Define ageing
- Ageing or senescence is the biological process of growing old, with associated changes in physiology and increased susceptibility to disease, and increased likelihood of dying
- It has biological, psychological/cognitive, and social elements
What are the 2 theories of ageing?
Damage or error theories:
- Describe the accumulation of damage to DNA, cells and tissues as the cause of ageing
- For example, loss of telomeres, or oxidative damage
- Damage theories implicitly hold that if we could prevent or repair this damage, then we could prevent ageing
- Free radicals theorised to be a cause of the damage that induces ageing as they commonly cause damage to mitochondrial DNA – note that people who have chronic inflammation, and people with HIV, tend to age faster than peers – thought to be due to free radicals
- Another theory sates that, as proteins hang around in the body for longer, they get crosslinked – this is thought to damage them
Programmed ageing theories:
- Describe how genetic, hormonal, and immunological changes oer the lifetime of an organism lead to the cumulative deficits we see as we age
- Programmed ageing theories then to suggest this is part of an inescapable biological timetable, just as growth and puberty are programmed to occur
What is life expectancy?
Life expectancy is a statistical measure of how long a person can expect to live
- has been rising continuously for many years
- This means that there will be large increases in the ageing population
- The main reason for people living for longer is advances in public health
What is population ageing?
Population ageing refers to the increasing age of an entire country, due to increasing life spans, and falling fertility rates
- population ageing reflects the successes of public health policies, education and socioeconomic development, but brings big challenges for societies as they try to adapt – e.g. due to increasing costs
What are some activities that can reduce ageing?
- Exercise in middle age
- Decreased alcohol
- Decreased smoking
- Healthy diet
What challenges does society face as a result of population ageing?
- Working life/retirement balance
- Caring for older people, the sandwich generation
- Extending healthy old age not just life expectancy
- Inadequate or absent services
- Outdated and ageist beliefs/assumptions
- Medical system designed for single acute diseases
- Limited accessibility for those with disabilities
What is frailty?
- A physiologic syndrome characterised by decreased functional reserve and resistance to stressors, resulting from cumulative decline across multiple physiologic systems and causing vulnerability to adverse outcomes
- impaired ability to manage every day activities
- increased likelihood of adverse events
- deterioration when faced w/minor stressor and inability to recover to normal state
What diseases does frailty predispose to?
- Increased risk of falls
- Worsening disability
- Care home admission
- Death
How does disease presentation change with age?
- Non-specific presentation
- Falls, Reduced mobility, Recurrent infections, Confusion, Weight loss, “Not coping”, Iatrogenic harm – illnesses caused by retrieving healthcare treatements
- Multi-morbidity
- Frailty
What are the difficulties in managing disease in older people?
- Multimorbidity - conditions impact on one another, treatment for one condition may impact on another
- Polypharmacy - potentially inappropriate prescribing, adverse drug reactions
- Iatrogenic harm
How can care for elderlies be improved?
(1) Comprehensive geriatric assessment
- A multipdimersional interdisciplinary assessment that leads to an individualised, goal based plan
- Assessment domains - physical health, mental health, functional ability, social circumstances, enironment
- Benefits:-
- In the community, the CGA: Reduces admissions to institutional care, falls, Benefitted those in mild or moderate frailty
- For frail inpatients, the CGA: Reduced inpatient mortality, functional and cognitive decline, admission to institutional care
(2) Rehabilitation - to restore or improve functionality, prevent deconditioning
What are the key physical changes associated with the ageing brain?
- Atrophy
- Neurones shrink
- Decreased connections between neurones
- Ventricles enlarge
- Gaps between major gyri widen
- More CSF surrounding brain
- Decrease in grey + white matter
- Small vessel disease > walls of the small arteries in the heart are damaged
What are the key cognitive changes associated with the ageing brain?
- Processing speed slows
- Working memory slightly reduced
- Simple attention ability preserved, but reduction in divided attention
- Executive functions generally reduced (plan, adapt)
- No change in nondeclarative memory
- No change in visuospatial abilities
- No overall change in language (some reduction in verbal fluency)
- Dementia
- No change in nondeclarative memory, visuospatial abilities, language (some reduction in verbal fluency)
What is dementia?
Decrease in all cognitive functions, not just memory
- loss of executive function
- functional impairment,
- behavioral and psychological changes
- lack of insight
Impairment of funcition
Progressive and degnerative, irreversible
What is delirium?
An acute, global failure of higher brain function
- Affecting level and content of consciousness
- Alertness an cognition
- Medical emergency
How is dementia different from delirium?
What is a common presentation in elderlies?
Confusion - symptom NOT a diagnosis
Causes - delirium, verbral difficulties
What are some cognitive assessments done with elderlies?
Screening tests
- AMT, clock drawing test, 4AT, GP COG, 6CIT…
- Mini Mental State Examination (MMSE)
- Montreal Cognitive Assessment (MOCA)
Diagnostic tests
- Addenbrooke’s Cognitive Examination (ACE)
- Detailed neuropsychometric testing
What is the 4AT score used for?
4AT score - screeening tool for delirium and dementia
What is the MOCA test?
- Covers a variety of domains of cognitive function: attention and concentration, executive functions, memory, language, visuoconstructional skills, conceptual thinking, calculations, and orientation
- Can determine which aspect is the most impaired
- Brief to administer (10 mins)
- Validated in a range of populations
- Available in translated versions
- Widely used
What are the key issues associated with cognitive assessment of alder adults?
- GENERAL
- Hearing and visual impairment may limit testing
- Physical problems may limit testing
- Most assume numeracy and literacy
- Most assume some basic cultural knowledge
- Depression can masquerade as dementia
- Not valid in acute illness
- Normal cognitive changes (slower processing speed, slower reaction times) may affect administration
- Floor + ceiling effects - if highly educated
- MOCA SPECIFIC
- Education + language levels
- Practice/coaching effects
List 3 advantages, 3 disadvantages and 4 difficulties of application to elderlies wrt the mini mental state exam.
