Transcript Physiologic Ageing Changes and Their Clinical Implications

Principles of Geriatrics
ประเสริฐ อัสสันตชัย
เวชศาสตร์ ผ้ ูสูงอายุ ภ.เวชศาสตร์ ป้องกันฯ
คณะแพทยศาสตร์ ศริ ิราชพยาบาล
The world population will be older
More developed countries
Age
100+
1999
Males
Females
Age
100+
80
80
60
60
40
40
20
20
0
0
8
6 4 2 0 2 4 6 8
Percentage of population
2050
Males
8
Females
6 4 2 0 2 4 6 8
Percentage of population
United Nations 1999
Special Characteristics in Geriatrics
RAMPS
Reduced body reserve
Atypical presentation
Multiple pathology
Polypharmacy
Social adversity
Geriatric Giants -atypical presentation
Instability (Fall)
Immobility
Intellectual impairment
Incontinence
Inappetite
Iatrogenesis
What is “Geriatric Medicine” ?
“….that branch of general medicine concerned
with the
 clinical (physical & mental)
 rehabilitative
 social
 preventive
aspects of illness and health in the
elderly”
British Geriatrics Society
Examples of atypical presentation
diseases
 hyperthyroidism
 hypothyroidism
 infections
 peritonitis
 hypoglycemia
 congestive heart
failure
present as
mechanism
apathy not agitated ↓ ß-receptor sense
depression, weak
sedentary life
no fever,leucocytosis ↓ interleukin I
no guarding
weak rectus M.
no adrenergic
↓ ß-receptor sense
no dyspnea,
sedentary life
confusion,
↓ function of liver & brain
mild jaundice
RUQ pain
General changes in Aging
Physiologic changes
Clinical correlation
 osteoporosis,
loss real height, body
vertebral compression mass index ?
↑fat to lean body mass ↑ distribution of fat- soluble
ratio
drugs
 ↓ muscle mass
poor indicator of serum
creatinine to glomerular
filtration
 ↓ total body water
↓distribution of
water-soluble drug
 impaired shivering
less febrile during infection
Dermatologic Changes in Aging
Physiologic changes
 ↓stratum corneum
turnover rate
 ↓Pacinian corpuscle
 ↓Meissner corpuscle
↓capillary,
inflammatory cell
↓elasticity
↓sweat gland
↓sebaceous gland
 ↓ nail growth rate
Clinical correlation
↓frequency of local agent
↓high freq. vibration
↓low freq. vibration
↓urticaria, sign of
cellulitis
sodium depletion,
senile purpura
hyperthermia
xerotic dermatitis
↑duration of treatment of
onychomycosis
Cardiovascular Changes in Aging
Physiologic changes
Clinical correlation
 ↓ maximal heart rate stroke volume dependent
= 208 – (0.95xage)
cardiac output
 ↓ heart rate response syncope when change of
to postural stress,
posture
Valsalva manouvre
 atrial fibrosis
↑ atrial fibrillation
↓ pacemaker cell in SAnode
impaired LV filling
↑ reliance on atrial systole
↔LV contract&relax
↑ hemodynamic effect from
atrial fibrillation
↓ maximal C.O.
↓ hemodynamic reserve
Comparison of heart rate between the
old and the young
Actual
heart
Sympathetic stimulation
rate
Intrinsic heart rate
Vagal tone
Resting heart rate
Age 20
Age 80
Cardiovascular Changes in Aging
Physiologic changes
Clinical correlation
↓inotropic, chronotrpic
↓response to β
response to βadrenergic sti. receptor drugs
less distensible,
↑systolic BP
↓ compliance artery
 ↑peripheral vascular
↑ hypertension
resistance
impaired autoregulation
postural hypotension
degeneration of conducting ↑ heart block,
tissue
left axis deviation
calcification of aortic valve aortic stenosis/sclerosis
Framingham – Study
Blood pressure and age
BP (mmHg)
160
150
140
Systolic BP
Women
Men
130
120
90
80
Diastolic BP
Men
Women
70
36 41 46 51 56 61 66 71 76 81 years
Age
Kannel et al 1978
Distribution of systolic pressure with age among Thai elderly
P. Assantachai. Comprehensive study of the Thai elderly. Mahidol Fund 2000
170
170
160
160
150
140
Men
150
Women
140
130
130
120
120
110
Men
Women
110
60-64
65-69
70-74
75-79
80+
central
60-64
170
170
160
160
150
Men
140
Women
120
120
110
110
70-74
75-79
80+
south
75-79
80+
north
Men
140
130
65-69
70-74
150
130
60-64
65-69
Women
60-64
65-69
70-74
75-79
80+
northeast
Respiratory Changes in Aging
Physiologic changes
Clinical correlation
↓ chest wall compliance
↑ work of breathing,
↑ diaphargm and abdominal
muscle dependency
↓respiratory m.strength ↓ maximal inspiratory &
expiratory pressure
↓ elastin in alveolar wall ↓alveolar elasticity recoil
↓ distal bronchiole diameter, ↑ closing volume
rearrangement in collagen
↑ residual volume
↓ vital capacity, tidal
volume
kyphoscoliosis, costal
cartilage calcification
Respiratory Changes in Aging
Physiologic changes
Clinical correlation
thinning of alveolar wall, ↓ alveolar surface area
enlagement of terminal lung unit
ventilation-perfusion
↓PaO2 =(100-0.32x age)
mismatching
↓ FEV1, FVC
inadequate cough
less effective ciliary action
↓ventilatory response to
prolonged hypercapnia
hypercapnia
Age Distribution of Respiratory Complications
%
80
70
60
50
40
30
20
10
0
0-4
5-9
10-19
20-39
40-49
50-59
age groups
Source: Betts FR, Douglas RG. Influenza virus. In: Mandsel GL, Douglas RG, Bennet JE,
Eds. Principles and practice of infectious diseases, Churchill Livingstone Inc. 1990: 1306-1325
Dr.Prasert Assantachai, M.D., Division of Preventive Medicine, Siriraj Hospital
50-69
+70
years
Endocrine Changes in Aging
Physiologic changes
Clinical correlation
impaired glucose tolerance ↑ DM
↑ BS 5.3 mg%/10yrs after 30 years old
↑ serum insulin
metabolic syndrome
↓ DHEA
↓ libido
↓free testosterone
↓ T3
sick euthyroid syndrome
↑ PTH
interpretation & ↓Ca
↓ vitamin D by skin
↓ Ca absorption
↑ serum homocysteine ↑ atherosclerosis
Changes in blood glucose levels with age
180.00
170.00
160.00
150.00
140.00
130.00
120.00
110.00
100.00
90.00
80.00
Postprandial
Fasting
age20 age30 age40 age50 age60 age70 age80 age90
Elahi D, et al. Eur J Clin Nutr 2000; 54: S112-S120.
Dietary therapy: special considerations
for older people with diabetes
financial difficulty
shopping difficulty due to mobility
problems
poor food preparation skills esp. widowed
men
ingrained dietary habits
difficulty following dietary instruction
because of impaired cognitive function
↓ taste
↑ frequency of constipation
Hematologic Changes in Aging
Physiologic changes
Clinical correlation
↓ bone marrow reserve
↓ response during
stress
↑ anemia
↓ reticulocytosis to
erythropoitin
↓ erythropoietin
production
↑ anemia
Gastrointestinal Changes in Aging
Physiologic changes
poor oral health
maxillary bone loss
Clinical correlation
↑ gingivitis, dental caries
poorly fitting denture,
malnutrition
↑ hiatus hernia
weakening of lower
esophageal sphincter
 ↓ parietal cell,
↓ hydrochloric acid,
atrophic gastritis
bacterial over growth,
anemia
 ↓response to gastric ↑NSAID-induced PU
mucosal injury
Gastrointestinal Changes in Aging
Physiologic changes
Clinical correlation
↓liver size and blood flow ↓drug clearance
esp. phase I metabolism
↓ cytochrome P450
prolonged half life of
oxidation
drug via liver
biotransformation
↓pancreatic mass
dyspepsia
↓effective colonic
constipation
contraction
weakening of muscular
diverticulum,
layer
diverticulosis
↓gut-associated lymphoid infection, malignancy
tissue
Neurologic Changes in Aging
Physiologic changes
Clinical correlation
 loss of neurone &
subdural hematoma after
brain weight
trivial head injury
impaired autoregulation ↓ brain blood flow
↓ dendritic connections impaired memory
retrieve
short term memory loss ↑interview time
↓ dopamine activity
↑Parkinsonism
↑ neurofibrillary tangle pathologic change of
& senile plaques
Alzheimer disease
↓ acetylcholine activity ↑amnesia
Neurologic Changes in Aging
Physiologic changes
Clinical correlation
↓ serotonin activity :↑depression
change of sleep
:unnecessary narcotic
pattern
drug
 change of
:↑sensitivity to
pharmacodynamics benzodiazepines
 slow central processing :↓ intelligence
& reaction time
Neuropathological Changes
Characteristic of Alzheimer disease
Normal
AD
AP
AP = amyloid plaques
NFT = neurofibrillary tangles
NFT
Courtesy of George Grossberg, St Louis University, USA
The Cholinergic Deficit in AD Underlies
the Clinical Symptomatology
 Cholinergic deficit
 progressive loss of
cholinergic neurones
N. basalis Meynert
 progressive decrease in
available ACh
 impairment in ADL,
behaviour and cognition
Cortex
Hippocampus
Bartus et al., 1982; Cummings and Back, 1998, Perry et al., 1978
Peripheral Nervous System Changes in Aging
Physiologic changes
 ↓ vibratory sense esp.
feet
↓ thermal sensitivity
 ↓ size of large
myelinated fiber
 ↓ two-point
discrimination test
Clinical correlation
interpretation of
neuropathy
↑ injury esp.men
↓propioceptive &
vibratory sense
impaired use of
fine instrument
Renal Changes in Aging
Physiologic changes
Clinical correlation
↓ 25%renal mass esp.cortex ↓ nephron, ↓excretion
↓ creatinine clearance
of water soluble drugs
~ 10 ml/decade
↓ medullary tonicity
poor concentrating &
diluting ability
↑basal level of ADH
75% of SIADH >65 yr.
2-2.5 greater increase
↑tendency of ↓[Na]+
in ADH response to stress
↓ammonia production
susceptibility to acidosis
Renal Changes in Aging
Physiologic changes
Clinical correlation
↓ 1-alpha hydroxylase
↓ active vitamin D
↓ calcium absorption
hyporeninemic
hypoaldosteronism
↓ distensibility of
juxtaglomerular apparatus
Age-related changes in sodiummodulating factors
↓ functioning nephron number
↓ renin-angiotensin-aldosterone
formation and effect
↓ insulin secretion
↑ atrial natriuretic peptide levels with
relatively reduced effect
↑ plasma norepinephrine levels
↓ renal dopamine
↓ kallikrein-kinin activity
Genitourinary Changes in Aging
Physiologic changes
↓ elasticity of detrusor
muscle
↓ prostatic secretion in urine
↓ Tamm-Horsefall protein
↔ refractory period for
erections for men
↓ intensity of orgasm for
men and women
Clinical correlation
urgency incontinence
↑ residual urine
↑ UTI
↓ libido
Muscle Changes in Aging
Physiologic changes
↓ muscle fiber
↓ muscle strength except
diaphragm,
leg weaker than arm
↑ fat infiltration
↑ fatigability
↓ innervation (motor unit)
↓ basal metabolic rate
4%/decade after age50
Clinical correlation
sarcopenia
intact diaphragmatic
activity
tend to fall
↑ fat to lean body
mass ratio
↓ muscle endurance
poor fine movement
↓nutritional
requirement
Bone & Joint Changes in Aging
Physiologic changes
↓ rate of fracture healing
↓ bone mass :cortical bone
0.6%,trabecular 0.7%/yr.
proteoglycans
glycosaminoglycans
Clinical correlation
longer duration of
follow up
↑ osteoporosis
↑ fracture
disordered cartilage
matrix
↑ osteoarthritis
Bone Remodeling–Normal
Bone
Ca
Osteoclast
Ca
Osteoblast
Bone Remodeling–Osteoporotic
Ca
Osteoclast
Bone
Ca
Osteoblast
Osteoporotic Bone Loss
Normal Bone
Reproduced from J Bone Miner Res. 1986;1:15-21
with permission of the American Society for Bone and Mineral Research
Immune System Changes in Aging
Physiologic changes
↓ cell-mediated immunity
macrophage function
↑autoantibodies
Clinical correlation
↑ TB, leprosy
↑ temporal arteritis,
↑ bullous pemphigoid
lower affinity Ab production ↑ nonresponders to
vaccine
↓ delayed-type
poor prognosis in
hypersensitivity
anergy case
↓B cell production by
serious infection in
bone marrow
malnutrition
Changes of Vision in Aging
Physiologic changes
 impaired dark adaptation
 denature of lens protein
Clinical correlation
fall at night
cataract, glaring
effect
 presbyopia
bifocal lens
↓dynamic acuity
↓seeing moving target
↓contrast sensitivity
↓ color discrimination
↓lacrimation
dry eye
↓aqueous humor reabsorption glaucoma
Changes of Audition in Aging
Physiologic changes
Clinical correlation
↓ hair cells of organ of Corti presbycusis, high
tone hearing loss
↓discriminating source of
↑ handicap
sound
↓discriminating of verbal
poor compliance to
sound from noise
hearing aids
↑ keratin wax content
ear wax impaction
Changes of Other Sensory Functions in Aging
Physiologic changes
↓ smell ~ 50%
↓thirst drive
↓ gustatory sense
↑threshold vestibular
responses
Clinical correlation
↓ appetite
poor fluid intake
dehydration
spicy, salty food
poor body balance
Approach to an elderly patient
Physical assessment
Mental assessment
Function assessment
Social assessment
Thank you for your excellent attention