The whole world is now much concerned about old age and its related problems and Gerontology has been introduced in Medical Science. National Institute on Aging is working in this matter in Silverspring, USA.
Modern Gerontology rejects the concept of old age as an illness. The compliance of elderly and aged usually reflect illness and not old age.
Old age is a health and social problem. Your age is what you consider suitable according to your physical and mental condition. According to US Department of Health and Human Service, people of 60-65 years are old. But Swedish law describes only people over 65 years who can be called old. In fact those who are old in mind are old. Like all old instruments, the instruments of our body also get wasted and degenerate due to long use in old age. But the rate of degeneration is not the same for everybody. Some
people remain active like 60 at the age of 75-80.
Old people can be divided into four categories: a.  Aged: 60-65 years, b. Old: 65+ years, c. Very old: 75-90+ years, d. Cenetarian: 100+b years
In fact instead of dividing life span like young and old, weakened it is better to divide it as functional and non-functional life. After independence our social and economical condition has improved. Infant mortality rate was 145 in 1970. in 1990 it came down to 114. In 2000 it became 54.
According to UNICEF, infant mortality rate for under one year age was 41, under five years was 57 in 2009. Besides in 50’s our average longevity was 37 years, in 1970-75 it increase to 54, in 2000 it became 59. Life expectancy in 2009 was 67 years. This improvement is because of increased health consciousness of the
public and naturally as the number of old people increase day by day.
We must remember old age is not a disease. Aging of the individual denotes a physiological process that begins at conception and entails changes, characteristics to delivere the species throughout the whole life cycle. In the later years such changes result in limitation of the adaptability of the organism with its environment i.e old age.
On the basis of health, economic and social status the following categories of old people belong to high risk groups regarding expectation of life, probability of surviving and illness:
a.     Very old people (80-90 years and over)
b.     Aged people living alone (one person households)
c.     Aged women especially widows or single
d.     Aged people living in institutions
Besides the above some other people can also be grouped under this heading:
e.    isolated old people (alone or aged couples)
f.    childless old people
g.    aged people suffering from severe illness or handicaps
h.    aged couples with one spouse seriously ill or handicapped
i.    aged people having to live on minimum support provided by state, social security or relatives
However an individual may belong to more than one of the above groups. Due to changes in the body in old age, the result of various biochemical tests will be different from the young which is shown in the table below:
    Young    Old
Albumin     37-51g/litre    33-49g/litre
Globulin    19-33g/litre    20-41g/litre
Urea    3.2-7.2m.mol/litre    3.9-9.9m.mol/litre
Creatinine    62-123µmol/litre      52-159µmol/litre
Potassium    3.6-4.7m.mol/litre   3.6-5.2m.mol/litre
Urate (Men)        0.24-0.46m.mol/litre
        0.19-0.31m.mol/litre
Urate (Women)       0.16-0.37m.mol/litre
        0.13-0.46m.mol/litre
Calcium (Women)   2.18-2.55m.mol/litre
        2.18-2.68m.mol/litre
Phosphate (Men)      0.79-1.40m.mol/litre
        0.66-1.27m.mol/litre
Phosphate (Women)  0.82-1.37m.mol/litre
        0.94-1.56m.mol/litre
However there will be no change in Sodium, Chloride, Bicarbonate, Magnesium, Bilirubin, AST (Aspertate
 aminotransferase), ALT (Alanine aminotransferase), LDH (Lactate dehydrogenase), T4 (Thyroxine),
T3 (Triiodo thyronine) etc.
It should be remembered that a chronic pathological process often develops mainly from physiological changes in the body and there is a close connection between the process and the development of malignant tumours or cardiovascular diseases e.g atherosclerosis, hypertension etc. Elderly people often appear subclinically malnourished and some authorities believe that nutritional requirements are increased in old age. In fact, energy requirements decrease by 5% after 40 years, 10% by 60-70 years and another 10% after 70 years but protein requirements remain the same whatever the person’s age since adulthood and fat should not be more than a third of energy intake. Diet should contain soft or semi-solid food with enough roughage for maintaining the tone of intestine containing iron, riboflavin, ascorbic acid, vit. D and niacin like a normal adult. One should avoid sedentary lifestyle and remain active doing moderate light exercise daily.
Nutritional problems are specially found in:
a.     Those living alone
b.     Diseased person who find difficulty in shopping and cooking
c.     Depressed or mentally ill person
d.     Those living in old peoples home
e.     Recently bereaved person
Diseased old people should be accurately diagnosed as there occurs difficulty due to:
a.     Multiple pathology
b.     Altered symptoms
c.     History taking (loss of memory, communicational problems, hearing loss, dysarthria etc-information should be collected from relatives and old hospital records)
d.     Physical signs
e.     Functional diagnosis
In case of younger patients, all data collected by investigation and physical examination are aimed at one diagnosis but this is not true in case of the elderly as multiple conditions coexist in the body and minor illness may become severe. There may be also side effects from other drugs that they are taking for some other conditions e.g postural hypotension in a depressed elderly patient who is also suffering from ischaemic heart disease.
Disease has been described in medical textbooks after observing signs and symptoms in young patients but same disease can cause altered signs and symptoms in old. Four common non-specific symptoms that occur in old patients are: a. Acute confusion, b. Falls, c. Incontinence, d. Generalized unwell feeling
Due to aging there occurs cerebral atrophy (specially frontal lobe) with shrinkage of gyri and widening of sulci, loss of purkinje cells and memory. An MSQ (Mental Status Questionnaire) can be asked to assess him e.g Home/Village, Date of Birth, Age, This day, This month, This year, Prime minister now and Prime minister before etc. More than 40% in 80’s have diminished or absent ankle jerks, 50% over 60’s have some loss of vibration sense in distal part of lower limbs.
Acute confusional state may be precipitated by other illness e.g:
a.    Pneumonia and other infection
b.    Chronic obstructive lung disease with hypoxia
c.    Psychotropic drugs, Levodopa, anticolinergic, cimetidine, alcohol
d.    Electrolite imbalance
e.    Uraemia, Trauma (neck fermur), stroke etc
There is reduction in the perception of viceral pain in the aged, so acute painful conditions e.g acute cholecystitis, acute pancreatitis or acute Myocardial infarction may be painless and only mild discomfort, so patient may ignore them. An acute M.I patient may have sudden dyspnoea, confusion, syncope, thromboembolism and death but no chest pain.
In case of hypothyroidism all clinical manifestations occur very less. Tachycardia is absent in 25% elderly patients because of disturbance in the conductive system but there can occur angina, arrhythmia, heart failure, constipation and occasionally goiter, diarrhea, anorexia, hyperkinesis etc.
In old age there is reduction in number of alveoli, cilia and elasticity of lungs causing decreased basal ventilation and cough reflex. So even in the presence of friction, rub and infection there may be very weak cough, less pain and no fever. Sometimes basal creps can be heard though there is no respiratory or cardiac diseases.
Post menopausal osteoporosis in women and senile osteoporosis in men is very common. Osteoporosis is also common in carcinomatosis, hyperparathyroidism, hyperthyroidism, hypercortisolism, immobilization, drugs (e.g corticosteroids) etc. Decline in renal function with age is well-known but serum creatinine rise is less because of wasting of muscles reducing endogenous creatinine production from muscle breakdown.
There is a high incidence of senile cataract in countries with abundant short wave-length sun light and glaucoma in people over 65 years. They often suffer from enlarge prostate with acute retention of urine. The other diseases the old people suffer from are hypertension, stroke, parkinsonism, hypothermia (temp. less than 35ºC) due to decline in thermoregulation with age. Blood sugar may be high as insulin is inactive in cold. ECG may show cardiac dysrhythmias.
During physical exam each organ system should be examined in detail although presenting problem may be attributed to certain specific organ system. About 10% of population over 65 consumes about 25% of medications in USA. While treating elderly one should be very careful as they run a greater risk of having problems with drugs as there occurs 40% decline in liver blood flow between 40-80 years and 50% decline in glomerular filtration between 50-90 years age plus control of bladder and bowel function may be compromised. One should use Paracetamol instead of NSAID for fear of fluid retention, renal failure etc. H2 receptor antagonist can be used to prevent peptic ulceration. Most elderly patients have hypertension with cardiac failure and require diuretics. A loop diuretic may cause increased tissue concentration of nephrotoxic drugs e.g Gentamycin and loss of potassium causing confusion and lessen intestinal motility. Aminoglycoside (Ototoxicity and Nephrotoxicity), Benzodiazepine (Depression of CNS), Carbamazepin (Ataxia somnolence), Chlormethiazole (confusion), Degoxin (Nausea, Abnormal colour vision), Helopericol (Extra pyramidal symptoms), Levodopa (Hypotension), Opiates (Respiratory depression), Metochlorpromide (Confusion, Extra pyramidal symptoms), Thyroxin (Myocardial infarction) should be given in lesser dosage in the old. Digoxin toxicity may manifest during hypokalaemia induced by diuretics or diarrhea or following transient renal impairment. Cimetidine, Doxicycline, Kanamycine, Lithium, Penicillin-G, Phenobarbitone, Practolol, Procainamide, Tetracycline etc also impaired and excreted through kidney. So all elderly patients should be prescribed least number of medicines with lowest possible dosage.
 (Reprint)