With life, aging is an unavoidable consequence. The lifespan may range from a few seconds to a hundred years, but aging is a must. It occurs in all organisms, be it a virus or a large mammal including human being. The process of human aging in terms of physiology and psychobiology remains a mystery, not yet unravelled. There is a need for knowing the aging process today because the longevity of life has increased and so the problems of pathological disorders of the aged can only be well understood if the physiology of aging is known. Several theories have been proposed to explain aging . 1 Theories of Aging Dysdifferentiation Impaired homeostasis Immune deficiency Cellular impairment DNA error theory Killer hormone Free radical Dysdifferentiation It could be thought to occur at the system level, disrupting homeostasis which alters the ability to adapt and respond to appropriate stimuli or by altering cell-cell communication. Aging could be thought of in terms of this theory as a process of successive development, organization and dysdifferentiation. Impaired Homeostasis Refers to the impairment of the ability to correct perturbations caused by various types of stresses. Immune Deficiency Aging has also been attributed to alterations in the immune system. Lymphoid tissue is lost from the thymus, spleen, lymph nodes and bone marrow with aging. This theory is attractive because of the possibility of manipulating this system. Cellular Impairment This theory propounds the concept that cellular aging is a preprogrammed process. For example, fibroblasts in culture are capable of only a limited number of divisions in the diploid state before they enter into a phase of irregular cycle and death.

Prescribing drugs to elderly women is a difficult task and it requires understanding very clearly, the choice of the drug for a disease process, the therapeutic goals, changes in their dosages and the risks of the drugs in the elderly. Older people will always have some or other drug related problems but it is essential to take precautions and follow certain guidelines before prescribing drugs in this age group 1 . At the same time, it is important to avoid over caution and unrealistic fears of their adverse effects and deny them the benefits of modern drugs. Some chronic conditions in the elderly women, that necessitates use of drugs include; cardio- vascular problems like angina pectoris, hypertension and congestive heart failure, musculoskeletal complaints of arthritis and osteoporosis, psychiatric illnesses like depression and confusion, neurological diseases like stroke, Parkinsons disease and genitourinary complaints of urinary incontinence and vulvovaginal atrophy. When prescribing medicines for the elderly, the changes that need to be considered are 2 to select the appropriate drug avoid unnecessary drug therapy. to be aware of the co-morbidities to start with the low dose to extend the interval between drug dosing to titrate the dose to achieve maximum therapeutic benefit. to ensure patient compliance to consider alternative treatments and quality of life. to review periodically, the medicine prescribed to be aware of the potential of drug for adverse effects. Older people are major consumers of prescribed and non-prescribed medication 2 . The multiple pathology in older women makes it imperative that the correct choice of drug be made, and the drug prescribed should not aggravate a coexisting disease, e.g.  blockers prescribed for angina and hypertension worsen peripheral vascular disease. Non-steroidal anti-inflammatory drugs (NSAIDs) prescribed for pain make hypertension or heart failure more difficult to control. In women with impaired coagulation, drugs with anticholinergic effects worsen the state of confusion. Lower starting dose may be required in elderly patients related to changes in bio-availability, distribution, protein binding, and elimination. The bio-availability of drug is influenced by absorption from gut which is deviated from normal, in the elderly. The first pass clearance through the liver may be changed resulting in increased bio-availability. Some of the age related pharmacological changes also influence the pharmacokinetics of the drug eg. reduced gastric output and altered gastric emptying affect the absorption of the drug 3 .

The aged or the elderly population includes individuals 65 years or more. Those aged 65 to75 years are called young olds, 75 to 85 years are old olds and more than 85 years are oldest olds. Aging is a progressive degenerative process that afflicts all living beings sooner or later. Although it results in deleterious changes (senescence), beneficial adaptive changes may result. There is however, considerable variation among elderly people as not all the functions deteriorate at the same rate nor to the same extent in an individual. The pattern of age related pathology amongst individuals is genetically determined. As a result of senescence, there is gradual decline in the functional and reserve capacity of different systems limiting their ability to respond to increased demand. This can become clinically important for cardiac, pulmonary, renal and cognitive functions. Clinical presentation may vary from individual to individual. Unique Features of Disease in Old Age are: Multiple organs may be involved in disease process and hence the patient is likely to suffer from more than one disease at a time. Functional response and integration of control mechanisms of many organ systems may be altered. Acute illness tends to be more severe as response to disease is poor and recovery slow. Illness often tends to become chronic. As multiple medical problems coexist in an aged individual, the specific signs and symptoms of a particular disease may not be present. There may be multiple complaints without a single major complaint or the major complaint may not be directly attributable to the specific identifiable disease. The disease may present in atypical manner due to decrease in the reserve capacity of the individual and due to impaired adaptive responses like impaired immune response, reduced pain perception or poor thermal regulation, all of which can alter disease presentation. Due to coincident pathology a disease in one organ may affect another organ, thus respiratory infection may result in decompen- sation of cardiac function and manifest as heart disease resulting in atypical presentation of the disease. The presence of multiple diseases may also contribute to late presentation of disease thus stroke or arthritis may limit the activity of respiratory muscles so that dyspnoea may not be apparent until heart failure is very advanced. On the other hand, the disease may have silent presentation as the patient may not complain of pain, because the threshold for perception of pain is increased especially for visceral pain as a result of autonomic nervous system dysfunction. Hence cardiac infarction may be painless 1 , pleural pain may be absent in pneumonia or pleural infarction and perforated peptic ulcer or acute cholecystitis may be painles s . The patient may only complain of recently developed extreme weakness which may be due to myocardial infarction 1, 2 or an acute illness and should be investigated. There may be absence of fever and leukocytosis in the presence of definite infection.

Across the continents and in all cultures the quest for elixir of life was always there. Prevention of aging and prolongation of life, have been the ambition of man. Comprehensive understanding and holistic approach to the process of aging enables us to be pragmatic in the health care of elderly men and women. There has been a considerable increase both in absolute and relative numbers of the elderly people in both developed and developing countries, attributable to a decline in the mortality rates due to improved health care facilities, changed lifestyles and diversification of food habits. Hence nutrition in the elderly assumes great significance. The aging process brings with it certain degenerative changes that are influenced by genetics, nutrition, socioeconomic, psychological conditions, illnesses and availability of health care. In this connection, it is important to consider the following interrelated aspects: 1 . The aging process 2 . Need for good nutrition 3 . Easy dietary tips for the elderly. THE AGING PROCESS AND NUTRITION Physiologic Changes and its Influence on Nutrition Old age brings with it many physiological changes that require a modification of nutritional requirement in the elderly. Throughout the adult life, continuous changes occur in the body composition and metabolism. The lean body mass progressively reduces as age advances whereas fat accumulates. Loss of lean body mass is most extensive from the skeletal muscle. The mineral content of the skeleton falls by 15-30 percent in the elderly. Total body protein (kg) and fat (kg) in woman Age Muscle protein Nonmuscle protein F a t (Yrs) (kg) (kg) (kg) 20-29 1.85 7.23 1 6 40-49 1.94 6.53 21.2 70-79 1.11 6 . 1 2 3 These changes result in reduction of total energy expenditure and Basal Metabolic Rate leading to reduced food intake. Durnin in 1992 demonstrated overall reduction in BMR by 19 percent in men and 13.5 percent in women. Decreasing metabolic rate from 35 years of age, reduces the requirement at the rate of 5 to 20 percent between 35 and 70 years of age.

In India, there are 34.36 million women aged 60 years and above (Registrar general census operation 2001). Sixty five percent of these women are widows and proportion rises to 80 percent among women aged 70 and above. 1 Seventy three percent are illiterate with no provision of pension or medical insurance. Forty percent live below poverty line with problems of food and shelter hence under these circumstances economic problems gain importance. Appropriate care of geriatric women requires understanding of medical problems related to aging combined with gynaecological prob- lems related to decline in the female endocrine system affecting reproductive organs. The other systems affected are cardiovascular, central nervous system, skeleton in addition to skin and breast. In a small study conducted by the author in an urban slum of Delhi 13 percent geriatric women were found to be suffering from gynaecological problems. Upto 30 percent of postmenopausal women have gynaecological problems which contribute to morbidity and disability of geriatric women. Clinical approach to a geriatric women is very important and may be time consuming due to disabilities (impaired hearing, visual problem due to cataract, walking difficulty due to arthritis, mental confusion due to senile changes etc). Good care of elderly women requires eleciting relevant medical and gynaecological history, Symptoms of dyspareunia, pruritis vulva, urinary incontinence, discharge and bleeding pervagina should be asked directly as women may not give the history pertaining to such symptoms. A thorough clinical examination of all the systems of the body including breast and the genital tract should be done. In women suffering from arthritis gynaecological examination in altered position like Sims lateral position may be mandatory. Due to narrowing of vagina, use of narrow speculum or digitally directed blind PAP smear, cyto brush or moistened cotton applicator may be required. Per rectum examination is a must for valuable diagnostic information. On the basis of examination findings , patient is referral for specialised evaluation and proper therapy. Schedule for follow up/periodic check up with relatives should be planned. Following is the list of common gynaecological problems in geriatric women. Genitourinary problems a . Uterovaginal prolapse* b Urinary problems Postmenopausal bleeding per vagina* Vulvovaginal disorders* Reproductive tract infections* Sexuality among geriatric women Gynaecological cancers Gynaecological emergencies and operative care* *Will be dealt within this chapter.

Sexuality is the quality of bodily functions which lead to sex. Sex is the activity or phenomena of life, concerned with sexual desire or reproduction. It has been seen that sexual desire can persist long after reproductive function ceases. Sexuality is therefore a function of the body as well as the mind. Physical, psychological and social health are all required to fulfil sexual desire and sexuality. A decrease in sexual activity with advancing age is considered to be normal. 1 In the study of healthy men and women ranging in age from 80 to 102 years, it was found that there was sexual activity in both sexes. 2 Touching and caressing without coitus were reported by 64 percent of women, masturbation by 40 percent and sexual intercourse by 30 percent. There is a decrease in sexual activity and enjoyment during the early post menopausal years and in healthy women, sexual interest and activity remain relatively constant thereafter, although coital opportunity and frequency decrease precipitously with age. 2 Sexual behavior continues into old age as long as the general health of the individual is main- tained. 3,4 It has been seen that the frail elderly, although not able to participate in overt sexual behav- ior, will still demonstrate certain behavior which expresses the patients sexual feelings. 73.8 percent of married older men and 55.8 percent of married older women were sexually active. 5 Reviews of geriatric sexuality in women emphasize the potential to retain sexual activity and enjoyment when health is sustained and in most cases when a partner is available. Besides, altered body image, previous attitude towards sex and sexuality, depression, dyspareunia are some of the factors which hamper sexual activity in aging women. In conservative societies in many parts of the world, cessation of sexual activity with aging in women is considered customary. Menopause is taken as a signal to stop all reproductive and sexual activity. At times, these beliefs can lead to suppression of sexual urges and to erratic sexual behavior. Anatomical Changes The period of active cyclic growth and development in the human female reproductive system comes to a close at menopause. Follicles cease to develop and ovulation ceases. The ovarian stroma shows fibrotic change and masses of hyalinized collagenous fibres . The uterus and vagina cease their own periodic activity and their mucosal linings become relatively stable. The organs decrease in size and varying degrees of fibrosis occur in their walls. In the vagina, the epithelium becomes thin. There is a lowered resistance to infection due to fall in vaginal PH. There is a drying process with some keratinization of the vaginal outlet and vulva. These changes often lead to vulvitis , dyspareunia and reduced sexuality.

Osteoporosis is a systemic skeletal disease characterized by low bone mass and micro-architectural deterioration of bone tissue with consequent increase in bone fragility and susceptibility to frac- tures. It is the most common disease of skeletal system in the elderly. The magnitude of the problem is enormous. 80 percent of the affected population are elderly women between 60 to 80 years of age 1 . Hip, spine and wrists are commonest sites of fracture. The incidence of hip fracture i s 15 percent with osteoporosis in women and 30 percent of the women die within one year of hip fracture. 50 percent of the affected women have loss of social independence 2 . It puts a great strain on the health care resources of the state. Life time risk of hip fracture is similar to combined risk of endometrial and ovarian cancer 3 . It is a preventable public health problem. PATHOPHYSIOLOGY Bone is an active living tissue. A continuous process called bone-remodeling involves constant bone formation and constant resorption. The osteoblasts, the bone forming cells originate from mesen- chymal stem cells and osteoclasts, the bone resorbing cells arise from haemopoietic white cell lineage. The development process of these cells is regulated by sex steroids. The amount of bone at any point of time reflects a balance between osteoblastic and osteoclastic process which is in turn influenced 3 by multitude of stimulating and inhibiting agents . High turn- over states may be induced by: parathyroid hormones; thyroid hormones and prostaglandins. Estrogens and calcitonin inhibit bone resorption. Incremental loss of bone mass takes place with aging. 80 percent of the total bone is cortical, found predominantly in the shafts of long bones and have significant supporting role in vertebrae. Trabecular or cancellous bone is less compact and comprises of only 20 percent of skeleton. It is found in vertebral bodies and distal end of long bones. The two factors which determine the probability of developing osteoporosis in later life are peak bone mass achieved in young age and bone loss in old age 3 . The peak bone mass is influenced by hereditary and endocrine factors. It is seen that most of the bone in hips and vertebral bodies is accumulated by late adolescent years i.e. upto 20 yrs. The bone mass starts decreasing from 30 yrs of age at the rate of 0.5 to 1 percent annually. There is an accelera- tion of bone loss after menopause, 5 percent of trabecular bone, 1-3 percent in cortical bone and 1.5 percent of total bone will reduce every year after menopause with estrogen deficiency 4 . The Risk Factors The risk factors which affect the peak bone mass, hasten the onset of bone loss or increase the rate of bone loss, lead to the development of osteoporosis.

The quality of life of an older woman is affected by medical problems causing morbidity and disability. Many of these problems have an underlying gynecological background, in terms of menopause and declining ovarian function 1 . During early years of aging ovaries, women face menopausal symp- toms of varying degrees, due to estrogen deficiency. An older geriatric woman faces the long term consequences of prolonged estrogen deprivation. Atrophic changes due to a fall in circulating estrogens occur in all target tissues with estrogen receptors. These are skin and connective tissue loss, genitourinary atrophy, osteoporosis and cardiovascular disease. THE AGING OVARIES AN D CLINICAL CONCERNS The ovaries atrophy with loss of follicles and their responsiveness. They become sclerotic, small, and non-palpable, with a size of 1.5 x 1 x 0.5 cms. The earliest symptoms of declining ovarian activ- ity include hot flushes, palpitations, night sweats, fatigue, anxiety and mood swings . Many of these symptoms may linger on to older age 2 . The bladder and urethral mucosa containing estrogen receptors undergo atrophic changes due to estrogen deficiency and contribute to recurrent urinary tract infections, urge and stress incontinence 3 . The vaginal mucosa becomes thin, dry and shiny and the vagina becomes short and narrow. The vulvar skin becomes thinned out and there is introital narrowing. The cervix becomes small and gets flushed with vaginal wall. There is vaginal dryness, burning sensation, recurrent vaginitis, dyspareunea, apareunea and loss of libido 4 . Estrogen defi- ciency leads to increased bone reabsorption and negative calcium balance. By 70 years of age 50 percent of bone mass is lost in women as compared to 25 percent in men 5 . Long term effects of skeletal loss or osteoporosis leads to fractures, spinal deformities, loss of stature and arthritis result- ing in considerable morbidity in elderly women. The common sites of fracture are wrist, spine and hip 6 . The risk of cardiovascular diseases in women increases sharply in fourth and fifth decades of life and reaches almost equal to men in sixth to ninth decades of life 7 . Unfavourable changes in lipid and carbohydrate metabolism contribute significantly to increased incidence of coronary artery dis- ease in menopausal women 8 . The skin changes are caused both by aging and estrogen deficiency. The skin loses 30 percent of its thickness by 60 years of age 9 . Alveolar bone resorption and tooth loss are linked to estrogen deficiency in elderly women . The prevalence of Alzheimer s disease and dementia with cognitive decline are found to increase with advancing age with greater preponderance among women 10 . This has been linked with estrogen deprivation with age. THE MAGNITUDE OF THE PROBLEM The mean age of menopause in Indian women is 51.45 + 2.03 years and their life expectancy is 64.8 years 11 .

The increasing number of aged women require the establishment of geriatric gynecology as a new subspecialty of our profession. The care of senior women in the gynecologists office should not be limited to the conventional gynecological diseases. One should also include, a new understanding and broadening of our specialty, the women-specific diseases of old age. The genital as well as extragenital diseases should therefore also be touched upon. This extension of gynecology follows logically from the broad spectrum of effects of the female sexual hormones in the hands of the gynecologists and especially of long-term estrogen substitution into many neighbouring medical specialties, like internal medicine, orthopedics, psychiatry and others. The gynecologist must have a working knowledge of these women-diseases including their physiopathology, differential diag- nosis, treatment and, above all, prevention. The new understanding is moreover based upon the unique position of the gynecologist in the regular prevention and last, but not the least, upon the special confidence of the clients to their women-doctor and upon the special human intimacy in the relation between female patients and gynecologists. The care of senior women today includes life style counseling with the aim of prevention of preventable diseases. Medicine, which has given thirty additional years to the life of women, has also to take the responsibility to preserve physical and mental wellbeing through this segment of existence. The common urinary problems that are encountered in geriatric women are: 1 . Urinary tract infection 2 . Urinary incontinence The less common urinary problems are: 1 . Stones in the urinary tract 2. Malignancy 3 . Urinary fistula Urinary Tract Infection Alterations in the vaginal flora following the menopause place women at an increased risk of uri- nary tract infections, especially if they are sexually active. There is a rise in vaginal pH and a fall in the number of lactobacilli, promoting colonisation with gram negative bacteria which act as uropathogens . Estrogen reverses these changes and may well have a role in preventing recurrent urinary tract infection. Further studies are required to determine which route of administration is the most efficacious. Urinary symptoms of frequency, urgency, dysuria, haematuria and incontinence are seen regu- larly in clinical practice.

Alzheimer s disease (AD) is the most common form of dementia among the elderly. A higher prevalence of AD in women than in men suggests a link between gonadal hormone levels and AD. There is age related reduction in cerebral processing resources for encoding and retrieval of infor- mation. Healthy older persons maintain functional ability in everyday activities while persons with dementia are not able to do so. Dementia of Alzheimer type (DAT) was first described by Alois Alzheimer of Germany in 1907 and is a type of primary degenerative dementia, the other type being Picks disease which can be differentiated from DAT by direct examination of brain tissue. The term dementia i s derived from the Latin word dement-meaning out of ones mind. Its essential feature is broad based intellectual decline of sufficient severity to interfere with social or occupational function. Multi-infarct dementia (MID) and dementia due to other etiologies are dif- ferent than the primary degenerative dementia. In MID the onset is abrupt and earlier than AD and course is slower and personality may be preserved till late. The course of remaining dementia is variable. Approximately 4-5 percent of population above the age of 65 years is severely demented. An additional 10 percent suffer mild to moderate dementia. Alzheimer disease is responsible for 50-60 percent cases of severe dementia and 50 percent patients present between the ages of 65-69 years. Earlier onset is associated with severe illness and shorter course, average survival time being 8-9 years. Rate of dementia due to AD doubles every 5 years over the age of 65 years, rates are a little lower for Asian population. 1, 2 In an Indian urban population aged over 65 years the prevalence of AD was found to be 1.5 percent. 3 AD was the most common cause followed by vascular dementia. RISK FACT ORS Old age women Family history of AD Lower intelligence Small head size History of head trauma Point mutation on gene 21,1,14 in younger age onset group (< 60), while in older age familial and sporadic group Apo E gene on chromosome 19 i.e. e-4 allele homozygous status of apo E which is involved i n cholesterol transport. Aberrant processing of amyloid precursor protei n (APP), altered synthesis of AP P and allele contribute to defective repair response following neuronal injury. · Women who have experience d myocardial infarction are five time s more likely to develop demen- tia.

Increasing age is the single most important risk factor for development of cancer. Fifty-eight percent of all cancers occur in people over the age of 65. Each year, for every 100 Americans over 65, two are diagnosed to have cancer and one of them will die. 1 For every 100 black males over 65, three will develop cancer. Indian cancer registry 2 [Mumbai,1999] shows that only 3.72 percent of total popula- tion is above 65 years of age , but it contributes to 31.91 percent of new cancer cases registered, in contrast population under 15 years is as high as 27.51 percent but it contributes to only 3.35 percent of new cancer cases. This shows significant impact of the aging process on cancer development. In the year 1999, of the 40 patients registered with multiple cancer, 18 were above 60 years of age, accounting for an alarmingly high incidence of 45 percent. Between the ages of 20 and 60, the inci- dence of cancers is about the same in men and women. After age 60 cancer rates in men are 70 percent higher, and they increase to two times the female rate by age 85 (3381/100,000 in men and 1795/100,000 in women). 3 Mumbai registry 2 shows a sharp rise in cancer incidence with increasing age [TableI] Age spe- cific incidence in females is higher than males between 25 to 64 years, but after 64 the rise in cancer incidence is much sharper in males than in females and in fact the male: female cancer incidence ratio reverses after the age of 70 years [TableI]. In females cancer breast is by far the most common cancer at all ages being 21.2/100,000 but its incidence peaks between the age of 65 to 69 years being 149.3/100000, cancer cervix ranks second followed by cancer ovary, cancer oesophagus and cancer uterus in that order in ranking as per Mumbai cancer registry. For past several years cancer screen- ing programs are active and the trends studied from 1982 to 1999, show that age adjusted cancer incidence rates are seen to decrease by 0.36 percent per year only in males , but they are seen to increase by 0.34 percent per year in females. Both these figures are statistically significant. Major proportion of cancer cases is seen in the elderly patients, hence these figures stress the need for more aggressive cancer screening programs in these patients. Cancer, the second leading cause of death in the United States, caused 547,000 deaths in 1995. The leading causes of cancer deaths in women are due to lung, breast, colon, and pancreas cancer. In men the major causes are lung, prostate, colorectal, and pancreas cancers. Indian data 2 show that age specific cancer death rates in men are lungs 7.2, oesophagus 4.1, prostate 3.3 per 100,000 popula- tion. In women the cancer death rates are breast 11.7, cervix 6.2, oesophagus 3.6 and ovary 3.6 per 100,000 population. There is also a clear association between incidence and mortality with aging process. The registry shows that women above 65 years of age contribute to 27.21 percent cases of cancer but to 36.7 percent of total cancer deaths. Hence with aging the incidence : mortality ratio reverses.

It is expected that the population of earth will stabilize at eleven billion in the year 2100-2150. Almost 95 percent of this growth will be in the developing countries . As complications associated with pregnancy, abortion and childbirth are reduced by population control and other measures, it is expected that people will be living longer. By the year 2025, 70 percent of all people above 60 years will be living in developing countries 1 . The experience in industrialized society is that more women outlive men. About 55 percentgirls but only 35 percent boys live long enough to celebrate their 85 th birthday 2 . In 1980 there were 63 men for every 100 women of 65 years or older in the developed world as against 87 in the developing world, indicating that this trend is true even amongst developing countries 3 . Hence the proportion of women in the aging population will be larger. India which is presently the second most populous country will have a major share of this population. In the developed countries hypertension (30.2 percent) is the second most common health condi- tion after arthritis (52.2 percent) observed in women 65 years and above. Cardiovascular diseases (19 percent) also account for a significant presence 4 . This chapter will discuss physiological changes of aging on cardiovascular system and focus primarily on hypertension and Ischemic heart disease as seen in the elderly women. EFFECTS OF AGING ON CARDIOVASCULAR PHYSIOLOGY All who survive must age. The mechanism of aging is as yet unknown but it is postulated that senescence at predetermined time, oxidant damage, and non enzymatic glycolation of proteins resulting in organ dysfunction . Having attained a peak physiological performance in youth, all sys- tems of body show a physiological decline with aging. It is usually evident earlier in stress testing but subtle changes in baseline function are also present. The effects of aging on physiological func- tions of the heart are however independent to the effects of coronary atherosclerosis 5 . Aging essentially has no effect on cardiac output in the sitting position though it is reduced in the supine position unlike at a younger age, as the heart does not respond to the increase in preload. Age related reduction in arterial compliance results in an increase in afterload 6 . Beta adrenergic mediated responses diminish with increasing age reducing the contractility of heart and it s rate 7 . Collagen accumulation in the ventricle causes it to become thick and stiff resulting in slower con- traction and relaxation 8 . These changes predispose the heart to arrhythmias and diastolic dysfunction . They also limit the physiological response to intensive exercise because unlike younger people the elderly cannot increase the cardiac output by increasing their heart rate but depend on an increase in the stroke volume and left ventricular end diastolic volume to achieve this 9 .

Critical care has emerged as a very important aspect of medical care especially during the last quarter of twentieth century. Initially the benefits of advances in medical management and of high technology like ventilators, defibrillators etc were more often available for younger patients . Today, in the advanced countries like USA, more than 50 percent of these resources are utilized for the elderly while they form only 13 percent of the total population. The older population is increasing all over the world and is likely to grow more rapidly in less developed countries in the next 20 years. The propor- tion of very old, that is, above the age of 80 year s , is going to increase much more than those of younger elderly persons. Life expectancy at 65 years has increased and a woman at 65 years can expect to live for another 19 years. Women continue to outnumber men in all older age categories and make a significant proportion of people requiring critical care. CRITI C AL CARE OF GERIATRIC WOMAN The geriatric women, who require critical care include cases of cardiac disorders, cancer and its complications, stroke, delirium or coma, injuries sustained due to fall, respiratory disorders, sepsis, diabetes related problems, vascular and renal disorders and other life threatening conditions. There exists a golden period immediately after any of these serious conditions, e.g. stroke or coro- nary insufficiency, when immediate and appropriate treatment is most important in preventing death or disability. Providing high quality care in the shortest possible time is the essence of critical care. The critical care should start at the place of onset of critical illness or injury and continue during the transport, in the emergency department, in the operation theatre if surgical intervention is required and in the intensive care unit. High level of pre hospital care should be available for geriatric patients . Well- trained paramedical staff and integrated hospital transport system avoids the initial delay in instituting the management of the patient in the crucial period. First step in caring for the critically ill geriatric patient is to recognize the seriousness of the condition. At times the gravity of the situation may not be apparent initially in a geriatric woman. Early signs are sometimes overlooked and missed. Subtle change in a physical sign may be the first indication of general collapse in an elderly woman. Slight change in mental status may indicate serious haemodynamic or metabolic abnormality. Other warning signs include decreased urinary output, dyspnea or hyperpnea, fever , unexplained fatigue, chest pain, tachycardia or palpitations. Hence physicians and care providers to the elderly should be on high alert for detecting the critical illnesses. Providing critical care to the elderly involves an integration of various aspects of medical care. It requires a multidisciplinary approach.

The human breast has two components, glandular tissue and fatty stroma and both of them are sensitive to ovarian hormones. Stroma is the most sensitive tissue of the body to the estrogens during reproductive life but even after menopause, both stroma and glandular tissues are sensitive to the exogenous steroids. At menopause due to fall in circulating estrogens there is reduction in the amount of lobular and alveolar systems and ultimately only fat, connective tissue and mammary ducts remain. The com- position of adepose tissue also changes at the menopause. Levels of protein CD 36 are lower in adipocytes in postmenopausal women as compared to pre-menopausal, thereby affecting the storage and transport capacity of fatty acids. 1 Within adipocyte, the estrone and estradiol levels are lower in postmenopausal women than in pre-menopausal women: the levels are related to the body mass index and are raised by HRT. 2 Surgeons treat most of the women with breast diseases but the effects of hormones on the breasts are important to Obstetricians and Gynaecologists. Breast Cancer Breast cancer is one of the commonest breast diseases of the women and is the single most important cause of the deaths in women between 35-54 years of age. The mean and medium age of women with breast cancer is 60 and 61 years respectively. The probability of developing disease increases throughout life. Epidemiology of Breast Cancer There are many risk factors for its developments e.g. country in which a woman lives her family history, the age of menarche and menopause, parity and the age at which she had first full term pregnancy, Nulliparous women and those who have never breast fed, are at higher risk. Ovarian Steroidal Activity The female hormones play role in the etiology of breast cancer. The risk is less in late menarche and early menopause. A woman who has menopause at 55 years of age has double the risk as compared to a woman who has had menopause before the age of 44 years. 3 Post menopausal obesity is a breast cancer risk due to increased levels of bioavailable estrogens and decreased hormone binding pro- teins. Oral Contraceptiv e Pill Numerous case control studies on the effect of OCP on breast cancer. are available in literature.

As the population in the geriatric age group rises with each passing decade, so do the innumerable problems associated not only with their health, but also with related matters especially legal and ethical issues. This chapter deals with some of the common legal problems faced by the elderly persons. In the western world most of the problems arise with the basic day to day care of the elderly. Though this was not a major issue in our country, with the increasing influence of the west as well as the rising incidence of nuclear families, care of the aged parent is today becoming an increasingly heavy burden not only for their children to bear, but also for the state. Some importan t questions are to be answered here, of which the most important is who is supposed to be held liable, or responsible for care of the elderly Taking care of an aging or ill parent is one of the toughest responsibilities some people will ever face. But many families never even discuss this sometimes delicate issue, until there is a crisis . Sud- denly forced to cope with a host of concerns from health care to housing in an emergency situation, it is no wonder so many caregivers feel overwhelmed. In fact, it is the custom in certain countries especially Australia, to assess the care giver before they are allowed to care for the elderly [Aged Care Act, Australia 1997]. It is very well for authorities in the so called developed countries to make provisions for acts such as these, but is the same appli- cable in non-welfare states like ours The specifications in the Aged Care Act 1997,of Australia are quite precise. This act defines its objectives very clearly, involving criteria to be met by the care provider as well as the situations where care has to be given. The objects of the Aged Care Act, 1997, Australia are as follows: a . to provide for funding of aged care that takes account of: i . The quality of the care ii. The type of care and level of care provided iii. The need to ensure access to care that is affordable by, and appropriate to the needs of, people who require it i v . Appropriate outcomes for recipients of the care v . Accountability of the care providers for the funding and for the outcomes for recipients; b . To promote a high quality of care that meets the need of individuals and accommodation for the recipients of aged care services. c. To protect the health and well-being of the recipients of aged care services; d. To ensure that aged care services are targeted towards the people with the greatest needs for those services. e .

Clinical Practice of Common Geriatric Problems in Women Editors Maya Sood Khanna DGO MD FICOG FIAMS FRSH FICMCH Co-ordinator and Chairperson Geriatric Committee of FOGSI Ex-Director, Professor and Head Department of Obstetrics and Gynaecology Lady Hardinge Medical College and Associated Smt SK Hospital, New Delhi Ex-Vice President, FOGSI Ex-President, AOGD and NAVSEWI ( Delhi Branch) Senior Consultant, Obstetrics and Gynaecology Indraprastha Apollo Cliniq Affiliated to Apollo Hospitals, New Delhi a n d Holy Angels Hospital, New Delhi. Chitra Raghunandan MD Professor Department of Obstetrics and Gynaecology Lady Hardinge Medical College and Associated Smt SK Hospital, New Delhi. Usha Gupta MD MNAMS Professor, Department of Obstetrics and Gynaecology Lady Hardinge Medical College and Associated Smt SK Hospital, New Delhi.