An Ageing World And Its clinical Consequences BRUNO LUNENFELD MD PhD International society for men’s health and aging (ISSAM) 1
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An Ageing World And Its clinical Consequences
BRUNO LUNENFELD MD PhD
International society for men’s health and aging (ISSAM)
1
OUTLINE
An aging world- demographic data
Life and health expectancy
Aging Clinical consequences
Preventive strategies
2
Global Population Adds Another Billion at Record Rates
Source: Population Reference Bureau estimates and projections; and UN Population Division, World Population Prospects: The 2008 Revision (2009
Human populations have grown at about 0.05% annually for about 10,000 years, until about 1800.
The rate grew by 0.5%, till 1930, And to 2% since 1960s Today we have reached the 7
billion mark
0.05%
by 0.5%,
0.7%
2%
3
Over the past century, the world has seen
enormous changes, including historically
unprecedented declines in mortality rates and
increases in population, followed by equally
unprecedented declines in fertility rates.
Lunenfeld, B. (2008) An Aging World--demographics and challenges. Gynecol. Endocrinol. 24, 1-3. 4
Aging world
4
Adapted from World Population Data Sheet 2010
2010 551 million people > 65 years
2010
6,892million
2050
9,482 million (37.6%)
2050 1964 million people > 65 years
21%
8%
5
The projected two billion elderly people (65 years and over) of the year 2050 are already around us
as teenagers and young people
6
The 20th century was the century of population growth; the 21st century will be remembered as the century of aging.
This century will see a new set of demographic
challenges, including a mix of falling fertility
rates alongside persisting worldwide
population growth, and the subsequent aging
of populations in both developing and
developed countries.
Lunenfeld, B. (2008) An Aging World--demographics and challenges. Gynecol. Endocrinol. 24, 1-3. 7
Aging world
7
Implications of aging populations
It is projected that by 2050, there will be more elderly people in the world than children. This has far-reaching implications on the social, economic and health aspects of human development.
While population ageing is a global phenomenon, the South-East Asia Region, parts of Africa and south America has certain unique features of its own.
Much of the ageing in the rest of the world occurred after the population became rich.
By contrast much of the elderly population in the South-East Asia Region parts of Africa and south America are still living below the poverty line.
8
AGING
Life and health expectancy
9
40 y 26 y 33.1 y 11.5 y 6.3 y 7.5 y 44.7 y 4.3 y gain 10
Europe 1800-1900 fu
nct
ion
al c
apac
ity
age
Frailty
Early life
Adult life
Older age
Disability
Preventive strategies Clean water
Sanitation Nutrition
Life expectancy
45
0.2-1yr Clinical disease-free period
11
B
communicable diseases
Infectious diseases
Louis Pasteur 1822 Semmelweis 1818
Jenner 1749
B. Lunenfeld & Stratton P The clinical consequences of an ageing world and preventive strategies Best Practice & Research Clinical Obstetrics & Gynaecology, 2013
11
Europe 2014 fu
nct
ion
al c
apac
ity
age
5 yrs.
Frailty
Early life
Intervention
& life style
Adult life Older age
Disability
Preventive strategies Sanitation,refrigeration
Vaccination, Antibiotics Nutrition, exercise
Life expectancy 80
2 yrs.
Non-communicable diseases: chronic degenerative diseases
cancer CVD
Clinical disease-free period
12
C
Vaccinati
on
Hilleman (1919
Vaccines
A Flemming Penicillin 1940
Waksman Streptomycin
1955
Conover Tetracycline
1957
Adapted from B. Lunenfeld & Stratton P The clinical consequences of an ageing world and preventive strategies Best Practice & Research Clinical Obstetrics & Gynaecology, 2013
50
Increased longevity without quality of life is an empty prize.
Health expectancy is more important than life expectancy. Dr Hiroshi Nakajima,
Director-General, W.H.O 1979
Europe 2014 fu
nct
ion
al c
apac
ity
age
5 yrs.
Frailty
Early life
Intervention
& life style
Adult life Older age
Disability
Preventive strategies Sanitation,refrigeration
Vaccination, Antibiotics Nutrition, exercise
Life expectancy 80
2 yrs.
Non-communicable diseases: chronic degenerative diseases
cancer CVD
Clinical disease-free period
14
C
Vaccinati
on
Hilleman (1919
Vaccines
A Flemming Penicillin 1940
Waksman Streptomycin
1955
Conover Tetracycline
1957
Adapted from B. Lunenfeld & Stratton P The clinical consequences of an ageing world and preventive strategies Best Practice & Research Clinical Obstetrics & Gynaecology, 2013
50
Nutrition, exercise , Yearly medical visit, & flu vac, urine & blood ex. including PSA, Testosterone Every 5 yrs pneumococcal vaccine and Colonoscopy
EU25 Life Expect Healthy
Life expect with
moderate AL
Life Expect with severe
AL
Healthy/Life Expect
(in years) (in years) (in years) (in years) (in %)
At birth
Men 77.1 61.3 10.5 5.3 79.5
Women 83 61.9 14.1 7 74.6
Difference 5.9 0.6 3.6 1.7 -4.9
At age 50
Men 29.5 17.4 7.7 4.4 59.0
Women 34.4 17.7 10.6 6.1 51.5
Difference 4.9 0.3 2.9 1.7 -7.5
At age 65
Men 17.6 8.4 5.7 3.5 47.7
Women 21.1 8.4 7.7 5 39.8
Difference 3.5 0 2 1.5 -7.9
Values Of Life And Health Expectancy 2010
Men Women
LE (in years)
HLY (in years)
LE (in years)
HLY (in years)
At birth
Min value 77.77 52.33 77.37 52.04
Max value 79.79 71.68 85.32 71.64
Difference 12.03 19.35 7.96 19.60
At age 50
Min value 22.78 9.85 29.80 9.67
Max value 31.47 25.41 36.76 25.97
Difference 8.69 15.55 6.96 16.30
At age 65
Min value 13.20 3.33 17.03 2.82
Max value 18.89 14.13 23.43 15.47
Difference 5.69 10.80 6.41 12.65
Minimum and maximum values of life and health expectancy
(Member States of the European Union (EU27), in 2010)
country year age
Men
Total LE LE
without AL
LE with moderate
AL
LE with severe AL
% without
AL
% with moderate
AL
% with severe AL
Sweden 2010 0 79.61 71.68 4.71 3.22 90.05 5.91 4.04
country year Age
Men
Total LE LE
without AL
LE with moderate
AL
LE with
severe AL
% without
AL
% with moderate
AL
% with severe
AL
Sweden 2010 65 18.31 14.13 2.32 1.86 77.15 12.7 10.15
country year age
Men
Total LE LE
without AL
LE with moderate
AL
LE with
severe AL
% without
AL
% with moderate
AL
% with severe
AL
Sweden 2010 85 5.67 3.87 0.69 1.11 68.29 12.2 19.51
18
When discussing age related problems, it is often difficult to separate and to distinguish between
Ageing amplifiers determined by environmental and developmental factors ( which can be modified)
Acute or chronic illness or inter current diseases ( which can be prevented, delayed or cured).
Risk factors due to hormone deficiency ( which can be prevented )and
The natural ageing process, primarily genetically determined . Whether this can be influenced or changed in the near future is still debatably
19
AGEING
The major causes of morbidity and mortality all take effect
over extended periods.
DNA is constantly damaged and being repaired,
Bones are constantly worn away and rebuilt
Atheromas are constantly accumulating inside arteries, and
are constantly being removed .
If the rate of decay is faster then the rate of repair healthy
tissue will be lost until damage will produce symptoms and
finally result in disease .
Ageing is not a uniform process in the body, and different
tissues age at different rates and mechanisms may vary.
20
“the tragedy of life is what dies inside a man while he lives’’
Albert Schweitzer
21
Preventive strategies
• The promotion of healthy aging and the prevention, or drastic reduction of morbidity and disability of the elderly must assume a central role in the formulation of the health and social policies.
• It must emphasize an all-encompassing lifelong approach to the aging process beginning with pre-conceptual events and focus on appropriate interventions at all stages of life.
22
We Know the “Big Picture”
)
Accumulated Risk (range
23
These include: • Cardiovascular diseases
• Prostate cancer
• Malignant neoplasm
• Urological problems
• Chronic obstructive pulmonary diseases
• Degenerative & metabolic diseases (arthrosis, diabetes, metabolic syndrome osteoporosis)
• Visual loss (macular degeneration, cataract)
• Hearing loss
• Lack of concentration Anxiety, mood, depression and sleep disorders
• Sexual dysfunction
• Various dementia (i.e. Alzheimer disease)
Five of six men in their sixties have one or more of these diseases
Ageing is Associated with Increased Incidence of Defined Diseases
24
Specific measures for the promotion of healthy aging should include
1) safe environment, and prevention of injuries
2) healthy lifestyle including proper nutrition,
3) appropriate exercise,
4) avoidance of smoking,
5) avoidance of drug and alcohol abuses,
6) social interactions to maintain mental health,
7) screening for preventable disorders/ deficiencies with early intervention
25
Specific screening and early intervention measures for the promotion of healthy
aging should include • Preventive strategies for Cancers
i. Colorectum Cancer (CRC)
ii. Lung Cancer
iii. Prostate cancer
• Medical health care including the control of chronic illnesses
• Prevention of chronic respiratory diseases
• Treatment of urinary tract infection and incontinence
• Preventive medical strategies to maintain Quality of life and delay, decrease or prevent frailty and disabilities
26
The promotion of a safe environment • Falls are the most common–and preventable–threat
to senior independence.
• Falls account for significant morbidity, including fracture, impaired mobility, depression, admission to long-term care facilities,
• Reduced fitness and muscle strength, loss of vision, dementia, chronic health problems such as arthritis, as well as infections and other illnesses are major risk factors
• Prescription drugs are potential risk factor because some can lead to dizziness
27
Prevention of fracture risk
• In older men low testosterone levels are associated with increased fall risk.
• TRT has beneficial effects on muscle mass and strength that may reduce propensity to fall and therefore decrease fracture risk.
• Physical exercise, including stretching and equilibrium exercises are mandatory in combination with TRT
[.
Healthy lifestyle including proper nutrition and avoidance of drug and alcohol abuses
• A healthy lifestyle includes regular physical activity, avoidance of drug and alcohol abuses, healthy eating, and balancing the number of calories one consumes with the number of calories one’s body uses.
• A healthy lifestyle including regular physical activity should avoid obesity
• Regular exercise (aerobic, anaerobic, stretching and strengthening one’s balance and coordination) can strengthen the cardio-vascular system as well muscles around joints.
29
Obesity
Obesity impacts quality of life and shortens life expectancy.
Obesity is a chronic condition that cannot be ameliorated simply with lifestyle behavior alone*
Obesity contributes to insulin resistance, type 2 diabetes (T2DM) and is associated with a host of comorbidities and therefore represents a healthcare crisis.
30
Desirable outcomes in management of overweight and obesity
Lifestyle changes produce moderate effects on weight loss but in most cases are unsustainable.
Desirable outcomes in management of overweight and obesity necessitates development and utilization of new well tolerated and efficacious agents, which can be used in combination with lifestyle changes to achieve weight loss.
Contemporary approaches to management of obesity include lifestyle modifications* and pharmaco-therapeutic agents, such as incretin and glucagon- peptide-1 (GLP-1) receptor agonists **enzyme inhibitors (dipeptidyl peptidase inhibitors)*** angiopoietin-like proteins****and bariatric surgery *****
31
Obesity and Testosterone
• Meta-analyses of randomized trials in middle-aged and older men have demonstrated the beneficial effects of TRT in reducing fat mass with a significant increase in lean body mass and grip strength.
• Rodrıguez- Tolra et al. demonstrated clearly that TRT in men with TD decreased fat mass overall, and to the greatest extent in the android and gynecoid regions and caused improvements in body composition, increasing lean mass, primarily in arms and legs
• TRT is potentially an effective treatment in aging obese men with TD. There is also some evidence that long-term T may result in substantial and sustained reductions in body weight, waist circumference and BMI in obese hypogonadal men
• The successful achievement of weight loss, as well as the consistent increase in lean mass lead to beneficial effects on diabetes mellitus type 2
Preventive strategies for Cancers Primary prevention concerns measures aimed at reducing carcinogen initiation and actions during the phase before focal lesions become
apparent, including education for awareness of risk factors
Reduce exposure to tobacco to the lung, oral cavity and pharynx to decrease respiratory cancers
Reduce salt intake and identify and treat Helicobacter pylori infections to decrease gastrointestinal cancers and heart disease
Reduce food intake, improve the diet and increase exercise to decrease colon-rectum and kidney cancer,
Increase water intake, particularly to decrease urinary bladder cancer
33
Obesity contributes to premature cardiac aging
Obesity contributes to premature cardiac aging via disrupted mitochondrial biogenesis and function and is an independent risk factor for development of heart failure *
Testosterone therapy ameliorates this dysfunction.
Yin XJ Clin Endocrinol Metab 2014;99:209–216
Preventive strategies for Cancers • Secondary prevention covers screening and early
detection, along with education to help ensure that patients comply with screening guidelines and present for treatment as soon as symptoms develop.
• Screening for colorectal cancer, like that recommended by the U.S. Preventive Services Task Force (USPSTF) can reduce morbidity and death through early detection and treatment of cancers and pre-cancers.
• Yet many adults are not receiving regular, recommended, potentially lifesaving screenings.
35
Cardio Vascular disease
• In a recently presented study by Tan et al that included 19,968 hypogonadal men who received TRT during a 5-year period , the risk for myocardial infarction was 7-fold lower and the risk for stroke 9 times lower compared with samples from the general population.
• No worsening of preexisting myocardial infarction or stroke in patients on TRT was observed.,
[Robert Tan
Cardiovascular Disease
• Patients with cardiovascular disease should be assessed for TD
• Some observational studies including meta-analysis show that low endogenous testosterone levels are associated with increased risk of all-cause and cardiovascular disease-related mortality [31-33].
Medical health care including the control of chronic illnesses
• Cigarette smoking is the most common preventable cause of lung cancer, the leading cause of cancer death in both men and women in our society
• Physicians are uniquely positioned to impact smoking rates
• Antismoking policies may contribute to other health gains, including the prevention of chronic respiratory and cardiovascular diseases.
38
Colorectal Cancer
• The obvious factors which need to be avoided as preventive measures are obesity and excessive alcohol consumption.
• Furthermore Dietary fat, total energy intake, and red meat intake were associated with an increased risk for colorectal serrated polyps.
39
Colorectum Cancer
• Dietary principles that decrease colorectal cancer risk entail increasing vegetables and fruit while reducing meat and refined carbohydrate consumption.
• An added benefit arises from ingesting olive oil and other unsaturated fats, common to the Mediterranean diet rather than using animal and saturated fats.
Eur J Cancer Prev. 2004 Oct;13(5):447-52. 40
Colorectum Cancer
• Screening subjects 50 to 60 years old for occult blood and subjects 60 to 72 years old with colonoscopies every 10 years is the most cost-effective strategy .
Clin Gastroenterol Hepatol. 2012; 10(3):266-271
41
Osteoporosis • The World Health Organization identifies
that osteoporosis is one of the leading health problems in the Western world. As many as 1 in 2 postmenopausal women and 1 in 5 older men are at risk for an osteoporosis-related fracture.
• Dual-energy X-ray absorptiometry (DXA) is currently the procedure of choice to diagnose osteoporosis and assess fracture risk. Evidence is lacking about optimal intervals for repeated screening
42
Osteoporosis • The most serious consequence of this disorder is
fractures, which have a serious negative impact on quality of life and are often the trigger for accelerated deterioration, ultimately ending in death.
• Despite the availability of effective preventive treatments, osteoporosis is frequently underdiagnosed and undertreated, particularly among the elderly, who are also at greatest risk.
• The management of osteoporosis involves improving bone health via adequate nutrition, calcium and vitamin D supplements, HRT and fall prevention strategies.
• Although these measures are important in the management of all patients, most elderly patients are likely to need additional pharmacological therapy to adequately reduce their fracture risk.
43
Frailty
• Frailty is a state of global deficiency of physiological reserves and functional dysregulation involving multiple organ systems, resulting in poor homeostasis and increased vulnerability when faced with stressors
• Frailty is characterized by unintentional weight loss and sarcopenia/muscle wasting, weakness, and exhaustion.
• Even minor negative events are likely to result in adverse outcomes such as falls, hospitalization, disability and death.
44 Fried et L Gerontol A Biol Sci Med Sci, 2004; 59: 255-263
Frailty
• Elevated levels of inflammatory markers have been associated with, and predict poorer outcomes in older adults, and are consistently associated with cardiovascular disease, diabetes, cancer, and all-cause mortality
• Preventing old age frailty should be recognized as an important goal of obesity and CVD risk control,
• Multi-component exercise programs (usually focused on resistance, balance, aerobic, and flexibility training) have been shown to improve mobility, balance confidence, and lower blood lipid profiles they also reduce fall risk and fall rate, as well as improve quality of life
• Exercise training complemented by social and cultural activity will increase its effect on quality of life.
45
Conclusion
• The 20th century was the century of population growth
• The 21st century will be remembered as the century of aging.
• Increase in life expectancy is one of the highest achievements of humankind
• However, aging and age-related disease is also a mounting challenge for individuals, families and for social, economic, and health care systems.
46
Conclusion
• Since health expectancy has lagged behind the increase in life expectancy, the rise in morbidity will increase the burden on national healthcare systems
• Strategies decreasing, delaying or preventing frailty, lung, breast and colon cancer, cardiovascular disease, metabolic syndrome, osteoporosis and osteopenia have been described.
• Implementing preventive health strategies may increase health expectancy, and permit women and men to age gracefully, maintain independent living, free of disability, for as long as possible
47
Conclusion
• To achieve this objective, adopting a holistic approach to aging will enable a quantum leap towards multidisciplinary and internationally-coordinated, collaborative research efforts to enrich our understanding of healthy aging, thus preventing the preventable, and postponing and decreasing the pain and suffering of the inevitable.
48
Conclusion
"If we could give every individual the right amount of nourishment and exercise,
not too little and not too much, we would have found the safest way to
health“
Hippocrates
49
Erectile Dysfunction And/Or Diminished Libido
• The initial assessment of all men with erectile dysfunction and/or diminished libido should include determination of TT and whenever possible a free T level.
• These symptoms, with or without a testosterone deficiency, might be related to co-morbidities (i.e. T2DM, hyperprolactinemia, the metabolic syndrome, bladder outlet obstruction, peripheral vascular disease or medications)
• Men with poor morning erections, erectile dysfunction and/or diminished libido and documented TD, are candidates for TRT.
• Meta-analyses of randomized, placebo-controlled trials of TRT in men with sexual dysfunction and varying TT levels demonstrated benefits in some aspects of sexual desire, erectile function and performance
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