Organ system function and ageing

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The function of various organ systems changes as people age. In bladder cancer (as with other disorders), this is relevant not only to quality of life issues associated with ageing, but also to risk factors and side-effects associated with various treatments that may influence the choice of therapeutic approach.

Renal function deteriorates in the elderly. The normal glomerular infiltration rate of 140 ml/min/1.73m2 is maintained until the fourth decade and then decreases by 8 ml/min/1.73m2per decade.8 In addition, a normal renal blood flow of 600 ml/min is maintained until the fourth decade and then begins to decrease by 10% per decade. Each of these determinants of renal function is further affected by hypertension and diabetes, both of which become more common and severe with ageing. By the eighth decade, glomerulosclerosis increases to involve 30% of glomeruli.

Immunologic function also declines with age and appears to correspond to the increased occurrence of infections and cancer in the elderly.9 Involution of the thymus accelerates decreased immune function. Interactions between the immune system and the nervous and endocrine systems, each affected by neural and cellular networks and also by chemical transmitters, may all be compromised in ageing.

Although ageing per se is not a cause of anaemia, anaemia is common in the elderly, its prevalance increasing to as high as 40%.9 Malignancy and marrow sclerosis are often found to account for this problem. Similarly, various gastrointestinal symptoms and conditions appear to increase with age.10 These include dysphagia, ulcers and ischaemic bowel disease. Drug-induced liver disease is associated with increased drug sensitivity in the elderly. Each may play an important role in therapeutic options in bladder cancer.

Chronic obstructive pulmonary disease is the fourth leading cause of death in the elderly.11 Risks are increased by co-morbid diseases, cigarette-smoking, decreased ventilatory responses to hypoxia and hypercapnia, and a decreased perception of dyspnea. Smoking is associated with a fourfold increase in post-operative pulmonary complications.12 Risks of pulmonary complications can be significantly reduced by cessation of smoking, and this is mandatory before any major surgery. Indeed, significant reduction of such risks can be achieved with cessation of smoking as early as four to eight weeks before surgery.

The prevalance of heart failure and various arrhythmias also increase with age.13 Most patients with coronary disease, congestive heart failure secondary to coronary disease, and acute myocardial infarction are over 65 years of age. Interestingly, more elderly women than men have myocardial infarctions (38% verus 23% respectively). The mortality from myocardial infarction is increased tenfold in the elderly.14 Hypertension doubles the risk of cardiovascular events in the elderly. Control of hypertension decreases the risks of complications associated with cardiovascular problems. In this regard, both non-pharmacologic and drug treatments can be effective in the elderly.

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