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Download Physiologic Ageing Changes and Their Clinical Implications
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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
