REVIEW THE EFFECTS OF AGING ON BODY SYSTEMS; REVIEW THE IMPORTANCE OF

DISTINGUISHING POTENTIALLY REMEDIAL PATHOLOGY FROM EXPECTED IRREVERSIBLE

AGE-RELATED CHANGES.

Physiologic rhythm

Desynchronization of circadian pattern of body temperature, plasma cortisol, and sleep

Haematopoietic and immune system

Adaptive immune system declines (function of memory cells + RBC turnover are relatively preserved)
Procoagulant
Chronic, low-level inflammatory state - inflammaging

Gastrointestinal tract

interstitial cells of Cajal decreased gastric motility

absorption (villous and mucosal atrophy)
CCK more satiety

Hepatobiliary system

Liver mass decreases, as well as perfusion and blood flow

Cytochrome p450 content decreases
LDL, HDL

Renal system

GFR
excretion of acid load

Cardiovascular system

Cardiomyocytes hypertrophy and loss of myocytes occurs

Aortic valve and mitral annulus thicken and develop calcific deposits
Left atrium enlarges and left ventricle stiffens
Decrease in maximum heart rate, possibly due to decreased parasympathetic tone and decreased
sympathetic responsiveness
Increased systolic and same diastolic possibly from artery stiffening

Respiratory system

Alveolar ducts enlarge due to loss of elastic tissue, resulting in a decreased surface area for gas
exchange
Increased V/Q mismatching
Decreased chest wall compliance and flattened diaphragm
Slower mucociliary clearance

Genitourinary system

Less control over bladder

Slow erections and small ejaculate volumes
 Decrease in sperm production
chromosomal abnormalities in sperm/impaired motility + fertilisation
seminiferous tubules/Leydig cells
Enlargement of prostate
The vagina loses elasticity. The clitoris, like the older penis, needs greater stimulation and becomes
less engorged
Vaginal dryness due to oestrogen and diminished blood flow to vagina

Musculoskeletal system

Muscles mass decreases in relation to body weight as does total body water and serum albumin
Increase in total body fat
Mineral loss in cortical and trabecular bone
Progressive decline in osteoblast number and activity but osteoclasts remain unchanged

Skin

Atrophy, decreased elasticity and impaired metabolic and reparative responses

Thinning of skin
Decreased Meissners corpuscles, decreasing sensory perception
Decrease in subdermal fat, leading to wrinkling

Vision

Loss of elasticity in the lens leads to presbyopia (near-vision declines)

Pupils get smaller, resulting in less light reaching the retina. This makes it more difficult to see in
dimly-lit areas, or telling one dark area from another.

Hearing

Decrements in high frequency hearing acuity (due to loss of hair cells in the organ of Corti) and
impaired speech recognition in noisy environment

Taste and smell

Diminished taste, but this is mostly due to altered olfaction

 REVIEW THE PRESENTATION OF DEMENTIA IN THE CLINICAL SETTING

According to the DSM-V, the criteria for dementia are as follows:

Evidence from the history and clinical assessment that indicates significant cognitive impairment in at
least one of the following cognitive domains:
Learning and memory
Language
Executive function Aphasia, apraxia, agnosia, executive
Complex attention function
Perceptual-motor function
Social cognition
The impairment must be acquired and represent a significant decline from a previous level of
functioning
The cognitive deficits must interfere with independence in everyday activities
In the case of neurodegenerative dementias such as Alzheimer disease, the disturbances are of
insidious onset and are progressive, based on evidence from the history or serial mental-status
examinations
The disturbances are not occurring exclusively during the course of delirium
The disturbances are not better accounted for by another mental disorder (e.g., major depressive
disorder, schizophrenia)
REVIEW THE PHARMACOKINETIC PROCESSES OF DRUG ABSORPTION, DISTRIBUTION,
METABOLISM AND ELIMINATION AND DESCRIBE THE EFFECTS OF AGING ON THESE
PROCESSES; BRIEFLY EXPLAIN THE MECHANISMS BY WHICH THE
PHARMACODYNAMICS OF DRUGS MAY BE ALTERED IN THE ELDERLY PATIENT

Absorption
Drug absorption is determined by the drugs physiochemical properties, formulation, and
route of administration. Unless administered IV, these drugs must cross several cell
membranes to reach the systemic circulation
Passive diffusion: Lipid-soluble drugs diffuse the most rapidly across cell membranes from a
region of high concentration to one of low concentration
Facilitated passive diffusion: Carrier molecule in the membrane combines reversibly with the
substrate molecule outside the membrane and they diffuse, releasing the substrate at the
interior surface
Active transport: Selective, requires energy expenditure, may involve transport across the
concentration gradient. Seems to be limited to drugs that are structurally similar to
endogenous substances
Pinocytosis: Particle is engulfed by cell as the membrane invaginates and encloses it. Energy
expenditure is required
Effect of ageing: Slowed gastric emptying and reduced parietal cell function means
absorption may be impaired due to altered pH. However, since most drugs are absorbed
passively in the small intestine, absorption is not really affected.
Distribution
Once absorbed, drug must be transferred between locations
Most of the drug is first distributed to organs with high blood supply then slowly to those
with poor blood supply
Rate depends on permeability of capillaries and also on perfusion
Blood-brain barrier: Only lipid soluble drugs
Placental barrier: Permeable to lipid soluble and many water soluble drugs
Volume of distribution
Major determinant of half-life of a drug
Total amount of drug in body/Plasma drug concentration
Effect of ageing
Reduction in total body water = higher concentrations of water-soluble drugs such
as ethanol and digoxin
An increase in the body fat percentage results in a smaller volume of distribution of
lipophilic drugs such as diazepam. This may cause an increased elimination half-life.
A reduction in albumin levels may result in an increase in unbound concentrations
of certain drugs such as warfarin and phenytoin
Clearance
Metabolism
Chemical changes which affect a drug
Primary aim to increase water solubility for increased excretion
Factors that affect metabolism include: drug interaction, disease status, hormonal
status, age and sex, nutritional status, genetic factors
Phase 1: Adds reactive group to drug molecule by reduction, hydrolysis or oxidation.
Oxidation is mainly by cytochrome p450 in the liver which enables Phase 2
Phase 2: Conjugation reaction producing mainly inactive hydrophilic products for
excretion
 First-pass metabolism: Only relevant to oral administration. Drugs may be partially
or completely inactivated in the liver or intestines before entering the systemic
circulation
Effects of ageing
Hepatic blood flow, cytochrome p450 levels and hepatic mass are reduced
Excretion
Total clearance is volume of blood cleared of drug per unit time
CL (total body) = CL(hepatic) + CL (renal) + CL (other)
Effects of ageing
Renal elimination is reduced leading to prolonged half-life and higher
concentrations of drugs or metabolites
As a result of the reduced muscle mass in older people, the serum creatinine can
remain within the 'normal' range despite a significant impairment in glomerular
filtration rate. Most elderly patients will therefore require an adjustment in the
dose of drugs that are excreted by the kidneys

In terms of pharmacodynamics changes, it is generally considered that enhanced sensitivity to drugs occurs
with ageing. Reduced doses are therefore recommended. Furthermore, with increasing age, regulatory
mechanisms are decreased, which may result in orthostatic hypotension when antihypertensive and
antidepressant drugs are administered, and an increased risk of opiate-related respiratory depression.
However, older people show reduced sensitivity to certain medications such as beta-blockers, which is
attributable to down-regulation of myocardial beta-1 adrenergic receptors.
 DEFINE POLYPHARMACY AND CONSIDER FROM THE PERSPECTIVE OF PRESCRIBING
DRUGS AND EDUCATING PATIENTS THE HEALTH BENEFITS, RISK ASSESSMENTS AND
HARM MINIMISATION FOR PATIENTS, PARTICULARLY THE ELDERLY, REQUIRED TO BE
ON MULTIPLE MEDICATIONS

Polypharmacy >5 medications, in 20-40% of older people. While polypharmacy most commonly refers to
prescribed medications, it is important to also consider the number of over-the-counter and
herbal/supplements used.

Negative outcomes of polypharmacy:

ADRs (in 81% of patients on 6 or more drugs)

Impaired hepatic or renal function
Risk of falling and of recurrent falls
Medication adherence, which is compounded by visual or cognitive compromise in many older adults
Polypharmacy increases the possibility of prescribing cascades. A prescribing cascade develops
when an adverse drug event is misinterpreted as a new medical condition and additional drug therapy
is then prescribed to treat this medical condition.

A balance is required between over- and underprescribing. Multiple medications are often required to manage
clinically complex older adults. Clinicians are often challenged with the need to match the complex needs of
their older patients with those of disease-specific clinical practice guidelines. In many cases, the adverse
effects of drugs may offset the substantial benefits. It is also important to reconsider medication
appropriateness late in life. If a patients life expectancy is short and the goals of care are palliative then
prescribing a prophylatic medication requiring several years to realize a benefit may not be considered
appropriate. Dosage also has to be considered due to age-related changes in drug absorption, distribution and
metabolism.
 OUTLINE THE PRINCIPLES OF SAFE PRESCRIBING FOR THE ELDERLY PATIENT

The decision to prescribe a medication to an older patient is guided by the ethical principles of:

Beneficence: What is the evidence for the likely benefit in this particular patient?
Non-maleficence: What are the adverse effects likely to be in this patient given their age, co-
morbidities and other medications?
Autonomy: What does the patient want?
 REVIEW THE USE OF A PATIENTS AHD TO INFORM THEIR END OF LIFE CARE
AHD must be signed and witnessed - must include a certificate signed and dated by a doctor stating
the principal appeared to have capacity
A principal may
Give directions about health matters for future healthcare
Consent to particular future healthcare despite objection when it is provided
Authorise WWLSM
Authorise an attorney to physically restrain, move or manage them for the purpose of
healthcare
AHDs have priority over a general or specific power for health matters given to any attorney
Concerns
Currency: Peoples views/wishes can change over time. It is recommended that AHDs be
reviewed every 5 years
Specificity: Document must accurately detail patients wishes
1. AHD
2. Guardian
3. POA
4. SHA
DISCUSS THE IMPACT OF THE AGING POPULATION ON THE AUSTRALIAN HEALTH CARE
SYSTEM
Population aged 65 and older: 12% of population estimated to rise to 18% in 2021 while youth
population expected to remain the same
Life expectancy 77 for men and 83 for women
Older people use more healthcare than younger people aged care spending expected to treble from
0.7% of GDP to 1.8% in 2041-2042
Lower participation rates in work, productivity
Aged care facilities need more beds and residents are remaining in care longer
Increased need for specific specialties (neurology, geriatrics, oncology)
Impact on carers
Impact on demand for disability support services

DESCRIBE HOW A CLINICIAN CAN ASSIST PATIENTS TO MINIMISE THE HARM

ASSOCIATED WITH POLYPHARMACY

Prevention: Avoid prescribing for minor, non-specific or self-limiting complaints. Only prescribe when
there is good evidence of likely efficacy as well as a strong need for the medication
Regular medication review: An accurate drug history is essential for patients on multiple medicines.
This is best achieved when the medication review is done in the patients home. Alternatively ask the
patient to bring in all their medicines (prescribed and non-prescribed). A review includes assessing
appropriateness and ongoing need for therapy, adverse effects and interactions, the dosage regime
and formulations, and also compliance.
Non-pharmacological approaches: Use lifestyle measures whenever possible either as an adjunct or
instead of medications
Communication: Talk with the patient about their concerns, expectations, difficulties in using the
medications and their ability to follow the medication regimen. Discuss changes to the medication
regimen with the patients other healthcare providers
Simplify: Reduce the regimen to essential drugs. Consider fewest possible dosage intervals and dose
reduction where appropriate. Limit use of optional, trivial and placebo medications.

DESCRIBE THE SUPPORT SERVICES AVAILABLE FOR INDIVIDUALS WITH A DEMENTING

ILLNESS, AND THEIR CARERS (REVISION)

Support for patients

Ozcare
Blue Care
Meals on wheels
Alzheimers Australia
Dementia and memory community centres
Early intervention and counselling programs
Information, awareness, education, training
National Dementia helpline
Support specialist advice, referrals, information, support
Dementia behaviour management advisory service
Clinical interventions to help aged care staff, 24 hour helpline, information, assessment
Extended aged care at home for dementia (EACHD) high level support
Care by an allied health professional such as a physiotherapist or podiatrist
Personal care
 Home help
Assistance with continence management

Support for carers

Carers Queensland
Carer advisory service
Support groups
Family support
Education and training
No interest loan scheme
National respite for carers program

DISCUSS THE PROCESSES INVOLVED WITH ORGANISING RESIDENTIAL CARE FOR THE
ELDERLY

Government initiatives and programs available for home care include

Home and Community Care (HACC) bulk provider of home and community based services for
elderly. HACC provides nursing, delivered meals, transport and shopping assistance, allied health,
respite, home care services for all patients with moderate, severe or profound disabilities, and their
carers. Aims to enhance independence of people in these groups and avoid their premature or
inappropriate admission to long-term residential care.
Extended Aged Care at Home (EACH) individually planned and co-ordinated packages of care for
those living at home who would otherwise be eligible for admission to high-level residential care.
Home-based services include nursing care, allied health professionals, personal care, domestic
assistance, in-home respite, transport, social support, assistance with continence. Also has a
specialised dementia package (EACH-D) with tailored care to suit the needs of dementia patients.
Community Aged Care Package (CACP) designed to provide support services for older people with
complex needs living at home who would otherwise be eligible for admission to low-level residential
care. Home-based services include home nursing assistance, which may be provided through HACC.
Residential Aged Care Package (RACP) provides monetary contribution to nursing home entry, low
or high care levels.
National Respite for Carers Program (NRCP) allows carers (of older people, people needing palliative
care and people with disabilities) to have a break to look after their own health and well-being.

Residential aged care

Can be temporary or permanent. Short term care is respite care.

Constant nursing care with facilities to provide nursing, physical, speech, and occupational therapists, social
works and other rehab therapies

5 Steps of Organising Entry into Residential Aged Care

Step 1 Assessment of Eligibility

ACAT assessment determines eligibility for government support for residential aged care; patients can contact
ACAT directly, or be referred by a doctor, health centre or hospital. The cost of the assessment is covered by
the Australian Government. Role of ACAT includes

Approve eligibility for entry into residential aged care, in either low level care or high level care
Provide information about residential aged care and home care services
 Help arrange special respite care if this is required
Approve eligibility for a package of community care to help a patient continue living at home
Refer a patient to other services that will help them to continue living at home

Frequency of Assessment

Once a patient has been approved by ACAT for high level residential aged care, or for low level or high
level residential respite care they do not need to be assessed again.
ACAT approvals for low level residential care require re-assessment every 12 months.

Step 2 Finding an Aged Care Home

Following ACAT assessment, a suitable residential aged care home is sourced for the patient. The facility
chosen will depend on vacancies available, level of care required and cost.

Step 3 Working out the Cost

While the Australian Government assists with the cost of residential aged care by providing funding to aged
care homes, those who can afford to do so are also expected to contribute to the cost of their care.

Summary of fees:

Daily fees are charged for the daily costs of living, nursing care, personal care etc. Some of these are
income tested. All residents are charged these except ex-prisoners of war (for which the DVA pays).
Accommodation payments are charged to cover the cost of accommodation in an aged care home. This is
only payable if a clients assets exceed an amount set by the Government

Step 4&5 Apply & Move in

Fill in the form entitled: Application for Respite Care or Permanent Entry to an Aged Care Home