ATrain Education

 

Continuing Education for Health Professionals

Elders and Their Care

Module 3

Age-Related Changes in Elders

Metabolic Changes

As we age, our metabolism slows and our lean body mass decreases; the proportion of the body that is made up of fat typically doubles between the ages of 25 and 75. Because of the slowing metabolism, the body is less able to tolerate changes in temperature.

Metabolism is the rate at which calories are burned and it ultimately determines how easily weight is gained or lost. Metabolism is influenced by age, gender (men have a higher resting metabolic rate than women), heredity, and the proportion of lean muscle a person has (more lean muscle usually means a higher metabolic rate) (Bouchez, 2006).

Each decade after the age of 30 there is a 2% decrease in metabolism, which makes it more difficult to maintain a desirable weight and body composition. To match this decreased energy metabolism, there must either be a 2% decrease in food intake or a 2% increase in energy expenditure. If an average person consumes 2000 calories a day, that person must decrease caloric intake by 50 calories per day to maintain a stable weight. In one year, the extra 50 calories per day can account for a 5-pound weight gainand, over 10 years, a 50-pound weight gain (Benardot, 2005).

Musculoskeletal Changes

Sarcopenia and osteoporosis are two of the most common musculoskeletal changes that occur with age. Osteoporosis, which involves a gradual loss of bone density and a thinning of bone tissue, is a silent disease because it progresses without symptoms. Sarcopenia is the age-related loss of muscle mass and strength.

Osteoporosis

Musculoskeletal Change over the Lifespan

image: bone density changes

After the mid-thirties, people begin to lose bone mass slowly. Women lose bone mass faster after menopause but it happens to men, too. Source: Surgeon General, 2005.

Osteoporosis is a disease of the bones that occurs when the body fails to form enough new bone, when too much old bone is reabsorbed by the body, or both. Bone mineral is lost and replaced throughout life, but loss begins to outstrip replacement around age 35. Women can lose up to 20% of their bone density in the first 5 to 7 years after menopause.

Half of all women and 1 in 4 men over the age of 50 will break a bone due to osteoporosis. Most will break a bone in the hip, spine, or wrist. If diagnosed early, the fractures associated with osteoporosis can often be prevented. Unfortunately, osteoporosis frequently remains undiagnosed until a fracture occurs (NIH, 2011a).

Several risk factors increase the chances of developing osteoporosis or having a fracture:

  • A thin, small-boned frame
  • Previous fracture or family history of osteoporotic fracture
  • Estrogen deficiency, resulting from early menopause (before age 45), either naturally, from surgical removal of the ovaries, or as a result of prolonged amenorrhea (abnormal absence of menstruation) in younger women
  • Advanced age
  • A diet low in calcium
  • Caucasian or Asian ancestry (African Americans and Hispanics are at lower but significant risk)
  • Cigarette smoking
  • Excessive use of alcohol
image: elderly woman

Elderly Asian woman showing evidence of osteoporosis. Photo by James Heilman, MD. Courtesy of Wikimedia Commons.

Prolonged use of certain medications such as glucocorticoids, anti-seizure drugs such as phenytoin and barbiturates, some drugs used to treat endometriosis, excessive use of aluminum-containing antacids, the acid-blocking drugs called proton pump inhibitors, certain cancer treatments, and excessive thyroid hormone (NIH, 2011b).

Diagnosing osteoporosis involves several steps, starting with a physical exam and a careful medical history, blood and urine tests, and possibly a bone mineral density assessment. The physical exam should include checking for loss of height and changes in posture and may include checking balance and gait (NIH, 2011b).

If there is back pain, a loss in height or a change in posture, an x-ray of the spine may be done to look for spinal fractures or malformations due to osteoporosis. However, x-rays cannot necessarily detect osteoporosis. Blood and urine tests can help identify conditions that may be contributing to bone loss, such as hormonal problems or vitamin D deficiency. If the results of the physical exam, medical history, x-rays, or laboratory tests indicate osteoporosis or significant risk factors for the disease, a bone density test may be done (NIH, 2011b).

Most Critical Systemic Hormones Regulating Bone

Calcium regulating hormones

Parathyroid hormone
Calcitriol (active vitamin D)
Calcitonin

Sex hormones

Estrogen
Testosterone

Other systemic hormones

Growth hormone/insulin-like growth factor
Thyroid hormone
Cortisol

Bone mineral density (BMD) testing can be used to definitively diagnose osteoporosis, detect low bone mass (osteopenia) before osteoporosis develops, and help predict risk of future fractures. In general, the lower the bone density the higher the risk for fracture. The results of a bone density test will help guide decisions about starting therapy to prevent or treat osteoporosis. BMD testing may also be used to monitor the effectiveness of ongoing therapy (NIH, 2011b).

The most widely recognized test for measuring bone mineral density is a quick, painless, noninvasive technology known as dual-energy x-ray absorptiometry (DXA). This technique uses a scanner with low levels of x-rays. DXA can determine bone mineral density of the entire skeleton and at various sites that are prone to fracture, such as the hip, spine, or wrist. Bone density measurement by DXA at the hip and spine is generally considered the most reliable way to diagnose osteoporosis and predict fracture risk (NIH, 2011b).

For both women and men, the diagnosis of osteoporosis using DXA measurements of BMD is currently based on a number called a T-score. The T-score represents the extent to which bone density differs from the average bone density of young, healthy people (NIH, 2011b).

The U.S. Preventive Services Task Force, an independent panel of experts in primary care and prevention, recommends that all women age 65 and older be screened for osteoporosis. The task force also recommends screening for women under the age of 65 who are at high risk for fractures (NIH, 2011b).

The primary goal in treating people with osteoporosis is prevention of fractures. A comprehensive treatment program includes a focus on proper nutrition, exercise, and prevention of falls that may result in fractures (NIH, 2011b).

There are also several medications that have been shown to slow or stop bone loss or build new bone, increase bone density, and reduce fracture risk. While taking medication to prevent or treat osteoporosis, it is still essential to obtain the recommended amounts of calcium and vitamin D along with exercise and a healthy lifestyle. Medications used for the prevention or treatment of osteoporosis, include: bisphosphonates*; estrogen agonists/antagonists (also called selective estrogen receptor modulators or SERMS); parathyroid hormone; estrogen therapy; hormone therapy; and a recently approved RANK ligand (RANKL) inhibitor (NIH, 2011b).

*Note: The Food and Drug Administration (FDA) is warning there is a possible risk of a rare type of femoral fracture in people who take drugs known as bisphosphonates to treat osteoporosis. The possible risk of thigh fracture is to be reflected in a labeling change and a medication guide be provided to users of the medication (FDA, 2011).

Bisphosphonates are a class of drugs that slow or inhibit the loss of bone mass. FDA says it is not clear whether bisphosphonates are the cause of the unusual bone breaks known as subtrochanteric femur fractures, which occur just below the hip joint, and diaphyseal femur fractures, which occur in the long part of the thigh (FDA, 2011).

The changes to labeling and the medication guide will affect only bisphosphonates approved for osteoporosis. These include:

  • Oral bisphosphonates such as Actonel, Actonel with Calcium, Atelvia, Boniva, Fosamax, Fosamax Plus D, and their generic products
  • Injectable bisphosphonates such as Boniva and Reclast and their generic products
  • Labeling and the medication guides for bisphosphonates that are used for other conditions will not change (FDA, 2011)

The FDA has reported that the optimal duration of bisphosphonates treatment for osteoporosis is unknownan uncertainty the agency is highlighting because these fractures may be related to use of bisphosphonates for longer than five years (FDA, 2011).

For people with osteoporosis resulting from other conditions, the best approach is to identify and treat the underlying cause. The dose of the medication contributing to osteoporosis may be decreased or a different medication may be prescribed. People who require long-term glucocorticoid therapy for diseases such as rheumatoid arthritis or lupus can take osteoporosis medications. It is also important to stay as active as possible, eat a healthy diet that includes adequate calcium and vitamins, and avoid smoking and overuse of alcohol (NIH, 2011b).

If a person has already experienced a fracture, he or she may be referred to a specialist in physical therapy or rehabilitation medicine to assist with daily activities, safe movement, and exercises to improve strength and balance (NIH, 2011b).

Sarcopenia

Sarcopenia is the age-related decrease in muscle mass and is to muscles what osteoporosis is to bone. It is estimated that muscle mass declines 22% for women and 23% for men between the ages of 30 and 70, with a decline of muscle strength of up to 30%. As muscles lose strength, coordination and balance deteriorate and joint capsules tighten and lose flexibility. Lean muscle mass is lost and is replaced with adipose tissue (Winkler, 2011).

Regardless of a person’s level of activity, there is a decrease in muscle mass and muscle fiber size with age. By the age of 60, degenerative changes in weight-bearing joints are essentially a universal occurrence (Winkler, 2011).

This progressive loss of muscle mass leads to a decrease in physical activity and a rise in the incidence of falls and related fractures. A long rehabilitation time may follow an injury, leading to prolonged bed rest and disuse atrophy’s causing even more muscle loss (NIH, 2011c).

Sarcopenia is a major public health problem that affects about 25% of people younger than 70 years and 40% of those 80 years and older. Healthcare costs related to sarcopenia totaled about $18.5 billion in the United States in the year 2000 (NIH, 2011c).

The consequences of muscle loss include decreased strength and endurance, loss of bone strength, increased fall and fracture risk, and a decreased ability to perform activities of daily living (ADLs). Men tend to have greater muscle mass than women, particularly in the upper body; however, rates of loss appear to be uniform between genders (NIH, 2011c).

The best approach to restoring or maintaining muscle mass and strength is exercise, particularly resistance training. During 10- to 12-week studies of strength training, with training sessions 2 to 3 times a week, results consistently showed significant strength gains for older adultsincluding the frail elderly 90 years and older (JAP, 2003).

Resistance training is primary for the prevention, treatment, and even reversal of sarcopenia. It has been shown to influence hormone levels, the neuromuscular system, and protein synthesis. A program of progressive resistance training can have positive effects in as little as 2 weeks (WebMD, 2009a).

Strengthening exercises are both safe and effective for women and men of all ages, including those who are not in perfect health. In fact, people with health concernsincluding heart disease or arthritisoften benefit the most from an exercise program that includes lifting weights a few times each week.

There are numerous benefits to regular strength training. It can be helpful in reducing the effects of diseases and chronic conditions such as arthritis, impaired balance, lack of flexibility, bone loss, and muscle weakness. Strength training, particularly in conjunction with regular aerobic exercise, can also have a profound impact on a person’s mental and emotional health.

Tufts University recently completed a strength-training program with older men and women who had moderate to severe knee osteoarthritis. The results of this 16-week program showed that strength training decreased pain by 43%, increased muscle strength and general physical performance, improved the clinical signs and symptoms of the disease, and decreased disability. Strength training to ease the pain of osteoarthritis was as effective, and sometimes more effective, than medications. Similar effects of strength training have been seen in patients with rheumatoid arthritis.

As people age, poor balance and flexibility contribute to falls and broken bones. These fractures can result in significant disability and, in some cases, fatal complications. Strengthening exerciseswhen done properly and through the full range of motionincrease flexibility and balance and decrease the likelihood and severity of falls. One study in New Zealand in women 80 years of age and older showed a 40% reduction in falls with simple strength and balance training (Wilks, 2018).

Studies are also being done to develop medications that can prevent muscle wasting. If these medications are found to be effective they would supplement, but not replace, resistance training. The medications include (WebMD, 2009a):

  • Urocortan II: has been shown to cause muscle growth in rats, but not yet tested in humans.
  • Hormone replacement therapy (HRT): has been shown to increase lean body mass in post-menopausal women.
  • Testosterone and growth hormone.

Nutrition can also be a factor in the development of sarcopenia. Older individuals may not be consuming enough calories and protein. Nutritional intervention along with resistance training can increase muscle protein synthesis in older adults. Protein-rich foods such as whey protein or oral nutrition supplements can serve as practical, convenient, and inexpensive ways to deliver added protein (Stout, 2009).

Integumentary Changes

The integumentary system consists of the skin, hair, and nails; it has a variety of functions. It acts as a waterproof shield and insulates the body against extremes of temperature. It also helps to regulate temperature, cushion and protect the deeper tissues, shield the body from sunlight and harmful chemicals, and excrete wastes. The skin contains sensory receptors to detect pain, sensation, pressure, and temperature and is involved in vitamin D synthesis.

Skin

Skin is the largest organ of the integumentary system and contains three primary layers: the epidermis, dermis, and hypodermis. The outermost layer, the epidermis, is a waterproof barrier and contains no blood vessels. The dermis lies just below the epidermis and contains connective tissue, nerve endings for touch and temperature, and hair follicles, sweat glans, sebaceous glands, and lymphatic and blood vessels. The hypodermis lies below the dermis and connects it to underlying muscle and bone.

Cross Section of Human Skin

image: skin cross section

Source: Wikipedia.

As we age, structures within the skin begin to atrophy and lose elasticity and turgor. A decrease in the number of nerve endings leads to decreased sensation. Melanocytes (pigment-producing cells) decrease, causing gray hair and making the skin more susceptible to sun damage.

As we age the epidermis begins to thin, reducing its protective function and allowing chemicals and pathogens easier access to the body. Adipose tissue also decreases with age, reducing the ability of the skin to cushion the body against trauma and to protect against environmental temperature change. Reduced collagen causes skin to tear more easily.

Older adults who are bedridden or wheelchair-bound must be turned or repositioned often to prevent skin breakdown. Those with incontinence must be cleansed frequently to prevent skin breakdown and infection (CaregiverSupport.org, n.d.).

Hair and Nails

With a decrease in pigment-producing melanocytes, hair color fades and turns gray or white. Hair strands become smaller and many hair follicles stop producing hair altogether, causing hair thinning and baldness. Nails grow more slowly and may become yellowed and brittle (Medline Plus, 2010a).

Heat Intolerance

[This section is taken largely from CDC, 2009a.]

Older adults adjust less well to sudden changes in temperature and are more prone to heat stress than younger people. They are more likely than younger people to have a chronic medical condition that changes normal body responses to heat. They are also more likely to be taking prescription medications that impair the body’s ability to regulate temperature or inhibit perspiration.

Heat stroke is the most serious heat-related illness in all ages. It occurs when we are no longer able to control body temperature. This creates a cascade in which body temperature rises rapidly, the body loses its ability to sweat and thus the ability to cool. Body temperatures can rise to 106°F or higher within 10 to 15 minutes. Heat stroke can cause death or permanent disability if emergency treatment is not provided.

Warning signs of heat stroke vary but include the following:

  • An extremely high body temperature (above 103°F)
  • Red, hot, and dry skin with no sweating
  • Rapid, strong pulse
  • Throbbing headache
  • Dizziness
  • Nausea

Heat exhaustion is a milder form of heat-related illness that can develop after several days of exposure to high temperatures and inadequate or unbalanced replacement of fluids. Warning signs of heat exhaustion vary but may include the following:

  • Heavy sweating
  • Pale skin
  • Muscle cramps
  • Tiredness or weakness
  • Dizziness
  • Headache
  • Nausea or vomiting
  • Fainting

Skin may be cool and moist, pulse rate is usually fast and weak, and breathing is fast and shallow.

To protect elders from heat stress, encourage them to drink cool, nonalcoholic beverages. If the person is on a limited fluid intake, consult a health professional about how much fluid intake is safe. Avoid extremely cold liquids because they can cause cramps.

A cool shower, bath, or sponge bath is helpful, and, if possible, provide an air-conditioned environment. If older adults don’t have air conditioning, consider advising a visit to an air-conditioned shopping mall or public library to cool off.

Lightweight clothing is recommended and, if possible, the older person should remain indoors during the heat of the day. Strenuous activity is to be avoided.

Severe heat stress can be a life-threatening emergency and may require immediate medical assistance. The following cooling measures should be started while awaiting emergency medical care:

  • Get the person to a shady area.
  • Cool the person rapidly, using whatever methods you can. For example, you can:
    • Immerse the person in a tub of cool water.
    • Place the person in a cool shower.
    • Spray the person with cool water from a garden hose.
    • Sponge the person with cool water.
    • If the humidity is low, wrap the person in a cool, wet sheet and fan vigorously

Monitor body temperature and continue cooling efforts until the body temperature drops to 101° to 102°F. If emergency medical personnel are delayed, call the hospital emergency room for further instructions. Do not give alcohol to drink.

Hypothermia

Hypothermia can be a problem for older adults because of the body’s decreased ability to regulate and sense temperature. In addition, older adults may be taking certain medications such as antidepressants, antipsychotics, and sedatives that can change the body’s ability to regulate temperature (Mayo Clinic, 2011a).

Diseases such as Parkinson’s, hypothyroidism, stroke, and arthritis may interfere with the body’s temperature regulation. Conditions that decrease sensation and movementsuch as stroke, arthritis, and spinal cord injuriescan prevent a person from sensing changes in body temperature and can also prevent that person from moving to a warmer environment or obtaining blankets or warm clothing. Health problems such as diabetes that interfere with circulation, and some skin problems that cause the body to lose more heat than normal, can also contribute to hypothermia (Mayo Clinic, 2011a).

Hypothermia is most likely at very cold temperatures, but it can occur even at cool temperatures (above 40°F) if a person becomes chilled from rain, sweat, or submersion in cold water. Hypothermia can be deadly if not treated quickly and it can happen anywhere. Older people can have a mild form of hypothermia if the temperature in their home is too cool. Shivering is one way the body tries to stay warm but may not mean a person is hypothermic.

When hypothermia is suspected, look for the “umbles”stumbles, mumbles, fumbles, and grumbles. Check for:

  • Confusion or sleepiness
  • Slowed, slurred speech, or shallow breathing
  • Weak pulse
  • Change in behavior or in the way a person looks
  • A lot of shivering or no shivering; stiffness in the arms or legs
  • Poor control over body movements or slow reaction

A body temperature a few degrees lower than 98.6°F can be dangerous and may cause an irregular heartbeat, leading to heart problems and death. A body temperature below 96°F is an emergency situation.

Keep the person warm and dry and, if possible, move to a warmer place. Wrap the person in blankets, towels, coats, or whatever is available. Even your own body warmth will help. Give the person something warm to drink but avoid alcohol or caffeinated drinks.

In the emergency room setting, the person may be given warm IV fluids and placed on a warming blanket. Recovery depends on how long individuals were exposed to the cold and their general health.

Cardiovascular Changes

Hardly as big as the palm of a hand, the heart is the strongest muscle in the body, pumping up to 5 quarts or more of blood per minute to the body’s organs, tissues, and cells. The adult heart beats more than 100,000 times a day and pumps about 2,000 gallons of blood through 60,000 miles of blood vessels every 24 hours (Young, 2002). In a lifetime, the heart beats more than 2.5 billion times. Even at rest, the heart is working twice as hard as the leg muscles would while running at full speed. So, by the time people reach the age of 65, their hearts have done an extraordinary amount of work.

Age is the major risk factor for cardiovascular disease. Heart disease and stroke incidence rises steeply after age 65, accounting for more than 40% of all deaths among people age 65 to 74 and almost 60% at age 85 and above. Older adults are much more likely than younger people to suffer a heart attack or stroke, or to develop coronary heart disease and high blood pressure leading to heart failure. Cardiovascular disease is also a major cause of disability, limiting the activity and eroding the quality of life of millions of older people each year. The cost of these diseases to the nation is in the billions of dollars.

The left ventricle of the heart thickens over time. The thicker left ventricular walls are thought to be caused by the heart’s adjusting rather than its simply declining with age. Scientists think that the increased thickness allows the walls to compensate for the extra stress they bear with age (stress imposed by pumping blood into stiffer blood vessels, for instance). When walls thicken, stress is spread out over a larger area of heart muscle.

Cross Section Showing the Heart’s Ventricles

image: heart cross section

An anterior view of the heart sectioned to show the interior of the right and left ventricles with a continuous planar section to show the interiors of the atria and vessels of the heart. Illustration provided by 3DScience.com. Used with permission.

Healthy younger and older hearts appear about the same when reclining; however, while sitting, the heart rate is lower in older people compared to younger men and women. This is due in part to age-associated changes in the sympathetic nervous system’s signals to the heart. With age, some of the pathways in the sympathetic nervous system may develop fibrous tissue and fatty deposits and the SA node, the heart’s natural pacemaker, loses some of its cells.

But, while the resting older heart can keep pace with its younger counterpart, even an older heart in peak condition is no match for a younger one during exercise or stress. The body’s capacity to perform vigorous exercise declines by about 50% between the ages of 20 and 80. About half of this decline can be attributed to changes in the typical aging heart.

Age-related changes in heart muscle cells (myocytes) help explain alterations in the heart as a whole. There are fewer myocytes to do the work as we age and those that remain enlarge, compromising their ability to pump blood efficiently.

As the heart ages, it thickens and becomes less elastic, and it may become enlarged in size. The older heart is less able to relax completely between beats and its pumping chambers become stiffer. The heart is not able to pump as vigorously as it once did and is also less responsive to adrenaline. The older heart is less able to supply adequate blood and oxygen to muscles during exercise (Young, 2002).

The older heart is less able to accelerate to meet the body’s oxygen demands during pain, anxiety, fever, or hemorrhage. In addition, an older person may not exhibit the typical heart attack symptoms of chest pain and diaphoresis but instead may have only shortness of breath, anxiety, and confusion. Those with diabetes and long-standing angina are much less likely to exhibit typical symptoms of heart attack (Larsen, 2008).

Atherosclerosis

Atherosclerosis is the disease behind the disease. When atherosclerotic processes take hold in the arteries that supply blood to the heart, the condition becomes coronary artery disease (CAD). Atherosclerosis is a degenerative disorder that injures the inner walls of large arteries. In atherosclerosis, thick abnormal patches called plaques accumulate at scattered locations along the artery’s innermost layer. The plaques are disorganized masses filled with cholesterol, other lipids, and cells, all covered by a white fibrous coating (Mitchell and Schoen, 2009).

Atherosclerotic plaques narrow an artery and hinder blood flow. Further, the surface of a bulging atherosclerotic plaque sometimes tears, exposing material that stimulates clot formation. Clots and ruptured plaque material can then break away from the wall, be carried by the blood, and clog arteries downstream.

Atherosclerosis can damage tissues throughout the body:

  • In the cerebral circulation, atherosclerotic obstructions cause strokes.
  • In the legs, atherosclerotic obstructions cause claudication (pain when walking) and gangrene.
  • In the intestines, atherosclerotic obstructions cause ischemic bowel.
  • In the coronary arteries, atherosclerotic obstructions cause heart attacks. (Libby, 2008)
image: sectioned elastic artery
image: atherosclerotic plaque

Left: In this image we see a representation of a sectioned elastic artery. Elastic arteries are vessels that can handle a great deal of pressure, eg, the aorta, which takes pressure directly from the constant beating of the heart. Right: This image illustrates an atherosclerotic plaque, as found in this cross section of an artery, with the plaque forming on the inside wall. Illustration provided by 3DScience.com. Used with permission.

Beginning in childhood, a cascade of events slowly and quietly leads to the development of atherosclerosis. Children develop fatty streaks along the walls of their large arteries. These streaks are sites where lipoprotein particles are protected from direct contact with the blood. When sequestered in this way, the lipoproteins become oxidized into destructive molecules, and the resulting oxidants injure nearby cells.

In the arterial walls, leukocytes (white blood cells) are attracted to the areas of cell injury, and the incoming leukocytes initiate a local inflammatory reaction. Some of the attracted leukocytes are macrophages. Macrophages are clean-up cells, and they begin to engulf the local lipids. When macrophages are overwhelmed by the lipids in their vicinity, they become bloated with fatty debris. The accumulation of fat-filled macrophages, which are called foam cells, is a characteristic of atherosclerotic plaque.

In a person with a healthy balance of blood fatslow blood levels of LDL cholesterol and high blood levels of HDL cholesterolthere is only a modest accumulation of lipids in arterial walls. The available macrophages can swallow and cart off sufficient lipids from the fatty streaks to avoid a lipid buildup, and few foam cells accumulate. When this and the other lipid-removal mechanisms are working smoothly, the amount of sequestered lipid can be controlled and atherosclerosis cannot get a foothold.

A variety of conditions can make the lipid removal systems inefficient. These atherogenic forces are known as atherosclerotic risk factors. Atherosclerotic risk factors include smoking, diabetes, hypertension, obesity, physical inactivity, and the accumulated wear of old age. When these conditions interfere with lipid removal, atherosclerosis can slowly but inexorably clog arteries (Libby, 2008).

In atherosclerosis, the body’s lipid removal systems are working poorly. Foam cells die before they can remove lipids, and a core of necrotic cells forms inside the expanding yellow streak. The body attempts to repair the damage: smooth muscle cells crawl into the mass and begin to create a meshwork of collagen and other extracellular matrix materials. By this point, the yellow streak has become an atherosclerotic plaque.

Plaque buildup can occlude vessels and cause angina. Angina is chest pain or discomfort that is caused when the heart muscle does not get enough blood and is the most common symptom of CAD. This may lead to heart failure and arrhythmias (CDC, 2009b).

For some people, the first sign of CAD is a heart attack (myocardial infarction, or MI). A heart attack occurs when plaque totally blocks an artery carrying blood to the heart. It also can happen if a plaque deposit breaks off and occludes a coronary artery (CDC, 2009b).

The risk of heart disease increases for men after age 45 and for women after age 55 (or after menopause). Risk increases if the person’s father or a brother was diagnosed with heart disease before 55 years of age, or if the mother or a sister was diagnosed with heart disease before 65 years of age. However, there are things that can be done to reduce the risk of heart disease.

  • Eat a healthy diet:
    • Choosing healthful meal and snack options and plenty of fresh fruits and vegetables can help avoid heart disease and its complications.
    • Eating foods low in saturated fat and cholesterol and high in fiber can help prevent high blood cholesterol. Limiting salt or sodium in the diet can also lower blood pressure.
  • Maintain a healthy weight.
    • Being overweight or obese can increase your risk for heart disease.
  • Exercise regularly.
    • Physical activity can help you maintain a healthy weight and lower cholesterol and blood pressure. The Surgeon General recommends that adults should engage in moderate-intensity exercise for at least 30 minutes on most days of the week.
  • Don’t smoke. Cigarette smoking greatly increases the risk for heart disease.
  • Limit alcohol use which can contribute to high blood pressure.
  • If the older adult has high cholesterol, high blood pressure, or diabetes:
    • Have cholesterol levels checked at least once every 5 years.
    • Monitor blood pressure.
    • Manage diabetes by closely monitoring blood sugar levels.
    • Medication to treat high cholesterol, high blood pressure, or diabetes should be taken as directed by a primary care provider.

It is important to know the symptoms of heart attack. Acting fast at the first sign of heart attack symptoms can save lives and limit damage to the heart. Treatment works best when it’s given right after symptoms occur.

Heart attack symptoms include:

  • Chest pain or discomfort. This involves uncomfortable pressure, squeezing, fullness, or pain in the center or left side of the chest that can be mild or strong. This discomfort or pain often lasts more than a few minutes or goes away and comes back.
  • Upper body discomfort in one or both arms, the back, neck, jaw, or upper part of the stomach.
  • Shortness of breath, which may occur with or before chest discomfort.
  • Nausea (feeling sick to your stomach), vomiting, light-headedness or sudden dizziness, or breaking out in a cold sweat.

Symptoms also may include sleep problems, fatigue (tiredness), and lack of energy. It is important to call 911 immediately and do not drive yourself to the hospital.

Coronary Artery Disease

Coronary artery disease can take a chronic course called stable angina. It can also give rise to sudden cardiac emergencies called acute coronary syndromes. Acute coronary syndromes range from temporary episodes of significant ischemia (unstable angina) to permanent heart muscle damage (myocardial infarction) to sudden cardiac death.

In stable angina, coronary arteries are partly occluded. At rest, dilation of the downstream arteries allows sufficient blood flow to meet the demands of the heart muscle cells. However, during exercise, the increased oxygen and nutrients needed by the heart exceed the capacity of the already-dilated arteries. Therefore, when the person exercises, the heart muscles become ischemic, and typically the person feels angina. In most cases, the ischemia of stable angina is transitory and does not cause significant muscle cell death.

Symptoms in stable angina occur when the demands on the heart exceed the blood flow through pre-existing stenosis. These symptoms occur predictably, whenever the patient’s heart accelerates to a certain level of activity. In stable angina, the event that initiates symptoms is external (eg, exercise, stress, cold weather).

In acute coronary syndromes, the event that initiates symptoms includes an internal change, specifically, a change in the atherosclerotic plaque in the patient’s coronary arteries. When a patient suffers an acute coronary syndrome:

  • Plaque has expanded, eroded, or ruptured, or
  • A thrombus has moved or broken loose, or
  • A coronary artery has suddenly tightened in a vasospasm

When atherosclerotic plaque erodes or ruptures, it can produce thrombi that occlude coronary arteries. At one end of the spectrum of acute coronary syndromes, the sudden obstruction can be temporary and clear spontaneously; this is called unstable angina. Although it can be significant, the ischemia of unstable angina is sufficiently brief to avoid killing heart muscle. Unstable angina is a warning that additional dangerous changes may occur and cause myocardial infarction or sudden cardiac death.

At the other end of the spectrum of acute coronary syndromes, the sudden arterial obstruction can persist, causing sufficient ischemia to kill muscle cells; this is called a myocardial infarction (MI, or heart attack). After an MI, intracellular proteins leak from the damaged cells and circulate in the bloodstream. An MI can be diagnosed by finding cardiac-specific intracellular proteins (cardiac biomarkers) in the blood of a person who has the signs and symptoms of an acute coronary syndrome.

Myocardial infarctions can be definitively diagnosed in symptomatic patients from blood samples. When heart muscle cells die, heart-specific intracellular molecules (cardiac biomarkers) will leak into the bloodstream, and these molecules can be detected in standard blood tests.

In most cases, ECG waveforms will also show distinctive changes during and after a myocardial infarction. ECG changes can be used to identify those myocardial infarctions that affect large areas of heart muscle, a situation that can sometimes be improved by immediate reperfusion therapies. Two reperfusion techniques are commonly available for patients who have had serious myocardial infarctions within the last hour: an intravenous (IV) injection of a “clot-busting” drug or angioplasty (reaming out the artery to remove the obstruction).

The abrupt release of atherosclerotic thrombi that causes myocardial ischemia can also trigger fatal ventricular arrhythmias. This appears to be the critical event behind most cases of sudden cardiac death, a condition in which patients die unexpectedly and within minutes of the onset of symptoms (Mitchell and Schoen, 2009).

Stroke

[This section taken is taken largely from NINDS, 2012.]

Stroke is the number one cause of serious adult disability in the United States and it is devastating to the stroke patient and family. Stroke strikes all age groups, from fetuses still in the womb to centenarians. However, older people have a higher risk for stroke than the general population and the risk for stroke increases with age. For every decade after the age of 55, the risk of stroke doubles, and two-thirds of all strokes occur in people over 65 years old. People over 65 also have a seven-fold greater risk of dying from stroke than the general population, and the incidence of stroke is increasing proportionately with the increase in the elderly population.

Men have a higher risk for stroke, but more women die from stroke. The stroke risk for men is 1.25 times that for women. But, because men do not live as long as women and are usually younger when they have a stroke, they have a higher rate of survival than women. Because women live longer than men and generally have strokes at an older age, they are more likely to die from them.

Stroke, sometimes called a “brain attack,” occurs when the blood supply to part of the brain is suddenly interrupted or when a blood vessel in the brain bursts, spilling blood into the spaces surrounding brain cells. Ischemia occurs when brain cells die because they no longer receive oxygen and nutrients from the blood or when they are damaged by sudden bleeding into or around the brain. Ischemia ultimately leads to infarction, the death of brain cells that are eventually replaced by a fluid-filled cavity (infarct) in the injured brain.

Stroke symptoms include sudden numbness or weakness, especially on one side of the body; sudden confusion or trouble speaking or understanding speech; sudden trouble seeing in one or both eyes; sudden trouble walking; dizziness, or loss of balance or coordination; or sudden severe headache with no known cause.

The symptoms of stroke appear suddenly, and often there is more than one symptom at the same time, so that stroke can usually be distinguished from other causes of dizziness or headache. There are two forms of stroke: (1) ischemic, or blockage of a blood vessel supplying the brain, and (2) hemorrhagic, or bleeding into or around the brain.

 

Diagram Illustrating an Ischemic Stroke

image: ischemic stroke

This shows how an ischemic stroke can occur in the brain. If a blood clot breaks away from plaque buildup in a carotid artery, it can travel to and lodge in an artery in the brain. The clot can block blood flow to part of the brain, causing brain tissue death. Source: NIH, n.d.

 

 

Diagram Illustrating a Hemorrhagic Stroke

image: hemorrhagic stroke

This shows how a hemorrhagic stroke can occur in the brain. An aneurysm in a cerebral artery breaks open, which causes bleeding in the brain. The pressure of the blood causes brain tissue death. Source: NIH, n.d.

 

Age, and the diseases that occur more frequently with age, are major risk factors for stroke. The most important risk factors for stroke are hypertension, heart disease, diabetes, and cigarette smoking. Others include heavy alcohol consumption, high blood cholesterol levels, illicit drug use, and genetic or congenital conditions, particularly vascular abnormalities.

After hypertension, the next biggest risk factor for stroke is heart disease, in particular, atrial fibrillation. Atrial fibrillation leads to an irregular flow of blood and the occasional formation of blood clots that can leave the heart and travel to the brain, causing a stroke.

Strokes can affect the entire body. Some of the disabilities that can result from a stroke include paralysis, cognitive deficits, speech problems, emotional difficulties, daily living problems, and pain.

Today, there are treatments to prevent stroke in those who have risk factors, and medications and surgical interventions are available to treat acute ongoing strokes. Those who are left with disabilities from stroke often face a long rehabilitation. It is important to call 911 as soon as stroke is suspected because clot-busting drugs are usually only given within 3 hours of onset of symptoms.

Medication or drug therapy is the most common treatment for stroke. The most popular classes of drugs used to prevent or treat stroke are anti-thrombotics (antiplatelet agents and anticoagulants) and thrombolytics, which break up blood clots.

For most stroke patients, physical therapy (PT) is the cornerstone of the rehabilitation process. A physical therapist uses training, exercises, and physical manipulation of the stroke patient’s body with the intent of restoring movement, balance, and coordination. The aim of PT is to have the stroke patient relearn simple motor activities such as walking, sitting, standing, lying down, and the process of switching from one type of movement to another.

Another type of therapy involving relearning of daily activities is occupational therapy (OT). OT also involves exercise and training to help the stroke patient relearn everyday activities such as eating, drinking, dressing, bathing, cooking, reading and writing, and toileting. The goal of OT is to help the patient become independent or semi-independent.

Speech and language problems arise when brain damage occurs in the language centers of the brain. Due to the brain’s great ability to learn and change (called brain plasticity), other areas can adapt to take over some of the lost functions. Speech language pathologists help stroke patients relearn language and speaking skills (including swallowing), or learn other forms of communication. Speech therapy is appropriate for any patients with problems understanding speech or written words, or problems forming speech. A speech therapist helps stroke patients help themselves by working to improve language skills, develop alternative ways of communicating, and develop coping skills to deal with the frustration of not being able to communicate fully. With time and patience, a stroke survivor should be able to regain some, and sometimes all, language and speaking abilities.

Many stroke patients require psychological or psychiatric help after a stroke. Psychological problems, such as depression, anxiety, frustration, and anger, are common post stroke disabilities. Talk therapy, along with appropriate medication, can help alleviate some of the mental and emotional problems that result from stroke. Sometimes it is also beneficial for family members of the stroke patient to seek psychological help as well.

Urinary Changes

Problems in the urinary system can be caused by aging, illness, or injury. With age, changes in the kidneys’ structure cause them to lose some of their ability to remove wastes from the blood. Further, the muscles in the ureters, bladder, and urethra tend to lose some of their strength. Older adults may have more urinary infections because the bladder muscles do not tighten enough to empty the bladder completely. A decrease in strength of muscles of the sphincters and the pelvis can also cause incontinence, the unwanted leakage of urine. Illness or injury can also prevent the kidneys from filtering the blood completely or block the passage of urine (NKUDIC, 2010).

With age, the number of nephrons (the filtering units of the kidneys) decreases and the kidneys are less able to filter waste from the blood. Blood vessels that supply the kidneys become stiffer, causing the kidneys to filter blood more slowly. The overall amount of kidney tissue also decreases and there is a reduced capacity for renal regeneration in the face of acute renal insults (Medline Plus, 2011).

Because of age-related changes to the kidneys, older adults are more susceptible to the development of dehydration and drug toxicity due to reduced drug excretion. An important cause of renal toxicity is failure to adjust medication dosage to decreases in glomerular filtration rate, which measures how much blood passes through the tiny filters in the kidneys (glomeruli) each minute.

Changes in immune system function with aging can lead to an increased inflammatory response to renal injury and increased susceptibility to infection. Because the older person is less likely to develop a fever or an increase in white blood cells, kidney infections may go unnoticed and untreated, leading to sepsis and kidney injury.

In the older male, benign prostatic hypertrophy (BPH) can develop. The prostate gland, which surrounds the urethra, grows larger and may cause difficulty in urination. In addition, an infection or a tumor may cause problems passing urine. Men in their thirties and forties may begin to have urinary symptoms and need medical attention, but for others symptoms aren’t noticed until much later in life.

Urinary Tract Infections

Urinary tract infections are the most common infection found in older adults. Most urinary tract infections (UTIs) are not serious, but some infections can lead to serious problems, such as kidney infections. Recurrent or chronic kidney infections can cause permanent damage, including kidney scars, poor kidney function, high blood pressure, and other problems. Some acute kidney infectionsinfections that develop suddenlycan be life threatening, especially if the bacteria enter the bloodstream, a condition called septicemia (NKUDIC, 2011).

Symptoms of UTI vary by age, gender, and whether a catheter is present. Among young women, UTI symptoms typically include a frequent and intense urge to urinate and a painful, burning feeling in the bladder or urethra during urination. The amount of urine per void may be very small (NKUDIC, 2011).

Older people with UTIs are more likely to be tired, shaky, and weak, and to have muscle aches and abdominal pain. There may be a change in appetite, new or increased confusion, new or increased incontinence, and the inability to do ADLs. Frequently, confusion is the only symptom seen in the older adult (Wells, 2009), and UTIs can go unrecognized by the patient because the symptoms are too vague to suggest urinary tract involvement.

Urine may look cloudy, dark, or bloody, or have a foul smell. In a person with a catheter, the only symptom may be fever that cannot be attributed to any other cause. Normally, UTIs do not cause fever if they are in the bladder. A fever may mean the infection has reached the kidneys or has penetrated the prostate. Other symptoms of a kidney infection include pain in the back or side below the ribs, nausea, and vomiting (NKUDIC, 2011).

Older adults are more susceptible to UTIs than younger adults for several reasons. They are generally more susceptible to infections and, if they are incontinent, to bacteria that can travel through the urethra to the bladder. Incomplete emptying of the bladder allows urine to stagnate, which is conducive to bacterial growth.

Bacteria may be introduced into the bladder on or around a urinary catheter. The Infectious Diseases Society of America recommends using catheters for the shortest time possible to reduce the risk of a UTI (NKUDIC, 2011).

Prostate Cancer

Prostate Anatomy

image: prostate anatomy

Source: NCI, n.d.

Prostate cancer is the most commonly diagnosed cancer in men, and second only to lung cancer in the number of cancer deaths. Out of every three men who are diagnosed with cancer each year, one is diagnosed with prostate cancer (Medline Plus, 2007).

Prostate cancer symptoms vary from person to person, and some men do not have symptoms at all. Symptoms of prostate cancer include:

  • Difficulty in starting urination
  • Weak or interrupted flow of urine
  • Frequent urination, especially at night
  • Difficulty in emptying the bladder completely
  • Pain or burning during urination
  • Blood in the urine or semen
  • Pain in the back, hips, or pelvis that doesn’t go away
  • Painful ejaculation (CDC, 2011b)

Men have a greater chance of getting prostate cancer if they are age 50 or older, are African-American, or have a father, brother, or son who has had prostate cancer.

Not all medical experts agree that screening for prostate cancer will save lives. Currently, there is not enough credible evidence to decide if the potential benefit of prostate cancer screening outweighs the potential risks. The potential benefit of prostate cancer screening is early detection of cancer, which may make treatment more effective. Potential risks include false positive test results, treatment of prostate cancers that may never affect health, and mild to serious side effects from treatment (CDC, 2011b).

Respiratory Changes

Alveoli and Lungs of the Respiratory System

image: alveoli and lungs

This image shows a male torso with head turned sideways to reveal the major anatomic elements of the respiratory system. To the left is a close-up view of the alveoli, tiny air sacs responsible for the oxygen-carbon dioxide exchange of the blood in the lungs. Illustration provided by 3DScience.com. Used with permission.

The lungs bring oxygen from the air into the blood and send carbon dioxide and water back into the air. The respiratory tract also warms and moistens the incoming air, regulates air flow, removes airborne particles, and cools the entire organism.

Alveoli of the Respiratory System

image: alveoli

The respiratory tubes, or bronchioles, end in minute alveoli, each of which is surrounded by an extensive capillary network. The alveoli are responsible for gas exchange in the blood. Illustration provided by 3DScience.com. Used with permission.

Similar to other organ systems, aging of the pulmonary system is associated with structural changes leading to a progressive decline in function. Decreased collagen and elastin result in the loss of elastic recoil of the lungs. There is decreased diameter of small airways and a tendency to early closure, leading to air trapping and ventilation/perfusion mismatches.

With age, there is a decrease in the number of alveoli (the primary gas exchange units of the lungs) and lung capillaries, with a corresponding decrease in gas exchange.

Aging lungs become stiffer and less able to expand and contract. Vital capacity, muscle strength, and endurance decrease. The chest wall becomes more rigid and the diaphragm and other muscles of respiration become weaker. A decreased cough reflex and a reduction in the number of cilia that sweep mucous up and out of the lungs results in increased likelihood of infection (Medline Plus, 2010b).

Endocrine Changes

The endocrine system is made up of glands that secrete hormones that regulate the body’s growth, metabolism, and sexual development and function. With age, some hormones increase or decrease, some target organs become less receptive, and hormones may be broken down more slowly.

Despite these age-related changes, the endocrine system functions well in most older people. However, some changes do occur because of normal damage to cells during the aging process and genetically programmed cellular changes. These changes may alter:

  • Hormone production and secretion
  • Hormone metabolism (how quickly excess hormones are broken down and leave the body, eg, through urination)
  • Hormone levels circulating in blood
  • Biologic activities
  • Target cell or target tissue response to hormones
  • Rhythms in the body, such as the menstrual cycle

Increasing age is thought to be related to the development of type II diabetes. Diabetes is a disorder that causes repeated episodes of inappropriately high concentrations of glucose in the bloodstream. This chronic hyperglycemia gradually produces tissue damage, notably to eyes, kidneys, nerves, heart, and blood vessels. With aging, the target cell response time becomes slower, especially in people who might be at risk for this disorder.

Only two-tenths of 1% (.002) of people younger than 20 years have the disease, whereas more than 23% of people over the age of 60 years have the disease. It is estimated that one-quarter of the people with type 2 diabetes are unaware that they have the illness.

The American Diabetes Association estimates that 21 million people have diabetes, with another 54 million people having prediabetes, a condition with increased blood sugar levels that are not yet elevated enough to be called diabetes. Being overweight causes heightened insulin resistance and increases the odds of developing type 2 diabetes. The epidemic of obesity in this country correlates with the increased incidence of type 2 diabetes.

The signs and symptoms of endocrine system diseases affect many body systems. In elders they are frequently subtle and may be harder to detect than in younger people. At times, these signs are incorrectly linked with other causes, such as the changes of normal aging, other medical disorders or conditions, or drug therapy (The Hormone Foundation, 2012).

The aging process affects nearly every gland. For example, the hypothalamus is responsible for releasing hormones that stimulate the pituitary gland. During aging there is either impaired secretion of some hypothalamic hormones or impaired pituitary response. These changes appear to influence the endocrine system’s ability to respond to the body’s internal environment. As a result, the body cannot respond as well to internal and external stresses (The Hormone Foundation, 2012).

With increasing age, the pituitary gland can become smaller and more fibrous and may not work as well; for example, production of growth hormone may decrease, leading to a hormone imbalance that causes problems such as decreased lean muscle, decreased heart function, and osteoporosis (The Hormone Foundation, 2012).

Aging affects a woman’s ovaries. These organs eventually exhibit the most common endocrine change related to aging: menopause. In menopause, the ovaries stop responding to follicle-stimulating hormone and luteinizing hormone from the anterior pituitary. Ovarian hormone production of estrogen and progesterone slows down and then stops. Eventually a woman stops having periods altogether (The Hormone Foundation, 2012).

Gastrointestinal Changes

The digestive system is made up of the digestive tracta series of hollow organs joined in a long, twisting tube from the mouth to the anusand other organs that help the body break down and absorb food. Digestion is the process by which food and drink are broken down into their smallest parts so the body can use them to build and nourish cells and to provide energy (NDDIC, 2008).

All organ systems change with age, including the gastrointestinal tract. As we grow older, the prevalence of gastrointestinal problems increases. Gastroesophageal reflux disease, or GERD, occurs when the lower esophageal sphincter does not close properly and stomach contents leak back (reflux) into the esophagus. Heartburn that occurs more than twice a week may be considered GERD, and it can eventually lead to more serious health problems (Medline Plus, 2007).

Food intake may decrease in the older adult for several reasons. An older person’s ill-fitting dentures or tooth decay can making chewing difficult. Decreased saliva production causes dry mouth, which may increase tooth decay and even make swallowing more difficult. Taste becomes less acute, making food less appetizing.

Decreased intestinal motility and slower stomach emptying can lead to altered absorption of nutrients and medications. Decreased physical activity, decreased intestinal motility, and a lessened urge to defecate can lead to constipation.

Constipation

Nearly everyone becomes constipated at one time or another, but older people are more likely than younger people to become constipated. Constipation is a symptom, not a disease. An individual may be constipated if there are fewer bowel movements than usual, it takes a long time to pass stools, and the stools are hard. There is no correct number of daily or weekly bowel movements. Being regular is different for each person. For some, it can mean bowel movements twice a day and for others having movements three times a week is normal.

The cause of constipation is not always known. It may be poor diet, not getting enough exercise, or using laxatives too often. Reasons for constipation include:

  • Diet low in fiber, vegetables, fruits, and whole grains
  • Loss of interest in cooking and eating
  • Dental problems
  • Lack of water and other fluids
  • Overuse of laxatives and enemas
  • Lack of exercise
  • Holding back or ignoring the urge to have a bowel movement

In addition, constipation can result from medical conditions such as stroke, diabetes, a blockage in the intestines, or Irritable bowel syndrome (IBS), and from medications used to treat depression, antacids containing aluminum or calcium, iron supplements, some antihistamines, certain painkillers, some hypertension drugs (including diuretics), and some drugs used to treat Parkinson’s disease.

Older adults regularly taking narcotic pain medications frequently experience constipation. Opioid pain medications slow movement of stool through the intestinal tract and the stool becomes hard and more difficult to expel. The usual treatments of fiber, fluids, and exercise are not sufficient. Stool softeners such as docusate and peristalsis-inducing medications such as senna and bisacodyl are the treatment of choice (Herndon, 2002).

When serious causes of constipation have been ruled out, dietary and lifestyle changes can be tried for problems with constipation. Fiber should be added to the diet by eating more fresh fruits and vegetables, either cooked or raw, and more whole-grain cereals and breads.

If the diet does not include natural fiber, a small amount of bran may be added to baked goods, cereal, and fruit. This may cause some bloating and gas in the beginning, so diet changes should be made slowly to allow the system to adapt. Fiber products such as psyllium seed may be used and are found in the grocery store.

Drinking more water and juiceat least three 12-oz glasses of water each day unless medically contraindicatedand staying active helps prevent constipation and is also important for overall health.

If these changes don’t work, laxatives may be considered. If constipation continues to be a problem, it is important to seek medical advice. A change in bowel habits, blood in the stool, abdominal pain, or recent unexplained weight loss may be signs of a more serious problem (NIA, 2011a).

Other Gastrointestinal Problems

Up to 40% of older adults experience some kind of gastrointestinal symptoms (McLaughlin, 2010).

  • Gallstones are most prevalent in adults over age 60 and are formed from hardened digestive fluid in the gallbladder. They can cause abdominal pain, especially in the right upper abdomen and right upper back.
  • Loss of muscle strength with aging can lead to diverticular disease. Diverticulosis is very common and occurs in 10% of people over age 40 and in 50% of people over age 60. Although most people have few or no symptoms, the diverticula may become infected (diverticulitis) or cause bleeding (WebMD, 2010).
  • About 90% of colon cancer occurs in adults over age 50. Symptoms can include rectal bleeding, constipation or loose stools, weight loss, abdominal pain, and fatigue. It is recommended that all individuals over the age of 40 have yearly digital examinations of the rectum and their stool be tested for occult blood (Lee, n.d.).

Sensory Changes

As the senses become less acute with age, less information can be gathered and processed about the world around us. The prevalence of sensory impairments is increasing as life expectancy increases. In order to maintain independent living, health, and quality of life for older adults it is important to minimize the impact of sensory impairments.

Sensory impairments are a substantial problem for older Americans. One out of 6 older Americans has impaired vision; 1 out of 4 has impaired hearing; 1 out of 4 has loss of feeling in the feet; and 3 out of 4 have abnormal postural balance testing (CDC, 2010a).

Hearing

Hearing loss is one of the most common conditions affecting older adults. One in 3 people older than 60 and one-half of those older than 85 have hearing loss, making it hard to understand and follow a doctor’s advice, respond to warnings, and to hear doorbells and alarms. Hearing loss can also make it difficult to enjoy talking with friends and family (NIDCD, 2011).

Some people lose their hearing slowly as they age, a condition is known as presbycusis. The loss associated with presbycusis is usually greater for high-pitched sounds and most often occurs in both ears. Because the loss of hearing is gradual, people may not realize that their hearing is diminishing.

Presbycusis most commonly arises from gradual changes in the inner ear as a person ages, but may also result from changes in the middle ear or from complex changes along the nerve pathways leading to the brain (NIDCD, 2011).

Presbycusis can be a type of sensorineural hearing loss that is most often caused by a loss of hair cells (sensory receptors in the inner ear). This can occur as a result of heredity as well as aging. It can also be caused by health conditions such as heart disease, stroke, hypertension, diabetes, and tumors. Hearing loss may be due to the side effects of some medicines such as aspirin and certain antibiotics such as aminoglycosides, vancomycin, and erythromycin (NIDCD, 2011).

Another reason for hearing loss may be exposure to too much loud noisea condition known as noise-induced hearing loss. Many construction workers, farmers, musicians, airport workers, tree cutters, and people in the armed forces have hearing problems because of too much exposure to loud noise (NIDCD, 2011).

Vision

In adults, visual impairment is associated with loss of personal independence and difficulty maintaining employment, often leading to the need for disability pensions, vocational and social services, and nursing home or assistive living placement. Older adults represent the vast majority of the visually impaired population. For older adults, visual problems have a negative impact on quality of life equivalent to that of life-threatening conditions such as heart disease and cancer (NEI, n.d.a).

Between the ages of 40 and 50, most people begin to have difficulty focusing their vision up close. This is a condition call presbyopia and it is a normal result of aging caused by a loss of elasticity of the lens. Presbyopia is easily corrected with glasses. The lens also thickens and discolors, making it more difficult to distinguish colors. Pupils decrease in size and more light is needed to see well.

There are certain diseases that are not a normal part of aging that can lead to vision loss. The leading causes of visual impairment are diseases that are common in elders: age-related macular degeneration (AMD), cataract, glaucoma, diabetic retinopathy, and optic nerve atrophy (NEI, n.d.a).

Over two-thirds of those with visual impairment are over age 65. Although there are no gender differences in the prevalence of vision problems in older adults, there are more visually impaired women than men because, on average, women live longer than men. However, African Americans are twice as likely to be visually impaired than are whites of comparable socioeconomic status. As the older adult population grows, the number of people with visual impairment and other aging-related disabilities will increase (NEI, n.d.a).

* * *

Age-Related Macular Degeneration (AMD) is a disease associated with aging that gradually destroys sharp central vision. It is a leading cause of vision loss in Americans 60 years of age and older. Central vision is needed for seeing objects clearly and for common daily tasks such as reading and driving. AMD affects the macula, the part of the eye that allows us to see fine detail. AMD causes no pain (NEI, 2009a).

In some cases, AMD advances so slowly that people notice little change in their vision. In others, the disease progresses faster and may lead to a loss of vision in both eyes (NEI, 2009a).

Visual Result of Macular Degeneration

image: normal vision vs. macular degeneration

Normal vision and vision impaired by macular degeneration. Source: NIH, n.d.

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A cataract is a clouding of the lens in the eye that affects vision and generally is related to aging. By age 80, more than half of all Americans either have a cataract or have had cataract surgery. A cataract can occur in one or both eyes and cannot spread from one eye to the other (NEI, 2009b).

With age, some of the protein that makes up the lens may clump together and start to cloud a small area of the lens, causing a cataract. Over time the cataract may grow larger and cloud more of the lens. Researchers suspect that there are several causes of cataract (eg, smoking, diabetes) or it may be that the protein in the lens changes from the wear and tear it takes over the years (NEI, 2009b).

* * *

Glaucoma is a group of diseases that damage the eye’s optic nerve and can result in vision loss and blindness. However, with early detection and treatment, serious vision loss may be prevented (NEI, n.d.b).

Several large studies have shown that eye pressure is a major risk factor for optic nerve damage. In the front of the eye is a space called the anterior chamber. Aqueous humor flows continuously in and out of the chamber and nourishes nearby tissues. The fluid leaves the chamber at the open angle where the cornea and iris meet.

Cross Section of the Eye

image: cross section of eye

The anterior chamber is seen here between the cornea and the pupil. Source: NIH, n.d.

When the fluid reaches the angle, it flows through a spongy meshwork, like a drain, and leaves the eye. When the drainage system does not work properly, the aqueous humor is not able to filter out of the eye at its normal rate, and pressure builds within the eye that may cause damage to the optic nerve and subsequent vision loss (NEI, n.d.b).

Drainage System of the Eye

image: drainage system of eye

Source: NIH, n.d.

Visual Result of Glaucoma

image: normal vs. glaucoma-impaired vision

Normal vision and vision impaired by glaucoma. Source: NIH, n.d.

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Diabetic retinopathy is the most common diabetic eye disease and a leading cause of blindness in American adults. It is caused by changes in the blood vessels of the retina (NEI, 2009c).

Some diabetic retinopathy is caused by blood vessels that swell and leak fluid. It can also be caused by abnormal new blood vessels that grow on the surface of the retinathe light-sensitive tissue at the back of the eye. Initially, there may not be noticeable changes to vision, but over time it can cause vision loss. Diabetic retinopathy usually affects both eyes (NEI, 2009c).

Visual Result of Diabetic Retinopathy

image: normal vs. diabetic retinopathy

Normal vision and vision impaired by diabetic retinopathy. Source: NEI, NIH, n.d.

* * *

Optic nerve atrophy in older adults is most commonly caused by poor blood flow, which damages the optic nerve. Vision becomes dim, the field of vision is reduced, and there is difficulty distinguishing colors. Damage to the optic nerve is permanent and treatment consists of preventing further damage and treating the underlying cause (Medline Plus, 2010c).

It is important for older adults to have yearly eye exams to detect problems in the early stages. Blood pressure should be monitored and exercise and a healthy diet are important. Smoking and sun exposure have been linked to both cataracts and macular degeneration. Sunglasses with 100% UVA and UVB protection should be worn.

Smell and Taste

Smell and taste are closely linked in the brain, but they are actually distinct sensory systems. True tastes are detected by taste buds on the tongue and the roof of the mouth, as well as in the throat region, and are limited to sweet, salty, sour, bitter, savoryand perhaps a few other sensations. The loss of smell is much more common than the loss of taste, and many people mistakenly believe they have a problem with taste, when they are really experiencing a problem with their sense of smell.

Our sense of smell helps us enjoy life and is also a warning system that alerts to danger signals such as a gas leak, spoiled food, or a fire. Any loss in our sense of smell can have a negative effect on our quality of life. It can also be a sign of more serious health problems.

As with vision and hearing, people gradually lose their ability to smell as they get older. Smell that declines with age is called presbyosmia and is not preventable. Roughly 1% to 2% of people in North America say that they have a smell disorder. Problems with smell are more common in men than women. In one study, nearly one-quarter of men ages 60 to 69 had a smell disorder, while about 11% of women in that age range reported a problem. Many people who have smell disorders also notice problems with their sense of taste (NIDCD, 2009).

Age is only one of the many reasons for problems with smell. Most people who develop a problem with smell have recently had an illness or injury. The most common causes are the common cold and chronic nasal or sinus infection.

Problems with the sense of smell can also be a sign of other serious health conditions. A smell disorder can be an early sign of Parkinson’s disease, Alzheimer’s disease, multiple sclerosis, and (rarely) brain tumor. It can also accompany or be a sign of obesity, diabetes, hypertension, and malnutrition.

When smell is impaired, people often change their eating habits. Some may eat too little and lose weight while others may eat too much and gain weight. Food becomes less enjoyable and people may use too much salt or sugar to improve the taste, a practice that can worsen certain medical conditions such as high blood pressure, kidney disease, or diabetes. In severe cases, loss of smell can lead to depression.

It is important to identify and treat the underlying cause of a smell disorder. Certain antibiotics, some blood pressure pills, some cholesterol-lowering drugs, and some antifungal medications can cause problems with smell. The sense of smell usually returns to normal when the medicine is stopped.

Surgery to remove nasal obstructions such as polyps can restore airflow. Some people recover their ability to smell when the illness causing their olfactory problem is resolved. Occasionally, a person may recover the sense of smell spontaneously.

People with head and neck cancers who receive radiation treatment to the nose and mouth commonly experience problems with their sense of smell and taste as a side effect. Older people who have lost their larynx or voice box commonly complain of poor ability to smell and taste.

Tobacco smoking is the most concentrated form of pollution that most people are exposed to. It impairs the ability to identify and enjoy odors.

* * *

Taste buds, located mainly on the tongue’s surface, palate, and oropharynx, are primarily responsible for sweet, sour, bitter, salty, and metallic sensations. The physiologic role of the taste system includes: triggering reflexes that control the secretion of oral, gastric, pancreatic, and intestinal juices; reinforcing the ingestive process by enhancing feelings of pleasure and satiety; and enabling us to determine food quality so we can distinguish nutrients from potential toxins. Taste (and smell) dysfunction can alter food choices and patterns of consumption, producing weight loss, malnutrition, and in some cases impaired immunity and even death (NDICD, 2010).

Taste function decreases with aging to some degree and can be influenced by central tumors and lesions (eg, ischemic infarcts secondary to stroke). Taste can also be adversely affected by a number of medications. The most debilitating taste disorders are those in which a persistent, often chronic, bad taste is present, such as a bitter or salty taste. The causes of these taste disorders are poorly understood, although they usually appear later in life. In addition to dental and oral health considerations (eg, the presence of certain metals in oral appliances, purulent discharge from infected teeth or gums), viruses, physical damage to one or more taste nerves, and various medicines may be the cause. Among offending medicines are lipid reducing agents, antibiotics, antihypertensives, anxiolytics, and antidepressants.

Need for Touch

Touch is the first sense that babies develop in the womb and is necessary for the continued physical and emotional development of humans. Studies have shown that children deprived of human touch were more likely to become aggressive and violent than children raised with a loving and nurturing parent. Massage therapy has been shown to be beneficial in reducing anxiety and decreasing episodes of defiance in adolescents with behavioral disorders.

The skin is the largest organ in the body and is the sense that remains most intact as we age. Touch therapy has been shown to ease the aches, pains, and stress of older adults. Since many older adults, especially those in nursing homes, may be touch deprived, appropriate physical contact can provide reassurance as well as a greater sense of safety and security (Casciani, 2008).

Sleep Changes

Sleep needs change over a person’s lifetime. Children and adolescents need more sleep than adults. Older adults need about the same amount of sleep as younger adultsseven to nine hours of sleep per night. However, older adults may get less sleep than they need, often because they have trouble falling asleep. A study of adults over 65 found that 13% of men and 36% of women take more than 30 minutes to fall asleep.

There are many possible explanations for these changes. Older adults may produce and secrete less melatonin, the hormone that promotes sleep. They may also be more sensitive toand may awaken because ofchanges in their environment, such as noise. Older adults may also have other medical and psychiatric problems that can affect their nighttime sleep. Researchers have noted that people without major medical or psychiatric illnesses report better sleep.

Not sleeping well can lead to a number of problems. Older adults who have poor nighttime sleep are more likely to have depressed mood, attention and memory problems, excessive daytime sleepiness, more nighttime falls, and use more over-the-counter or prescription sleep aids. Poor sleep is also associated with a poorer quality of life.

Insomnia

Insomnia is the most common sleep complaint at any age. It affects almost half of adults 60 and older. Any one or a combination of the following symptoms may indicate insomnia:

  • Taking a long timemore than 30 to 45 minutesto fall asleep.
  • Waking up many times each night.
  • Waking up early and being unable to get back to sleep.
  • Waking up feeling tired, and unable to function well during the day.

Disorders that cause pain or discomfort during the night such as heartburn, arthritis, menopause, and cancer also can interfere with sleep. Medical conditions such as heart failure and lung disease may make it more difficult to sleep through the night.

Neurologic conditions such as Parkinson’s disease and dementia are often a source of sleep problems, as are psychiatric conditions, such as depression. Although depression and insomnia are often related, it is currently unclear whether one causes the other.

Many older people also have habits that make it more difficult to get a good night’s sleep. They may nap more frequently during the day or may not exercise very much. Spending less time outdoors can reduce exposure to sunlight and upset the circadian biologic clock and sleep cycle. Drinking too much alcohol or caffeine can delay falling asleep or staying asleep.

Also, as people age, their sleeping and waking patterns tend to change. Older adults usually become sleepier earlier in the evening and wake up earlier in the morning. If they don’t adjust their bedtimes to these changes, they may have difficulty falling and staying asleep.

Many older adults take a variety of medications that may negatively affect sleep. Many medications have side effects that can cause sleepiness or affect daytime functioning.

Sleep-Disordered Breathing

Sleep apnea and snoring are two examples of sleep-disordered breathingconditions that make it more difficult to breathe during sleep. When severe, these disorders may cause people to wake up often at night and be drowsy during the day.

Snoring is a very common condition, affecting nearly 40% of adults. It is more common among older people and those who are overweight. When severe, snoring not only causes frequent awakenings at night and daytime sleepiness but it can also disrupt a bed partner’s sleep.

There are two kinds of sleep apnea: obstructive sleep apnea and central sleep apnea. Often, both types of sleep apnea occur in the same person.

  • Obstructive sleep apnea occurs when air entering from the nose or mouth is either partially or completely blocked, usually because of obesity or extra tissue in the back of the throat and mouth. If these episodes occur frequently or are severe, they may cause a person’s sleep to be fragmented throughout the night. This may result in their being sleepy during the day.
  • Central sleep apnea is less common. It occurs when the brain doesn’t send the right signals to start the breathing process.

Obstructive sleep apnea is more common among older adults and among people who are significantly overweight. Obstructive sleep apnea can increase a person’s risk for high blood pressure, stroke, heart disease, and cognitive problems. However, more research is needed to understand the long-term consequences of obstructive sleep apnea in older adults.

Movement Disorders

Two movement disorders that can make it harder to sleep include restless legs syndrome, or RLS, and periodic limb movement disorder, or PLMD. Both of these conditions cause people to move their limbs when they sleep, leading to poor sleep and daytime drowsiness. Often, both conditions occur in the same person.

Restless legs syndrome is a common condition in older adults and affects more than 15% of people 80 years and older. People with RLS experience uncomfortable feelings in their legs such as tingling, crawling, or pins and needles that are alleviated by moving the leg. This often makes it hard for them to fall asleep or stay asleep, and causes them to be sleepy during the day.

Periodic limb movement disorder, or PLMD, is a condition that causes people to jerk and kick their legs every 20 to 40 seconds during sleep. As with RLS, PLMD often disrupts sleepnot only for the patient but the bed partner as well. One study found that roughly 40% of older adults have at least a mild form of PLMD.

Insomnia interventions include:

  • Limit excessive noise and light in the sleep environment.
  • Limit time spent in bed while not sleeping, and use bright lights to help with circadian rhythm problems. Circadian rhythm is our 24-hour internal body clock, which is affected by sunlight.
  • Relaxation techniques also may help to reduce physical and emotional tensions that can interfere with sleep.
  • There are cognitive therapies aimed at changing attitudes and concerns people may have about insomnia and not being able to sleep well.
  • Medications also can be useful early in treatment and, if necessary, can be used from time to time for difficulty falling asleep.
  • People who are diagnosed with sleep apnea should try to lose weight if possible, but often they may need other treatments as well. Adjusting the body position during the night may be of benefit if sleep apnea occurs more often while lying on the back.

Medical interventions include:

  • Nasal continuous positive airway pressure (CPAP) is the most effective and popular treatment for sleep apnea. This device keeps air passages open by supplying a steady stream of air pressure through the nose during sleep.
  • Dental devices may be used for mild cases of sleep apnea.
  • Surgery to increase the airway size in the mouth and throat can be used in severe conditions.

People who suffer from movement disorders during sleep such as restless legs syndrome or periodic limb movement disorder are often successfully treated with the same medications used for Parkinson’s disease. People with restless leg syndrome often have low levels of iron in their blood and may benefit from supplements.

Sleeping Well

Older adults with sleep problems should follow a regular schedule of bed and waking times to stay in sync with the body’s circadian clock and try to avoid napping during the day. Regular exercise at the same time every day, at least 3 hours before bedtime, is also helpful.

Drinks with caffeine should not be consumed late in the day. Even small amounts of alcohol before bedtime can make it harder to stay asleep. Smoking is dangerous for many reasons, including the hazard of falling asleep with a lit cigaretteand the nicotine in cigarettes is a stimulant.

A safe and comfortable place to sleep is important. Make sure there are locks on all doors and smoke alarms on each floor. The room should be dark, well ventilated, and as quiet as possible.

A bedtime routine tells the body that it is time to wind down. Some people watch the evening news, read a book, or soak in a warm bath. The bedroom should be used only for sleeping. After turning off the light, allow about 15 minutes to fall asleep. If unable to sleep and not drowsy after 15 minutes, a person needs to get out of bed and then return to bed when sleepy.

Psychosocial Changes

Loss

All older adults experience loss with agingloss of social status and self-esteem, loss of physical capacities, and the death of friends and loved ones.

The loss of a spouse is common in late life. About 800,000 older Americans are widowed each year and bereavement is a natural response to the death of a loved one. The death of a spouse can also result in financial difficulties and loss of social contacts. Its features, almost universally recognized, include crying and sorrow, anxiety and agitation, insomnia, and loss of appetite (Moen et al., 2000).

The losses experienced by older adults often occur over short periods of time. Experiencing more than one loss at a time or over a short period of time can cause prolonged grieving. An older people who experience loss may feel numb and overwhelmed and may also lack the support systems they once had. But, in the face of loss, many older people have the capacity to develop new adaptive strategies, even creative expression. Those experiencing loss may be able to move in a positive direction, either on their own, with the benefit of informal support from family and friends, or with formal support from mental health professionals.

Social Roles

Social roles are important components of self-concept. Older adults face many challenges, including the loss of careers, loss of family members and friends, changes in physical and mental abilities, difficulties in accessing affordable and high quality healthcare, decreased financial security, and decreasing opportunities to remain engaged in society (Cornwell, 2008).

Remaining socially integrated in society has many benefits for the older adult. Although the oldest old have a smaller social network, they tend to have more contact with the core group. Social networks are important for older adults because they provide resourcessuch as access to information and other resourcesthat are crucial for successful aging and social support (Cornwell, 2008).

As people age they may become more dependent on family members for care and support and adult children may feel that there has been a role reversal, concerned that they have become their parent’s parent. But it is difficult for an older adult to give up a lifetime of independence and, like any other adult, they want their decisions to be respected. It is important, even with an older person who has dementia, to make collaborative decisions about care, living arrangements, and outside help when needed.

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