2) Ageing and the body

Question 1

Why is it important to know about the elderly?

Answer 1

• Most branches, you will be treating elderly
• > 50% elderly have at least 2 chronic conditions
• There are nearly 12 million people aged 65 and above in the UK of which:
  – 5.4 million people are aged 75+
  – 1.6 million are aged 85+
  – Over 500,000 people are 90+ (579,776)
  – 14,430 are centenarians (ONS, 2018f, 2018e).

Question 2

How does ageing affect out skin?

Answer 2

• Elastic tissue becomes less effective as we age
• Skin becomes less tight
• More susceptible to damage and therefore more fragile

Question 3

What issues might more fragile skin cause?

Question 4

Where else may reduced elasticity cause problems?

Answer 4

• Respiratory system
• CVS
• Renal system
• Musculoskeletal system
• GI system
• Malnutrition
• Neurological system
• Dementia

Question 5

How does reduced elasticity cause problems in respiratory system?

Answer 5

*Elasticity in the lungs is important for normal function
– Lung compliance
– Elastic recoil allows for passive exhalation
*Reduction in TLC, FVC, FEV1, vital capacity as we age
* Holding terminal airways and alveoli open

Question 6

What are other causes of reduced elasticity in combination with ageing?

Answer 6

– Work exposure
– Smoke exposure
– Repeated infections
– Chemical/toxin exposure
These factors can cause it to occur earlier

Question 7

Why are elderly more prone to respiratory infections?

Answer 7

*Reduced lung function puts people at greater risk of respiratory infections
– More likely to be acutely unwell
– More likely to need hospitalisation
– More likely to need oxygen / IV antibiotics
* More prone to post operative complications
– Atelectasis
– Pneumonia
– Pulmonary embolism
*Sedating drugs more likely to cause respiratory problems

Question 8

How does ageing affect CVS?

Answer 8

*Blood vessels become more stiff as we age – particularly arteries
*Elastic recoil is reduced and therefore arteries are less expansile
* Increases resistance to blood flow
* Leads to hypertension
* Increased cardiovascular work
* Increased risk of left ventricular hypertrophy (LVH)
*Decreased left ventricular volume
*Can lead to heart failure
– Think back to CVS left sided heart failure initially which can then lead to the right side
failing

Question 9

What is a risk of uncontrolled hypertension and how does it occur?

Answer 9

Atrial fibrillation
- Hypertension causes increased stretch of atria leading to small areas of damage
- New foci of electrical activity created

Question 10

What are the key features on an ECG of AF?

Answer 10

• Irregularly irregular rhythm
• No p waves
• Wavy baseline

Question 11

How does ageing affect the renal system?

Answer 11

• GFR decreases as we age (approx by 1ml/min/m2 from 30-40 yrs)
• Could be due to structural changes, atheromatous vascular disease, reduced CO (cause is unknown)
• Unable to excrete medications

Question 12

Examples of co-morbidites that elderly have that may also effect renal system.

Answer 12

Diabetes
– Uncontrolled/poorly controlled diabetes
– Leads to diabetic nephropathy – damage to microvascular structures due to
hyperglycaemia

Hypertension
– Medication reduces blood pressure
– Some medications nephrotoxic – ACE inhibitors, NSAIDS particularly
– Need to prescribe with caution and review medications when patients are unwell

Question 13

How does ageing affect MSK?

Answer 13

Bone
- Bone density decreases (gradual decline)
- More quickly in women after menopause

Muscle
- Multifactorial
- Use it or loose it

Bone marrow changes
- Less cellular and more fatty
- Decreased cellular production

Question 14

Explain the composition of bone marrow

Answer 14

Red marrow
- Contained within spongy bone
- Hematopoietic stem cells to form: RBC, WBC, platelets

Yellow marrow
- In medullary cavity of shaft of long bones
- Made mostly of fat
- Contains mesenchymal stem cells: cartilage, fat, bone cells

Question 15

Consequences of decreased bone density and muscle mass?

Answer 15

• Bone fractures
• Osteoporosis ( holes inside widen and outer walls thin, bone becoming more fragile)

Question 16

How does ageing affect GI system?

Answer 16

Liver function gradually reduces over time
– Decreasing blood flow to the liver
– Decreased mass of functional liver cells
*Slower transit through intestines
– Increased constipation
*Decreased absorption
– Reduction in absorption of nutrients and medication

Question 17

Effects of malnutrition

Answer 17

• Issue in elderly
• important for recovery from illnesses (more malnourished the longer their hospital stay)
• Affects wound healing
• Post surgery likely to have wound breakdown or delayed healing
• High risk of pressure ulcers (difficult to heal without good nutrition)
• Patients need to be screened on admission

Question 18

Hoe does ageing have an effect on the neurological system?

Answer 18

Brain undergoes changes as we age
– Some parts shrink – particularly areas
related to learning and complex mental
activities
– Some cells deteriorate
– Reduced communication between
neurons
– Reduction in blood flow
– Neuronal density reduces by almost 1/3
by the age of 80

Question 19

What are the 4 types of dementia?

Answer 19

• Alzheimer’s
• Vascular
• Lewy body dementia
• Fronto-temporal dementia
  Risk increases as we increase in age
  need comprehensive assessment to diagnose (Hx, Examination, investigations)

Question 20

How do we treat elderly?

Answer 20

• Body systems are interdependent (can’t just focus on one as often multi-morbid)
• Medications: side effects and unintended consequences
• Operation: high physiological stress and low physiological reserve
• Need holistic approach: system interconnected, need to consider physical, social and mental well being

Question 21

Why do we need to carefully prescribe for elderly?

Answer 21

Likely to be on other medication: risk of interactions (wore side effects)

Reduced renal and liver excretion of drugs
- Reduced dose
- Close monitoring
- Alternative meds
- General rule is to start on a lower dose

Question 22

What are the questions you need to ask yourself before prescribing?

Answer 22

*Does something need prescribing?
* Is there an alternative strategy?
* If not what is the lowest possible dose?
*Does that drug interact with any other medications?
* If there is an interaction which medication is the most important?
* Is there a more suitable alternative?

Question 23

What is compassionate care for the elderly?

Answer 23

*Requires a patient centred approach
– What does the patient want? (ask them and/or their family!)
– How can we achieve it?
– What are the persons beliefs?
– Treating with dignity
– Working in accordance with best interests
* Is a hospital the best place for them?
*What social needs do they have?
* Loneliness is a big factor in older people
– People don’t want to be discharged sometimes because theyre lonely and like having
company
*Can think about planning for the future
– Advance care planning – what would you want if X were to happen to you
– Emergency health care plans
* Reducing admission to hospital unless there are no other options
– RESPECT forms
* What is important to the patient – treatment v symptom control
* Resuscitation
* Involve family/carers/friends
– They know the person better than you and can give insight / context