General other systemic effects of ageing:
- Renal blood flow decreases
- Reduction in kidney mass and subsequently GFR
- Changes in diurnal ADH production -> nocturia
- Reduction in cardiac compliance and increased cardiac risk
- Decreased pulmonary surface area, chest wall elasticity, and respiratory muscle strength
- Loss of hepatocytes and liver metabolic function
- Reduced immunological and T cell function – more prone to infections
- Slowing of bowel motility and water reabsorption – more prone to constipation
- Atherosclerosis (ED)
Urology and ageing:
The prevalence of most urological conditions and cancers increases with age.
Can be difficult to differentiate between normal ageing process and reversible pathology causing signs and symptoms in elderly patients.
However, conditions common in the elderly such as UTIs and incontinence should not be accepted as ‘part of ageing’ and should be assessed and treated.
Structural lower tract changes include:
- Increased collagen relative to smooth muscle in bladder
- Reduced contractility
- Reduced compliance and elasticity
- Reduced permeance and compliance of submucosa vascular and neural networks
- Atrophy of skeletal muscle -> pelvic floor and sphincteric dysfunction
Significant overlap in structural changes normal with ageing and exacerbated or brought on by post-menopause, BPH etc.
Urodynamic findings (may not be solely ageing but related to other pathology)
- Increased PVR
- Reduced flow rate
- Reduced bladder capacity
- Reduced sensation of filling
- “DODU” – detrusor overactivity with detrusor undercontractility – overactivity in filling phase with poor flow and weak contractility with voiding (also DHIC)
Other significant contributors to LUT function and continence are medications or co-morbidities which:
- Affect production of urine (OSA, DM, CHF)
- Affect bladder storage and voiding (neurological, coughing, constipation, medications)
- Affect ability to locate to get to the toilet on time (dementia, mobility, frailty, arthritis)
Physiological alterations associated with ageing lead lo loss of functional reserve and impaired ability to respond to stressors and maintain homeostasis.
Clinically evaluating the geriatric patient:
- Assess co-morbidities (can use Charlson Comorbidity Index)
- Functional assessment
- Performance status
- Activities of daily living
- Mobility
- Timed up and go test
- Slow gait speed is one of strongest predictors for poor outcomes
- Cognition (e.g MMSE)
- Depression
- Surgical risk
- Pre-operative assessment by physicians
- Physical / medical risk – ASA score, co-morbidities, cardiovascular assessment
- Functional risk – frailty, nutrition, cognition, mobility
- Social risk – caregiver support, home situation
Frailty
Complex condition which overlaps but not identical to comorbidity or disability.
“Vulnerability for developing increased dependency and/or mortality when exposed to physiological stressors”
“Loss of in-built reserves in multiple body systems, rendering the frail individual vulnerable to even minor stressors”
Frailty phenotype (3 or more may be considered frail, 1-2 pre-frail)
- Unintentional weight loss
- Exhaustion
- Low physical activity
- Slow walking speed
- Muscular weakness / reduced grip strength
Frailty index:
- Accumulated deficits over time with increasing quantitative deficits indicating higher degree of frailty
- e.g. “Deficit Accumulation Index”
Frailer patients have more complications and longer LOS, independent of age or co-morbidities.
Clinical Frailty Score:
