Reproduction 7 - Ageing Flashcards
What is ageing?
Ageing or senescence is the biological process of growing old, with associated changes in physiology and increased susceptibility to disease and increased likelihood of dying.
What are the two main theories of why organisms age?
- Damage or error theories (the idea that external or environmental forces gradually damage cells and organs, leading to ageing and death)
- Programmed ageing theories (the idea that ageing is genetically programmed to occur with time, and this process of deterioration eventually leads to death)
Define population ageing
The increasing age of an entire country, due to increasing life spans, and falling fertility rates (mainly due to better public health)
What are the consequences of population ageing?
- Working life/ retirement balance
- Caring for older people, the sandwich generation
- Extending healthy old age, not just life expectancy
- Inadequate or absent services
- Outdated and ageist beliefs/ assumptions
- Medical system designed for single acute diseases
- Limited accessibility for those with disabilities
What is life expectancy, and how has it been changing?
- Life expectancy is a statistical measure of the number of years a person can expect to live.
- Life expectancy has been rising continuously for many years; for a baby girl born today it is around 83 years, compared with 80 years for a baby girl born in 1998 (79 and 75 for a baby boy).
- Life expectancy has not plateaued
How is disease different in older people?
Older people are more likely to have an atypical or non-specific presentation of disease
Define non-specific presentation
A non-specific presentation means presentations where the underlying pathology is not immediately obvious, or clearly linked to the presentation.
What do older people seek medical attention for?
- Falls, delirium and reduced mobility are all very common reasons for older people seeking medical attention
- Can be due to stroke, myocardial infarction, infections and changes to medications.
What are the giants of geriatric medicine?
- Immobility
- Intellectual impairment
- Instability
- Incontinence
- Iatrogenic problems.
What are iatrogenic problems?
- Iatrogenic problems are illnesses caused by receiving healthcare treatments and are more common in older people.
- They include mistakes in providing care, and known complications of treatment.
Define fraility, and give an example
- Loss of biological reserve across multiple organ systems, leading to vulnerability to physiological decompensation and functional decline after a stressor event
- Eg. young people with pneumonia can recover at home with antibiotics, while a frail older person may end up in hospital due to delirium and reduced mobility
What are the challenges of medicine for the elderly?
- Atypical and non-specific presentations can lead to delays in treatment
- Older people often present with multiple problems which need to be managed simultaneously (hence MDT needed)
- Changes in pharmacokinetics and pharmacodynamics can make drug treatments in older people more likely to cause harm (doctors must think carefully before prescribing)
- Many drug trials have low numbers of older people, so treatment evidence is extrapolated from younger people
Describe the ageing brain
- CT and MRI show increased CSF, enlarged ventricles and gaps between gyri
- Loss of connections between neurons
- 50% normal elderly people show some degree of white matter changes
- Decreases in weight at a rate of 2-3% per decade from 40-50 years
Why have rates of diagnosis of dementia been low historically?
- Misinterpretation (believing it is normal for older people to have poor memory)
- Fatalism (can’t do anything about it so no point diagnosing it)
- Social isolation (so no one notices any problems)
What proportion of people with dementia have a diagnosis?
Around 70%
What is dementia?
- A chronic, progressive, degenerative, irreversible disease which causes a decline in all cognitive functions.
- The most common types of dementia (Alzheimer’s and vascular) often start with memory problems, but over time will include all cognitive functions.
- Dementia is more common with increasing age.
Define mild cognitive impairment
A specific term used to refer to people who have mild problems which do not interfere with their day-to-day life and don’t meet the diagnostic criteria for dementia.
What is delirium?
- An acute episode of confusion, usually with a clear precipitant such as infection or medication changes.
- Delirium usually resolves, but can leave some people with residual problems (ie dementia).
- Delirium is much more common in people who already have dementia.
List common forms of cognitive assessment
- Abbreviated Mental Test (AMT) and clock drawing tests are brief screening tests for cognitive impairment
- Montreal Cognitive Assessment (MOCA) is a more detailed examination in wide general use
- Mini Mental State Examination (MMSE) is a slightly outdated assessment which is less widely used than previously.
- Confusion Assessment Method (CAM) and 4AT are tools to help distinguish between delirium and dementia
- Addenbrookes cognitive examination (ACE) is diagnostic
List the theories of programmed ageing
- Genetic life span theory
- Genetic predisposition theory
- Telomere theory
- Specific system theories (neuroendocrine theory)
List theories of damage or error
- Wear and tear theory
- Rate of living theory
- Waste product
accumulation theory - Cross-linking theory
- Free radical theory
- Autoimmune theory
- Error theories
- Order to disorder
theory
What are the issues of multimorbidity?
- Two or more chronic conditions
- Conditions impact on one another
- Treatment for one condition may impact on another
- Negative impacts (worse quality of life, more likely to be depressed, increased functional impairment, burden of treatment, polypharmacy)
Why do older people take more drugs?
- Multimorbidity
- Guidelines (do not take into account comorbidities)
- Undetected non-adherence (prescribing another drug without knowing the patient isn’t taking their medication)
- Infrequent review
- Poor communication
List the normal cognitive changes in older people
Seen at 70 or older - Processing speed slows - Working memory slightly reduced - Simple attention ability preserved, but reduction in divided attention - Executive functions generally reduced - No change in nondeclarative/ implicit memory - No change in visuospatial abilities - No overall change in language (some reduction in verbal fluency) - Reduction in problem solving ability
Describe the changing nature of the older population
- Increasing numbers of BAME older people
Increasing education of older people - Reduction in poverty
- More people are working for longer
- More complex/ nuanced retirement process
Compare chronological and biological age
- Chronological age is the age from the time you were born
- Biological age considers lifestyle and the effects on age of the body
- Not everyone ages at the same rate
How can ageing be prevented?
- Exercise
- Healthy diet
- Drink in moderation
How has retirement age changed?
- Previously 65 for men (life expectancy was 65 in the 1920s)
- Age has now increased
- Dependency ratio (number of people who are dependent to the number of people who are working age)
Compare healthy life expectancy and life expectancy
- Life expectancy is how long somebody is expected to live
- Healthy life expectancy is life expectancy without any improvement in the age at which morbidities develop
What is the sandwich generation?
- Generation looking after children under 16, whilst caring for an older relative
- Mostly women
- Most of these people are in paid work
List implications of increased life expectancy for health care services
- Increasing demand for primary, secondary and tertiary health care
- Increasing complexity
- Navigating the health and social care divide
Describe development of frailty
- Genetic factors and environmental factors lead to cumulative molecular and cellular damage
- Reduced physiological reserve
- Physical activity and nutritional factors lead to frailty
- Therefore, stressor events lead to falls, delirium and fluctuating disability
How could frailty be treated?
- Exercise
- Nutrition
- Drugs
- Prevention is better than cure
List the non-specific presentations
- Falls
- Reduced mobility
- Recurrent infections
- Confusion
- Weight loss
- Not coping
- Iatrogenic harm
Give examples of atypical disease presentations in elderly people
Acute coronary syndrome
- Less likely to have chest pain
- More likely to have shortness of breath
PE
- Less likely to have pleuritic chest pain
- Less likely to have haemoptysis
- More likely to have other symptoms
- More likely to have syncope
What is polypharmacy associated with?
- Falls
- Increased length of stay
- Delirium
- Mortality
40% prescriptions inappropriate
Why are older people at increased risk of adverse drug reactions?
- Reduced physiological reserve
- Impaired compensation mechanisms
- Comorbidities
- Polypharmacy
- Cognitive impairment
List common iatrogenic harm affecting older people
- Adverse reactions to medication
- Nosocomial conditions (infections, pressure sores, constipattion, delirium, malnutrition, loss of muscle mass or deconditioning)
- Falls
- Psychological/ cognitive damage
How is comprehensive geriatric assessment beneficial?
- Reduce falls
- Most benefit in mild or moderate frailty
- Reduces inpatient mortality
- Reduces functional and cognitive decline
- Reduces admission to institutional care
What is a CGA?
Multidisciplinary assessment - Medical - Functional - Social - Psychological/psychiatric Problem list is created Plan
How is rehabilitation used?
- Aim is to restore or improve functionality
- Multidisciplinary
- Rehabilitation alongside acute illness to prevent deconditioning
- Prehabilitation (increasing fitness before surfery)
List advantages of MOCA
- Covers a variety of domains of cognitive function
- Brief to administer (10 mins)
- Validated in a range of populations
- Available in translated versions
- Widely used (can be used for comparison)
List problems with MOCA
- Education level will affect results
- Language level will affect results
- Floor and ceiling effects (educated people with dementia may score well)
- Can be poorly administered
- Possibly practice/ coaching effects
List the problems with cognitive assessments
- Hearing and visual impairment may limit testing
- Physical problems may limit testing
- Most assume numeracy and literacy
- Most assume some basic cultural knowledge
- Depression can masquerade as dementia
- Not valid in acute illness
- Normal cognitive changes (slower processing speed, slower reaction times) may affect administration
- Must be interpreted in context
