Community Care of Older People

David Beales

• Publisher: CRC Press
• Year: 2018
• eBook ISBN: 9781315345994
• Edition: 1
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

This comprehensive book gives an up-to-date profile of all aspects of the care of older people in the community, with particular emphasis on the importance of maintaining function and independence as well as health. In a uniquely broad approach, the book is edited by two family doctors with a particular interest in the elderly and a consultant geriatrician, and the varied subjects are each presented by experts in their field. This accessible book enables primary care teams to produce optimal standards of care in old age, and is helpful in the organization of preventive care programmes. Emphasizing the need for joint working, the book draws together practical knowledge and skills to produce an essential source of reference and advice for all those involved in delivering a co-ordinated service. It is essential reading for all doctors in general practice and in public health, medical students and all other professionals whose work brings them into contact with elderly people. It is particularly useful for general practice teams, allied professionals such as nurses and physiotherapists, as well as patients and carers seeking an understanding of good practice. It also contains much practical information vital to the work of voluntary agencies, social service departments and specialists in geriatric medicine.

CHAPTER 1

Ageing - the biology of growing old

Ioan Davies

This chapter introduces the biology of growing old. Changes in physiological effectiveness with increasing age are discussed, and the scope for modifying these changes is examined, with a view to improving the quality of life in later years. Finally, some of the mechanisms of ageing are discussed.

What is ageing?

Box 1.1 Definitions

Ageing the period of the lifespan characterized by a failure to maintain homeostasis under conditions of physiological stress. This failure is associated with a decrease in viability and an increase in vulnerability of the individual

Longevity Maximum lifespan recorded for a species

All organisms undergo a period of development and growth before they become reproductively mature. Under natural conditions, the time of reproductive activity in most species is short, and is followed closely by death. In the wild, ageing is probably not a major determinant of the time of death. Most of the recognizable features of ageing occur in animals protected from their environment, e.g. humans and domestic species, and after the period of reproductive activity has ceased. The definition of ageing (Box 1.1) implies that ageing is in the later part of the lifespan. However, events that obviously take place during the early development of complex multicellular organisms, such as mammals, influence ageing to a great extent. Notice that particular emphasis is placed upon the failure to maintain homeostasis because it is in the integration of complex physiological functions that the greatest age-associated changes are observed.¹ There is one certainty, and that is longevity is defined by a specific endpoint - death, which enables us to define accurately the length of the lifespan.

There are a number of predictions for the maximum length of life of the human species. Olshansky² has reviewed the current evidence and argues that as the actuarial estimate of average life expectancy approaches 80 years, large reductions in the death rate are required to produce even marginal increases in mean lifespan. Some demographers have estimated that life expectancy will soon approach 100 years but these estimates are based on unrealistic changes in human behaviour and mortality patterns. However, even though Olshansky² claims that there is no indication that humans can have a maximum lifespan much greater than 110 years, a Frenchwoman, Jeanne Calment recently died at the age of 122 years. This is a milestone in the survival of humankind and fuels the belief that breakthroughs in molecular and cellular biology will permit the extension of the average, and ultimately our maximum lifespan. It is also clear that unless there is a parallel reduction in the disabling diseases of later life, by a simultaneous compression of morbidity, the quality of our prolonged existence may be poor.

Age-associated changes in physiological effectiveness

As we get older the body composition changes; lean body mass is reduced and the fat content of the body increases.³ Among other things this can alter the pharmacodynamics of fat-soluble drugs. The location of body fat also changes with age; a general loss of fat from beneath the skin is associated with an increase in the trunk region. In addition, water is lost progressively from the body, and is redistributed within the body compartments. This in turn alters the pharmacodynamics of water-soluble therapeutic agents.

The skin, particularly those areas exposed to the sun, usually shows marked age-associated changes.⁴ Wrinkles, and other blemishes, are caused by alterations that occur in the cells of the skin, the subcutaneous fat and the connective tissues. Age-changes in connective tissues take place despite the damage done by prolonged exposure to ultraviolet (UV) radiation, which is a major factor in skin cancer.

The musculoskeletal system

Bone is a living tissue and constantly undergoes remodelling in response to forces applied to it during exercise, and after damage. Bone loss in ageing is universal, but occurs at different rates in individuals. Bone loss is seen in everyone by the fifth decade, in both sexes, and the rate of loss is greater in females after the menopause.

Osteoporosis

This condition is not one entity but the result of several age-associated events, all leading to a reduction in bone mass. Osteoporosis has characteristic features that separate it from other forms of bone disease. In simple terms, a person with osteoporosis has a lower bone mass than might be expected from age and sex norms, and an increased risk of fracture. A major factor in the determination of bone density (see Box 1.2) in old age is the bone mass at maturity. The differences in bone mass between the sexes with age may be accounted for by the lower bone densities at maturity and more rapid bone loss after the menopause. Given that osteoporosis is only apparent at some critical bone mass, this level will be reached sooner in people starting with lower bone densities. Clearly, if women at the age of 18 years have a 20% lower bone mass than men of the same age, a more rapid bone loss in women aged over 50 years might account for the higher prevalence of osteoporosis in women, suggesting some critical level of bone mass beyond which there is an associated risk of fracture. The rate of bone loss in women is often described as linear after the age of 50. However, it is now known that the rate of bone loss is most rapid in the 5–10 years after the menopause.

Box 1.2 Determinants of bone density

• Gender
• Genetic background
• Endocrinology
• Nutrition
• Ethnicity
• Exercise
• Age

In younger adults (20–50 years of age) bone fracture is usually by violent direct trauma to the bone, whereas in old people the fractures result from moderate to minimal trauma. In old people, the sites of fractures are often different, taking place through the trabecular region close to the joint. The trauma that precipitates an osteoporotic fracture is nearly always a fall (see Box 1.3). However, with vertebral collapse fractures there may be no history of trauma, or the force causing the collapse may be muscular.

Cartilage

Age also affects cartilaginous structures. In old people the joint cartilage tends to become thinner, due in part to wear and tear. Furthermore, cartilage can become calcified with age making flexible joints like the costal cartilage more rigid, affecting movements of the rib cage during breathing. The fibrocartilage of the intervertebral discs loses water leading to a reduced ability to bear weight.

Box 1.3 Ageing changes and functional consequences

Type of change	Functional alteration
Age-associated changes	Diminished postural control Abnormal gait Weakness Poor vision Slow reaction time
Specific disease	Arthritis Cerebrovascular disease Parkinson’s disease Retinal degeneration Meniére’s disease Blackouts (large number of causative factors involved: low blood sugar, low blood pressure, disturbances in heart rhythm, acute onset of a stroke, epilepsy, etc.)
Drugs	Sedatives Blood pressure lowering agents Antidiabetic drugs Alcohol
Environmental factors	Slippery surfaces (particularly street surfaces in bad weather; contributing factors may include poor footwear and walking appliances) Uneven surfaces Tripping over unseen obstacles

Muscle

Changes in muscle function are another feature of advanced age. However, it is very difficult to differentiate between a loss of function due to inactivity and a genuine age-associated change.⁵ In skeletal muscle there is a general reduction in muscle mass with increasing age, partly due to cell death and partly atrophic change. Atrophy is most likely due to inactivity.

In conjunction with a loss of muscle mass, there is an overall reduction in muscle strength. Fast-twitch fibres appear to atrophy before slow-twitch muscles. Thus, strength appears to be influenced more than endurance in old people, but it is known that people in their 70s can increase their muscle strength using suitable training programmes.

There is now extensive research into the reversal of the effects of muscle atrophy with age. Injection of natural growth hormone (GH) (see later) is able to promote muscle growth in old people and the use of such compounds may make it possible to regain sufficient muscle function to undergo rehabilitation. Advances in the use of artificial electrical stimulation to muscles in chronically disabled people are also proceeding rapidly.

The cardiovascular system

One of the biggest problems we have in understanding the effect of age on the heart is the impact of disease on the heart itself.⁶ About 75% of men have significant narrowing of the coronary arteries by the age of 60 years. In women this figure is about 25% (at the same age), although by 80 years of age about 60% of women have similar damage. However, in old people without coronary artery disease cardiac output is not markedly affected by age. There are age-changes in the blood vessels. They become less compliant because of changes in the connective tissue components of the vessel wall. This means that a greater pressure has to be exerted by the heart to pump blood through the vessels. This leads to a rise in systolic blood press...

Table of contents

• Cover
• Title Page
• Copyright Page
• Contents
• About the Editors
• List of Contributors
• Preface
• Introduction
• 1 Ageing - the Biology of Growing Old
• 2 The Demography of old Age
• 3 The Presentation and Management of Physical Disease in Older People
• 4 The Presentation and Management of Mental Disease in Older People
• 5 Prescribing and the Older Patient in the Community
• 6 Nutrition of Older People
• 7 Anticipatory Care of Older People in the Community
• 8 The Practical Organization of Screening and Socio-Medical Assessment in Old Age
• 9 Health Promotion and Keeping Fit in Old Age
• 10 Community Nursing and Primary Care
• 11 Institutional Care of Older People in the Community
• 12 Disability and Rehabilitation for Older People
• 13 Special Services for Older People
• 14 Law and the Older Patient
• 15 Medical Ethics in Community Care
• 16 Older People in Ethnic Minority Groups
• 17 Taking the Diploma in Geriatric Medicine
• 18 The Carer’s Perspective
• Appendix 1: The Bicester System of Screening for the Elderly
• Appendix 2: Mcintosh Over 75s Assessment Questionnaire- Data Store
• Appendix 3: Phoenix Surgery Anticipatory Care Model for People Over the Age of 75 Years in Cirencester
• Cardiff-Newport Questionnaire
• Training Programme for Staywell 75+ Volunteer Visting Scheme
• Winchester Questionnaire
• Phoenix Surgery Letters
• Further Information
• Index