Common Chronic Conditions
What are the most common chronic conditions experienced by older adults? Arthritis and various forms of cardiovascular disease are the most prevalent (National Center for Health Statistics, 2008b). Four others are also extremely important: diabetes, cancer, incontinence, and stress.
Arthritis. We saw in Chapter 3 that osteoarthritis and rheumatoid arthritis afflict many adults. It is estimated that everyone over age 60 shows some physical evidence of one form of arthritis, with most of them reporting pain (National Institute of Arthritis and Musculoskeletal and Skin Diseases, 2008a, 2008b). Because it is so common, most people assume that arthritis is simply a part of normal aging and further assume they must simply learn to live with it. Consequently, many people fail to seek appropriate therapy.
Rheumatoid arthritis is not strictly an age – related condition; in fact, many young and middle-aged adults have symptoms. The cause of rheumatoid arthritis remains unknown. In contrast,
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Arthritis is a painful and debilitating disease that decreases the quality of life.
osteoarthritis is age related, with symptoms usually not beginning until later in life. Genetic and environmental factors (such as overuse) have been identified. As you would imagine, the primary problem facing people with arthritis is pain. Strangely, the pain often is variable; people have both good days and bad days. In most cases, people with arthritis structure their days around these variations, doing more when they can. However, reducing physical activity has a paradoxical effect. Movement stimulates the secretion of synovial fluid, which lubricates the surfaces between and increases blood flow to the joints. Movement also keeps muscles toned and limber. All are important in keeping joints flexible; refraining from movement ultimately makes the joints hurt worse. Lack of movement over long
periods of time can eventually result in the joints “freezing” in place, a condition called contracture that may require physical therapy to address. Thus people with arthritis must be encouraged to keep moving, because the pain accompanying the arthritis is usually less than the pain that results from the effects of contracture.
There are several ways to treat arthritis (Med – linePlus, 2008). Several types of medication help alleviate the pain of arthritis. Exercise is essential for maintaining healthy joints and should include range-of-motion, strength training, and low-impact aerobics. Other prevention approaches include taking glucosamine and chondroitin, and eating a diet rich in antioxidants and omega-3 fatty acids (found in cold-water fish such as salmon as well as some nuts, such as walnuts). The pain of arthritis can be managed in most people by taking over-the – counter medications, such as acetaminophen or aspirin, or one of several prescription drugs, such as nonsteroidal anti-inflammatory drugs (NSAIDs), cyclo-oxygenase-2 (COX-2) inhibitors (particularly helpful for people who cannot take NSAIDs due to stomach problems), corticosteroids, diseasemodifying anti-rheumatic drugs (DMARDs, which help over the long term), and a new class of DMARDs called tumor necrosis factor (TNF) blockers. All these drugs have potentially serious side effects, so they should be taken only under the supervision of a physician; for example, the Food and Drug Administration has warned about fungal infections as a side effect of TNF blockers (Food and Drug Administration, 2008).
Diabetes Mellitus. The disease diabetes mellitus
occurs when the pancreas produces insufficient insulin. The primary characteristic of diabetes mellitus is above-normal sugar (glucose) in the blood and urine caused by problems in metabolizing carbohydrates. People with diabetes mellitus can go into a coma if the level of sugar gets too high, and they may lapse into unconsciousness if it gets too low.
There are two general types of diabetes. Type I diabetes usually develops earlier in life and requires the use of insulin, hence it is sometimes called insulin-dependent diabetes. Type II diabetes typically develops in adulthood and is often effectively
managed through diet. There are three groups of older adults with diabetes: those who developed diabetes as children, adolescents, or young adults; those who developed diabetes in late middle age and also typically developed cardiovascular problems; and those who develop diabetes in late life and usually show mild problems. This last group includes the majority of older adults with diabetes mellitus. In adults, diabetes mellitus often is associated with obesity. The symptoms of diabetes seen in younger people (excessive thirst, increased appetite and urination, fatigue, weakness, weight loss, and impaired wound healing) may be far less prominent or absent in older adults. As a result, diabetes mel – litus in older adults often is diagnosed during other medical procedures, such as eye examinations or hospitalizations for other conditions.
Overall, diabetes is more common among older adults, members of minority groups, and women; for example, African Americans and Latinos born in 2000 have a 2 in 5 risk for diabetes over their lifetimes, more than twice the rate for European Americans (Office of Minority Health and Health Disparities, 2008). The chronic effects of increased glucose levels may result in complications. The most common long-term effects include nerve damage, diabetic retinopathy (discussed in Chapter 3), kidney disorders, cerebrovascular accidents (CVAs), cognitive dysfunction, damage to the coronary arteries, skin problems, and poor circulation in the arms and legs, which may lead to gangrene. Diabetes also increases the chance of developing atherosclerosis and coronary heart disease.
Although it cannot be cured, diabetes can be managed effectively through a low-carbohydrate and low-calorie diet; exercise; proper care of skin, gums, teeth, and feet; and medication (insulin). For older adults, it is important to address potential memory difficulties with the daily testing and management regimens. Education about diabetes mellitus is included in Medicare coverage, making it easier for older adults to learn how to manage the condition.
Cancer. Cancer is the second leading cause of death in the United States, behind cardiovascular disease. Every year, nearly 1.5 million new cases of cancer are
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diagnosed, and more than 565,000 diagnosed persons die (American Cancer Society, 2008b). Over the life span, nearly one in every two American men and one in three American women will develop cancer (American Cancer Society, 2008b). There is evidence that cancer is present in many people whose cause of death is officially listed as some other disease, such as pneumonia, so that the true incidence rate may be underestimated.
Many current deaths caused by cancer are preventable. Some forms of cancer, such as lung and colorectal cancer, are caused in large part by unhealthy lifestyles. The American Cancer Society (2008c) estimates that cancers caused by smoking alone account for about 1 in every 5 deaths in the United States each year. Most skin cancers can be prevented by limiting exposure to the sun’s ultraviolet rays. Clearly, changes in lifestyle would have a major impact on cancer rates. The risk of getting cancer increases markedly with age (American Cancer Society, 2008b). Figure 4.5 depicts the incidence rates for cancer as a function of age. As can be seen, the largest number of cases occurs in the
age group 80 to 84. Notice that after age 40 the incidence rate increases sharply.
The incidence and mortality rates of some common forms of cancer in men and women are shown in Figure 4.6. Notice that prostate cancer is the most common form of cancer in men and breast cancer is the most common form in women in all ethnic groups (American Cancer Society, 2008b). Gender differences are apparent in some forms of cancer; for example, lung cancers are more common in men (American Cancer Society, 2008b). Ethnic differences are apparent in cancer rates, as depicted in Figure 4.7.
Death rates from various forms of cancer differ: Lung cancer kills more than three times as many men as prostate cancer and considerably more women than breast cancer (in women). Five-year survival rates for these cancers also differ dramatically. Whereas only 15% of patients with lung cancer are still living 5 years after diagnosis, an average of 86% of female patients with breast cancer and 97% of patients with prostate cancer are (American Cancer Society, 2008b).
Why older people have a much higher incidence of cancer is not understood fully. Part of the reason is the cumulative effect of poor health habits over a long period of time, such as cigarette smoking and poor diet. In addition, the cumulative effects of exposure to pollutants and cancer-causing chemicals are partly to blame. As noted earlier in this chapter, some researchers believe that normative age-related changes in the immune system, resulting in a decreased ability to inhibit the growth of tumors, may also be responsible. Research in molecular biology and microbiology is increasingly pointing to genetic links, likely in combination with environmental factors (Wallace, 2006). The National Cancer Institute initiated the Cancer Genome Anatomy Program (CGAP, http://cgap. nci. nih. gov/) to develop a comprehensive list of all genes responsible for cancer. For example, two breast cancer susceptibility genes that have been identified
are BRCA1 on chromosome 17 and BRCA2 on chromosome 13. When a woman carries a mutation in either BRCA1 or BRCA2, she is at a greater risk of being diagnosed with breast or ovarian cancer at some point. Similarly, a potential susceptibility locus for prostate cancer has been identified on chromosome 1, called HPC1, which may account for about 1 in 500 cases of prostate cancer.
Although genetic screening tests for breast and prostate cancer for the general population are not yet warranted, such tests may one day be routine. Genetics also is providing much of the exciting new research on possible treatments by giving investigators new ways to fight the disease. Age-related tissue changes have been associated with the development of tumors, some of which become cancerous; some of these may be genetically linked as well. The discovery that the presence of telomerase causes cells to grow rapidly and without limits on the number
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Source: Ries, L. A.G., Melbert, D., Krapcho, M., Stinchcomb, D. G., Howlader, N., Horner, M. J., Mariotto, A., Miller, B. A., Feuer, E. J., Alterkruse, S. F., Lewis, D. R., Clegg, L., Eisner, M. P., Reichman, M., & Edwards, B. K. (eds). SEER Cancer Statistics Review, 1975-2005, National Cancer Institute. Bethesda, MD, http://seer. cancer. gov/csr/1975_2005/, based on November 2007 SEER data submission, posted to the SEER website, 2008.
of divisions they can undergo provides additional insights into how cancer develops (Londono-Vallejo, 2008; see Chapter 3). What remains to be seen is how these genetic events interact with environmental factors, such as viruses or pollutants. Understanding this interaction process, predicted by the basic developmental forces, could explain why there are great differences among individuals in when and how cancer develops.
The most effective way to address the problem of cancer is through increased use of screening techniques and preventive lifestyle changes. The American Cancer Society (2008) strongly recommends these steps for people of all ages, but older adults need to be especially aware of what to do. Table 4.1 shows guidelines for the early detection of some common forms of cancer.
As Moses is learning, one of the biggest controversies in cancer prevention concerns screening
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and treatment for prostate cancer. The Current Controversies feature summarizes the issues: lack of data about the causes and the course of the disease and disagreement over treatment approaches. This controversy mirrors similar debates over the treatment of breast cancer, contrasting the relative merits of radical mastectomy (removal of the breast and some surrounding tissue) with lumpectomy (removal of the cancerous tumor only) and how chemotherapy, radiation, and drugs such as tamoxifen fit into the overall treatment approach.
In general, cancer treatment involves several major approaches that are typically used in combination (National Cancer Institute, 2008): surgery, chemotherapy, radiation, and others (e. g., biological therapy, gene therapy, bone marrow transplant). In addition, numerous alternative therapies, such as herbal approaches, exist. Continued advances in genetic research probably will result in genetically
Summary of American Cancer Society (ACS) Recommendations for Early Cancer Detection
Cancer-related checkup A cancer-related checkup is recommended every 3 years for people aged 20-40 and
every year for people age 40 and older. This exam should include health counseling and, depending on a person’s age, might include examinations for cancers of the thyroid, oral cavity, skin, lymph nodes, testes, and ovaries, as well as for some nonmalignant diseases.
Breast Women 40 and older should have an annual mammogram and an annual clinical breast
exam (CBE) performed by a health care professional and should perform monthly breast self-examination. The CBE should be conducted close to the scheduled mammogram. Women ages 20 to 39 should have a CBE performed by a health care professional every 3 years and should perform monthly breast self-examination.
Colon and rectum Men and women aged 50 or older should follow one of the examination schedules below:
A fecal occult blood test every year and a flexible sigmoidoscopy every 5 years.
A colonoscopy every 10 years.*
A double-contrast barium enema every 5 to 10 years.*
A CT colonography (virtual colonoscopy) every 5 years.
Prostate The ACS recommends that both the prostate-specific antigen blood test and the rectal
examination be offered annually, beginning at age 50, to men who have a life expectancy of at least 10 years and to younger men who are at high risk. Men in high-risk groups, such as those with a strong familial predisposition (i. e., two or more affected first-degree relatives) and African Americans, may begin at a younger age (i. e., 45 years).
Uterus Cervix: All women who are or have been sexually active or who are 18 and older
should have an annual Pap test and pelvic examination. After three or more consecutive satisfactory examinations with normal findings, the Pap test may be performed less frequently. Discuss the matter with your physician.
Endometrium: Women at high risk for cancer of the uterus should have a sample of endometrial tissue examined when menopause begins.
engineered medications designed to attack cancer cells. As with any health care decision, people with cancer need to become as educated as possible about the options.
Incontinence. For many people, the loss of the ability to control the elimination of urine and feces on an occasional or consistent basis, called incontinence, is a source of great concern and embarrassment. As you can imagine, incontinence can result in social isolation and lower quality of life if no steps are taken to address the problem.
Urinary incontinence, the most common form, increases with age and varies across ethnic groups
as a function of gender (Tennstedt et al., 2008). Among community-dwelling older adults, roughly 20% of women and 10% of men have urinary incontinence. But rates are much higher if the person has dementia and is living in the community (about 35%) or if the person is living in a nursing home (roughly 70%). European American women report a higher rate of urinary incontinence than either African American or Latina women; rates for men do not vary across ethnic groups.
Urinary incontinence occurs for five major reasons (Department of Urology, Cornell University,
2008) . Stress incontinence happens when pressure in the abdomen exceeds the ability to resist urinary
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