A Geriatric Watch List

Common Health Conditions in Old Age

International Day of Older Persons – October 1, 2022

Background

Life expectancy in every country in the world is increasing due to industrialization and the resultant simultaneous advancement in the medical field. The older population in France took 150 years to go double from 10%. In low middle income (LMIC) countries like Brazil and China, the progression is faster. India is also not an exception. Though perceived as a young nation, India is aging. By 2019, 139 million people (10.1%) were aged more than 60 years. This is expected to double (19.5%) to 319 million by 2050, and every 5th (1 in 5) person will be aged more than 60 years.

There’s little notion available whether the current older generation is in better health than their parents. Advancement in science has made their lives better but we should remember the old age population comprises three generations, young old (60-74 years), old (75-84 years) and the oldest old (85+ years). As the population ages, their healthcare and other needs including dependency also increase. Healthy ageing doesn’t merely imply being disease and medicines-free.

Ageing Process

Only a small proportion of people’s life is attributed to genetic factors. Most of them are influenced by epigenetic factors like socio-economic status, physical environment, social support, education and personal as well as behavioural choices like alcohol, tobacco and other substance use throughout the life course. The diversity of health in old age happens due to the influence of all these factors. One size doesn’t fit everything in old age. An 80-year-old can be in better health (both physical and mental) than a 40-year-old. Chronological age holds a little lesser value in old age health and biological age supervenes.

The most common problems that happen in old age are non-communicable diseases like stroke, heart diseases, lung diseases, osteoarthritis, etc. Sensory impairments (both vision and hearing) are the most common cause of disability in old age. This leads to dependency in old age even to carry out basic activities like washing clothes, cooking food, grocery shopping and taking bath.

Sensory Impairment

Hearing impairment is widely prevalent in aging. This is partly attributed to age-related hearing cell degeneration as well as increased ear wax production. Hearing impairment interferes with quality of life as it interferes with communication and social interactions. Hearing aid usage can increase the quality of life and communication and can prevent cognitive decline due to hearing loss which is about 15%. Dizziness is also common among older adults. It occurs commonly due to the malfunction of the vestibular apparatus and the fluid responsible for maintaining equilibrium during human locomotion. While medications can help in acute events, vestibular rehabilitation is recommended in the long term.

Visual acuity declines with age, partly due to physiological processes like presbyopia (stiffness of lens and associated muscles) or acquired etiologies like cataracts. While visual impairment is widely prevalent in about one-fourth of the oldest old, the rate of decline is also higher. Corrective glasses for refraction and cataract surgeries can restore the function to the desired level.

Osteoarthritis and Osteoporosis

Arthritis is one of the commonest problems among older adults, widely prevalent among more than half of the population. One of the risk factors is obesity; weight loss can prevent joint damage and other lifestyle disorders. In contrast to popular belief, arthritis is not limited to the knee but also occurs in the hip, shoulder and spine. Another condition that commonly occurs in older adults is softening of the bone and loss of bone density known as osteoporosis. Sometimes it can present as cramps alone; severe muscle and joint pains are often mistaken for fatigue. Exercise is the key for both conditions. Nonpharmacological measures such as weight loss, exercises, muscle strengthening and resistance exercises can help in the long term. Simple analgesics can help decrease arthritic pain. Opioid analgesics can cause dependency in the long term and NSAID classes are not preferable. For osteoporosis, getting calcium, vitamin D and protein supplements are advised. If advanced, patients may be prescribed medicines like parathormones and bisphosphonates.

Frailty and Sarcopenia

Frailty is characterized by slowness in walking, weakness, fatigue, weight loss and self-reported exhaustion. Physical frailty is the vulnerability of older adults to external stressors. Frailty can be easily assessed through validated instruments. The prevalence of frailty varies between different settings and age groups. At 65 years, the prevalence of frailty was 7% in the first year whereas in the 85+ population it rose to 38%. Frailty can be predictive of falls, hospitalization and mortality. Frailty can be prevented by ensuring adequate exercise, nutrition and revision of medications.

Incontinence

It is more common in older women (20%) than men. It is one of the leading social stigmata, barring older adults from getting adequate care. The commonest causes in men of the lower urinary tract symptoms (LUTS) are prostate enlargement, medications and immobility. Sometimes, dementia also can manifest initially as incontinence. Common causes in women are overflow incontinence, stress incontinence and functional incontinence. The changes in women are driven by weak abdominal muscles and pelvic floor muscles as well. Kegel’s exercise is a set of exercises that could help in strengthening the muscles of the pelvic floor and the abdomen.

Cognition and Dementia

Normal aging isn’t equivalent to dementia. Brain ageing differs in each individual as it is influenced by individual co-morbid conditions, education and other epigenetic factors like socio-economic environment. A minuscule forgetfulness and small word-finding difficulty is a normal part of ageing and may impact a small difficulty in driving. The alarm signs should be when the memory loss is disruptive to daily tasks, difficulty in making plans, social disinhibition and withdrawal, vision difficulty or rarely difficulty in controlling urine and hallucinations.

Depression and Sleep Issues

Older people go through grief due to the loss of dear ones, loss of jobs and financial resources. Often, depression and anxiety are mistaken for sleeplessness and not treated. Depression prevalence is around 20% in old age. Depression prevalence widely varies, peaking in 65-75 years; with advancing age (85+ age) depression was less prevalent. Loneliness is an important cause of depression due to the deprivation of social interaction and social pleasures. Sometimes, depression can be mistaken for sleep issues also. Due to the ageing physiology, the REM sleep or the deep sleep reduces with age. Five to seven hours of uninterrupted sleep is good for older people.

Polypharmacy and Multimorbidity

Taking five or more medicines/components is known as polypharmacy. Polypharmacy leads to serious adverse events such as falls, delirium, incontinence, frequent hospitalizations and infections. Older adults over 65 years at least have 2 or more conditions known as multimorbidity. Multimorbidity leads to polypharmacy and can be vice versa. The medications in old age should be revised from time to time and goals of care should be discussed with the patient as well as the caregiver.

Cardiovascular System

The leading cause of death in older people comprises a range of entities like heart failure, hypertension and arrhythmias. The blood vessel undergoes wear and tear and remodelling with advancing age. This leads to atherosclerosis and inflammation, the root cause of a variety of vascular conditions namely stroke, heart attack, peripheral vascular disease, cholesterol disorders, cognitive disorders and other end-organ diseases including kidney diseases. To stay heart healthy, one should keep away from smoking, alcohol and other substances. Adequate sleep and physical activity are also a must to keep away obesity and stress.

Cancer

The incidence of cancer also increases with age. The most common cancers in men are prostate cancer and in women they are cervical as well as endometrial cancers. These are common statistics but there are regional variations across the nation influenced by substance use like smoking, tobacco, alcohol and socio-economic factors. Screening is recommended for certain cancers (for example, cervical cancer screening for up to 65 years and lung cancer in heavy active smokers), or someone with a strong family history (e.g., colon or rectum). Some cancers are associated with obesity (e.g., postmenopausal breast cancer, endometrial cancer).

Diabetes Mellitus

Diabetes is increasingly common, and Asians are more susceptible to it. About one in four older adults are suffering from it. One could be at increased risk if they are more than 45 years of age, have obesity, altered cholesterol levels, sedentary lifestyle, have prediabetes and if any first-degree relatives have diabetes. After the age of 60 years, at least one annual checkup is recommended.

Vaccination

Pneumonia and flu vaccines are mandatorily advised for older adults apart from COVID vaccines. Flu vaccines should be taken annually just before the rainy season as flu breakouts usually coincide with the peak rainfall. Two types of pneumonia vaccines are there, the conjugate vaccine and the polysaccharide ones. The conjugate vaccine is a one-time thing, and the polysaccharide vaccine should be given once in 5 years.

Medical Emergencies in Old Age

Falls and Balance Issues

Falls and balance issues are much more common in older adults. One in three older adults experience falls, and it rises to 65% in the case of the 80+ population. Falls are not a normal part of ageing. Falls are usually multifactorial, due to the interaction between the comorbidities of the patient, medications and the environment. Injuries and disabilities will follow a fall. One such thing is a hip fracture; without surgery, the older person will never walk again. Medication adjustments, home environment adjustment, physical activity and assistive device use, if necessary, will prevent falls.

Delirium

It is an acute state of confusion associated with older adults. It can be due to a wide variety of reasons ranging from infections, electrolyte disorders, low sugar levels, falls, increased BP levels, stroke, diarrhoea, heart attack, etc. It leads to poor healthcare outcomes, prolonged hospital stay and decreased functional outcomes post hospital discharge.

Conclusion

The diversity in health in old age is not merely due to diseases but due to the impact of physical health and the environment also. Healthy ageing is a wider concept and can be achieved. The public health and the policy agencies should make policies of inclusivity for older persons and make them age-friendly and age centric. This can prevent ageism in healthcare, discrimination and inequities. The WHO along with the UN general assembly announced this decade (2021-2030) as a decade for healthy aging. The aim is to bring governments, policymakers, private sector to one point to foster healthy happy aging.