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COMMON DISEASES AND THE ELDERLY
HL DHAR
Director, Medical Research Centre, Bombay Hospital Trust, Mumbai 400 020.
This article deals with three most common conditions from which elderly subjects suffer i.e. hypertension, arthritis and diabetes.
Hypertension is reversible and prevents or reduces many complications. Primary osteoarthritis is almost a disease of elderly population. Isolated knee joint osteoarthritis is seen most commonly in clinical practice, obesity and female sex are common risk factors. Diabetes mellitus is a common metabolic disorder in aging populations and vast majority of elderly are type 2 diabetics. Elderly patients with diabetes may suffer from some unique syndrome like diabetic neuropathy, amylotrophy, malignant otitis etc and modification of conventional risk factors such as hypertension reduces the risk of complications.
INTRODUCTION
According to Asokan[1] top ten geriatric problems in India are hypertension, cataract, osteoarthritis, COPD, ischaemic heart disease (IHD), diabetes, benign prostatic hypertrophy (BPH), dyspepsia, constipation and depression. Old age people are generally susceptible to high BP, diabetes, bronchitis, arthritis, osteoporosis and heart disease[2-4] and common risk factors are obesity, diabetes, hypertension and various cardiovascular disorders[5] and other extraneous factors e.g. Smoking.
Present article outlines most common conditions like hypertension, arthritis and diabetes.
HYPERTENSION
Hypertension is the most prevalent and remediable risk factor in the cardiovascular diseases. Prevalence rate is 5.1% (60-70 years), 12.6% (70-80 years) and 23.6% (80+).6 Hypertension in elderly may be primary or essential (more common), isolated systolic hypertension (ISH) which occurs in 15% of people aged 60 years or more and secondary due to atherosclerotic changes or primary aldosteronism.
Systolic blood pressure is better predicted than diastolic blood pressure of cardiovascular events, congestive cardiac failure, stroke and end stage renal disease. In isolated systolic hypertension for 1 mm rise in systolic blood pressure there is 1% increase in mortality.[6] Elderly hypertensives are at higher risk for development of chronic brain syndrome, senile dementia, abdominal aortic aneurysms and peripheral vascular disease.
Detection and evaluation
The diagnosis should never be made on a single reading. Accurate measurement of blood pressure in sitting/standing position and that to average of three readings over two occasions should be taken.
History and physical examination, blood investigation (Hb, electrolytes, serum creatinine, blood glucose) X-ray, urine analysis etc. should be done. Further evaluation for secondary hypertension if DBP > 105 is necessary.
Target of blood pressure
Ideal blood pressure among young people should be 120-140 systolic and 80-90 diastolic. In older person blood pressure may go upto 140 systolic and 90 diastolic. However, older person is leveled as hypertensive when systolic goes beyond 160 and diastolic above 95 mm of Hg (WHO criteria). But in case of diabetics and ISH, blood pressure should be reduced to adult level (140 systolic and 90 diastolic).
Treatment
Non pharmacologic : Life style modifications includes (i) Dietary sodium restriction to about 6 gm/day (ii) exercise (iii) cessation of smoking and (iv) control of lipids.
Pharmacotherapy : Factors contributing to increased risk of pharmacological treatment of hypertension are
•Diminished baroceptor activity (orthostatic hypotension)
•Impaired cerebral autoregulation (cerebral ischaemia)
•Sensitivity to hypokalaemia (arrhythmia and muscle weakness)
•Decreased renal and hepatic function (drug accumulation)
•Poly pharmacy (drug interaction)
•CNS changes (depression and confusion)
Drugs [6,7]
Diuretics proven to decrease cardiovascular (CV) events and stroke but limitations are side effects e.g. electrolyte disturbances, adverse effect on insulin resistance and lipids and therefore should be used with caution in elderly but still first line therapy in congestive heart failure (CHF).
Beta blockers are proven drug to decrease CV events and strokes but not considered first line of therapy in elderly hypertension because of side effects (alterations in lipid and glucose metabolism, bronchospasm, orthostatic hypotension and depression) but useful in associated coronary artery disease (CAD).
Calcium channel blockers found to be effective and well tolerated and do not adversely affect lipid and glucose metabolism and peripheral blood flow, preferred drugs in concomitant DM, IHD, CVA, hyperlipidaemia, renal dysfunction and airway disease.
ACE inhibitors have cardio and renoprotective properties and do not adversely affect lipid and glucose metabolism, beneficial in coexisting DM/CHF.
Angiotensin receptor II antagonists Losartan and Valsartan have been found to be effective in elderly hypertensive.
ARTHRITIS
Arthritis is a common and often chronic condition among the aged. A major consequence is the limitation of the ability to conduct activities of daily living leading to loss of independence.
Prevalence of arthritis increases drastically with age. This is primarily due to the high incidence of osteoarthritis in the elderly. The socio-economic burden of this disease is substantial. Knee osteoarthritis, a problem that is much more prevalent in India than in the West, accounts for at least as much disability as any other chronic conditions including congestive heart failure, diabetes, heart disease, chronic obstructive airway disease or depression.[8]
Primary osteoarthritis (OA) is almost a disease of elderly population while secondary osteoarthritis e.g. Paget’s disease, osteopetrosis etc. can affect any age.[9] OA presents as loss of cartilage and accompanying periarticular bone response. Age related changes in articular cartilage are distinct from those of OA, but give clues to increasing susceptibility of cartilage to damage in old age.
Osteoarthritis was earlier described as a disease of wear and tear, a degenerative disorder but recent advances show that it represents a dynamic process, which involves uncoupling of balance between cartilage degeneration and regeneration. Changes in cartilage in osteoarthritis some what differs from normal aging changes. It usually presents as joint pain with structural changes, crepitus, bony enlargements, deformity, instability and restriction of movements may occur. Associated muscular weakness and wasting may also occur. Morning stiffness is a common complaint but brief in duration usually 5-15 minutes but not exceeding 30 minutes.
Joints involved in osteoarthirits: knee joint > hand joint > spinal apophyseal > hip > achromioclavicular and others.
Isolated knee joint osteoarthritis
It is seen most commonly in clinical practice usually one of the compartments of knee joint bears the brunts of attack of the disease, obesity and female sex are common risk factors.
Osteoarthirits of spine
It is commonly seen in lumbar and cervical area. Radiological pictures suggest intervertebral disc degeneration, osteophyte formation with epiphyseal joint involvement. It is characterized by local pain or pain in bending backward.
Nodal, Generalised osteoarthritis
It is seen in middle aged ladies who present as hand joint arthritis, specially distal inter phalangeal involvement, Heberden nodes (bony enlargement of distal inter phalangeal (DIP) joints, Bouchard nodes (bony enlargement at proximal inter phalangeal (IP) joint).
Erosive osteoarthritis (Inflammatory OA)
It can be confused with rheumatoid arthritis (RA) as the patients have inflammation of IP joints with erosive changes. OA of hand usually affects DIP joints with minimal or no signs of inflammation thus mimicking RA.[10] The absence of any signs or symptoms in the wrist and metacarpo-phalangeal joints should raise the suspicion that RA is not present, confirmed by negative rheumatoid factors (RF).
Investigations
Radiology : Plain X-ray of affected joints is sufficient to diagnose OA. Joint space narrowing, osteophytes with subclinical bone sclerosis and subchondral cyst are the main findings.
Management
Although there is no known cure for most forms of arthritis, treatment designed for individual patient can reduce/eliminate symptoms and limit functional impairment. The goals of contemporary management of arthritis extend beyond pain control to the enhancement of patients’ functional status and health-related quality of life.
Non-pharmacological treatment : Patient education regarding joint protection and avoidance of excessive joint loading is important for these patients. Physical measures like hot pack, paraffin bath or occupational therapies may be helpful.
Drug therapy : Since elderly patients are more prone to develop complications of NSAIDs, physicians should be careful in selecting proper drugs on individual basis looking into the cost, efficacy and toxic profile. However, paracetamol may be tried initially as an analgesic in osteoarthritis. Other NSAIDs can be used specially newer selective cyclooxygenase II (Cox-II) inhibitors. Locally applied NSAIDs are also useful.
DIABETES MELLITUS
Diabetes Mellitus (DM) is a common metabolic disorder in aging populations with increased morbidity, disability and premature death. The prevalence of diabetes is about 20% in persons over 65 years of age and about 40% in persons over 85 years.[11,12] There is hardly any report from India regarding the prevalence of diabetes in the elderly. A recent communication from Kolkata (NSR Medical college) as per patients attending OPD service, the prevalence was 11% in persons aged between 65-69 years.[13] In another study at Bhubaneshwar (Orissa), prevalence of diabetes was found as high as 20% in the age group of 65 and above.
The vast majority of patients with DM in the elderly are type 2 (NIDDM) diabetics. Very rarely autoimmune destruction of Beta cells leading to Type 1 (IDDM) DM can occur in the elderly.[14] Some cases could be secondary to associated diseases or drugs.
Pathophysiology
Type 2 diabetes in the elderly has a strong genetic predisposition. Elderly patients with a family history of diabetes are more likely to develop the disease as they age.[15] Physiological changes that occur with aging produce glucose intolerance even in healthy older individuals. These changes manifest primarily as an elevation in post prandial blood glucose levels by as much as 15 mg/dl, and fasting blood glucose about 1-2 mg/dl per decade after 30 years of age.[16,17] Age related changes in carbohydrate metabolism such as increased fasting hepatic glucose production,[18] alterations in glucose induced insulin release[19,20] and resistance to glucose disposal[21,22] may explain the progressive noninsulin-mediated glucose uptake in the elderly.[23] In normal subjects this pathway is responsible for uptake of approximately 50% of glucose after meals. Moreover, a strong correlation between tumour necrosis factor levels and insulin resistance has been observed in obese elderly diabetics.[24]
Factors other than those intrinsic to the aging process may also contribute to glucose intolerance. There is a decrease in lean body mass and increase in body fat (especially central distribution) with aging and this may contribute to insulin resistance.[25] Furthermore, lifestyle changes such as decrease in levels of physical activity and intake of diet rich in saturated fat and low in complex carbohydrates may accelerate these changes in body composition.
Lower testosterone level in men and higher values in women also appear to be risk factors for the development of diabetes in elderly.[26] Older individuals may suffer from multiple ailments requiring multiple drugs. Some of these drugs may exacerbate glucose intolerance e.g. diuretics, oestrogen, glucocorticoids, tricyclic antidepressants etc. Stressful events such as myocardial infarction, infections and surgery can precipitate hyperglycaemia.
Treatment
About half of the elderly patients with diabetes are unaware of their illness because of symptoms of hyperglycaemia are infrequent and are generally non-specific such as confusion and incontinence. Diabetes is often detected for the first time when an elderly person is hospitalized with a complication related to diabetes. Elderly patients with diabetes may suffer from some unique syndromes like diabetic neuropathy, diabetic amylotrophy, malignant otitis externa and papillary necrosis with pyelonephritis.[20] Modification of conventional risk factors such as treatment of hypertension[27,28] reduces the risk of complications.
Tight control or a near normal serum glucose level may pose a greater risk of hypoglycaemia in this population, but age per se should not be an excuse for suboptimal control of blood glucose.[29]
Diet and exercise
Dietary therapy remains the corner stone of management of diabetes. About three quarters of diabetic patients can be controlled by diet alone.[30] However, dietary therapy should be decided on an individual basis looking into co-existing illness, nutritional deficiency including trace elements. Weight loss in obese elderly diabetics improves insulin resistance and glycaemic control.[31] However, many older diabetic patients are not obese, are malnourished and chronically ill and therefore unnecessary calorie restriction should be avoided in them. A diet comprising relatively high carbohydrate (50 to 60% of total calories), low fat (< 30% of total calories with < 10% calories from saturated fat) and moderate protein (about 20% of total calories) would be appropriate for most of the patients.[32] Recently Dhar[33] has reported that an Indian elderly normally requires about 1600 calories (male) and 1425 calories (female) comprising 18% fat, 68% carbohydrate and 14% protein (male) and 20% fat, 67% carbohydrate and 13% protein (female). Adjustment has to be made in diabetics with less carbohydrate and more protein in acute illness, trauma and surgery.
Drug Treatment
Basic principle of drug therapy consists of hypoglycaemia should be avoided and tight control of blood sugar should not be attempted. Few minutes of hypoglycaemia in elderly person may lead to irreversible brain damage.
Sulphonylureas may be considered as first line therapy in lean elderly diabetics. However, sulphonylurea - induced hypoglycaemia is more common with increasing age. 10-20% of patients initiated with sulphonylureas fail to respond.[34] An additional 5-10% of patients per year who initially respond to sulphonylureas will stop responding. Usually Gliclazide and glipizide are preferred to glyburide.
Metformin is safe, effective and an ideal drug for first line therapy in obese elderly diabetics[35] as it assists with weight loss, improves insulin sensitivity, reduces lipid levels and the incidence of hypoglycaemia is very low with this drug. However, significant liver, renal and cardiac disease factors that may be more common in the elderly are contraindications.
Thiazolidinedions particularly rosiltazone can be given as a first line therapy to those who can not tolerate metformin or have a contraindication to the drug,[36] however, liver function tests need to be monitored regularly.
a- Glucosidase inhibitors inhibit the digestion and absorption of simple sugars from the gastrointestinal tract. They may also improve insulin sensitivity,[37] and can be useful as primary therapy in elderly patients with modest fasting hyperglycaemia, especially if they are obese, or combined with other oral agents. The major side effects are flatulence and diarrhoea.
Insulin is indicated in elderly patients in whom hyperglycaemia is not controlled with diet and oral agents. The principles of insulin therapy are essentially the same in older and younger patients with diabetes, however, impairment in cognitive function may adversely affect the compliance of insulin regimen.[38] Elderly patients living alone may be at higher risk of hypoglycaemia. Due to compliance problems a combination of daytime sulphonylurea and bedtime one injection of insulin may be more effective [39,40] than a single injection of insulin alone.
Other drugs : Repaglinide, a non-sulphonylurea drug has a rapid onset and very short duration of action. It results in more physiologic insulin profile and can be given just before a meal in patients with irregular eating habits. The kinetics of repaglinide are not altered with age [41] and frequency of hypoglycaemia may be similar as in young patients.
Complications
Diabetic ketoacidosis and diabetic hyperosmolar coma are the most serious acute complications of diabetes characterized by relative or absolute hypoinsulinaemia. Acute infection is the most frequently encountered predisposing factor (pneumonia being the most common). [42] The principle objective in treating diabetic hyperosmolar coma is to correct the hyperosmolar state. Majority of the patients can be managed without insulin.[36]
Chronic complications in elderly patients with diabetes is cardiovascular disease with twice the mortality rate of age-matched controls without diabetes. According to an estimate, the life expectancy of patient who develop diabetes after the age of 65 is shortened by at least 4 years. [43] The diabetic patient is uniquely predisposed to accelerated atherosclerosis, leading to macrovascular complications of diabetes. [ 25] Dyslipidaemia a common problem in diabetic patients greatly increases the risk of macrovascular complications [44] and therefore, hyperlipidaemia needs to be treated aggressively in elderly patients. [45] Diabetic neuropathy is the most common cause of end-stage renal disease. Intervention at an early stage of microalbuminuria can reverse proteinuria and preserve renal function. [46] Diabetic retinopathy is a leading cause of blindness. Older patients with diabetes are also at a higher risk of blindness from cataracts, muscular degeneration and glaucoma. [47] Therefore, close surveillance by ophthalmoscopic examination is warranted in these patients. Another troublesome complication of diabetes in these patients is peripheral neuropathy and diminished pain sensation increases the risk of foot injury, ulcers and neuropathic arthropathy. Ulcers and infections are often difficult to treat and amputation of a gangrenous lesion is often required.
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