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Ageing and Family Medicine - Coggle Diagram

- - - - Telomeres - repeated DNA sequences (TTAGGG)
        Telomerase - enzyme that repairs telomeres
      - Progeria - associated with ageing in first decades of life
        
        Werner - 2nd-3rd decade
        Hutchinson Gilford - 1st decade
    - - Growth arrest
        Increase in size
        Express p16INK4a and SA-Bgal
        Nuclei contain active DDR proteins
  - - - Internal cascade of biochemical events, usually physiological
      - Blebbing
        Loss of membrane asymmetry and attachment
        Cell shrinkage
        nuclear fragmentation, chromatin condensation
    - - Due to external influences, usually pathological
  - - - Hearing - presbycusis - gradual loss of high tone hearing
        Vision - presbyopi and cataract formation
        Skeletal - loss of height and bone density
        Muscle - sarcopenia
        Renal - reduction in GFR, decreased functioning nephrons
        Hepatic - reduced rate of regeneration, reduced blood flow
- - - - Asking focused question (PICO model)
        
        Finding evidence
        
        Critical appraisal - systematic evaluation of clinical research papers
        
        Making decision
        
        Evaluating performance
      - Limitations
        
        RCTs do not usually include frail old people
        
        Hypertension in very elderly trial
        
        Risks of post-hoc subgroup analyses
        
        Subgroups of older people smaller in numbers
        Oldest old different outcomes - masked in reporting of whole trial
        
        Extrapolation of data
        
        Number needed to treat decreases for more prevalent conditions in older people, theorhetically more likely to benefit
      - Levels of evidence
        
        Systematic review/metaanalysis of RCT
        Case control/cohort studies
        Non-analytic studeis
        Expert opinion
  - - - Explicit - occurs when there is conscious awareness/intention/control
        Implicit - exist and operate without conscious awareness, intention or control
        Self-referential - occurs as people age themselves - fear/grief at ageing, affects engagement with health services
    - - Explicit - policies restricting treatments on basis of age only, restriction of access to service because of cognitive/sensory impairment
        Implicit - procedure - can be attitudinal and deeply entrenched
- - - - Edmonton frail scale - scores various domains of fuctional ability
        Walk speed
        Traditional assessment - end of bed assessment
  - - - Administration - impairments/disabilities makes it difficult to obtain/comply with medication regimes
      - Absorption - older people have slowed gastric emptying and reduced parietal cell function
        But most drugs passively absorbed in small intestine - largely unaffected
      - Distribution
        Reduced total body water, decreased Vd, increase initial concentration of water-doluble drugs
        Lipophilic - increased body fat percentage, increased Vd, increased elimination t1/2
        Albumin-bound drugs - reduction in albumin, increased levels of unbound drugs, larger Vd
      - Metablism - reduced - be careful of drugs with narrow therapeutic index
      - Elimination - excretion mostly in kidneys
        Use creatinine clearance or eGFR to assess renal function
        Cannot use creatinine alone - older people reduced muscle mass, may not rise above normal range even when significant impairment is present
    - - Concurrent use of multiple drugs by single person
      - Error of commision
        
        Beers criteria - explicit criteria for drugs to be avoided in older people
        
        STOPP (screening tool of older persons) - systems-defined medicine review tool, 65 rules relating to most common and potentially dangerous instances of inappropriate prescribing in older people
      - Error of omission
        
        START (screening tool to alert doctors to the right treatment) - detects prescribing omissions in elderly patients
  - - - Eating
        Bathing
        Dressing
        Toileting
        Transferring
        Continence
    - - Instabillity
        Immobility
        Incontinence
        Impaired intellect
        Iatrogenic
        Frailty
    - - Medical
        Mental
        Functional
        Social
        Environment
  - - - Presbycusis - age-related decline in ability to hear high frequencies
        Noise-induced hearing loss
    - - Uncorrected refractive error e.g. mypoia
        Cataracts
        Claucoma
        Macular degeneration
    - - Pseudobulbar palsy - UMN lesion of cerebral hemispheres - slurred, high pitched, weak articulation
        Bulbar palsy - LMN lesion of brainsteam or lesions of lower cranial nerves - indistinct articulation, hypernasality, bilateral weakness, sparing of ocular muscles
      - Disruption to integrated action of UMN, basal ganglia, cerebellum
        Multiple sclerosis - cerebellar lesion - slurred, scanning, staccato speech
        Parkinson's disease - extrapyrimidal - dysthythmic, dysphoric, monotonous voice (bradykinesia, cognitive deficit, speech deficit)
    - - Receptive - Wenicke's
        Expressuve - Broca's
        Fluent - normal rhythm and articulation but meaningless
        Non-fluent - difficulty forming words and sentences, hesitant speech with pauses
- - - - 4 main perceptions (SRBB)
        
        Perceived seriousness
        Perceived risk
        Perceived benefits
        Perceived barriers
      - Health belief model does not consider changes in attitudes, views and behaviours over time - poor predictor of health behaviours
    - - Focuses on intention to adopt behaviour - attitude is strong predictor of intention, motivated behaviour
      - Attitude - postive/negative feelings about a behaviour
        Behaviour belief - behaviour performance -> outcome
      - Subjective norm - what others think about behaviour
        Motivation to comply *affected by others thoughts), normative beliefs (others disapproval affecting motivation to comply
      - Does not consider effect of wider social determinants/changes in behaviours
      - Theory of planned behaviour = perceived behavioural control _ theory of reasoned action
    - - Precontemplation
        Contemplation
        Preparation
        Action
        Maintenance
        Relapse
    - - Unaware of issue
        
        Unengaged by issue
        
        Deciding whether to act
        
        Decision not to act
        
        Decision to act
        
        Acting
        
        Maintenance
  - - - Relationship between illness beliefs and response to illness
        
        Representation - making sense of problems - cognitive/emotional
        
        Coping response - deal with problem, return to normal state
        
        Appraisal - assess how successful coping stage has been
    - - Kubler-Ross
        Denial -> anger -> bargaining -> depression -> acceptance
      - Moos and shaefer (crisis theory) - chnages provoked by illness lead to crisis
        Personal, illness-related, environmental factors
    - - Tension management
        
        Fictional acceptance - polite acceptance
        Breaking through - person is normal appart from stigmatising feature
        Consolidation - maintaining new perception that person is normal
      - Information management
        
        Passing as normal (not being open)
      - Collective response
        
        Soending time with fellow sufferers - safety in numbers
  - - - Oral contraceptive pills - worries about side effects
        Painkillers - worry about addictive paracetamol
        Polypharmacy - multiple medicines