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Elderly (Aging)

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Nearly 500 million adults, nearly 7% of with world’s population, is over the age of 65 years.

 Age is the leading predictive factor for most chronic diseases.

Age is the major risk factor for the geriatric syndromes including: frailty and immmobility, decreased physical resilience, delayed or incomplete recovery from stress stressors such as surgery, hip fracture, and pneumonia.

There are more than 4 million major operations performed annually in United States on individuals age 65 years and older.

Aging is a process of a decline in physical functioning and muscular strength in both men and women.

The decline is associated with structural changes such as lowered muscle mass and reduce strength, balance, coordination, flexibility that contribute to increased disability, frailty, and falls.

Addressing the needs of older individuals requires inclusion of frailty, multimorbidity, depression, quality-of-life, and cognition.

Healthy aging is described as the process of developing and maintaining the functional ability that enables well-being in older age, emphasizing benefits of maintaining healthy behaviors through life, by engaging in physical activity, maintaining adequate nutrition, especially in old age.

In the elderly an accumulation of fat mass occurs simultaneously with reduced muscle mass and strength leading to metabolic dysregulation, resulting in accelerated disease onset and increased mortality.

 

Malnutrition in dietary protein intake is a major cause of reduced muscle mass, strength, and function in older adults.

 

 

Maintaining muscle mass and strength while reducing fat mass accumulation are vital to maintaining mobility and reducing disease risk in the elderly.

Aging is the natural process of physiological alterations within organ systems , decreasing their functional capacity.

Aging is characterized by progressive reduction of physiological reserve and increased vulnerability to internal and external stressors, associated with the growing risk of disease, disability, and death.

For successful aging biological age, is less than chronological age and functional status is maintained or the decline in functional status is relatively slow or delayed.

Aging and impaired organ functioning increases risk of disease.

Inflammation plays an essential role in aging and age-related diseases. 

People aged 65 years or older occupy 2/3 of medical beds in hospitals.

A cumulative decline in the function of multiple physiologic systems.

Aging is heterogenous in individuals, and it’s impact of a particular disease depends on molecular, epicenetic and individual factors.

Associated with decreased organ function reserve, as well as comorbidity, frailty, and limited ability to tolerate infections or chemotherapy stressors.

Declines and secondary physiological differences that occur with age very in different individuals and organ systems, so there are differences in life expectancy, functional status, and health status among patients of looidentical chronological ages.

With aging reduced capacity to repair DNA results in increased fragility of organs to regenerate.

During aging there is a decrease in food and energy intake, such as reduced appetite, loss of acuity of taste, smell, and site, or difficulty chewing and swallowing.
Energy requirements decline with age due to a reduced basal metabolic rate.
The requirements for essential nutrients may be increased later in life, specifically a growth of protein intake is needed to compensate for age related decreases in skeletal muscle mass, strength, and function.
US recommended dietary allowance for protein is 0.8 g per kilogram per day based on short term nitrogen balance studies.
Recommendations for older adults suggest an average protein intake of 1-1.2 g per kilogram per day and even higher for those with acute or chronic diseases.

Consuming less than the protein RDA results in significant declines in muscle mass, strength, and function in older populations.

In those over the age of 75 years, 5% have exudative macular degeneration and 5% have glaucoma.

One of the first signs of age on the human face is the increase in prominence of the nasolabial folds.

Physical activity prevents cognitive decline in older community-dwelling women.

Patients who are older are more prone to develop infections, with a 13 fold higher risk relative to people who are less than sixty years.

Both mobility limitations and cognitive limitations are associated with increased mortality risk in the elderly.

Approximately one-third of seniors over age 65 experience a fall, and this percentages rises with age to affect more than 50% of seniors over age 80.

Approximately 47 million (15%) of the population In US currently older than 65 years.

Nearly 25% of patients over the age of 85 years reside in nursing homes.

Comprise about 13% of the population of the U.S.

Over the age of 85 there are 4 men for every 10 women.

The number of women 85 years of age and older is increasing rapidly, with 11.6 million projected by the year 2050.

Relatively few males live to be the oldest of age with women outnumbering men 2.2 to 1 at age 85 years, greater than 3 to 1 for nonagenarians and 4 to 1 in centenarians.

By 2030 1 in 5 individuals in the U.S. will be 65 years or older.

Life expectancy 47.3 years in 1900 up to 75.2 years for men and 80.4 years in 2005.

Ten to 50% of individuals over 65 years can maintain physical and cognitive function and free of major chronic illnesses (Newman AB, Reed DM, WilcoxBJ, von Faber M).

More than half of ICU bed-days in the U.S. involve patients over the age of 65 years.

Aging associated with declining memory performance, increases systolic pressure and increased prevalence of hypertension.

The brains ability to learn, remember, and solve problems slows with age. 

 

 

Hearing loss that often accompanies aging makes it more difficult to distinguish speech in a noisy environment, and because hearing requires more concentration than usual, even mild loss of the ability to focus can affect speech comprehension.

 

 

These memory problem may simply reflect a slower processing speed and poor encoding and retrieval of new memories as a result of diminished attention. 

 

 

The ability to make sense of what one knows and to form reasonable arguments and judgments remains intact.

 

 

Brain regions involved with memory processing, such as the hippocampus and especially the frontal lobes, undergo anatomical and neurochemical changes over time.

 

 

With age, it takes longer to absorb, process, and remember new information. 

 

 

The natural loss of receptors and neurons that occurs with aging may make it harder to concentrate, to learn information and to recall, because of not fully  learning  in the first place. 

 

 

With age, slower processing of facts held in working memory may dissipate before you have had a chance to solve a problem.

 

 

The ability to perform tasks that involve executive function declines with age. 

 

 

The aches and pains of getting are distracting, and some of the medications used to treat it also can affect concentration.

Associated with polypharmacy, impairments and cognitive function, and impairments in activities of daily living.

Aging is associated with decreasing lung function due to decrease muscle performance and or decrease elastic recoil of the lung, reducing reversibility and potentially leading to fixed airflow obstruction.

Lung function decline is higher in inactive than active patients.

Approximately 1.4 million elderly patients are discharged from hosptials after receiving ICU care in the U.S.

Account for 18% of suicide deaths in the U.S.

1/5 of elderly Americans die in ICUs, and about half of these individuals have mechanical ventilation and 25% undergo cardiopulmonary resuscitation in the days before death.

Complete tooth loss, dry mouth, and cumulative oral health problems are associated with incidence of frailty independent of socioeconomic factors and comorbidities.

Medicare analyses showed that 31.9% of patients underwent an inpatient surgical procedure during the year before death and 18.3% underwent the procedure in their last month of life, and 8% underwent such a procedure during our last week of life (Kwok AC et al).

Following acute hospitalization 30 to 50% of the patients experience a loss of essential

activities of daily living within six months.

20 to 30% of patients elderly are readmitted to the hospital within six months of acute hospitalization.

20 to 30% of elderly patients die within six months of acute hospitalization.

Chronic pain is an epidemic in older adults with 52.8% of patients reporting pain that interfered with activities of daily living in the previous month.

In older people chronic pain leads to reduce physical activity, increases the frailty syndrome, increases falls, increases physical disability, and increases cognitive impairment.

Projected 60% of cancer incidence and 70% of cancer related mortality occur in individuals 65 years of age or more.

Chronically disabled individuals over the age of 65 years exceed 7 million in the U.S.

Muscle strength is inversely related to mortality risk in older adults.

Muscle mass index, defined as muscle mass divided by the square of height is inversely related to mortality risk in older adults independent of fat mass and cardiovascular and metabolic risk factors.

Low muscle mass in the elderly related to physical inactivity, increased levels of proinflammatory cytokines, however, the main cause is probably increased activity of the ubiquitin-proteasome system with increased muscle protein degradation.

Anabolic processes that promote muscle bulk in the elderly may be associated with longer survival.

Renal dysfunction in elderly associated with an increased risk of death.

In the elderly a lower GFR, as estimated by serum cystatin C levels, is linearly related to the risk of cardiovascular events, premature death, and a decline in functional status.

Obesity in elderly associated with lower all- cause mortality.

Aging and obesity share numerous causative mechanisms mostly linked to dysfunctional adipose tissue, such as metabolic dysfunction, multi organ damage, endocrine disruption, impaired immune function, and chronic inflammation.

Multiple chronic medical conditions are 7 times more likely among people age 60-79 and 14 times more likely among people older than 80 is compared with people age 25-39 (van de Akker m).

Aging is associated with functional changes such as declines in muscle strength, aerobic capacity, bone density and other factors that can reduce functional reserve.

In a study of 1,217,103 Medicare patients over the age of 65 he was found to 82% have at least one chronic medical condition and 65% have multiple chronic medical processes (Wolf JL).

Among the nursing home residents with end-stage renal disease the initiation of dialysis is associated with substantial declines in functional status (Tamura).

Chemotherapy trials reveal responses, toxicity and survival rates of elderly patients are similar to those of younger patients.

80% of community dwellers over the age of 65 years have at least 1 chromic disease and 48% have 3 or more such illnesses.

Increased morbidity and mortality after myocardial infarction in elderly related to increased vascular stiffness which increases left ventricular afterload.

Even mild degrees of anemia in elderly increase mortality risk with acute myocardial infarction.

Chronic kidney disease of the fastest growing health conditions in older people.

Approximately 30% of individuals older than 70 years have CKD.

Surgical risk of mild anemia does not increase risk of death unless cardiac disease or major blood loss occurs.

In elderly survivors of ICU stays have a high mortality over subsequent years in excess of that seen in comparable controls, and the risk is concentrated early after hospital discharge among those requiring mechanical ventilation (Wunsch H).

The most common medical conditions among the elderly or hypertension, congestive heart failure, vision problems, endocrine or metabolic conditions, atrial fibrillation, anemia, dementia, and musculoskeletal diseases (Marengoni A).

Increased risk of unrecognized cardiovascular disease and limited physiologic reserve may render the elderly more vulnerable to milder degrees of anemia when undergoing stressful surgery.

30% have nuchal rigidity in the absence of meningitis and 12% have a positive Kernig sign.

For individuals who live past age 65, now average three years of self-care disability at the end-of-life, requiring long-term services and support.

For those living past 85 years old nearly half will have serious cognitive impairment.

Population 65 years and older are prone to dementia and its subtle, pre-clinical forms, collectively termed cognitive impairment.

Sedentary men have a reduced life expectancy of about 5 years, compared with men who were moderately to vigorously physically active. 

Elderly patients with acute venous thromboembolism have a substantial long-term mortality rate, approximately 21%, and several factors including age, diabetes, cancer, polypharmacy, no physical activity, systolic hyportension, anemia, an elevated troponin, elevated C reactive protein and elevated D dimer are associated with increased risk of long term mortality.

In a study of community-dwelling persons 70 years of age or older (or ≥65 years of age among blacks and Hispanics in the United States) and did not have cardiovascular disease, dementia, or physical disability randomly assigned to receive 100 mg per day of enteric-coated aspirin or placebo orally.(Aspirin in Reducing Events in the Elderly (ASPREE) trial).

In the above study there was no benefit with continued aspirin use with regard to the primary end point: rate of the composite of death, dementia, or persistent physical disability, but the rate of major hemorrhage was higher in the aspirin group than in the placebo group, 3.8% vs. 2.8%.

Aspirin use in healthy elderly persons did not prolong disability-free survival over a period of 5 years but led to a higher rate of major hemorrhage than placebo.

Randomized trials have shown the efficacy of aspirin for the secondary prevention of cardiovascular disease among persons with a history of coronary heart disease or stroke.

Evidence supporting a benefit of aspirin therapy in the primary prevention of cardiovascular or other chronic disease is less conclusive despite favorable trends suggesting that aspirin use reduces the incidence of cardiovascular events and possibly reduces the incidence of cancer and cancer-related mortality, particularly from colorectal cancer.

Statins decrease major vascular events like stroke and heart attack regardless of age.

The evidence is less robust for people over age 75, but evidence suggests this age group may also benefit.

In the Cholesterol Treatment Trialists’ Collaboration analysis 28 large research clinical trials of statin therapy compared to placebo or usual care.

The analysis included over 185,000 patients,of which 8 percent were over age 75.

Participants took statins for about five years, on average.

For each 1.0 mmol/L (38.6 mg/dL) decrease in LDL that resulted from statin use, the risk of major vascular events decreased by 21 percent overall.

All age groups showed a significant decrease in major vascular events associated with statin use.

There was a significant trend towards smaller risk reduction with increasing age for major coronary events like heart attacks.

Results showed less evidence of benefits for statins in people over age 75 who do not already have vascular disease.

The absolute benefit of decreasing LDL with statins may be substantial in older individuals, because the absolute risk of major vascular events increases exponentially with age in untreated individuals.

Individuals aged 70 to 100 years with elevated low-density lipoprotein (LDL) cholesterol have the highest risk for myocardial infarction and atherosclerotic cardiovascular disease (ASCVD).

 

 

Lipid-lowering therapies are also effective for reducing cardiovascular events in individuals aged 75 years or older.

 

 

Copenhagen General Population Study (CGPS) analyzed 91,131 individuals over 

 

7.7-year follow-up period.

 

 

Myocardial infarction per 1.0 mmol/L increase in LDL cholesterol increased with a hazard ratio of 1.34, and for ASCVD per 1.0 mmol/L increase in LDL cholesterol, with a hazard ratio of 1.16. 

 

 

The risk was high in all age groups, but especially among those aged 70 to 100 years.

 

 

Risk of myocardial infarction was also increased with a 5.0 mmol/L or higher LDL cholesterol versus less than 3.0 mmol/L in individuals aged 80-100 years.

 

 

 Bacteremia accounts for 7% of infections occurring in older individuals and results in death rates of 11-30% after one week and up to 45% after one month.

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