Lesson 1

Topics

To be old is not to be sick

Physiological ageing that is, the changes that can occur with aging itself, apart from the influence of disorders and other factors.

Predicting how a particular person will age is hard, because each person ages at a different pace. In addition, how well a person takes care of the body influences how the person ages. Nonetheless, some changes are almost universal. Knowing what changes may be expected can help a person adjust to aging.

Eye

This change in vision, called presbyopia, occurs because the lens in the eye stiffens.

As people continue to age, vision changes in other ways. Seeing in dim light becomes more difficult. This change occurs because the lens tends to become denser. Also, the retina, which contains the cells that sense light, becomes less sensitive. So for reading, brighter light is needed. On average, 60-year-olds need 3 times more light to read than 20-year-olds.

Older eyes are less able to adjust partly because the muscles that widen and narrow the pupils tend to weaken as people age. Consequently, older people may be unable to see when they first enter a dark room. Or they may be temporarily blinded when they enter a brightly lit area.

The lens tends to yellow slightly with aging. Yellowing affects how colors at the blue-violet end of the light spectrum are seen. Blues tend to lose their vividness and look more like gray. This change is insignificant for most people. However, older people may have trouble reading black letters printed on a blue background or reading blue letters. At the other end of the spectrum, reds tend to appear more vivid.

The number of nerve cells that transmit visual signals from the eyes to the brain decreases. This change affects the way depth is perceived, and judging distances becomes more difficult.

Many older people are bothered by dry eyes. This change occurs because the number of cells that produce fluids to lubricate the eyes decreases. In some older people, tear production decreases.

The whites (sclera) of the eyes may turn slightly yellow or brown. A gray-white ring (arcus senilis) may appear on the surface of the eye. The ring is made of calcium and cholesterol salts. The lower eyelid may hang away from the eyeball because the muscles that close the eye tend to weaken and the tendons that hold the eyelid in place stretch. The eye may appear to sink into the head because the amount of fat in the area around the eye decreases.

The serious eye problems that tend to occur during old age are caused by a disorder, not by aging itself. Examples are glaucoma, retinopathy, macular degeneration, and cataracts.

Ear

Exposure to loud noise over time damages the ear's ability to hear. Some structures in the ear that help with hearing or balance deteriorate slightly. Also, earwax tends to accumulate more as people age. This accumulation can interfere with hearing.

Difficulty hearing high-pitched sounds causes that they may have trouble understanding what women and children s say. The sentence sounds as if the person speaking is not pronouncing the words clearly, and the meaning is lost. Speaking loudly does not help because it tends to accentuate the vowels, not the consonants. Many older people have more trouble hearing in loud places or in groups because there is more background noise. Hearing aids can help people with hearing loss hear better.

Mouth and nose

The abilities to taste and smell start to gradually diminish. The number and the sensitivity of taste buds on the tongue decrease. These changes tend to reduce the ability to taste sweet and salt more than the ability to taste bitter and sour. The ability to smell declines slightly. Strong smells remain easy to detect, but more subtle smells become more difficult to notice and identify. Older people may notice that their mouth feels dry more often. As people age, less saliva is produced. However, dry mouth may result from a disorder or the use of certain drugs.

The gums recede slightly. Also, tooth enamel tends to wear away. These changes make the teeth more susceptible to decay and cavities (caries), which make tooth loss more likely.

Skin

As people age, the skin tends to become thinner, less elastic, drier, and finely wrinkled. The layer of fat under the skin thins and is replaced by more fibrous tissue. As this layer thins, the skin is torn more easily, wrinkles are more likely to develop, and tolerance for cold decreases. The number of nerve endings in the skin decreases. As a result, sensation, including sensitivity to pain, may be reduced, and injuries may be more likely. The number of sweat glands and blood vessels also decreases, and blood flow in the deep layers of the skin decreases. Thus, older people are more likely to develop disorders due to overheating, such as heatstroke.

The number of pigment-producing cells (melanocytes) decreases. Thus, the skin has less protection against ultraviolet (UV) radiation, such as that from sunlight.

Bone and joints

As people age, bones tend to become less dense. Thus, bones become weaker and more likely to break. Bones become less dense partly because the amount of calcium they contain decreases. Part of the reason is that less calcium is absorbed in the digestive tract and levels of vitamin D (which helps the body use calcium) decrease slightly.

As people age, the amount of bone marrow decreases. Bone marrow is less able to increase its production of blood cells in response to the body's needs.

As people age, the cartilage that lines the joints tends to thin .Joints may be slightly more susceptible to injury. Ligaments, which bind joints together, tend to become less elastic as people age, making joints feel tight or stiff.

Muscle and body fat

As people age, the amount of muscle tissue (muscle mass) and muscle strength tend to decrease. This process is called sarcopenia Loss of muscle mass begins around age 30 and continues throughout life. Muscle mass decreases because the number of muscle fibers decreases. This change may occur because the levels of growth hormone and testosterone, which stimulate muscle development, decrease with aging. Also, muscles cannot contract as quickly in old age. Regular exercise can partially overcome or at least significantly delay the loss of muscle mass and strength. As people age, the amount of body fat tends to increase.

Brain and Nervous System

As people age, the number of nerve cells in the brain decreases only slightly. As cells are lost, new connections are made between the remaining nerve cells. New nerve cells may form in some areas of the brain, even during old age. In addition, the brain has more cells than it needs to perform most activities—a characteristic called redundancy.

The substances and structures involved in sending messages in the brain change. The levels of some chemical messengers (neurotransmitters) and enzymes decrease, and others increase. The number of some types of receptors on nerve cells decreases, and the number of others increases. Because of these changes, the brain may function slightly less well. Older people may react and do tasks somewhat more slowly. Some mental functions may be subtly reduced. They include vocabulary, short-term memory, the ability to learn new material, and the ability to recall words.

After about age 60, the number of cells in the spinal cord begins to decrease. As a result, older people may notice a decrease in sensation. As people age, nerves may conduct signals more slowly. Usually, this change is so minimal that people do not notice it. Also, the nervous system's response to injury is reduced. Nerves may repair themselves more slowly and incompletely in older people than in younger people. Therefore, older people are more vulnerable to injury and disorders.

Heart and Blood Vessels

As people age, the heart and blood vessels change in many ways. The walls of the heart become stiffer, and the heart fills with blood more slowly.

The walls of the arteries become thicker and less elastic. The arteries become less able to respond to changes in the amount of blood pumped through them. Thus, blood pressure is higher in older people than in younger people.

Despite these changes, a normal older heart functions well. At rest, the differences between young and old hearts are trivial. The differences become apparent only when more work is required of the heart, as occurs when a person exercises vigorously or becomes sick. An older heart cannot increase how fast it beats as quickly or as much as a younger heart. Regular exercise can reduce many of the effects of aging on the heart and blood vessels.

Muscles of Breathing and the Lungs

As people age, the muscles used in breathing, such as the diaphragm, tend to weaken. Also, slightly less oxygen is absorbed from air that is breathed in. In people who do not smoke or have a lung disorder, the muscles of breathing and the lungs continue to function well enough to meet the needs of the body during ordinary daily activities. But these changes may make exercising vigorously (for example, running or biking energetically) more difficult. Older people may also have more difficulty breathing at high altitudes.

The lungs become less able to fight infection, in part because the cells that sweep debris out of the airways are less able to do so. Cough, which also helps clear the lungs, tends to be weaker.

Kidneys and Urinary Tract

As people age, the kidneys tend to become smaller (because the number of cells decreases), and less blood flows through them. Beginning at about age 30, the kidneys begin to filter blood less well. As years pass, they may remove waste products from the blood less well. They may also excrete too much water, making dehydration more likely. Nonetheless, they almost always function well enough to meet the body's needs.

The urinary tract changes in several ways that may make controlling urination more difficult. The maximum volume of urine that the bladder can hold decreases. Older people may be less able to delay urination after they first sense a need to urinate. The bladder muscles may contract sporadically, apart from any need to urinate. The bladder muscles weaken. As a result, more urine is left in the bladder after urination is finished. These changes are one reason that urinary incontinence (the uncontrollable loss of urine) becomes more common as people age.

As women age, the urethra (which carries urine out of the body) shortens and its lining becomes thinner. The muscle that controls the passage of urine through the urethra (urinary sphincter) is less able to close tightly and prevent leakage. These changes may result from the decrease in the estrogen level that occurs with menopause.

As men age, the prostate gland tends to enlarge. In many men, it enlarges enough to partly block the passage of urine.

Digestive System

Aging affects the digestive system in several ways. But these changes have little effect on function.

The muscles of the esophagus contract less forcefully, but movement of food through the esophagus is not affected. Food is emptied from the stomach more slowly, and the stomach cannot hold as much food because it is less elastic. But in most people, these changes are too slight to be noticed.

Certain changes in the digestive system cause problems in some people. The digestive tract may produce less lactase, an enzyme the body needs to digest milk. As a result, older people are more likely to develop intolerance of dairy products (lactose intolerance). People with lactose intolerance may feel bloated or have gas or diarrhea after they consume milk products. In the large intestine, materials move through a little more slowly. In some people, this slowing may contribute to constipation.

The liver also changes. It tends to become smaller (because the number of cells decreases), and less blood flows through it. Certain enzymes produced in the liver work less efficiently. These enzymes help the body process drugs and some other substances. As a result, the liver may be slightly less able to help rid the body of drugs and other substances. And the effects of drugs—intended and unintended—last longer.

Reproductive Organs

The effects of aging on the reproductive system are more obvious in women than in men. In women, most of these effects are related to menopause, when the levels of female hormones (particularly estrogen) decrease, menstrual periods end permanently. The decrease in female hormone levels causes the ovaries and uterus to shrink. The tissues of the vagina become thinner, drier, and less elastic (a condition called atrophic vaginitis). The breasts become less firm and more fibrous, and they tend to sag. Some of the changes that begin at menopause may interfere with sexual activity. However, for most women, aging does not significantly affect sexual activity.

In men, the changes in the reproductive system are less dramatic. Most men remain fertile until death, even though testosterone levels decrease, resulting in fewer sperm and a decreased sex drive (libido). Most men can continue to have erections and reach orgasm throughout life. However, erections may not last as long or may be slightly less rigid. In addition, the time needed to achieve a second erection may increase markedly. Erectile dysfunction (impotence) becomes more common as men age.

Endocrine System

As people age, the levels and activity of some hormones (in addition to sex hormones) decrease. For example, the level of growth hormone decreases, causing changes in muscles such as a decrease in muscle mass. The level of aldosterone, a hormone produced by the adrenal glands, also decreases. This decrease may contribute to the tendency of older people to become dehydrated more easily.

Most hormonal changes do not affect how the body functions. However, during certain circumstances, the body's functions may be affected. For example, after eating a large meal, insulin released from the pancreas is not used as efficiently as usual. Insulin helps control the level of sugar in the blood. When insulin is used less efficiently, the level of sugar in the blood rises slightly higher than usual, and the level takes longer to return to normal. This change may have no noticeable effect. But in some people, it can be an early warning of diabetes.

Immune System

As people age, the immune system becomes less effective. But the change is so slight that most people do not notice it. Most people notice that the body is less able to fight infections only when infections linger or become severe. People who are infected with tuberculosis during early adulthood may have no symptoms until old age. Then, symptoms develop because the immune system is weaker.

The immune system may be less able to distinguish the body's own cells from foreign substances that invade the body. Consequently, disorders in which the immune system attacks some of the body's own cells (autoimmune disorders) become more common.

The cells of the immune system destroy cancer cells, bacteria, and other foreign substances more slowly. This slowdown may be one reason that cancer is more common among older people. Also, vaccines tend to be less protective in older people. These changes in the immune system may help explain why some infections, such as pneumonia and influenza, are more common among older people and result in death more often.

Changes in the immune system may have one beneficial effect. Allergy symptoms may become less severe.

USUAL AGING

• Multiple illnesses ;

• Multiple medications'

• Decreased function

Pathologic and accelerated ageing

Progeria

A rare congenital disorder of childhood (one per 8 million live births) that is characterized by rapid onset of the physical changes typical of old age, usually resulting in death before the age of 20. Also called Hutchinson-Gilford syndrome.

mutations in the LMNA (lamin A protein) gene on chromosome 1;

Signs and symptoms

The earliest symptoms include failure to thrive and a localized scleroderma-like skin condition. As a child ages past infancy, additional conditions become apparent. Limited growth, alopecia, and a distinctive appearance (small face and jaw, pinched nose) are all characteristic of progeria. People diagnosed with this disorder usually have small, fragile bodies, like those of elderly people. Later, the condition causes wrinkled skin, atherosclerosis, and cardiovascular problems.

Diagnosis

Diagnosis is suspected according to signs and symptoms, such as skin changes, abnormal growth, and loss of hair. It can be confirmed through a genetic test.

Treatment

No treatments have been proven effective. Most treatment focuses on reducing complications (such as cardiovascular disease) with heart bypass surgery or low-dose aspirin. Children may also benefit from a high-calorie diet.

Growth hormone treatment has been attempted.

Prognosis

There is no known cure. Few people with progeria exceed 13 years of age. At least 90% of patients die from complications of atherosclerosis, such as heart attack or stroke.

Mental development is not affected. The development of symptoms is comparable to aging at a rate eight to ten times faster than normal, although certain age-related conditions do not occur. Specifically, patients show no neurodegeneration or cancer predisposition. They do not develop physically mediated "wear and tear" conditions commonly associated with aging, like cataracts (caused by UV exposure) and osteoarthritis.

Werner syndrome

Werner Syndrome is a very rare, autosomal recessive disorder characterized by premature aging. Werner's syndrome more closely resembles accelerated aging than any other segmental progeria. For this reason, Werner syndrome is often referred to as a progeroid syndrome, as it partly mimics the symptoms of Progeria.

Pathophysiology

Werner syndrome is an autosomal recessive disorder. The gene associated with Werner Syndrome lies on Chromosome 8.

The disorder is directly caused by shorter-than-normal length telomere maintenance. As a result DNA replication is impaired, thus making the times DNA can multiply in cells to not be able to have as many populations as normal cells do.

Symptoms

Individuals with this syndrome typically develop normally until they reach puberty. Following puberty they age rapidly, so that by age 40 they often appear several decades older. The age of onset of Werner syndrome is variable, but an early sign is the lack of a teenage growth spurt, which results in short stature. Other signs and symptoms appear when affected individuals are in their twenties or thirties and include loss and graying of hair, hoarseness of the voice, thickening of the skin, and cloudy lenses (cataracts) in both eyes. Overall, people affected by Werner syndrome have thin arms and legs and a thick torso.

Affected individuals typically have a characteristic facial appearance described as "bird-like" by the time they reach their thirties. Patients with Werner syndrome also exhibit genomic instability, hypogonadism, and various age-associated disorders; these include cancer, heart disease, atherosclerosis, diabetes mellitus, and cataracts. However, not all characteristics of old-age are present in Werner patients; for instance, senility is not seen in individuals with Werner syndrome. People affected by Werner syndrome usually do not live past their late forties or early fifties, often dying from the results of cancer or heart disease.

ATYPICAL PRESENTATION

Overview/Definition

Because illness in older adults is complicated by physical changes of aging and by multiple medical problems, it is essential to recognize more commonly seen atypical presentations of illness in older adults.

 Risk Factors 

• Over age 85 in particular

• Multiple co-morbidities

• Multiple medications

• Cognitive or functional impairment

Consequences (of not identifying) 

• Increased morbidity and mortality

• Missed diagnosis

• Unnecessary use of Emergency Rooms

Assessment/Screening Tools

Three strategies to assess for atypical presentation of illness include: (1) Vague Presentation of Illness; (2) Altered Presentation of Illness; and (3) Non-presentation (under-reporting) of Illness.

Vague Presentation of Illness Table lists some non-specific symptoms, such as falls, confusion or other symptoms that may signify an impending acute illness in an older adult. Changes in behavior or function in an older adult are often a prodrome (symptoms(s) indicative of an approaching disease) of an acute illness, especially for frail older adults. It is essential to take reports seriously from patients, family and non-professional care providers as to subtle symptoms such as mild confusion, changes in ability to perform activities of daily living (ADL), and decreased appetite. Timely identification of acute illnesses with vague presentation enables early treatment of illness resulting in reduced morbidity and mortality and an enhanced quality of life in older adults.

Non-specific Symptoms that may Represent Specific Illness

Confusion Self-neglecting Falling Incontinence Apathy Anorexia Dyspnea Fatigue

Altered Presentation of Illness Some of the more common altered presentations in older adults are listed in Table below. The presentation of a symptom or a group of symptoms in older adults may present a confusing picture to health care provides. The classic presentation of common illnesses in a general adult population such as chest pain during a myocardial infarction, burning with a urinary tract infection or sadness with depression does not hold true with older adults. For example, a change in mental status is one of the most frequently presenting symptoms at the onset of acute illness in older adults.

Illness	Atypical Presentation
Infectious diseases	Absence of fever Sepsis without usual leukocytosis and fever Falls, decreased appetite or fluid intake, confusion, change in functional status
"Silent" acute abdomen	Absence of symptoms (silent presentation) Mild discomfort and constipation Some tachypnea and possibly vague respiratory symptoms
"Silent" malignancy	Back pain secondary to metastases from slow growing breast masses Silent masses of the bowel
"Silent" myocardial infarction	Absence of chest pain Vague symptoms of fatigue, nausea and a decrease in functional status. Classic presentation: shortness of breath more common complaint than chest pain
Non-dyspneic pulmonary edema	May not subjectively experience the classic symptoms such as paroxysmal nocturnal dyspnea or coughing Typical onset is insidious with change in function, food or fluid intake, or confusion
Thyroid disease	Hyperthyroidism presenting as "apathetic thyrotoxicosis," i.e. fatigue and a slowing down Hypothyroidism, presenting with confusion and agitation
Depression	Lack of sadness Somatic complaints, such as appetite changes, vague GI symptoms, constipation, and sleep disturbances Hyper activity Sadness misinterpreted by provider as normal consequence of aging Medical problems that mask depression
Medical illness that presents as depression	Hypo- and hyper- thyroid disease that presents as diminished energy and apathy

Depression: Although most depression in older adults is associated with a sad mood, it often presents as a preoccupation with somatic symptoms related to appetite changes, vague GI symptoms, constipation, and sleep disturbances. Also problematic is that clinicians may interpret patient's sad affect as an appropriate reaction to multiple medical problems and thus miss the primary pathology of depression. Older adults are more likely than their younger counterparts to present with an agitated depression. In addition, the diagnosis of depression is complicated by the overlay of multiple medical problems and their corresponding symptoms that mask the depression.
Paradoxically, it is equally important to recognize medical illnesses that may present as depression. For example, both hypo and hyper thyroid disease may present as diminished energy and apathy and be miss-diagnosed as depression in older adults.

Infectious Diseases: The lack of typical signs of infection in older adults is common. Older adults with sepsis may not present with the usual leukocytosis and fever but rather with a decreased appetite and or functional status. Considering the frequency of infections in older adults, more often affecting the urinary tract, the respiratory tract, the skin or the GI tract, an infection should be suspected with any change in condition, including falls, a decrease in food or fluid intake, confusion, and/or a change in functional status

Acute Abdomen: Most patients suspected of having an "acute abdomen" present with a series of complaints and or signs such as pain, diminished or absent bowel sounds, and fever. Atypical assessment would also include vital signs, recording a patient's intake and output and possibly their abdominal girth. However, in older adults an acute abdomen may present silently with mild discomfort and constipation with some tachypnea, and possibly some vague respiratory symptoms. Therefore, it is extremely important to recognize those patients with significant bowel disturbances and a change in food or fluid intake.

Malignancy: A comprehensive physical exam is vitally important in older adults who may not be aware of hidden masses. For example, breast masses in older women may be very slow growing and exist for some time before they are discovered during a work up for back pain secondary to bone metastases. Silent masses of the bowel especially those from the ascending colon, may exist without major symptoms due to reduced neuronal sensitivity in the GI tract.

Myocardial Infarction: Most myocardial infarctions in older adults do NOT present with clinical symptoms such as chest pain. Clinicians need to be astute to patients at risk who present with vague symptoms of fatigue, nausea, and a decline in functional status. When patients do present with a more classic picture of an acute event, a more common complaint than chest pain is shortness of breath.

Pulmonary Edema: Older adults experiencing pulmonary edema will often exhibit specific clinical signs associated with CHF such as increased fluid retention, fatigue, and possibly dyspnea. However, the patient may not subjectively experience or recognize the classic symptoms such as paroxsymal nocturnal dyspnea, or coughing. More typically the onset is insidious and presents as a change in function, decreased food or fluid intake, or confusion.

Thyroid Disease: Although patients will often present with the classis signs and symptoms of both hypothyroidism and hyperthyroidism, it is not uncommon to see altered presentation of both. For example, hyperthyroidism may present as "apathetic thyrotoxicosis" whereby a patient presents with fatigue and a slowing down as opposed to the classic thin, hyperactive hyperthyroid patient. There is also cardiac presentation of hyperthyroidism (new or worsening CHF, AF) and moreover muscle wasting primarily in proximal muscles and anorexia weight loss.

Also, hypothyroidism, classically seen presents as fatigue and weight gain and instead may present with confusion and agitation.

Non-presentation of Illness

A host of illnesses in older adults may go unrecognized for many years and significantly impact quality of life and are summarized below.

"Hidden" Illness in Older Adults

Depression Incontinence Musculoskeletal stiffness Falling Alcoholism Osteoporosis Hearing loss Dementia Dental Problems Poor nutrition Sexual dysfunction Osteoarthritis

Factors that contribute to the under-reporting of illnesses are:

• The insidious nature of the onset of the illnesses and the vague symptoms associated with these problems

• A tendency on the part of patients and families to regard many of these symptoms as a "normal" part of aging

• Reluctance of older people to complain about problems because of concerns as to being ignored or generating burdensome tests

• Communication deficits including hearing impairments, poor vision, and speech problems

DEEP IN for quick screening

D - Dementia, Depression, Drugs

E - Eyes

E - Ears

P - Physical Performance

I - Incontinence

N - Nutrition

Dementia

Mini-Cognitive Assessment Instrument (Mini-Cog)

Step 1 Ask the patient to repeat three unrelated words, such as: ball, dog, television

Step 2. Ask the patient to draw a simple clock set to 10 minutes after eleven o'clock (11:10). A correct response is a drawing of a circle with of the numbers placed in approximately the correct positions, with the hands pointing to the 11 and 2.

Step 2. Ask the patient to recall the three words from step 1. One point is given for each item that is recall correctly.

Depression

• Single questions: Do You often feel sad or depressed? (Sen/Spe - 0.85/0.65)

• 5 Item Geriatric Depression Scale (Sen/Spe - 0.97/0.85)

• 15 Item GDS (Sen/Spe - 0.94/0.83)

Drugs

• Greater than or equal to four prescribed

• Any Of The “Antis”

• Benzodiazepines

• Not prescribed

• Alternative

Eyes

• Because of your eyesight, do you have difficulty with ….

• Driving

• Watching TV

• Reading

• Or any Daily Activity

If YES to question - eye test necessary

Ears

Whisper voice test

• Explain that you will whisper some numbers

• Ask senior to close eyes

• 0,6m apart

• You exhale and then whisper four random single numpers at 1 sec intervals

Fail screen if Senior cannot hear at least to numbers (Sen/Spe -80-100%/82-89%)

Physical Performance Testing in the elderly - timed perforemnce tests - dependency risk

Rapid Gait - > 11sec (RR-6,4) - 3m out and back “as quickly as possible”

Three (3) chair stands >10sec (RR-4,4)

Incontinence

Two questions:

• In the last year, have you ever lost urine and gotten wet?

• Have you lost urine on at least 6 separate days?

If YES to both? Risk of urinary incontinence

Nutrition screen Weight (kg)/height (m²) - 1min - BMI <22 or >25

Comprehensive Geriatric Assessment

The Comprehensive Geriatric Assessment (CGA) is the diagnostic cornerstone of modern

geriatric medicine. The focus of the comprehensive geriatric assessment help

to identify the medical and psychosocial needs of the older adults. The assessment involves obtaining a comprehensive history and conducting a physical examination, as well as the use of detailed, validated instruments to quantify psychosocial health and functional abilities.

Overview of the Comprehensive Geriatric Assessment

Component Elements

Medical Assessment

Problem List

Co morbid conditions and disease severity

Medication review

Nutritional status

Delirium Screening

Functional Assessment

ADLs

IADLs

Activity/exercise status

Gait and balance

Palliative Performance Scale

Psychological

Assessment

Mental status (cognitive) testing

Mood/depression testing

Social Assessment

Information support needs and assets

Care resource eligibility/financial assessment

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