescription for Mrs B involve?
Diet - home deliveries from the supermarket for meals, corner shop for snacks and convo with shopkeeper
Batch cooking
What matters to Mrs B?
She actively engages with NHS (attends annual appointments)
Cares about her health - took the initiative to make the appointment
Refer to dietician
Last cup of tea before 4pm - switch out tea for hot choc
Sleep - fix sleep schedule esp diverging due to social isolation
Join group activities - helps social isolation and if its cooking/exercise, also helps that
Drinking - lower ability to clear, so maybe lessen drinking habits or if she enjoys it, go to the pub and socialise
Take up a healthy hobby
Go outside in the garden or park
causes of malnutrition
Poor dentition
Difficulty swallowing
Declining coordination + eyesight
Arthritis
Low mood
Cognitive decline
Cancer, heart failure, CKD, hypothyroidism
Coeliac disease + IBD can cause malabsorption
Medications (diuretics, antihypertensives)
Reduced physical activity
Dependent on staff if in care homes etc.
nutritional challenges faced by older people
- Decreased food intake
- Decreased basal metabolic rate, lean body mass, sense of taste/smell
- Malnutrition is not a normal part of ageing
effects of malnutrition
- Impaired immune function
- Poor wound healing
- Osteoporosis
- Cognitive impairment
- Mood disturbance
- Joint + muscle pain
- Calcium, vitamin D/C/B12, folate deficiencies
- –>Osteomalacia, anaemia, sarcopenia
assessment of malnutrition
Changed weight/BMI Mental health Social/drug/past medical history Food and fluid diary MUST = malnutrition universal screening tool
support for malnutrition
Doctors, dieticians, occupational therapists, social care, speech and language therapist, dentists
key points
Key points
a. Malnutrition is when a diet does not contain the right amount of nutrients, which may
be in the form of under-nutrition or over-nutrition. This can result in various health
problems which can be mitigated with a multi-disciplinary approach to improve
nutrition.
b. Sleep plays an important role in disease prevention and health promotion. Long term
use of hypnotics can have various negative health effects especially among the elderly
population.
c. Social prescribing is a personalised solution for an individual’s need, provided with the
support of healthcare professionals.
what is sarcopenia
Sarcopenia is loss of lean muscle mass. This is associated with falls, reduced functional ability and is a component of frailty syndrome. Malnutrition is a risk factor for sarcopenia.
What is the title of the health professional whose formal role within the NHS is to assess, diagnose and treat dietary and nutritional problems?
Dietitians are employed by the NHS to assess, diagnose and treat dietary and nutritional problem. They work both in the community and in hospitals. ‘Dietitian’ is a legally protected title and all dietitians must be registered with the Health & Care Professions Council.
What proportion of over 65s in the UK are malnourished?
Around 10% of over 65s in the UK are malnourished, equivalent to over one million people.
In an elderly person, what factors could contribute to sleeping difficulty?
- Stress: finances around retirement, support required to or from other family/friends, bereavement, social isolation, loneliness, illness of friends or family, difficulties with activities of daily living, fear of falling.
- Mental health problems: Depression and anxiety are common in the elderly population which can result in poor sleep.
- Physical Inactivity: Physical activity typically declines with age. Less physical activity with age is associated with poor sleep
- Diet: Caffeine use and timing of meals disrupting sleep
- Chronic conditions disrupting sleep eg osteoarthritis causing pain
- Less of purpose/ structure to the day so naps during the day
- Sedative substances such as medication or alcohol to assist with falling asleep but affect quality of the sleep
- Physiological changes in sleep as people age: melatonin production decreases, sleep is more fragment, fall asleep and waking from sleep happens earlier in the day .
- Reduced exposure to sunlight in house bound and in those with cataracts, limited social activities or in nursing home, disrupting the bodies biological clock.
What has to be present for diagnosis of chronic insomnia
Impact on daily functioning attributed to sleep loss
what is clinically significant insomnia in middle aged adults
Insomnia is diagnosed when difficulty initiating and/or maintaining sleep is present 3 or more nights a week and results in difficulties in the patients waking life. This can manifest across various domains: difficulty concentrating; impacting relationships or mood instability for example. In middle aged adults sleep onset of greater than 30 minutes, or being awake for greater than 30 minutes in total during the desired sleep period is considered clinically significant.
What happens in OSA and what is first line treatment
Obstructive Sleep Apnoea (OSA) is a disorder of the upper airway. Essentially the airway becomes obstructed during sleep. This leads to oxygen desaturation, which causes a micro-arousal from sleep. This reinvigorates the nerves and opens the airway. Often you will hear loud snoring, a pause in breathing and then a large gasp of air. This is the airway closing, causing snoring. The airway closes so breathing stops. The airway opens and there is a gasp for air. Firt Line treatment is continuous positive airway pressure (CPAP). The creates a pneumatic splint in the airway to keep it open. It is very effective, however it is difficult to support patients in using it.
What are hypnotics and the cons
Benzodiazepines are GABA receptor agonists and have anxiolytic, hypnotic and
sedative effects.
- Zopiclone is an example of ‘Z-drug,’ a non- benzodiazepine hypnotic which was
developed to overcome some of the adverse side effects of benzodiazepines. - short term management of insomnia
under certain circumstances, following lifestyle interventions such as addressing
sleep hygiene. - every effort must be made to avoid dependence, keeping to
a minimum dose for the shortest possible time due to the risk of dependence. - Tolerance can develop rapidly, resulting in higher doses required to achieve the
desired effects. - can have serious ‘hangover’ effects, including drowsiness, unsteady gait,
slurred speech, and confusion. Hypnotic use has been associated with accidents
such as road traffic accidents too.
effects older people in hypnotic long term use
- Reduced social functioning due to effects on memory and gait disturbance.
- Impaired cognitive function secondary to benzodiazepines can be wrongly diagnosed as dementia.
- Mood disturbance, ie. this could be first presentation or aggravation of pre-existing depression, emotional blunting, in between doses increased anxiety.
