Physiologic Ageing Changes and Their Clinical Implications

1
Physiologic Ageing Changes and Their Clinical
Implications

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• ??????????????????? ?.?????????????????
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The world population will be olderMore developed
countries
United Nations 1999
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Special Characteristics in Geriatrics

• RAMPS
• Reduced body reserve
• Atypical presentation
• Multiple pathology
• Polypharmacy
• Social adversity

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Geriatric Giants -atypical presentation

• Instability (Fall)
• Immobility
• Intellectual impairment
• Incontinence
• Inanition
• Iatrogenesis

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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
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Examples of atypical presentation

• diseases present as mechanism
• hyperthyroidism apathy not agitated ? ß-receptor
  sense
• hypothyroidism depression, weak sedentary life
• infections no fever,leucocytosis ? interleukin I
• peritonitis no guarding weak rectus M.
• hypoglycemia no adrenergic ? ß-receptor sense
• congestive heart no dyspnea, sedentary life
• failure confusion, ? function of liver
  brain mild jaundice
• RUQ pain

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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

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Dermatologic Changes in Aging

• Physiologic changes Clinical correlation
• ?stratum corneum ?frequency of local agent
• turnover rate
• ?Pacinian corpuscle ?high freq. vibration
• ?Meissner corpuscle ?low freq. vibration
• ?capillary, ?urticaria, sign of
  inflammatory cell cellulitis
• ?elasticity sodium depletion, senile
  purpura
• ?sweat gland hyperthermia
• ?sebaceous gland xerotic dermatitis
• ? nail growth rate ?duration of treatment
  of onychomycosis

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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
• ? hemodynamic effect from atrial
  fibrillation
• ? maximal C.O. ? hemodynamic reserve

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Comparison of heart rate between the old and the
young
Actual heart rate
Sympathetic stimulation
Intrinsic heart rate
Vagal tone
Resting heart rate
Age 20
Age 80
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Cardiovascular Changes in Aging

• Physiologic changes Clinical correlation
• ?inotropic, chronotrpic ?response to ß
• response to ßadrenergic 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

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Framingham Study Blood pressure and age
Kannel et al 1978
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Distribution of systolic pressure with age among
Thai elderly P. Assantachai. Comprehensive study
of the Thai elderly. Mahidol Fund 2000
central
north
south
northeast
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Respiratory Changes in Aging

• Physiologic changes Clinical correlation
• kyphoscoliosis, costal ? chest wall
  compliance cartilage calcification ? 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

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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

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Age Distribution of Respiratory Complications


80
70
60
50
respiratory complications
40
30
20
10
0
years
0-4
5-9
10-19
20-39
40-49
50-59
50-69
70
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
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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

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Changes in blood glucose levels with age
Postprandial
Fasting
Elahi D, et al. Eur J Clin Nutr 2000 54
S112-S120.
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Natural History of Type 2 Diabetes
Emerging Strategies
Glucose
Post-prandial glucose
Fasting glucose
mg/dL
Relative to normal
Insulin resistance
250
200
()
150
100
At risk for diabetes
Insulin level
50
Beta-cell dysfunction
0
25
30
0
5
10
15
20
-10
-5
Years
R.M. Bergenstal, International Diabetes Center
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Hematologic Changes in Aging

• Physiologic changes Clinical correlation
• ? bone marrow reserve ? response during
  stress
• ? reticulocytosis to ? anemia
• erythropoitin
• ? erythropoietin ? anemia
• production

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Gastrointestinal Changes in Aging

• Physiologic changes Clinical correlation
• poor oral health ? gingivitis, dental caries
• maxillary bone loss poorly fitting denture,
  malnutrition
• weakening of lower ? hiatus hernia
• esophageal sphincter
• ? parietal cell, ? hydrochloric acid,
  atrophic gastritis bacterial over growth,
  anemia
• ?response to gastric ?NSAID-induced PU
• mucosal injury

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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

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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

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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

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Neuropathological ChangesCharacteristic of
Alzheimer disease
Normal
AD
AP
NFT
AP amyloid plaques NFT neurofibrillary tangles
Courtesy of George Grossberg, St Louis
University, USA
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Peripheral Nervous System Changes in Aging

• Physiologic changes Clinical
  correlation
• ? vibratory sense esp. interpretation of
• feet neuropathy
• ? thermal sensitivity ? injury esp.men
• ? size of large ?propioceptive
  myelinated fiber vibratory sense
• ? two-point impaired use of
• discrimination test fine instrument

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Renal Changes in Aging

• Physiologic changes Clinical correlation
• ? 25renal 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 gt65 yr.
• 2-2.5 greater increase ?tendency of ?Na
• in ADH response to stress
• ?ammonia production susceptibility to
  acidosis

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Renal Changes in Aging

• Physiologic changes Clinical correlation
• ? 1-alpha hydroxylase ? active vitamin D
• ? calcium absorption
• ? distensibility of hyporeninemic
• juxtaglomerular apparatus hypoaldosteronism

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Genitourinary Changes in Aging

• Physiologic changes Clinical correlation
• ? elasticity of detrusor urgency incontinence
• muscle ? residual urine
• ? prostatic secretion in urine
• ? Tamm-Horsefall protein ? UTI
• ? refractory period for ? libido
• erections for men
• ? intensity of orgasm for
• men and women

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Muscle Changes in Aging

• Physiologic changes Clinical correlation
• ? muscle fiber sarcopenia
• ? muscle strength except intact diaphragmatic
• diaphragm, activity
• leg weaker than arm tend to fall
• ? fat infiltration ? fat to lean body
  mass ratio
• ? fatigability ? muscle endurance
• ? innervation (motor unit) poor fine movement
• ? basal metabolic rate ?nutritional
  4/decade after age50 requirement

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Bone Joint Changes in Aging

• Physiologic changes Clinical correlation
• ? rate of fracture healing longer duration
  of follow up
• ? bone mass cortical bone ? osteoporosis
• 0.6,trabecular 0.7/yr. ? fracture
• proteoglycans disordered cartilage
  glycosaminoglycans matrix
• ? osteoarthritis

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Bone RemodelingNormal
Bone
Ca
Ca
Osteoblast
Osteoclast
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Bone RemodelingOsteoporotic
Bone
Ca
Ca
Osteoblast
Osteoclast
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Osteoporotic Bone Loss
Normal Bone
Reproduced from J Bone Miner Res.
1986115-21 with permission of the American
Society for Bone and Mineral Research
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Immune System Changes in Aging

• Physiologic changes Clinical correlation
• ? cell-mediated immunity ? TB, leprosy
• macrophage function
• ?autoantibodies ? 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

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Changes of Vision in Aging

• Physiologic changes Clinical correlation
• impaired dark adaptation fall at night
• denature of lens protein cataract, glaring
  effect
• presbyopia bifocal lens
• ?dynamic acuity ?seeing moving target
• ?contrast sensitivity ? color discrimination
• ?lacrimation dry eye
• ?aqueous humor reabsorption glaucoma

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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

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Changes of Other Sensory Functions in Aging

• Physiologic changes Clinical correlation
• ? smell 50 ? appetite
• ?thirst drive poor fluid intake
• dehydration
• ? gustatory sense spicy, salty food
• ?threshold vestibular poor body balance
• responses

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• Musculoskeletal disorders
• Osteoarthritis, crystal-induced arthropathy
• Osteoporosis
• Atherosclerosis-related disorders
• Hypertension, Diabetes mellitus, Dyslipidemia
• Circulatory disorders stroke, coronary heart
  disease
• Neurodegenerative disorders
• Parkinsons disease
• Dementia
• Delirium
• Depression

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Approach to an elderly patient

• Apply RAMPS during daily practice
• Geriatric assessment
• Physical assessment
• Mental assessment
• Function assessment
• Social assessment

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• mental ????????????
• social ?????????????? (??????? ???????????
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• function ????????????????????????????????? ?

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• Thai mental state examination (TMSE)
• Chula mental test (CMT)
• Mini-mental state examination
• (MMSE-THAI)

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  ????????????? T 36.8 o C, R 27 / min., P 108
  / min. totally irregular, BP 110 / 60 mmHg.
  ?????????? 38 ??. ??????? 165 ??. mildly pale,
  raised JVP, systolic murmur at apex grade I,
  crepitation sound at both lower lungs, otherwise
  unremarkable finding. ???????????????????????
  hemoglobin 11.2 gm/dl., serum Na 129 mEq/L
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• ?. under-nutrition
• ?. hyponatremia
• ?. anemia
• ?. atrial fibrillation
• ?. mitral regurgitation

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• ????????????? T 37.8 o C, R 28 / min., P 110 /
  min., BP 100 / 50 mmHg. hyposthenic built,
  unkempt, partially responded to external stimuli,
  Glasgow Coma Scale E2,V2, M4, moderately pale,
  flat JVP, dry lip and tongue, fine crepitation at
  both lower lungs, pressure ulcer grade III at
  presacral area (foul smell) and grade I at left
  pinna, left hemiparesis, Babinski sign present
  at left side, otherwise unremarkable finding.
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