Key issues

Social aspects of ageing

The ageing body need not be an ill body; healthy ageing is achievable. Many problems can be alleviated or reversed:

• Ill health.
  
• Reduced body function.
  
• Uncertain social status due to retirement and disabilities.
  
• Fall in income, poverty.
  
• Lower living standards.
  
• Bereavement and loneliness.
  
• Unhappiness, grief, depression.
  
• Increased risk of accident.
  
• Greater vulnerability to abuse and security violations (robberies, attacks).
  
• Dependency.
  
• Loss of dignity.

"The human being has not yet been identified whose old age,lifespan and death are physiologically normal."
V Kovenchevsky, Physiology and pathology of ageing. Hafner, New York, 1961

Ageism

This is prejudice against older people. Ageism implies that as soon as a person can be described as old they are automatically:

• Of little value.
  
• A burden on society.
  
• Unable to look after themselves.
  
• Slow to accept change.
  
• Slow, deaf or stupid.
  
• Child-like or sweet.
  

Young people with ageist views appear not to appreciate that old people were once young themselves.

"Everyone faces at all times two fateful possibilities: one is to grow older, the other not."
Anonymous.

Medical aspects of ageing

Many diseases and conditions which are commonly perceived to be an unavoidable part of old age can in fact be cured or limited.

Special medical features of illness in old age

• Multiple diseases. Failure in one system may lead to failure in another - a cascade effect. No one disease dominates the clinical picture.
  
• Multiple organ failure.
  
• Multiple causes of the same symptom. Symptoms which are common to a number of diseases of old age are confusion, falls, incontinence, immobility. These have been called the Geriatric Giants.
  
• Different presentation to the young.
  
• Late presentation because of low health expectations by the patient, failure to recognize the problem or low expectation or fear of treatment or hospitalization.
  
• Presentation of a social problem may obscure an underlying disease or complicate its management.
  
• Multiple drug use may complicate management.
  
• Some drugs cause as well as cure health problems and this may be critical in older people.
  
• Intellectual failure and inability to communicate may complicate history-taking, diagnosis and management.

The geriatric giants

Surgery

Age-associated illness and problems may reduce the benefits of surgery:

• Recovery time may be lengthy because the older person has reduced reserves.
  
• Complications may have serious consequences since the old person may have a number of health problems.
  
• Anesthesia may be complicated because:
  
• It depresses body functions which may already be depressed in older people. An example is respiratory function.
  
• Blood pressure may be more labile.
  
• Fragile elderly skin may develop pressure sores and also damage from intubation and similar procedures.

Complications of surgery include:

• Deep vein thrombosis (calf flaccidity during anesthesia; post-surgery bed-rest).
  
• Respiratory infection.
  
• Confusion (e.g. due to premedication, anesthesia).
  
• Wound infection.
  
• Pressure sores.
  
• Stroke (especially with open heart surgery).
  

The likelihood of complications depends on the type of operation and the experience of the medical team.

Post-surgical outcomes in patients aged 65 and more,
in relation to their pre-operative health status

Compliance

Whatever the illness and whatever the age of the patient, there are always some people who do not comply with treatment. This means that they take none, a little, some or most of their treatment, but not all of it. Full compliance may be more important for some drugs than others; in those with a long half-life, for example, missing one dose may not have much effect.

Since ill health is more likely in old age, so is a lack of compliance. Any problems can usually be resolved by individualizing management:

• Swallowing problems may mean that capsules are unsuitable.
  
• A shaky hand or failing eyesight may mean that liquid formulations cause difficulties. A patient with memory problems may either forget to take their medication or take two doses by mistake.
  
• Blister packs and childproof bottles are hard for patients with arthritis to open.
  
• Multiple drug use may lead to confusion.
  
• Some patients will self-regulate drug doses according to perceived health. Some fail to understand instructions or cannot read the labels.
  
• Fear of side effects.
  
• A relatively fit and cognitively intact older person may comply better than younger patients.

Treatment

It is important to:

• Prioritize treatments - give too many at once and the patient may randomly choose not to take some.
  
• Start with a low dose to avoid problems with side effects, and increase dosage slowly after review.
  
• Avoid unnecessary drug therapy and review repeat prescriptions frequently as they may cease to be appropriate.
  
• Be aware of other pathologies or other drugs the patient is using which may affect drug choice. Drugs can interact with pre-existing disease or other drugs.
  
• Remember that laboratory test values may be affected by age, so that age-adjusted values and age-specific norms should always be used.
  

Older people require a generalist to ensure that the existence of multiple disease does not lead to multiple referrals, opinions and dilution of responsibility, but they also require the involvement of, and cooperation between, specialities for maximum benefit.

Timely treatment

An older person who falls ill may live alone, be isolated and have pre-existing mobility problems. They may therefore not be discovered and given treatment for several days after the onset of illness, which may seriously worsen. Also, they may be frail and vulnerable and any delay in treatment could lead to weakness (for example if the illness results in them not eating adequately), falls, dehydration, incontinence, constipation, pressure sores, and deep vein thrombosis. Such problems are less likely to develop in the young old than the old old. But for all ages, timely and effective treatment is likely to be rewarded by fewer complications.

"If an old person is unwell on Monday, the chances are that he / she will be worse on Tuesday and by the end ofthe week may be bed-ridden, dehydrated, confused and incontinent."
Williamson. Ann Intern Med 1978

Drug metabolism in older people

Various age-related changes affect drug metabolism but these rarely cause any problems if the patient is started on a low dose.

• Pharmacokinetics
  
• Drug-protein binding may decrease because of changes in body composition so that there is more free drug in the body compared to younger people and less drug is mobilized for treatment. This affects drug dose and duration of effect.
  
• Metabolism in the liver decreases - this affects drug dose. Kidney blood flow and function fall so that there is reduced renal clearance, and the potential for accumulation of drugs such as digoxin and gentamicin (which are excreted in active form by the kidney).
  
• Less gastric acid and reduced stomach emptying may affect the absorption of tablets but does not have a major clinical impact.

The end result may be:

• A longer duration of effect - so that drugs should be given less frequently in older people.
  
• Increased therapeutic effect - so that the starting dose should be lower in older people.
  
• Toxicity problems - monitoring is needed.

Pharmacodynamics

There is an increase in receptor sensitivity to psychotropic drugs and anticoagulants.
Drugs that affect preload (e.g. ACE inhibitors, tricyclic antidepressants, beta-blockers, levodopa) may lead to postural hypotension and an increased risk of falling.

Healthy ageing - ageing versus disease

Increases in the average lifespan mean that a larger proportion of life is now spent in old age. This has socio-economic consequences and it is important for society as well as for the older person that as many of these years as possible are spent in relatively good health. Prevention of the preventable diseases of old age is therefore increasingly important.

Potentially preventable diseases in old age

Strokes	Treat hypertension Stop smoking Use anticoagulants or low-dose aspirin Exercise Control fat in diet
Osteoporosis	Exercise Increase calcium intake HRT Stop smoking Calcitonin /diphosphonates Reduce alcohol intake to 1-2 drinks a day
Ischemic heart disease	Treat hypertension Exercise Stop smoking Low-salt diet Low-fat diet Weight reduction Low alcohol consumptionadvice
Alcohol-related problems	Advice on reducing drinking (optimum is 1-2 drinks a day)
Smoking problems (lung-cancer, Chronic Obstructive Pulmonary Disease, chronic bronchitis)	Advice on stopping smoking
Diverticular disease and gall bladder problems	High fiber diet
Malnutrition and vitamin deficiencies	Eat proper diet
Obesity	Reduce food intake Change medication (some can cause fluid retention)

Stages of disease prevention

• Primary prevention (before a disease starts) is by immunization (where appropriate), good nutrition, lifestyle changes (e.g. stopping smoking or minimizing alcohol consumption) and exercise.
• Secondary prevention (after a disease has started but before it has a clinical effect) is by health checks (e.g. for blood pressure, cholesterol levels), screening (cancers of the breast and cervix) and stress management.
• Tertiary prevention targets the complications of diseases.

"One can survive everything nowadays, except death."
Oscar Wilde

Exercise

A gradual build-up of activity (which needs to be kept up to be of benefit):

• Speeds up the elimination of waste from the body.
  
• Tones up muscles.
  
• Makes lungs function more efficiently.
  
• Increases mental alertness and reflexes.
  
• Reduces anxiety and improves wellbeing and concentration.
  
• Helps to protect against heart disease.
  
• Helps to protect against osteoporosis.
  
• Provides relief from the day's strains and stresses.
  
• Can be a social event and provides a sense of achievement.
  
• Improves sleep.
  
• An important part of rehabilitation after a heart attack or heart surgery.

Exercise needs to be chosen carefully for each individual so that it does not overload the body. With aerobic exercises, the heart pumps more blood with each beat and has to do less work overall, improving stamina. Swimming and dancing are examples of aerobic exercise.

"I have two doctors - my left leg and my right."
Anonymous

Alcohol

Many people reduce their alcohol consumption as they get older, because of social or income changes. Older persons who drink alcohol in excess are particularly vulnerable to its many disadvantages, because of age-related changes in body function and age-associated pathologies.

Alcohol:

• Depresses the central nervous system (depresses mood) - any mood benefits are short-lived.
  
• Deprives the body of essential minerals and vitamins (such as folate) because it creates a feeling of fullness so the person eats less, and because it reduces absorption of nutrients.
  
• Puts an extra burden on the liver and causes cirrhosis of the liver.
  
• May cause degeneration of the brain cerebellum leading to permanent unsteadiness; causes falls, hypothermia, confusion, and forgetting (Wernicke-Korsakoff's syndrome).
  
• Damages the heart
• Is expensive.

Some older people who abuse alcohol will have done so for many years but others only begin after a severe stress such as bereavement. Drinking 1-2 drinks a day (2-3 units) may actually be good for you. But some people should not drink alcohol at all, including those with:

• Liver disease.
  
• Chronic stomach or gastrointestinal problems (e.g ulcers).
  
• Medication that reacts with alcohol.

"There is no short cut to longevity. To win it is the work of a lifetime, and the promotion of it is a branch of preventive medicine."
Sir James Crichton-Browne

Medical and social care

Daily living

Diseases may damage or impair the function of body systems, handicap the patient's lifestyle and lead to disabilities

Simplified Barthel scale for tasks of daily living

Assessment

Assessment of the older patient should include:

• Comprehensive list of medical problems, including depression.
  
• Prioritization of problems.
  
• Drug taking - may hoard out-of-date medicines and self-prescribe, may try other peoples' or may use traditional remedies.
  
• Cognitive function.
  
• Functional abilities (premorbid and current).
  
• Social background and back-up network, accommodation.
  
• Family/carers/help.
  
  Information can be obtained from:
• History and examination of the patient.
  
• Corroboration from carers and relatives.
  
• Other healthcare professionals who have seen the patient.
  
• Use of specific assessment scales.

Rehabilitation

Rehabilitation reduces or reverses the handicap caused by disease. More precisely, it enables the individual to achieve their fullest possible physical, mental and social capability by identifying any problems and then defining a series of goals to overcome them:

• Full activity after a severe illness.
  
• Maximum achievable after a damaging illness.
  
• As much independence as possible when continuing impairment is unavoidable.

Physical rehabilitation may reduce impairments e.g. exercise to improve muscle strength. Social care, including social rehabilitation (which may be undertaken by the patient's family after instruction), may help the patient develop practical strategies to reduce the effects of a disability.

Rehabilitation staff include the occupational therapist, speech therapist and physiotherapist.

The patient's friends and family are of great importance because they:

• Are with the patient far more than a therapist is.
  
• Are involved when the patient is discharged or therapy ceases (the patient may feel abandoned).
  
• Can carry out rehabilitation in the home environment.

The relative need for involvement of the family, friends or carers varies with country.

Barriers to successful rehabilitation

The patient may have:

• Poor motivation.
  
• Dementia.
  
• Depression.
  
• Communication problems.
  
• Arthritis, pressure sores or other co-existing disabilities.
  
• Other hidden problems (periodic reassessment by the therapist may reveal these).
  
• Unrealistic expectations.
  
• Problems accepting that full function may never be restored.
  
• The person who can no longer manage alone
  
• Sheltered accommodation

An older person who has some health problems but can still live a relatively independent life may choose sheltered accommodation:

• Self-contained housing.
  
• Purpose-built, with built-in aids and adaptations for disabled living and frailty.
  
• Warden on call.
  
• Companionship without invasion of privacy.
  
• Safety and reassurance.

Carers

These are people who look after a mentally or physically disabled person. Each type of carer (government, private, social, family) operates under different constraints and with a different philosophy (which may be dictated by economics as well as healthcare commitment).

Professional carers

These include:

• Nursing/home help (including charity workers).
  
• Specialized volunteer services (e.g. lunches cooked).
  
• Clubs and day centers.
  
• Transport schemes.
  
• Holiday and day trip schemes.

Their advantages are that they:

• Can draw on a large pool of people with a range of skills and resources.
  
• Have formal arrangements for psychological and practical support of the carer.

Informal carers (family and friends)

• Little or no training.
  
• No extra practical help/support.
  
• No financial help.
  
• Lack of recognition.
  
• May have previously not had a particularly good relationship with the patient.
  
• May spend years caring for a person without any days off for themselves.
  
• May be elderly themselves and have their own health problems.
  
• May not recognize (or feel comfortable admitting) the effect on their mental and physical health of caring.
  
• Need a break from caring (and patients need a break from their carers). This can be achieved by:
  
• Temporary admission of the patient to hospital.
  
• Support networks and clubs.
  
• Day centers.
  
• Need someone who can take over in an emergency.

The advantages of informal carers are:

• Shared life history with the patient.
  
• Continuity of care.
  
• May be highly committed.
  
• Flexible, not constrained by job descriptions.

Institutional care

Reasons for institutional care include:

• Lack of a carer.
  
• Urinary and especially faecal incontinence.
  
• Night-time wakefulness.
  
• Unsuitable housing.
  
• Poor local services.
  
• Disabilities of such an extent as to require daily medical/nursing attention.
  
• Wishes of the person. Persuasion by a relative.
  
• Financial incentives (the family carer needs to work, the disability requires costly specialist equipment, or the state offers financial incentives).

The best institutions:

• Remember that the patient is an individual.
  
• Allow the person to control as much of their lives as possible and do not enforce rigid routines (such as waking up times) where they can be avoided.
  
• Allow relatives to spend as much time with the patient as they wish, take over some care and take the patient out on trips.

Hospital

There is great pressure on the resources of hospital wards and sometimes they are not the best place for older people, especially when chronic care is needed. They may be impersonal, and the patient may lose their autonomy and be made dependent. In some unmodernised institutions:

• Bed rest can cause pressure sores and also weaken muscles and encourage osteoporosis.
  
• High beds and bed rails can lead to falls, incontinence and dependency.
  
• The person who refuses help.

An old person who can no longer manage alone (e.g. those with dementia or self-neglect) may not wish to be helped, even when they pose problems in the community (e.g. inappropriate behavior, lack of hygiene, leaving gas taps open and unlit). In such cases, if they cannot be persuaded, more forceful measures may have to be invoked:

• Enforced temporary admission to hospital as the law of the country allows.
  
• Power of attorney or other legal safeguards to protect the old person's finances.
  
• Home visits from local healthcare teams.
  
• Often though, action is only taken once a serious crisis has arisen.

International variations in settings for long-term care

Australia	Nursing homes, hostels, home care
Canada	Chronic care or rehabilitation hospitals, nursing homes, home care
China	Hospitals, other institutions, home care (informal)
England	Hospitals, nursing homes, residential homes, home care
France	Hospitals, nursing homes, residential care, home care
Germany	Hospitals, nursing homes, residential care, home nursing care
United States	Rehabilitation hospitals, nursing homes, home nursing care