• Who are the aged?
• Why do we age?
• How do we age?
• Can we stop ageing?
• What should we do to prepare for healthy ageing?

• Ageing is a gradual, continuous process of natural change that begins in early adulthood.
• Many bodily functions begin to decline during early middle age.
• There is no specific age at which people become old or elderly.
• The designation of age 65 as the beginning of old age is arbitrary and may be influenced by socioeconomic factors.
• Factors such as retirement age and subverted medical care coverage entitlement may play a role in determining the perception of old age.

• Although people age somewhat differently, some changes result from internal processes, that is, from ageing itself.
• Thus, such changes, although undesired, are considered normal and are sometimes called "pure ageing", "usual ageing" or "senescence".
• These changes occur in everyone who lives long enough, and that universality is part of the definition of pure ageing.
• For example, presbyopia occurs in virtually all older people and is considered normal ageing.

• Chronological age is based solely on the passage of time. It is a person's age in years. Chronologic age has limited significance in terms of health.
• Biological age refers to changes in the body that commonly occur as people age. Most noticeable differences in apparent age among people of similar chronologic age are caused by lifestyle, habit, and subtle effects of disease rather than by differences in actual ageing.
• Psychological age is based on how people act and feel. For example, an 80-year-old who works, plans, looks forward to future events, and participates in many activities is considered psychologically younger.

• Disengagement theory (Cumming & Henry 1961)
  • a natural withdrawal or disengagement from life roles as the way to greater life satisfaction for older adults.
• Activity theory (Lemon, Bengtson, & Peterson 1972)
  • maintenance of activity is critical to high levels of life satisfaction in old age.
• Continuity theory (Atchley 1989)
  • preserve and maintain both internal psychological structure and external structure in the social and physical environment by making adaptive choices that allow them to feel a sense of continuity between past and current events.

These theories discussed how individual adapt and adjust to the changes associated with ageing.

(Putnam, 2002)

• Old cells sometimes die because they are programmed to do so. The genes of cells program a process that, when triggered, results in death of the cell. This programmed death, called apoptosis, is a kind of cell suicide. The ageing of a cell is one trigger to make room for new cells.
• Old cells also die because they can divide only a limited number of times. This limit is programmed by genes. When a cell can no longer divide, it grows larger, exists for a while, then dies. The mechanism that limits cell division involves a structure called a telomere which are used to move the cell's genetic material in preparation for cell division. Every time a cell divides, the telomeres shorten a bit. Eventually, the telomeres become so short that the cell can no longer divide. When a cell stops dividing, it is called senescence.

• Cells may also be damaged by harmful external substances, such as radiation, sunlight, and chemotherapy drugs or by certain by-products of their own normal activities. These by-products, called free radicals, are given off when cells produce energy.

• Afterall, ageing is inevitable and it is a normal process for everyone, regardless of their wealth, status or background.
• The point is how we can age successfully.
• Maintaining good lifestyle habits, e.g. healthy eating, regular exercise and build up social connection. Many people can still have a healthy ageing process and enjoy their golden years with grace and joy.

• Functional ability comprises the health-related attributes that enable people to be and to do what they have reason to value.
• It is made up of the intrinsic capacity of the individual, relevant environmental characteristics and the interactions between the individual and these characteristics.
• Several domains of functional ability appear crucial to allowing people to achieve these ends.
• These are the abilities to:
  • meet their basic needs,
  • learn, grow and make decisions,
  • be mobile,
  • build and maintain relationships, and
  • contribute to society.

• Environments comprise all the factors in the extrinsic world that form the context of an individual's life.
• These include – from the micro-level to the macro-level – home, communities and the broader society.
• Within these environments are a range of factors, including the built environment, people and their relationships, attitudes and values, health and social policies, the systems that support them, and the services that they implement.

• 6 key domains of intrinsic capacity (IC):

• Vitality
• Locomotor capacity
• Psychological capacity
• Cognitive capacity
• Hearing capacity
• Visual capacity

• How to measure intrinsic capacity?

• WHO Integrated Care for Older People (ICOPE) Screening Tool
• The World Health Organization's ICOPE Handbook App is a digital application developed by WHO which is used to assess the intrinsic capacity of older adults and provide a personal care plan which enable them to achieve healthy ageing.

• Intrinsic capacity peaks in early adulthood and tends to decline from midlife onwards. There is great variability in these trajectories and some components of capacity may remain stable or even increase over the life course.
• These trends highlight the diversity that is a hallmark of older age and that counters the stereotype that there is such a thing as a typical older person.

• declines in physical and mental capacity.
• physical and social environments – including their homes, neighbourhoods, and communities, as well as their personal characteristics (e.g., sex, ethnicity, or socioeconomic status)
• healthy behaviours.

• At any point in time, an individual may have reserves of functional ability that they are not drawing on. These reserves contribute to an older person's resilience.
• The Healthy Ageing model conceptualizes resilience as the ability to maintain or improve a level of functional ability in the face of adversity.
• This ability comprises both components intrinsic to each individual and environmental component that can mitigate deficits.

Although research is limited, some of the things that older people identify as important include having:

• a role or identity;
• relationships;
• the possibility of enjoyment;
• autonomy (being independent and being able to make their own decisions);
• security;
• the potential for personal growth.

• One way of assessing the interaction between individuals and their environment is through the notion of person–environment fit.
• This reflects the dynamic and reciprocal relationship between individuals and their environments.
• The concept of person–environment fit considers:
  • individuals and their health characteristics and capacity;
  • societal needs and resources;
  • the dynamic and interactive nature of the relationship between older people and the environments they inhabit;
  • the changes that occur in people and places over time.

• However, an environment is not neutral in its relationship with different individuals.
• Indeed, the same environment may affect different individuals in very different ways, influenced strongly by the range of personal characteristics that help determine a person's social position.
• The result can be a systematic and unequal distribution of access to resources or exposure to negative environmental characteristics, or both.
• When these interactions are unfair, they result in health inequities.
• The cumulative impact of these inequities across our life course is a powerful influence on Healthy Ageing.

• Healthy Ageing reflects the ongoing interaction between individuals and the environments they inhabit. This interaction results in trajectories of both intrinsic capacity and functional ability.
• To illustrate how these might be conceptualized and used, the above Figure shows three hypothetical trajectories of physical capacity for individuals beginning from the same starting point in midlife.
  • Individual A can be considered as having the optimal trajectory, in which intrinsic capacity remains high until the end of life.
  • Individual B has a similar trajectory until a point when an event causes a sudden fall in capacity, followed by some amount of recovery and then a gradual deterioration.
  • Individual C has a steady decline in function.
• Each trajectory sees the person die at around the same age, but the levels of physical capacity they have enjoyed in the interim are very different.
• From the original starting point in the Figure, the goal would be for each individual to experience the same trajectory as individual A.
• Figure also shows alternative trajectories for individuals B and C.
  • For Individual B, a more positive trajectory might, for example, result from access to rehabilitation, and a negative trajectory might result from a lack of access to care.
  • For Individual C, a more positive trajectory might result from a change in a health-related behaviour or having access to medication.

• These hypothetical curves are an example of the diversity of older age and reflect the weak link at an individual level between intrinsic capacity and chronological age.
• However, at a population level, more general trends can be observed, with the average capacity at age 65 being very different from that at 80.

• These population averages can be seen in Fig. It is worth noting, however, that even at a population level, there are significant differences in these average trajectories of intrinsic capacity.
• In developing a country specific response to population ageing, a first step might be to identify these differences and why they exist.
• Even if an individual's intrinsic capacity has fallen below its peak, the person may still be able to do the things that matter to them if they live in a supportive environment.
• This reflects the concept of functional ability: the ultimate goal of Healthy Ageing. Here, too, the concept of trajectories can be applied.

• Fig. shows average trends from midlife in intrinsic capacity and functional ability.
• The additional functioning associated with functional ability reflects the net benefits accrued from the environment that a person lives in.
• This may become increasingly important as decrements in a person's capacity increase.
• It is assumed that the environment always enables functional ability to be greater than might be possible through intrinsic capacity alone.
• However, it is possible that in some settings the barriers that the environment puts in the way of older people may be greater than the benefits it provides.

• This can be achieved in two ways:
  • by supporting the building and maintenance of intrinsic capacity
  • by enabling those with a decrement in their functional capacity to do the things that are important to them
• These general trajectories can be divided into three common periods:
  • a period of relatively high and stable capacity
  • a period of declining capacity
  • a period of significant loss of capacity
• It is important to note that these periods are not defined by chronological age, are not necessarily monotonic (that is, continually decreasing) and that trajectories will differ markedly among individuals (and may be disrupted entirely by an unexpected event such as an accident).
• Some people may, for example, die suddenly from any of a variety of causes while still in the period of high and stable capacity.

• Healthy Ageing considers these phases of older age as part of a continuous trajectory of ability and capacity.
• Public-health interventions should similarly be seamless to remain relevant for older people as they transition from one phase to another.

• Dealing with diversity
  • Shaping policy to foster Healthy Ageing will require active efforts to better understand the diverse needs of older populations.
  • Another approach that is increasingly used is the concept of being person-centred.
  • This strategy is designed to encourage a fundamental paradigm shift in the way health services are funded, managed and delivered so that all people have access to health services that respond to their preferences, are coordinated around their needs, and are safe, effective, timely, efficient and of an acceptable quality.
• Reducing inequity
  • Several steps can help ensure that policy choices enhance equity.
  • These include:
    • making a commitment that all older people will have equal opportunities to improve or maintain their health;
    • assessing health policies and programmes in relation to inequalities, from inputs to outcomes, and gauging to what extent these are fair or unfair.
    • involving older people and other stakeholders in identifying interventions that draw on the evidence for what works locally and elsewhere.
• Enabling choice
  • Older people with the lowest intrinsic capacity and functional ability at any given age are not only less likely to be financially secure and well educated but are also less likely to have had the opportunity to develop the skills and knowledge that allows them to make the choices that are in their best interest.
  • Therefore, fostering the abilities to choose and to self-manage in this group may be a useful strategy for overcoming some of the inequities experienced in older age.
• Ageing in place
  • To encourage the ability of older people to live in their own home and community safely, independently, and comfortably, regardless of age, income or level of intrinsic capacity.
  • Emerging technologies, provide opportunities to learn, and monitor the safety and ensure the security of an older person, may make this goal more achievable in the future.
  • Ageing in place can be further enhanced by creating age-friendly environments that enable mobility and allow older people to engage in basic activities.
  • However, as with other policies on ageing, putting too rigid an emphasis on one-size-fits all solutions can present problems.
  • For example, ageing in place may not be the prime goal for isolated older people, for those with high unmet needs for care and inappropriate housing, or for those living in unsafe or less than supportive neighbourhoods.

• The World Health Organization, Member States and Partners for Sustainable Development Goals created a Global Strategy and Action Plan for Ageing and Health for 2016–2020.
• The United Nations Decade of Healthy Ageing (2021–2030) is a global collaboration, aligned with the last ten years of the Sustainable Development Goals, to improve the lives of older people, their families, and the communities in which they live.
• To foster healthy ageing and improve the lives of older people, their families, and communities, fundamental shifts will be required not only in the actions we take but in how we think about age and ageing.
• The Decade will address four areas for action:
  • Age-friendly environment
    Age-friendly environments are better places in which to grow, live, work, play, and age. We can create them by addressing the social determinants of healthy ageing and enabling all people, irrespective of their level of physical or mental capacity, to continue to do the things they value and live dignified lives.
  • Combatting Ageism
    Ageism is stereotyping (how we think), prejudice (how we feel) and discrimination (how we act) towards people on the basis of their age. It affects people of all ages but has particularly negative effects on the health and well-being of older people.
  • Integrated care
    Older people require a comprehensive set of services to prevent, slow, or reverse declines in their physical and mental capacities. These services need to be delivered to meet the person's needs (person-centred), coordinated between different health and social care providers, and avoid causing the user financial hardship.
  • Long term care
    Many older people experience declines in their physical and mental capacity which means they can no longer care for themselves without support and assistance. Access to good-quality long-term care is essential for these people to maintain their functional ability, enjoy basic human rights and live with dignity.

• The 2015 World report on ageing and health defines the goal of healthy ageing as helping people to develop and maintain the functional ability that enables wellbeing.
• This concept of healthy ageing inspires a new focus for health care in older age – a focus on optimizing people's intrinsic capacity and functional ability as they age.
• In October 2017, WHO published Integrated care for older people: Guidelines on community-level interventions to manage declines in intrinsic capacity.
• These guidelines set out 13 evidence-based recommendations for health and care workers to help develop and carry out person-centred integrated care for older people (ICOPE) at the community level.
• The ICOPE approach embodies the focus on optimizing intrinsic capacity and functional ability as the key to healthy ageing.

• Combining its two Greek roots.
• Syndrome means basically "running together".
• So when diagnosing a condition or disease, doctors tend to look for a group of signs and symptoms existing together.

• Geriatricians have embraced the term "geriatric syndromes" or "geriatric giants", using it extensively to highlight the unique features of common health conditions in the older adults.
• Unlike other classical syndromes, like Down's Syndrome where a single and unique pathology (Trisomy 21) has been identified, geriatric syndromes are not caused by specific pathology or disease, rather, are a manifestation of multifactorial conditions affecting several organ systems.

• Three "I":
  • Instability (Falling)
  • Insanity (Delirium)
  • Incontinence
• They are common geriatric syndromes in older patients and characterized by the presence of other disorders (multifactorial) clustering at the same time. (refer to diagrams)
• These clusters are only examples, and the surrounding co-morbidities can be variable.

• With time, there are other geriatric syndromes described other than the three classical giants.
  • Iatrogenicity (any injury or illness that occurs as a result of medical care)
  • Pressure injury
  • Failure to thrive, or unintentional weight loss
  • Refusal to eat, etc
• All these syndromes are manifestations of underlying multiple comorbidities and should not be regarded as a single disease alone.
• They are associated with substantial morbidity and poor outcomes.

• They are also called non-specific presentations.
• Weakness, fatigue, dizziness, as well as impaired mobility are among the most frequently reported non-specific complaints (NSCs)
• In contrast to specific complaints such as chest pain, which can be caused by a small number of diseases, NSCs can be caused by numerous underlying conditions.
• Non-specific presentations, which are specific for older people, challenge models of care that are based on single system problems.

• Traditional signs and symptoms of illness can be less obvious (or are less frequent) in older people.
• For example, respiratory and non-respiratory symptoms are less commonly reported by older patients with pneumonia (in 20% they do not complain of cough, in 35% neither dyspnoea nor sputum was reported, in 50% no fever, in 60% no tachycardia)
• Therefore, acute illness can present with non-specific signs and symptoms such as functional decline or weakness.
• The three geriatric syndromes: Falling, Delirium and Incontinence can also be regarded as NSCs because they are manifestations of a cluster of other co-morbidities, which are not easy to notice or diagnose in the initial stage.
• Sometimes NSCs are also taken as "atypical presentations" because the complaint may not indicate the culprit condition and often can lead to a wrong diagnosis.

• Age-related physiology factors:
  • such as immuno-senescence – age-associated immuno-deficiency.
  • There may be absence of fever or high white cell count even when having infection.
• Communication failure:
  • The classification of complaints as 'non-specific' is subjective and depends on physician related factors such as clinical experience, training, and the setting.
  • Patient-related factors include the patient's ability to articulate symptoms, cognitive status. Under reporting of symptoms may occur.
• Variation in physiological reserve and cross system presentation:
  • All organs or systems in our body are inter-connected in order to function in a co-ordinated manner.
  • Therefore, when an organ X is being stressed, all other organs will be stressed too.
  • In the diagram (organ development and degeneration trajectory) organ X is having ample reserve and organ Y is marginal in reserve (most vulnerable). When organ X is stressed, its function drops modestly while organ Y's function can drop dramatically below the line of illness presentation threshold. Therefore, organ Y will act as the presenting system instead of organ X, making the presentation atypical and can mis-direct the diagnosis process.
    ➜ The most vulnerable system (lowest reserve) acts as the presenting system instead of the system being stressed.

• Mrs. Wong, a 75-year-old female, complaining of poor short-term memory for 6 months. She left keys in door lock and lost her way in familiar MTR stations and forgot what overcoat she had worn when leaving barber shop.
• Physical examination did not reveal any remarkable abnormalities.

• She underwent all basic investigations for suspected dementia.
• All tests were normal except the thyroid function.
• She had hypothyroidism.

• Hypothyroidism in Mrs. Wong was presented as cognitive decline instead of the classical symptoms of cold intolerance, weight gain, lethargy...

• The answer is yes.
• The brain reserve is marginal in this woman.
• The brain is the vulnerable organ in her and therefore it acts as the presenting organ.
• In future, therefore she will have higher risk of dementia.

• Mr. Chan, a 78-year-old male, who was a smoker and living alone.
• One day he was found lying on floor with wetted pants by his neighbours.
• He was brought to the emergency department by ambulance.
• Physical examination revealed no fever. The pulse was fast, and the blood pressure was on the low side.
• He was delirious and uncommunicable.

• Urine multi-stix test revealed that there were white blood cells, nitrite and glucose.
• The diagnosis was urosepsis in underlying undiagnosed diabetes.

• Mr. Chan's illness presentation was the 3 geriatric giants:
  • Instability (falling on ground)
  • Incontinence (wetted pants)
  • Insanity (delirium)
• In this case of urinary tract infection, there is no fever due to immune-senescence.
• The system being stressed is the urinary tract.
• The typical or specific complains should have been urinary frequency, dysuria and fever, which were all absent in this case.

• X: Locomotor system – falling on ground
• Y: Urological system – wetted pants or incontinence
• Z: Brain – delirium

• Mrs Lam, 83-year-old woman, attended the geriatric clinic with her daughter (collateral informant), complaining of forgetfulness for one year.
• She enjoyed good past health and was living alone independently in a village house.
• She liked planting flowers and gardening.
• She could manage cooking and shopping.
• Physical examination revealed that:
  • She had a blunted affect.
  • She did not speak much or spontaneously but she was communicable.
  • Her face was erythematous, swollen and there was generalized eczema all over the body.
  • Her daughter did not recall any drug or allergen exposure.
  • However, there was a strong temporal relationship between the cognitive decline and the skin problem.

• The disease was presented as a cognitive complaint instead of saying feeling unhappy, insomnia or loss of appetite.
• This is called "pseudo-dementia". That is the dementia is not real and the true diagnosis is depression.
• She was treated with topical steroid and anti-pruritic therapy with urgent referral to dermatology since it affected her mood.

• Follow up 4 weeks later with normal skin and appeared cheerful.
• She could manage her own affairs again and resumed planting flowers in her backyard.
• Her memory problem recovered.

• The daughter complained that her mother's cognitive problem recurred.
• Her skin condition was perfect.
• This time the dementia was real, indicating that her brain had limited reserve and was vulnerable.
• Therefore, the cognitive domain had acted as the presenting system while in fact it was the affective domain (mood) being stressed.
• This is an illustration of cross system presentation accounting for the atypical presentation of illness in old age.

• Geriatric syndromes are common presentation of illness in older adults while specific complaints indicating one disease are rare.
• Geriatric Syndromes are just manifestations of a cluster of co-morbidities behind the scenes.
• They can act as cross-system presentation systems and often mis-guide the diagnostic process in clinicians unfamiliarized with older patients.
• This phenomenon challenges traditional models of care that are based on single system problems.

• Non-vertigo dizziness is a common non-specific complaint and may only represent feeling weak which may demand a workup for general frailty. However, it is important to rule out iatrogenic causes like use of psychotropic medications causing "dizziness".
• Syncope though is not as common as dizziness, may indicate serious underlying medical conditions and warrants prompt medical attention.
• The causes are various and many a times can co-exist. It is essential to rule out readily treatable conditions, like overtreatment of hypertension causing postural dizziness or syncope, or over-treated diabetes mellitus causing hypoglycaemia. Other specific causes include cardiac arrhythmias, low cardiac out diseases, vasovagal episode (relatively uncommon in older persons), neurological diseases etc. All these require specific investigation with equipment in a specialist setting and therefore referral to a specialist is sometimes warranted.

• Defined as an acute and transient global cognitive impairment due to widespread disturbance of cerebral metabolism.
• Not easy to differentiate delirium from dementia and often they co-exist.
• Knowing the pre-morbid cognitive function from a collateral informant is critical in making the diagnosis.
• Cause
  • Unlike younger people, the causes of delirium in older adults usually are extra-cranial
  • Adverse drug reactions (anti-cholinergic, psychotropics etc.)
  • Hospitalization in an unfamiliarized environment
  • Poor lighting
  • Metabolic and electrolyte disturbance
  • Hypoxia due to various reasons
  • Severe constipation or acute urinary retention
  • Severe pain
  • Systemic infection and reversible causes
  • Generally, these causes can occur together
• Management
  • Placing the older adults in a quiet and calm environment accompanied by the usual caregiver and treating the underlying reversible conditions.
  • Restraints can aggravate the condition and should be avoided as far as possible. They often cause more harm than good.
  • Sedation is only indicated for uncontrollable agitation after failure of all non-pharmacological methods. They should be reviewed regularly and weaned off as soon as possible.

• Defined as having a body core temperature below 35 degrees Celsius.
• Multiple age-related physiological changes that predispose an older adult to hypothermia:
  • Cognitive decline can impair recognition of a cold environment. The shivering activity to generate heat to regulate normal body temperature is impaired in old age.
  • In face of coldness, peripheral vasoconstriction is inefficient to reduce body heat loss. The basal metabolic activity is diminished and cannot generate body heat readily.
  • The mobility or muscle activity is low to generate adequate body heat.
  • The loss of subcutaneous fat reduces heat insulation and cannot prevent body heat loss.
  • A frail older adult can have one or more of these characteristics and therefore it is not uncommon that he or she can suffer from hypothermia in winter.
• Preventive measures
  • Avoid sitting or lying for a long period. Move around regularly. Muscle activity can generate heat.
  • Eat well and eat warm food.
  • Maintain a warm home environment.
  • Wrap up well with multi-layer clothes. Wear a hat, gloves and stockings even indoors.