EFFECT OF AGING ON

FUNCTION OF ORGANS
(GERIATRIC PROBLEM)

Wasilah Rochmah
Geriatric Sub-Division, Department of Internal Medicine
School of Medicine, Gadjah Mada University
Yogyakarta

OLD
AGE

The last period of life

Makes geriatrics demands
on medical services
30% of consultation to
general practitioner
40% OF HOSPITAL BEDS

(2000 )

2025 ?

Guatemala
Singapore
Mexico
Philippine
Indonesia
Brazil
India
China
Hongkong
Bangladesh
Canada
Australia
Poland
Japan
Israel
United States
New Zealand
France
Bulgaria
Luxemborg
Hungary
Italy
Belgium
Greece
Uruguay
Denmark
Germany
Austria
Noorway
United Kingdom
Sweden

67
65
56
51
51
49
48
47
38
38
36
36
23
21

136
125
122
121
116
105
99

264
236
219
201

357
348
324
310
301
292

PERCENT INCREASE
ELDERLY POPULATION

1985-2025

LIFE CYCLE

Adult

20

Adolescence

12

30

40
50

Child

5
Birth

65

Old

Death

WHAT IS
AGING?

AGING is a process that convert healthy

adults into frail ones, with diminished
reserve in most physiologycal systems
and exponentially increasing vulnerability
to most diseases and to death

INTERNAL FACTORS
GENETIC
BIOLOGIC

AGING PROCESS

AN ELDERLY PERSON
with
DIMINISHED RESERVE
in most
PHYSIOLOGICAL
SYSTEM

EKSTERNAL FACTORS

ENVIRONMENT LIFE STYLE

SOCIO-CULTURAL
ECONOMIC
(Aswin, 2002 modified Miller, 1994; Boedi-Darmojo, 1994)

O
S

&

T
L
U
C

SO
C

&

EC
O

NO

AGING
ED

U
C

AT
IO
N

FU

O
I
T
C
N

(Troll, 1982)

THEORIES OF AGING
FREE RADICAL (Harman)
GLYCOSYLATION (Monnier)
DNA REPAIR RATE (Hart & Setlow)
TELOMERE SHORTENING
mtDNA MUTATION
(15 - 32)

FREE RADICAL THEORY

(Harman, 1956)
OXIDATIVE
METHABOLISM

MAIN PRODUCT

ADVERSE PRODUCT
(FREE RADICAL/ OXIDANT)
+ (DNA, PROT, LIPID)
DISFUNGSIONAL MOL.

ACCUMULATION
(age-related)

CELL DISFUNCTION
(15 - 19)

DNA REPAIR RATE THEORY

(Hart & Setlow, 1974)
DNA REPAIR RATE DIFFERENCES AMONG SPESIES
SPESIES WITH HIGH MLP*
DNA REPAIR RATE

FIBROBLAST CULTURE
UV

DNA DAMAGE

(* MLP: Maximum Lifespan Potential)

GLYCOSILATION THEORY
(Monnier, 1990)
PROTEIN
GLYCOSILATION
NON-ENZ.

GLYCOSILPROT

DYSFUNCTION

Accumulation (age related)

CR (Calorie restriction)

LIFE EXPECTANCY

TELOMERE SHORTENING THEORY

(Hastle et al, 1990)
PROPORSIONAL TELOMERE SHORTENINGRELATED AGE
CHROMOSOMAL TELOMERE FETAL
SOMATIC CELL ARE LONGER THAN IN ADULT
TELOMERE SHORTENING - RELATED STEP
OF FIBROBLAST CULTURE
(Exception: cancer cells)

MITOCHONDRIAL DNA (mtDNA) MUTATION

THEORY
mtDNA MUTATION

MITOCHONDRIAL
DISFUNCTION

FREE RADICAL
PRODUCTION RATE

mtDNA MUTATION RATE

FREE RADICAL

DEGENERATION

AGE - RELATED

CHANGES IN BODY COMPOSITION

with AGING
25 YEARS OLD

70 YEARS OLD

14%
30%

6%

53%
19%

61%

5%
12%
SOLID CELLS
BONE MINERAL
FAT
H2O

(Merriman, 1989)

AGING OF THE BRAIN AND NERVOUS SYSTEM

Loss of cells
Shrinking of gyri
Widening of the sulci
Reduction of the blood suply

Slower reflex responses

Sensory deficits
Slower autonomic responses
Slow thinking and memory changes
Loss fibration sense

PHYSIOLOGYCAL CHANGES OF THE

CARDIOVASCULAR SYSTEM IN THE ELDERLY

Anatomycal
changes

Hemo-dynamic

Neuro-endocrinological
changes
changes

inversely

Stroke volume
Heart rate
Cardiac output

Arterial stiffness & Systemic

vascular resistance

HYPERTENSION

(Wong & Wong, 2005)

AGING IN THE RESPIRATORY SYSTEM

Chest wall
become stiffer
Scoliosis

HYPERVENTILATION

VC 75% left
RV by 50%
FEV1 by 25ml/years
from 25 years old

Changes in p02 alv/arterial

Biochemical changes in old age

.
Biochemical

Young adult

Elderly

Albumin
Globulin
Urea
Creatinin
Potassium
Urate (men)
Calcium (women)
Phosphat (men)
Phosphat (women)

37.00 51.00 g/l

19.00 23.00 g/l
3.20 7.20 mmol/l
62.00 123.00 umol/l
3.60 4.70 mmol/l
0.24 0.46 mmol/l
2.18 2.55 mmol/l
0.79 1.40 mmol/l
0.82 1.37 mmol/l

33.00 49.00 g/l

20.00 41.00 g/l
3.90 9.90 mmol/l
52.00 159.00 umol/l
3.60 5.20 mmol/l
0.19 0.31 mmol/l
2.18 2.68 mmol/l
0.66 1.27 mmol/l
0.94 1.56 mmol/l

PROTEIN BINDING DRUG

Available
drug
Protein
bound
drug

More protein available

Less protein available

Less active drug available

More active drug available

AGING IS CHARACTERIZED by
A failure to maintain homeostasis under condition
of physiological stress
the failure which is associated with a decrease in
viability and an increase vulnerability of the
individual
Three Important facts about biological aging
1. UNIVERSAL
2. DETERIORATIVE
3. DOES NOT CAUSE BREAKDOWN

PHYSICAL CAPACITY
100%

exercise

50%

?
expected

Chronic

acute
0

10

20

30

40

60

age

(Brocklehurst & Allen, 1987)

PSYCHOL.,
PSYCHOL.,
SOC-CULT.,
SOC-CULT.,
ECONOMIC
ECONOMIC

ENVIRONM.,
ENVIRONM.,
LIFE
LIFE STYLE,
STYLE,
HABITS
HABITS
DISEASES
DISEASES

PHYSICAL
PERFORM.

DRUGS

ASSOCIATION

FOOD
SUPLEMENT
EXERCISE

QUALITY
of LIFE

HEALTHCARE
INSTRUMENTS

GERIATRIC PROBLEMS
1. Immobility
2. Instability
3. Intelectual impairment
4. Impairment of vision & hearing
5. Insomnia
6. Isolation (depression)
7. Immune deficiency
8. Infection
9. Irritable colon
10. Inanition (malnutrition)
11. Incontinence
12. Impotence
13. Iatrogenesis
14. Impecunity

Health Promotion &

omprehensive Geriatric Assesment

of the elderly
Wasilah Rochmah

Geriatric Sub-Division, Department of Internal Medicine

School of Medicine, Gadjah Mada University
Yogyakarta

The concept of health status in the Elderly

WHO defined:
HEALTH IN THE ELDERLY AS
A STATE OF COMPLETE PHYSICAL,
PSYCHOLOGICAL and SOCIAL WELL BEING ,
and
NOT MERELY THE ABSENCE OF DISEASE and
INFIRMITY
( cit. Cuccione, 2000)

Anamnese
Physical Examinations
Laboratories
Supporting Examinations

DIAGNOSES
DISEASES
Anatomy/Histology
Fisiology
Pathology

DIAGNOSES DO NOT TELL THE WHOLE STORY IN GERIATRIC

COMPREHENSIVE GERIATRIC ASSESSMENT (CGA)
is needed

why CGA is needed ?

DISEASE or PATHOLOGY

DIAGNOSES

IMPAIRMENTS

DISABILITY (function
limitations)
HANDICAPS

COMPREHENSIVE GERIATRIC ASSESSMENT

A MULTIDEMENTIONAL ANALYSIS TO MEASURE CAPABILITIES

OF MEDICAL, FUCNTIONAL, PSYCHOLOGICAL, and
SOCIAL INFORMATION about
THE ELDERLY PERSON/PATIENT

MULTIDISIPLINARY TEAM
In INTERDISIPLINARY METHOD
DIAGNOSIS
IMPAIRMENT
DISABILITY
HANDICAP

ANAMNESIS
MEDICAL HISTORY :
Current Problems
Medication Use
Nutritional State
Geriatric Syndromes
Health Promotion

IMPAIRMENT

BASIC ACTIVITY :
ACTIVITIES OF DAILY LIVING
(ADL)
INSTRUMENTAL ACTIVITIES
OF DAILY
LIVING (IADL)

DISABILITY

HANDICAPS

NAGIS MODEL OF HEALTH STATUS

DISEASE or PATHOLOGY
IMPAIRMENTS

LOSES
WELL- BEING

FUNCTION LIMITATIONS
DISABILITIES/HANDICAPS
QUALITY of LIFE

(Cuccione, 2000)

MULTIDISIPLINARY TEAM
in INTERDISIPLINARY METHODE

NUTRITIONIST

NURSE

MEDICAL REHABILITATION

PSYCHOLOGIST

SOCIAL WORKER

X
P

PHYCISIAN

S
T
S

OTHER DISIPLINES

DEVELOPING :
DIAGNOSES
RESULT OF CGA

MANAGEMENT
THERAPEUTIC PLAN

HEALTH PROMOTION and

PREVENTION in THE ELDERLY
WHAT?
WHY?
WHEN?
HOW?

PREVENTION OF :
AVOIDABLE DECLINE

HEALTH PROMOTION

FRAGILITY
DEPENDENCE
Buchner & Wagner
PREVENTION OF
IMPAIRMENTS
DISABILITIES
HANDICAPS
(WHO Int. Class.)

(Cuccione,
2000)

Preventing Functional Loss as a Conceptual Loss

Classification
Level
Planes of
Experience

Disease
(or injuries
or congenital

Impairment

Disability

Exteriorized

Objectified

Hand
Socialized

General Progression of the Consequences of Diseases

Example

Hypertension

Stroke

Disarthria
Hemipareses
isolation,
Depression
mobility and
independence
handicaps

SOURCE: From WHOs International Classification of Impairment, Disabilites, and Hand

Adapted from The Second fifty years. Washington, DC, National Academy Press, 1990.

Conceptual model of risk factors for frailty

At point 1:

At point 2:

At point 3:

Risk factors for

accelerated
chronic loss of
physiological
capacity , e.g.:
- disease
- inactivity

Risk factors for

acute/subacute
loss of
physiological
capacity, e.g.:
- influenza
- Hip fracture

Risk factors for blocked

recovery from
physiological loss, e.g.:
- depressive ilness
- inactivating drugs
- fear of falling
- malnutrition
- misbelief that rast
is healthful

Physiologic
Capacity

Level of
physiologic capacity
associated with
dificulty in recover

time

(cit. Mourey, 1994)

GENERAL PRINCIPLE PREVENTION IN MEDICINE

PRIMARY:
activities that reduce the likelihood that disease or
functional impairment will develop
SECONDARY:
the early detection and treatment of disease
in order to forestall its consequences

TERTIARY:
the attempt to slow the progression of establ
disease or to reduce resulting disability

DISEASE RELATED AGING PROCESS

NUTRITION

ANEMIA
ELECTROLYTE DISTURBANCES
BODY FLUID DISTURBANCES

ENDOCRINE/METABOLISM

OBESE
GLUCOSE INTOLERANCE/DM
HYPO/HYPER THYROID

CARDIOVASCULAR SYSTEM

ISOLATED SYSTOLIC HYPERTENSION

ARTERIOSCLEROTIC HEART DISEASE
HEART FAILURE

MUSCULOSCELETAL SYSTEM

POLIMYALGIA/ARTHRALGIA
OSTEOARTRITIS
OSTEOPOROSIS

NERVOUS SYSTEM

DEMENTIA
PARKINSON DISEASE
STROKE

The Methodology of Geriatric Medicin

Ascertainment
Prevention
Supervision

HEALTH

ILLNESS

Assessment
Diagnosis
Therapy
Follow up

PLACEMENT

Housing
Hostel
Hospital

The Various Levels of Organization at whi

Ageing Studies can be Carried Out
LEVELS OF RESEARCH
Races
Population
Organism
Organs
Tissues
Cells
Subcellular Organelles
Metabolic Pathways
Enzymes
Molecular Structures
Atomic Reactions

RELATED DISCIPLINES
Economics
Sociology
Demography
Psychology
Physiology
Anatomy
Histology
Cytology
Biochemistry
Molecular Biology
Organic Chemistry

Thank you
for your
attention