How and Why Older People Get Sick

Epidemiology of Ageing

  • UK statistics:

    • 1981: 600,000 people aged >85 years

    • 2011: 1.5 million people aged >85 years

    • 2026 (projected): 2.4 million people aged >85 years

  • Prevalence of chronic illness/disability restricting daily activities:

    • 50-64 years: 25%

    • >85 years:

      • Men: 66%

      • Women: 75%

  • UK life expectancy at birth:

    • Males: 79.5 years

    • Females: 83.1 years

  • In 2021, 18.6% of the UK population was aged >65 (16.4% in 2011), including 500,000 people >90.

Changes in Ageing and Clinical Consequences

  • Central Nervous System (CNS):

    • Changes: Neuronal loss, cochlear degeneration, lens rigidity, lens opacification, anterior horn cell loss, dorsal column loss, slowed reaction time.

    • Clinical Consequences: Increased risk of delirium, hearing loss, presbyopia, cataract, muscle wasting, reduced proprioception, increased risk of falls.

  • Respiratory System:

    • Changes: Reduced lung elasticity, increased chest wall rigidity, increased V/Q mismatch, reduced cough/ciliary action.

    • Clinical Consequences: Reduced vital capacity/peak flow, increased residual volume, reduced oxygen saturation, increased risk of infection.

  • Cardiovascular System:

    • Changes: Reduced maximum heart rate, dilatation of aorta, reduced elasticity of vessels, reduced number of pacing myocytes in sinoatrial node.

    • Clinical Consequences: Reduced exercise tolerance, widened pulse pressure, increased risk of postural hypotension.

  • Gastrointestinal System:

    • Changes: Reduced motility.

    • Clinical Consequences: Constipation.

  • Renal System:

    • Changes: Loss of nephrons, reduced glomerular filtration rate, reduced tubular function.

    • Clinical Consequences: Impaired fluid balance, increased risk of dehydration/overload, impaired drug excretion/metabolism.

  • Endocrine System:

    • Changes: Deterioration in pancreatic beta-cell function.

    • Clinical Consequences: Increased risk of impaired glucose tolerance.

  • Bones:

    • Changes: Reduced bone mineral density.

    • Clinical Consequences: Increased risk of osteoporosis and fragility fractures.

Frailty

  • Definition: Loss of physiological reserve, leading to increased vulnerability to poor health outcomes.

  • Frailty is distinct from disability (established loss of function) and co-morbidity (number of diagnoses).

  • Prevalence:

    • 60-69 years: 6.5%

    • >90 years: 65%

Clinical Issues in Older Patients

  • Multiple comorbidities: Symptoms may be related to a combination of multiple diseases.

  • Nonspecific symptoms: Patients may present with loss of function.

  • Atypical/late presentation: Diseases may present differently compared to younger patients.

  • Lack of physiological reserve: Illnesses come on quicker, recovery takes longer, increased risk of complications, may not return to previous baseline.

  • Altered drug metabolism: Doses may need adjusting, increased risk of side effects, likely to be on multiple medications.

Common Presentations of Frailty

  • Postural hypotension

  • Falls

  • Neck of femur fracture

  • Delirium

  • Poor nutrition

Case Study: Doreen

  • 76-year-old woman

  • Past medical history:

    • Osteoarthritis

    • Chronic Kidney Disease

    • Hypertension

    • Postural hypotension

  • Social history:

    • Lives with husband who has dementia

    • Three daughters: Maggie (nearby), Elsa (Birmingham), Jane (New Zealand)

    • Cooks and shops independently, mobilizes independently but limited walking distance

    • Maggie helps with cleaning once a week

    • No carers

    • Smokes 20 cigarettes/day

Clinical Frailty Scale: Rockwood Score

  • A tool to assess frailty levels, ranging from very fit to terminally ill.

  • Scores range from 1 (Very Fit) to 9 (Terminally Ill).

  • Takes into account both physical and cognitive function; dementia is considered in the scoring.

Case Study: Doreen's Progression

  • Husband develops a cough and fever, becomes more confused.

  • Doreen tries to manage alone, leading to a fall due to postural hypotension and a hip fracture.

  • She is admitted to hospital.

Postural Hypotension

  • Definition: A fall in systolic blood pressure of ≥20\geq 20 mmHg and/or a fall in diastolic blood pressure of ≥10\geq 10 mmHg from lying to standing.

  • Causes: Ageing, hypovolaemia, medication (diuretics, anti-hypertensives), autonomic dysfunction (e.g. diabetes mellitus, Parkinson’s Disease).

  • Management: Stop medications, lifestyle factors (adequate fluid intake, standing slowly, stockings), Fludrocortisone (promotes Na+Na^+ and water retention).

Polypharmacy

  • Definition: Commonly defined as 5 or more medications at one time.

  • Nearly 50% of older adults take one or more medications that are not medically necessary.

  • Strong relationship between polypharmacy and negative clinical consequences.

Falls

  • Presentation of multiple underlying pathologies: acute illness (e.g., infection, stroke), blackouts, secondary to gait and balance issues.

  • Incidence: >65-year-olds - 30% fall each year; >80-year-olds - 40% fall each year.

  • 10-15% of falls result in serious injury.

Risk Factors for Falls

  • Age, loss of muscle mass, visual impairment, cognitive impairment, gait or balance abnormality (use of walking aid), postural hypotension, previous falls, impaired activities of daily living, alcohol/medications, arthritis/pain, peripheral neuropathy, Parkinson’s disease.

Falls Prevention

  • Multi-disciplinary approach, falls clinic, rationalise medications, visual aids, walking aids, footwear, review home circumstances.

Fractured Neck of Femur

  • Common and associated with high mortality (10% die within 1 month, 1/3 die within 1 year).

  • Often occurs with minor trauma in the elderly due to decreased bone density and osteoporosis.

  • Osteoporosis: Low bone mass and micro-architectural deterioration of bone tissue → bone fragility → increase in fracture risk.

  • Fragility fracture: Result from a fall from standing height or less; other common sites include spine and wrist.

Presentation of Fractured Neck of Femur

  • Usually after a fall, presenting as painful, shortened and externally rotated leg.

  • Investigations: X-ray, sometimes CT.

  • Management: Analgesia, surgery (total hip replacement/hemiarthroplasty, dynamic hip screw), excellent holistic postoperative care.

  • NICE guidelines advise surgery on day of or day after admission.

Doreen's Post-Fracture Progression

  • Has a right total hip replacement.

  • Gets confused and agitated in hospital.

  • Makes slow progress with physiotherapy.

  • Develops a small pressure sore, managed by the tissue viability team.

  • Maggie notices Doreen looks more gaunt.

  • Eric is placed in 24hr care as Maggie cannot cope.

Dementia, Delirium, and Depression

  • Present similarly in the elderly and commonly get mixed up.

  • Dementia: Syndrome associated with an ongoing decline in brain functioning.

  • Delirium: Acute confusional state with reversible* cognitive dysfunction (*may not recover back to previous baseline).

  • Depression: Common mental health problem causing persistent low mood and loss of interest in activities.

Delirium

  • Very common in the elderly, affecting up to 30% of older inpatients.

  • Characterized by fluctuating abnormalities of thought, perception, and levels of awareness.

  • Usually hypoactive or hyperactive.

  • More common with a background of dementia.

  • Associated with high rates of mortality (25% to 33%).

Delirium: Precipitating and Predisposing Factors

  • Precipitating factors: Pain, infection, nutrition, constipation, hydration, medication, environment.

  • Predisposing factors: Old age, dementia, frailty, sensory impairment, polypharmacy, renal impairment.

Delirium – Assessment

  • Need to assess fully to work out the cause.

  • History – may need collateral.

  • Comprehensive examination – obs, CVS, resp, abdo, GU, neuro, skin (wounds).

  • Assessment tools – AMTS, MOCA, 4AT.

  • Investigations: CXR, ECG, urine culture (do not do urine dip in >65), CT head, 'Confusion bloods' (full blood count, urea and electrolytes, liver function tests, clotting tests, thyroid tests, calcium, B12 and folate, ferritin, glucose).

Delirium Management

  • May persist for months after initial triggering event/illness.

  • Talk to families.

  • Supportive – may be specialist teams to help think about the environment.

  • Medication review – avoid sedatives.

  • Identify and treat the underlying cause.

Doreen's Final Trajectory

  • Discharged to residential care.

  • Still confused.

  • Maggie feels she is “not as sharp as she used to be”.

  • Mobilises with a zimmer frame.

  • Needs help with washing and dressing.

  • She starts to eat less and refuses most of her meals.

Nutrition in the Elderly

  • The elderly are particularly at risk of under-nutrition due to reduced muscle mass, increased percentage body fat, reduced basal metabolic rate and reduced energy requirements.

  • Weight tends to fall over the age of 70.

Nutrition: Risk Factors and Clinical Consequences

  • Why might patients lose weight? Decreased appetite, difficulty preparing food, loss of taste, financial difficulties, difficulties getting shopping, poor dental health, illness, cognition.

  • Clinical consequences: Impaired immunity, muscle weakness, poor wound healing.

Outcomes in Acute Care Associated with Frailty

  • Clinical Frailty Scale (CFS) is correlated with length of stay, readmission rate, in-patient mortality, care intentions, service referrals, and post-discharge support.

  • Higher CFS grades are associated with higher readmission rates and mortality.

Trajectories of Frailty

  • High: Number of deaths in each trajectory, out of the average 20 deaths each year per UK general practice list of 2000 patients.

  • Different trajectories: Cancer (n=5), Organ failure (n=6), Physical and cognitive frailty (n=7), Other (n=2).

  • BMJ

Is Frailty Preventable?

  • Yes, “healthy ageing” reduces the risk of developing frailty.

  • Key components: Good nutrition, staying physically active, remaining engaged in the local community/avoiding loneliness.

Adapting Care for the Elderly

  • Move towards Holistic patient-centred care based on the individual patient

  • The Past: Single organ specialties, Disease focused goals, Non-integrated services, Reactive care

  • The Future: Patient centred care, Principles of Comprehensive Geriatric Assessment, Proactive person-centred care planning

Summary

  • We are an ageing population.

  • More elderly people now are living with significant comorbidity and frailty.

  • There are several challenges when dealing with elderly patients: They present atypically/non-specifically, have multiple comorbidities and have reduced physiological reserve.

  • Geriatricians need to take a holistic approach when caring for elderly patients, considering multiple comorbidities and biopsychosocial aspects of disease.

  • Highlighted some examples of common conditions affecting elderly patients, but there are many more.