Ageism in health care

Pair of oldies (over 60s) at Guggenheim Museum Bilbao

Australia’s population is ageing. There is an explosion of people aged over 60 about to present itself to the health care system of Australia. The general consensus if you ask the much older population (my mother, her friends and relatives) is that the health care system doesn’t really have a solution for the problems (pain in joints, difficulty walking etc) that come in the older years. I attended the Explain Pain 3 (EP3) course with Prof Lorimer Moseley, Assoc Prof David Butler and Prof Peter O’Sullivan in Melbourne in early November and Dave’s lecture on the use of metaphors in educating around pain science was fantastic. Using metaphors when teaching patients pain science allows the educational point to ‘stick’ with the patient and makes learning and understanding easier.

Oldies are Goldies is one of the metaphors he used to combat the problem of ageism in health care regarding persistent pain where many health professionals write off pain and different ailments older people suffer with as being a natural part of ageing, when there is plenty of evidence to say that much can be done for persistent pain (AND urinary incontinence and other pelvic floor dysfunction, see later) regardless of the age of the patient. Instead of the usual negative metaphors such as Getting old ain’t for sissies, Oldies are Goldies has a connotation that there’s something to look forward to in the golden years – retired from work, opportunities to travel and spend valuable time with the grandchildren and share wisdom gained with younger friends and family. If you want to learn more about these fabulous metaphors that Dave and Lorimer utilize so effectively in their pain education, I recommend you read any of the Explain Pain books available at the NOI Group website. 

There are different books for different target audiences. The Protectometer is a book written specifically for the general public – the patients in pain- and Explain Pain (2013) and Explain Pain Supercharged (2017) are both targeting health professionals.

As Dave pointed out, we are all living longer – 60 is the new 40, 80 is the new 60…?

Link to buy Explain Pain Supercharged

This is usually a good thing but ageism is in the air. Ageism is a negative perception of getting older and older people. It’s a really big DIM (Danger In Me) as opposed to a SIM (Safety In Me)and it needs to be challenged. Young and old people can be ageist, older people can be ageist about themselves. This constantly feeds negative messages to the over-vigilant brain. Health professionals and sometimes government departments and companies can be ageist. Let’s challenge it, first by obliterating some myths about pain and ageing.

Myths about pain and ageing

Myth 1: Pain is inevitable with ageing

This is not true but most people including some health professionals think it is. Sure, there may be a few more illnesses and surgical procedures, but people over sixty have no more migraines, no more back pain, no more neck pain than younger people have. In fact, the oldies may have less pain.

Myth 2: If you have pain now, then you will have worse pain later

This is not true either. Pain comes and goes in older people just like it does in younger people. Even though x-rays and scans may show things such as narrowing of joint spaces, this has no relation to increased pain. These are age changes and more age does not equal more pain.

Myth 3: Toughing it out makes it easier to tolerate

Some of us oldies think ‘I can grin and bear it!’ This might be true for a while, but we know that it doesn’t make anything easier in the long run and being stoic can lead to depression, which in turn increases pain more in oldies than it does in younger people. You don’t have to ‘grin and bear it’, ‘suck it up’ or accept it as part of ageing – seek help from an up-to-date health professional, just as you would if you were younger. ⁽¹⁾

But what about pelvic floor dysfunction? Surely there is no hope for people with bladder, bowel and pelvic floor health issues?

The following is taken from my books: Pelvic Floor Essentials (2018) and Pelvic Floor Recovery: Physiotherapy for Gynaecological and Colorectal Repair Surgery(2018).⁽²⁾

As we age there are obvious changes that occur to muscles, collagen and the nervous system which can significantly affect bladder, bowel and pelvic floor function. Significantly though, we can hasten or exaggerate these changes, not only through bad habits, but also through inactivity and weight gain. Older people should do some form of physical exercise regardless of age, weight, health problems or abilities and be encouraged to develop habitual physical activity behaviours.⁽³⁾ While there are substantial physiological changes that do occur with ageing, one of the critical things to remember the old saying:

“If you don’t use it, you will lose it”.

We have already seen that if you do not maintain regular training of your pelvic floor throughout your life there will be a 5% to 10% loss of muscle strength per week which is worse in older age groups compared to younger age groups.⁽⁴⁾ The more sedentary you are, the more likely you are to hasten the problems that come after the age of 60 – when the ageing process really kicks in!

If you are suffering incontinence (leakage of urine or faeces), it is also important to use proper incontinence pads especially when exercising as they have material in them to ensure good absorption of the urine compared with less adequate menstruation pads. Research has shown that women see urinary incontinence as a barrier to exercise (38% with moderate leakage and 85% with severe incontinence stop exercising due to UI).⁽⁵⁾ Therefore it is better to exercise with an appropriate pad (as long as you have had your exercise regime assessed by a pelvic health physiotherapist) than to stop exercising because you are leaking. Also, if you try a device to help reduce leakage such as a pessary or Contiform®, remember to ask your doctor about using local supplemental oestrogen. If you cannot use an oestrogen-based product (due to previous oestrogen-dependent breast cancer), try a vaginal moisturizer twice a week or a medical lubricant to help insert the devices.

As we age, fat is often deposited around the middle waist area. This increases intra-abdominal pressure, especially when exercising. Evidence tells us that if you are overweight, losing 5% to 10% of body weight can significantly help to reduce incontinence episodes and decrease risk of worsening prolapse.⁽⁶⁾  Finding a variety of exercises to do such as walking, dancing, cycling, swimming, Tai Chi, bowls, golf, resistance training plus many more is a prescription for a healthy life.

Dementia is another serious disease process which comes with ageing and has a detrimental effect on continence. There are many types of brain impairment that come under the broad category of dementia but almost all of them result in loss of continence control for both bladder and bowel. This sadly often results in nursing home admission. Some recent research into continence and nursing home admission has demonstrated the staggering statistics that at 6 months after admission, 28% of nursing home residents developed urinary and faecal incontinence (dual incontinence); at 1 year 42% did so; and at 2 years, 61% had dual incontinence. Significant predictors for the length of time to developing dual incontinence were already having urinary incontinence, greater functional or cognitive deficits, more co-morbidities, older age and lesser quality of nursing home care.⁽⁷⁾

An important management strategy can be to institute timed voiding – either nursing staff prompting the client at 2 hours to go to the toilet or by the client using a watch that vibrates to alert them to go to the toilet every two hours to help stay dry. Other neurological conditions such as Parkinson’s Disease or stroke can mean the woman can suffer with slowness of their gait, leading to functional incontinence – where they are just too slow to get to the toilet. The impact of this will be exacerbated by any urinary or faecal urgency. See Chapters 4 and 6 of Pelvic Floor Essentials for management strategies.

Some of the changes that occur with the ageing process

• A decline in muscle mass, although continuing to exercise regularly throughout your whole life can minimize this.
• Less elastin in the collagen which results in less strength, plasticity and elasticity of the fascia.
• Average loss of 2% per year from age 15 to 80 years in the total number of striated muscle fibres in the wall of the urethra leading to decrease in urethral closing pressure.⁽⁸⁾
• Stiffer smooth muscle (which is found in the bladder and internal anal sphincter).
• Urodynamic studies show advancing age is associated with a reduced bladder capacity, an increase in uninhibited contractions, decreased urinary flow rate, reduced urethral closing pressure (particularly in women), and increased post-void residual urine volume.⁽⁹⁾
• Decreased number of motor neurons.
• Decreased conduction velocity of the nerves.
• Higher excitability threshold of the nerve therefore making it harder for the muscle to get going.

So as I am looking out the window of my Bilbao apartment and watch the massive crowds, particularly many older men and women walking up and down the pathways (promenading), I say to all our Aussie 60 year olds – keep walking (promenading), keep socializing and keep learning (using your brain) to make the charge towards the Queen’s telegram much more fun and comfortable!

 

1. Taken directly from the brilliant Explain Pain Supercharged Butler and Moseley, 2017 Page 214
2. Croft, S (2018) Pelvic Floor Essentials, Pelvic Floor recovery: Physiotherapy for Gynaecological and Colorectal Repair Surgery
3. Taylor D (2014). Physical activity is medicine for older adults. Postgraduate Medical Journal, 90(1059), 26–32. http://doi.org/10.1136/postgradmedj-2012-131366
4. Morkved S, & Bo K(2014). Effect of pelvic floor muscle training during pregnancy and after childbirth on prevention and treatment of urinary incontinence: A systematic review. British Journal of Sports Medicine, 48(4), 299-310. 10.1136/bjsports-2012-091758.
5. Nygaard I, Girts T, Fultz N, Kinchen K, Pohl G, Sternfeld B. (2005) Is urinary incontinence a barrier to exercise in women? Obstetrics & Gynaecology Vol 106 (Issue 2) .
6. Wing RR, Creasman JM, West DS, et al. (2010) Improving urinary incontinence in overweight and obese women through modest weight loss. Obstet Gynecol; 116(2 Pt 1):284–92 .
7. Bliss D, Gurvich O, Eberly L, Harms S. (2018)Time to and predictors of dual incontinence in older nursing home admissions. Neurourology and Urodynamics. 37:229–236. https://doi.org/10.1002/nau.23279 .
8. Bo K, Berghmans B, Van Kampen M, Morkved S. (2007) Evidence-Based Physical Therapy for the Pelvic Floor. Bridging Science and Clinical Practice. Churchill Livingstone Elsevier.
9. Siroky, M. B. (2004). The aging bladder. Reviews in Urology, 6 Suppl 1(Suppl 1), S3-S7.