Empowerment of the ageing population: a contribution to active ageing

Empowerment is fundamental to release the potential generated by the longevity revolution and to actualize the concept of active ageing. It is a key component in the promotion and maintenance of health, the fostering of lifelong learning and social participation, as well as in the safeguarding of protection until the end of life. The definition of empowerment becomes more complex in the context of increasing numbers of the very old, with its frequent association with dementia and limited functional capacity. Active ageing highlights that ageing is a lifelong process firmly rooted in the ideas of health prevention and health promotion. Implicit to it, is the view that actions at both the personal and the public policy level are essential to optimize opportunities for people as they age.

Hearing impairments and their treatments

Hearing loss is highly prevalent and increases as a function of age. Although hearing loss affects many aspects of ageing and communication, it is often overlooked and treated as a rather inconsequential side effect of ageing. The purpose of this chapter is to introduce age-related hearing loss, the broader implications of age-related hearing loss as it relates to healthy ageing, and practical strategies for primary care management of hearing loss. A majority of the cases of age-related hearing loss remain untreated. Primary and/or geriatric care clinics may serve as the entry point for many older adults with hearing loss. Including questions about hearing loss or screening for hearing loss at other health encounters may increase access for older adults to hearing loss treatment.

Common age-related eye diseases and visual impairment

General physicians have an essential role in preventing vision loss in older people. However, most vision-threatening eye disorders are initially asymptomatic and often go underdiagnosed. Therefore screening, early detection, and timely intervention are important in their management. The most common cause of visual impairment is uncorrected or undercorrected refractive error, followed by cataract, age-related macular degeneration, glaucoma, and diabetic retinopathy. Spectacles and cataract surgery can successfully restore sight for uncorrected refractive error and cataract, respectively. Visual impairment as a result of age-related macular degeneration, glaucoma, and diabetic retinopathy can be prevented with appropriate treatment if they are identified early enough. This chapter provides an overview of common age-related eye disease and visual impairment.

Sexuality in older persons

Sexuality is defined as the dynamic outcome of physical capacity, motivation, attitudes, opportunity for partnership, and sexual conduct. Sexual health in older persons is a topic deserving increasing interest and attention for both a public audience and physicians. Over half of people over 65 years of age, report sexual dysfunction, women more so than men. Since sexual health is dependent on general health and can be considered a mirror of general health, its assessment should be part of the routine clinical assessment, even in older subjects. However, asking about sexual health especially in older persons is often a difficult or embarrassing task for many primary care physicians. In addition, many patients find difficult to raise sexual issues with their doctor. Early recognition of sexual symptoms is the first step to starting multimodal treatments aimed at improving sexual health and related quality of life in older persons.

Constipation and faecal incontinence

Constipation and faecal incontinence are the two main functional digestive disorders reported by old people. Prevalence increases with age and predominantly affects women. Both are associated with poorer quality of life. Clinical assessment of constipation including a detailed history is the best approach to identify features suggesting abnormal transit or evacuation problems. As for many geriatric syndromes, medication related effects should always be considered. Faecal incontinence is a marker of disability assessed by most activities of daily living (ADL) scales. In severe cases, faecal incontinence is also associated with high mortality rates. The main risk factor for transient faecal incontinence is the coexistence of a functional digestive disorder such as constipation (especially with faecal impaction) or diarrhoea. These two conditions must be identified since they can be improved by specific therapeutic programmes, which are usually multidimensional and multiprofessional.

Management of acute kidney injury and chronic kidney disease

Both acute and chronic states of kidney disease have considerable healthcare impact as they can produce enormous disease burden and costs. To classify chronic kidney disease into the CKD staging system, glomerular filtration rate as an index of kidney function, as well as albuminuria as a marker of kidney damage have to be assessed as correctly as possible. Misclassification is a serious concern due to the difficulties in precise GFR assessment and correct interpretation of results. Differentiating between pure senescence and true disease among older adults can be a delicate issue. To find the right renal replacement option for individuals that progress to end-stage renal disease can be challenging, and some older patients may even benefit from conservative care without dialysis. To prevent acute kidney injury as a frequent and potentially life-threatening complication, clinicians need to develop an understanding of the common vulnerability to kidney damage among older adults.

Parkinsonism, Parkinson’s disease, and related conditions

Parkinson’s disease (PD) is a progressive neurodegenerative condition characterized clinically by fatiguable bradykinesia, rigidity and tremor and pathologically by deposition of Lewy bodies and cell loss in the substantia nigra and other brain regions. Parkinsonism is the term used to describe the clinical features of conditions resembling PD. Their management requires specialist assessment and a multidisciplinary approach. Levodopa remains the mainstay of treatment for PD. Although other treatments are used, older people are more sensitive to their side effects. Non-motor symptoms, particularly neuropsychiatric problems, significantly impact quality of life and need special consideration in older people. Towards the later stage of the disease, management can be complex, and should involve advanced care planning.

Examining the nervous system of an older patient

Ageing is associated with changes in the nervous system, especially the accumulation of neurodegenerative and white matter lesions within the brain. Abnormalities are commonly found when examining older people and some of these are associated with functional impairment and a higher risk of death. In order to reliably interpret examination findings it is important to assess cognition, hearing, vision, and speech first. Clarity of instruction is key. Interpretation of findings must take into account common age-related changes. For example, genuine increased tone should be distinguished from paratonia. Power testing should look for asymmetry within the individual, rather than compare to the strength of the examiner. Parkinsonism should be looked for and gait should be observed. Neurological assessment can incorporate a range of cortical abilities and tests of autonomic function, but the extent of these assessments is likely to be determined by the clinical situation and time available.

Valvular heart disease: state of the art and treatment perspectives

Decision-making for the management of valvular disease (VHD) is rapidly evolving with advances in surgical and interventional techniques. The main causes of VHD has moved from rheumatic to degenerative, more particularly in industrial countries. In this chapter will be briefly discuss the aetiologies, presentation, and natural history of VHD in adults. The medical and surgical options available to date and the threshold for intervention will be then described. The role of a multidisciplinary Heart Valve Team working together with a geriatrician has become crucial to determine the optimal therapeutic option for VHD in older adults. Surgical valve replacement has been for decades the only possible option for the three leading VHDs in developed countries: aortic stenosis (AS), aortic regurgitation (AR) and mitral regurgitation (MR). Mitral stenosis (MS) has almost disappeared in Western countries while its prevalence remains high in the developing world.

Syncope and neurocardiovascular instability

The prevalence of syncope rises with age and is challenging because of atypical presentation, overlap with falls, and poor recall of events. Cardiac causes and multiple comorbidities are more common, and related morbidity and mortality are higher than in younger patients. Hence, a high index of suspicion for cardiovascular causes of falls and dual pathology will increase successful diagnosis and intervention. Age-related neurohumoral and physiological changes plus chronic diseases and medications often contribute to syncope. Orthostatic hypotension, carotid sinus syndrome, vasovagal syncope, postprandial syncope, sinus node disease, atrioventricular block, and ventricular tachycardia are other common causes. Management is often based on removing or reducing the predisposing or precipitating factors through medication adjustments, behavioural strategies, and more invasive cardiac interventions if indicated. It is often not possible to identify a single cause of syncope in older persons, hence apragmatic management of each diagnosis is recommended.