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PHYSIOLOGY OF AGING Special considerations when

PHYSIOLOGY OF AGING Special considerations when






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    PHYSIOLOGY OF AGING Special considerations when PHYSIOLOGY OF AGING Special considerations when Presentation Transcript

    • PHYSIOLOGY OF AGING Special considerations when dealing with older patients
      • Dr. Jos. Zebley
      • MAFP February 2010
      • Annapolis Md
    • Physiology of Aging
      • “We are all amateurs; we don’t live long enough to become anything else.”
      • Charlie Chaplin
    • Significance of Human Aging
      • People live longer now than ever before
      • By 2030, 20% of the US population will be 65 and older
      • Significant challenge to medicine - ethical, financial, etc.
    • Question # 1
      • Patients over 60 make up
      • a 20%
      • b 30%
      • c 40%
      • of all physician visits
    • Demographic Imperative
      • Patients over 60 make up 40% of all physician office visits and average 11 physician visits a year compared to an aggregate average of 5 visits a year for those under 65
      • There are over 1.5 M elderly nursing home residents and this number is expected to increase dramatically as the Baby Boom generation enters its seventh decade
    • Baltimore Sun 7/19/2009
    • Question # 2
      • What would improve life expectancy more:
      • A Finding cures for diabetes, cancer, heart disease, and stroke
      • B Slowing down the rate of aging
    • Significance of Human Aging
      • Gender and genetics are significant factors
      • Lifestyle and genetic expression are major factors
      • Various theories of aging attempt to explain the process - bottom line, there is disruption of homeostasis
    • Stages of Life
      • Chronological age has typically been used to note life’s transitions
      • We need to think in physiological terms rather than these old chorological terms
    • Stages of Life - 2
      • Physiological adulthood is attainment of optimally integrated function
      • Function in adulthood is the “standard measure”
      • It is incorrect to state that the changes with aging are necessarily “abnormal” they are however deviations from the standard ranges for young adults.
      • Four observations of the elderly:
        • Greater heterogeneity in responses to stressors
        • Changes in function do not occur simultaneously
        • Changes in function no longer occur to the same degree
      • _ There is reduced redundancy and ability to repair
      • Old age should not be viewed as a “disease” nor should a time clock be put on aging
    • Human Longevity
      • Significant increase in longevity over past centuries
      • Due to decline in deaths resulting from accidents and infectious diseases along with improved public health
      • Heart disease, cancer and stroke now most common cause of death
      • Death rates have actually declined in the elderly
      • Is there a limit to the human life span and should we prolong life at the expense of overall health?
      • Should be speaking of “health span” not life span
    • Life span vs Health span
    • Concepts of Aging
      • Chronologic age and physiologic age are not the same as noted before
      • They vary based on the complex interactions of genetics and the environment
      • So individuals age at different rates and there is significant variability in physiological response
    • Successful Aging - 2
      • The prevalence of disease increases with age
      • Different forms of aging:
        • Aging with disease and disability
        • Usual aging; absence of pathology but presence of decline in function
        • Ideal healthy aging; no pathology or functional loss
    • Healthy Aging
    • Successful Aging - 3 H omeostasis less efficient, but still present
    • Question # 3 Watching Television reduces longevity: A True B False
    • Physiological Changes
      • Heterogeneity of various values and functions
      • Many associated with physical inactivity
    • Successful Aging - 4
      • Recent research:
        • Elderly individuals with weak muscles are at greater risk for mortality than age-matched individuals
        • Increase in amount and rate of loss of muscle increases risk of premature death (i.e. TV, computers)
        • Circulation Jan 2010 Dunstan, Barr, et al
        • Physical inactivity is 3rd leading cause of death in US and plays role in chronic illnesses of aging
    • New techniques for exercise
      • Wii golf and bowl
    • Aging and Disease
      • Aging is associated with
      • increase in incidence and severity of disease
      • Many disparate factors predispose individuals to functional losses later in life
      • Many conditions have suspected either genetic and/or environmental etiologies
    • Cell Senescence and Death
      • Cell senescence is much like apoptosis
        • Occurs throughout life
        • It arrests the growth of damaged/dysfunctional cells
        • Beneficial early in life; it may contribute to aging later on
    • Cellular Aging
      • Gene inducers can cause cancer
      • Senescence allows cells to more easily respond to inducers, but then cells withdraw from growth cycle are are less likely to move to tumorigenesis
      • Other contributions of cell senescence to aging:
        • Altered secretions of cells
        • Proteases, inflammatory cytokines, growth factors
        • Erosion of structure and integrity of tissues
    • System Review
      • Cardiovascular
      • Respiratory
      • Renal
      • Neurological
      • Hematological
      • Endocrine/Immune System
      • Hormonal/Metabolic
      • Musculoskeletal
      • Gastrointestinal
      • Special Senses
      • Skin
    • Question # 4
      • The aging Cardiovascular System has a:
      • A Reduced Cardiac output
      • B Increased Stroke Volume
      • C Reduced Peripheral Resistance
    • Cardiovascular System
      • Reduced - Resting and maximal cardiac output - Stroke Volume - Maximal heart rate - Response to sympathetic nervous system stimulation
      • Increased - Systolic Blood Pressure - Peripheral resistance - Total cholesterol and LDL particle number
      • The resting cardiac output can remain stable with conditioning exercise in the absence of disease however the CO with exercise will be reduced even in healthy aging
    • Heart to Heart
    • Question # 5
      • Senile emphysema is due to:
      • A Chest wall Stiffness
      • B Alveolar Stiffness
      • C Kyphosis
      • D All the above
    • Respiratory System
      • Reduced
      • - Lung surface area - Alveolar elasticity
      • - Forced Expiratory Volume (FEV 1) - Maximal Oxygen Consumption (VO2 max)
      • - P O2
      • Increased
      • - Chest wall stiffness
      • Osteoporosis and kyphosis can reduce the thoracic capacity. That and alveolar stiffness leads to “senile emphysema” with an FEV1/FVC < 70% of the predicted for age and gender
    • Home Oxygen
    • Question # 6
      • Reduced Spirometric Parameters are associated with:
      • A 1 of 5
      • B 2 of 5
      • C 3 of the 5
      • leading causes of death in men
    • Respiratory System - 2
      • Impaired ability to clear secretions
      • Increased tendency to aspiration
      • The reduced activity of effector T cells increases risk of pneumonia
      • Reduced spirometric parameters are associated with all cause mortality and specifically with
      • - CVD
      • - COPD - Lung cancer (3 out of 7 leading causes for women and 3 of the 5 leading causes for men)
    • Question # 7
      • Average creatinine clearance decreases 10ml/min for every decade after age 30
      • True
      • False
    • Renal system
      • Decreased renal mass and size - 150 to 200 gms at 30 yrs but only 110 to 150 by 85 yrs
      • - Mostly loss of renal cortex 40% less glomeruli by age 80
      • Reduced Renal blood Flow - 10% reduction per decade after age 20
      • - Afferent and efferent arterioles to the cortex atrophy
      • Number and length of tubules decreases
      • Average Creatinine clearance decreases 0.75ml/min/yr based on the healthy volunteers of the BLSA with 30% showing NO loss. This decline begins in the fourth decade and averages 10 ml/min every decade. Reduced muscle mass makes the serum creatinine an unreliable marker for renal function.
    • With age comes new skills
    • Renal function
      • The ability to concentrate urine declines --> frequency.
      • Ability to elaborate dilute urine can be reduced. Water overload can easily lead to CHF and hyponatremia. SIADH like pattern
      • Total body water is reduced from 60% at age 20 to only 45 % of body mass by age 80. Thirst is blunted with age with an increased risk of dehydration and volume depletion
      • There is greater sensitivity to drug induced nephrotoxicity (ACEIs, aminoglycosides)
      • Reduced volume of distribution of water soluble drugs (dig) can lead to toxicity
      • Increased fat and reduced muscle mass lead to an increased volume of distribution of lipophilic drugs (Benzos) with reduced clearance and risk of toxicity
    • Question # 8
      • Cognitive function is affected more than recall memory in normal aging
      • A True
      • B False
    • Neurological System
      • Neuronal loss is normal in the aging brain but the ability to learn remains generally unchanged
      • There is loss of dendritic arborization
      • Recall memory is affected more than cognitive function in normal aging
      • Cerebral atrophy shows up on CTs and MRI scans
      • Lowered seizure threshold
      • Reduced Sympathetic nervous system activity
      • Reduced Neurotransmitter levels
      • Changes in sleep patterns
      • Abnormalities in EEG tracings
      • Increased risk of stroke
    • New skills
    • Nervous System - 2
      • Aging leads to increased cerebral amyloid
      • Average amount of brain protein is reduced with a marked loss in multiple enzymes (carbonic anhydrase and the dehydrogenases) but with a relative increase in abnormal proteins such as amyloid in tangles and plaques.
      • Loss of RNA (messenger and transcription) but not DNA
      • Loss of lipids, and lipid turnover rate, and a decrease in catabolism and synthesis.
    • Hematological
      • The age related reduced marrow production is not necessarily associated with anemias. Many complex factors involved.
      • Hemoglobin of 12g/dl is now considered the current lower limit of normal in the elderly (over 75)
      • There is however diminished reserve capacity
    • Balance in aging
    • Common causes of Anemia Hypoproliferative
      • Hypoproliferative anemias in the elderly
      • Iron Deficient erythropoiesis - Nutritional Iron Deficiency - Chronic disease - Inflammation
      • Erythropoietin Lack - Renal - Endocrine
      • Stem cell dysfunction - Aplastic anemia - Red blood cell aplasia
    • Causes of anemia Ineffective erythropoiesis
      • Megaloblastic - Vitamin B 12 deficiency - Folate deficiency - Refractory anemia
      • Microcytic - Thalassemia - Sideroblastic anemia
      • Normocytic Anemias - Stromal disease - Dimorphic anemia
      • - Blood Loss
    • Hemolytic Anemias in the Elderly
      • Immunologic - Idiopathic - Secondary to drugs, tumour, or chronic disease
      • Intrinsic - Metabolic - Abnormal hemoglobin
      • Extrinsic - Mechanical - Lytic substances
    • Endocrine System
      • Insulin production increases and then decreases
      • Insulin receptors become less effective
      • Adrenal androgens decline with reduction in libido and sexual functioning. There is no known alteration of the HPA axis but there is an increase in stress mediated Cortisol secretion
      • Reduction in episodic release of Growth Hormone
      • Disorders of Vitamin D absorption, bone and mineral metabolism, and parathyroid disorders
      • Changes in testicular and ovarian function
      • Hyperthyroidism more prevalent in the elderly
      • Hypothyroidism in over 4% of people over 60
    • Question # 9
      • Fractures are related to:
      • A Visual impairment
      • B Osteoporosis
      • C Reduced muscle mass
      • D All the above
    • Musculoskeletal System
      • Osteoarthritis - Changes in cartilage chemistry and thickness - Changes in synovial fluid - Changes in the intervertebral discs - Changes in the menisci
      • Osteoporosis - Reduced calcium reserves or increased loss - Increased osteoclastic activity over osteoblasts
      • Polymyalgia Rheumatica
      • Reduced muscle mass
      • These all present multiple risk factors for fractures
    • Gastrointestinal
    • Question # 10
      • Elderly patients require more PPIs for longer periods of time than younger patients
      • - True
      • - False
    • Gastroenterology
      • Multiple functional changes - Dry mouth, reduced sense of taste, dental issues - Swallowing disorders, risk of aspiration
      • - Impaired peristalsis (presbyesophagus)
      • - Reduced gastric secretions
      • - Reduced intestinal absorption
      • - Impaired colonic motility
      • and impaired ano rectal function
      • - Reduced gallbladder emptying - Reduced hepatic function
      • Dyspepsia, bloating, constipation, flatulence
    • PPIs in the elderly
      • Overuse of PPIs is associated with
      • - Increased incidence of pneumonia
      • - Increased incidence of hip fractures
      • - Increased incidence of C. Difficile
      • Wean patients off PPIs and H2 Blockers if possible
      • CMAJ August 12, 2008; 179 (4).Targonik LE, Lix LM, et al
      • CMAJ September 26, 2006; 175 (7) Dial S, Delaney C, et al
    • Gastric Acidity
      • Reduced gastric secretions lead to an increased post prandial gastric pH (6.5)
      • Fasting pH (1.3) in over 75 yr olds is statistically different from average young patients and 11% had a median fasting pH of >5
      • The rate of return to pH 2.0 was significantly longer than in younger cohorts (> 4 hrs)
      • Pharm Res 1993 Feb;10(2):187-96.
      • Upper gastrointestinal pH in seventy-nine healthy, elderly, North American men and women. Russell TL, Berardi RR, et al.
    • Immune System
      • Diminished cell mediated immunity
      • Increased incidence of anergy
      • Reduced helper,cytotoxic and effector T cells
      • Increased cytokine antagonists
      • Changes in neutrophil and macrophage function
      • Clinical implications
      • Atypical presentations of infectious illnesses
      • Poor or delayed response to antibiotic therapies
      • Reduced protection of the urinary or the respiratory mucosae
    • Special Senses
      • Vision
      • Hearing
      • Smell
      • Taste
      • Touch
    • Touch
    • Treatment Implications
      • The normal elderly person can undergo most of the same urgent or emergent interventions as the younger adult as long as attention is paid to the physiological changes discussed above
      • Consider earlier and more aggressive treatment of infections BUT with attention to renal function
      • Pay closer attention to nutrition and bowel function
      • Pay close attention to CNS changes as harbingers of other pathologies
      • Screen carefully for metabolic disorders: thyroid, anemias, bone disease, vit deficiencies etc…
    • Current Areas of Research
      • Caloric Restriction Altered dietary intake
      • Genetic causes of age related illnesses
      • Effects of IGF (insulin growth factors), TNF (tumor necrosis factors), and inflammatory cytokines etc…
      • Pharmaceuticals and pharmacogenomics in the aging individual
    • Conclusion
      • Aging is not for sissies
      • Maintain a maximal muscle mass. Exercise of some form is ALWAYS better than less exercise of any kind at any age and in any condition
      • Develop and nurture a close relationship between the physician and the elderly patient and the family. This allows the Doc to pick up on subtle changes early in any disease process
      • Maintain careful hydration and nutritional status
      • Avoid excess weight gain BUT protect against weight loss. Dropping LDL, triglycerides, albumin are all red flags for senesence and decline.
    • Go Granny Go
    • Conclusion
      • Discuss end of life care and review regularly
      • Learn the principles of palliative and end of life care
      • Apply common sense to protocols and screening guidelines
      • Don’t do anything to your patient that you would not want done to you ~ unless the family and / or patient insist and understand some of the unintended consequences
    • The End