Clinical problems of aging - Geriatrics Health Issue

1. CLINICAL PROBLEMS OF AGING
CHAIRPERSON : Dr. Sachin Hoskatti
STUDENT: Dr. Zahura

2. INTRODUCTION
• Geriatics term of greek origin
`gerras` --- old age
`iatros` --- healer or physician
• Branch of medicine that deals with the
problems and diseases of old age and aging
people

3. WHO CLASSIFICATION
• Elderly – 50 to 75yrs
• Old age – 76 to 90 yrs
• Very old – above 91yrs

7. Programmed death
• The first evolutionary theory of aging was
proposed by Weissman in 1882.
• This theory states that aging and death are
programmed and have evolved to remove
older animals from the population so that
environmental resources such as food and
water are freed up for younger members of
the species.

8. Mutation accumulation
• This theory was proposed by Medawar in 1952.
• Natural selection is most powerful for those
traits that influence reproduction in early life, and
therefore, the ability of evolution to shape our
biology declines with age.
• Germline mutations that are deleterious in later
life can accumulate simply because natural
selection cannot act to prevent them.

9. Antagonistic pleiotropy
• George C. Williams extended Medawar’s theory
when he proposed that evolution can allow for
the selection of genes that are pleiotropic, i.e.,
beneficial for survival and reproduction in early
life, but harmful in old age.
• For example, genes for sex hormones are
necessary for reproduction in early life but
contribute to the risk of cancer in old age.

10. Life history theory
• Evolution is influenced by the way that limited
resources are allocated to all aspects of life
including development, sexual maturation,
reproduction, number of offspring, and
senescence and death. Therefore, “trade-offs”
occur between these phases of life.

11. Disposable soma theory
• Kirkwood and Holliday in 1979
• There are finite resources available for the
maintenance and repair of both germ and soma cells,
so there must be a trade-off between germ cells (i.e.,
reproduction) and soma cells (i.e., longevity and aging).
• The soma cells accumulate damage that causes aging
while resources are preferentially diverted to the
maintenance and repair of the germ cells.
• For example, the longevity of the nematode worm,
Caenorhabditis elegans, is increased when its germ
cells are ablated early in life.

12. Grandmother hypothesis
• Hamilton in 1966
• In this situation, the presence of a long-lived
grandmother who shares in the care of her
grandchildren can have a major impact on
their survival.
• These children share some of the genes of
their grandmother including those that
promoted their grandmother’s longevity.

13. Mother’s curse
• Mitochondrial dysfunction is a key component of
the aging process.
• Mitochondria contain their own DNA and are
only passed on from mother to child .
• Therefore, natural selection can only act on the
evolution of mitochondrial DNA in females. The
“mother’s curse” of the maternal inheritance of
mitochondrial DNA might explain why females
live longer and age more slowly than males.

14. Adaptive senectitude
• Many traits that are harmful in younger humans
such as obesity, hypertension, and oxidative
stress paradoxically appear to be associated with
greater survival and function in very old people.
• Perhaps driven by the grandmother effect, this
might represent “adaptive senectitude” or
“reverse antagonistic pleiotropy,” whereby some
traits that are harmful in young people become
beneficial in older people.

16. SYSTEMIC EFFECTS OF AGING
• Body composition
• Balance between energy availability & energy
demand
• Signalling networks that maintain homeostasis
• Neurodegeneration

17. BODY COMPOSITION
• Weight declines in men between 65 & 70
years and later in women
• Lean body mass(muscle,visceral organs)
decreases after 3rd decade
• Atrophy greater in fast twitch fibres
• Fibroconnective tissue tends to increase in
many organ systems-----muscle quality &
function affected
• Progressive demineralisation

18. BALANCE BETWEEN ENERGY
AVAILABILITY & ENERGY DEMAND
• Older age,pathology & physical impairment
increase the energy cost of motor acivities
• Low energy levels
• Require more energy both at rest and during
physical activity

19. SIGNALLING NETWORKS THAT
MAINTAIN HOMEOSTASIS
• Hormones
DECREASE NO CHANGE INCREASE
GROWTH HORMONE PROPOLTLACTIN CCK
LH(MALE) THYROTROPIN LH(WOMEN)
IGF-1 THYROID HORMONES FSH
TESTOSTERONE
ESTRADIOL
PREGNENOLONE
EPINEPHRINE CORTISOL
25(OH) VITAMIN D GLP1 PROLACTIN
ALDOSTERONE GASTRIC INHIBITORY
POLYPEPTIDE
NOREPINEPHRINE
VIP
MELATONIN
PARATHORMONE

20. • Inflammatory mediators- IL-6, CRP
• Antioxidants

21. NEURODEGENERATION
• Brain atrophy occurs after 60yrs age- decline
in cognitive & motor function
• Spinal cord—reduced number of motor
neurons, damage to myelin, increased
branching complexity, serving larger motor
units

22. PHYSIOLOGICAL CHANGES
IN OLD AGE

23. The muscles used in breathing, such as the diaphragm, tend to
weaken.
The number of alveoli and capillaries in the lungs
decreases. Thus oxygen absorbed is less from air breathed in.
 The lungs become less elastic.
 Effectiveness of cough mechanism lessens
 Increased airway resistance,dead space,energy of breathing
 Interstitial fibrosis, emphysema
RESPIRATORY CHANGES

24. The heart and blood vessels become stiffer. The heart fills
with blood more slowly.
Atherosclerosis
Arteriosclerosis--blood pressure tends to increase.
Heart rate slows
Decreased blood flow to all organs
Baroreceptor sensitivity decreases—orthostatic
hypotension
CARDIOVASCULAR CHANGES

25. GASTROINTESTINAL CHANGES
As people age, the taste buds on the tongue decrease in
sensitivity. This change affects mostly tasting sweet and salt
more than bitter and sour.
Decreased salivation—difficulty in swallowing
Periodontal disease rate increases

26. • GI motility decreases-- constipation
• Stomach pH increases
• Intestinal absorption decreases
• LIVER -- decreased blood flow
altered clearance of drugs
metabolizes less efficiently
reduced regenerative capacity

27. Women :
 In women, most of these effects are related to menopause due to
decreased estrogen production
 Ovaries and uterus to shrink, breast tissue diminishes,atrophic
vaginitis
Supportive musculature of reproductive organs weakens---uterine
prolapse
Endometrial atrohy,hyperplasia,carcinoma
Uterine leiomyomas
REPRODUCTIVE SYSTEM CHANGES

28. Men :
 In men, changes in sex hormone levels are less sudden.
 Levels of male hormone testosterone decreases, resulting in
lesser sperm production,testicular atrophy
 BPH, adenocarcinoma of prostrate

29.  The cells of the immune system act more slowly.
This slowdown of immune system causes:
1. Cancer is more common among older people.
2. Vaccines tend to be less protective in older people.
3. Infections such as pneumonia and influenza, are more common
among older people and result in death more often.
4. Allergy symptoms may become less severe.
IMMUNE SYSTEM

30. ENDOCRINE SYSTEM
DECREASE NO CHANGE INCREASE
GROWTH HORMONE PROPOLTLACTIN CCK
LH(MALE) THYROTROPIN LH(WOMEN)
IGF-1 THYROID HORMONES FSH
TESTOSTERONE
ESTRADIOL
PREGNENOLONE
EPINEPHRINE CORTISOL
25(OH) VITAMIN D GLP1 PROLACTIN
ALDOSTERONE GASTRIC INHIBITORY
POLYPEPTIDE
NOREPINEPHRINE
VIP
MELATONIN
PARATHORMONE

31. MUSCULOSKELETAL SYSTEM
• Sarcopenia
• Fatty infiltration of muscles
•The amount of muscle tissue and muscle
strength tend to decrease as age increases.
Muscles cannot contract quickly.
• Osteoarthritis
• Osteoporosis, pathological fractures
• By 80yrs of age 2inches of height lost

32. The skin tends to be thinner, less elastic, drier and finely wrinkled.
With aging the body produces less collagen and elastin. so, the
skin tears more easily.
The fat layer under the skin thins, this causes wrinkles to appear,
and tolerance to cold decreases.
The number of sweat glands and blood vessels decreases, and
blood flow to deep layer of skin decreases.
SKIN

33. The number of pigment-producing cells (melanocytes) decreases.
As a result, the skin has less protection against ultraviolet
radiation causes large, brown spots appear on skin.
The skin is less able to form vitamin D when it is exposed to
sunlight. Thus, the risk of vitamin D deficiency increases.

34. RENAL SYSTEM
• Size & number of nephrons decreases
• Filtration & reabsorption reduced
• Reduced hormonal response to vasopressin
• Bladder mucle weakens,decreased bladder
capacity leading to increase in residual urine
and frequency-----UTI, incontinence

35. URINE INCONTINENCE
• DETRUSOR OVERACTIVITY (URGE
INCONTINENCE)—Detrusor overactivity refers
to uninhibited bladder contractions that cause
leakage.
• It is the most common cause of established
geriatric incontinence, accounting for two-
thirds of cases, and is usually idiopathic.

36. • detrusor overactivity also may be due to
bladder stones or tumor, the abrupt onset of
otherwise unexplained urge incontinence—
especially if accompanied by perineal or
suprapubic discomfort or sterile hematuria—
should be investigated by cystoscopy and
cytologic examination of a urine specimen.

37. Treatment
• timed and prompted voiding
• Pelvic floor muscle (“Kegel”) exercises
• Antimuscarinic agents

38. URETHRAL INCOMPETENCE (STRESS
INCONTINENCE)—
• Urethral incompetence is the second most
common cause of established urinary
incontinence in older women.
• Stress incontinence is most commonly seen in
men after radical prostatectomy.
• Stress incontinence is characterized by
instantaneous leakage of urine in response to a
stress maneuver.

39. • URETHRAL OBSTRUCTION—urethral obstruction
(due to prostatic enlargement, urethral stricture,
bladder neck contracture,or prostatic cancer) is a
common cause of established incontinence in
older men but is rare in older women.
• Surgical decompression is the most effective
treatment for obstruction, especially in the
setting of urinary retention due to benign
prostatic hyperplasia.

40. • DETRUSOR UNDERACTIVITY (OVERFLOW
INCONTINENCE)—
• Detrusor underactivity is the least common cause of
incontinence.
• It may be idiopathic or due to sacral lower motor nerve
dysfunction.
• When it causes incontinence, detrusor underactivity is
associated with urinary frequency, nocturia, and frequent
leakage of small amounts.
• Augmented voiding techniques (eg,double voiding,
suprapubic pressure) can prove effective. If further
emptying is needed, intermittent or indwelling
catheterization is the only option.

41. NERVOUS SYSTEM
 The number of nerve cells in the brain typically decreases.
 However, the brain compensates it by as cells are lost, new
connections are made between the remaining nerve cells.The brain
has more cells than it needs to do most activities - a characteristic
called redundancy.
 Blood flow to the brain decreases.

42. Some mental functions—such as vocabulary, short-term memory,
the ability to learn new material, and the ability to recall words—
may be subtly reduced after age 70.
Therefore, in older people with damaged nerves, sensation and
strength may be decreased.

43. DEMENTIA
• an acquired, persistent, and progressive
impairment in intellectual function, with
compromise of memory and at least one
other cognitive domain, most commonly
aphasia, apraxia, agnosia and impaired
executive function

44. TREATMENT
• Acetylcholinesterase inhibitors—a trial of
acetylcholinesterase inhibitors (eg,
donepezil,galantamine, rivastigmine) in most
patients with mild to moderate Alzheimer
disease.
• Memantine (5 mg orally daily to 10 mg twice
daily), an N-methyl-D-aspartate (NMDA)
antagonist, with or without concomitant use of
an acetylcholinesterase inhibitor.

45. DEPRESSION
Depression occurs 16-65% of elders living in
the community.
Depression including: sleep disturbance, lack
of interest, feelings of guilt, lack of energy,
decreased concentration and, loss of appetite.
Losses can lead to depression.

46. TREATMENT
• Selective serotonin reuptake inhibitors (SSRIs),
particularly sertraline, are often used as first-line
agents because of their relatively benign side-effect
profile
• Mirtazapine is often used for patients with weight loss,
anorexia, or insomnia.
• Duloxetine is useful in patients who also have
neuropathic pain and is better tolerated than
venlafaxine among older adults.
• Adding methylphenidate to an SSRI appears to enhance
clinical response rates

47. DELIRIUM
• Delirium is an acute, fluctuating disturbance
of consciousness, associated with a change in
cognition or development of perceptual
disturbances

48. Evaluation of most patients should include
• complete blood cell count;
• blood urea nitrogen (BUN);
• serum electrolycreatinine,
• glucose, calcium, albumin, and liver tests;
• urinalysis; and ECG.

49. • In selected cases, serum
magnesium,medication levels, arterial blood
gas measurements,blood cultures, chest
radiography, urinary toxin screen,and lumbar
puncture may be helpful.
• When delirium develops during a
hospitalization in the absence of trauma or
new localizing neurologic signs, a head CT is
rarely revealing.

50. • Antipsychotic agents (such as haloperidol,0.5–
1 mg orally, or quetiapine, 25 mg orally, at
bedtime or twice daily) are considered the
medications of choice.

51. As people age increases this occurs,
 The lens stiffens, making focusing on close objects harder.
 The lens becomes denser, making seeing in dim light harder.
 The pupil reacts more slowly to changes in light.
 The lens yellows, changing the way colors are perceived.
 The number of nerve cells decrease, impairing depth perception.
 The lacrimal gland produce less fluid, making them feel dry.
EYES

52. A change in vision is the first undeniable sign of aging.
Changes in lenses of the eyes can cause the following.
1. Loss of near vision.
2. Need for brighter light.
3. Changes in color perception.

53. Appearance of eyes changes in several ways:
1.The whites (sclera) of the eyes may turn slightly yellow or brown.
2. ARCUS SENILIS gray-white ring may appear on the surface of
the eye. The ring is made of calcium and cholesterol salts.
3.The lower eyelid may hang away from the eyeball because the
muscles around the eye weaken and the tendons stretch.
4.The eye may appear to sink into the head because the amount of
fat around the eye decreases

54. As people age, hearing high-pitched sounds becomes more
difficult. This change is considered age-associated hearing loss
(presbycusis). These changes tend to speed up after age 55.
Gradually, hearing lower pitches also becomes more difficult.
Membrane becomes less flexible, middle ear ossicles stiffens ---
reducing hearing sensitivity
Vestibular apparatus degenerates-- dizziness
EARS

55. The ability to taste and smell gradually diminish.
As people age, the taste buds on the tongue decrease in sensitivity.
This change affects mostly tasting sweet and salt more than bitter
and sour.
The ability to smell diminishes because the lining of nose
becomes thinner and drier and the nerve ending in the nose
detoriate.
TASTE AND SMELL

56. FALL RISK FACTORS
AND TARGETED INTERVENTIONS

58. ORAL PROBLEMS
• Tooth loss
• Coronal & root caries
• Periodontal disease
• Xerostomia

59. INVOLUNTARY WEIGHT LOSS
• Most studies of involuntary weight loss in
older adults define it as loss of 5% of body
weight in 6 months or 10% of body weight in 1
year
• The causes of involuntary weight loss are
many but generally break down along medical
(60–70%) and psychiatric (10–20%) causes,
while up to 25% of the time a cause will not
be identified.

60. • Social factors such as access to food and
dental health should also be explored.

61. NUTRITION
• Fruits,vegetables,whole grain
• Good hydration 1oooml
• Fish once a week
• Calorie intake BMI 20-27, IF BMI> 27 5-10%
calorie restriction
• Salt <6g/day
• Vitamin D fortified foods, supplements

62. RECOMMENDED NUTRIENT INTAKE
FOR OLDER PERSONS BY WHO
Carbohydrates : 60%
Protein : 0.91 g/kg/ day.
Fat : 30%E for sedentary older persons
35% E for active older persons.
Saturated fat should not exceed 8% of E
Calcium : 800- 1200 mg /day
Iron : 10mg/day
Selenium : 50-70 microgram/ day
Zinc : Men - 7 mg/day , women – 4.9 mg/day.
Riboflavin : Men – 1.3 mg , Women – 1.1 mg

63. Folate : 400 microgram/day.
Vitamin B12 : 2.5 microgram/day.
Vitamin C : 60-100 mg/day.
VitaminA : 600-700 microgram retinol equivalents /Day.
Vitamin D : 10-15 microgram/day.
Vitamin E : 100-400 IU/day.

64. PRESSURE INJURY

66. Major changes can be scary and may lead to feelings of insecurity
and/or loss of self-worth.
 Age related changes.
 losses that occur with aging
 Chronic diseases.
 Increased dependency..
 Function impairment.
PSYCHOLOGICAL CHANGES
•

67. • Memory loss is one of the most common psychological effects of
aging.
 Remembering everyday things become more difficult.
 Memory loss affects short-term memory more than long-term.
• Absent mindedness is also a characteristic psychological effect of
aging.
 Clear, lucid thoughts become increasingly difficult.
 Older people may repeat themselves in conversation.

68. Breavement
Bereavement is a natural response to death of a loved one. It
makes a older person to crying and sorrow, anxiety and
agitation, sleep problems and eating problems.

70. EXERCISE
• Exercise is the only treatment that can prevent
or even reverse sarcopenia (age-related
muscle wasting).
• 150min/week moderate intensity aerobic
activity ( brisk walk)
• Muscle strengthening activities on 2 or more
days a week

71. PERIODIC FASTING
• Alternate-day fasting diet, the “five:two”
intermittent fasting diet, and a 48-h fast once
or twice each month.
• For example improved morbidity and
longevity were observed among Spanish home
nursing residents who underwent alternate-
day fasting

72. PHARMACOLOGICAL INTERVENTION
• Resveratrol, an agonist of SIRT1, is a
polyphenol that is found in grapes and in red
wine. The potential of resveratrol to promote
lifespan was first identified in yeast

73. PHARMACOLOGICAL INTERVENTION
contd...
• Rapamycin, an inhibitor of mTOR, was originally
discovered on Easter Island (Rapa Nui; hence its
name) as a bacterial secretion with antibiotic
properties.
• Immunosuppressant and cancer
chemotherapeutic in humans.
• Extends lifespan in all organisms tested so far,
including yeast, flies, worms, and mice.
• Limited by adverse effects related to
immunosuppression, wound healing, proteinuria,
and hypercholesterolemia,

74. PHARMACOLOGICAL INTERVENTION
contd...
• Spermidine is a physiologic polyamine that
induces autophagy-mediated lifespan extension
in yeast, flies, and worms.
• Spermidine levels decrease during the life of
virtually all organisms including humans, with the
stunning exception of centenarians.
• Oral administration of spermidine and
upregulation of bacterial polyamine production in
the gut both lead to lifespan extension in short-
lived mouse models.

75. PHARMACOLOGICAL INTERVENTION
contd...
• Metformin has other actions including inhibition
of mTOR and mitochondrial complex I and
activation of the transcription factor SKN-1/Nrf2.
• Metformin increases lifespan in different mouse
strains
• At a biochemical level, metformin
supplementation is associated with reduced
oxidative damage and inflammation and mimics
some of the gene expression changes seen with
caloric restriction.

76. HORMESIS
• The term hormesis describes the, at first sight
paradoxic, protective effects conferred by the
exposure to low doses of stressors or toxins
• Adaptive stress responses elicited by noxious
agents (chemical, thermal, or radioactive)
precondition an organism, rendering it resistant
to subsequent higher and otherwise lethal doses
of the same trigger.
• The lifelong and periodic exposure to various
stressors can inhibit or retard the aging process.

77. IMMUNIZATION
• INFLUENZA annually
• PNEUMOCOCCAL once at age of 65yrs
• SHINGLES once after age 50yrs

78. NATIONAL PROGRAMMES
• NATIONAL PROGRAMME FOR HEALTH CARE
FOR ELDERLY
• OLD AGE SOCIAL & INCOME SECURITY`
• INDIRA GANDHI NATIONAL OLD AGE PENSION
SCHEME
• PROGRAMME OF ALL INCLUSIVE CARE FOR
ELDERLY

79. NGO
• Help age india
• Age well foundation
• Age care india
• Elder home society
• Age care centre for retired personnel

80. REFERENCES
• HARRISONS PRINCIPLES OF INTERNAL
MEDICINE 18TH,19TH EDITION
• CMDT 2018
• PARKS COMMUNITY MEDICINE
• BROCKLEHARTS GERIATIC MEDICINE &
GERONTOLOGY