Further considerations
Cancer
Cancer is not a single disease – there are many types. Cancer differs with the organs and cells of the body that it affects and also with cell type within an organ. Cancer also differs in severity and treatment requirements. This will depend on one or more factors among:
Most cancers develop slowly over
a period of months or years. The success of treatment depends primarily on detecting
the cancer early and unfortunately older people tend to be slower than younger
people at reporting possible symptoms. Added to this, it is often difficult
to detect cancer before it is advanced as it does not usually have specific
symptoms. Its main clinical effect is to disrupt function in the parts of the
body that it affects. The most likely symptoms, depending on the cancer, are:
Reliable tests (mammography, cervical smear test) exist for the detection of breast and cervical (womb neck) cancer before symptoms develop and so many countries have screening programmes for these cancers.
Common cancers
and some of their causes
Smoking
Lung cancer is one of the most difficult cancers to cure but one of the easiest
to prevent. A regular cigarette smoker has an up to 40 times greater risk of
getting lung cancer than a non-smoker.
Smokers also have a greater risk of mouth and throat, esophageal (gullet), bladder and pancreatic cancer. Gastric and pancreatic cancers have a very poor prognosis, partly because they are not usually diagnosed until they are very advanced.
Chemical
There are about 40 chemicals and industrial processes which are known to cause
cancer. Most of the known occupational carcinogens have either been withdrawn
or are tightly controlled. But there are many suspected and untested chemicals
that are still in widespread use.
UV
light
Overexposure to ultra-violet (UV) radiation from the sun can cause various forms
of skin cancer, which is especially common in fair-skinned people in hot countries.
Sun beds may possibly have the same effect. Some skin cancers are harder to
cure than others.
Alcohol
Cancers of the mouth, throat, gullet and liver are very common in heavy drinkers.
A combination of smoking and drinking does the most damage.
Food
A few foods are known to cause cancer. These include young bracken shoots eaten
in Japan, and a high fat, low fiber diet which may encourage cancers of the
bowel and breast. Deaths from breast cancer are decreasing even though the number
of new cases is rising.
Cancer of the colon and rectum is usually discovered after a change in bowel
habits, or rectal bleeding. It has a poor survival rate.
The
Pill
Women who have been using the oral contraceptive pill for more than four years
have a slightly higher risk of cervical cancer. The reasons for this are complex
and may not be simple cause and effect. Similarly, some studies have linked
the Pill with a higher risk of breast cancer but there is conflicting evidence.
On the other hand, the Pill is known to reduce the risk of cancer of the ovary
and the womb. Therefore women can use the Pill unless they have a family history
of breast cancers.
Viruses
Some viruses make the body’s cells more susceptible to cancer. For example,
there is a link between cervical cancer and a wart virus called Human Papilloma
Virus (HPV), which can be passed between partners during sexual intercourse.
However, cancer is never "catching" (infectious).
Palliative
care
A programme of palliative care assumes that the diagnosis has been made that
a condition is irreversibly fatal and that death will come within a short while.
It has two main aims:
In the frail older person, perception of healthiness and mental well-being can be as important to quality of life as actual health and functioning. For example, an older person may resist necessary hospital treatment because she believes that hospitalization at her age is for the dying and believes that by staying at home she will circumvent death.
Palliative care in older people may also need to consider:
It is important to remember that the patient is alive until he or she dies and should not be left to simply wait for death. The patient should be involved in decisions about their care although this causes complications for those with dementia.
Hospices play a useful role although relatives may be highly critical of the staff. For example, since the staff spend more time with the patient than a relative can, there may be fears that they will supplant the relative in the affections of the patient. The topic of wills and bequests cannot be ignored.
Pain relief
Usually the patient in terminal care has chronic pain which can be relieved using the "analgesic ladder":
As a rule, older people report pain less frequently and require smaller doses of analgesic drug to achieve adequate pain relief.
The goal is full pain relief and no break-through pain (with as few side effects as possible). But this goal may need to be compromised:
Acute pain is treated more specifically, depending on the part of the body affected and the type of pain.
Sleep
Old people go to sleep earlier and rise earlier, but they spend the same amount
of time as younger people trying to sleep. It is the quality of sleep that changes;
it becomes shorter, lighter and more broken with age and older people find it
hard to get back to sleep once awake. Deep sleep is rare. Snoring is common,
may disrupt sleep and cause apnea (periodic cessation of breathing) and is also
associated with an increased risk of hypertension
and heart disease.
Shifts of sleep stages in older people
"Old age is
always wakeful; as if the longer linked with life the less man has to do with
aught that looks like death."
H Melville in Moby Dick
Reasons for poor sleep include:
Sex
Sex drive (libido) is commonly thought to decrease with age but many elderly
people are sexually active. Many more would like to be if they were not restricted
by the views of society that sex in old age is odd. Institutions need to recognize
this, but they must also deal with demented patients who have lost their inhibitions.
Problems of old age
Sexuality may be affected by ill health but health problems rarely prevent sexual intercourse in old age if precautions are taken:
Bereavement
There are four main stages of grief:
An inability to work through these phases is unhealthy and is particularly likely when death has been sudden or untimely. There is a high incidence of illness and death in the surviving spouse following bereavement. It helps if the bereaved has someone to talk to, whether it is a relative, friend, similarly bereaved person (e.g. at a support group), doctor or counselor. Men and women may have different needs. Women tend to live longer than men and are more likely to spend the last years of life without their "life partner". They may lose their sense of purpose. Bereaved men may never before have had to care for themselves.
Hallucinations
Hallucinations, which may be auditory or visual, may occur after a stroke, in
dementia or because of psychiatric disease.
Some old people hallucinate after bereavement. This may be a source of comfort
to them. They may need reassurance that this is not the onset of schizophrenia
(which is highly unlikely to first appear in old age).
Infections
Older people are more likely to suffer from infectious diseases because of:
Shingles
The chickenpox virus lies dormant in the body, in the nervous system, long after
the illness has gone. It can be reactivated, as shingles, in response to stress
or illness. This means that shingles itself cannot be "caught" from
someone else with shingles. On the other hand, someone can catch chickenpox
from shingles.
Urinary
tract infections
These are common in old age, and if left untreated can result in kidney failure.
They are encouraged by:
Fungal
infections
These are more common in middle age and beyond. Onychomycosis, a localized fungal
infection of the nail or nail bed may arise (although not exclusively) after
micro trauma to the nails, perhaps through badly fitting shoes. The fungi can
easily invade the damaged tissue. The nail slowly becomes thickened, creamy
white, yellow or black, and may often crumble. It can eventually become detached.
Elderly people are often slower to seek treatment, through shame or because
they do not notice the problem, perhaps because of poor eyesight, lack of self-awareness
or loss of dexterity.
Fungal nail infection
Likewise, tinea pedis (Athlete’s
foot) is more common in older people. It can invade cracks and fissures which
arise from conditions associated with old age, such as vascular disease and
loss of skin hydration.
If dentures do not fit well, thrush (Candida) in the mouth can be a real problem.
Candida infections are more common in older people because of subtle changes
in body chemistry, including the onset of diabetes,
as well as urinary incontinence and hygiene problems. They may affect various
moister parts of the body, including the breasts and groin.
Falls
Falls occur more commonly in older people, especially in women and in the institutionalized.
Older people are also more likely to injure themselves seriously and may die
as a result. Principal causes of recurrent falls are:
A search must be made for underlying disease. Postural blood pressure should be measured and the patient asked exactly how the fall happened and whether they tripped or "dropped".
Vertigo
Ageing of the labyrinth, the part of the ear that controls balance, may cause
intermittent vertigo. The patient may have dizziness upon:
These may lead to falls.
Complications of falls
Immobility
Many older people (up to 20% in developed countries) can walk unaided, others
may need a stick or a frame, or walk slowly or be unable to walk far. Reasons
for partial or complete immobility are:
Complications of immobility
Depression
Many old people have depression but it often remains undiagnosed. Depression
may be especially hard to detect in older people since it may be concealed by
other health problems and since its main symptom, unhappiness, might be seen
as normal in an old person with a number of problems. Suicide attempts are far
more successful than in younger depressives.
Depression may be the reason for confusion, immobility, falls, incontinence or it may be as a result of these. Other factors leading to depression include:
The older person may be less able to cope with the unfavorable events in life if they live alone, their confidantes have died and their family lives far away, if they are house-bound or if their health problems make socializing harder, so that they are no longer part of a supportive social network.
Acute
confusional states or delirium
Illness can cause short bouts of confusion (delirium) by temporarily depriving
brain cells of energy, oxygen, vitamins or hormones:
Clinical
features of acute confusion
Confusion, which is a reduced level of arousal, is often mistaken for dementia.
This can have serious consequences because the correct treatment can only be
given once the underlying problem, e.g. oxygen starvation (anoxia), has been
accurately diagnosed.
Self-neglect
Old people may neglect the essentials of hygiene and self-care because they
have dementia. However, psychological and physiological
disorders may be insufficient to account for self-neglect, which may lead to
hypothermia, malnutrition
and infections. Risk factors for self-neglect include:
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