Ageing CVS : Heart
• Cardiac output – down
• Cardiac Index falls 0.79%/year
• Cardiac output 80yr old is ~ 1⁄2 that of a 20yr old
• A) reduced ionotropic response to catecholamines (endo + exo) and a reduced response to cardiac glycosides
• B) increased myocardial stiffness > diastolic dysfunction
• C) increase atherosclerosis esp thoracic aorta > increased
afterload
• D) increased myocardial deposition of amyloid after age 70
Pathophysiology of orthostatic hypotension
• BP = stroke volume x HR x systemic vascular resistance
• Baro-reflex : on standing HR ^ & systemic resistance ^. This
response is blunted with ageing
• This leads to tendency to Orthostatic Hypotension and ^ risk of falls
• Resting Adrenaline levels and resting musc. sympathetic activity occur with age. This results from ^ pre-synaptic secretion and reduced excretion.
• There is reduced cardiac and vascular responsiveness to catecholamines with age
Ageing Eye
- Reduced visual acuity : Cataracts; Macular degeneration
- Loss of peripheral vision (Glaucoma)
- Loss of dark adaptation : reduction in the numbers of rods and Cones in the retina
- Contrast sensitivity: vitreous Dx and debris eg floaters
Age-related changes in Special senses
- Presbyacusis : High frequency hearing loss; Vestibular Dysfunction
- Reduction in sense of smell
- Oral – dentition ie poor dentition; edentulous
- Loss of taste
- Reduced Saliva production and quality
Musculoskeletal ageing
• Age-related loss of muscle mass- Sarcopenia 30% loss 3rd to 8th decade
• Osteo-arthritis – Load bearing joints: Hips, knees spine – Repetitive strain IPJs
Osteoporosis /Osteopenia – Reduced activity, dietary Ca+ Vit D., Oestrogen deficiency
Benefits of Exercise in ageing
- Increased muscle strength
- Increased Aerobic capacity
- Increased Bone Mass/ Mineral density • Increase Insulin sensitivity
- Reduction in BP
- Decrease central adiposity
- Increased sense of well-being
causes of PROTEIN-CALORIE MALNUTRTION in the Elderly
- Physical limitations
- Poor oral health and dentition
- Poverty / Social isolation / Depression
- Poly-pharmacy and drug nutrient interactions • Alcohol abuse
Ageing CVS : Hypertension
• Progressive increase in BP after 1st decade
• Preventive value of early Rx of hypertension in early adult life >
reduction in Stroke, CCF,IHD
• Atherosclerosis – intimal hyperplasia,
– collagenisation of media
- vessel calcification
In association with diet, obesity, smoking
Ageing Respiratory system
- Linear reduction in Lung volumes • TLC remains constant
* Residual volume reduces with age
Ageing Kidneys
• Total kidney weight declines with age – by 9th decade its 70% that of the 3rddecade
• Decrease in number and size of glomeruli • Reduced Creatinine clearance
[140-Age (yrs)]x weight (Kg) x constant Serum creatinine (micromole/l)
Cockcroft and Gault Formula
Serum creatinine reduces because of reduction in body muscle mass
Renally excreted Drugs have a prolonged half-life
Accelerated Aging Syndromes
Accelerated Aging Syndromes
Werner’s syndrome (“adult” progeria) Autosomal recessive inherited disease
Patients prematurely develop arteriosclerosis, glucose intolerance, osteoporosis, early graying, loss of hair, skin atrophy, and menopause
Don’t typically suffer from Alzheimer’s disease or hypertension
Assoc sarcomatous tumours ; cataracts on the posterior surface of the lens, not in the nucleus, as is usually seen in older people. Also have laryngeal atrophy and ulcerations on the arm and legs. Most patients die before the age of 50
Theories of Aging
• StochasticTheories (Extrinsic)
Somatic Mutation and DNA Repair
Error-Catastrophe
Protein Modification
Free Radical (Oxidative Stress) / Mitochondrial DNA
• Developmental-Genetic Theories (Intrinsic)
The Ageing Eye
- Presbyopia- loss of lens flexibility to focus on near objects. Need for reading glasses
- Loss of muscle power in lower eyelids which sag and – Ectropion
- Dry Eyes – reduced tear production, changes in tear quality
- Floaters degenerative changes in the vitreous humour – if severe and acute may be a sign of vitreous detachment or retinal detachment
- AMD
- Cataract
- Glaucoma
Medical Eye Dx in the Elderly
- DM retinopathy
- Hypertensive retinopathy
- Vascular disease – ischaemic optic neuropathies
- Systemic Inflammatory Dx that affects the eyes – GCA, RhA, SLE, sarcoidosis etc
Prevention of aging related eye disorders
- Healthy lifestyle – diet, exercise
- Avoidance of harmful agents like UV
- Tight control of DM and other medical conditions that affect the eye
- Antioxidants eg: vit E, C and B carotene can counteract the effects of free radicals and may be useful in AMD
- Eye check-ups every 2years for the over 60’s
Outline Immunosenescence
- Lifelong chronic antigen load seems to be the major driving force of immunosenescence, which impacts on human lifespan by reducing the number of virgin, i.e. antigen-non experienced, T cells, and simultaneously fills the immunological space with expanded clones of memory and effector, i.e. antigen- experienced, T cells
- Such lifelong and chronic antigen load is responsible for the chronic inflammatory status that characterises ageing
- The progressive loss of naïve T cells ie: both CD4+ and CD8+ T lymphocytes is paralleled by a concomitant increase of memory CD28- T cells expressing a senescent phenotype, i.e. progressive shortening of telomeres and reduced replicative capacity
CONTROL OF RESPIRATION in ageing
- Reduction in the partial pressure of oxygen in the blood, due to ventilation and perfusion mismatch in the dependent portions of the lungs
- Reduction in maximum oxygen consumption (VO2max) - from reduced muscle mass but this is reversible with endurance training eg long walks
- Chemo-sensitivity to oxygen and carbon dioxide tension declines with age resulting in relative hypoventilation in response to hypoxemia or hypercarbia.
- The aged are vulnerable to vital organ ischemia during stresses such as surgery, acute pulmonary infections, or high altitude, when oxygen availability is reduced.
Case Study 1: 22 year old female, Usually fit and well, 1 week of productive cough. Today increasing SOB, high fever.
O/E: temp 39.5, P=110 reg
, BP 90/50, RLL crepitations
- What is the diagnosis?
- What treatment should be started?
TBD in lecture discussion
Case Study 2: 87 year old female presents with falls. Multiple falls over last few months, initially about weekly. Accelerated in last week, now 3-4 falls per day. Found on floor by neighbour, confused and unable to get up.
Fall: Doesn’t really remember, Thinks she trips, Usually whilst mobilising, Occasionally feels light-headed
• No palpitations / chest pains
• No LOC
• No ictal features
TBD in lecture discussion
Strategies for problem-solving approach in elderly
- Use problem lists - Include both chronic and acute
- Remember extrinsic factors
- Consider each problem and optimise management
- Utilise the multidisciplinary team
- Allow time for improvement to occur
What makes elderly care more complex?
What makes it difficult? • Multiple pathology • Multiple aetiology • Atypical presentation of disease • Cognitive impairment • Complex social situations
Anaemia • Hb 9.3, MCV 100.1, WCC 11.4, Plts 144 • B12, folate – normal • TFTs – normal • GGT - 62 • Iron 4.2 (low) • Transferrin 1.7 (low)
- What is the cause of her haematological abnormalities?
- What tests does she need?
TBD in lecture discussion
