Healthy Ageing
Welcome to the Healthy Ageing Module.
This module will provide you with an interactive case study in which you will consider the components of successful ageing, and common health problems related to ageing.
Once you have completed the Pre-Module Test below you will be able to commence the Healthy Ageing Case Study.
Module
- Mrs Browning Age 65
- Mrs Browning Age 75
- Mrs Browning Age 85
- Mrs Browning Age 95
- Ageing Well Conclusion
Interactive Case Study
Mrs Browning is a 65 year old woman who is concerned that she isn’t sleeping as well as she used to.
Review Mrs Browning’s history through the links below before moving on to her interview and assessments.
- History of Presenting Complaint
- Medical History
- Medication History
- Social History
Mrs Browning has come in for assessment because she is concerned that she isn’t sleeping as well as she used to and consequently, she is having some trouble maintaining her level of energy and participation in her every day life. She is feeling irritable, having trouble with her regular commitment to charity work and is also concerned about her safety whilst driving. She is unable to identify a likely cause of her sleeping problems and feels that sleeping pills may help.
Mrs Browning ’s medical history is unremarkable. She had a hysterectomy at age 43. She has had mild osteoarthritis in her hands for several years, but is not on any medication for this. Mrs Browning is happy for the arthritis to remain untreated so long as she can still cook, garden, do her crafts and hold her hand of cards! She last saw the doctor 2 years ago for a chest infection that was treated with antibiotics.
Mrs Browning is currently taking no medications
Mrs Browning is a part-time kindergarten teacher and retired semi-professional athlete. Up until the age of 32, Mrs Browning played state level basketball and made the national team twice in her mid-twenties, Mrs Browning has stayed exceptionally active and still swims regularly with her swimming squad at Challenge Stadium, plays tennis twice a week and cycles around the bridges or King’s Park on the weekends with her husband, Denny. Mr and Mrs Browning have 5 children and 14 grandchildren.
Mrs Browning is also a volunteer at Shenton Park Dog Shelter and her local “Save The Children” Charity Shop. She enjoys a varied social life, including a regular card night with friends, movies, theatre, fishing and travelling. Mrs Browning also enjoys various crafts, including quilting and scrapbooking.
Family History
Mrs Browning knows little of her family history, as the majority of her family still live in Canada. She emigrated to Australia after meeting and falling in love with Denny during the war. Her father died in a skiing accident at 68 and her mother developed diabetes later in life and passed away at 84, presumably of a heart attack. To the best of her knowledge, Mrs Browning has no family history of cancer, heart disease, or osteoporosis.
Patient Interview
For more information on the common side effects of over the counter medications,
Substance | Side-Effects |
Alcohol | Sleep induction and sleep duration |
B blockers | Alteration of sleep physiology, increase in nightmares |
Caffeine | Stimulant |
Corticosteroids | Stimulant, may cause agitation, vivid dreams |
Diuretics | Nocturia |
Theophylline | Stimulant |
Guarana | Stimulant |
Ephedrine | Stimulant |
And for more information on safe alcohol consumption, see the following link,
https://www.nhmrc.gov.au/your_health/healthy/alcohol/index.htm
Physical Assessment
Investigations
Request further laboratory tests to help determine cause of insomnia, buy clicking on the tabs below. Review results before proceeding.
- Sleep Study
- Cholesterol Levels
- Blood Glucose
- Exercise Stress Test
- Urea and Electrolytes
- Thyroid Function Tests
- Full Blood Count
- Geriatric Depression Scale
Polysomnography is not a first line investigation. It can help determine whether there is an underlying sleep disorder or obstructive sleep apnoea. Results of Mrs Browning’s test result showed no evidence of an underlying sleep disorder or obstructive sleep apnoea.
Normal Polysomnography
Mrs Browning may be interested in her cholestrerol levels as part of a general health assessment, but it is not mandatory in the investigation of insomnia. Her total fasting cholesterol is normal, 3.1mmol/L (normal range <5.5mmol/L).
“Checking sugars” is often wise, especially if there is polyuria. At 4.2mmol/L, Mrs Browning’s fasting blood glucose is within the normal limit (normal range <= 6.0 mmol/L).
This is not indicated unless Mrs Browning complains of angina or other cardiac symptoms.
Impaired kidney function, or electrolyte imbalances, can contribute to malaise.
Urea 5.1 mmol/L (normal range 3.0-8.0 mmol/L)
Na 138 mmol/L (normal range 134-146 mmol/L)
K+ 4.1 mmol/L (normal range 3.4-5.0 mmol/L)
Cr 60 µmol/L (normal range 50-95 µmol/L for adult females)
Both hyper and hypo thyroidism can contribute to sleep disorders.
TSH 1.6 mU/L (normal range 0.40-4.0 mU/L)
It is often worthwhile checking haemoglobin levels in people who are tired. Occasionally there is an important underlying cause such as anaemia. Mrs Browning’s haemoglobin is at a healthy 138g/L (normal range for adult females is 115-160 g/L). Excluding blood dyscrasias is often important in people presenting with non-specific symptoms such as insomnia. Mrs Browning's cell counts were all within normal range.
Even though Mrs Browning assures you that her mood is good and she seems to have a positive outlook on life, to be safe, you perform a geriatric depression scale. She scores 1/15 indicating she is unlikely to be depressed (a score higher than 5 indicates depression). There is no evidence of elevated mood during your history taking or your interview (occasionally bipolar disorder can present with altered sleep patterns).
To view Mrs Browning's GDS, please click here.
Diagnosis
Based on the results of your assessments of Mrs Browning, the most likely cause of her insomnia is:
Treatment Options
Mrs Browning’s insomnia is due to normal age-related changes in the circadian rhythm.
Based on this diagnosis, which of the following treatment options might be considered in Mrs Browning’s case?
Summary
Insomnia is the most common sleep complaint in older adults, with a prevalence of 20-40%. It is not benign, and can lead to decreased quality of life, worsening cognitive performance, increased falls risk, and an increased risk of hypertension and coronary artery disease.
Rather than prescribe benzodiazepines, such as temazepam, Mrs Browning is counselled about the normal changes in her sleeping patterns, a number of lifestyle changes are suggested.
These include:
- regular physical activity early in the day
- taking a short nap early in the day
- trying relaxation meditation before bedtime
- drinking a glass of hot milk or eating a banana before retiring
- avoiding high protein foods at night
- increased daytime light exposure
- limits on alcohol and caffeine
If her sleeping problems persist, Mrs Browning will attend the 12 week sleep course.
It has been ten years since you last saw Mrs Browning. She represents at the age of 75 because she is concerned that she has “started to go weak”
History of Presenting Complaint
Mrs Browning is still very physically and socially active. She is no longer cycling but still swims 3 times a week, plays social tennis and enjoys a daily walk with her dog, Max. The reason for Mrs Browning’s visit is that she has started to notice a decrease in her muscle strength, not just with exercise, but also with less challenging activity such as housework and gardening. Mrs Browning also feels that her balance is not as good as it could be. She denies any muscle aches and has had no falls. She still takes no regular medication.
Patient Interview
Take a relevant history and perform necessary assessments to investigate the cause Mrs Browning’s muscle weakness.
Please click on the questions below to obtain Mrs Browning’s answer
- How is your sleep these days?
- Are you able to perform your general activities of daily living, such as food, shopping, cooking, doing the laundry, taking a shower, dressing and using the bathroom?
- And do you experience any pain associated with your weak muscles?
- Have you had any dizzy spells or shortness of breath?
- What about headaches?
- Have you had any falls recently?
- How is your diet? Any changes recently?
- Have you been unwell in any other way?
Physical Assessment
Investigations
Request further laboratory tests to help determine the cause of Mrs Browning’s muscle weakness, by clicking on the tabs below. Review results before proceeding.
- Full Blood Count
- Urea and Electrolytes
- Calcium and Vitamin D
- Creatinine Kinase
Haemoglobin 138 g/l (normal range 135-180 g/L)
MCV 91 fl (normal range 80-100 fl)
WBC 7.0x10^9/L (normal range 4.0-11.0x10^9/L)
Platelets 255x10^9/L (normal range 150-400x10^9/L)
Urea 6.0 mmol/L (normal range 3.0-8.0 mmol/L)
Creatinine 78 µmol/L (normal range 50-95 µmol/L for adult females)
Sodium 141 mmol/L (normal range 134-146 mmol/L)
K 3.8 mmol/L (normal range 3.4-5.0 mmol/L)
There is no evidence of renal failure or disordered potassium regulation, although calculation of the glomerular filtration rate would be recommended.
Ionized Ca 1.30 mmol/L (with normal range: 1.12-1.32 mmol/L)
Vitamin D 85 nmol/L (within normal range: >50 nmol/L)
Creatinine Kinase 12 U/L (normal range for adult females <150 U/L)
Physical Function Assessment
The physical function assessment reveals that Mrs Browning has moderate joint changes indicative of osteoarthritis particularly affecting her hands and knees. She has reduced grip strength in both hands and hip and knee extensor strength (unable to rise from a standard chair without using her arms to push off). She finds kneeling in the garden uncomfortable and it is increasingly difficult to get up from kneeling. Joint range is within normal limits although she has tight hip flexors bilaterally, and is beginning to exhibit an increased thoracic kyphosis and concomitant increased cervical lordosis.
Differential Diagnosis
Based on the results of Mrs Browning’s assessments, what is the most likely cause of her muscle weakness? Please click on the diagnosis you feel is most likely and submit your answer to obtain feedback.
Summary
Mrs Browning is otherwise very well and the problems she is experiencing are likely to be due to normal age related changes in neuromuscular condition.
Mrs Browning is counselled about these changes, and encouraged to maintain her physical and social activity.
She has been prescribed specific mobility exercises (including stretches in prone lying) and specific strengthening exercises for hands and her leg extensors (which can be performed as a home program). It was also recommended that she commence a class activity such as Tai Chi or Physio Chi (a modified version of Tai Chi especially designed for older adults).
Mrs Browning feels more confident after starting the strengthening exercises and has decided to take up Tai Chi to help with muscle strength, flexibility and balance.
There is one more thing to consider…
Mrs Browning represents at the age of 85 because she wants to continue driving.
History of Presenting Complaint
Mrs Browning is now a spritely 85 year old, who still swims, plays occasional tennis and practices regular Tai Chi. She has maintained a busy social life since her husband passed away 3 years ago. She is otherwise well, but is needs a doctor to sign off on her driver’s license.
Patient Interview
Take a relevant history and perform necessary assessments to investigate Mrs Browning’s ability to drive.
Please click on the questions below to obtain Mrs Browning’s answer
- Tell me about your driving?
- Have you noticed any changes in your eyesight at all?
- I’m sorry to hear that Mrs Browning. Are there any particular conditions in which you find it more difficult to see?
- What about your hearing? Have you noticed any changes?
- Are there any other conditions in which you find it difficult to hear people talk, other than if a lot of people are talking at once?
- Do you experience any pain in your ears or ringing in your ears?
- What about itchiness?
- Have you had any headaches or fevers lately?
- Are you concerned about the changes you have noticed in your hearing and vision?
- When I saw you some years ago, we noted that you had some arthritis in your hands and knees. How is that going now?
- Have you been prescribed any medications for your arthritis?
- What about any other medications?
- Have you experienced any chest pain, dizziness or breathlessness recently?
Physical Assessment
Possible causes of vision loss
Based on the history given, what are the possible causes of deterioration in Mrs Browning’s eyesight? Click on those condition/s that you think are likely and then submit your answer to obtain feedback.;
Possible causes of hearing loss
Based on the history given, what is the most likely cause of Mrs Browning’s hearing loss? Click on the condition that you think are likely and then submit your answer to obtain feedback.
Further Examinations and Investigations
Request further tests to help determine the cause Mrs Browning’s hearing and eyesight issues, buy clicking on the tabs below. Review results before proceeding.
- Visual acuity and examination of fundi
- Ophthalmological review
- Hearing screen
- Ear examination
- Hearing Tests
On physical examination there is reduced visual acuity with 6/9 on the left and 6/7.5 on the right. Her visual fields are normal and her eye movements are intact. The fundi are difficult to visualise because of a cloudy appearance in the anterior chamber in both eyes. It is possible that she has bilateral cataracts and probable macular degeneration.
Cataracts
Macular Degeneration
Photo source: Moran Eye Centre
In order to formally rule out glaucoma as a possible contributory cause of deterioration of Mrs Browning’s eyesight, she is referred for pressure testing. Pressure in both eyes was within the normal range: 16mmHG in the left eye and 17mmHG in the right.
This examination also confirmed the presence of bilateral cataracts.
A simple bedside screen indicates Mrs Browning has difficulty with higher pitched whispering, especially in the left ear.
There is no evidence of cerumen impaction or ear infection.
Mrs Browning does appear to be experiencing some degree of hearing loss, so she is also referred her to an audiologist as part of her medical check-up. The hearing test shows evidence of presbycusis (normal age related hearing loss), more marked at higher frequencies, although it is not yet severe enough to necessitate hearing aids.
https://www.nidcd.nih.gov/health/age-related-hearing-loss
Management of cataracts
It appears that Mrs Browning has bilateral cataracts.
Cataract surgery is associated with a small number of risks, including infection and bleeding. It is important to keep the eyes clean after surgery, wash hands before touching the eyes, and that use medication to help prevent infection.
Follow up Assessments
Mrs Browning’s cataracts are individually removed, 6 weeks apart and both surgical procedures were successful. The ophthalmologist also noted some mild macular degeneration and arranges for Mrs Browning to have a post-surgical visual assessment. Click on the image below to see the outcome.
Mrs Browning also attends a follow-up visit with the Audiologist with regard to the results of her hearing test. Click on the image below to see the recommendations made.
Case Summary
After a short recovery, Mrs Browning is able to continue driving and after making family and friends aware of her slight hearing difficulty, is feeling much more comfortable in social gatherings.
Mrs Browning represents at the age of 95 because she is worried about her bowel habit.
History of Presenting Compliant
At 95 years old, Mrs Browning is still driving, swimming and practicing Tai Chi. Mrs Browning’s eyesight is still quite good, having responded well to the cataract surgery 10 years ago and her mild osteoarthritis is responding well to simple analgesics. She is still quilting, having recently completed a bedspread for her third great-grandchild and is teaching her five granddaughters the art of scrapbooking. She had hearing aids fitted 4 years ago and is very happy with the result. Mrs Browning loves spending time with her children and grandchildren and is still quite socially active.
She is otherwise well, but has noticed that her bowels have become sluggish. This has been slowly progressive over the last few years and she has bouts of quite severe constipation. She has been taking Metamucil, which helped initially, but does not seem to be working as effectively anymore. Mrs Browning is concerned that she may have bowel cancer. She also confesses to moments of urinary incontinence.
Patient Interview
Take a history and perform necessary assessments to determine the most likely cause of Mrs Browning’s constipation and incontinence.
Click on the questions below to see Mrs Browning's response.
- Mrs Browning, can you please tell me about your diet. What foods do you regularly eat?
- What about snacks during the day?
- Do you eat out very often?
- Do you prepare most of your own meals?
- How many glasses of water would you drink each day?
- Do you drink much tea of coffee?
- Do you still have a nip of alcohol on some evenings?
- Are you taking any medications such as strong pain killers or blood pressure tablets?
- What about your supplements, in particular iron supplements?
- Have there been any significant changes in your level of physical activity recently?
- You mentioned that you have taken Metamucil to help with your constipation, but that it is not effective anymore. Have you taken any laxatives to help alleviate the problem?
- Did you take the laxatives as recommended by the pharmacist?
- In regards to the moments of urinary incontinence, when does this tend to occur?
- Do you ever get a sudden, strong urge to urinate and sometimes don’t make it to the toilet on time?
- Do you always recognise the need to go to the toilet?
- Do you experience any pain when you urinate?
- What about when you use your bowels? Do you feel any pain then?
- Have you taken any antihistamines, decongestants or cold and flu tablets recently?
Physical Assessment
Investigations
Based on the patient history and physical examination, what would be the next steps in investigating Mrs Browning’s symptoms?
Please click on the tabs below to obtain the results of the investigations
- Exclude anaemia and faecal occult blood
- Investigate possible UTI
- Rule out bowel pathology as potential cause of constipation
FBP showed normal Hb and FOBT was negative - no blood in stools.
An MSU was performed and the urine culture was positive. The UTI was successfully treated with a 10 day course of amoxicillin 500mg.
A colonoscopy was scheduled for Mrs Browning. Despite her age, this test was considered appropriate as she is in good health and it has greater diagnostic yield than alternatives tests to investigate altered bowel habit.
The results revealed no significant pathology. There was no evidence of benign polyps or adenoma’s.
Multidisciplinary Assessments
Please click in the tabs below to obtain the results of the continence and diet assessments.
- Nurse
- Dietitian
Incontinence in the elderly can be the result of a number of factors. In Mrs Browning’s case, straining to empty the bowels has weakened the pelvic floor muscles, resulting in stress incontinence.
As result of urine being retained in the bladder for long periods of time, Mrs Browning has recently developed a UTI, which was successfully treated with amoxicillan.
After Mrs Browning’s constipation was alleviated through dietary changes, she was still experiencing less frequent moments of stress incontinence when coughing, sneezing or getting up from a chair. She was therefore prescribed specific exercises to strengthen her pelvic floor muscles. Over time, this should significantly reduce Mrs Browning’s incidences of incontinence.
In the meantime, low absorbency hygiene products appropriate for stress incontinence have been recommended.
Mrs Browning is not eating enough good sources of soluble and insoluble fibre in her diet. As fibre is indigestible, it adds bulk to the faeces making it more easily pushed along the digestive tract. Soluble fibre helps to soften the faeces. Good sources of soluble fibre include legumes, fruits and vegetables. Insoluble fibre adds bulk to the faeces helping it to move more quickly through the bowel. Good sources of insoluble fibre are in wheat bran, wholegrain breads and cereals.
Mrs Browning eats predominantly white bread, meat, potatoes and boiled vegetables. In recent years, her intake of biscuits and cake has increased, while her intake of fresh fruit has decreased. Porridge is a good source of fibre, so it is recommended that this remain in her diet. Muesli and other wholegrain breads and cereals, along with fruit and natural yoghurt, can also be added to Mrs Browning’s breakfast foods.
Legumes, such as baked beans, lentils, kidney beans, split peas and chick peas would also be healthy additions to her diet. She should add these to the soups and casseroles that she already makes. Mrs Browning might also steam or lightly stir-fry her vegetables, rather than boil them, as this retains more of the natural fibre and nutrients present in these foods.
Mrs Browning’s water intake, at 2-4 glasses per day, is also insufficient. She is advised to drink at least 8 glasses per day, particularly with the increase in her dietary fibre intake. The fibre in faeces will only plump up with water. Constipation may reoccur from a high fibre diet if insufficient water is consumed.
Summary
Mrs Browning is reassured that the colonoscopy results and changes in her bowel habits are most likely due to decreased gut motility that occurs as a normal part of ageing. She has been given specific advice on increasing the amount of fibre in her diet and the importance of increasing her water intake in line with this.
Mrs Browning’s incontinence problems were related to the constipation. After increasing the fibre and water in her diet and regularly performing the pelvic floor exercises, both the constipation and incontinence have markedly improved and are no longer a concern for Mrs Browning or affecting her quality of life.
Mrs Browning comes to see you a year later for a routine check-up. She has moved suburbs and is now living in a retirement village - primarily for the community atmosphere and fabulous social life. She is still well and active and has recently met a new man, Charles, who is 15 years her junior and enjoys similar interests.
A few things to consider after completion of this module…
- Reflect upon ageing well issues. How can you assist people to age well, to maintain physical and social activity and maximise quality of life? What multi-disciplinary care team members might be able to assist in this?
- Take some time to think about what you consider to be the most important aspects of fostering positive attitudes towards ageing and overcoming prejudices towards elderly people.
Healthy Ageing Post-Module Test
Module Feedback
Select the appropriate user group to ensure that your feedback is delivered appropriately:
- WACHS Users
- ECU Nursing
- All other users
The physiotherapy consult finds her Berg balance scale is 27/56. She has difficulty transferring, turning, reaching and balancing on one foot. The physio recommends some lower limb strengthening and gait exercises and some mild exercises to help rebuild her wasted quadriceps. It is important that Mrs Scott maintains participation in physical activity, in order to maintain muscle strength and joint range of movement and to improve her balance.
The physiotherapist prescribed specific mobility exercises (including stretches in prone lying) and specific strengthening exercises for hands and her leg extensors (which can be performed as a home program).
The physiotherapist uses models of anatomy to explain the physiology of voiding and bladder control problems. To help reduce stress incontinence, Mrs Scott’s pelvic floor muscles are assessed and found to be lax. Mrs Scott has been performing the exercises prescribed by the NCA, so the physiotherapist checks her technique to ensure she is doing them correctly. Further advice was needed to refine technique. Mrs Scott is aware that she needs to do these exercises at least 5 times per day, every day in order to recondition her pelvic floor.
To further address urge incontinence Mrs Scott will perform timed voiding, as advised by the NCA.
Fortunately, Mrs Wood has a normal CT scan.
CT is a relatively inexpensive, quick and non-invasive scan that produces images of brain structures such as the grey matter, white matter, cerebrospinal fluid cavities and blood vessels. These images may also reveal abnormalities such as tumours, strokes, and head injuries. The role of CT imaging in the diagnosis of dementia is primarily one of exclusion. Evidence based guidelines suggest that structural neuro-imaging with either CT or MRI scan is appropriate in the routine initial evaluation of patients with dementia.
MRI is a structural neuro-imaging method that provides images of the brain and other anatomical structures. Some studies using MRI have demonstrated that medial temporal lobe (MTL) atrophy can be predictive of Dementia Alzheimer’s Type (DAT) and that has been associated with neuropsychological and post-mortem data. MRI may assist in the diagnosis of DAT.
An MRI may be obtained if it is suspected that the patient has dementia, however MRI is not required to make a diagnosis of dementia
Dr Zheng’s brain MRI is provided below:
Brain imaging indicates volume loss, consistent with dementia. No evidence of masses or vascular disease.
General Appearance:
Mr Thomas is sweating and looks short of breath. His legs are constantly moving and he appears confused and agitated. His skin is moist and tribal scarring is noted on left and right upper arms, midline of chest and left and right thighs. His eyes are wandering and he appears to have trouble maintaining attention, although this does fluctuate. Admission staff report that his speech was slow and at times, incoherent. Mr Thomas also exhibited impaired orientation. His wife reports that he had trouble sleeping last night.
Height: 168cms
Weight: 75kgs
Temperature: 36.7
Respirations: 28 shallow
Please move your cursor over Mr Thomas as if you were examining him. You must complete the examination before you go on.
General Observations:
Patient answered greeting when approached. He is sitting in a chair with no evidence of agitation or distress. Mr Thomas is now eating a full diet, opens bowels daily and urine output is in keeping with fluid intake. His mouth is moist and mucosa intact. The IV access is removed.
Height: 168cms
Weight: 75kgs
Temperature: 36.7
Respirations: 18 even
Cognitive Testing
MMSE – 25/30 – may indicate resolution of delirium
KICA – 35/39 –Improvement in KICA score supports diagnosis of delirium.
Mrs Thomas does not think Mr Thomas is quite back to baseline, but is improving day by day.
General Appearance:
Mr Scott looks well. His affect is reactive but be appears to be slightly anxious.
Height: 184cms
Weight: 98kg (which has remained constant)
Please move your cursor over Mr Scott as if you were examining him. You must complete the examination before you go on.
General Appearance:
Mrs Scott looks well. She is reactive but has restricted mobility.
Height: 164cms
Weight: 76kg (which has remained constant)
Please move your cursor over Mrs Scott as if you were examining her. You must complete the examination before you go on.
Please move your cursor over Dr Zheng as if you were examining him. You must complete the examination before you go on.
General Appearance:
No tremor is observed. He is well groomed and does not appear anxious. He has normal attention and affect.
Height: 160cms
Weight: 70kgs
Temperature: 37.1
Please move your cursor over Mr Thomas as if you were examining him. You must complete the examination before you go on.
General Appearance:
General Appearance: Mrs Browning looks well. Her affect is reactive and she doesn’t appear to be distressed or anxious.
Height: 178cms
Weight: 65kg (has remained constant)
Please move your cursor over Mrs Browning as if you were examining her. You must complete the examination before you go on.
General Appearance:
Mrs Browning looks happy and healthy.
Height: 178cms
Weight: 65kg (has remained constant)
Please move your cursor over Mrs Browning as if you were examining her. You must complete the examination before you go on.
General Appearance:
Mrs Browning appears well. She is well presented, and is in high spirits.
Height: 178cms
Weight: 66kg (an increase of 1 kg)
Please move your cursor over Mrs Browning as if you were examining her. You must complete the examination before you go on.
General Appearance:
Your general observation is that Mrs Browning appears to be a very alert, independent and capable elderly woman. She is cheery, well presented and easily mobile.
Height: 178cms
Weight: 67.5kg (an increase of 1.5 kg)
Please move your cursor over Mrs Browning as if you were examining her. You must complete the examination before you go on.
