The Pathophysiology of Getting Older Quiz

Answer: Fasting serum glucose level

Diabetes mellitus, in its simplest terms, is high blood sugar which causes metabolic disorders and major health deficits. These include complications from heart disease, strokes, diabetic retinopathy (irreversible eyesight failure), all of which can end in blindness, kidney failure, and possible amputations from poor limb blood flow.

There are two types: Type I and Type II.

In Type I, which is normally diagnosed soon after birth, a lack of insulin means additional insulin must be given, for a lifelong period, by injection to keep blood glucose (sugar) levels within the acceptable range.
Type II is more insidious: It is characterised by increased "insulin resistance" frequently caused by obesity, and occurs as we get older. This type of diabetes is treated by oral medication but often large scale lifestyle changes are required: better diet, more exercise, less alcohol, less stress.

As obesity rates rise in the western world, we are on the verge of a diabetes epidemic. Just as we saw the effects of a lifetime of smoking on older people in the late 20th century where people died prematurely of blood and cardiac related problems, the 21st century will be characterised by premature disease in the not-so-old due to obesity-related diabetes .

As we entered the 21st century,, we moved from a hospital based health care system that treated diseases, through a paradigm shift where prevention became the main theme. We are living longer but at what price? Our sedentary lifestyle means we suffer chronic diseases such as diabetes and hypertension earlier and, as we live longer we have a longer period of decreased quality of life as we contract chronic diseases earlier than our forebears but paradoxically, live longer.

Diabetes Mellitus is easily diagnosed. We have a simple blood glucose test after we have fasted overnight. If the levels are above normal, we then take a Glucose tolerance test which means we drink a liquid with a prescribed amount of glucose and monitor the blood glucose levels over the next two hours. In diabetics, the blood glucose levels will not drop as readily as those in unaffected people. People with DM can monitor their diabetic control compliance by measuring their glycosylated haemoglobin.
Acute diabetics can monitor their glucose levels by taking finger prick specimens and placing the specimen in a portable instrument to give an instantaneous glucose reading.

Answer: Haemoglobin

The most common blood tests ordered are Urea and Electrolytes, and Complete Blood Count (CBC). These are general non-specific tests that are good screens for checking body systems. The CBC checks all the blood cells parameters such as red and white blood cells and platelets. Haemoglobin is the protein on red blood cells which carries the oxygen to the individual cells and it is this displacement of the oxygen at the cellular level that gives each cell its energy.

A symptom of low haemoglobin is increased tiredness. Those people with low haemoglobin may require a blood transfusion to replace their haemoglobin, but it is important to understand what has caused the anaemia and to treat the underlying cause.

Answer: They are much smaller (called microcytes)

Anaemia (an = without, aemia = of the blood) therefore means without blood which is obviously an exaggeration. Perhaps "hypoaemia" would have been a better term.

Red blood cells are bi-concave: this means they are shaped like a doughnut but the "hole" in the middle is not complete and there is a thin membrane instead. It is this shape that maximises the oxygen carrying capacity of the red cell. Changes to this shape reduce oxygen carrying cells. In iron deficiency anaemia, the cells (microcytes), are smaller than the normal blood cell. Additionally, the cells are hypochromic. This means they stain less intensely than normal cells. These hypochromic microcytes are characteristic of iron deficiency anaemia or thalassemia. Thalassemia can be distinguished from iron deficiency anaemia by the presence of elliptocytes or sickle cells, although more sophisticated tests are necessary to confirm a diagnosis of thalassemia.

In anaemia due to Vitamin B12 or folate deficiency the red cells are seen as as macrocytes.

Answer: The blood flow in the arteries of the heart is slowed or stopped causing part of the heart to die

"Myo-" is a prefix meaning muscle. "Cardial" means of the heart Infarction is tissue death caused by a reduction or stoppage in blood flow. These artery blockages are due to mechanical compression, rupture, or vasoconstriction. The first two are usually caused by injury, the latter by disease.

Therefore myocardial infarction means death of cardiac muscle (due, usually in people, as they age, to hardening of the arteries as the arteries that give the heart its own blood flow (the coronary arteries) restrict blood flow.

Hence the heart itself has such an insufficient capacity, that part of the heart muscle dies. This is accompanied with severe crushing pain. Mortality due to MI decreased dramatically towards the end of the 20th century as the effects of cessation of smoking became apparent. Unfortunately increased obesity levels are causing MI rates to rise again. Regardless of smoking status or obesity, some vasoconstriction of the coronary arteries does occur, (usually with some cholesterol derivative) which reduces fitness and aerobic capacity over time. Now you know why you need to have your cholesterol levels checked regularly as you get older.

Answer: Yes

The body does a remarkable job in keeping everything in check. As cells and tissues get old and die, they are usually replaced by new ones. Cancer is where there is abnormal growth and/or increased rate of growth of a particular type of cells that is not able to be controlled by the body's natural regulatory functions. This can happen in a multitude of tissue types. The key fact we need to know is it malignant or benign. This means is it "spreadable" (malignant) - does it have the capacity to move to other sites (metastases) or is it self contained (benign)? Cancers (correct name neoplasms - new growth) that metastasise (spread) to the liver, pancreas, lymph nodes or bone have poor prognoses as these sites have large blood supplies to further spread the cancer. In the case of the bone, any treatments will have difficulty reaching this site due to this tissue having a poor blood supply.

If your biopsy has a well defined margin, this is a good sign as it is much less likely to spread as it appears to be self contained.

Answer: White Blood Cells

Leukaemia (literally, white blood) is a group of diseases of the bone marrow that result in a proliferation of white blood cells, often immature and non-functional. The bone marrow, if overridden with these type of cells, causes platelet numbers to drop resulting in excessive bleeding, and increased bruising ability. Decreased white cell functional activity means inability to fight infections, often simple ones, with recurrent infections being common. Finally red cell production is decreased causing anaemia and tiredness. There are acute and chronic variants. In the elderly, the most common is chronic lymphocytic leukaemia (CLL).

Factors that initiate leukaemia are unclear, although they may include a genetic predisposition, exposure to radiation and carcinogenic chemicals (e.g, benzene), and in particular viruses such as the Human T-Cell leukaemia virus (HTLV).

In elderly patients, there may be no symptoms initially, and the diagnosis is often made on a routine blood test. There is no cure and treatment is based upon preventative or supportive treatment for secondary diseases that arise from leukaemia.

Globally, in 2012, 352,000 people were diagnosed with some form of leukaemia with 265,000 deaths.

Answer: Undiagnosed hypertension often has no symptoms initially

Hypertension is usually symptomless, which is why doctors are always keen to take our blood pressure. Symptoms when they occur, are vague and non-specific: lightheadedness, vertigo, tinnitus (buzzing or hissing in the ears), altered vision or fainting episodes can all occur.

Hypertension is when blood pressure exceeds 140/90 mm Hg.

Approximately one billion adults, or over 20% of the population of the world, have hypertension. It is treatable but there is no cure. Lifestyle changes such as moderate exercise, reduction in sodium (salt) and caffeine (some people), and a healthy weight, all help to reduce blood pressure.

Answer: Surgery to replace the lens in the eye

Cataracts are the clouding of the lens within the eye causing visual problems like blurry vision, faded colour and poor night vision. They can be bilateral of affect a singular eye. They are associated with aging but other risk factors are smoking, increased alcohol consumption, exposure to prolonged sunlight and diabetes. Treatment is surgical replacement of the biological lens with an artificial crystalline lens, an operation that is done in the day hospital setting with only topical anesthesia. Unfortunately many people in Africa and South America, predominantly, do not have access to such surgery and therefore the prevalence of blindness due to cataracts is very high whereas in Australia, Canada and the US it is less than 5%.

This is significant given 50% of all people over 80 in these countries have, or have had, cataracts.

Answer: Antibiotics do not work on viruses

Infections are found mainly in the very young who have little immune systems of their own and depend on passive immunity from their mother, and the elderly who have less than optimal functioning immune systems. The discovery of penicillin in 1929 meant that antibiotics could cure infections due to bacteria where previously no treatment was available. However, because of overprescription of antibiotics, resistance has developed to many common antibiotics and stronger antibiotics, normally reserved for serious infections, have to be used for relatively minor infections. When one presents to a physician with a sore throat, the cause is most likely to be a virus. All viruses are unaffected by antibiotics. A viral sore throat is usually self limiting and will disappear within a couple of days. If the person has a persistent sore throat then antibiotics are now indicated.

Of course for major infections like meningitis and septicaemia, (both of which are prevalent in the elderly), antibiotics are needed and fast. In addition, usually immediate hospitalisation is necessary, so that intravenous antibiotics can be used.

Answer: There is no actual single diagnosis

There are eight stages to life with old being the final stage in the life course of an individual. This period is usually associated with declining function, both mental and physical. As such old age is a "social construct" as opposed to a definitive "biological stage". Some of the biological processes of reaching old age include but are not limited to:
- The cardiac system becomes less efficient. Vasoconstriction hinders circulatory flow.
- Bones become thinner and weaker, prone to osteo- and rheumatoid arthritis.
- Falls that do not cause injury in younger people cause death and morbidity in the elderly.
- Most elderly persons have at least one chronic condition: diabetes; uncontrolled hypertension; diagnosed arthritis, and heart disease of some type.
- Sleep problems are common.
- The senses lose function: tastebuds weaken, eyesight fails, hearing is harder, skin loses elasticity.
- Reduced mental and cognitive ability.
- Depression is common.

Cause of death can be any or a combination of these things. Our attitudes to death of the elderly is different to those that die "prematurely". We speak of elderly death in such terms as "She had a good innings", "It was a merciful release". We do not get to choose when we die, but we all hope it will be merciful, without pain and not in a hospital. Sadly, these criteria are not commonly met.

In the western world we have repeatedly pointed to increased life span as a measure of success of our collective health systems. However with reductions in violent crimes causing death, workplace accidents, the road toll and health improvements due to large numbers ceasing smoking, the price we pay for that is living with chronic conditions for longer and decreased quality of life.

Our wishes as we approach old age differ but there are some common elements: All of the preparedness we can muster earlier in life to live a healthy lifestyle will minimise complications and chronic diseases as we age; we are starting to realise that health systems for the elderly are not so much to cure illnesses but to support the patient and manage their way through the latter part of life with decreased function. Perhaps the hardest lesson to learn is one of acceptance.