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Strategies for Successful Aging. Steve Swedlund, MD Program Director,Geriatric Fellowship WSUBSOM. ‘Strategies for Successful Aging’ Learning objectives. The learner shall: Describe trends in aging in US, and World.

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Strategies for successful aging

Strategies for Successful Aging

Steve Swedlund, MD

Program Director,Geriatric Fellowship

WSUBSOM


Strategies for successful aging learning objectives
‘Strategies for Successful Aging’Learning objectives

The learner shall:

  • Describe trends in aging in US, and World.

  • Recite 3 age-related physiologic changes for these organ systems: brain, eye, ear, cardiac, pulmonary, gastrointestinal, renal, genital, musculoskeletal, endocrine, immune.

  • Describe interventions to slow disease-related changes in organ functions.

  • Discuss ‘successful aging,’ and interventions for success.


Global aging trends
GLOBAL AGING TRENDS

The number of older adults is increasing faster in developing countries than in more developed countries

Between 2006 and 2030, projected to increase by 140% vs. 50%, respectively

Individuals ≥80 yr are the fastest-growing age group in the world

Increasing at a rate of 3.8% per year

Slide 3


Demography of aging in the us

DEMOGRAPHY OF AGINGIN THE US

Slide 4


Aging of the us population 1 of 2
AGING OF THE US POPULATION (1 of 2)

2000

2030

Slide 5


Aging of the us population 2 of 2
AGING OF THE US POPULATION (2 of 2)

Number of people 65 yr, in millions

Slide 6



Life expectancy
Life expectancy

If the pace of increase in life expectancy in developed countries over the past two centuries continues, most babies born since 2000 will celebrate their 100th birthdays.

The Lancet, 3 October 2009



Physiology of aging caveat
Physiology of Aging--Caveat

  • It is sometimes difficult to discern physiologic changes in the body from pathophysiology.


Brain
Brain

  • Can you describe changes in brain structure and function with aging?


Age related structural and physiologic changes in brain
Age-related Structural and Physiologic Changes in Brain

  • Brain mass decreases after age 30 years.

  • Tends to involve mild decline in memory.

  • More time needed to recall new information.

  • Learning tends to be slower.


Primary interventions to protect from cognitive decline
Primary interventions to protect from cognitive decline?

  • Physical activity/exercise/leisure activities.

  • Avoid metabolic syndrome.

  • Do not smoke.

  • No clear role for nutrition, vitamins, food supplements, statins, antihypertensive or anti-inflammatory medications, avoiding alcohol.

  • Not a clear role for cognitive exercises.

    NIH State-of-the-Science Conference Statement on Preventing Alzheimer’s Disease and Cognitive Decline—April 26-28, 2010.



Sleep changes with aging1
Sleep changes with aging

  • Total sleep time increases.

  • Latency stays same or increases.

  • Frequency of waking after sleep onset increases.

  • Less REM sleep.

  • Sleep efficiency decreases.

  • More daytime napping.


Interventions to enhance sleep in older patient
Interventions to enhance sleep in older patient?

  • Establish bedroom for only sex or sleep (no TV, or other functions)

  • Physical activity/Exercise during the day.

  • Limit daytime napping to 30 minutes, or less.

  • Separate alcohol intake and sleep by at least 6 hours.

  • Limit caffeine to early in day, and limited amounts.

  • Limit fluid intake, after supper.


Vision and aging
Vision and aging

  • What changes occur in the aging eye?


Physiologic changes in vision
Physiologic Changes in Vision

  • Dynamic vision peaks at about age 18 years and then decreases.

  • Dark adaptation decreases with age, in a linear fashion.

  • Lens becomes less compliant, and leads to ‘presbyopia.’

  • Lens becomes denatured and causes halos and glare around lights during acitivities at night (such as with driving at night).


Primary interventions to protect vision
Primary interventions to protect vision?

  • Use lenses to protect eyes from ultraviolet light.


Hearing and aging
Hearing and aging

  • What happens to the ear and hearing function with aging?


Ear hearing function with aging 1 of 2
Ear/Hearing function with aging (1 of 2)

  • Cerumen becomes thicker and more tenacious.

  • Skin of auditory canal becomes thin.

  • TM gets thicker and appears duller.

  • Loss of Cochlear sensory hair cells.

  • Calcification of auditory structures.

  • Cochlear neuronal loss.


Hearing and aging 2 of 2
Hearing and Aging (2 of 2)

  • Hearing thresholds go up at higher frequencies (4000 to 6000 Hz), and this leads to ‘presbycusis.’

  • Speech discrimination decreases, due to changes in central auditory processing.


The aging heart
The aging heart

  • What would you say happens to the heart with aging?


The aging heart1
The aging heart

  • The heart and great vessels become less compliant.

  • Maximum Heart Rate decreases (220 bpm minus age=MHR).

  • Decrease in myocardial relaxation.

  • Beta adrenergic receptors in heart are less responsive to agonists (natural beta blockade).

  • Baroreceptors become less responsive.


Primary interventions for heart health
Primary interventions for heart health?

  • Regular physical activity, strive for 150 minutes of moderate level activity per week.

  • Diet for keeping lipids low.

  • Avoid tobacco.


The lungs and aging
The lungs and aging

  • What happens to function of lungs?


Lungs and aging
Lungs and aging

  • Chest wall becomes less compliant.

  • Forced Vital Capacity decreases.

  • Forced Expiratory Volume at 1 second decreases. (25-30 ml/yr)

  • Residual Volume increases.

  • Pa02 decreases. (Pa02=110-(0.4 x age))

  • A-a gradient increases. (A-a gradient= (age/4) plus 4)


Interventions to protect lungs
Interventions to protect lungs?

  • Inhale clean air, do not smoke.


Kidneys and aging
Kidneys and aging

  • How do you describe changes in renal function with aging?


The aging kidney
The Aging Kidney

  • More loss of cortical nephrons, in relation to loss of medullary nephrons = less diluting and concentrating ability.

  • GFR decreases with aging; Cockroft-Gault formula: (140-age )(weight in Kg)(0.85 if female)/(72) (Serum Creatinine) = GFR

  • More free water is excreted in the later half of the day, as opposed to the first half of the day, as we age.


Bladder and aging
Bladder and aging

  • What happens with the bladder?


Bladder and aging 1 of 2
Bladder and aging (1 of 2)

  • Total bladder capacity tends to go down.

  • Detrusor contractility decreases.

  • Slower rate of expressing urine.

  • More random contractions.

  • Detrusor becomes overactive.

  • Lowering of estrogen in females associated with change in urethral mucosa, less ability to withstand increased intra-abdominal pressure.


Bladder and aging 2 of 2
Bladder and aging (2 of 2)

  • Males with 5-dihydro-testosterone reductase are developing prostatic hyperplasia, and then bladder outlet resistance.

  • Females have more UTIs than males from birth to age 80, and then males = females in rate of UTIs.


Sexual function
Sexual function

  • What are the 5 phases of sexual function?

  • How do the 5 phases change with aging?


Sexual function and aging
Sexual function and aging

  • With respect to phases of sex (excitement, plateau, orgasm, resolution, and refractory period),

    • Excitement phase is prolonged. Vaginal lubrication is lessened.

    • Plateau phase is prolonged.

    • Orgasm is less intense, shorter, and may not occur.

    • Resolution is shorter.

    • Refractory period is prolonged.


Vagina and aging
Vagina and aging

  • How would you describe changes here?


Vagina and aging1
Vagina and aging

  • Vaginal pH increases, and less likely to withstand infections.

  • Vaginal rugae become smaller.

  • Vaginal mucosa thins, with waning estrogen.


Aging skin
Aging Skin

  • Can you list things that occur with aging skin?


Aging skin1
Aging Skin

  • Skin becomes thinner, and we reach more ‘definition’– that is we can see our tendons, muscles, and veins.

  • Subcutaneous layer thins.

  • Less capillaries per unit volume of skin.

  • Rete pegs flatten out.

  • Less sebaceous oil secreted onto skin.

  • Number of melanocytes decrease.


Interventions to protect skin
Interventions to protect skin?

  • Limit exposure to sunlight.

  • Apply moisturizers to skin daily, particularly within a few minutes after bathing.


Aging musculoskeletal system
Aging Musculoskeletal system

  • What happens with bones and muscles?


Aging musculoskeletal system1
Aging musculoskeletal system

  • Bone mass peaks in 4th decade, and then decreases (more rapidly right after menopause in females).

  • Most of the bone loss is cancellous bone.

  • Number of muscle cells decreases (‘sarcopenia’ describes loss of muscle mass).

  • Strength tends to decrease, but this is may be affected by amount of exercise.


Primary interventions for bone and muscle
Primary interventions for bone and muscle?

  • Build bone at young age with calcium and vitamin D intake and exercise, and stay active with weight bearing activity; minimize alcohol intake.

  • Maintain muscle mass with exercise.


Endocrine changes with aging
Endocrine changes with aging

  • What can you describe?


Endocrine system and aging
Endocrine system and aging

  • Nocturnal ADH secretion in younger patients becomes blunted in aging patient. (more free water excreted later in day)

  • Higher resting levels of catecholamines in blood circulation (but less responsive beta adrenergic receptors).

  • FSH and LH increase at menopause in females, as estrogen decreases.

  • Testosterone tends to decrease in males.


Endocrine and aging
Endocrine and aging

  • TSH is unchanged.

  • T4 is unchanged.

  • Insulin resistance tends to increase.


Immune function changes with aging
Immune Function changes with aging

  • What would you say about immune function as we age?


Immune function and aging
Immune function and aging

  • Number of neutrophils does not change, nor does the adherence or chemotaxis functions, but the intracellular killing function decreases.

  • Marked decrease in T cells (shift from naïve to memory subtypes).

  • Moderate decrease in function of the natural killer cells.


Immune function with aging
Immune function with aging

  • IL-2 is markedly decreased, after stimulation.

  • Moderate decrease in delayed-type hypersensitivity.


Psychology of aging
Psychology of Aging

  • How we humans deal with stress is a BIG factor in health outcomes.


Stressors loss and grief
Stressors--Loss and Grief

  • Retirement is a loss of roles, responsibilities, and rewards

  • Sensory and functional losses occur as we age.

  • Loss of loved ones, friends, a partner, cause intense grief which may last 6 – 12 months.


Stressors new role
Stressors—new role

  • Taking the role of a caregiver can be a stressor.


Tools for stress
Tools for stress

  • What are they?


Tools for stress1
Tools for stress

  • Moderators

    • Positive emotional responses

    • Confidence, rises to the challenge

    • Optimistic

  • Mediators

    • Self efficacy

    • Social networks

    • Healthy behaviors

    • Religious activity


Moderators of stress definition
Moderators of Stress--definition

  • Behavioral and emotional responses a person employs to address demands.

    • Example: Invoking confidence and optimism in the face of bad news helps a person meet the challenge and strengthens the likelihood of a positive outcome.


Coping behaviors
Coping Behaviors

  • Selection, optimization, and compensation

  • Re-frame how they judge their own performance

  • Do selected things more and derive optimal credit for doing them

  • As losses continue, employ compensatory strategies to place performance capacities in the best light possible. ( case example of comparing self to self at a younger age)


Mediators of stress
Mediators of Stress

Definition - the internal and external resources the person can bring to assess and interpret the stress- mediators shape the person’s response to stress.

Personal Qualities such as self-efficacy and coping

External Resources such as a social network and formal services


Robust social networks
Robust Social Networks

  • Reduced mortality risks

  • Better physical health outcomes

  • Reduced risk of ADL disability or decline

  • Increased likelihood of ADL recovery

  • Buffered impact of negative life events

  • Promotes strong self-efficacy beliefs


Self efficacy mastery internal locus of control resilience competence
Self-Efficacy (mastery, internal locus of control, resilience, competence)

Strong self efficacy beliefs:

  • buffer the effects of stress exposure,

  • help maintain good function,

  • slow functional decline among those with poor physical performance,

  • contribute to good choice making, good performance and persistence of effort, increased productivity,

  • contribute to over-all physical performance, independently of ability.

    (MacArthur Study of successful aging)


Anticipatory guidance and the physician
Anticipatory Guidance and the Physician

WHY USE ANTICIPATORY GUIDANCE?

The psychosocial aspects of aging have broad ramifications for health treatment.

Appreciating the stressors associated with retirement, and understanding the patient’s behavioral or emotional response, improves the physician’s ability to treat the patient.


Anticipatory guidance and modifying self efficacy
Anticipatory Guidance, and modifying self-efficacy

The physician can help the patient with:

  • Encouragement (being persuaded to undertake a targeted activity)

  • Reinforcement (experiencing pleasure from success)

  • Performance accomplishment (directing patient to succeed in a series of increasingly difficult tasks)

  • Vicarious learning and social modeling (helping patients to see others like themselves succeed in a targeted area)


Promote healthy behaviors
Promote Healthy Behaviors

  • Implementing positive behaviors – exercise, controlling intake of food, tobacco, alcohol, and active relaxation or stress-reduction techniques all have a positive effect on well-being.

  • When proposing that older people make these changes, invoke the use of social networks and self-efficacy to promote change.


Spiritual or religious involvement
Spiritual or Religious Involvement

  • Religion plays a more important part in the lives of older persons than in those of younger persons, they are more actively involved in attending religious services and in carrying out regular private religious practices.*

  • There are consistent positive relationships between religious involvement and indicators of good health.*

    *proven by many research studies


How to define successful aging
How to define successful aging?

  • What have studies shown?


Healthy aging
Healthy Aging

  • Healthy aging extends beyond the mere presence of disease or infirmity to include physical, mental, and social well-being.

    (Constitution of World Health Organization, 5th edition, 1952.)


One definition schmidt 1994
One Definition(Schmidt 1994)

Successful aging: minimal interruption of usual function although minimal signs and symptoms of chronic disease may be present.

(Using this definition, about 50% of older adults age successfully.)


Books about aging
Books about aging

  • Aging Well (Vaillant, 2002)

  • Aging with Grace (Snowdon, 2001)


George vaillant

Aging Well: Surprising Guideposts to a Happier Life from the Landmark Harvard Study of Adult Development

GEORGE VAILLANT


Aging well
Aging Well Landmark Harvard Study of Adult Development

Pulls together data from 3 separate longevity studies (beginning in their teens, following 824 individuals for more than 50 years):

  • Male Harvard graduates

  • Inner-city, disadvantaged males

  • Intellectually gifted women.


Vaillant asked for a definition of wisdom 1 of 2
Vaillant asked for a definition of wisdom (1 of 2) Landmark Harvard Study of Adult Development

  • Empathy, through which one must synthesize both care and justice.

  • Tolerance and a capacity to appreciate paradox and irony even as one learns to manage uncertainty.

  • Self-awareness combined with an absence of self-absorption.

  • The capacity to “hear” what others say.


Vaillant asked for a definition of wisdom 2 of 2
Vaillant asked for a definition of wisdom (2 of 2) Landmark Harvard Study of Adult Development

  • Perspective, sense of larger context of life, realization that there are two sides to everything, nothing is black or white. Patience. Sense of irony of life.

  • A sense of connectedness of all things.


Aging well1
Aging well Landmark Harvard Study of Adult Development

The book beginswith an all-inclusive definition of aging that suggests decay,change, and continued growth. It ends with an admonition thatthe final "task of Integrity is acceptance of one’s oneand only life cycle as something that is to be and that permitsno substitutions."


George vaillant1

" Landmark Harvard Study of Adult DevelopmentOwning an old brain, you see, is rather like owning an old car.... Careful driving and maintenance are everything."

GEORGE VAILLANT


David snowdon ph d

AGING WITH GRACE: What the Nun Study Teaches Us About Leading Longer, Healthier, and More Meaningful Lives

DAVID SNOWDON, PH.D.


The nun study
The nun study Leading Longer, Healthier, and More Meaningful Lives

  • The School Sisters of Notre Dame in Mankato, Minnesota

  • 75 to 104 years old and agreed to donate their brain tissue after their deaths

  • High ability in written and oral expression correlated with a low rate of Alzheimer‘s


The nun study1
The nun study Leading Longer, Healthier, and More Meaningful Lives

Major factors in avoiding dementia or Alzheimer's:

  • Avid readers

  • Individuals involved in community affairs compared to more reclusive members of the order

  • Heredity, diet, and exercise


The nun study2
The nun study Leading Longer, Healthier, and More Meaningful Lives

Suggests that living a fulfilling and worthwhile life and altering our own lifestyles and those of our children so that old age need not be an inevitable slide into ill health and mental confusion, but instead, years of productivity in which intellectual and spiritual vigor and good health are retained.


Evidence for optimal aging
Evidence for optimal aging Leading Longer, Healthier, and More Meaningful Lives

  • Do physical activity/exercise/leisure activity.

  • Watch your weight.

  • Don’t smoke.

  • Manage stress (moderate and mediate)

  • Marry well.

  • Participate in social networks.

  • Participate in religion.

  • Be a life-long learner.

  • Save for retirement.


Example of optimal aging
Example of Optimal Aging Leading Longer, Healthier, and More Meaningful Lives


Savilla s advice
Savilla’s advice Leading Longer, Healthier, and More Meaningful Lives

  • Don’t drink.

  • Don’t smoke.

  • Eat greens daily.

  • Oatmeal is good for you.

  • Marry well.

  • Walk daily.

  • Read the Bible.

  • Don’t worry too much, be happy.


Question 1
Question #1 Leading Longer, Healthier, and More Meaningful Lives

  • When an 80 year old patient presents to your office with complaints of poor sleep, and after you gather a sleep history, what can you tell the patient?

    • A. It is reasonable to take a 2 hour nap each afternoon.

    • B. Sleep becomes less efficient as we age.

    • C. Drinking a mixed drink with one ounce of alcohol will help with sleep.

    • D. Limiting caffeine intake, and drinking caffeinated beverages only in the morning may help with sleep quality.


#1 Leading Longer, Healthier, and More Meaningful Lives

  • When an 80 year old patient presents to your office with complaints of poor sleep, and after you gather a sleep history, what can you tell the patient?

    • A. It is reasonable to take a 2 hour nap each afternoon.

    • B. Sleep becomes less efficient as we age.

    • C. Drinking a mixed drink with one ounce of alcohol will help with sleep.

    • D. Limiting caffeine intake, and drinking caffeinated beverages only in the morning may help with sleep quality.


Question 2
Question #2 Leading Longer, Healthier, and More Meaningful Lives

  • Which of the following are true:

    • A. TSH does not change with aging.

    • B. Insulin resistance increases with aging.

    • C. Diurnal ADH secretion curve is blunted, so there is less at night.

    • D. Serum Catecholamine levels tend to go up with aging.


#2 Leading Longer, Healthier, and More Meaningful Lives

  • Which of the following are true:

    • A. TSH does not change with aging.

    • B. Insulin resistance increases with aging.

    • C. Diurnal ADH secretion curve is blunted, so there is less at night.

    • D. Serum Catecholamine levels tend to go up with aging.


Question 3
Question #3 Leading Longer, Healthier, and More Meaningful Lives

  • Which physiologic changes of aging can lead to wide pulse pressure?

    • A. Stiffening of the great vessels.

    • B. ASCVD.

    • C. Hyperthyroidism.

    • D. Arterio-venous shunt.


#3 Leading Longer, Healthier, and More Meaningful Lives

  • Which physiologic changes of aging can lead to wide pulse pressure?

    • A. Stiffening of the great vessels.

    • B. ASCVD.

    • C. Hyperthyroidism.

    • D. Arterio-venous shunt.


Question 4
Question #4 Leading Longer, Healthier, and More Meaningful Lives

  • Aging of the kidneys leads to:

    • A. loss of cortical nephrons more than medullary nephrons.

    • B. less ability to adapt to extreme changes in fluid status.

    • C. Consideration of changing medication doses, for those drugs excreted through the kidney.

    • D. Reduction of the estimated GFR.


4 aging kidneys
#4 Aging kidneys Leading Longer, Healthier, and More Meaningful Lives

  • Aging of the kidneys leads to:

    • A. loss of cortical nephrons more than medullary nephrons.

    • B. less ability to adapt to extreme changes in fluid status.

    • C. Consideration of changing medication doses, for those drugs excreted through the kidney.

    • D. Reduction of the estimated GFR.


Question 5
Question #5 Leading Longer, Healthier, and More Meaningful Lives

  • More skin infections in the elderly may be due to which of the following physiologic changes?

    • A. Thinning of the skin.

    • B. Drying of the skin.

    • C. Functional changes in the immune system.

    • D. Decrease in number of natural killer cells.


#5 Leading Longer, Healthier, and More Meaningful Lives

  • More skin infections in the elderly may be due to which of the following physiologic changes?

    • A. Thinning of the skin.

    • B. Drying of the skin.

    • C. Functional changes in the immune system.

    • D. Decrease in number of natural killer cells.


6 true or false
# 6--True or False? Leading Longer, Healthier, and More Meaningful Lives

  • Aging is characterized by mortality increasing exponentially, while biochemical composition of tissue changes, and physiologic capacity decreases, while ability to maintain homeostasis diminishes, and susceptibility and vulnerability to disease increases.


6 true or false1
#6--True or False? Leading Longer, Healthier, and More Meaningful Lives

  • Aging is characterized by mortality increasing exponentially, while biochemical composition of tissue changes, and physiologic capacity decreases, while ability to maintain homeostasis diminishes, and susceptibility and vulnerability to disease increases.

  • True.


7 true or false
#7--True or False? Leading Longer, Healthier, and More Meaningful Lives

  • When a person participates in a robust social network, he or she likely will experience: reduced mortality risks, better physical health outcomes, reduced risk of ADL disability or decline, increased likelihood of ADL recovery, buffered impact of negative life events, promotion of strong self-efficacy beliefs.


7 true or false1
#7--True or False? Leading Longer, Healthier, and More Meaningful Lives

  • When a person participates in a robust social network, he or she likely will experience: reduced mortality risks, better physical health outcomes, reduced risk of ADL disability or decline, increased likelihood of ADL recovery, buffered impact of negative life events, promotion of strong self-efficacy beliefs.

  • Answer: TRUE.


Bibliography
Bibliography Leading Longer, Healthier, and More Meaningful Lives

  • Geriatric Review Syllabus. 7th ed. 2010.

  • NIH State-of-the-Science Conference Statement on Preventing Alzheimer’s Disease and Cognitive Decline. April 26-28, 2010.

  • Aging Gracefully. David Snowdon, 2001.

  • Aging Well. George Vaillant, 2002.


Bibliography1
Bibliography Leading Longer, Healthier, and More Meaningful Lives

  • Table 22, Life Expectancy at birth, at 65 years of age, and at 75 years of age, by race and sex: United States; Health, United States 2010, page 153, accessed on 4/5/11 at www.cdc.gov/nchs.

  • You’re Only Old Once: A Book for Obsolete Children, Dr. Suess and A.S. Geisel, 1986.


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