bluuebunny/crossref_metadata_2025 huggingface dataset:
PET Brain Imaging Methodologies
Authors: Hillmer Ansel T. , Cosgrove Kelly P. , Carson Richard E.
Published: December 2017

While quantitative and pharmacologically specific aspects distinguish molecular imaging, they also impose the need for considerable expertise to design, conduct, and analyze molecular imaging studies. Positron emission tomography (PET) brain imaging provides a powerful noninvasive tool for quantitative and pharmacologically specific clinical research. This chapter describes basic methodological considerations for PET brain imaging studies. First the physiological interpretation of the most common outcome measures of binding potential (BPND) and volume of distribution (VT) are described. Next, aspects of acquisition of PET imaging data and blood measurements for analysis are discussed, followed by a summary of standard data analysis techniques. Finally, various applications for the study of mental illness, including group differences, measurements of drug occupancy, and assay of acute neurotransmitter release are discussed.
Neurodevelopmental Mechanisms for Psychotic Disorders
Authors: Gamo Nao J. , Sakurai Takeshi , Jaaro-Peled Hanna , Sawa Akira
Published: December 2017

The current understanding of the mechanisms underlying psychotic disorders, including schizophrenia, is far from satisfactory and has hampered the establishment of effective treatments, as well as accurate diagnosis and prognosis in patients. A prevailing hypothesis that attempts to understand these mechanisms is the “neurodevelopmental hypothesis.” In this chapter, we address experimental strategies to characterize the biological mechanisms underlying psychotic disorders, including a complementary combination of human cell and animal models that pays attention to the developmental trajectory, in particular key neural circuitries that may underlie behavioral changes relevant to psychotic disorders. In addition, we discuss a “dimensional” approach to understanding psychiatric disorders to more easily translate findings between animal models and human applications.
Neuroendocrine Mechanisms of Depression
Authors: Goldstein Jill M. , Holsen L. , Cherkerzian S. , Misra M. , Handra R.J.
Published: December 2017

Studies have demonstrated that major depressive disorder (MDD) is intimately tied to neuroendocrine dysregulation. This arises, in part, from the fact that brain regions that regulate mood also regulate primary neuroendocrine axes and metabolic functions. We and others demonstrated that the origin of MDD-neuroendocrine deficits begins in fetal development, is sex-dependent, emerges just post-puberty, and can be catalyzed by pregnancy (postpartum) and menopause. Here, we critically review clinical and preclinical studies to argue that higher MDD risk in women may arise, in part, from hormone-dependent pathogenic processes initiated during fetal development that drive sex-dependent developmental alterations of HPA circuitry emerging post-puberty with lifelong consequences.
What are Fear and Anxiety? Listening to the Brain
Authors: Ledoux Joseph
Published: December 2017

Imprecise language plagues discussions of “anxiety disorders” and other forms of mental illness. For example, failure to clearly distinguish the constructs “fear” and “anxiety” leads to confused interpretations of findings. Moreover, because both terms are most commonly used to refer to subjective experiences, their use in describing both subjective experiences and behavioral and physiological responses that sometimes, but not always, occur with the experiences, is also problematic. The failure of anxiolytic drug development is due in part to unrealistic expectations generated by imprecise use of the terms fear and anxiety. In order for the science of fear and anxiety to advance, scientists need to pay more attention to their scientific language.
Reward Circuitry and Drug Addiction
Authors: Steele Vaughn R. , Pariyadath Vani , Goldstein Rita Z. , Stein Elliot A.
Published: December 2017

Addiction is a complex neuropsychiatric syndrome related to dysregulation of brain systems including the mesocorticolimbic dopamine reward circuit. Dysregulation of reward circuitry is related to each of the three cyclical stages in the disease model of addiction: maintenance, abstinence, and relapse. Parsing reward circuitry is confounded due to the anatomical complexity of cortico-basal ganglia-thalamocortical loops, forward and backward projections within the circuit, and interactions between neurotransmitter systems. We begin by introducing the neurobiology of the reward system, specifically highlighting nodes of the circuit beyond the basal ganglia, followed by a review of the current literature on reward circuitry dysregulation in addiction. Finally, we discuss biomarkers of addiction identified with neuroimaging that could help guide neuroprediction models and development of targets for effective new interventions, such as noninvasive brain stimulation. The neurocircuitry of reward, especially non-prototypical nodes, may hold essential keys to understanding and treating addiction.
Neuroimaging and Cerebrospinal Fluid Biomarkers of Alzheimer’s Disease
Authors: Gordon Brian A. , Vos Stephanie J.B. , Fagan Anne M.
Published: December 2017

Alzheimer’s disease is characterized by a long asymptomatic (preclinical) phase during which disease-related pathology accumulates in the absence of overt cognitive symptoms. The most prominent neuropathologies are extracellular amyloid plaques and intraneuronal neurofibrillary tangles. Until recently such pathology was observable only at autopsy. Now these, and other novel pathological markers, can be measured in living individuals using cerebrospinal fluid assays, blood tests, and neuroimaging techniques to track disease progression. Understanding changes in these biomarkers is critical for diagnosis, monitoring disease progression, and for the development of disease-modifying therapies. This chapter reviews the current scientific understanding regarding the use of biomarkers to assess Alzheimer’s disease pathology.
Animal models of Alzheimer’s Disease
Authors: Morgan David
Published: December 2017

In the discovery phase of drug development for Alzheimer’s disease it is useful to have animal models in which proof of principle can be obtained. Models of disease symptoms (memory impairment) and models of the disease pathology (lesions, amyloid-depositing models, tau-depositing models) are described and discussed. Moreover, these different types of models can be combined in an attempt to more faithfully replicate the disease condition. Although worms, flies, fish and dogs have been explored, the bulk of the research has focused on rodents, especially mice. Each of these approaches has limitations, but all have contributed to the development of agents designed to prevent or treat Alzheimer’s and other dementias.
Cellular Mechanisms of Dementia
Authors: Gan Li
Published: December 2017

Neurodegenerative dementias, including Alzheimer’s disease (AD), Parkinson’s disease (PD) and Frontotemporal dementia (FTD), pose enormous challenges for our aging society. Genetic and mechanistic studies have revealed common molecular and cellular pathways, including imbalanced proteostasis and aberrant innate immune responses. Key pathogens in AD, PD, and FTD accumulate and spread from one brain region to another, resulting in network dysfunction and cognitive decline. These diseases are multifactorial, caused by interactions among multiple genetic, epigenetic, and environmental factors and pathways. Combination therapies that target multiple pathways may also be needed to stop or delay the dementing conditions in neurodegenerative dementias.
Current Treatments for Alzheimer’s Disease
Authors: Sano Mary , Neugroschil Judith
Published: December 2017

Five medications representing two classes of drugs have been approved by the US Food and Drug Administration for the treatment of Alzheimer’s disease since 1994. There have been no new approved agents since 2003, although hundreds of clinical trials are in progress. This chapter reviews the pharmacology underlying the currently approved treatments, acetylcholinesterase inhibitors and the NMDA receptor antagonist memantine, and the data supporting their efficacy. Other approaches currently in use or being developed are also reviewed, including the use of hormones, agents that modify cardiovascular and metabolic risk, as well as a number of vitamin supplements and nutritional approaches.
Diagnosis and Epidemiology of Pediatric Psychiatric Disorders
Authors: Robinson Elise B. , Neale Benjamin M. , Daly Mark J.
Published: December 2017

Pediatric psychiatric conditions are rising in estimated prevalence, and these disorders place an enormous burden on parents, educators, and the health care system. This rise in prevalence likely contains elements of diagnostic changes, greater awareness of these disorders, and true changes in incidence. It has been estimated that there is nearly a 50% lifetime childhood prevalence of one or more mood, anxiety, or behavioral disorders (excluding eating and substance abuse disorders) and that more than 20% of children meet the definition of severe impairment. This chapter focuses on epidemiology, heritability, and implied genetic architecture in representative pediatric neuropsychiatric conditions. We consider five major diagnostic categories and highlight major diagnosis within each, specifically, intellectual disability, pervasive developmental disorders (autism spectrum disorder [ASD]), hyperactive and inattentive behavior (attention deficit/hyperactivity disorder [ADHD]), obsessive compulsive disorder (OCD) and tic disorders (TD) (which includes Tourette Syndrome [TS] and other chronic tic disorders).
Neurodevelopmental Mechanisms of Pediatric Psychiatric Disorders
Authors: De Rubeis Silvia , Roeder Kathryn , Devlin Bernie
Published: December 2017

The development of the human brain is a complex process that begins during the first weeks of gestation and extends at least through adolescence and early adulthood. This chapter will review the perturbations of the developmental trajectories during prenatal and early postnatal life that can lead to psychiatric disorders of childhood onset. We will provide a general view of the epochs and trajectories of brain development, from embryonic neurulation to postnatal development, with an emphasis on the development of the neocortex. Within each developmental window, we will consider some salient cellular and molecular pathways, and discuss how genetic and environmental insults underlying psychiatric disorders disrupt them.
The Neurobiology of Tic Disorders and Obsessive-Compulsive Disorder
Authors: Pittenger Christopher
Published: December 2017

Obsessive-compulsive disorder (OCD) and Tourette syndrome (TS), along with other tic disorders, involve pathophysiological alterations in the cortico-striatal circuitry. Both are neurodevelopmental conditions, although OCD can also have adult onset. They are frequently comorbid and often run together in families. Recent genetic studies suggest shared risk factors, especially in the case of early-onset OCD. Because of these shared characteristics, they are treated together here. Structural and functional neuroimaging studies are refining our understanding of the abnormalities in corticostriatal connectivity that accompany symptomatology; in the case of TS, these have been accompanied by exciting observations in postmortem tissue that are beginning to connect observed anatomical and network abnormalities to underlying cellular substrates. Finally, recent advances in animal modeling of pathophysiology have allowed testing of specific etiological hypotheses and have established several systems in which more precise mechanistic studies of pathophysiology are now proceeding.
Neurobiology of Eating Disorders
Authors: Hildebrandt Thomas , Heywood Ashley
Published: December 2017

Eating disorders are recognized by a primary disturbance in eating that results in impairing levels of distress. Commonly beginning in adolescence and affecting primarily females, these illnesses have diagnostic criteria that are actively debated but retain core features including disturbances in the maintenance of a healthy weight, episodic binge eating and/or compensatory behaviors, and body image disturbances. This chapter will provide a summary of the primary neurobiological understanding of eating disorders form experiments using animal models as well as the growing literature in humans. Dysregulation in appetite hormones and peptides, adrenal hormones, ovarian hormones, the serotonergic and dopaminergic systems, and several central nervous system neurocircuits all show strong correlation to the development and maintenance of these chronic and frequently relapsing disorders.
Current Treatments for Pediatric Psychiatric Disorders
Authors: Trelles M. Pilar , Siper Paige M. , Grice Dorothy E.
Published: December 2017

Many psychiatric disorders of childhood have a chronic course. As such, they impact multiple developmental epochs and negatively influence developmental trajectories. While early identification and intervention may minimize, or even prevent, symptoms being carried into adulthood, the availability of evidence-based treatments is sparse in children and adolescents compared to adult populations. Establishing effective interventions for psychiatric symptoms presenting in childhood is critical given the chronic course of most psychiatric disorders. This chapter describes psychopharmacological and psychosocial interventions used for the treatment of childhood psychiatric conditions, with an emphasis on empirically supported treatments. Both symptom- and diagnosis-specific approaches are described as well as the use of combined interventions for the following childhood psychiatric conditions: autism spectrum disorder (ASD), intellectual disability (ID), attention-deficit/hyperactivity disorder (ADHD), anxiety, depression, obsessive compulsive disorder (OCD), chronic tic disorders, eating disorders, and conduct problems.
Population ageing in Europe
Authors: Grundy Emily M. , Murphy Michael
Published: December 2017

Population ageing—the process leading to increases in the representation of older people in the total population—was a predominant trend in trend in twentieth-century Europe, which will intensify over the course of the current century. This chapter presents information on the past, current, and likely future size and demographic characteristics of Europe’s older populations over the period 1950–2050 and explains the demographic changes driving population ageing. Information on the availability of close relatives (spouses and children) related to these demographic changes is also provided together with consideration of variations across Europe in the living arrangements and family support of older people. Policy implications, and possible policy responses, to these changes are considered in the final sections.
Ageing in North America: Canada and the United States
Authors: Crimmins Eileen M. , Beltrán-Sánchez Hiram , Brown Lauren , Yon Yongjie
Published: December 2017

Canada and the United States, while similar in many ways, differ somewhat in age structures, life expectancies, policies relevant to an ageing population, and the challenges they face with future ageing. Canada is the older and longest-lived. Both countries have made changes in their healthcare systems to provide access to healthcare across their populations. Socioeconomic differences in the ageing process are an issue in both of these countries. In this chapter, we first outline the demographic conditions relevant to the ageing population in these countries, then examine health issues relevant to the ageing population including a number of dimensions of health and healthcare. We then lay out specific socioeconomic and cultural challenges related to an ageing population in each country and how these are likely to be dealt with in the future.
Population ageing in Sub-Saharan Africa
Authors: Cassim Bilkish , Aboderin Isabella
Published: December 2017

Sub-Saharan Africa (SSA), the youngest and poorest region of the world, is facing an incipient ageing of its population. Its already considerable and rising population of older adults is exposed to a triple burden of disease from persisting communicable and rising non-communicable diseases (NCDs), as well as trauma and injury, while at the same time it lacks access to requisite care. Challenges in addressing this gap include pervasive economic strain and underresourced health systems with competing priorities, as well as insufficient robust data on the patterns of ill health, disability, and care access in older age. Strategies for, and action on adapting SSA’s health and care systems to its ageing populations are urgently needed, and may be forged within the context of a World Health Organization (WHO) decade on healthy ageing 2020–2030.
Health expectancies
Authors: Robine Jean-Marie , Jagger Carol
Published: December 2017

In its first section, this chapter describes the ongoing adult longevity revolution, which is now the main reason for assessing the quality of years lived and to complete the calculation of life expectancy by those of health expectancies. Then, it introduces the main health expectancies used in the United States of America (US) to monitor Healthy People 2020, the national health agenda, in Japan to monitor Health Japan 21, the health promotion plan, and in Europe to monitor the social and health targets of Europe 2020, the current strategy of the European Union. Finally, this chapter summarizes recent trends in health expectancies observed in the US, Japan, and Europe, as well as in other parts of the world, and discusses these observations in relation to the theories on population health which have been proposed since the 1980s.
Economic implications of population ageing
Authors: Mason Andrew , Lee Ronald
Published: December 2017

For decades to come, population ageing will be one of the most important long-term trends affecting the economies of high-income and many developing countries. Government budgets are threatened as growth in revenue declines and growth in spending, particularly on pensions and healthcare, rises. The effects of ageing on the public sector are less important, however, than the effects on economic growth and standards of living. Slow growth in the working-age population is a serious concern, but three other ageing-related changes will have favourable effects. First, people are healthier and can extend their working lives. Second, older societies will be wealthier with ample resources available to fund needed investment. Third, smaller cohorts of workers will have benefitted from higher spending on their health and education. The decline in numbers may be more than offset by the increase in their productivity.
A life course approach for understanding later life sustainability
Authors: Syddall Holly , Sayer Avan Aihie
Published: December 2017

This chapter describes a life course approach for understanding later life sustainability, focusing on grip strength as a marker of physical sustainability, and explaining how a life course approach recognizes that muscle strength in later life reflects not only rate of loss in later life, but also the peak attained earlier in life. We present evidence that risk factors operating throughout the life course have an impact on physical sustainability in later life with particular consideration of the effects of body size, socioeconomic position, physical activity, diet, and smoking. We have shown that low birth weight is associated with weaker grip strength across the life course and that there is considerable evidence for developmental influences on ageing skeletal muscle. Finally, a life course approach suggests opportunities for early intervention to promote later life physical sustainability; but optimal strategies and timings for intervention are yet to be identified.
Comprehensive geriatric assessment
Authors: Heckman George , Jónsson Pálmi V.
Published: December 2017

In the context of population ageing, the provision of person-specific care to older persons is complicated by the presence, in a single individual, of multiple chronic conditions, and an increasingly complex, non-institutionally-based, service delivery framework. The most complex seniors benefit from a comprehensive geriatric assessment which, in order to promote greater health system integration and coordination, must be standardized across care delivery sectors. InterRAI instruments provide such functionality, which not only supports more efficient and comprehensive care planning, but leads to multiple useful derivative applications for clinicians, health administrators, and policy makers, such as screeners, risk stratification algorithms, outcome scales, quality indicators, and case-mixed indices. Furthermore, clinical information collected through interRAI instruments provide a rich and robust resource for health research.
Communication
Authors: Allwood Rebecca , Harwood Rowan H.
Published: December 2017

Communication is part of everyday experience, and may be overlooked as a professional skill. However, it is central to healthcare practice. Working with older people can challenge our ability to communicate because of speech, sensory, and cognitive changes related to age or disease, environment, relationships, or social factors. The means our mechanisms of communication must be understood, and problems addressed, in order to enable adequate communication. Multiple sources (such as family members or professional staff) may need to be approached to ascertain full information, and to engage and include important stakeholders in a person’s care. Communication is required in making diagnoses, understanding problems, giving information, including imparting distressing news, delivering care, making decisions, and defusing conflict. Approaching these situations in the right way can improve the experience for patients and their families, maximize satisfaction with the consultation, and improve clinical outcomes.
Optimizing pharmacotherapy for older patients
Authors: O’Mahony Denis
Published: December 2017

The prevalence of complex multimorbidity is increasing steadily in tandem with global population ageing. Complex multimorbidity is in turn intimately associated with polypharmacy, the relationship being one of cause-and-effect. Polypharmacy commonly leads to prescription of inappropriate drugs, resulting in a substantially higher risk of drug-related problems, principally adverse drug–drug and drug–disease interactions. These problems become manifest in the form of common geriatric symptoms such as falls, acute confusion, and incontinence and commonly result in increased healthcare utilization, including hospitalization, with obvious economic consequences. In addition, adverse drug reactions and adverse drug events lead to death in older people.

The challenge of optimization of pharmacotherapy in older people with complex multimorbidity is a major one. There is increasing evidence that avoidance of potentially inappropriate medications (PIMs) and potential prescribing omissions (PPOs) using validated PIM and PPO criteria lists leads to better and safer pharmacotherapy in this high-risk population.
General principles of recovery and rehabilitation
Authors: Wyller Torgeir Bruun , Bautz-Holter Erik
Published: December 2017

Illness tends to affect function in frail elderly patients, and these patients have limited capacity to spontaneous physical recovery. This chapter argues that rehabilitation should be firmly integrated into health services for elderly people and not separated from conventional medical treatment. Further, we argue that these two aspects should be handled simultaneously. Rehabilitation is goal-based, and setting goals in cooperation with patients is a crucial condition for successful rehabilitation, and for its evaluation, clinically as well as scientifically. The World Health Organization International Classification of Functioning, Disability, and Health (ICF) is recommended as a conceptual framework for assessment, goal setting, and evaluation in rehabilitation. Rehabilitation can be considered an iterative rather than a linear process, with regular evaluations and renegotiation of goals playing a crucial role in the efficacy of such a process.
The approach of dying and death, and the mourning process of the survivors
Authors: Martin Jonathan , Nicholson Caroline , George Rob
Published: December 2017

The approach of death often brings the complexity of a person’s life into sharp focus, thereby setting the backdrop for the losses occurring to him or her: the physical limitations inherent to most dying; the social ‘disintegration’ that inevitably accompanies a person’s ultimate leave-taking; and the ‘Why?’ question that often arise.

Like the grief work in which those close to the dying person will usually find themselves engaging, both now and later, for the dying person these accumulating losses are underpinned, consciously or unconsciously, by existential/spiritual questions. Such issues are usually well outside most clinicians’ comfort zone, so how should we approach the multidimensional suffering that may occur during the dying process, and what are the particularities of this period for the older person? This chapter outlines both an approach to care and a practical method for how to support a person, and their loved ones, at this time.
Clinical interventions in home care
Authors: Caplan Gideon
Published: December 2017

Healthcare interventions at home are vital for frail older people who frequently have difficulty accessing services. These clinical interventions include primary and secondary care, acute, subacute, and chronic disease management. Randomized controlled trial and meta-analyses have demonstrated improved health outcomes, such as decreased mortality, reduced hospitalization, and cost-effectiveness from many clinical interventions in home care, but not all. Hospital in the Home provides acute and subacute care at home across a wide range of diagnostic groups, whereas most chronic disease management programmes are disease specific. Improvements in and increased portability of technology has assisted many of these developments, but most home care remains proudly ‘high touch’. Ongoing improvements in technology hold the promise of greater benefits, but completely understanding the role of technological innovation in delivering improved outcomes cost effectively is a work in progress.
Critical illness and intensive care
Authors: Duggan Maria Carlo , Frimpong Kwame , Ely E. Wesley
Published: December 2017

Older adults constitute the majority of intensive care unit (ICU) patients, and are increasing in both absolute and relative numbers. Critical care for elderly people should be tailored to their unique physiology, susceptibilities to complications, social circumstances, values, and goals for their care. Knowledge of the short and long-term outcomes of critical illness should guide therapy and goals of care. With a growing number of elderly ICU survivors, the functional, cognitive, and psychological consequences of critical illness and ICU exposure will become a more prominent problem to address. In this chapter, we will discuss morbidity and mortality of elderly ICU patients, provide an evidence-based bundle for the management of pain, agitation, and delirium that has been developed with the vulnerabilities of older patients in mind (though it is also being applied broadly to younger patients as well), and explore the long-term physical, cognitive, and psychological consequences that ICU survivors face.
Preoperative assessment and perioperative management
Authors: Dhesi Jugdeep , Partridge Judith
Published: December 2017

The demographic changes in the surgical population pose a new challenge for geriatricians. Despite symptomatic and survival benefits following surgery, older people consistently suffer from excess medical morbidity, mortality, and adverse functional outcomes. This is predominantly related to physiological change, multimorbidity, and geriatric syndromes. For these reasons, geriatricians are increasingly asked for their medical and rehabilitation expertise in the management of elective and emergency surgical patients. This chapter describes the goals of preoperative risk assessment, modification of risk through medical and functional optimization, and presents different models of care which can be employed in older patients. The evidence behind comprehensive geriatric assessment in the surgical setting is presented, including discussion about collaborative decision-making and effective communication involving older patients, their relatives, surgeons, anaesthetists, physicians, and allied health professionals in the perioperative period. The future challenges in terms of research, education, and service development are discussed.
Long-term care
Authors: Schols Jos M. G. A. , Gordon Adam
Published: December 2017

In this chapter, institutional long-term care for older people is addressed from a European perspective. A short historical overview is followed by some thoughts on how long-term institutional care may develop in the future, including a consideration of the role of informal care as a competing and complementary sector. It then describes the clinical profile of nursing home residents including reason(s) for admission, access issues, and length of stay. Thereafter, the types of care offered to nursing home residents will be described, with particular attention given to staffing and financing issues. Special consideration is given to the medical care of nursing home residents. Finally, we consider quality assurance in long-term care and how this is approached in different legislations before closing with a description of relevant themes and issues for research in the nursing home setting.
Environment and ageing biology
Authors: Karlamangla Arun S. , Seeman Teresa E.
Published: December 2017

Psychosocial factors over the life course and major life events are associated with the health, functional status, and survival of older adults. This chapter discusses the biological mechanisms through which these influences are thought to operate, and how life stresses might accelerate the usual ageing of biological systems. It starts with a brief description of psychosocial determinants of health and functioning before elaborating on the allostatic mechanisms by which the body adapts its internal physiological milieu in response to perceived stressors. The price paid for frequent and recurring adaptation is eventual dysregulation of the mediators of allostasis, or allostatic load. We close with a brief discussion of allostatic load links to health outcomes in older adults and potential interventions that might ameliorate the impact of psychosocial adversities on health.
Inflammation and its role in ageing and disease
Authors: Wang Jintang , Leng Sean X.
Published: December 2017

Ageing is a complex process characterized by progressive loss of homeostasis and physiologic reserve with increased disease susceptibility and vulnerability to adverse health outcomes. It is often accompanied by a low-grade, systemic, unresolved, and smouldering chronic inflammation marked by 2–4-fold increase in circulating levels of multiple inflammatory mediators. This chapter begins with a brief discussion of the basic biology thought to drive chronic inflammation, and then proceeds to provide an overview of current evidence supporting significant contribution of age-related chronic inflammation to frailty and late-life functional decline, neurodegenerative diseases, cardiovascular diseases, and age-related metabolic diseases. It ends with a brief discussion of the anti-inflammatory properties of caloric restriction (CR) and physical exercise, suggesting the possibility of developing interventional strategies to mitigate age-related chronic inflammation and its adverse impact on the health and well being of older adults.
Immune system changes and immunosenescence
Authors: Pawelec Graham , Müller Ludmila , Fülöp Tamas , Dunn-Walters Deborah
Published: December 2017

The immune system defends against infection, but older people paradoxically suffer not only from failing immunity resulting in increased susceptibility to infections and decreased responsiveness to vaccination, but at the same time increased inflammation and immunopathology accompanying immune responses. Interventions to reduce such deleterious effects while enhancing protective immunity are challenging but need to be confronted if we are to deal successfully with the increasing numbers of elderly and frail people in modern societies. To do this, we need to understand the mechanisms responsible for age-associated increased susceptibility to infections and immune-influenced chronic degenerative diseases of ageing. Defining relevant age-associated alterations and identifying reliable biomarkers for monitoring clinically-relevant immune status in the elderly population is crucial to overcoming these problems. Here, we briefly outline age-associated changes to immunity collectively termed ‘immunosenescence’.
Mitochondrial decline and chronic conditions of older adults
Authors: Marzetti Emanuele , Landi Francesco , Martini Francesca , Leeuwenburgh Christiaan , Calvani Riccardo
Published: December 2017

Ageing involves a progressive deterioration of physiological integrity which leads to increased vulnerability to stressors and multisystemic functional decline. Mitochondrial dysfunction is increasingly recognized as a common denominator of ageing and an important causative factor for major age-related conditions. Mitochondrial function becomes perturbed by age-associated accumulation of mtDNA mutations, altered mitochondriogenesis and dynamics, and abnormal regulation of mitophagy. These alterations result in diminished bioenergetic efficacy, enhanced oxidative stress, and eventually loss of cellular viability. This series of events is proposed to be a major mechanism in the ageing process and the development of chronic diseases. This chapter provides an overview on the mechanisms believed to underlie the loss of mitochondrial function with ageing. Special attention is paid to the consequences of mitochondrial dysfunction in postmitotic tissues (i.e. heart, skeletal muscle, and central nervous system), where mitochondrial damage is proposed to be responsible for the appearance of age- and disease-associated phenotypes.
Delirium
Authors: MacLullich Alasdair M. J. , Marcantonio Edward R. , Meagher David J.
Published: December 2017

Delirium is a complex medical emergency affecting at least 15% of older hospitalized patients. It causes considerable patient and carer distress, and is associated with adverse outcomes including falls, increased length of stay, new institutionalization, new and exacerbated long-term cognitive impairment, and mortality. Causes include medical illness, trauma, surgery, psychological stress, and drugs. The mechanisms involve direct effects on the brain such as hypoxia, and likely altered inflammatory and stress pathways. Older age, neurodegeneration, and medical comorbities greatly increase vulnerability. Detection involves eliciting evidence of acute inattention, altered level of arousal, and/or psychosis; brief tools such as the 4AT can improve detection rates. Care involves multiple aspects: treating all precipitating causes, optimizing general care, communicating with patients and carers, preventing complications, and treating distress and agitation. Detection of undiagnosed underlying dementia is important. Risk reduction in vulnerable patients, involving optimizing medical status, the care environment, and patient experience, is effective.
Benign prostatic hyperplasia and prostate cancer
Authors: Savdie Richard , Chedgy Edmund C. P. , Molokwu Chidi
Published: December 2017

The most common pathologic conditions of the prostate are benign prostatic hyperplasia (BPH) and prostate cancer. Both of these conditions have age as a risk factor. Therefore the importance of understanding their impact in the ageing male is clear. In particular, both of these conditions can have an effect on quality of life in the ageing male.

This chapter will aim to evaluate the background and diagnostic differences between the two conditions, with a focus on the benefits and pitfalls of prostate-specific antibody (PSA) testing. Furthermore, the effects of both these common conditions, including their impact on the male lower urinary tract, are explored. Subsequently, a focused outline of the treatment options for both BPH and prostate cancer will be presented. The discussion will focus on mechanisms of optimizing treatment options in an elderly population. Finally, the potential complications of different treatments for prostate cancer will be explored.
Sarcopenia—definitions and epidemiology
Authors: Morais José A.
Published: December 2017

Sarcopenia is a progressive and inevitable loss of skeletal muscle mass and strength associated with ageing that places older adults at high risk for adverse health outcomes. Up to of 15% of older adults suffer negative healthcare consequences because of sarcopenia. Furthermore, it is responsible for two to four times greater risk of disability. Expert groups have proposed clinical oriented criteria based on gait speed <0.8 m/s and low handgrip strength before performing muscle mass assessment. Multiple aetiologies are implicated in the development of sarcopenia including age-related, lifestyle, neurodegeneration, hormonal, and inflammation factors. Resistance exercise training and higher than recommended protein intake are two accessible means to counteract sarcopenia. Hormonal interventions, despite amelioration in muscle and fat masses, have not led to significant gains in function. Sarcopenia shares many features with frailty and can be considered as one of its underlying mechanisms.
Sarcopenia
Authors: Robledo Luis Miguel F. Gutiérrez , Pérez-Zepeda Mario Ulises
Published: December 2017

Sarcopenia is a muscle wasting condition that develops gradually during ageing and results in a loss of muscle mass and strength, leading to impairment in physical performance ability with loss of mobility and function, falls, and mortality. Diagnostic criteria include measurements of physical performance, muscle strength, and body composition. Sarcopenia is a treatable malady of ageing. It is clear that both aerobic and resistance exercise can improve muscle function. Furthermore, there is increasing evidence that high-quality protein supplementation can enhance muscle mass and function. Also, low 25(OH) vitamin D levels requires replacement therapy. Aside from exercise and nutritional supplementation, the pharmaceutical approach to sarcopenia is still under development. A specific well-directed programme of lifelong training could preserve body balance, muscle structure, and contractile properties up to old age, which in turn would improve quality of life and reduce risk of undue functional impairment.
From nutritional screening to assessment and nutritional planning in community, acute, and long-term care
Authors: Gioia Gianfranco , Molfino Alessio , Fanelli Filippo Rossi , Muscaritoli Maurizio
Published: December 2017

Age-related malnutrition is the result of age-related metabolic derangements. Sarcopenia in older people is also the result of malnutrition-related metabolic changes determining the lack of long-term muscle anabolic response to nutrient intake. Frailty is associated with the presence of nutritional derangements. Nutritional screening tools and nutritional assessment in ageing take into account diagnostic parameters for detecting the risk or the presence of protein-energy malnutrition in its different forms and stages. Nutritional screening represents the first step in the nutritional care process. A full nutritional assessment is necessary if the risk of malnutrition is detected during a nutritional screening. Nutritional and metabolic interventions are recommended for all those patients identified by screening and assessment as at risk for malnutrition or malnourishment. Nutritional plans offer several options to the patients according to the clinical setting (i.e. nutritional counselling, food fortification, oral nutritional supplements, and artificial nutrition).
Management of common fractures in older adults
Authors: Sanguineti V. Ana , Wild Jason R. , Joseph Bellal , Fain Mindy J.
Published: December 2017

Falls account for nearly 75% of all geriatric trauma, and are the most common cause of fractures in older people. Most falls occur from standing height or less, resulting in fragility fractures in older adults who often have multiple comorbidities and functional impairments. These fractures can lead to functional decline, institutionalization, and death. Fragility fractures are seen in the hip, spine, and wrist, pelvis, humerus, rib, and ankle. This fracture pattern identifies groups at increased risk for future falls and fractures, and those who can benefit from targeted programmes to prevent falls and optimize bone health. Management depends upon the site of fracture, the risks and benefits of non-surgical versus surgical intervention, and the patient’s goals of care.
Low back pain in older adults
Authors: O’Sullivan Kieran , Fersum Kjartan Vibe , Dankaerts Wim , O’Sullivan Peter
Published: December 2017

Low back pain (LBP) is one of the most common reasons for enduring long-term disability and difficulty with activities of daily living. The assessment of LBP in older adults should first carefully rule out the rare possibility that the pain represents a serious spinal or systemic pathology. Thereafter, a clinical reasoning framework can be used to identify the specific mix of biopsychosocial factors which are most relevant in the pain presentation of each individual patient. A cognitive functional approach for each patient should then address those specific factors for each person, with a view to enhancing pain control, maintaining participation in valued activities, and reducing dependence on the health service.
Epidemiology of infection in elderly populations in various settings
Authors: Gavazzi Gaëtan , Fraisse Thibaut , de Wazières Benoit
Published: December 2017

Age is associated with an increased risk of infection because of individual susceptibility (immunosenescence, comorbidities, malnutrition, functional status), as well as collective risk factors. Outcomes are also of concern, because for all infections, older patients exhibit higher short and long-term mortality rates. Over the last decade, subgroups of older populations (either community-dwelling, hospitalized or nursing home residents) have been distinguished, because epidemiological data regarding infections differ between these groups in terms of incidence, type, severity, and microbiology. Although urinary tract and respiratory tract infections appear to be the most frequent infections in these specific populations, skin/soft tissue and gastrointestinal infections, as well as meningitis are frequent in community-acquired infection (CAI), whereas outbreaks (respiratory and gastrointestinal) are more specific to nursing home infections, and antibiotic resistance is emerging as a major issue for both hospitalized and nursing home elder populations.
Infective endocarditis
Authors: Müller-Werdan Ursula , Werdan Karl
Published: December 2017

Infective endocarditis (IE) can involve native and prosthetic valves but also prosthetic surfaces of the heart like pacemakers and defibrillators. At least one-fourth of IE patients are aged >70 years. In the aged patient, healthcare-associated IE plays a prominent role, not only in patients with pre-existing valve disease, but also in those without. Blood culture and echocardiography are the cornerstones of diagnostics, antibiotics and—in 50%—valve surgery are the cornerstones of therapy. The geriatrician should cooperate with an Endocarditis Team—infectious disease specialist, cardiologist, and cardiac surgeon—when taking care of these patients, which have a mortality of 15–20%, with patients aged ³70 years having a 60% higher risk of dying.
Healthcare-associated infections and emergence of antibiotic resistance
Authors: Huttner Benedikt , Harbarth Stephan
Published: December 2017

Healthcare-associated infections (HAI) present a significant challenge to the safe delivery of healthcare. The pool of patients at increased risk for HAI—such as chronically ill and immunosuppressed individuals—has been steadily growing due to the ageing of the population and advances in medicine. At the same time, pathogens resistant to multiple antimicrobials have become increasingly prevalent, complicating the management of HAI and increasing their associated morbidity and mortality. Older people are especially affected by these trends. Limitation of the use of invasive devices, preventing transmission through hand hygiene and other measures, and the appropriate use of antimicrobials for treatment and prophylaxis have all been recognized as key strategies for the control of HAI and antimicrobial resistance.
Healthcare-associated infections and infection control
Authors: Astagneau Pascal , Seringe Elise , Bricaire François
Published: December 2017

Healthcare-associated infections (HAI) in older people frequently occur in mid or long-term cares facilities. The most frequent infections are those of the urinary tract, respiratory tract, skin/soft tissue, and gastrointestinal tract. The spectrum of pathogens are different in epidemic and endemic situations. Outbreaks occurring in long-term care frequently involve seasonal viruses such influenza, scabies, and multidrug-resistant bacteria such as Clostridium difficile. Ageing is a risk factor for HAI, which impairs immunological, metabolical, and neurological functions. Indwelling devices, poor nutritional status, and lack of mobility also increase the infection risk in the cared-for elderly. Infection control measures have to be implemented according to standard recommendations, including the use of alcohol-based hand rubs. Control measures should be adapted to the organization of healthcare facilites for older people, in particular environment and poor staff ressources. Focus should be made on vaccination programme of healthcare staff, especially against influenza.
Epidemiology of cancers in older adults
Authors: O’Hanlon Shane , Gosney Margot
Published: December 2017

Increasing life expectancy has led to a higher incidence and prevalence of cancer in older people, with the largest increase in the 75 and over age group. This group is much more likely to develop cancer than younger people. The incidence rate is higher for older males and varies by cancer type. The rate begins to decline in the 85 and over age group, however mortality continues to rise with age. Older people with cancer are undertreated compared to younger people. Overall survival rates are improving, but there is a widening gap in outcomes between younger and older people. The United Kingdom has poorer outcomes than the United States and other European countries. This chapter discusses recent trends in cancer epidemiology and outlines modern approaches towards assessment and care, including consideration of frailty and comprehensive geriatric assessment.
Screening for cancer
Authors: Horgan Anne , Alibhai Shabbir M. H.
Published: December 2017

Cancer screening is the early identification of an asymptomatic malignancy. The aim of screening is to identify cancer at a stage where it can be more effectively treated and ideally with curative intent. Guidelines regarding screening in the older population differ widely across countries, in part due to the underrepresentation of older adults in the large screening trials on which the recommendations are based. In this chapter, we present the screening recommendations for colorectal, lung, breast, and prostate cancer from four international groups. The benefits of screening in the overall population are highlighted, and the data supporting screening in older adults outlined. Factors to be considered in screening decisions are discussed, including remaining life expectancy and patient and physician wishes. Potential methods to overcome these challenges along with supportive evidence are highlighted.