AGING & HEALTH

Widayanti.dr., M.Kes
O Many chronic diseases increase in prevalence
with age
O Older persons usually have multiple chronic
diseases
O Functional problems that pose difficulties or
require help in performing basic activities of
daily living (ADLs) increase with age and are
more common among women than men
O Rates of cognitive impairments， such as
memory problems， also increase with
aging
O Health care expenditures increase with age,
increase more with disability & are highest
in the last year of life
O New medical technologies and expensive
medications are greater influences on
health care costs
 SYSTEMIC EFFECTS OF AGING
Systemic consequences of aging can be clustered
into 4 main domains or processes:
(1) body composition
(2) balance between energy availability & energy
demand
(3) signaling networks that maintain homeostasis
(4) neurodegeneration.
 Body Composition
O Over the life span, body weight tends to increase
through childhood, puberty & adulthood until late
middle age
O Weight tends to decline in men between ages 65
and 70 years and in women somewhat later
O Lean body mass, composed predominantly of
muscle and visceral organs, decreases steadily
after the third decade
O Fat mass tends to increase in middle age and then
declines in late life
O Waist circumference continues to increase
across the life span, a pattern suggesting that
visceral fat, which is responsible for most of the
pathologic consequences of obesity, continues
to accumulate
O With age, fibroconnective tissue tends to
increase in many organ systems
O In combination, the loss of muscle mass and
quality result in reduced muscle strength, which
ultimately affects functional capacity & mobility
O Progressive demineralization and architectural
modification occur in bone, resulting in a
decline of bone strength
O Loss of bone strength increases the risk of
fracture
O Women ,compared with men, tend to lose bone
mass at a younger age and more quickly reach
the threshold of low bone strength that
increases fracture risk
O AII of these changes in body composition
can be attributed to disruptions in the links
between synthesis, degradation and repair
that normally serve to remodel tissues.
O Such changes in body composition are
influenced not only by aging and illness but
also by lifestyle factors such as physical
activity and diet
 Balance Between Energy
Availability & Energy Demand
O The storage of ATP is only enough for 6 sec; therefore,
ATP is constantly resynthesized by aerobic/anaerobic
glycolysis
O Fitness. maximal energy that can be produced by an
organism over extended periods, is estimated
indirectly from peak oxygen consumption (VO2 max)
O VO2 declines progressively with aging and the rate of
declìne is accelerated in persons who are sedentary
& in those affected by chronic diseases
O BMR declines with aging parallel with declining in the
highly metabolically active tissues that make up lean
body mass
O Older persons with poor health status &
morbidity have a higher BMR than healthier
individuals of the same age and sex
O A high BMR is a risk factor for mortality and
may contribute to the weight loss that often
accompanies severe illness
O Sick older people may consume all their
available energy performing the most basic
ADLs & consequent fatigue and restriction
may lead to a sedentary life
O Energy status can be assessed clinically by
simply asking patients about their perceived
level of fatigue during daily activities such as
walking or dressing.
O Energy capacity can be assessed more
precisely by exercise tolerance during a
walking test or a treadmill test coupled with
spirometry
 Signaling networks that maintain
homeostasis
O The main signaling pathways that control
homeostasis involve hormones, inflammatorγ
mediators and antioxidants; all are profoundly
affected by aging
O Sex hormone levels decrease with age
O Most aging individuals, even those who remain
healthy and fully functional, tend to develop a mild
proinflammatory state characterized by high levels
of proinflammatory markers, including interleukin 6
(1L-6) and C-reactive protein (CRP)
O Aging is also thought to be associated with
increased oxidative stress damage, either
because the production of ROS increases or
because antioxidant buffers are less
effective
 Neurodegeneration
O Some studies in humans suggest that
neurogenesis in the hippocampus continues at
low levels throughout life
O Brain atrophy occurs with aging after the age of
60 years
O Atrophy proceeds at varying rates in different
parts of the brain
O Age-associated brain atrophy may contribute to
age-related declines in cognitive and motor
function
O In mild cognitive impairment, atrophy has been
found mostly in the prefrontal cortex and
hippocampus
O Functional imaging studies have shown that
some older people have diminished coordination
between the brain regions responsible for
higher-order cognitive functions
O Amyloid plaques and neurofibrillary tangles have
been found at autopsy in many older individuals
who had normal cognition
O Cortical and subcortical changes are reflected in
the high prevalence of slow and unstable gait,
poor balance & slow reaction times
O These movement changes can be elicited more
overtly with "dual tasks" in which a cognitive and
a motor task are performed simultaneously
O The spinal cord also experiences changes after
the age of 60 years, including reduced numbers
of motor neurons and damage to myelin
O The motor neurons that survive compensate by
increased branching complexity
O As motor units become larger, they decline in
number at a rate of 1 % per year, starting after
the third decade
O These larger motor units contribute to
reductions in fine-motor control and manual
dexterity
Systemic Changes Coexisting with and
Affecting One Another
O Body composition interacts with energy balance & signaling
O Higher lean body mass increases energy consumption and
improves insulin sensitivity and carbohydrate metabolism.
O Higher fat mass, especially visceral fat mass, is the culprit in
the metabolic syndrome and is associated with low testosterone
levels, high sex hormone-binding globulin level & increased
levels of proinflammatory markers such as CRP and IL-6
O Altered signaling can affect neurodegeneration; insulin
resistance and adipokines such as leptin & adiponectin are
associated with declines in cognitive function
O Combined with loss of motor neurons and dysfunction of the
motor unit, a state of inflammation & reduced levels of
testosterone and IGF - l have been linked to accelerated decline
of muscle mass & strength
O The hypothalamus normally functions as a
central regulator of metabolism and energy
use and coordinates physiologic responses
through hormonal signaling
O The central nervous system (CNS) also
controls adaptive sympathetic /
parasympathetic activity, so that age-related
CNS degeneration may have implications for
autonomic function
 Frailty
O Frailty has been described as a physiologic
syndrome that is characterized by decreased
reserve and diminished resistance to
stressors,that results from cumulative
decline across multiple physiologic system,
and that causes vulnerability to adverse
outcomes and a high risk of death
O Characterized by weight loss, fatigue,
impaired grip strength, diminished physical
activity and slow gait (Frailty Index)
Four main consequences of frailty are
important for clinical practice:
( 1 ) ineffective or incomplete homeostatic
response to stress
(2) multiple coexisting diseases (multi- or
comorbidity) and polypharmacy
(3) Physical disability
(4) Geriatric syndromes
O Older persons have a reduced ability to
tolerate infections, less able to build a
dynamic inflammatory response to
vaccination or infectious exposure
O Infections are more likely to become severe
and systemic and to resolve more slowly
O Drug treatment planning is made more
complex because comorbid diseases
increases with age
 Geriatric Syndromes
O "multifactorial health conditions that occur when the
accumulated effects of impairments in multiple
systems render an older person vulnerable to
situational challenges“
O Includes incontinence, delirium,falls, pressure ulcers,
sleep disorders, problems with eating or feeding, pain
& depressed mood
O A proinflammatory state and a lack of estrogen
signaling cause bladder muscle loss and detrusor
underactivity, while a chronic urinary tract infection
may cause detrusor hyperactivity; all of these factors
may contribute to urinary incontinence
 Delirium
O Delirium is an acute disorder of disturbed attention
that fluctuates with time.
O It affects 15-55% of hospitalized older patients.
O Delirium may be associated with a substantially
increased risk for dementia
O The clinical presentation of delirium are
( 1 ) a rapid decline in the level of consciousness, with
difficulty focusing, shifting, or sustaining
attention
(2) cognitive change (rumbling incoherent speech,
memory gaps, disorientation, hallucinations)
 Persistent Pain
O Persistent pain results in restricted activity,
depression, sleep disorders, and social
isolation and medication
O The most common causes of persistent
O pain are musculoskeletal problems, but
neuropathic pain and ischemic pain occur
frequently
 Urinary Incontinence
The three main clinical forms of urinary incontinence are as follows:
( 1 ) Stress incontinence is the failure of the sphincteric mechanism to
remain closed when there is a sudden increase in intraabdominal
pressure, such as a cough or sneeze. In women this condition is due
to insufficient strength of the pelvic floor muscles， while in men it is
almost exclusive1y secondary to prostate surgery
(2) Urge incontinence is the loss of urine accompanied by a sudden
sensation of need to urinate and inability to control it and is due to
detrusor muscle overactivity (lack of inhibition) caused by loss of
neurologic control or local irritation
(3) Overflow incontinence is characterized by urinary dribbling, either
constantly or for some period after urination. This condition is due to
impaired detrusor contractility (due usually to denervation) or bladder
outlet obstruction (prostate hypertrophy in men & cystocele in women)
O The first line of treatment is bladder training associated with pelvic
muscle exercise (Kegel exercises)
 Screening Tests
O Osteoporosis: Bone mineral density (BMD) should be measured at least
once after the age of 65 years. lnterval between evaluations should be
2-3 years.
O Hypertension: Blood pressure should be determined at least once a year
or more often in patients with hypertension.
O Diabetes: Serum glucose and hemoglobin A1c should be checked every
3 years or more often in patients who are obese or hypertensive
O Lipid disorders: A lipid panel should be done every years or more often in
patients with diabetes or any cardiovascular disease
O Colorectal cancer: A fecal occult blood test and a sigmoidoscopy or
colonoscopy should be done on a regular schedule up to the age of 75
years
O Breast cancer: Mammography should be done every 2 years between
the ages of 50 and 74 years.
O Cervical smear: A Pap smear should be done every 3 years up to the age
of 65 years
Preventive Interventions
O Influenza: Immunize annually
O Shingles: Administer herpes zoster vaccine once
after the age of 50 years.
O Pneumonia: Administer pneumococcal vaccine
once at the age of 65 years.
O Myocardial infarction: Prescribe daily aspirin for
patients with prevalent cardiovascular disease
or with a poor cardiovascular risk profile.
O Osteoporosis: Prescribe calcium at 1200 mg
daily and vitamin D at >800 IU daily
 Exercise
O Physical activity has clear benefits in older adults,
improving physical function, muscle strength, mood,
sleep and metabolic risk profile
O Some studies suggest that exercise can improve
cognition and prevent dementia
O The Centers for Disease Control and Prevention
recommends that older persons should spend at
least 1 50 min per week in moderate-intensity
aerobic activity (e.g. brisk walking) and should
engage in muscle strengthening activities that work
all major muscle groups (legs, hips,back, abdomen,
chest, shoulders, and arms) at least 2 days a week.
 Nutrition
O Encourage the consumption of fruits and vegetables;
they are rich in micronutrients, mineral, and fibers
O Fluid intake should be at least 1 000 mL daily
O Encourage the use of fat-free and low-fat dairy products
O Limit consumption of foods with high caloric density,
high sugar content, and high salt content.
O Limit the intake of foods with a high content of
saturated fatty acids and cholesterol.
O Introduce vitamin D-fortified foods and/or vitamin D
supplements into the diet.
O The diet includes adequate food-related intake of
magnesium, vitamin A, and vitamin B 1 2