Aging, mortality, the prospect of growing old and it's issues

	Aging. Mortality. Denial. Reality. Action...

You can be wise...or otherwise. Age on your terms...

Until a person is in their fourth, fifth or even sixth decade of life, the finality of aging may not mean a lot, even though it's a lifelong process. Childhood, adolescence and young adulthood are typically filled with feelings of immortality. It's often only when a person starts to notice physical changes that they accept that they are actually getting older.

So what exactly is aging — what causes it, how does the body change and how long can a person expect to live?

Some of the physical effects of aging are wrinkles, gray hair and slower reflexes, but what else is going on that you're not seeing? As individuals age, time takes its toll on the organs and systems in the body. How and when this occurs is unique to the individual. And everyone doesn't undergo the same changes. Still, in general, some of the age-related changes that occur include changes in:

• Bones - As one ages, the bones become less dense as they slowly lose mass and minerals. Gradual loss of density weakens the bones and makes them more susceptible to fracture.
• Brain - The number of neurons (cells) in the brain decreases. However, in some areas of the brain, the number of connections between cells increases, perhaps helping to compensate for the cellular decrease and maintain normal brain function.
• Cardiovascular system - The size of the heart increases slightly. The blood pressure increases, the maximum heart rate decreases and the heart may take longer to return to its normal resting state after physical activity.
• Hearing - The normal wear and tear of sounds over the years can damage the cells of the inner ears. The walls of the auditory canals also thin, and the eardrums thicken. Some will have greater difficulty hearing higher frequencies.
• Kidneys - The size of the kidneys shrinks, and the amount your bladder can hold decreases. The kidneys also become less efficient at removing wastes from the blood.
• Muscles - Muscle mass and strength decrease, though increased physical activity can reduce this effect. As the amount of water in the tendons and ligaments decreases, stiffness increases.
• Reproductive system - Women produce less estrogen, progesterone and testosterone as they age. The uterus and the vagina shrink, and there's less vaginal lubrication. Men produce less sperm, and their levels of testosterone decrease.
• Skin - The skin thins, and the nails grow at about half the pace they once did. The sweat and oil (sebaceous) glands become less active, and the moisture in the skin decreases.
• Vision - The eyes are less able to produce tears, the retina thins and the lenses yellow. In ones 40s, focusing on objects that are close-up becomes more difficult due to changes in the lenses. Later, the irises stiffen, making the pupils less responsive. This can make it more difficult to adapt to different levels of light. Further changes to the lenses can make an individual sensitive to glare.
• Falls – According to the AARP, one of every three Americans, aged 65 years and older, falls each year. Among older adults, falls are the leading cause of injuries, hospital admissions for trauma, and deaths due to injury. In 1999, about 10,000 seniors died of fall-related injuries. Fractures are the most serious health consequence of falls.

Approximately 250,000 hip fractures, the most serious fracture, occur each year among people over age 65. Many of these falls and resulting injuries can be prevented. Strategies to prevent falls among older adults include exercises to improve strength, balance, and flexibility; reviews of medications that may affect balance; and home modifications that reduce fall hazards such as installing grab bars, improving lighting, and removing items that may cause tripping.

Driving - While rates of motor vehicle related death and nonfatal motor vehicle related injuries among older adults vary by state, there are some consistencies. In most states, the fatality rates for men are twice those for women. In all states, motor vehicle-related fatalities are higher among adults 75 years and older, as compared with adults between 65 and 74 years of age. Among older adult drivers, the number of motor vehicle-related fatalities increased 30% and the number of nonfatal injuries increased 21% between 1990 and 1997.

How Long Do People Live?

One hundred twenty-two years is the longest documented human life span. Though a life span this long is rare, improvements in medicine, science and technology in the last century have helped more people live longer, healthier lives. In the early 1900s the average life expectancy in the United States at birth was only about 50 years. Today, it's close to 77.

According to the AARP, the 85-plus group is the fastest-growing demographic segment in the United States, although the number of people 100 and older has exploded as well. And, the U.S. Census Bureau projects that the number of people age 85 and older could increase from 4 million in 2000 to 19 million by 2050. And the number of people age 100 and older is projected to more than quadruple from 65,000 in 2000 to 381,000 in 2030.

In the last 10 years, scientists have made great progress in the study of aging. Currently, thousands of research projects on how to slow aging are under way in numerous medical specialties throughout the world. Scientists are studying a variety of topics including everything from cloning for spare parts to how DNA mutations affect aging to fighting cancer with viruses.

But longer lives also mean that some people may spend more time in an incapacitated state at the end of their lives, in part because the United States has done too little to promote healthy aging. Rates of obesity, sedentary lifestyle, smoking and alcohol abuse are still too high. However, researchers say it's never too late to clean up your act. For example, if an individual quits smoking, their risk of heart disease begins to fall almost immediately. Living a healthy lifestyle can improve how an individual ages. No matter the age, an individual can begin preparing now for their later years. An individual is the master of their own quality of life.

Clearly, old isn't what it used to be. And as more than 70 million baby boomers approach their retirement years, the definition continues to evolve.

ELDERLY, ALCOHOL AND ALCOHOLISM

While alcoholism has been increasingly diagnosed and treated in the general population as a whole, older persons, and 60 years of age and over, still constitute a "hidden" group with a significant number having medical problems associated with alcoholism and excessive drinking. The primary care physician can be the front line identifier of alcoholism and/or excessive drinking in the elderly. They need not be an expert or specialist in alcoholism or addiction medicine to assess the elderly patient, diagnose the disorder and provide for treatment. Physicians can update their own awareness in assessing and establishing a diagnosis, and in referring the elderly patient for on-going treatment for alcoholism and for any medical or psychiatric complications.

ELDERLY ALCOHOLIC/EXESSIVE DRINKERS DISPLAY:

• Severe memory loss.
• Inability to concentrate.
• Defensiveness or irritation when asked even routine, general questions about alcohol use.
• Extreme mood swings, even during a single office visit.
• Undo concern about physical ailments, sometimes bordering on hypochondria.
• Suicidal ideation.

ACUTE PRESENTING PROBLEMS IN THE ELDERLY

ALCOHOLIC/EXCESSIVE DRINKER PRESENTS:

• Severe gastrointestinal complaints.
• Loss of consciousness.
• Panic attack.
• Renal and bladder complications.
• Hypoglycemia.
• Angina and other cardiac involvement.
• CNS (Central Nervous System) including ataxia and dyskinesia.
• Blackouts.

Treatment of Alcoholism

The treatment of substance abuse and dependence in older adults is similar to that for other adults. Treatment involves a combination of pharmacological and psychosocial interventions, supplemented by family support and participation in self-help groups.

Pharmacotherapy for substance abuse and dependence in older adults has been targeted mostly at the acute management of withdrawal. When there is significant physical dependence, withdrawal from alcohol can become a life-threatening medical emergency in older adults. The detoxification of older adult patients ideally should be done in the inpatient setting because of the potential medical complications and because withdrawal symptoms in older adults can be prolonged. Benzodiazepines are often used for treatment of withdrawal symptoms.

In older adults, the doses required to treat the signs and symptoms of withdrawal are usually one-half to one-third of those required for a younger adult. Short or intermediate acting forms usually are preferred.

Misuse of Prescription and Over-the-Counter Medications

According to the AARP, older persons use prescription drugs approximately three times as frequently as the general population and the use of over-the-counter medications by this group is even more extensive. Annual estimated expenditures on prescription drugs by older adults in the United States are $15 billion annually, a fourfold greater per capita expenditure on medications compared with that of younger individuals. Not surprisingly, substance abuse problems in older adults frequently may result from the misuse, that is, underuse, overuse, or erratic use—of such medications; such patterns of use may be due partly to difficulties older individuals have with following and reading prescriptions. In its extreme form, such misuse of drugs may become drug abuse.

Depression:

Depression is one of the most common conditions associated with suicide in older adults and is a widely under-recognized and under-treated medical illness. In fact, several studies have found that many older adults who die by suicide, up to 75 percent, have visited a primary care physician within a month of their suicide. These findings point to the urgency of improving detection and treatment of depression as a means of reducing suicide risk among older persons.

Older Americans are disproportionately likely to die by suicide. Comprising only 13 percent of the U.S. population, individuals age 65 and older accounted for 18 percent of all suicide deaths in 2000. Among the highest rates (when categorized by gender and race) were white men age 85 and older: 59 deaths per 100,000 persons in 2000, more than five times the national U.S. rate of 10.6 per 100,000.

Depression often co-occurs with other serious illnesses such as heart disease, stroke, diabetes, cancer, and Parkinson’s disease. Because many older adults face these illnesses as well as various social and economic difficulties, health care professionals may mistakenly conclude that depression is a normal consequence of these problems, an attitude often shared by patients themselves. These factors together contribute to the under-diagnosis and under-treatment of depressive disorders in older people. Depression can and should be treated when it also occurs with other illnesses, for untreated depression can delay recovery from or worsen the outcome of these other illnesses. The relationship between depression and other illness processes in older adults is a focus of ongoing research.

Mental Disorders

Older adults are encumbered by many of the same mental disorders as are other adults; however, the prevalence, nature, and course of each disorder may be very different. This section provides a general overview of assessment, diagnosis, and treatment of mental disorders in older people. Its purpose is to describe issues common to many mental disorders.

Assessment and Diagnosis

Assessment and diagnosis of late-life mental disorders are especially challenging by virtue of several distinctive characteristics of older adults. First, the clinical presentation of older adults with mental disorders may be different from that of other adults, making detection of treatable illness more difficult. For example, many older individuals present with somatic (body related) complaints and experience symptoms of depression and anxiety that do not meet the full criteria for depressive or anxiety disorders. The consequences of these less than clinically diagnosed conditions may be just as deleterious as the syndromes themselves. Failure to detect individuals who truly have treatable mental disorders represents a serious public health.

Detection of mental disorders in older adults is complicated further by high seeming connection with other medical disorders. The symptoms of somatic disorders may mimic or mask psychopathology, making diagnosis more taxing. In addition, older individuals are more likely to report somatic symptoms than psychological ones, leading to further under-identification of mental disorders.

Primary care providers carry much of the burden for diagnosis of mental disorders in older adults, and, unfortunately, the rates at which they recognize and properly identify disorders often are low. With respect to depression, for example, a significant number of depressed older adults are neither diagnosed nor treated in primary care. In one study of primary care physicians, only 55 percent of internists felt confident in diagnosing depression, and even fewer (35 percent of the total) felt confident in prescribing antidepressants to older persons.

Stereotypes about normal aging also can make diagnosis and assessment of mental disorders in late life challenging. For example, many people believe that “senility” is normal and therefore may delay seeking care for relatives with mind-dementing illnesses. Similarly, patients and their families may believe that depression and hopelessness are natural conditions of older age, especially with prolonged bereavement.

Cognitive decline, both normal and pathological, can be a barrier to effective identification and assessment of mental illness in late life. Obtaining an accurate history, which may need to be taken from family members, is important for diagnosis of most disorders and especially for distinguishing between somatic and mental disorders. Normal decline in short-term memory and especially the severe impairments in memory seen in mind-dementing illnesses hamper attempts to obtain good patient histories. Similarly, cognitive deficits are prominent features of many disorders of late life that make diagnosis of psychiatric disorders more difficult.

Overview of Treatment

Treatment of mental disorders in older adults encompasses pharmacological interventions and psychosocial interventions. While the pharmacological and psychosocial interventions used to treat mental health problems and specific disorders may be identical for older and younger adults, characteristics unique to older adults may be important considerations in treatment selection.

Pharmacological Treatment

The special considerations in selecting appropriate medications for older people include physiological changes due to aging; increased vulnerability to side effects, such as tardive dyskinesia; the impact of polypharmacy; interactions with other co morbid disorders; and barriers to compliance.

The aging process leads to numerous changes in physiology, resulting in altered blood levels of certain medications, prolonged pharmacological effects, and greater risk for many side effects. Changes may occur in the absorption, distribution, metabolism, and excretion of psychotropic medications.

As people age, there is a gradual decrease in gastrointestinal motility (movement), gastric blood flow, and gastric acid production. This slows the rate of absorption, but the overall extent of gastric absorption is probably comparable to that in other adults. The aging process is also associated with a decrease in total body water, a decrease in muscle mass, and an increase in adipose tissue. Drugs that are highly lipophilic, such as neuroleptics, are therefore more likely to be accumulated in fatty tissues in older patients than they are in younger patients.

The liver undergoes changes in blood flow and volume with age. Phase I metabolism (oxidation, reduction, hydrolysis) may diminish or remain unchanged, while phase II metabolism (conjugation with an endogenous substrate) does not change with aging. Renal blood flow, glomerular surface area, tubular function, and re absorption mechanisms all have been shown to diminish with age. Diminished renal excretion may lead to a prolonged half-life and the necessity for a lower dose or longer dosing intervals.

Pharmacodynamics, which refers to the drug’s effect on its target organ, also can be altered in older individuals. An example of aging-associated pharmacodynamic change is diminished central cholinergic (liver/bile) function contributing to increased sensitivity to the anticholinergic effects of many neuroleptics and antidepressants in older adults.

Because of the pharmacokinetic and pharmacodynamic concerns presented above, it is often recommended that clinicians “start low and go slow” when prescribing new psychoactive medications for older adults. In other words, efficacy is greatest and side effects are minimized when initial doses are small and the rate of increase is slow. Nevertheless, the medication should generally be titrated to the regular adult dose in order to obtain the full benefit. The potential pitfall is that, because of slower titration and the concomitant need for more frequent medical visits, there is less likelihood of older adults receiving an adequate dose and course of medication.

Increased Risk of Side Effects

Older people encounter an increased risk of side effects, most likely the result of taking multiple drugs or having higher blood levels of a given drug. The increased risk of side effects is especially true for neuroleptic agents, which are widely prescribed as treatment for psychotic symptoms, agitation, and behavioral symptoms. Neuroleptic side effects include sedation, anticholinergic toxicity (which can result in urinary retention, constipation, dry mouth, glaucoma, and confusion), extrapyramidal symptoms (e.g., parkinsonism, akathisia, and dystonia), and tardive dyskinesia.