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Chua et al, 2008 Annal Acad Med Singapore

  • 250 1st yr med students, before clinical exposure
  • UCLA Geriatrics Attitudes Scale. (The14‐item questionnaire ) + 15th item re willingness to consider Geriatric Medicine as a potential career choice.
  • mean UCLA attitudes score suggested a generally +ve attitude.
  • strong association between attitude scores and willingness to consider Geriatric Medicine as a career, but only 1/3 wanted to, more chicks

Wetsmoreland et al, JAGS, 2009

  • Aim to ↓ "agism" which is prevalent among medical trainees,
  • a new geriatrics educational experience for medical students aimed at improving attitudes toward older patients
  • 90‐minute Older Adult Session :
    • initial reflective writing exercise;
    • introduction to the session;
    • 75‐minute dialogue with the "Council of Elders," a group of active, "well" older adults;
    • and final reflective writing exercise.
  • provided to 237 1st & 2nd year med students during the 2006/07 academic year, Indiana Uni School of Medicine.
  • Responses on Geriatrics Attitude Scale after sig improved in 7/14 items, demonstrating better attitudes toward being with/ listening to older people & caring for older patients.

Why this topic is important to you as a doctor

  • 1. You will increasingly see a lot of older patients
  • 2. There are crucial differences in how to treat older people
  • 3. Effective help requires understanding of biological, psychological and social changes of ageing
  • 4. You will grow old ..........hopefully

Outline

  • What to expect with normal ageing:
    • Biological changes and neuropsychology of ageing (underpins psychosocial aspects)
    • Psychology of ageing, psychodynamics, personality
  • Successful adaptations to ageing, concepts of quality of life, happiness
  • Prevention – what promotes well‐being
  • Successful ageing in drs


Biological changes

  • Musculoskeletal function
  • Cardiovascular ageing–lower efficiency
  • Pulmonary efficiency
  • Sensory changes–eyesight, hearing
  • Increase in fatigue
  • Slower recovery time after injury & vulnerability to injury eg lower back
  • Circadian rhythm & sleep:Increasing difficulty coping with shift work after 40

Cognition and Ageing; Very Important For Exam

  • Crystallised intelligence: robust (knowledge, wisdom, vocabulary)
  • Fluid intelligence ↓: learning, sorting
  • Speed: ↓, memory retrieval slower, more difficult
  • Competing tasks leads to poorer performance
  • Memory: OK for semantic (vocab grows), procedural, recognition, BUT episodic more vulnerable
    • Things you learn recently = highly affected

Brain & Ageing: Cognitive Function

  • Greater heterogeneity
  • Medium‐term memory
  • Reaction time increases
  • Speed of information processing decreases

Random study

  • Christenson H. What cognitive changes can be expected with normal ageing? Aus NZ J Psychiatry 2001; 35: 768‐75.
  • Knowledge/wisdom stable
  • Speed goes down
  • Memory composite goes down
  • But there's a spread - between and within individuals
    • Can't just ask for mandatory retirement because there will be a lot of highly functioning older people

Psychodynamic contributions

  • Freud–meaning of defences, relationship between loss and depression
  • Bowlby attachment theory–secure vs insecure, loss, dependency, internal images of mother
  • Post‐freudian object relations‐
    • Winnicott – concept of internalisation of the mother, self objects & transitional objects that stand in for the mother – loss a/w ageing →depression and anxiety
    • Kohut – development of the self, narcissistic disturbances relate to illness, death depleted self objects.

Developmental theories of ageing

  • Erikson 1966
    • generativity v stagnation –establishing and guiding next generation, mentoring and social connection, a sense of agency and progression productivity creativity vs stagnation and interpersonal impoverishment→ CARE
    • Ego integrity vs despair and disgust ie acceptance personal life, position in world affairs and history, one’s own life is own responsibility, valuing experience‐ vs time too short to try out different routes→WISDOM

OTHER THEORIES

  • Hildebrand1982‐developmental tasks‐ fear of diminution loss of sexual potency, threat redundancy, limitation of what can one achieve, remake marital relationship after children left, feeling of having failed as a parent, awareness ageing death
  • Colarusso & Nemiroff 1981‐ 7 hypotheses for adult dev’t‐ ongoing dynamic process, fundamental issues childhood continue in altered form, influenced by bodily changes, influenced by adult past as much as childhood, finiteness of time
  • Schmid (1990) +ve attempts at self consolidation, nothing to lose like adolescent rebellion

Good to “feel” young

  • People generally "feel" (felt age) and would "like" (ideal age) to be younger,
  • Better for well‐being to feel young than to want to be young
  • felt age entails perceptions of current circumstances as they relate to expectations about ageing, whereas ideal age reflects a comparative overview of the life cycle.

Happiness in ageing

  • the degree to which persons feel they have effectively used resources in the past, yet remain optimistic & feel they still have enough to flourish in the present or future
  • older people are more likely to feel real pride and not hubristic pride

Reflection, achievement v optimism and goals

  • Psychological wealth
  • Happiness = (what we have)/(what we want)

Adding life to years = or > adding years to life

  • WHO : QOL “a state of complete physical, mental, and social well‐being and not merely the absence of disease or infirmity”
  • perceptions surrounding quality of life, happiness, and well‐being are in the eye of the beholder.

Personality and age

Emotional well‐being and stability & longevity

  • increased ability to regulate emotions can lead to contentment and acceptance of life
  • emotional well‐being ↑ from early adulthood to old age.
  • ageing a/w more +ve overall emotional well‐being, with greater emotional stability and with more complexity (greater co‐ occurrence +/‐ve emotions).
  • These findings remained robust after accounting for other variables that may be related to emotional experience (personality, verbal fluency, physical health, and demographic variables).
  • emotional experience predicted mortality; controlling for age, sex, and ethnicity, individuals who experienced relatively more positive than negative emotions in everyday life were more likely to have survived over a 13 year period. – Carstensen 2011
  • Highly neurotic and low self esteem and high standards --> perceive health worse.

Interactions between disability, chronic illness & psychosocial effects

  • Relate to morale, depression
  • Suicide
  • Also consider subjective perceptions of health (NB high neuroticism and low conscientiousness, low extraversion, and low openness were associated with worse health ratings)

Social aspects of ageing

  • Life stage of the family
    • Launching family
    • Empty nest
  • Carer burden
  • “Women in the middle” = children + caring for their parents

Friends and more friends

  • Positive social support, social participation, and feelings of social connection.
  • Relate to wellbeing, morale, depression
  • Buffer against mistreatment

Dependency/handicap: Facts About Older People

  • Fully 88% of people aged 60 years and over in NSW are free from ‘severe handicaps’ which would necessitate assistance with personal care, mobility or verbal communication.
  • Older people are more likely to provide than to receive assistance.

Facts About Older People (cont’d)

  • 1/5 older people in NSW serve as volunteers in community organisations
  • Older people twice as likely to give as to receive financial aid from their children
  • Half of all older people provide practical help to their families and friends

Friends and more friends

  • Positive social support, social participation, and feelings of social connection.
  • Relate to wellbeing, morale, depression
  • Relates to suicide risk

Rowe & Kahn (1987; 1997)

  • Recognised that role of ageing perse in age‐associated physiological & cognitive deficits was over‐stated
  • Major role of extrinsic lifestyle factors
  • Made distinction btw USUAL AGEING & SUCCESSFUL AGEING

SUCCESSFUL AGEING (Rowe & Kahn)

  • low probability of disease & disease related disability
  • high cognitive & physical functional capacity
  • active engagement with life (interpersonal relations, control, self‐efficacy, activities)
  • criteria have come under criticism for excluding physically disabled individuals and for implying that most successful agers are those who have necessarily been successful throughout their entire life.

Healthy ageing: how is it defined? (Peel et al, 2004)

  • Reviewed 18 studies: no consensus
  • Consider age, sex, culture/cohort effect
  • Def’ns ranged from purely biological: survival without disease or morbidity
  • To comprehensive: sustained well‐being using bio‐pycho‐social model
  • Most emphasised functional independ.

Mental Well Being

  • 11 included measures of mental health usually cognitive functioning, also psychiatric morbidity, positive perceived health, life satisfaction / personality resources such as sense of control

The subjective nature of healthy ageing

  • WHO SHOULD DEFINE?
  • The person or the researcher

What are the determinants of healthy ageing?

Healthy aging ‐ behavioral determinants (Peel et al, 2005)

  • Extrinsic environmental factors including elements of lifestyle‐ v. impt role in determining risk for disease
  • not smoking,
  • being physically active,
  • moderate alcohol consumption.

It’s not too early to start preparing

  • Hillsdon et al (2005) 9‐year follow‐up of 6,398 relatively healthy, mostly working, middle‐aged men and women
  • level of physical activity at baseline predicted higher physical function at follow‐up even after controlling for the presence of chronic illnesses and baseline physical function.

139 teachers followed since 1978, interviewed in late middle age

  • adaptational skills to support later life satisfaction
    • proactive coping‐ planning, preparation, transition
    • Maintenance of achievements
    • Social connectedness passing on the baton
    • Smelling the roses

Wilhelm et al, submitted 2012

Importance of preparing for ageing

  • proactive coping +ve strategies are adopted before the challenges and deficits of later life have even begun
  • Late middle age important
  • Ouwehand et al 2007 have stressed the importance of proactive coping as a key process for successful aging, wherein preparation for expected losses and future challenges may buffer against the stress of the change itself.
  • Note relative independence of long‐standing illness& successful aging. Physical inactivity in the absence of chronic illness could lead to later loss of function; or loss of physical function could be delayed or even avoided by being physically active.
  • ?validity of criteria for successful aging that require an absence of physical disease or disability.

It’s never too late

  • Current non‐smoking & having quit for sometime were both a/w health ageing
  • Cognitive(pref complex) leisure activities:
    • Protective effect ‐ Dosage effect (i.e. 1,2, 3 activities ↓ risk of dementia by 0.77, 0.41, 0.21)
    • May still apply to activities in late life (controversial)

==Vaillant & Western, 2001==

  • F/‐UPof332boysfor60yrsdeath
  • +veageingat70predictedbyvariablesat50
  • Uncontrollable:parentalsocialclass,environmental strengths, no. family problems, major depression, ancestral longuevity, premorbid physical health
  • Controllable: alcohol abuse, smoking, marital stability, BMI, coping mechanisms, education
  • Psychiatric>imptthansociologicalpredictors

Abnormal ageing

  • 5% people > 65 have dementia
  • 3‐25% have MCI (converts to dementia 10‐12% per year)
  • 10‐15% depressive symptoms, about 1‐3% community dwelling >60 have frank depression, 25% in sick older people, 34‐ 40% in nursing homes
  • 10% anxiety

Prevention

  • Depression ‐ ↑mental health literacy, exercise,
  • Cognitive decline – exercise, food, activities, health literacy, risk factors

Addressing risk factors for depression

  • ↑ mental health literacy
  • Rx undertreated conditions that ppte depression: disability, pain, insomnia, incontinence
  • Exercise
  • Faulty thinking habits
  • ? Nutritional supplements (eg B6, B12, Folate only works for elevated homocysteine – also helps dementia)

Exercise for managing depression

  • METHODS: 32 subjects (mean 71 yrs), 20‐wk, randomized, controlled trial, with f‐up at 26 mths. Subjects were community‐dwelling patients with major or minor depression or dysthymia. Exercisers engaged in 10 wks of supervised weight‐lifting exercise then 10 wks of unsupervised exercise. Controls attended lectures for 10 weeks.
  • RESULTS: Depression scores sig ↓at 20 wks and 26 mths of follow‐up in exercisers compared with controls (p <.05‐.001). At the 26‐month follow‐up, 33% of the exercisers were still regularly weight lifting, versus 0% of controls (p <.05).
  • CONCLUSIONS: Unsupervised weight‐lifting exercise maintains its antidepressant effectiveness at 20 weeks in depressed elderly patients. Long‐term changes in exercise behavior are possible in some patients even without supervision.

Cognitive Behavioral Therapy

  • 3 magistrates at a bus stop, they miss bus
    • 1:“what’s the point,why do I bother? I’m hopeless, I can’t do anything right ” → depressed
    • 2:“Oh my god, there will be no more buses, my reputation will be in shatters!” → anxious
    • 3:“SO, I’ll wait & read Marie Claire” →OK

Risk factors

  • Vascular risk factors
  • Hypertension
  • Diabetes
  • Smoking
  • Hypercholesterolaemia
  • Diet / Nutrition
  • OTHER: head injury, alcohol, depression, social activities

Enhancing reserve: Cognitive leisure activities

  • Complex mental activity–brain teasers
  • learning something new–artistic, studying, U3A, languages
  • Memory training (e.g. 12 wk programme benefits 5yrs later; “ brain gyms” & computer games for staying mentally fit
  • Protective effect ‐ Dosage effect (i.e. 1,2, 3 activities ↓ risk of dementia by 0.77, 0.41, 0.21)
  • May still apply to activities in late life
  • +veeffectonmood as well
  • PURPOSE::Toassesstheimpactof24wkofresistance training at two different intensities on cognitive functions in the elderly. METHODS:: Sixty‐two elderly individuals were randomly assigned to three groups: CONTROL (N = 23), experimental moderate (EMODERATE; N = 19), and experimental high (EHIGH; N = 20). Assessed on physical, hemodynamic, cognitive, & mood parameters before and after the program
  • CONCLUSION‐Moderate‐&high‐intensityresistance exercise programs had equally beneficial effects on cognitive functioning & mood.

Brain food

  • Flavonoids‐catechins e.g. tea, dark chocolate, red wine, black grapes, apples, cherries
  • Curcumin‐ curry spice turmeric
  • Resveratrol – red wine blueberries, peanuts
  • Ginkgo biloba
  • Omega ‐3 F/A

102‐year‐old doctor has time to spare for patients

  • “Dr. Denmark weighs newborns on the same scale she used on some of their parents decades ago
  • Georgia (CNN) ‐‐ At age 102, Dr. Leila Denmark is the oldest known practicing doctor in America. And her old‐fashioned ways suit patients just fine.
  • The suburban Atlanta pediatrician doesn't accept medical insurance, she has no office staff and the wait to see her may take up to four hours ‐‐ no appointments; first come, first served.
  • But the drawbacks don't seem to matter to parents, including some who once were Dr. Denmark's patients when they were children themselves. Some travel hundreds of miles to have their children treated by a doctor with 70 years of experience.”
  • Some doctors become demented

Adaptive ageing in Drs

  • Doctors aged 60 or older from OZ, Canada, US (N=25)
    • (i) insights into physical/ psychological effects of ageing and effects on practice;
    • (ii) Doctors identified as dealing with ageing well indulge in a range of generative behaviours such as mentoring, passing on skills and knowledge to others, and finding new goals and directions
    • (iii) need for adaptations in working hrs, choice of work; (iv) the importance of long‐term retirement planning;
    • (v) the usefulness of a transitional phase to ease into retirement;
    • (iv) need to cultivate a variety of medical and non‐medical pursuits and relationships early in one’s career .

Successful ageing in drs is...

  • Self care not self sacrifice
  • Not super doctors
  • Younger doctors burn out too often