HD118

What is the most rapidly growing segment of the population?

Leading cause of death for the over 65 popn?

Definition of Aging

Characs of Aging

>85 years old

Heart Disease, then Cancer

Deteriorative changes with time during postmaturational life that underlie an increasing vulnerability to challenges thereby decreasing the ability of the organism to survive

• Mortality increases exponentially
• Biochemical composition of tissue changes
• Physiologic capacity decreases
• Ability to maintain homeostasis diminishes
• Susceptibility and vulnerability to disease increases
• Environmental and genetic factors influence the rate of aging

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Theories of Aging: Stochastic theories

Theories of Aging: Programmed theories

Theories of Aging: Disposable Soma Theory

Accumulation of random damage to vital molecules which eventually results in physiologic decline and death

• Wear and tear
• Free radical theory of aging
• Macromolecular damage: (DNA damage, cross linking of collagen/elastin, glycation of tissues, mitochondrial failure)

• Ageing is under the active genetic control because ageing is beneficial or necessary
• Notion of a biologic clock
• Genetic programme to die (apoptosis)

• A gene will wish to preserve itself - the individual in which it resides is expendable
• An organism must allocate resources to maintenance and reproduction
• Genes which increase early survival and reproduction are favored
• There is little selection on genes which are deleterious in late life

Problems: Menopause and Specied w/ death immediately after repo

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Mechanism of Aging: Oxidative Stress

Mechanism of Aging: Chromosomal Alterations

Mechanism of Aging: Immunological

Mechanism of Aging: Neuroendocrinologic

Mechanism of Aging: Developmental - Genetic

Oxygen converted during metabolism causes protein, lipid, and DNA damage over time

Against: Antioxidants do not delay human senescence or disease

Age-acquired chromosomal instabilities contribute to gene silencing or expression of disease-related genes (eg cancer genes)

For: Damage by free radicals causes mitochondrial DNA -> more oxidants = vicious cycle and this is linke w/ neurodegeneration

This would mean our longevity comes from our Mothers

Against: The practical impact on nondiseased aging appears to be minimal

Time-acquired deficits, primarily in T- cell function, increase susceptibility to infections and cancer
For: Some diseases are associated with aging
Against: Immunologic function is apparently not directly related to healthy aging

Hypothalamic and pituitary responses are altered

No support

Senescence (biological aging) results from activation or suppression of specific “aging” genes

For: Longevity appears to be hereditable, Longevity appears to be hereditable

Against: Evolutionary pressures appear to select for reproductive fitness rather than senescence

HD118

Telomere

Cellular changes with age

Heat-shock response

• TTAGGG segment at end of chromo provides stability
• cell division results in progressive shortening
• “telomerase” is needed to add onto the telomere; this enzyme is not expressed in most somatic cells, but it is found in germ cells and cancer cells

• Loss of proliferative potential
• Slower onset of lymphocyte proliferation
• Diminished cloning efficiency of individual T cells
• Fewer population doublings of fibroblasts
• But...Proliferative potential does not invariably diminish with age

• Aging attenuates inducible responses requiring enhanced gene expression
• All species studied have age-related defect in heat- shock response

HD118

Life Span Extension

Resveratrol

The Fries Hypothesis

1. Metabolic and Insulin Signaling

• There appears to be endocrine regulation of aging
  Certain genes, especially those that appear to play roles in metabolic and insulin signaling (eg, GH, IGF-1), extend life span

2. Caloric Restriction

• Caloric restriction can increase the average and maximum lifespan
• Composition of the diet does not affect longevity so long as malnutrition is prevented
• Rats kept lean by forced exercise but fed an unrestricted diet had an increase in the average but not maximum lifespan
• If the body weight of genetically obese mice is normalized by caloric restriction, then they live as long as control mice despite having twice the body fat content

extends the lifespan of diverse species

• Advances in public health and lifestyle will delay chronic illness associated with aging
• this will result in compression of the period of morbidity as the average lifespan approaches the biologic upper limit set by genetic endowment

HD121

Life Span vs Life Expectancy

Compression of Morbidity

Functional Status

Activities of Daily Living and Instrumental Activities of Daily Living

Life Span: is the species-specific longest duration of life, excluding premature death (humans 122, but it is not increasing)

Life Expectancy:  The average number of additional years of life that is expected for a member of a population (as you get older your life expectancy increases)

Compression of Morbidity: Life expectancy is increasing, and the goal is to minimize the period in which people have disabilities prior to death. An ex would be if life expectancy stays at 75 but morbidity is decreased to 5 years from 10 years. Not clear if this is actually happening yet.

Functional Status: is a person’s ability to perform those activities of daily living deemed necessary in a modern society. Three domains: mobility, instrumental activities of daily living, basic activities of daily living.

Activities of Daily Living: Dressing, Bathing, Eating, Grooming, Toileting, Continence.
Instrumental Activities of Daily Living: Cooking, Cleaning, Shopping, Money management, Transport, Telephone, Medications

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Functional Trajectories of

diseases in Elederly (graphs)

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Body Weight changes occuring in Elderly

Body weight: increases until age 50 (men) or 60 (women) then declines after age 80. BMI decreases in oldest old:

• Low BMI and declining BMI are associated with higher mortality
• Increasing BMI associated with better survival in oldest old (>85)

We see:

• Dec Bone mass, lean mass, water content
• Dec Total body fat, commonly with Inc intra-abdominal fat stores

Since Percentage fat increases, with decrease in muscle mass then fat soluble drugs have much longer half-life, thereby increasing the chance of side-effects, time to medication effect, and duration of adverse effects

• Opposite for water soluble drugs (ex gentimiaciin)
• Less predictable drug effects (heterogeneity)

HD121

Thermoregulation changes in Elderly

Electrolyte Regulation in Elderly

Immune Changes in Elderly

• Decreased ability to produce heat -- due to lower muscle mass
• probable decrease in febrile response    
• relying on temp alone as sign of infection may be problematic
• temp more likely means bacterial infection
• Increased susceptibility to heat stroke and to hypothermia

• Basal levels of electrolytes is NORMAL
• Decreased sensitivity to thirst -> prone to dehydration
• 25% decrease renal mass -> less concentrating ability, and therefore more prone to dehydration
  
• Decline in GFR of 1% per yr steadily with age but Cr does NOT change (since muscle mass changes proportionally) but Some show NO decline!
  
• Blunted ADH sensitivity to standing -> nocturnal urination.

• Decreased T cell function (more susceptible to some infections such as TB)
• Less responsive to vaccination
• More auto-immunity

HD121

Changes in CNS in Elderly

Vision and Hearing Changes in Elderly

Autonomic Nervous System Changes

Cardiovascular System Changes

Respiratory System Changes

Key Point

• Generally, CNS changes are due to pathology, NOT to normal ageing
• Some minor changes occur with ageing, these may serve to decrease “reserve”
• Examples:
• Brain size decreases, cerebral atrophy common
  neuronal loss
• Basic Language, Memory normal (although more subjective complaints)
• Divided attention seems to decline as a function of normal ageing
• Note: Normal elderly are cognitively intact

• Presbyopia (lens of the eye loses its ability to focus)
• Less ability to adapt to low or high light changes
• Bilateral loss of hearing
• Smell (and taste) decline with age

• Insensitivity to B-adrenergic stimulation: Relative B-Blockade (may be deconditionning)
• Decreased Baroreceptor response
• More predisposition to postural hypotension
• More fall risk

• Intimal thickening of arteries -- predisposition to hypertension
• Infiltration of cardiac muscle -- predisposition to Heart Failure
• More likely disease and deconditionning

• Decreased elasticity of lung
• increased residual volume, decreased FEV1

As we get older, we become more different than each other - heterogenity

HD112

Demographic Trends of Elderly

Retirement Trends

• The proportion of seniors is expected to rise
  from 14% to 22% in the next 20 years.
• In the next 5-10 years, the number of seniors will
  surpass the number of children aged 14 or
  under for the first time ever
• Majority of people over 65 are Easten European

• The % of people aged 55+ in the labour force increased from 12.8% in 2001 to 16.5% in 2006
• 55% of Manitobans aged 65+ work full-time

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Diversity in Health in Elderly

Living Arrangements

Self-Rated Health - Very good indicator

% of Age 65-74 rating "Excellent or Very Good" = 46.6

% of Age 75+ rating "Excellent or Very Good" = 30.7

Chronic Conditions

High blood pressure #1, over 75 more like to have multiple conditions than 65-74

Functional Limitations also > in over 75 catgeory

• The majority of older adults live in their own homes (houses/apartments)
• 12.2% of seniors aged 75+ live in
  nursing homes; 87.8% live in their
  home
• Personal Care Home use is decreasing
• Women are more likely to requiring Assistance with at Least One Task of Daily Living
• Majority recieve both paid and unpaid care
• More women over 75 live alone b/c of widowing
• Type of Home Care Supports Received is most often meals, followed by housekeeping

• Majority of visits are to GP (3-5x per year median #)
• Women > Men
• About a third of individuals age 65+ are hospitalized in a given year
• Average length of stay increases with age
• Individuals aged 65+ incur about 2/3rds of all hospital days and inpatient cost

HD084

What is caregiving? + Stats

Concerns for future with Caregivers?

• Informal caregiver is a family member or a natural person who provides unpaid services on a daily basis like listening to the care recipient, giving companionship and phone contact, assisting with meals, medicines and helping with worries, anxiety and emotional needs
• It is not necessary that s/he may live with
  the frail person in the same house
• Provide 80% of all care to seniors in the community
• Women more likely to be high intensity caregivers
• 1 in 4 caregivers > age 65
• Not just family: friends 14%, neighbours 5%
• The majority of caregivers are middle-aged (35-64
  years old), majority are adult children
• Women caregivers handle the most difficult caregiving tasks (Men do financial etc.)
• An estimated 60% are working full or part-time

More childless women

More people with Dementia will be living at home

HD084

Caregiver Health FX

Factors that increase burden

Factors that decrease burden

• Caregiving for dementia more burdensome and difficult than chronic conditions/ disabilities
• Studies show increased self-reported symptoms of
  depression and anxiety and increased rates of diagnosis of depression and anxiety
• Some evidence of physical health deficits as well

• Behavioural disturbances
• Aggression
• Agitation
• Night time wandering
• Physical demands
• Incontinence, difficulty walking
• Family conflict

• Supportive family
• Finances
• Positive previous relationship
• Living apart from care recipient
• Non-spousal relationship

HD084

Assessing Burden on Caregiver

5 types of interventions to help care givers under stress

Brief Burden Interview:

• 12 items persons rate if the experience this never (0) to daily (4)
• Score of 12 or greater = risk of depression

1. Education
2. Support groups
3. Respite care
4. Family therapy
5. Individual treatment (referral to psychiatrist)

HD108

Defining Dementia

Dementia Prevalence Risks

• A decline from a previous level of function
• Demonstrable impairment of memory (DSM-3)
• Other impairment in at least one of:
• Language (naming)
• Judgment / frontal lobe function
• Construction / visuo-spatial function
• Abstraction
• Personality
• Impairment is sufficient to interfere with function and Activities of Daily Living.
• Insidious, and > 6 months  (ICD-10)

Using the criteria, Alzheimer now can be diagnosed to 80-90% probability

For 100%, biopsy or autopsy required

• Prevalence doubles for every increase of age of 5 years after age 65
• Prevalence of 1% at age 65
• 10% of those over age 65
• 25% of those age 85

HD108

Types of Dementia:

AD

VaD

FTD

Alzheimer’s disease
Diagnosis:

• Gradual onset & progressive impairment
• Memory & word finding problems, difficulty strategizing/planning
• Diffuse cerebral atrophy

Typical presentations

• Paranoia (at start)
• May not be diagnosed until late in its course (often misdiagnosed as depression)
• Commonly associated with multiple medication use, other illness

Aetiology

• Amyloid cleaved into fragments by secretases → certain cleavage patterns create neurotoxic fragments (Beta Amyloid)
• Neurotoxic fragments persist longer in the presence of E4 apolipoprotein

Vascular Dementia

• AD & VaD form ~80% of all dementias, can have mixed type between AD & VaD
• Typically co-existing heart disease, Hx of strokes

Frontal-temporal dementia

• Younger onset (usually in 50s)
• Primarily personality & behavioural change – often mis-diagnosed as having psychiatric disorder
• Devastating
• Differ from Alzheimer in profile
• FTD patients retain time/place orientation, can recall info about present & past (vs. severe memory loss in Alzheimer’s)
• Intellectual failure in FTD different from that in Alzheimer’s

HD108

Types of Dementia:

LBD

Parkinson’s dementia

Other types

Lewy Body Dementia

• Lewy body = eosionophilic inclusion bodies
• Observed in cerebral cortex and brainstem
• Often confused with Parkinson’s dementia & psychosis
• Some overlap with Parkinson’s
• Cognitive defects precede movement defects (vice versa in Parkinson’s)
• deficient in acetylcholine & dopamine – anti-psychotics contraindicated
• very sensitive to EPS

• Affects about 40% of people with Parkinson’s
• usually later in the illness and different type of memory trouble

CBGD (cortical basal ganglionic degeneration), NPH, CJD, HIV dementia, Korsakoff’s, hypothyroidism, paraneoplastic syndrome, hepastic encephalopathy, pseudodementia, MS

HD111

Healthy older adults...

Profound physical changes ages 20 to 70+

1. Are more intelligent than when they were younger
2. Remember events from all decades of their life equally
well
3. Less depressed than younger adults
4. Worry less than younger adults (except for health, sensory loss, and loss of independence)
5. Solve complex ethical problems better than younger
adults
6. More conscientious than younger adults
7. Report they are not lonely & have good social supports

8. Apart from dementia …older people have lower rates of
mental disorders than other adult age-groups

• Retina of 70 year old receives approx. 30% of light
  reaching retina of 20 year old
  
• Need brighter lights to read
• Implications for night driving?
• Respiratory efficiency (quarts inhaled) reduces by 50%
  
• Bladder loses 50% of capacity
  
• 60% of sleep awakenings are to go to the bathroom
  

HD011

Normal brain aging

Brian loss

• Greatest loss of cells is in infancy
• Loss after that is small:
• 2% volume & weight per decade
• lose 5% after age 60
• Frontal lobes: more significant decline

Cell loss is not evenly distributed

• More in vision, hearing, smell and voluntary movements
• Less loss in areas of verbal intelligence

Enriched environments and activity increases number of synapses throughout lifespan

• The more synapses, the more reserve to slow down decline
• We keep making new brain cells throughout lifespan (hippocampus)

HD011

Crystallized intelligence vs Fluid intelligence

Causes of processing speed decline

A walk a day?

Crystallized intelligence (knowledge) is preserved with ageing and may improve with accumulated experience:

• Factual knowledge
• Stored skills, abilities & procedures
• Long term memory storage
• Knowledge based on experience
• Problem solving based on experience

Fluid intelligence declines with age = dec speed

• Speed of processing
• Reaction times
• Attention
• Corresponds to what is called:
• Working memory
• Concentration
• Remembering to remember
• Source memory
• Executive functions
• Initiating and inhibiting actions

1. Summation of synaptic delays:

• Lower cortical arousal
• Decreased signal to noise ratio

2. Frontal lobe decline

Not due to loss of brain cells

increases brain volume in areas important for attention and memory (MRI) -> Delays Alzheimers

HD011

Immediate and Long Term memory in elderly

Hierarchy of competencies

Legal standards levels

Immediate memory (ability to hold information in consciousness) does not decline

Long term: No age decline on well learned new material but there is a Decline in forming new episodic memories due to fluid intelligence

financial (higher) > testamentary > decisions over health/personal interventions

LS1 – evidencing a choice (yes/no – consistent)
LS2 – reasonable outcome of choice
LS3 – appreciation of consequences of choice
LS4 – provide rationale for choice
LS5 – understand the Tx situation & choices

HD122

6 steps to assessing competency

1) valid trigger, reason to determine competence
2) inform patient that they’re being assessed & consequences thereof
3) gather info about context, choices & consequences of proposed decision
4) educate regarding above info
5) assess competence – ability to make decision, ability to understand risks & benefits, consistency of decision

• Take personal beliefs, actions into account – cultural, ethical beliefs: if congruent → suggests competence
• Attention/concentration (delirious?)
• No delusions affecting the decision present
• Communication – language (aphasia), hearing, eyesight, (sometimes) reading/writing
• Cognitive testing
• always test memory (MMSE)
• executive function

6) Action taken to provide least intrusive remedy to accomplish task in hand

HD114

Energy Reqs in Elderly

Normal BMR

Protein

There is a decreased BMR and activity level over time:

• 5% decline/10 years between 35-55 years
• 8% decline/10 years between 55-75 years
• <21 kcal/kg increases likelihood of frailty

23-29.9
due to declining stature, and fact that seniors who are <23 or >29 have a higher mortality/morbidity

• Current research indicating needs may be increased to 1.2g/kg
• Emphasis on meat and dairy protein
• low protein intakes, especially low biological value & low physical activity can lead to “sarcopenia”
• hip fracture and fall prevention research: adequate protein + resistance exercise = muscle synthesis
• Increased requirements for surgery, infection, trauma, pressure ulcers.

HD114

Vitamin D Requirements in Elderly

Vitamin B12

Calcium

< 50 years - 600 IU 
51-70 years - 600 IU
70+ years - 800 IU

• All those over 50 years should take a vitamin D supplement (1000 IU daily, UL = 4000 IU daily)
• Low serum levels linked to falls in elderly, prevention of diabetes, dementia and frailty

Natural Sources: Milk, Margarine, Egg, Salmon, Herring, Tuna

Oral supplements 1000 ug daily to treat B12 deficiency as effective as monthly injections

Source: meats, fish, dairy, eggs

51-70: men 1000mg and women 1200 mg from diet and supplements
>70 years: 1200 mg from diet & exercise

• Absorption decreased with high phosphorus foods
• Supplements likely needed, but high doses may increase risk of renal calculi and cardiovascular disease 

Sources: milk, cheese, yogurt, cottage cheese, ice cream, fortified soy/rice beverages, salmon, broccoli

HD114

Zinc & Sodium Reqs in Elderly

Fibre

Fluid

Zinc: taste & smell, wound healing, immune function. 27% elderly deficient in zinc.
Sodium & hypertension: Limiting to 1500-2300 mg daily as per DASH guidelines

25-30 grams/day

Good sources: Prunes and Bran

“6-8 glasses /day” + fluid in foods (30 mL/kg (55-75 yrs); 25 mL/kg > 75 yrs)

Dehydration is usually due to:

• Decreased thirst sensation
• Medications (eg diuretics)
• Excessive caffeine use
• Laxative abuse
• Conscious restriction to reduce urinary frequency

HD114

Physical Factors Influencing Nutritional Intake in Elderly

(Sensory, Oral, GI, Mobility)

Medication Side Effects

Sensory:

• Taste: affects salivary and pancreatic flow, fewer taste buds, affected by disease and medications, greater threshold for sweet and salty, lower threshold for bitter
• Smell: threshold 11x higher in elderly
• Sight: ability to shop, cook, feed self
• Hearing
• Touch/ Manual dexterity
• Role of sensory decline in food borne illnesses

Oral Health

• Xerostomia (decreased salivation)
• Decreased thirst sensation
• Dental decay in 60% elderly
• Chewing less efficient with dentures (Affects food choices)

GI:

• Dysphagia: Difficulty swallowing
• Decreased digestive enzymes
• Constipation

ACE-inhibitors: dry mouth, loss of taste, anorexia, nausea, weight loss
Antidepressants: dry mouth, weight gain
Antacids: muscle weakness, phosphate depletion, bone weakening
Antihistamines: dry mouth, loss of appetite

HD114

Psychological Factors Influencing Nutritional

Intake in Elderly

Social Factors Influencing Nutritional

Intake in Elderly

• Cognitive impairment
• Depression, isolation, loneliness
• Personal beliefs and meaning of food
• Mental health issues
• paranoia, mania

• Eating alone
• Cooking for one
• Housebound elderly who lack family support, men and recently bereaved at greatest risk
• At risk for alcoholism

HD114

Screening Tools for Elderly Nutrition (4)

1. Nutrition Checklist:

Disease - affects food choice?

Eating poorly
Tooth loss/mouth pain

Economic hardship

Reduced social contact

Multiple meds

Involuntary weight gain/loss

Needs assistance in self-care

Elder years (>80)

2. Community screening tool

• 24% at HIGH risk
• 38% at MODERATE risk

3. MNA Screening form:

1. BMI

2 Weight loss in past 3 months?
3. Acute illness or major stress in last 3 months?
4. Mobility
5. Dementia/Depression
6. Has appetite and food intake declined in past 3 months?

4. S.C.R.E.E.N. - Seniors in the Community: a Risk Evaluation Tool for Eating and Nutrition

15 question scale developed for self-evaluation by community living elderly, focuses on subjective assessment

HD119

WHO on elder abuse

National Academy of Science Defn

A single or repeated act, or lack of appropriate action, occurring within any relationship where there is an expectation of trust which causes harm or distress to an older person

(a) intentional actions that cause harm or create a serious risk of harm (whether or not harm is intended), to a vulnerable elder by a caregiver or other person who stands in a trust relationship to the elder,
or

(b) failure by a caregiver to satisfy the elder’s basic needs or to protect the elder from harm

This definition encompasses two key ideas:

• that the old person has suffered injury, deprivation, or unnecessary danger,
• and that a specific other individual (or individuals) is/are responsible for causing or failing to prevent it.

HD119

5 types of Elder Abuse

Epi of Elder Abuse

Homicide stats

1. Physical abuse: acts done with the intention of causing physical pain or injury
2. Psychological abuse: acts done with the intention of causing emotional pain or injury
3. Sexual assault
4. Material exploitation: misappropriation of the old person’s money or property
5. Neglect: failure of a designated carer to meet the needs of a dependent old person.

Not enough studies being done so reasonable variation in findings but as a general = 3-8% (similar across different cultures)

• Senior women (65+) experienced family-mediated violence 22% more often than senior men
• Over 1/3 of older women were assaulted by a spouse and 1/3 by an adult child
• Almost ½ of older men were victimized by an adult child and only 1/5 by a spouse
• In 8 out of 10 cases of senior abuse, the perpetrator was a male
• 49% of violent incidents against seniors go unreported

• Same trends (Women by kids and spouse, men by kids)
• Usually there was a Hx of violence in family

HD119

RFs for Elder Abuse (5)

Screening

Clinical Triggers of suspicion (6)

• Shared living accommodations
• Increased exposure
• Not true for financial abuse
• Cognitive impairment
• Social isolation
• Mental illness and alcohol misuse in abuser
• Dependence upon older person

Possible: Physical impairment, Intergenerational transfer

• No RCT saying that screening works (contrary guidelines)
• No valid reliable screening tools
• High index of suspicion usually used

1. Delays in seeking treatment
2. Disparities in history
3. Implausible or vague descriptions of injury
4. Frequent visits
5. Presentation without caregiver
6. Inconsistent findings and history

HD119

Targets for managing Elder Abuse (5)

1. Caregiver Stress
2. Substance abuse or mental illness
3. Longstanding spousal abuse
4. Aggressive behavior by abused
5. Financial abuse