Physiologic Ageing Changes and Their Clinical Implications

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1 Physiologic Ageing Changes and Their Clinical Implications
รศ.นพ. ประเสริฐ อัสสันตชัย เวชศาสตร์ผู้สูงอายุ ภ.เวชศาสตร์ป้องกันฯ คณะแพทยศาสตร์ศิริราชพยาบาล

2 The world population will be older More developed countries
8 6 4 2 20 40 60 80 100+ Age Males Females 1999 Percentage of population 2050 The proportion of elderly people and particularly of very elderly people is increasing in industrialized countries. Consequently, because the incidence of hypertension and cardio- and cerebrovascular disease increases considerably with age, the prevalence and burden of these diseases is expected to rise in future years. United Nations 1999

3 ผู้ที่อายุยืนที่สุดในโลก ??

4 Special Characteristics in Geriatrics
RAMPS Reduced body reserve Atypical presentation Multiple pathology Polypharmacy Social adversity

5 Geriatric Giants -atypical presentation
Instability (Fall) Immobility Intellectual impairment Incontinence Inanition Iatrogenesis

6 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

7 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

8 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

9 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

10 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

11 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

12 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

13 Framingham – Study Blood pressure and age
BP (mmHg) 70 80 90 120 130 140 150 160 36 41 46 51 56 61 66 71 76 81 Women Men Systolic BP Diastolic BP years Age The influence of age on blood pressure levels is illustrated by data from Framingham. Although hypertension is a major risk factor for cardiovascular and cerebrovascular disease in people of all ages, blood pressure tends to rise with age and the incidence of hypertension increases markedly in older people. This increase in blood pressure with age is much greater for systolic than diastolic pressure and systolic pressure increases consistently, while diastolic pressure peaks at 50–60 years and then begins to decline. The increase in systolic blood pressure is due to progressive loss of arterial elasticity that occurs with age. In women, blood pressures are initially lower than those in men of the same age and rise more steeply with age until, at around the age of 50–60, systolic equals that of men, whereas diastolic remains slightly lower than that in male counterparts. Both raised systolic and diastolic pressures are associated with increased risk of vascular events, but the disproportionate increase in systolic and diastolic BP with age also increases the pulse pressure (systolic BP – diastolic BP), which is in itself an independent risk factor for cardiovascular complications, such as atherosclerosis, coronary artery disease, myocardial infarction and increased left ventricular mass.    Reference: Kannel WB, Gordon T. Evaluation of cardiovascular risk in the elderly: The Framingham Study. Bull NY Acad Med 1978; 54(6): Kannel et al 1978

14 Distribution of systolic pressure with age among Thai elderly. P
Distribution of systolic pressure with age among Thai elderly P. Assantachai. Comprehensive study of the Thai elderly. Mahidol Fund 2000 central north south northeast

15 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

16 Respiratory Changes in Aging
Physiologic changes Clinical correlation thinning of alveolar wall, ↓ alveolar surface area enlagement of terminal lung unit ventilation-perfusion ↓PaO2 =( x age) mismatching ↓ FEV1, FVC inadequate cough less effective ciliary action ↓ventilatory response to prolonged hypercapnia hypercapnia

17 Age Distribution of Respiratory Complications
% 80 70 60 respiratory complications 50 40 30 20 10 0-4 5-9 10-19 20-39 40-49 50-59 50-69 +70 years 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: Dr.Prasert Assantachai, M.D., Division of Preventive Medicine, Siriraj Hospital

18 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 ↓ T sick euthyroid syndrome ↑ PTH interpretation & ↓Ca ↓ vitamin D by skin ↓ Ca absorption ↑ serum homocysteine ↑ atherosclerosis

19 Changes in blood glucose levels with age
Postprandial Fasting Elahi D, et al. Eur J Clin Nutr 2000; 54: S112-S120.

20 Natural History of Type 2 Diabetes
Emerging Strategies Natural History of Type 2 Diabetes Glucose Post-prandial glucose 100 200 150 300 250 350 mg/dL Fasting glucose Relative to normal 250 Insulin resistance 200 (%) 150 100 At risk for diabetes 50 Beta-cell dysfunction Insulin level -10 -5 5 10 15 20 25 30 Years R.M. Bergenstal, International Diabetes Center

21 Hematologic Changes in Aging
Physiologic changes Clinical correlation ↓ bone marrow reserve ↓ response during stress ↓ reticulocytosis to ↑ anemia erythropoitin ↓ erythropoietin ↑ anemia production

22 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

23 Gastrointestinal Changes in Aging
Physiologic changes Clinical correlation ↓liver size and blood flow ↓drug clearance esp. phase I metabolism ↓ cytochrome P 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

24 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

25 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

26 Neuropathological Changes Characteristic of Alzheimer disease
Normal AD AP NFT AP = amyloid plaques NFT = neurofibrillary tangles Courtesy of George Grossberg, St Louis University, USA

27 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

28 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 % of SIADH >65 yr. 2-2.5 greater increase ↑tendency of ↓[Na]+ in ADH response to stress ↓ammonia production susceptibility to acidosis

29 Renal Changes in Aging ↓ 1-alpha hydroxylase ↓ active vitamin D
Physiologic changes Clinical correlation ↓ 1-alpha hydroxylase ↓ active vitamin D ↓ calcium absorption ↓ distensibility of hyporeninemic juxtaglomerular apparatus hypoaldosteronism

30 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

31 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 %/decade after age50 requirement

32 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

33 Bone Remodeling–Normal
Ca Ca During normal remodeling, bone goes through several phases: (1) a resting phase, during which lining cells protect the surface of the bone; (2) a bone resorption phase, during which osteoclasts invade and erode the surface of the bone, dissolve the bone matrix, and create a cavity on the surface of the bone; and (3) a repair phase, during which osteoblasts fill the cavity with new bone matrix (osteoid) that fully restores the surface of the bone. Up to 10% of the skeleton undergoes remodeling at any time. Osteoblast Osteoclast

34 Bone Remodeling–Osteoporotic
Ca Bone Ca When osteoporosis occurs, more bone is resorbed than restored. Osteoclast activity increases because of decreased estrogen levels. The increased activity causes the osteoclasts to dig a deeper than usual resorption pit, causing greater bone removal at a single site. This activity also occurs at a greater number of sites. When the osteoblasts lay down the new bone matrix, the resorptive cavity is not completely filled. The imbalance in bone remodeling and the increase in bone turnover eventually lead to osteoporosis. Osteoclast Osteoblast

35 Osteoporotic Bone Loss
Normal Bone Normal trabecular bone, as shown on the left, appears as a dense network of trabeculae with small spaces. Osteoporotic bone, as shown on the right in a micrograph of postmenopausal osteoporosis, reveals lost bone and minimal trabecular connections. The loss of trabecular struts results in weakened bones and leads to fractures. Dempster DW, Shane E, Horbert W, Lindsay R. A simple method for correlative light and scanning electron microscopy of human iliac crest bone biopsies: qualitative observations in normal and osteoporotic subjects. J Bone Miner Res. 1986;1:15-21. Reproduced from J Bone Miner Res. 1986;1:15-21 with permission of the American Society for Bone and Mineral Research

36 โรคกระดูกพรุนและภาวะกระดูกหัก
ลักษณะการดำเนินชีวิต การสะสมมวลกระดูกให้ได้สูงสุดในวัยหนุ่มสาว มวลกระดูกต่ำผิดปกติ หรือ โรคกระดูกพรุน ความชรา การสูญเสียมวลกระดูกมากผิดปกติ กระดูกหัก หมดประจำเดือน ภาวะหกล้มและการบาดเจ็บ โรคต่างๆ และยาที่มีผลต่อกระดูก

37 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

38 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

39 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

40 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

41 โรคเรื้อรังที่พบบ่อยในคลินิกผู้สูงอายุ
Musculoskeletal disorders Osteoarthritis, crystal-induced arthropathy Osteoporosis Atherosclerosis-related disorders Hypertension, Diabetes mellitus, Dyslipidemia Circulatory disorders : stroke, coronary heart disease Neurodegenerative disorders Parkinson’s disease Dementia Delirium Depression

42 Approach to an elderly patient
Apply “RAMPS” during daily practice Geriatric assessment Physical assessment Mental assessment Function assessment Social assessment

43 การประเมินสุขภาพผู้สูงอายุ
physical : ปัญหาเกี่ยวกับสุขภาพทางกาย, สภาพโภชนาการ, ประวัติการใช้ยา mental : สมรรถภาพสมอง social : ลักษณะทางสังคม (ผู้ดูแล สิ่งแวดล้อม เศรษฐานะ) function : ประเมินสมรรถภาพในการทำกิจวัตรต่าง ๆ

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

45 การประเมินกิจวัตรประจำวัน (ADL = Activity of Daily Living)
1. อาบน้ำ แต่งตัว/ใส่เสื้อผ้า 3. ใช้ห้องสุขา 4. ลุกนั่ง/ลุกจากที่นอน 5. อุจจาระ/ปัสสาวะรด 6. กินอาหาร 7. ใช้โทรศัพท์ 8. ใช้รถ/การเดินทาง 9. จับจ่ายซื้อของ 10. การหุงหาอาหาร 11. การทำงานบ้าน 12. หยิบยากิน 13. การใช้เงิน ทอนเงิน

46 การประเมินด้านสังคมในผู้สูงอายุ
- ผู้ดูแล (care-giver) - เศรษฐานะ - สิ่งแวดล้อม

47 หญิงอายุ 78 ปี ญาตินำส่งโรงพยาบาลด้วยอาการซึมลงมา 3 วัน พร้อมกับอาการเบื่ออาหาร ไม่ลุกเดินเหมือนปกติ ตรวจร่างกายพบ T 36.8 o C, R = 27 / min., P =108 / min. totally irregular, BP =110 / 60 mmHg. น้ำหนักตัว 38 กก. ส่วนสูง 165 ซม. mildly pale, raised JVP, systolic murmur at apex grade I, crepitation sound at both lower lungs, otherwise : unremarkable finding. ผลตรวจทางห้องปฏิบัติการ hemoglobin 11.2 gm/dl., serum Na 129 mEq/L ผู้ป่วยได้รับการวินิจฉัยว่ามีภาวะหัวใจวาย ปัจจัยใดที่ทำให้ผู้ป่วยรายนี้มีแนวโน้มที่จะเกิดภาวะหัวใจวายได้มากที่สุด ก. under-nutrition ข. hyponatremia ค. anemia ง. atrial fibrillation จ. mitral regurgitation

48 ชายอายุ 81 ปี ญาตินำส่งโรงพยาบาลด้วยอาการซึมลง ไม่พูด ร่วมกับแขนขาอ่อนแรงครึ่งซีก มา 1 สัปดาห์
ตรวจร่างกายพบ 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. หลังได้รับการรักษาในโรงพยาบาล 3 สัปดาห์ แพทย์ให้กลับบ้านได้ ภายใน 1 สัปดาห์ต่อมา ผู้ป่วยมีอาการไข้สูง ไอ หอบ ต้องกลับมารับการรักษาในโรงพยาบาลอีกครั้งหนึ่ง สาเหตุพื้นฐานที่น่าจะเป็นไปได้มากที่สุด ที่ทำให้ผู้ป่วยรายนี้เกิดภาวะแทรกซ้อนจนต้องกลับมาพักรักษาในโรงพยาบาลอีก คือ ก. ปัจจัยด้านสังคม ข. ภาวะขาดสารอาหาร ค. การเกิดโรคหลอดเลือดสมองซ้ำ ง. การสูญเสียความสามารถในการกลืนทำให้มีอาการสำลักอาหารและเกิดปอดอักเสบตามมา จ. แผลกดทับที่เป็นแหล่งเพาะเชื้อโรค