Age old myths about old age

Nancy Stiles, MDAssociate Professor

GeriatricsAssociate Sanders-Brown Center on Aging

Aging

• Oldest old, most rapidly growing segment of our society

• Previously, limited numbers of older adults to study

• 1900 average life expectancy 50• 2000 average life expectancy 75• Prevalence of age-related conditions lead

to the misconception that these conditions were due to aging alone

If disease or impairment is due to aging alone:

• Must occur in all members of the species

• Must occur at the same point in the life cycle

• Must be irreversible

Aging

• Normal aging

• Typical aging

• Usual aging

• Age-related

Initial research in aging was flawed:

Diseases not yet discovered

Research subjects not screened for undiagnosed conditions

Refinement in diagnoses

Misinterpreting “average” scores as “normal”

Identification of actual cause of diseases

Prevention and Treatment

• Identification of risk factors

• Improved risk factor modification

• Innovations in care, new interventions

Common misconceptions

• Memory loss• Decline in organ system function• Falls • Weakness• Slowing down• Requiring a cane or walker• Urinary incontinence• Sleep disturbance• Functional decline

Approach to function

• Cognitive, physical, social, psychological

• Decline may be present for years, undetected, unrecognized

• Graph time vs function

• Identify confounding factors

• Review past work up

Cognitive function

• Memory lapse vs loss

• Decline from highest level of function

• Focus history taking on a “change in memory” (from highest level of function) rather than “memory problems”

• Ask about magnitude

Types of cognitive impairment

• Minimal cognitive impairment

• Alzheimer’s Disease

• Vascular Dementia

• Dementia with Lewy Body

• Others

Memory Disorders

• Can’t tell by looking• Coping through long term memory• Standard clinic visit often doesn’t

challenge patient to reveal deficits• Check memory based on medical record• Other clues: lack of logic in giving history,

forgetting issues in chronic conditions, trouble following steps in physical exam, difficulty with discharge instructions

Memory evaluation

• Document cognitive function

• Folstein MMSE is commonly used

• Brain imaging

• Lab testing

• Evaluate other diseases: depression, sleep apnea, medications, etc

Interventions/Treatment

• Medications

• Life style modification

• Safety:– Residential/Living alone– Cooking– Driving– Medications

Atherosclerosis

• “Hardening of the arteries”

• Autopsy study: 75% of men >50 yr and women >60yr had coronary artery stenosis

• Studies done in 1950-60’s

• Unclear if researchers recognized soft and non-occlusive plaques

• Impact of disease management today

Cardiovascular system

• No dramatic change in heart rate, left ventricular ejection fraction or cardiac output at rest

• Age-related:Stiffening of arteriesDiminished chronotropic response to stressImpaired orthostatic compensation under stress

Hypertension

• Age related: BP increases with age

• By age 65, 25% of whites and 33% of African Americans have HTN

• HTN is a risk factor for physical and cognitive decline– Cardiac and cerebrovascular disease – Common triad: mild memory problems, mild

gait difficulty, mild dysphagia

Respiratory system

• FEV1 declines by 30mL per year… but

• Longitudinal study on lung function only addressed smoking status

Factors associated with decreased FEV1

• Dyspnea on exertion• Obesity • Malnutrition• Hypertension or Hypotension• Major ECG abnormality• LE edema• Diabetes• Do the lungs suffer damage from vascular

disease like other organs???

Respiratory System

• Don’t attribute symptoms of dyspnea to just “old age”

• Other underlying diseases

• Diseases yet unrecognized

• Deconditioning

Diminished pulmonary function is associated with:

• Diminished information processing speed

• Diminished fine motor dexterity

• Increased subcortical atrophy

• Decreased cognitive function

Renal System

• Past research:

Animal models

Post mortem studies with no effort to exclude subjects with renal disease or significant co-morbidities

Research• Older research: CrCl declines from 120

ml/min per 1.73m2 in 4th decade to 90 ml/min per 1.73 m2 in 6th decade (average approx. 1.5 ml/min decline/yr)

• Updated study including only healthy elderly: – CrCl declines only 1 ml/min per 1.73m2 per

year– 35% of subjects showed no decline in Crcl

over 20 years

Age-related diminished renal function in:

• Homeostasis: Na, K concentrations

• Conservation of sodium

• Ability to concentrate urine

• Associated factors poorly defined

• In healthy elderly, renal reserve preserved (studies up to age 80 yr)

GI system and aging

• Clinically significant abnormalities in gastrointestinal function should not be attributed purely to aging.

• A modest age-related decrease in taste sensation and saliva production may occur

• Age-related decrease in gastric mucosa ability to resist damage.

• Modest age-related decrease in gastric emptying. • Diverticulosis increases with aging. • Hepatic blood flow decreases with aging, may account

for some of the decrease in hepatic drug elimination that occurs in the elderly.

• Constipation is not normal aging.

Anemia

• WHO Hgb <12g/dL women; <13g/dL men

• 11% >65 yr and 20% >85 yr are anemic

• Anemia is not “normal aging”

• 1/3 nutritional deficiencies

• 1/3 chronic disease

• 1/3 cause is not known

Anemia

• Questionable to consider anemia “asymptomatic”

• Associated with increased mortality, loss of mobility even at levels considered low normal by WHO criteria

• Question what is a normal Hgb???

Insomnia

• Previously, disrupted sleep considered “normal” aging

• Recent research does not support this

• 30% older persons report decreased quality of night-time sleep

Common causes of disrupted sleep in the elderly

• Sleep apnea– 60% >60yr have a respiratory disturbance

index of 10.

• Periodic limb movements in sleep and restless legs syndrome

• Circadian rhythm disturbance

• Depression

Physical functional decline

• Weakness

• Gait disorders and falls

• Impairments of common activities: shopping, light housework, preparing meals, bathing, dressing, getting in and out of bed or chair, getting outside and walking, continence

Weakness/Gait Disorders/Falls

• Usually multifactorial

• Slow progression

• Often no complaints about it

• Attributed by patient as inevitable consequence of aging

Systems to consider

• Bone

• Joints

• Muscle

• Peripheral nervous system and perceptual system

• Central nervous system

• Energy production and delivery

Falls

• Assessments– Functional reach – patient leans forward

without stepping. <6 inches is associated with increased risk of falls

– Timed Get Up and Go test – no assistive device. Get up from chair, walk 10 feet, turn around, walk back and sit. >30 seconds is associated with falls

– Berg balance test. 14 common tasks.

Assessment

• Medications: sedatives, diuretics, laxatives, alcohol

• General conditioning, orthostatic changes, exertion

• Lab work: CBC, CMP, B12, TSH, UA, xrays, brain imaging

Feet and ankles

• Foot posture

• Range of motion (ankle flexibility)

• Strength (toe plantar flexion)

• Deformity

• Sensorimotor function (plantar sensation)

• Impairments associated with impaired balance and functional ability

Urinary Incontinence

• 30% older women, 15% older men (non-institutionalized)

• Embarrassment makes diagnosis difficult• Ask about protective undergarments,

pads,”Depends”. “Do you wear a pad just in case”.

• Just because the patient does not report UI as a “problem” doesn’t mean that it is not.

• Newer medications, strategies, treatments available

Summary

• Don’t attribute physical and cognitive functional decline purely to aging

• A problem can exist even though the patient denies that “it’s a problem”

• Use your Review of Systems to hunt for functional decline that a patient may not recognize. Compare current function to 10 years ago.