It seems characteristic of older people these days that we think of ourselves as much younger than these old people we see around us. This because inside we still think of ourselves as being youthful if we feel well, even if our looks give our true ages away very quickly! In our society we are lucky that most of us stay fit and well much longer than we used to. We currently think of the “young old” as being around 65 to 74 years of age, the “middle old” 75 to 84 and the “old old” 85 years plus.
When we talk about the problems of older people with multi-morbidity using up so much of the available health resources, we really mean the over 85’s, because this is the age group that is expanding so much as more of us escape or survive the diseases that used to kill us, because of better healthcare and a higher standard of living. Fortunately only a few people younger than that use the health services very much if they do not have specific age-related diseases such as cancer, dementia and so on. Most health care is given in the two years or so before death, and this means that the vast majority of people between 65 and 85 are independent, enjoy life to the full and can contribute to society, sometimes by working for profit, sometimes doing voluntary work, and often by helping the next generation with childcare, education and so on.

Ageing is a process that starts with conception and continues throughout life, and its speed depends on genetic factors, which we can’t alter; and our environment and how we interact with it, which we certainly can. Sometimes the scars of a poor early environment, such as poverty, emotional trauma or neglect will affect our health, as we get older. But more often we harm ourselves with smoking, eating too much (or the wrong things), taking too little exercise or having a negative attitude to things. Apparently, the average lifespan of those with high levels of negative beliefs about old age is 7.5 years shorter than those with more positive beliefs. It does make sense. If one’s self perception of the ageing process is more positive, this can encourage people to do the best they can to stay fit and active. Dealing with these inevitable changes will be that much easier. So it is important to understand a bit more about aging, how it affects us and what we can do about it to prevent problems as much as possible, while we are still in the “young old” stage.

I talked about muscle loss in my first blog. While muscle weakness itself is a problem, muscle tissue also serves other functions. The contraction of muscle fibres produces heat (by burning carbohydrates such as glycogen and sugars) and in time these fibres become smaller in diameter, due to the ageing process. Muscular activity becomes less efficient and requires more effort to accomplish a given task. There is less muscle mass to generate heat and often people can’t be active because of arthritis or other problems. They often don’t want to be active either, because of impaired neurotransmission – their nerves don’t transmit so well. Also their skin provides less protection from heat loss because it has got thinner and there is less subcutaneous fat to insulate them. All these factors put the elderly at risk for hypothermia if they are in environments that younger people would think are quite warm enough. Hence the usual complaint of people visiting their relatives in nursing homes, and wondering how on earth they can put up with this heat.
For the “young old” this is a good reason to keep active, to keep more of these muscle fibres in trim. I don’t think it is commonly understood that even a small increase in activity for the over 85’s can make a big difference to health and survival. Such things as going to the kitchen to cook or seeing to the cat every hour or so, can make a huge difference, yet people often stay for hours just sitting in chairs, and so complain of the cold. Old people will live for much longer in well-heated homes than if they can’t afford to heat their homes of course, but their physical mobility and enjoyment of life would be so much better if they can be persuaded to move around more. There is a common misconception that to reap health benefits, continuous, vigorous exercise (athletics, jogging, or squash) is required, but nothing could be further from the truth. Every little helps.

It is well known that lack of thyroid hormone will cause people to be intolerant of cold. Recently I was at a dinner party, and was sitting next to someone who was complaining of a dreadful cold draught coming from the air conditioner. She asked the manager to turn it off, and the staff did so. But it didn’t make much difference and so I changed places with her. Although there was a draught it didn’t bother me, and when I asked her, she did indeed have a thyroid problem. An increase in her dose soon sorted that one out. Lack of thyroid can also cause dry skin, weight gain and muscle weakness so it is important to get it checked every now and then. That said, many people have marginally low thyroid levels for years before it really becomes a problem.

Thyroid isn’t the only hormone that can cause trouble as the production of all hormones is reduced eventually as we age. This can affect water balance, and mineral, electrolyte, carbohydrate, protein levels; lipid and vitamin disorders are all more common in the elderly. Nutrition and the ability to use food for energy is seriously affected in the very elderly and this can cause weight loss.
Diabetes is common in the elderly. There are many causes but a primary mechanism involves the reduced ability of aging skeletal muscle to absorb glucose.

The very elderly are also at risk for nutritional deficiencies due to anorexia. Age related anorexia has been linked to a lower satiety threshold, but in my experience is more often caused by a loss of interest in food, so that people just eat simple, less nourishing things. One elderly person I knew existed only on reconstituted dried soups and a bit of bread. Also if you feel ill you don’t want to eat, so that by this stage it is highly likely that there are a lot of pathologies going on which should be diagnosed properly. Before that stage, for the younger fitter people, it is most important to eat food high in protein, even if a bit overweight. Reduce the carbs, and increase the protein and fat.

I saw very few fat people in their eighties and nineties when I was in practice. Although many very obese people did not survive that long – diabetes, heart attacks strokes and even cancer are much commoner in such people – it also seemed that people lost weight naturally as they got older. So dieting is something for middle age and the young old and one would need to be very careful in recommending a diet for the over eighties.

Swollen ankles are something not confined to the elderly – many people find their ankles swell ate the end of the day. It is usually due to venous insufficiency – that is that the circulation of blood from the feet back to the heart is impaired. The main problem is gravity – the heart has to pump blood not only to the circulation in the legs but also all the way back up to the heart, and has to work against gravity all the way back. The only thing thong stopping blood and fluid pooling in the lower legs is good valves in the big veins, and unfortunately many people have varicose veins or valves that don’t do their job properly. Varicose veins re often hereditary and then get worse when pooling of blood causes the walls of the vein to bulge, and this stops the valves functioning, Of course the blood itself does not pool for long, but the increased pressure within the vein forces fluids out into the tissues, and this shows itself as swelling of the lower legs. Usually it is worse after standing or sitting for a long time, and exercise such as walking is far the best prevention. However if you do have to sit for long periods as in a plane for instance it is sensible to wear support stockings. Nowadays you will have to go to a health professional to get measured for these, so that would be a good time to check out if there is anything else causing it. Usually if the swelling goes down at night there isn’t much to worry abut but if more severe it may be due to the heart not pumping properly, and early heart failure can cause this. Not only does the heart not pump so well if it is under strain, but the volume of blood in circulation also increases (due to effects on the kidney). When you then lie down at night the fluid does go from the legs because gravity is no longer acting on them, but the extra fluid does not go away – it pools in the small of the back (again under gravity) and in the morning when you get up it comes straight back again into the legs. That would be a real danger signal. Remarkably though the heart, if still healthy, can usually pump adequately well into advanced old age.

When I was working in the surgery, I was quite often asked about sex relationships by elderly people – usually women of course. No doubt my male colleagues got the elderly men. My patients asked about dry vaginas, (especially when they had a new partner, which wasn’t uncommon), and sometimes about a mismatch of desire between them and their partners. It was interesting to see how many of them were enjoying an active sex life. But undoubtedly sexual interest does decline, as people get older. It is not entirely due to falling androgen levels in men it seems, but erectile dysfunction is common for other reasons. Diabetes is a common cause – 50% of men with diabetes have problems, as do many men who have heart problems; and many medications can cause impotence. Lowered sexual drive is also associated with lower attained education, and guess what? – lack of physical activity.

Here is the usual joke then
The manager of a nursing home was addressing the residents. “The female sleeping quarters will be out-of-bounds for all males, and the male dormitory to the females. Anybody caught breaking this rule will be fined £20 the first time.”
She continued, “Anybody caught breaking this rule the second time will be fined £60. Being caught a third time will cost you a fine of £180. Are there any questions?”

At this point, an older gentleman stood up in the crowd inquired: “How much for a season pass?

The next blog will be about mental health problems including dementia and depression – and the search for cures for dementia and old age.