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An overview of the effects of aging and appropriate responses to the issues arising from advancing age.
ATrain Education, Inc. is an approved provider by the American Occupational Therapy Association. The following course information applies to occupational therapy professionals:
Accredited status does not imply endorsement by ATrain Education Inc. or by the American Nurses Credentialing Center or any other accrediting agency of any products discussed or displayed in this course. The planners and authors of this course have declared no conflict of interest and all information is provided fairly and without bias.
No commercial support was received for this activity.
This course will be reviewed every two years. It will be updated or discontinued on December 1, 2021.
Criteria for Successful Completions
80% or higher on the post test, a completed evaluation form, and payment where required. No partial credit will be awarded.
ATrain Education, Inc. is approved as a provider by California Board of Registered Nursing (#CEP15099).
ATrain Education, Inc. is approved provider by the Florida Board of Nursing (#50-10593).
ATrain Education, Inc. is approved as a provider of continuing nursing education by the Washington D.C. Board of Nursing.
ATrain Education, Inc is recognized by the Physical Therapy Board of California as an approved reviewer and provider of continuing competency and continuing education courses for physical therapists and physical therapy assistants in the state of California.
ATrain Education, Inc. is recognized by the New York State Education Department's State Board for Physical Therapy as an approved provider of Physical Therapy and Physical Therapy Assistant continuing education.
ATrain Education Inc. is approved as a provider of continuing education by the Florida Board of Occupational Therapy.
This course is accepted by the Georgia State Board of Physical Therapy.
When you finish this course you will be able to:
Human populations continue to age at an impressive rate. In 1900 only 1% of the earth’s population—15 million persons—was older than 65 years of age. By the year 2050 these figures will have risen to 20% and 2.5 billion, respectively.
The growth in the number and proportion of older adults is unprecedented in the history of the United States. Two factors—longer life spans and aging baby boomers—will combine to double the population of Americans aged 65 and older during the next two decades. Improved medical care and prevention efforts have contributed to these dramatic increases in life expectancy over the past century. Every day in America about 10,000 people turn 65, and by 2030 older adults will comprise about one-fifth of the U.S. population (CDC, 2007).
The growth of the population age 65 and over affects many aspects of our society, challenging policymakers, families, businesses, and healthcare providers to meet the needs of aging individuals. Improving the health status and addressing the needs of this age group should be a top priority of American healthcare (Federal Interagency Forum on Aging-Related Statistics, 2010).
Source: AOA, 2011a.
The demographics of aging continue to change dramatically. The older population is growing rapidly and the aging of the baby boomers (born between 1946 and 1964) is accelerating this growth. The older population in 2030 is expected to be twice as large as in 2000, growing from 35 to 71 million and representing nearly 20% of the total U.S. population (Interagency Forum, 2010).
In 2009 older adults accounted for more than 1 in every 8 Americans. There were roughly 23 million older women and 17 million older men—a ratio of 135 women for every 100 men. The female to male ratio increases with age, to a high of 216 women for every 100 men in the 85 and over age group (AOA, 2011b).
Since 1900 the percentage of Americans aged 65 and above has more than tripled, and the older population itself is increasingly older. In 2008 the group of older adults:
Living to 100 is becoming more commonplace. In 1950 there were approximately three thousand centenarians in the United States. By 2009 there were more than 64,000 persons aged 100 or more and by 2050 there could be nearly 1 million American centenarians (AOA, 2011b).
This larger population of older Americans will be better educated than previous generations. In 1965 less than one-quarter of the older population had graduated from high school, and only 5% had at least a bachelor’s degree. By 2008, 77% had at least a high school diploma, and 21% had a bachelor’s degree or more (Interagency Forum, 2010).
Older Americans are becoming a more diverse population. Racial and ethnic minorities are the fastest growing segment of the older population and their numbers are projected to increase to about 40% by 2050. The population of older Asians is projected to double and the population of older Hispanics is projected to triple by 2050 (Fritz, 2005).
American attitudes about aging have been influenced by many years of television and movies celebrating youth and beauty. Aging is increasingly viewed as a social issue rather than a natural process. In the media, generally, older adults seem to be left out of the picture or are not seen as useful members of the family. They are often characterized as asexual, slow-thinking, chronically ill, and burdens on society (Life in the USA, 2010). These stereotypes of older Americans have resulted in the perception by society and by older adults themselves that they have less value than younger people.
Rather than assuming roles as leaders in their communities, as in some countries, the older adults in American society become invisible. Talents and experience gained after many years of work in their chosen fields are no longer valued. Instead, “they waste their prodigious talents traveling, entertaining, socializing, watching TV, or playing golf. And, unlike other cultures, older Americans often abandon themselves to control by other people, often their children and their healthcare providers” (Day, 2012). Capable and experienced older adults may be forced into retirement or feel pressured to retire at the height of their careers, causing economic hardship for them and their families.
Ageism—prejudicial behavior that treats people unfairly because of their age—leads to stigmatization and marginalization. It can inflict psychological and emotional abuse on older adults. Reaction to age discrimination may be acceptance, denial, or avoidance. Those who accept the stereotypes may become apathetic or depressed and withdraw from society. Those who deny the stereotypes may try to fight age with hair color, youthful clothing, and plastic surgery.
Although recent trends in the United States show improvements in functional health, increased levels of disability remain a major public health problem, especially in later life. Those adults with health risk factors such as being overweight, smoking, and having alcohol problems, as well as those with chronic health conditions, are more likely to have poor functional health (Lachman and Agrigoroaei, 2010).
There is increasing evidence that specific psychological, social, and physical protective factors are associated with better health in later life. Among these factors, control beliefs, social support, and physical exercise are consistently identified as predictors of functional health. Moreover, a variety of studies have shown that control beliefs, social support, and physical exercise are modifiable and thus can be subject to interventions to reduce disability and improve functional health (Lachman and Agrigoroaei, 2010).
Control beliefs involve the perception that we can influence what happens in our life and to what extent our actions can bring about desired outcomes such as good health. It includes beliefs or expectations about one’s abilities and perceptions about external constraints. Stronger beliefs about control over outcomes are associated with better reported health, fewer and less severe symptoms, faster recovery from illness, and higher functional status. Control beliefs show a pattern of decline in adulthood, making older adults more vulnerable in terms of expectancies about their ability to affect their health. The sense of control is related to functional health, in part, because those who have a higher sense of control are more likely to engage in health-promoting behaviors, such as exercising and eating a healthier diet (Lachman and Agrigoroaei, 2010).
Social interactions involve a combination of supportive and stressful experiences. High quality social relationships are those in which support is relatively high and strain relatively low. Social support is associated with health, in that those who are socially embedded and experience positive relationships are better off than those who are isolated or involved in strained or stressful relationships. There is also longitudinal evidence for the relationship between positive social exchanges and patterns of physical disability, and socially vulnerable elders are more likely to show disability, frailty, and higher mortality risk. The mechanisms that have been considered include physiologic factors such as stress hormones, immune functioning, and inflammatory processes that may be exacerbated for those with low social support or social isolation. Moreover, those who have supportive relationships are more likely to reap the benefits of a more active, engaged, and healthy lifestyle (Lachman and Agrigoroaei, 2010).
The benefits of physical exercise for health are widely documented. Those who engage in regular exercise are likely to reduce or avoid disability due to the positive effects on, for example, cardiovascular and pulmonary functioning, bone density, and muscle mass. Nevertheless, exercise maintenance is challenging and the long-term benefits of exercise interventions have not been conclusively demonstrated (Lachman and Agrigoroaei, 2010).
Health disparities are preventable differences in the burden of disease, injury, and violence, or in opportunities to achieve optimal health, experienced by socially disadvantaged racial, ethnic, and other population groups and communities. Health disparities exist in all age groups, including older adults. Although life expectancy and overall health have improved in recent years for most Americans, not all older adults are benefiting equally due to factors such as economic status, race, gender, and sexual orientation (CDC, 2011a).
Health disparity is defined as “a particular type of health difference that is closely linked with social, economic, or environmental disadvantage.” Health disparities adversely affect groups of people who have systematically experienced greater obstacles to health—based on their racial or ethnic group, religion, socioeconomic status, gender, age, mental health, cognitive, sensory, or physical disability, sexual orientation or gender identity, geographic location, or other characteristics historically linked to discrimination or exclusion (HealthyPeople.gov, 2011).
Although America’s older adult population is becoming more racially and ethnically diverse, the health status of racial and ethnic minorities lags far behind that of non-minority populations. The burden of many chronic diseases and conditions—especially high blood pressure, diabetes, and cancer—varies widely by race and ethnicity.
Aging encompasses an intricate web of interdependent genetic, biochemical, physiologic, economic, social, and psychological factors, some of which are better understood than others. A society’s ability to reduce the burden of illness among older adults depends on an increased understanding of the dynamics of aging and how health is affected by environmental and lifestyle factors (NIA, 2010a).
Socioeconomic circumstances and the places people live and work strongly influence their health. In the United States, as elsewhere, the risk for mortality, morbidity, unhealthy behaviors, reduced access to healthcare, and poor quality of care increases with decreasing socioeconomic circumstances (MMWR, 2011).
Because vulnerable populations are more likely than others to be affected adversely by economic recession, the recent downturn in the global economy has worsened health disparities throughout the United States. If the coverage and effectiveness of safety-net and targeted programs do not keep pace with needs, these disparities will only worsen.
A recent CDC report (MMWR, 2011) on health disparities in the United State noted these key points about health disparities:
During the two decades from 1980 to 2000, the U.S. population became steadily older and more ethnically diverse. There are approximately 14 million elder Hispanics, 8.6 million elder African/African-Americans, and 5.8 million elder adults from other racial and ethnic groups (NIA, 2010a). From 1992 to 2005, household income inequality has increased significantly.
Although the combined effects of these changes on health disparities are difficult to assess, the nation is likely to continue experiencing substantial racial, ethnic, and socioeconomic health disparities, even though overall health outcomes are improving for the nation (MMWR, 2011).
Differences in health—based on race, ethnicity, sexual orientation, or economics—can be reduced, but will require public awareness and understanding of which groups are most vulnerable, which disparities are most correctable through available interventions, and whether disparities are being resolved over time. These problems must be addressed with intervention strategies related not only to health and social programs but also, more broadly, to access to economic, educational, employment, and housing opportunities. The combined effects of programs universally available to everyone and programs targeted to communities with special needs are essential to reduce disparities (MMWR, 2011).
By 2019 the Hispanic population aged 65 and older is projected to be the largest racial/ethnic minority in this age group. In 2007 about 7.5% of Hispanic elders reported that they had no usual source of medical care. In 2000, 6.5% reported delays in obtaining healthcare due to cost, and in 2001, 20.7% reported that they were not satisfied with the quality of the healthcare they received. The comparable figures for the total population aged 65 or older show that 5.1% reported that they had no usual source of medical care, 4.8 percent reported delays in obtaining healthcare due to cost, and in 2001, 15.6% reported that they were not satisfied with the quality of the healthcare they received (AOA, 2010a).
Older Hispanic American Access to Medical Care
No usual source of medical care
Delays in obtaining healthcare due to cost
Not satisfied with the quality of healthcare received
Older Hispanic adults
Total population of older adults
Older adults who are members of racial and ethnic minorities living in the community are less likely to be diagnosed with depression than their white counterparts, or, when diagnosed, less likely to get treated (NIMH, 2012). In a recent study, about 6.4% of whites, 4.2% of African Americans, and 7.2% of Hispanics were diagnosed with depression. Among those diagnosed, 73% of whites received treatment (with antidepressants, psychotherapy, or both) while 60% of African Americans received treatment and 63.4% of Hispanics received treatment (NIMH, 2012). These kinds of diagnosis and treatment differences are consistent with previous studies. Researchers noted pronounced differences in socioeconomic status and quality of insurance coverage across ethnicities. Fewer whites reported having low incomes than ethnic minorities. However, these differences did not appear to account for the disparities in diagnosis or treatment rates.
Diagnosis and Treatment of Depression
Diagnosed with depression
Older Hispanic American adults
Older African American adults
Older white adults
In another study, Texas researchers examined the post-hospital care of 34,203 patients hospitalized for hip fracture between 2001 and 2005. All were aged 65 or older (mostly women) and on Medicare. The racial breakdown was 95.3% whites, 3.5% African Americans, and 1.3% Hispanics. The majority of patients (60.1%) were discharged to a skilled nursing facility or inpatient rehabilitation facility (23.5%). Fewer patients were discharged home to a home healthcare organization or outpatient therapy (5.8%), home to self-care (6.2%), or other environment (4.4%). Hispanics were nearly three times as likely to be discharged home to self-care as whites (16.4% vs. 5.9%). African Americans had nearly 50% higher odds of being discharged home to self-care than whites (8.7% vs. 5.9%) (AHRQ, 2009).
Post Hospital Care Following Hip Fracture
Discharged to home
The researchers offer some possible explanations as to why these higher rates of discharge home occur among minorities. First, minorities tend to have larger families with younger members who can care for older relatives. Also, minorities tend to have less favorable perceptions of rehabilitation facilities than do the family members of white patients (AHRQ, 2009).
Households containing families headed by African Americans aged 65 and older reported a median income in 2008 of about $35,000 compared to about $44,000 for all older households. The poverty rate in 2008 for African American elders was 20%, which was more than twice the rate for all older adults. Nonetheless, the 20% figure represents a significant decline from a 48% poverty rate for older African Americans in 1968 (AOA, 2010b).
In the years 2006 to 2008, 96% of African American elders reported that they had a usual source of care. Only 16% reported (in 2003) that they or a family member was unable to obtain or was delayed in receiving needed medical care. In 2008, 34% of African American elders had both Medicare and supplementary private health insurance, while 54% of all older adults had both Medicare and supplementary private health insurance (AOA, 2010b).
According to the American Heart Association, African Americans are less likely than whites and Hispanics to receive evidence-based stroke care (AHA, 2010). According to the AHA, African Americans were:
[This section is taken from healthypeople.gov, 2011.]
Lesbian, gay, bisexual, and transgender (LGBT) individuals encompass all races and ethnicities, religions, social classes, and ages. Sexual orientation and gender identity questions are not asked on most national or state surveys, making it difficult to estimate the number of LGBT individuals and their health needs.
Research suggests that LGBT individuals face health disparities linked to societal stigma, discrimination, and denial of their civil and human rights. Discrimination against LGBT people has been associated with high rates of psychiatric disorders, substance abuse, and suicide.
Experiences of violence and victimization are frequent for LGBT individuals and have long-lasting effects on the individual and the community. Personal, family, and social acceptance of sexual orientation and gender identity positively affects their mental health and personal safety.
Eliminating health disparities and enhancing efforts to improve health are necessary to ensure that LGBT individuals can lead long, healthy lives. The many benefits of addressing health concerns and reducing disparities include:
Efforts to improve LGBT health include:
Efforts to address health disparities among LGBT persons include:
The number of people aged 50 years and older living with HIV/AIDS has been increasing in recent years. This increase is partly due to antiretroviral therapy (HAART, which has made it possible for many HIV-infected persons to live longer) and partly to newly diagnosed infections in persons over the age of 50. As the population continues to age, it is important to be aware of specific challenges faced by older Americans and to ensure that they get information and services to help protect them from infection (CDC, 2008a).
In 2005 people aged 50 and older accounted for:
People over the age of 50 have many of the same risk factors for HIV infection as younger people. Many older people are sexually active—but may not be practicing safe sex to reduce their risk for HIV infection. Older women may be especially at risk because age-related vaginal thinning and dryness can cause tears in the vaginal area. HIV transmission through injection drug use accounts for more than 16% of AIDS cases among people aged 50 and older (CDC, 2008a).
Some older adults are less knowledgeable than younger people about HIV/AIDS and therefore less likely to protect themselves. Many do not perceive themselves as at risk for HIV, do not use condoms, and do not get tested for HIV. Older adults of minority races and ethnicities may face discrimination and stigma that can lead to delayed testing, diagnosis, and reluctance to seek services.
Healthcare professionals may underestimate their older patients’ risk for HIV/AIDS and may miss opportunities to deliver prevention messages, offer HIV testing, or make an early diagnosis that could help their patients get early care. In addition, physicians may miss a diagnosis of AIDS because some symptoms such as fatigue, weight loss, and mental confusion can mimic those of normal aging. Early diagnosis, which typically leads to the prescription of HAART and to other medical and social services, can improve a person’s chances of living a longer and healthier life (CDC, 2008a).
The stigma of HIV/AIDS may be more severe among older people, leading them to hide their diagnosis from family and friends. Failure to disclose HIV infection may limit or preclude potential emotional and practical support.
Stigma is founded on fear and misinformation. Theodore de Bruyn observed that stigma is associated with HIV/AIDS because “It is a life-threatening disease; people are afraid of contracting HIV; it is associated with behaviors that are considered deviant; [they have] a belief that HIV/AIDS has been contracted through unacceptable lifestyle choices; and, some believe it is the result of a moral fault that deserves punishment” (Bidwell, 2011).
In order to improve medical care for the increasingly older American population, three areas of change are recommended by the National Institutes of Medicine (IOM):
Congress passed the Older Americans Act (OAA) in 1965 to address a lack of community social services for older persons. The original legislation provided grants to states for community planning and social services, research and development projects, and personnel training in the field of aging. The law also established the Administration on Aging (AOA) to administer the newly created grant programs and to serve as the federal focal point on matters concerning older persons (AOA, 2010c).
Although older individuals may receive services under many other federal programs, today the AOA is considered to be the major vehicle for the organization and delivery of social and nutrition services to this group and their caregivers. It authorizes a wide array of service programs through a national network of fifty-six state agencies on aging. The AOA also includes community service employment for low-income older Americans; training, research, and demonstration activities in the field of aging; and vulnerable-elder rights protection activities. The most recent reauthorization of the AOA was in 2006 (AOA, 2010c).
The Program of All-Inclusive Care for the Elderly (PACE) is authorized by the Balanced Budget Act of 1997 (BBA) that features a comprehensive service delivery system and integrated Medicare and Medicaid financing. PACE is a capitation system that pays a set amount of money for each enrolled person to that person’s assigned physician. Payment is based on the average calculated healthcare utilization of that person (whether or not the service is used) over a certain period of time. It is designed to keep patients in the community as long as medically, socially, and financially possible (medicaid.gov, n.d.).
The program is modeled on the system of acute and long-term care services developed by On Lok Senior Health Services in San Francisco, California. The PACE model was developed to address the needs of long-term care clients, providers, and payers. For most participants, the comprehensive service package permits them to continue living at home while receiving services rather than be institutionalized. Capitated financing allows providers to deliver all the services participants need rather than be limited to those reimbursable under the Medicare and Medicaid fee-for-service systems (medicaid.gov, n.d.).
All PACE centers include adult daycare that is made up of nursing, physical, occupational and recreational therapies, meals, nutritional counseling, and personal care. A PACE-employed physician oversees all primary care. A dentist, audiologist, optometrist, podiatrist, and speech therapist may also be on staff. All prescription and non-prescription medications are paid for by PACE, and home healthcare (as well as social services, respite care, and hospital and nursing home care) is coordinated from the site (Larson, 2002).
Participants must be at least 55 years old, live in the PACE service area, and be certified as eligible for nursing home care by the appropriate state agency. The PACE program becomes the sole source of services for Medicare and Medicaid eligible enrollees (medicaid.gov, n.d.).
An interdisciplinary team, consisting of professional and paraprofessional staff, assesses participants’ needs, develops care plans, and delivers all services (including acute care services and, when necessary, nursing facility services) which are integrated for a seamless provision of total care. PACE programs provide social and medical services primarily in an adult daycare center, supplemented by in-home and referral services in accordance with the participant’s needs. The PACE service package must include all Medicare and Medicaid covered services, and other services determined necessary by the interdisciplinary team for the care of the PACE participant. PACE providers assume full financial risk for participants’ care without limits on amount, duration, or scope of services (medicaid.gov, n.d.).
The majority of older adults receive healthcare in primary care settings, yet many fail to receive the recommended standard of care for preventive services, chronic disease management, and geriatric syndromes. The GRACE model of primary care for low-income seniors and their primary care physicians (PCPs) was developed to improve the quality of geriatric care in order to optimize health and functional status, decrease excessive healthcare use, and prevent long-term nursing home placement (PubMed.gov. 2006).
The catalyst for the intervention is the GRACE support team, consisting of a nurse practitioner and a social worker. Upon enrollment, the GRACE support team meets with patients in their home to conduct an initial comprehensive geriatric assessment. The support team then meets with the larger GRACE interdisciplinary team (including a geriatrician, pharmacist, physical therapist, mental health social worker, and community-based services liaison) to develop an individualized care plan, including activation of GRACE protocols for evaluating and managing common geriatric conditions (PubMed.gov, 2006).
The GRACE support team then meets with the patient’s PCP to discuss and modify the plan. In collaboration with the PCP, and remaining consistent with the patient’s goals, the support team then implements the plan. With the support of an electronic medical record and longitudinal tracking system, the GRACE support team manages and coordinates care across multiple geriatric syndromes, providers, and sites of care (PubMed.gov, 2006).
The huge cost of putting older Americans in nursing homes and other institutional settings is not affordable in this time of economic hardship and tight resources. Although there have been billions of dollars spent to provide medical care to older Americans, there have been almost none spent to keep them healthy and living independently in their homes (Moeller, 2011).
Virtual villages help older adults age in place. The villages, scattered around the United States, are membership-driven communities open to older people residing in a particular service area. Begun in Boston in 2001, there are currently 65 “villages” nationwide and 120 more in development. The villages are volunteer-driven and are “meant to help seniors continue to live in their homes by delivering a multitude of services they no longer can do for themselves and to help them stay engaged through social events” (Bohan, 2011).
Services may include a range of low-cost home, medical, shopping, social services and activities to senior members. There are yearly dues ranging from $35 to $900 with many offering discounted rates. The villages often serve middle- or upper-middle-class older adults who may fall through the cracks of the American healthcare system (Bohan, 2011).
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 gain—and, over 10 years, a 50-pound weight gain (Benardot, 2005).
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.
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:
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
Other systemic hormones
Growth hormone/insulin-like growth factor
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:
The FDA has reported that the optimal duration of bisphosphonates treatment for osteoporosis is unknown—an 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 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 adults—including 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 concerns—including heart disease or arthritis—often 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 exercises—when done properly and through the full range of motion—increase 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):
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).
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 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.
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.).
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).
[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:
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:
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:
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 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 movement—such as stroke, arthritis, and spinal cord injuries—can 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:
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.
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.
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 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:
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 fats—low blood levels of LDL cholesterol and high blood levels of HDL cholesterol—there 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.
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:
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 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:
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).
[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.
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.
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.
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 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 infections—infections that develop suddenly—can 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).
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:
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).
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.
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).
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:
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).
The digestive system is made up of the digestive tract—a series of hollow organs joined in a long, twisting tube from the mouth to the anus—and 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.
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:
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 juice—at least three 12-oz glasses of water each day unless medically contraindicated—and 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).
Up to 40% of older adults experience some kind of gastrointestinal symptoms (McLaughlin, 2010).
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 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 noise—a 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).
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).
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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).
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).
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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.
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).
Source: NIH, n.d.
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 retina—the 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).
Normal vision and vision impaired by diabetic retinopathy. Source: NEI, NIH, n.d.
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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 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, savory—and 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.
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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.
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 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 adults—seven 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 to—and may awaken because of—changes 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 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:
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 apnea and snoring are two examples of sleep-disordered breathing—conditions 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 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.
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 sleep—not 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:
Medical interventions include:
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.
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 cigarette—and 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.
All older adults experience loss with aging—loss 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 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 resources—such as access to information and other resources—that 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.
Medication management is a challenge when caring for older adults. More than 90% of those 65 or older use at least one medication per week, 40% take five or more, and 12% use ten or more (Gurwitz, 2004). Medication-related problems are expensive—and deadly. In the United States, nearly 30% of all hospital admissions are older adults who have taken their medications improperly. Each year in the United States, medication-related problems account for 200,000 deaths and cost about $200 billion (Zagaria, 2006).
Older adults are at especially high risk for experiencing medication-related problems because of their high rate of medication use, age-related changes in physiology, sensitivity to medications, and polypharmacy.
Proper use of medications is critical to cost-effective disease management. As the number of older adults increases, healthcare professionals must spend more time evaluating medication regimens.
The decline of cognitive health—from mild cognitive decline to dementia—can have profound implications for an individual’s health and well-being. Limitations with the ability to manage medications and existing medical conditions effectively are particular concerns when an individual is experiencing cognitive decline or dementia.
Polypharmacy describes the use of multiple medications at one time, including over-the-counter (OTC) medications, dietary supplements, and herbal remedies. Polypharmacy includes prescribing more medications than are clinically indicated, using inappropriate medications, and using the correct medication for an inappropriate length of time (Lococo and Staplin, 2006; Pugh et al., 2005).
Polypharmacy significantly increases medication non-adherence, medication errors, adverse drug reactions, and drug-drug, drug-food, and drug-disease interactions. Cognitively impaired older adults, those who live alone, and those seeing multiple prescribers are especially at risk. Many of the drugs classified as potentially inappropriate for older adults offer little or no advantage over other, safer drugs, and some have a long half-life in older patients (Lococo and Staplin, 2006).
Drug metabolism is often impaired in older adults due to decrease in glomerular filtration rate and reduced hepatic clearance. Changes in body composition—a decrease in total body water and an increase in body fat—means water-soluble drugs become more concentrated and fat-soluble drugs have longer half-lives (CMDT, 2011).
Older adults currently make up about 13% of the American population but receive 34% of all prescriptions and consume 40% of all nonprescription medications (U.S. Census Bureau, 2010). The average person over the age of 65 takes twice as many medications as a younger person and this age group is the largest consumer of prescription and nonprescription medications in the United States. The use of prescription and nonprescription medications among this group has more than doubled since 1990 (Bushardt, 2008).
The classes of drugs most commonly associated with adverse drug reactions in older adults include diuretics, warfarin, nonsteroidal anti-inflammatory drugs (NSAIDs), selective serotonin reuptake inhibitors (SSRIs), beta blockers, and angiotensin-converting enzyme inhibitors (ACEI).
Because older adults often manage a number of chronic illnesses with medications, it is critical that medications be essential and taken as prescribed. Healthcare providers should determine if their patients are able to manage their medication regiment successfully once they leave the hospital or clinic.
In the home, medication management systems range from the methodical to the inventive. Some who have difficulty opening medication bottles utilize the “candy dish” method—dumping multiple medications into a bowl and fishing out the appropriate medication at the scheduled time. Some store medications in shopping bags or shoeboxes while others carefully fill medi-sets weeks in advance.
When financial resources are stretched, one common strategy is to extend medications by creative self-administration strategies. People with low income, inadequate prescription drug coverage, and high-cost medications are likely to stretch out their medication supply by skipping doses or extending the interval between doses.
Others may take a smaller dose (split tablets or take one when multiple tablets are prescribed) or substitute an OTC or herbal alternative. Taking a lower-than-prescribed dose is especially prevalent in patients with multiple medical conditions who are using many medications, those prone to medication side effects, and people who resist prescribed treatment due to personal or cultural beliefs. Adverse drug events can result from errors in prescribing or administering medication or patient noncompliance. In older adults, lower initial doses should be used and upward titration done at a slower rate than in younger patients. If there is renal failure, dosages for drugs that are renally excreted needs to be adjusted (Bergman-Evans, 2004).
The following recommendations are made to improve medication management in older adults.
1. Reduce Inappropriate Prescribing
A number of studies have looked at methods to reduce inappropriate prescribing for older adults. Evidence supports the following practice guidelines:
Recommended for prescribers:
2. Decrease Polypharmacy
Inappropriate prescribing and polypharmacy are closely linked. Evidence suggests that both can be reduced by up to 25% by utilizing a pharmacist to review the patient’s chart and medication list (Garcia, 2006).
Other recommendations include:
3. Avoid Adverse Events
An adverse drug event (ADE) is defined as “an injury resulting from the use of a drug.” Adverse drug events include “expected adverse drug reactions (or side effects) as well as events due to errors.” Adverse drug events due to errors are, by definition, preventable (Lococo and Staplin, 2006).
Adverse events can be categorized as fatal, life-threatening, serious, or significant. Events resulting in permanent disability included stroke, intracranial bleeding events, hemorrhagic injury to the eye, and drug-induced pulmonary injury. Deaths in one study were related to fatal bleeding, peptic ulcers, neutropenia/infection, hypoglycemia, drug toxicity related to lithium or digoxin, anaphylaxis, and complications of antibiotic-associated diarrhea (Lococo and Staplin, 2006).
Adverse drug events can result from errors in prescribing, administration, or patient noncompliance. In older adults, lower initial doses should be used and upward titration done at a slower rate than in younger patients. If there is renal failure, dosages for drugs that are renally excreted should be adjusted (Bergman-Evans, 2004).
The most common types of preventable adverse drug events include:
The most common medication categories associated with preventable adverse drug events include:
4. Maintain Functional Status
Older adults have good functional status when they are able to successfully and safely perform all the activities needed for daily living. A decline in functional status is a good indicator of a person’s overall health.
Functional decline can occur gradually or abruptly following an illness, injury, or personal loss. Determining the functional status includes a thorough assessment of an individual’s ability to perform basic activities such as dressing, bathing, grooming, and transferring and instrumental activities such as cooking, shopping, medication management, and other high-level cognitive tasks. Balance, postural control, and mobility are also essential components of a functional assessment.
Functional decline can be managed and even slowed by encouraging a range of activities:
5. Follow Beers Criteria
In 1991 thirteen nationally recognized geriatrics experts developed what is known as the Beers criteria, named after their colleague, Mark Beers. The researchers developed a list of medications that can lead to adverse drug events or are inappropriate for use in older adults, particularly in nursing home patients. The Beers criteria are commonly used to identify “potentially inappropriate medications” for older adults, meaning the risk may outweigh the benefit.
Zhan and colleagues (2001) refined the Beers list of medications by identifying drugs that should (1) always be avoided (have serious potential effects and alternative medications are available, (2) are rarely appropriate and (3) have indications for use in older patients but are frequently misused. Zhan’s research showed that 21.3% of older Americans received at least one potentially inappropriate drug and 2.6% received an “always avoid” drug.
A number of other studies have identified common medications that are associated with adverse drug events, including diphenhydramine, amitriptyline, and propoxyphene. Pugh and colleagues (2005) implicated pain relievers, benzodiazepines, antidepressants, and musculoskeletal agents as the cause of 61% of the incidents of inappropriate prescribing.
Fick and colleagues (2003) identified two classes of medications considered problematic when used with older adults:
Of particular note are 66 drugs considered to have the potential for severe adverse outcomes when used in older adults (see list that follows).
Medications Potentially Inappropriate for Older Adults
Source: Adapted from Fick et al., 2003.
There are many medications on the questionable list, and research constantly identifies other problematic medications. Deciding when a medication is inappropriate because of medical condition, genetic predisposition, or age is a complex task. Understanding the scope of the problem highlights the importance of being alert to polypharmacy when caring for older adults.
The absorption, distribution, metabolism, and excretion (known commonly as ADME) are important features of any medication and the importance of ADME is heightened in elders.
Medications are absorbed differently in older adults than in younger individuals. Age-related changes can impede absorption due to decreased blood flow to the tissues and the GI tract and changes in gastric pH (Banning, 2007). The use of certain medications can enhance this effect and alter absorption significantly. For example, proton-pump inhibitors (PPIs) such as omeprazole lower gastric pH and may inhibit Vitamin B12 absorption (Dharmarahan et al., 2008). Elders should take PPIs for the least time necessary to ameliorate the condition they are meant to treat. An older adult taking a PPI for a prolonged period of time should have periodic monitoring of vitamin B12 or take supplements.
Chronic illness and age-related variations in plasma proteins may also cause significant problems with medications that are highly protein bound, such as phenytoin and levodopa/carbidopa. Blood levels can vary, especially if food intake and dosing are not consistent. For example, if phenytoin is taken with a high-protein meal, less medication is absorbed because phenytoin binds with the protein in the stomach.
Decreased cardiac output in older adults and those with chronic conditions may reduce subcutaneous and intramuscular drug absorption, thus affecting the pharmacokinetics of injectable medications. Transdermal medications are absorbed through subcutaneous fat, which is reduced with aging (Banning, 2007).
Once a medication is absorbed into the bloodstream, it is distributed throughout the body and exerts both desired and undesired effects. Distribution dynamics can be affected by body weight and body composition, which changes with age. Distribution of a medication is also affected by impaired absorption, which influences its onset, strength, and duration.
In general as we age, total body water and muscle mass decrease while percentage of body fat increases. These changes can lead to drugs having a longer duration of action and increased effect.
Protein binding refers to the amount of medication bound to albumin in the blood. Serum albumin is decreased in older adults, creating unique issues with medications that are highly protein-bound, such as levodopa, warfarin, and phenytoin. Serum albumin is decreased 15% to 20% compared to the levels in healthy younger adults and is perhaps even lower during times of illness (Banning, 2007). If an older adult has low albumin, there is more drug free and active. This is one reason older adults need a lower dose of medication, especially if the drug is highly protein bound.
Following absorption across the gut wall, drug metabolism occurs almost entirely in the liver. With age and chronic illness, liver size and hepatic blood flow are decreased; therefore, dosing of medications that are significantly metabolized by the liver should be adjusted.
Age-related changes in renal function are an important factor in the clearance of drugs from the body. About two-thirds of the population experiences a decline in creatinine clearance with aging. This can lead to a prolonged half-life for many drugs and cause the build-up of toxic levels if the dose and frequency are not adjusted (Katzung, 2007). Renal impairment requires dosage adjustment of medications that are metabolized and excreted by the kidneys. There are two laboratory values commonly used to estimate renal function: creatinine clearance and glomerular filtration rate.
Impairment of cognitive functions presents significant problems for medication management. It is important to prescribe as few medicines as possible and to tailor doses to the person’s personal habits. It is also important to observe the person’s ability to use medication organizers if they are utilized.
Automated computer-based reminding aids, online medication monitoring and telemonitoring may be helpful for patients with mild dementia. Assistance with medication management should be implemented when safety becomes an issue (PubMed.gov, 2008).
According to a 2008 National Survey on Drug Use and Health, about 40% of adults age 65 and older drink alcohol, although most do not have a drinking problem. More men than women tend to abuse alcohol (NIH, 2010).
As people age, they can become more sensitive to alcohol’s effects. Older people metabolize alcohol more slowly than younger people so alcohol stays in the body longer. The amount of water in the body decreases with age and, as a result, older adults have a higher percentage of alcohol in their blood than younger people after drinking the same amount (NIH, 2010).
Heavy drinking over time can damage the liver, the heart, and the brain. It can increase the risk of developing certain cancers, damage muscles, and cause immune system disorders. It can also increase the risk of developing osteoporosis.
Alcohol abuse can worsen pre-existing conditions such as diabetes, high blood pressure, congestive heart failure, liver problems, and memory problems. Mood disorders such as depression and anxiety can also be worsened by alcohol abuse. Adults with major depression are more likely than adults without major depression to have alcohol problems (NIH, 2010).
Mixing alcohol with prescription (and some over-the-counter) medications can cause unintended side-effects such as sleepiness, confusion, dizziness, nausea, vomiting, headaches, and other health problems. Medications that can interact adversely with alcohol include:
Illicit drug use generally declines as individuals move through young adulthood into middle adulthood and maturity, but research has shown that the baby boom generation (people born between 1946 and 1964) has relatively higher drug use rates than previous generations. Higher rates of drug use and abuse may require the doubling of substance abuse treatment services needed for this population by 2020. Substance abuse at any age is associated with numerous health and social problems, but age-related physiologic and social changes make older adults more vulnerable to the harmful effects of illicit drug use (SAMHSA, 2010).
According to a Substance Abuse and Mental Health Services (SAMHSA) report, an estimated 4.3 million adults aged 50 or older (4.7%) used an illicit drug in the past year. In fact, 8.5% of men aged 50 to 54 had used marijuana in the past year (as opposed to 3.9% of women in this age group). The SAMHSA report also shows that marijuana use was more common than nonmedical use of prescription drugs among males 50 and older, (4.2% vs. 2.3%), and among females the rates of marijuana use and nonmedical use of prescription drugs were similar (1.7% and 1.9%) (SAMHSA, 2010).
Although use of illicit drugs is problematic for individuals of all ages, it may be of particular concern for older adults because they experience physiologic, psychological, and social changes that place them at greater risk of harm from illicit drug use. The increasing prevalence and effects of illicit drug use among older adults suggest the need both to better understand illicit drug use among this population and to plan for and develop age-appropriate prevention and treatment services (SAMHSA, 2011).
Marijuana use was more common than nonmedical use of prescription drugs for adults age 50 to 59, but among those aged 65 and older nonmedical use of prescription drugs was more common than marijuana (SAMHSA, 2011).
An estimated 4.8 million adults aged 50 or older, or 5.2%, had used an illicit drug in the past year. The most common illicit drug among older adults was marijuana (3.2%, or 3 million users), followed by nonmedical use of prescription-type drugs (2.3%, or 2.1 million users) (SAMHSA, 2011).
As with younger age groups, effective treatment for older adults begins with accurate screening, assessment, and diagnosis. However, addressing the needs of older adults presents different challenges and requires different strategies. For example, screening and assessment tools designed for younger adults may use criteria not relevant to older adults (eg, the negative impact of substance use on work or school), which calls for the development and use of age-specific tools to properly recognize and diagnose substance abuse problems among older adults (SAMHSA, 2011).
Importantly, age-appropriate screening can help clinicians intervene early and may improve medical care because many health conditions are associated with illicit drug use. In addition, while conducting screenings, clinicians should ask older adults about the specific types of drugs used and the duration of use because these factors tend to affect decisions about appropriate treatment. For example, use of marijuana may be a decades-long experience for some older adults, indicating a different intervention than one that is appropriate for those with an abuse history of a few years (SAMHSA, 2011).
Finally, treatment of older adults must be adjusted to account for the life stage of the individual and the aging process, and should be expanded to settings that are convenient and comfortable, such as retirement communities and senior centers. Also, treatment planning and approaches that include adult children and friends of substance-abusing older adults may be critical to treatment initiation, engagement, and recovery (SAMHSA, 2011).
The U.S. Department of Health and Human Services report, Healthy People 2010, identified health literacy as an important component of health communication, medical product safety, and oral health. In this report, health literacy was defined as “the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.” Nearly 90 million people in the United States have difficulty understanding and using health information. Poor health literacy is a stronger predictor of a person’s health than age, income, employment status, education level, and race (National Network of Libraries of Medicine, 2011).
Health literacy is not simply the ability to read. It requires reading, listening, analytical, and decision-making skills, and the ability to apply these skills to health situations. It includes the ability to understand instructions on prescription drug bottles, appointment slips, medical education brochures, and doctor’s directions and consent forms, and to negotiate complex healthcare systems.
Older adults have documented health literacy problems. In 2003 the first ever national assessment of health literacy was completed as part of a national assessment of adult literacy. The survey found that adults age 65 and older have lower health literacy scores than all other age groups surveyed. Only 3% of the older adults who were surveyed were measured as proficient (DHHS, ND).
Good health literacy includes the ability to:
In order to accomplish these tasks, individuals must be:
Oral language skills are important as well—patients must be able to articulate their health concerns and describe their symptoms accurately. They need to ask pertinent questions and be able to understand spoken medical advice and treatment directions. In an age of shared responsibility between healthcare provider and patient, patients need strong decision-making skills. Increasingly, health literacy also includes the ability to search the Internet and evaluate healthcare websites.
Anyone can have low health literacy, including people with good literacy skills. Even those who have a medical background can have trouble understanding healthcare information at some point in their lives.
Medicines are an important part of treating an illness because they often allow people to remain active and independent. However, medicine can be expensive. Some ideas from the Food and Drug Administration (FDA) to help lower costs include:
Because of age-related physiologic changes, declining health and functional status, and medication use, older adults can incur problems at low levels of alcohol consumption. Estimates of alcohol dependence in the population over the age of 65 range from 1% to 5%, while the prevalence of problem drinking in older adults varies from 10% to 15%. Within the high percentage of adults 65 and older who are admitted to a hospital at least once a year (20% of the population of this age), 20% to 50% who entered the hospital for non-alcohol or other drug-related problems were identified as having such problems (Lococo and Staplin, 2006).
[The following information is taken largely from NIA, 2011b.]
Studies find that effective communication with patients has specific benefits not only for patients but also for healthcare professionals. Patients are more likely to adhere to treatment and have better outcomes, express greater satisfaction with their treatment, and are less likely to bring malpractice suits. Learning effective communication techniques—and using them—may help health professionals build more satisfying relationships with older patients and become more skilled at managing their care.
Effective communication has practical benefits. It can help prevent medical errors, strengthen the relationship with patients, make the most of limited interaction time, and lead to improved health outcomes. When communicating with older adults:
For elder patients, obtaining a good history is crucial; it should include social circumstances, lifestyle, and both medical and family history. If feasible, gather preliminary data before the session by requesting previous medical records or having the patient and family members fill out forms at home. Try to structure questionnaires for easy reading by using large type and providing enough space between items for people to respond.
Try to have patients tell their story only once. For older patients who are ill, re-telling can be tiring. If the patient has trouble with open-ended questions, make greater use of yes-or-no or simple choice questions. During the interview, sit and face the patient at eye level. Use active listening skills, responding with brief comments such as “I see” and “Okay.” Remember that the interview itself can be beneficial. Giving your patient a chance to express concerns to an interested person can be therapeutic.
Older adults often have sensory impairments that affect communication. Vision and hearing deficits are common and need to be addressed in communication.
Age-related hearing loss is common: about one-third of people between the ages of 65 and 75, and nearly half of those over the age of 75, have a hearing impairment. It is not always obvious to healthcare providers when a patient is hard of hearing. The first step is to make sure your patient can hear you. If the patient uses a hearing aid, make sure it is working. Check for the presence of excess earwax. Healthcare providers can improve communication by using the following strategies:
If a patient is able to read lips, face the person directly at eye level to enable lip-reading and picking up visual clues. Keep your hands away from your face while talking so that your speaking is visualized.
Background noises (computers, traffic noise, other people talking, office equipment) can mask or distort your voice so be alert for signs that these ambient noises are adversely affecting communication.
If your patient has difficulty with letters and numbers, give a context for them. For example say, “m as in Mary, two as in twins, or b as in boy.” Say each number separately, for example, “five, six” instead of “fifty-six.” Be aware that certain letters sound alike for example m and n, and b, c, d, e, t, and v.
Keep a note pad handy so, if necessary, you can write what you are saying, including diagnoses and other important terms. Let your patient know when you are changing the subject by pausing briefly, speaking a bit more loudly, gesturing toward what will be discussed, gently touching the patient, or asking a question.
Visual disorders become more common as people age, and a person with impaired vision may experience difficulty in complex situations that demand rapid interpretation of multiple visual cues. Unfortunately, this is a common occurrence in a busy hospital or medical office. To ensure good communication for those with visual deficits:
Some words may have different meanings to older patients and those unfamiliar with medical terminology. For example, a diagnosis of dementia may bring up thoughts of insanity. The word “cancer” may be considered a death sentence. A family member may be sensitive about a diagnosis of “brain damage” following a stroke and feel the healthcare provider is questioning their loved one’s intelligence.
Although we cannot anticipate every generational difference in language, be aware of the possibility and work to make communication more clear. Use simple, common language, and ask if clarification is needed. Offer to repeat or reword the information: “I know this is complex—I’ll do my best to explain, but let me know if you have any questions or just want me to go over it again.”
Older patients often have multiple chronic conditions and may have vague complaints or atypical presentations. Begin the session by asking patients to talk about their major concern: “Tell me, what is bothering you the most.” Provide enough time for patients to answer your questions—giving people uninterrupted time to express concerns enables them to be more open and complete.
Ask, “Is there anything else?” This question, which you may have to repeat several times, helps to get all of the patient’s concerns on the table at the beginning of the visit. The main concern may not be the first one mentioned, especially if it is a sensitive subject. Encourage patients and caregivers to bring a written list of concerns and questions. Ask about all medications—including prescription, over-the-counter, and dietary supplements. Try to determine if the patient is using medications that have been prescribed for another family member.
Physicians and other healthcare providers typically underestimate how much patients want to know and overestimate how long they spend giving information to patients. Devoting more attention to educating a patient may seem like a luxury, but in the long run it improves adherence to treatment, increases well-being, and ultimately saves time.
Healthcare providers should provide key information and advice and encourage other team members to build on that. To explain a diagnosis, start by asking patients what they understand and how much more they want to know. When patients fail to understand their medical conditions they tend not to follow treatment plans.
After proposing a treatment plan, check with the patient on feasibility and acceptability; confirm that the patient understands the plan. Encourage patients and caregivers to take an active role in managing a chronic problem.
One of the challenges of caring for older people is the atypical presentation of symptoms. Deterioration in level of functioning is often the first symptom in an older person with an acute illness. An older adult may evidence only difficulty with ambulation or mentation when they are ill, while a younger person presents with completely different symptoms. Pneumonia in an older person may present with a change in mental status and a urinary tract infection may present as a fall. Vomiting may be the only symptom of a heart attack. Changes in vision, hearing, balance and postural control, or sensory loss can affect mobility and should be thoroughly assessed in older patients.
The visual system is a key component of motor control. It allows us to determine the movement of objects in our environment; it tells us where we are in relation to parts of our own body and to other objects (Shumway-Cook and Woollacott, 2011. Blindness or low vision affects more than 3.3 million Americans aged 40 years and older and this number is predicted to double by 2030 due to diabetes, other chronic diseases, and our rapidly aging population. Early detection and timely treatment of eye conditions has been found to be efficacious and cost effective (CDC, 2009c).
The leading causes of blindness and low vision in the U. S. are primarily age-related eye diseases such as age-related macular degeneration, cataract, diabetic retinopathy, and glaucoma. Other common eye disorders include amblyopia and strabismus.
Refractive errors are the most common visual problems in the United States. They include myopia (near-sightedness), hyperopia (farsightedness), astigmatism (distorted vision at all distances), and the presbyopia that occurs between age 40 and 50 years (loss of the ability to focus up close). Refractive errors can be corrected by eyeglasses, contact lenses, or surgery. Recent studies conducted by the National Eye Institute showed that proper refractive correction could improve vision among 11 million Americans 12 years and older (CDC, 2009c).
Elders should be assessed for other eye disorders associated with aging: age-related macular degeneration (AMD), cataract, diabetic retinopathy (DR), and glaucoma.
Hearing loss is one of the most common conditions affecting older adults. One in 3 people older than 60 and half of those older than age 85 have hearing loss. Hearing problems make it hard to understand and follow a doctor’s advice, to respond to warnings, and to hear doorbells and alarms. Hearing loss can also make it hard to enjoy talking with friends and family (NIDCD, 2011).
Hearing loss happens for many reasons. Some people lose their hearing slowly as they age (presbycusis). Another reason for hearing loss may be exposure to too much loud noise—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. Continuous exposure to loud noises can cause tinnitus, a ringing, hissing, or roaring sound in the ears. Hearing loss can also be caused by a virus or bacteria, heart conditions or stroke, head injuries, tumors, and certain medicines (NIDCD, 2011).
Balance is the ability to maintain the body’s center of mass over its base of support. Balance involves multiple systems that must interact flawlessly and automatically to coordinate input from the environment and the central nervous system. Postural control is the ability to maintain the segments of our body in relation to one another and to maintain stability and orientation in space (Shumway-Cook and Woollacott, 2011).
As healthcare professionals we often see clients who have poor balance and are at high risk for falling, whether from post surgical weakness, illness, neurologic disorders, or injury. Helping a patient reduce fall risk requires assessment of medications, sensory and musculoskeletal changes, and age-related and cognitive changes. All of these factors have been shown to affect balance and falls in one way or another. Because falls are a major concern in elders, a later section is focused on them.
The skin is our largest organ. It protects the body from infection and trauma. The skin also regulates body temperature by dilating and constricting blood vessels near the surface and releasing perspiration to cool the body.
When assessing skin color, look for cyanosis (blue-ish color), which may indicate poor oxygenation arising from respiratory or cardiac problems, or may signal low body temperature. Because skin color varies by race and ethnicity, it is important to inspect the ears, lips, inside of mouth, hands, and nail beds for signs of cyanosis.
The skin, sclera of the eyes, and mucous membranes should be inspected for jaundice, which may indicate liver disease. Skin pallor can indicate anemia. Erythema, or redness of the skin, may be due to fever, alcohol intake, or infection.
Skin should also be assessed for swelling, which can be a sign of injury or fluid retention. Bruising or bleeding of the skin should be noted, as it may indicate blood disorders or abuse.
A pressure ulcer is localized injury to the skin or underlying tissue (usually over a bony prominence) caused by pressure, or pressure in combination with shear and/or friction. Older adults are at high risk for the development of pressure ulcers—especially if they become less mobile due to injury or disease, or are hospitalized, bedridden, or chair ridden. Older adults in home care, during transition to a nursing home, and during long-term care may be at especially high risk for development of pressure sores (NINR, 2006).
Pressure is the foremost cause of ulcers, which can occur when a person is unable to perceive pressure or is unable to take action to relieve it. Tissue tolerance for pressure—and the ability of the tissue to withstand pressure—is influenced by moisture from any source, friction and shearing forces, nutrition, body temperature, hypotension, and hypoxia (NINR, 2006).
Skin becomes thinner with age, loses fat, and may take longer to heal following an injury. As physiology changes, the ability to heal following a wound is reduced by about 4% compared to younger adults.
Aging produces other changes in the structure of skin:
The skin of those at risk for skin breakdown should be assessed daily and should be cleansed immediately if soiled, avoiding hot water. It is important not to massage bony prominences and to use moisturizers on dry skin.
Frequent turning regimens (usually every 2 hours) should be part of the care plan for at-risk older adults. The heels of bedbound patients should be raised off the bed; do not use donut-type devices. A 30° lateral side-lying position can be used (the person should not be placed directly on the trochanter). The head of the bed should be kept at the lowest possible height and pillows can be used to prevent contact of bony prominences with each other. High-risk areas such as elbows, heels, sacrum, and the back of head should be protected from friction injury.
With high-risk patients, special mattresses, mattress overlays, and cushions can be used when frequent turning is either difficult or not possible. These devices are classified as static (nonmoving) or dynamic (movement of air currents by electrical systems). The static systems include foam, water, gel, and air-filled devices that are placed over the mattress or chair surface to provide for more even weight distribution, but these systems still require manual turning of patients. The dynamic support systems adjust weight distribution by alternating air currents and include two types: mattress overlays, such as alternating current pads, and air-fluidized beds (NINR, 2006).
Wheelchair cushions and pads frequently are used for patients confined to chairs. Sitting on a hard surface occludes blood flow to the skin at lower pressures and increases shear. These problems can be addressed by tipping the chair backward 20° (NINR, 2006).
Friction and sheer injuries to the skin can be minimized by use of protective dressings and proper lifting techniques during turning and transferring.
It is important to maintain proper nutrition in order to maximize skin health. A dietician can be consulted to correct any deficiencies of protein and calorie or vitamins. A glass of water should be offered at the time of turning to keep the person hydrated.
The Braden Scale is one of the most often used pressure ulcer risk assessment tools. It assesses six risk factors: mobility, activity, moisture, sensation, nutrition, and shear. The Braden Scale has high validity and reliability. Scores range from 6 to 23 with a score of 15 to 18 indicating risk; 13 to 14 moderate risk; 10 to 12 high risk; and ±9 very high risk. Perform the risk assessment on admission and repeat if there is a change in the patient’s condition. This scale is valid for use with individuals of all skin tones. See www.BradenScale.com to download a copy of the Braden Scale.
During a skin assessment, moles need to be assessed for possible skin cancer. A common mole (nevus) is a small growth on the skin that is usually pink, tan, or brown and has a distinct edge. People who have more than fifty common moles have a greater chance than others of developing melanoma. Most common moles do not turn into melanoma (NCI, 2011a).
A dysplastic nevus is an unusual mole that is often large and flat and does not have a symmetric round or oval shape. The edge is often indistinct. It may have a mixture of pink, tan, or brown shades. People who have many dysplastic nevi have a greater chance than others of developing melanoma, but most dysplastic nevi do not turn into melanoma (NCI, 2011a).
If the color, size, shape, or height of a mole changes or if it starts to itch, bleed, or ooze, the physician should be notified. Similarly, report to the doctor if a new mole doesn’t look like the client’s other moles. The only way to diagnose melanoma is to remove tissue and check it for cancer cells.
When assessing skin, look for signs of abuse. Healthcare providers are mandated reporters of elder abuse. While one sign does not necessarily indicate abuse, some tell-tale signs that there could be a problem:
Urinary incontinence can contribute to skin breakdown and infection and also to urinary tract infections (UTIs). It is important that incontinence be managed and that skin be cleansed and dried as soon as possible to prevent these complications.
Incontinence is often seen as part of aging, but it can occur for many other reasons. For example, UTI, vaginal infection or irritation, constipation, and some medications can cause bladder control problems that last a short time. When incontinence lasts longer, it may be due to (NIA, 2011c):
During urination, muscles in the bladder tighten to move urine into the urethra. At the same time, the muscles around the urethra relax and let the urine pass out of the body. Incontinence can occur if the muscles tighten or relax without warning (NIA, 2011c).
In order to determine the cause of urinary incontinence, urine and blood tests should be done to rule out infection. Tests may also be done to determine how well the bladder is emptying. A daily diary may also be kept to track times of urination or leakage. There are different types of urinary incontinence (NIA, 2011c):
There are several ways to improve bladder control (NIA, 2011c):
There are some medications that can cause or worsen urinary incontinence. Hypertension medications such as Hytrin, Minipress, and Cardura cause the bladder to relax and may cause stress incontinence with coughing or sneezing. Some antidepressants such as Tofranil and Elavil can impede bladder emptying. Diuretics cause increased urine formation, and sleeping pills may prevent waking to use the bathroom as needed (WebMD, 2009b).
Besides bladder control training, there are medications, surgeries, and devices that can help manage incontinence. Some drugs can help the bladder empty more fully during urination. Other drugs tighten muscles and can lessen leakage. Anticholinergic drugs such as Ditropan and Detrol can calm an overactive bladder. Topical estrogen can help rejuvenate the tissues in the urethral and vaginal areas. Imipramine (a tricyclic antidepressant) can help with mixed (urge and stress) incontinence. Cymbalta, another antidepressant, is sometimes used to treat stress incontinence (Mayo Clinic, 2011b).
A doctor may inject a substance that thickens the area around the urethra to help close the bladder opening. This reduces stress incontinence in women. The treatment may have to be repeated (NIA, 2011c).
Urethral inserts are small tampon-like disposable devices inserted into the urethra that act as a plug to prevent leakage. It’s usually used to prevent incontinence during a specific activity and then removed before urination. Pessaries are stiff rings inserted into the vagina and worn all day to help hold up the bladder and prevent urine leakage (Mayo Clinic, 2011b).
Surgery can sometimes improve or cure incontinence if it is caused by a change in the position of the bladder or blockage due to an enlarged prostate. In addition, absorbent underclothing can be worn under everyday clothing (NIA, 2011c).
The combination of an aging population and the breakdown of extended families has led to increasing social isolation of older Americans. Socially isolated older adults are frequently depressed; they often lack confiding relationships and perceive their friends as less supportive and reliable. Older adults who do not have close social ties report higher depressed mood than elders who are actively engaged in a supportive social network. The availability of a confidante was found to be the single most protective factor for four dimensions of depression—depressed affect, low positive affect, medical complaints, and interpersonal problems (NIMH, 2003).
Cognitive theory suggests that the way elders perceive their social contact is more important than their degree of isolation. Loneliness is associated with social isolation and social support, poor or perceived health, and depression—and both depression and loneliness compromise quality of life. Older women who experience loneliness, for example, report more hopelessness, self-focus, and poor health (NIMH, 2003).
Depression, one of the conditions most commonly associated with suicide in older adults, is a widely under-recognized and undertreated medical illness. Studies show that many older adults who die by suicide (up to 75%) visited a physician within a month before death. These findings point to the urgency of improving detection and treatment of depression to reduce suicide risk among older adults (NIMH, 2010).
Researchers have known for nearly a decade that social factors are not only related to the risk of depression but they may also influence the course of depression and play a role in suicide risk among elders. Depression is the most common risk factor for suicide among the elderly, and elders have the highest rates of suicide in the nation, with elderly males having a suicide rate 6 times the national average (NIMH, 2010).
The risk of depression in the elderly increases with other illnesses and when ability to function becomes limited. Estimates of major depression in older people living in the community range from less than 1% to about 5%, but rises to 13.5% in those who require home healthcare and to 11.5% in elderly hospital patients (NIMH, 2010).
An estimated 5 million have sub-syndromal depression, symptoms that fall short of meeting the full diagnostic criteria for a disorder. Sub-syndromal depression is especially common among older people and is associated with an increased risk of developing major depression. Depressive disorder is not a normal part of aging. Emotional experiences of sadness, grief, response to loss, and temporary “blue” moods are normal. Persistent depression that interferes significantly with ability to function is not (NIMH, 2010).
Health professionals may mistakenly think that persistent depression is an acceptable response to other serious illnesses and the social and financial hardships that often accompany aging—an attitude often shared by older people themselves. This contributes to low rates of diagnosis and treatment in older adults (NIMH, 2010).
Depression can and should be treated when it occurs at the same time as other medical illnesses. Untreated depression can delay recovery or worsen the outcome of these other illnesses. Antidepressant medications or psychotherapy, or a combination of the two, can be effective treatments for late-life depression.
Older Americans are disproportionately likely to die by suicide. Although they comprise only 12% of the U.S. population, people age 65 and older accounted for 16% of suicide deaths in 2004. Non-Hispanic white men age 85 and older were most likely to die by suicide. They had a rate of 49.8 suicide deaths per 100,000 people in that age group (NIMH, 2010).
If depression is suspected, older adults should ask themselves if they are feeling:
Or if he or she is:
These may be symptoms of depression, a treatable illness. Other symptoms that may signal depression, but may also be signs of other serious illnesses, should be checked by a doctor, whatever the cause. They include:
National Suicide Prevention Hotline
If you or someone you care for are in crisis and need help right away, call this toll-free number, available 24 hours a day, every day: 1-800-273-TALK (8255). You will reach the National Suicide Prevention Lifeline, a service available to anyone. You may call for yourself or for someone you care about. All calls are confidential.
More than one-third of people aged 65 and older fall each year, and those who fall once are 2 to 3 times more likely to fall again (Stevens and Sogolow, 2008). Repeated falls significantly limits a person’s ability to remain self-sufficient. Fall injuries are responsible for significant disability, reduced physical function, and loss of independence.
Because falls often cause injuries such as hip fractures and head trauma, they can increase the risk of early death. In the year 2000 direct medical costs for fall injuries in the United States totaled $19 billion. Despite these troubling statistics, studies have shown that preventive interventions can reduce falls (Stevens and Sogolow, 2008).
Facts About Falls
Source: CDC, 2011d.
Fall Risk in the Elderly
Source: CDC, 2011d.
Falls should not be seen as an inevitable consequence of aging, even though falls do occur more often among older adults and fall risk increases with age. Risk factors can be biologic, behavioral, or environmental (CDC, 2008b):
Biologic Risk Factors
Behavioral Risk Factors
Environmental Risk Factors
Polypharmacy is a well-established risk factor for falls in the older adult. In her seminal 1994 study of risk factors associated with falls in elders, Mary Tinetti studied modifiable risk factors and the effects of interventions on the risk of falling among community-dwelling older adults. Physicians, nurse practitioners, and physical therapists examined these risk factors in a control group and an intervention group:
Serotonin-reuptake inhibitors (SSRIs), tricyclic antidepressants, neuroleptic agents, benzodiazepines, anti-convulsants, and anti-arrhythmic medications have been shown to have the strongest link to an increased risk of falling. Others have noted that an increased risk of falls is especially associated with the following classes of medications:
The purpose of medication review and management is to identify and eliminate medication side effects and interactions, such as dizziness or drowsiness, that can increase the risk of falls. Many older adults are unaware that their daily medications may increase their fall risk. Aging affects the absorption, distribution, metabolism, and elimination of medications. Age can also increase sensitivity to potential side effects (CDC, 2008b).
Older adults may get prescriptions from multiple doctors. Fall risk increases with the total number of prescription and over-the-counter medications. Less well known is that fall risk can increase significantly in the days following a medication change.
Psychoactive medications (drugs that alter brain function) increase fall risk. These include antidepressants, tranquilizers, antipsychotics, anti-anxiety drugs, and sleep medications. Other medications that may cause problems include those prescribed to treat seizure disorders, blood pressure-lowering medications, cholesterol-lowering medications, heart medications, and painkillers (CDC, 2008b).
Drug side effects that can contribute to falling include blurred vision, hypotension leading to dizziness and lightheadedness, sedation, decreased alertness, confusion and impaired judgment, delirium, compromised neuromuscular function, and anxiety. Review and modification of medications by a healthcare provider can frequently reverse or minimize these effects.
Clinicians should regularly review each patient’s medications for potential interactions and side effects that may increase fall risk and, where possible, reduce or eliminate medications or select alternatives. Reducing the number and types of medications, particularly tranquilizers, sleeping pills, and anti-anxiety drugs, can be an effective fall prevention strategy when used alone or as part of a multi-component intervention (CDC, 2007).
Usually two or more risk factors interact to cause a fall (eg, poor balance and low vision). Home or environmental risk factors play a role in about half of all falls (CDC, 2008b). In older clients, the following factors should alert a healthcare provider to the possibility of increased fall risk and trigger a fall prevention assessment and intervention:
Twenty percent to 30% of people who fall suffer moderate to severe injuries such as bruises, hip fractures, or head traumas. These injuries can make it hard to get around and limit independent living and can increase the risk of early death.
Most fractures among older adults are caused by falls; the most common fractures are of the spine, hip, forearm, leg, ankle, pelvis, upper arm, and hand. Those who fall, even those who are not injured, develop a fear of falling. This fear may cause them to limit their activities, leading to reduced mobility and physical fitness, and increasing their actual risk of falling (CDC, 2011d).
A review of thirty-three studies that looked at fear of falling (FOF) in community-dwelling older adults found that FOF is widespread with both those who have a history of falls and those who had not yet experienced a fall (Scheffer et al., 2008). The main risk factor for developing a fear of falling was a previous fall. Several studies showed fear of falling increasing with age and was more prevalent in women than men. Other risk factors for developing a fear of falling included:
People may be unaware of the link between fractures and osteoporosis. Osteoporosis progresses without symptoms and in the most serious cases bones may become so fragile they break under the slightest strain. Falls are especially dangerous for people who are unaware that they have osteoporosis. If the patient and healthcare provider fail to connect a broken bone with osteoporosis, the chance is lost to make a diagnosis with a bone density test and begin a prevention or treatment program.
A traumatic brain injury (TBI) is caused by a bump or blow to the head that causes cognitive changes. People aged 75 and older have the highest rates of TBI-related hospitalizations. They also recover more slowly and die more often from TBI than younger people do. Falls are the most common cause of traumatic brain injuries (TBI); in the year 2000 TBI accounted for 46% of fatal falls among older adults (CDC, 2011d).
Symptoms of mild TBI include:
A person with moderate or severe TBI may show the symptoms of mild TBI but may also have:
Older adults taking blood thinners (eg, warfarin) should be seen immediately by a healthcare provider if they have a bump or blow to the head, even if they do not have any of the symptoms listed above.
Interventions can reduce fall risk through either exercise alone or by combining exercise with other risk-reduction approaches such as medication review and management, vision screening and correction, education, and safer living environments (CDC, 2008b).
Fall prevention programs should include education about fall risk factors and prevention strategies for older adults, families, and caregivers. Information can be communicated in an individual or a group setting. Exercise interventions can be offered in a community setting, at home with supervision, or in a program that combines group classes or one-on-one training with home-based exercise. Appropriate types of exercise that effectively reduce falls in older adults include:
Because polypharmacy has been shown to increase the risk of falls—especially in older adults—a medication review should be undertaken with medications adjusted or modified by a physician or nurse practitioner.
Vision should be assessed to determine if any visual changes are contributing to increased fall risk. Somatosensory changes should be assessed, particularly any sensory changes in the feet and legs (peripheral neuropathy, acute pain, arthritis, gout, swelling), or other sensory changes that may affect balance. A home safety assessment should be completed by a physical or occupational therapist with home modifications as needed.
Assistive devices can range from simple to complex and can improve function, increase independence, or simply make daily tasks easier. Some devices are designed to help with activities of daily living (ADLs) while others are designed to aid with balance and mobility.
Assistive devices designed to help with activities of daily living include those designed for cooking and eating, bathing and toileting, dressing, and grooming.
Cooking and eating aids include:
Bedroom aids include:
Bathing and toileting aids include:
Dressing aids include:
Grooming aids for personal hygiene needs include:
Mobility aids allow a person to move safely and independently both within the household and outdoors. They can also be of help for the caregiver if assistance is needed with mobility and transfers. Mobility aids include:
The design of commercial wheelchairs has changed surprisingly little since the first wheelchair was patented in the United States in 1869. The standard large-rear-wheel, small-front-wheel design is still the most common type of wheelchair despite years of innovative work by countless engineers and users throughout the world. In recent decades, mass production techniques involving lightweight materials such as aluminum and composite metals have changed the look of wheelchairs—at least in industrialized countries.
A wheelchair is more than simply a chair with wheels. It is a dynamic wheeled mobility device that must fit the individual needs of the user. When ordering a wheelchair, consider the following:
Large companies such as Everest and Jennings, Invacare, and Quickie make inexpensive institutional wheelchairs with prices ranging from as low as $150 up to more than $400. The common feature about these inexpensive chairs is the lack of options for sizing and seating. The chairs are available in standard widths of 16” and 18”— both of which are often too wide for the average adult user—especially older women. In ordering a wheelchair, you must specify the 16” width or the supply company will automatically deliver an 18” chair.
Under certain circumstances, Medicare will cover the cost of a wheelchair rental for home use. The coverage is usually only for low- to medium-cost wheelchairs and only those with a width of 16” or 18”. Medicare does not usually cover the cost of seat cushions or custom backs. Customized seating systems can be more than the cost of the wheelchair and are usually paid for by the client.
Note the foam padding covered on top with a low-shear, breathable fabric. Courtesy of Sunrise Medical.
Layered foam pads can be effective pressure reduction cushions for wheelchairs. Jay (Sunrise Medical) cushions, for example, offer a variety of cost-effective, pressure-relief cushions made of layered foam and a low-shear, breathable fabric cover.
Note the gel padding alternating with layered foam and covered on top with a low-shear, breathable fabric. Courtesy of Sunrise Medical.
Gel cushions provide an extra measure of pressure relief, although poor-quality gel cushions tend to bottom out—especially if the gel is contained in one large bag or chamber rather than several smaller chambers. Poorly designed gel cushions are not only useless but they may also increase the risk of skin damage. Rubber or other non-breathable material covering a cushion tends to cause moisture buildup between the skin and the pad, which can contribute skin breakdown.
Good-quality gel cushions can redistribute weight and reduce skin shear. Because they use a combination of high-quality layered foam and gel packets they do not bottom out. Special covers designed to wick heat and moisture away from the skin further reduce the risk of pressure ulcers and skin breakdown.
Assistive technology is any kind of technology that can be used to enhance the functional independence of a person with a disability. Assistive technology can be anything from a simple (low-tech) device such as a magnifying glass, to a complex (high-tech) device such as a computerized communication system. It can be big—an automated van lift for a wheelchair—or small—a grip attached to a pen or fork by Velcro. Assistive technology can also be a substitute, such as an augmentative communication device that provides vocal output for someone who is unable to communicate by voice.
Adequate nutrition is critical to health, function, and quality of life for people of all ages. For elders, nutrition is especially important because of their vulnerability to health problems and physical and cognitive impairments (AOA, 2011c).
Nutritional status has been shown to affect the age-related rate of functional decline for many organs and to be a determinant of changes in body composition associated with aging, such as loss of bone and lean body mass. Diet and nutrition have been related to the etiology of many chronic diseases affecting older people (eg, osteoporosis, atherosclerosis, diabetes, hypertension, and certain forms of cancer). These chronic diseases have been shown to cause physical and mental impairments in older people that threaten their independence, well-being, and quality of life (AOA, 2011c).
The Dietary Guidelines for Americans make seven broad dietary recommendations for people age 2 and older to help them choose food for a healthful diet:
For some of these recommendations, the Dietary Guidelines provide specific quantitative standards. Recommendations for a variety of foods are specified as a suggested number of daily servings from each of five basic food groups:
The Dietary Guidelines also state that total fat intake should not exceed 30% of food calories and saturated fat should be less that 10% of calories.
There is a reduction in total body protein with age. A decrease in skeletal muscle is the most noticeable manifestation of this change but there is also a reduction in other physiologic proteins such as organ tissue, blood components, and immune bodies, as well as declines in total body potassium and water. This contributes to impaired wound healing, loss of skin elasticity, and a decreased ability to fight infection (Chernoff, 2004).
Protein tissue accounts for 30% of whole-body protein turnover but that rate declines to 20% or less by age 70. The result of this phenomenon is that older adults require more protein/kilogram body weight than do younger adults (Chernoff, 2004).
Adequate dietary intake of protein may be more difficult for older adults to obtain. Dietary animal protein is the primary source of high biologic-value protein, iron, vitamin B-12, folic acid, biotin, and other essential nutrients. In fact, egg protein is the standard against which all other proteins are compared. Compared to other high-quality protein sources like meat, poultry, and seafood, eggs are the least expensive. The importance of dietary protein cannot be underestimated in the diets of older adults; inadequate protein intake contributes to a decrease in reserve capacity, increased skin fragility, decreased immune function, poorer healing, and longer recuperation from illness (Chernoff, 2004).
Most people meet at least some of their vitamin D needs through food intake and exposure to sunlight. It is produced when ultraviolet rays from sunlight strike the skin and trigger vitamin D synthesis. Vitamin D is a fat-soluble vitamin that is naturally present in very few foods, added to others, and available as a dietary supplement (ODS, 2011a).
Vitamin D promotes calcium absorption in the gut and maintains adequate serum calcium and phosphate concentrations to enable normal mineralization of bone and to prevent hypocalcemic tetany. It is also needed for bone growth and bone remodeling by osteoblasts and osteoclasts. Without sufficient vitamin D, bones can become thin, brittle, or misshapen. Together with calcium, vitamin D helps protect older adults from osteoporosis (ODS, 2011a).
Calcium, the most abundant mineral in the body, is found in some foods, added to others, available as a dietary supplement, and present in some medicines (such as antacids). Calcium is required for vascular contraction and vasodilation, muscle function, nerve transmission, and intracellular signaling and hormonal secretion, though less than 1% of total body calcium is needed to support these critical metabolic functions. Serum calcium is very tightly regulated and does not fluctuate with changes in dietary intakes; the body uses bone tissue as a reservoir for and source of calcium to maintain constant concentrations of calcium in blood, muscle, and intercellular fluids (ODS, 2011b).
The remaining 99% of the body’s calcium supply is stored in the bones and teeth, where it supports their structure and function. Bone itself undergoes continuous remodeling, with constant resorption and deposition of calcium into new bone. The balance between bone resorption and deposition changes with age. Bone formation exceeds resorption in periods of growth in children and adolescents, whereas in early and middle adulthood the processes are relatively equal. In aging adults, particularly among postmenopausal women, bone breakdown exceeds formation, resulting in bone loss that increases the risk of osteoporosis over time (ODS, 2011b).
In 2010 the Institutes of Medicine (IOM) published a study that supported the importance of calcium and vitamin D in promoting bone health, but not in other conditions. According to the study, evidence is emerging that too much of these nutrients may be harmful. There is evidence that some post menopausal women may be taking in too much calcium, increasing the risk of kidney stones (IOM, 2011).
The IOM also concluded that most North Americans are getting enough vitamin D through sun exposure and foods. Too much vitamin D (above 10,000 IU per day) may cause kidney and tissue damage. However, people with dark-pigmented skin and older people living in institutions may be at risk for too little vitamin D (IOM, 2011).
Although the use of nutritional supplements is a common practice among older adults, randomized controlled trials have given mixed results regarding health benefits. The health benefits of folic acid, vitamins B-12 and B-6, and omega-3 fatty acids in older adults were studied. Supplements of the B vitamins folate, B-12, and B-6 were studied as related to prevention of a number of major age-related chronic diseases, including cardiovascular disease, stroke, cognitive decline, and cancer (PubMed.gov, 2010).
While there are some encouraging findings regarding stroke, depression, and macular degeneration (although in only one study in the latter case), little evidence has been found for the benefit of B vitamins in delaying cardiovascular disease or age-related cognitive changes. In the few cancer-related studies, the evidence of benefit is coupled with concerns about enhancing the growth of existing undiagnosed cancers (PubMed.gov, 2010).
In contrast, clear health benefits have been shown with modest increases in consumption of fatty fish or fish oil supplements, including a reduction in the risk of sudden cardiac death. In addition, there is evidence that high-dose fish oil supplements may lower serum triglyceride levels (PubMed.gov, 2010).
Dementia is a descriptive term for a collection of symptoms that can be caused by a number of disorders that affect the brain. It is estimated that as many as 6.8 million people in the United States have dementia, and at least 1.8 million of those are severely affected. Studies in some communities have found that almost half of all people age 85 and older have some form of dementia. Although it is common in very elderly individuals, dementia is not a normal part of the aging process. Many people live into their 90s and even 100s without any symptoms of dementia (NINDS, 2011).
People with dementia have significantly impaired mental functioning that interferes with normal activities and relationships. They can lose their ability to solve problems and maintain emotional control, and may experience personality changes and behavioral problems such as agitation, delusions, and hallucinations.
Memory loss is a common symptom of dementia but by itself does not mean a person has dementia. Dementia is diagnosed only if two or more brain functions—such as memory, language, perception, reasoning, or judgment, among others—are significantly impaired.
Although memory and other cognitive functions change with age, age-related cognitive change is not dementia. Memory may not be as sharp and there may be word-finding difficulties—it may take longer to do certain mental tasks such as memorizing a string of words or numbers. Multi-tasking may be a thing of the past. Older adults with age-related cognitive changes can however read, operate a computer, manage their finances, and prepare their own meals—they do not forget what a coffee pot is or how to operate a microwave. They understand when they are in danger and know that they should call for help or get out of a house if there is a fire.
Mild cognitive impairment (MCI) is a condition in which people have memory problems that are noticeably worse than age-related changes. However, people with MCI do not have the problems associated with dementia such as personality and cognitive changes. Some people with MCI do go on to develop AD, but not everyone does.
The symptoms of a number of medical conditions mimic those of dementia and this must be considered when evaluating a person experiencing cognitive changes. Gerontology specialists speak of the “Three Ds”—dementia, delirium, and depression—because these are the most prevalent reasons for cognitive impairment in older adults. Delirium and depression can cause cognitive changes that may be mistaken for dementia, and healthcare providers and caregivers should learn to distinguish among the three conditions.
Delirium is a sudden, severe confusion with rapid changes in brain function. Delirium develops over hours or days and is temporary and reversible. It can occur after general anesthesia, from infections (eg, UTI, pneumonia), from fluid/electrolyte or acid/base disturbances, or from other conditions that deprive the brain of oxygen. Pain can also contribute to delirium, as can the medications used to treat pain. Being in an unfamiliar environment such as adult daycare or a nursing home can also contribute to delirium.
Depression is caused by neurochemical imbalances in the brain. It can lead to cognitive impairment, which should improve when the depression is treated. People with depression are aware of the date and time; however, they may answer “I don’t know” to orientation questions and may not make eye contact. They may have a flat affect (show little expression) and may speak in a monotone. A smile does not rule out the presence of depression; people who are depressed may smile while describing the hopelessness of life. Irritability or verbal expression of pessimism, sadness, or hopelessness may indicate depression. Depression commonly occurs in the early stages of Alzheimer’s disease (AD) as individuals become aware of their loss of cognitive function.
There are other conditions that can cause dementia-like symptoms; many of these conditions are reversible with appropriate treatment (NINDS, 2011):
[This section is taken largely from NINDS, 2011.]
For people with AD or other progressive dementias, early diagnosis allows them to plan for the future while they are still able to make decisions. There are a number of strategies for the assessment and diagnosis of dementia. Screening begins with a detailed patient history to determine when the symptoms began and to determine the person’s overall medical condition.
The physical examination helps to rule out treatable causes of dementia and identify signs of stroke or other disorders that can contribute to dementia. Look for signs of illness, such as heart disease or kidney failure, that can overlap with dementia. A review of medications is necessary to determine whether any medications or medication interactions are causing or contributing to the symptoms of dementia.
The neurologic examination assesses balance, motor control, sensory functions, and reflexes, and looks for the presence of any neurologic condition (eg, movement disorders, stroke) that may affect the patient’s diagnosis or is treatable with drugs.
Cognitive tests measure memory, language skills, math skills, and other abilities related to mental functioning. The Mini-Mental State Examination (MMSE) may be used to examine orientation, memory, and attention, the ability to name objects, follow verbal and written commands, write a sentence spontaneously, and copy a complex shape.
Brain scans are used to identify strokes, tumors, or other problems that can cause dementia. Cortical atrophy—degeneration of the brain’s cortex—is common in many forms of dementia and may be visible on a brain scan. Brain scans also can identify changes in the brain’s structure and function that suggest AD.
Electroencephalograms (EEGs) may be used in people with suspected dementia. Many patients with moderately severe to severe AD have abnormal EEGs. An EEG may also be used to detect seizures, which occur in about 10% of AD patients as well as in many other disorders.
A variety of laboratory tests are available to diagnose dementia or rule out other conditions, such as kidney failure, that can contribute to symptoms. A partial list of these tests includes a complete blood count, blood glucose test, urinalysis, drug and alcohol tests (toxicology screen), cerebrospinal fluid analysis (to rule out specific infections that can affect the brain), and analysis of thyroid and thyroid-stimulating hormone levels.
A psychiatric evaluation may be obtained to determine if depression or another psychiatric disorder may be causing or contributing to a person’s symptoms.
[This section is taken largely from NINDS, 2011.]
Even though Alzheimer’s disease is fairly common, it is not the only thing that causes dementia. Symptoms differ with each type of dementia, depending upon the part of the brain that is affected. Frontal-temporal dementia (FTD), which affects the front part of the brain, is the most common dementia in those under the age of 60; FTD is responsible for 5% to 10% of all cases of dementia.
Vascular dementia, which is caused by small repeated strokes, occurs in people with longstanding, inadequately controlled, high blood pressure. It is responsible for about 20% to 30% of all cases of dementia. Lewy Body dementia, which often accompanies Parkinson’s disease, can cause hallucinations and mental changes. It is responsible for a little less than 5% of all cases of dementia. Acquired immune deficiency syndrome (AIDS) can also cause a form of dementia called AIDS-related dementia.
The relative frequencies of dementia types are increasingly open to debate and the borders between the types are becoming less distinct as we learn more about dementia and brain anatomy. Studies have examined the agreement between the diagnosis made while the person was alive and the pathology found in the brain post mortem. These have suggested that mixed pathologies are more common than “pure” pathologies—meaning most people have a mixture of two or more types of dementia. This is particularly true for Alzheimer’s disease and vascular dementia, and for Alzheimer’s disease and dementia with Lewy Bodies (ADI, 2009).
The less common types of dementia (frontotemporal dementia, Creutzfeldt Jacob disease, and Huntington disease) are often misdiagnosed in life as Alzheimer’s disease. Population-based studies have suggested that frontotemporal dementia and vascular dementia are relatively common diagnoses in men who have an early onset of dementia. Alzheimer’s disease tends to predominate over vascular dementia among older people with dementia, particularly women (ADI, 2009).
The most common type of dementia, Alzheimer’s disease (AD), is caused by the formation of abnormal proteins within the brain called plaques and tangles. Damage typically begins in an area of the cerebrum called the hippocampus, which is responsible for the formation of new memories. In fairly rapid succession, plaques and tangles spread forward to the temporal and frontal lobes, affecting language, judgment, learning, comprehension, orientation, and emotions. Although almost everyone with AD is elderly, it is not considered to be a normal part of aging.
Source: Courtesy of the Alzheimer’s Association. Used with permission.
In most people, symptoms of AD appear after age 60. However, there are some early-onset forms of the disease that are usually linked to a specific gene defect, which may appear as early as age 30. AD causes a gradual decline in cognitive abilities, usually during a span of 7 to 10 years. Nearly all brain functions, including memory, movement, language, judgment, behavior, and abstract thinking, are eventually affected. Tangles are largely made up of a protein called tau which is part of a healthy nerve cell’s structural support and which is also responsible for delivering substances throughout the cell. In AD, tau is changed in a way that makes it collect into tangles, which causes the collapse of the neuron’s support and transport system.
Source: Courtesy of the Alzheimer’s Association. Used with permission.
Source: Courtesy of the Alzheimer’s Association. Used with permission.
In the earliest stages of Alzheimer’s disease, before symptoms can be detected, plaques and tangles form in the hippocampus, which is the area of the brain involved in learning new tasks, short-term memory, thinking, and planning. In the early stages of AD, patients typically experience memory impairment, lapses of judgment, and subtle changes in personality. As the disorder progresses, memory and language problems worsen and patients begin to have difficulty performing activities of daily living, such as balancing a checkbook or remembering to take medications. They also may have visual-spatial problems, such as difficulty navigating an unfamiliar route. They may become disoriented about places and times, may suffer delusions, and may become short-tempered and hostile.
In mild to moderate stages, plaques and tangles continue their spread from the hippocampus forward to the frontal lobes (shaded in blue, below). The frontal areas of the brain are involved with speaking and understanding speech, the sense of where your body is in space, and executive functions such as planning, ethical thinking, and judgment. Many people are first diagnosed with ADRD in this stage. Changes in personality and behavior occur and people begin to have trouble recognizing friends and family members.
Source: Courtesy of the Alzheimer’s Association. Used with permission.
In advanced Alzheimer’s, the hippocampus is severely damaged as plaques and tangles (shaded in blue) spread throughout the cerebral cortex. Individuals lose their ability to communicate, to recognize family and loved ones, and to care for themselves. Note that the hippocampus (shaded in dark blue), which is the region of the brain responsible for the formation of new memories, is severely damaged.
Source: Courtesy of the Alzheimer’s Association. Used with permission.
Many people with advanced AD eventually develop symptoms such as aggression, agitation, depression, sleeplessness, or delusions. On average, patients with AD live for 8 to 10 years after they are diagnosed. However, some people live as long as 20 years. Patients with AD often die of aspiration pneumonia because they lose the ability to swallow late in the course of the disease.
A view of how nerve cell loss changes the whole brain in advanced Alzheimer’s disease. Left side: normal brain; right side, a brain damaged by advanced AD. Source: Courtesy of the Alzheimer’s Association. Used with permission.
Frontotemporal dementia (FTD), sometimes called frontal lobe dementia, describes a group of diseases characterized by degeneration of nerve cells—especially those in the frontal and temporal lobes of the brain. In many people with FTD there is an abnormal form of tau protein in the brain, which accumulates into neurofibrillary tangles. This disrupts normal cell activities and may cause the cells to die.
Symptoms of FTD usually appear earlier that those seen with AD—usually between the ages of 40 and 65. Rather than a loss of short-term memory, FTD is characterized by behaviors associated with damage to the frontal lobes of the brain, namely loss of moral reasoning, disinhibition, behavioral and personality changes, and declining judgment.
In many cases, people with FTD have a family history of dementia, suggesting a genetic factor in the disease. The duration of FTD varies, with some patients declining rapidly over 2 to 3 years and others showing only minimal changes for many years. People with FTD live with the disease for an average of 5 to 10 years after diagnosis.
Vascular dementia is caused by damage associated with cerebrovascular or cardiovascular problems—usually strokes. It may also be caused by genetic diseases, endocarditis (infection of a heart valve), or amyloid angiopathy (a process in which amyloid protein builds up in the brain’s blood vessels, sometimes causing hemorrhagic or “bleeding” strokes). In many cases, it may coexist with AD. The incidence of vascular dementia increases with advancing age and its incidence is similar in men and women.
Other causes of vascular dementia include:
Symptoms of vascular dementia often begin suddenly—usually after a stroke. Patients may have a history of high blood pressure, vascular disease, or previous strokes or heart attacks. Vascular dementia may or may not get worse with time, depending on whether the person has additional strokes. In some cases, symptoms may get better with time. When the disease does get worse, it often progresses in a stepwise manner, with sudden changes in ability.
Vascular dementia with brain damage to the mid-brain regions may cause a gradual, progressive cognitive impairment that resembles AD. Unlike people with AD, people with vascular dementia often maintain their personality and normal levels of emotional responsiveness until the later stages of the disease. People with vascular dementia may wander at night and often have other problems commonly found in people who have had a stroke, including depression and incontinence.
Lewy body dementia (LBD) is one of the most common types of progressive dementia. It occurs sporadically, in people with no known family history of the disease, although rare familial cases have occasionally been reported. There is no cure for LBD, and treatments are aimed at controlling the parkinsonian and psychiatric symptoms of the disorder.
The symptoms of LBD overlap with AD in many ways, and may include memory impairment, poor judgment, and confusion. However, LBD typically also includes visual hallucinations, Parkinson-like symptoms such as a shuffling gait and flexed posture, and day-to-day fluctuations in the severity of symptoms. Patients with LBD live an average of 7 years after the onset of symptoms.
HIV-associated dementia (HAD) is caused by infection with the human immunodeficiency virus (HIV) that causes AIDS. HAD can cause widespread destruction of the brain’s white matter. This leads to a type of dementia that generally includes impaired memory, apathy, social withdrawal, and difficulty concentrating. People with HAD often develop movement problems as well. There is no specific treatment for HAD, but AIDS drugs can delay onset of the disease and may help to reduce symptoms.
Dementia pugilistica, also called chronic traumatic encephalopathy or boxer’s syndrome, is caused by head trauma, such as that experienced by people who have been punched many times in the head during boxing. The most common symptoms of the condition are dementia and Parkinsonism, which can appear many years after the trauma ends. Affected individuals may also develop poor coordination and slurred speech.
Creutzfeldt-Jakob disease (CJD) is a rare, degenerative, fatal brain disorder that affects about 1 in every million people per year worldwide. Symptoms usually begin after age 60 and most patients die within a year. CJD belongs to a family of human and animal diseases known as the transmissible spongiform encephalopathies (TSEs). Spongiform refers to the characteristic appearance of infected brains, which become so filled with holes that they resemble sponges when viewed under a microscope. CJD is the most common of the known human TSEs.
Many researchers believe CJD is caused by the presence of an abnormal form of a protein called a prion. Most cases of CJD occur sporadically—that is, in people who have no known risk factors for the disease. However, about 5% to 10% of cases of CJD in the United States are hereditary, caused by a mutation in the gene for the prion protein. In rare cases, CJD can also be acquired through exposure to diseased brain or nervous system tissue, usually through certain medical procedures. There is no evidence that CJD is contagious through the air or through casual contact with a CJD patient.
Patients with CJD may initially experience problems with muscular coordination; personality changes, including impaired memory, judgment, and thinking; and impaired vision. Other symptoms may include insomnia and depression. As the illness progresses, mental impairment becomes severe. Patients often develop myoclonus (brief involuntary jerking) and they may go blind. They eventually lose the ability to move and speak, and go into a coma. Pneumonia and other infections often occur in these patients and can lead to death.
Dementia may occur in patients who have other disorders that primarily affect movement or other functions. These cases are often referred to as secondary dementias. The relationship between these disorders and the primary dementias is not always clear. For instance, people with advanced Parkinson’s disease, which is primarily a movement disorder, sometimes develop symptoms of dementia. Many Parkinson’s patients also have amyloid plaques and neurofibrillary tangles like those found in AD. The two diseases may be linked in a yet-unknown way, or they may simply coexist in some people.
Common Types of Dementia
Early, characteristic symptoms
Proportion of dementia cases
*Alzheimer’s disease (AD)
Dementia with Lewy
Cortical Lewy bodies
Medications used to treat the cognitive effects of dementia have only a modest effect. The most commonly prescribed drugs in this category are anti-cholinesterase inhibitors and NMDA receptor antagonists.
Certain medications can be prescribed for mild to moderate ADRD to control cognitive symptoms. Two classifications of medications are approved for this purpose: anticholinesterase inhibitors and NMDA (memantine) receptor antagonists. These medications have a very slight effect on a person’s ability to perform daily activities and sometimes dampen behavioral and psychological symptoms (although this is an off-label use).
Anticholinesterase inhibitors slow the breakdown of acetylcholine, allowing it to stay in the brain a little longer. Tacrine was the first anticholinesterase inhibitor approved by the Food and Drug Administration (FDA). Three better-tolerated anticholinesterase inhibitors have also been approved:
Memantine (NMDA, Namenda) is approved for use in moderate to severe dementia. Memantine is a receptor antagonist that works by decreasing abnormal activity in the brain. It can help people with AD think more clearly and perform daily activities more easily, but it is not a cure and does not stop the progression of the disease. It may help patients maintain certain daily functions a little longer than they would without the medication.
In May 2012 a five-year prevention trial, jointly funded by the National Institutes of Health, Banner Alzheimer’s Institute, and Genentech, became the first clinical trial to focus on people who are cognitively normal but at extremely high risk of developing Alzheimer’s disease. The effort is an international collaboration, working with a Colombian clan who share a genetic mutation known to cause observable signs of Alzheimer’s disease at around age 45.
The study approach reflects new thinking—that testing therapies before signs of memory loss appear might be most effective in fighting Alzheimer’s disease. In this study, researchers will examine whether up to five years of an antibody treatment with crenezumab, which is designed to bind to and possibly clear away abnormal amounts of amyloid protein in the brains of people with Alzheimer’s, can prevent decline in cognitive function.
The study participants—some three hundred adult members of the Colombian clan that has a family history of early-onset Alzheimer’s, as well as a smaller number of U.S. participants age 30 and older—will include both carriers and non-carriers of the gene. The study will use brain scans, fluid biomarkers, and cognitive testing to track amyloid levels, changes in brain structure and function, and cognitive performance.
The study aims to do more than look at the potential effectiveness of one therapy. It will be a test of how and to what extent biomarkers may predict disease progress or treatment success and will contribute vitally important information and samples to the study of Alzheimer’s disease.
Geriatrics specialists refer to the challenging behaviors seen in dementia as behavioral and psychological symptoms of dementia (BPSD). It is estimated that up to 90% of patients with Alzheimer’s disease exhibit at least one BPSD and about one-third have severe behavioral problems (Liperoti et al., 2008). Challenging behaviors also occur in other types of dementia, and some may differ depending on the type of dementia.
Pharmacotherapy has only a modest effect on BPSD, and many of the medications have potentially serious side effects. The most commonly used drugs for the treatment of BPSD are the antipsychotics.
Typical antipsychotics have been used since the 1950s for the treatment of psychosis in dementia, but they can cause irreversible physical symptoms such as Parkinsonism and tardive dyskinesia (extrapyramidal symptoms). These agents have also been systematically used for the treatment of other behavioral and psychological symptoms of dementia (besides psychosis) despite a substantial lack of scientific evidence to support their use (Liperoti et al., 2008).
Atypical antipsychotics were approved exclusively for the treatment of schizophrenia by the FDA in the 1990s. Soon after, these medications became the new standard of care for BPSD because of their reported advantages over conventional agents, particularly with respect to extrapyramidal symptoms (restlessness; muscles spasms of the neck, eyes, tongue, or jaw; resting tremor; involuntary movements; muscular rigidity; postural instability). In the late 1990s, atypical agents accounted for more than 80% of antipsychotic prescriptions used in dementia patients (Liperoti et al., 2008).
Over the last decade, the off-label use of atypical antipsychotics has been promoted by clinical practice guidelines although only a limited number of clinical trials suggest their efficacy in dementia. In 2008 the FDA issued a “drug alert” notifying prescribers that both typical and atypical antipsychotics are associated with an increased risk of mortality in elderly patients treated for dementia-related psychosis (FDA, 2009).
Because of safety considerations associated with antipsychotic medications, non-pharmacologic approaches are generally recognized as the first-line strategy for the treatment of BPSD. Antipsychotic medications are recommended only for short-term treatment (up to 3 months) and among those patients who manifest severe symptoms that may cause extreme distress and harm to themselves or others.
A prescriber may still choose to prescribe antipsychotic medications for BPSD—and they may indeed be effective in some cases. The prescriber must, however, disclose to the patient or family that the medication is being used off-label* and obtain permission to use it for behavioral symptoms.
*Off-label use is the practice of prescribing pharmaceuticals for an unapproved indication, age group, dose, or form of administration.
[The following section is taken largely from NINDS, 2011.]
Those with moderate or advanced dementia often need round-the-clock care and supervision and also may need assistance with daily activities such as eating, bathing, and dressing. Meeting these needs takes patience, understanding, and careful thought by the person’s caregivers.
A typical home environment presents many dangers and obstacles to a person with dementia, but simple changes can overcome many of these problems. For example, sharp knives, dangerous chemicals, tools, and other hazards should be removed or locked away. Other safety measures include installing bed and bathroom safety rails, removing locks from bedroom and bathroom doors, and lowering the hot water temperature to 120°F (48. 9°C) or less to reduce the risk of accidental scalding. People with dementia also should wear some form of identification at all times in case they wander away or become lost. Caregivers can help prevent unsupervised wandering by adding locks or alarms to outside doors.
People with dementia may develop behavior problems because of frustration with specific situations. Understanding and modifying or preventing the situations that trigger these behaviors may help to make life more pleasant for the person with dementia as well as the caregivers. For instance, the person may be confused or frustrated by the level of activity or noise in the surrounding environment. Reducing unnecessary activity and noise (such as limiting the number of visitors and turning off the television when it’s not in use) may make it easier for the person to understand requests and perform simple tasks. Confusion also may be reduced by simplifying home decorations, removing clutter, keeping familiar objects nearby, and following a predictable routine throughout the day. Calendars and clocks also may help patients orient themselves.
People with dementia should be encouraged to continue their normal leisure activities as long as they are safe and do not cause frustration. Activities such as crafts, games, and music can provide important mental stimulation and improve mood. Some studies have suggested that participating in exercise and intellectually stimulating activities may slow the decline of cognitive function in some.
Caregivers provide assistance to someone who is, in some degree, incapacitated and needs help. The recipients of care live in both residential and institutional settings, and range from children to older adults. Typically, the recipients have a chronic illness or disabling condition and need ongoing assistance with everyday tasks to function on a daily basis (CDC, 2010b).
Caregiver demand is partly driven by the steady increase in our older adult population. As the number of older Americans rises, so does the number of needed caregivers. In 2030, when all baby boomers will be at least 65 years old, the population of adults in this age group is projected to be 71 million. The number of people 65 years old and older is expected to rise by 101% between 2000 and 2030, at a rate of 2.3% each year. However, over that same 30-year period, the number of family members who are available to provide care for these older adults is expected to increase by only 25%, at a rate of 0.8% per year (CDC, 2010b).
Caregiving exacts a tremendous toll on caregivers’ health and well-being, and accounts for significant costs to families and society as well. Family caregiving has been associated with increased levels of depression and anxiety as well as higher use of psychoactive medications, poorer self-reported physical health, compromised immune function, and increased mortality. Over half (53%) of caregivers indicate that their decline in health compromises their ability to provide care (NINDS, 2011).
The emotional and physical burden of caring for someone with dementia can be overwhelming. Support groups can often help caregivers deal with these demands and they can also offer helpful information about the disease and its treatment. It is important that caregivers occasionally have time off from round-the-clock nursing demands. Some communities provide respite facilities or adult daycare centers that will care for dementia patients for a period of time, giving the primary caregivers a break. Eventually, many patients with dementia require the services of a full-time nursing home (NINDS, 2011).
Source: CDC, 2011e.
It is important that caregivers take care of themselves and their health. Caregivers should get yearly flu shots and other vaccinations as recommended. They need to have regular health checkups, eat healthy foods, and not skip meals. Caregivers need to find resources if the burden becomes too great with time, asking for help and support from other family members, friends, and neighbors.
Research suggests that the physical and emotional demands on caregivers put them at greater risk for health problems like infectious diseases or chronic diseases such as heart problems, diabetes, and cancer. Depression is twice as common among caregivers as non-caregivers.
Learning coping strategies may help caregivers avoid reaching the point of exhaustion and burnout. Caregiver may be experiencing burnout if they become numb to a loved one’s needs and feelings. Coping strategies include:
The National Family Caregiver Support Program (NFCSP) started in 2000 as part of the reauthorization of the Older Americans Act (AOA) to help older adults and their families. Managed by the Administration on Aging, funds are given to aging service provider networks in all states and territories to help family caregivers with:
To gain access to services under the National Family Caregiver Support Program, contact the nearest Area Agency on Aging. The Eldercare Locator can help to find the nearest one. Call 1-800-677-1116 or visitwww.eldercare.gov.
Because of the aging U.S. population, there are an increasing number of older drivers—33 million over the age of 65 in 2009—who represent a 23% increase from 1999. Normal age-related declines in vision and cognitive functioning, as well as physical changes, may affect some older adults’ driving abilities.
The risk of being injured or killed in a motor vehicle crash increases as we age; an average of 500 older adults are injured every day in crashes. In 2008 more than 5,500 older adults were killed and more than 183,000 were injured in motor vehicle crashes. This amounts to 15 older adults killed and 500 injured in crashes every day.
Driving depends on three areas of wellness: physical fitness, clear thinking, and good vision. Dementia affects a driver’s ability to process information quickly and deal with unexpected circumstances. Regular screening for changes in cognition might help to reduce the number of driving accidents among elderly people, and some states now require that doctors report people with AD to their state motor vehicle department. However, in many cases it is up to the person’s family and friends to ensure that the person does not drive.
Older adults can take several steps to stay safe on the road:
Older adults do not always recognize or will not admit when they should no longer drive. If it is suspected that an older driver should no longer be driving, it is important to have a conversation with that person. During this conversation:
If the older adult refuses to give up driving when it is clearly unsafe, further steps may be necessary:
Both prescription and non-prescription medications impair driving ability, either by themselves or in combination with other drugs. In general, any drug with a prominent central nervous system effect can impair an individual’s ability to safely operate a motor vehicle. The level of impairment varies from patient to patient, between different medications within the same therapeutic class, and in combination with other medications or alcohol.
Medication side effects that can affect driving performance include drowsiness, dizziness, blurred vision, unsteadiness, fainting, slowed reaction time, and extrapyramidal side effects. In many cases, these side effects are dose-dependent and attenuate with time (NHTSA, n.d.).
When considering a new medication, review all prescription and non-prescription medications a patient is taking, including those taken seasonally. Combinations of drugs may affect drug metabolism and excretion to produce additive or synergistic interactions. Use of multiple psychoactive medications is a common cause of hospitalization for delirium among older adults.
Because individuals react differently to drug combinations, the degree of impairment caused by polypharmacy may vary from patient to patient. With polypharmacy’s strong but unpredictable potential to produce impairment, new medications should be added at the lowest dosage possible, while encouraging the patient to be alert to any impairing side effects, and adjusting the dosages of individual medications as needed to achieve therapeutic effects with a minimum of impairment (NHTSA, n.d.).
Medications that can impair driving include:
Each year hundreds of thousands of older people are abused, neglected, and exploited. Many victims are people who are frail and vulnerable and cannot help themselves. They often depend on others to meet their most basic needs. Abusers of older adults are both women and men and may be family members, friends, or “trusted others” (AOA, 2009).
Elder abuse is known to be widespread throughout the United States and the world but because it is largely hidden it is under-reported. Although estimates vary widely, experts believe that nearly 85% of elder abuse cases go unreported and 40% of all elder abuse involves some form of financial exploitation by caretakers, guardians/conservators, or attorneys (Abramson, 2003).
There are many reasons why victims do not report the abuse, including lack of confidence, a history of abuse, fear of retaliation by the abuser, cultural beliefs, embarrassment, and shame. For example, people who have never been self-confident are not likely to ask for help when they become dependent. Those who have been abused or neglected their entire lives expect maltreatment to continue, do not think someone would want to help, and often reject help when it is offered.
In general, elder abuse is a term referring to any knowing, intentional, or negligent act by a caregiver or any other person that causes harm or a serious risk of harm to a vulnerable adult. Legislatures in all fifty states have passed some form of elder abuse prevention laws. Laws and definitions of terms vary considerably from one state to another, but broadly defined, abuse may be:
While one sign does not necessarily indicate abuse, tell-tale signs of physical, emotional, financial, verbal, or sexual abuse, neglect, or mistreatment include:
Many older adults are ashamed to report abuse or are afraid a report will get back to the caregiver and the abuse will get worse. If you think someone is being abused—physically, emotionally, or financially—talk to the person alone and offer to get help from adult protective services (AOA, 2010d).
The Administration on Aging has a National Center on Elder Abuse with listings of government agencies and state laws that deal with abuse and neglect. Go to www.ncea.aoa.gov for more information or call the Eldercare Locator weekdays at 800 677 1116 (AOA, 2010d).
Many local, state, and national social service agencies can help with emotional, legal, and financial problems. Most states require doctors, nurses, and other healthcare professionals to report mistreatment of older adults; this is known as mandatory reporting. You do not have to verify that abuse is occurring, only alert others of your suspicions. Family and friends can also report suspected abuse:
If nursing home care abuse is suspected, call the Long Term Care Ombudsman at:
1001 Connecticut Avenue, NW, Suite 425
Washington, DC 20036
(phone) 202 332 2275
(fax) 202 332 2949
Both family caregivers and healthcare providers can look to established ethical decision-making standards that provide guidance in a challenging environment. When faced with an ethical dilemma, professional guidelines can help resolve the conflict. Although aimed at those who care for people with dementia, ethical guidelines published by the Nuffield Council on Bioethics provides guidance to all caregivers and healthcare providers working with older adults. When confronted with ethical conflicts:
The care of an older adult with a serious or potentially fatal disease begins with the onset of symptoms and continues until the patient is in remission or cured, or until the patient dies. Ideally end-of-life decisions are made early in the process, before they are needed.
Due to the sensitive nature of these decisions, there is often a conspiracy of silence that delays or prohibits discussion. Patients do not want to worry their families, and families are afraid that end-of-life discussions will cause the patient to become depressed or give up. Physicians often feel uncomfortable with these discussions and do not want to worry the patient or family. So end-of-life discussions are often delayed until patients are incapable of making their wishes known and, when the end nears, the issues remain unresolved and decisions are often made by people who may not know the patient’s desires (NCI, 2011b).
Care at the end of life is sometimes inconsistent with the patients' preferences to forgo life-sustaining treatment, and patients may receive care they do not want. For example, in the absence of an advanced directive, a patient’s desire to decline CPR may not be translated into a do-not-resuscitate (DNR) order. This may lead to unwanted treatment that prolongs a patient’s life against the patient’s wishes. Advance planning allows patients and families to reconcile their differences about end-of-life care and helps caregivers reach an agreement if they need to make decisions for the patient.
Families and surrogates who have discussed the contents of an advance directive with the patient have reported improved understanding, better confidence in their ability to predict the patient's preferences, and a stronger belief in the importance of having an advance directive.
Conversations with doctors about advance care planning have been shown to increase satisfaction among patients. Patients who talked with their families or physicians about their preferences for end-of-life care:
There are several types of advance directives. A living will allows people to declare in a detailed fashion (a written statement) their philosophies regarding medical care, nutrition, and other medical issues, so that healthcare providers and institutions can best carry out their wishes. A living will is a formal legal document authorized by state law that ensures personal autonomy while providing instructions for care in case someone becomes incapacitated and cannot make decisions. Living wills are not yet available or legally recognized in all states.
When drafting a living will, the following life-sustaining care should be addressed:
If a decision is made to forgo “aggressive medical treatment,” a patient can still receive antibiotics, nutrition, pain medication, radiation therapy, and other interventions when the goal of treatment becomes comfort rather than cure. This is called palliative care, and its primary focus is helping the patient remain as comfortable as possible. Patients can change their minds at any time and ask to resume more aggressive treatment. Any changes in the type of treatment a patient wants to receive should be reflected in the patient's living will.
Once a living will has been drawn up, patients should discuss their decisions with the people who matter most to them. Most states require that the document be witnessed. It is advisable to make copies of the document, place the original in a safe, accessible place, and give copies to the patient's doctor, hospital, and next of kin. Patients may also want to consider keeping a card in their wallet declaring that they have a living will and where it can be found (NCI, 2012).
A durable power of attorney is the legal document that names a patient’s healthcare proxy (HCP). This is an “agent” (a person) appointed to make a patient's medical decisions if the patient is unable to do so. An agent may have to exercise judgment in the event of a medical decision for which the patient's wishes are not known if the patient becomes too incapacitated to make such decisions. People usually assign someone they know well and trust to represent their preferences. Patients should ask this person for agreement to act as their agent. Once written, the durable power of attorney should be signed, dated, witnessed, notarized, copied, distributed, and incorporated into the patient's medical record (NCI, 2000).
Patients may also want to appoint someone to manage their financial affairs if they cannot. This is called a durable power of attorney for finances, and is a separate legal document from the durable power of attorney for healthcare. Patients may choose the same person or someone different from their healthcare proxy to act as their agent in financial matters (NCI, 2000).
A Do Not Resuscitate (DNR) order is a document that directs what measures should or should not be taken in events such as cardiac or respiratory arrest. Physicians may recommend a DNR order when cardiopulmonary resuscitation (CPR) would be considered medically futile and ineffective in returning the person to life. Patients may also request a DNR order when CPR is not consistent with their goals of care (NCI, 2012).
POLST is Physician Orders for Life-Sustaining Treatment. POLST communicates the patient’s desires for life-sustaining treatment and allows patients to choose what treatment options they want in an emergency situation. The POLST form becomes official orders for the patient in that situation and is valid in a hospital, nursing home, or long-term care facility (Morrow, 2010).
Artificial nutrition and hydration allows patients to receive nutrition and hydration when they are no longer able to eat or drink by mouth. This can be provided either through an IV or a stomach tube. Artificial nutrition and hydration is a medical treatment and can be refused by the patient. If patients are unable to make their wishes known, most states require that treatment continue in the absence of strong evidence of the patient’s wishes (Caring Connections, 2009).
Care at the end of life involves a team-oriented approach that includes expert medical care, pain management, and emotional and spiritual support. Care is tailored to the person’s needs and wishes while providing support to the person’s loved ones.
Palliative care manages the needs of patients who have a progressive incurable illness and often includes hospice. Palliative care utilizes an interdisciplinary approach that focuses on the physical, psychological, social, and spiritual needs of patients who have progressive incurable illnesses. Palliative care can be given at any time throughout the course of an illness, along with curative and aggressive treatments. It includes interventions that are intended to maintain quality of life and ease the suffering of both the patient and family. As death approaches, palliative care typically intensifies to ensure that comfort is a priority and practical needs are addressed (NCI, 2011c).
The goal of palliative care is to improve the patient’s and the family’s quality of life by preventing and relieving suffering. This includes treating physical symptoms such as pain, and dealing with emotional, social, and spiritual concerns. When palliative treatment is given at the end of life, care is taken to make sure the patient’s wishes about treatments are followed (NCI, 2011c).
Palliative care should be routinely integrated with life-prolonging therapies. It is a growing practice specialty for a number of healthcare providers, who typically work in teams. Palliative care is offered when the disease is advanced, life expectancy is short, and problems are urgent and complex. These problems are most often related to uncontrolled symptoms, conflicted or unclear goals of care, distress related to the process of dying, and increasing family burden.
The definition of palliative care has much in common with hospice, but in the United States palliative care is evolving in a way that goes beyond the American version of hospice. Palliative care aims to address the physical, psychosocial, and spiritual concerns that contribute to both the quality of life and quality of dying for patients with life-threatening illnesses at any phase of the disease. Although the focus intensifies at the end of life, the core issues of comfort and function are important throughout the course of the disease.
For the many patients with incurable and progressive diseases who are undergoing active life-prolonging therapies and have life expectancies that potentially extend to years, palliative care includes symptom management, therapy aimed at restoring function, practical support, and psychological interventions. At all stages of the disease, effective palliative care increases the likelihood that the patient will cope adequately with the rigors of therapy and maintain a satisfying level of physical and psychosocial functioning.
For a dying patient, optimal palliative care addresses the traditional concerns of the hospice movement. Preparation of the patient and family for the inevitability of dying and the comfort of the patient are often the biggest challenges during this time. This preparation may have to address a broad range of psychological, social, family, and spiritual concerns.
All patients with progressive incurable diseases, and the families of these patients, need ongoing palliative care throughout the course of the disease, from the time of diagnosis until the final outcome. During much of this period, palliative care will focus on the provision of medical and nonmedical interventions intended to help the patient and family maintain the best quality of life possible as the patient lives with the disease. As the disease becomes more advanced, palliative care begins to focus on maintaining patient comfort and ensuring that other needs are addressed. Support of the family during this time, including bereavement support, is essential.
[The following section on hospice is used with permission from Caring Connections, n.d.a.]
Hospice is not a place; hospice is a family-centered approach to care at the end of life. Hospice care is generally for people with an expected survival of 6 months or less. Its goal is to improve the quality of life that remains by focusing on providing care for the patient and the family rather than attempting to cure the disease. Hospice is designed to relieve or decrease pain or other symptoms, and provide as much quality time as possible with family and friends while meeting the physical, emotional, and spiritual needs of the dying individual. The goal of all hospice care is palliation, or making the patient as comfortable as possible—not dulled by social isolation, drugs, or heroic life-saving efforts. Care is organized around the following principles:
The hospice care team includes doctors, nurses, home health aides, social workers, chaplains, counselors, and trained volunteers who work together to address the dying person’s physical, emotional, and spiritual needs. The goal is to help keep the person as pain-free as possible, with loved ones nearby until death. The hospice team develops a care plan that meets each person’s individual needs for pain management and symptom control. The team usually consists of:
It is important to have a physician involved to ensure quality hospice care. Patients can generally choose to have their personal doctor work with the hospice medical director to coordinate medical care, especially when symptoms are difficult to manage. The hospice medical director is also available to answer questions the person or loved ones may have regarding hospice medical care.
In many cases, family members or loved ones are the dying person’s primary caregivers and have their own special needs for support. As a relationship with the hospice begins, hospice staff will want to know how best to support the person and family during this time.
Among its major responsibilities, the interdisciplinary hospice team:
Support can include conversations with the person and family members, teaching caregiving skills, prayer, telephone calls to loved ones, including family members who live at a distance, and companionship and help from volunteers.
Counseling and grief support for the dying person and their loved ones are important parts of hospice care. After the person’s death, bereavement support is offered to families for at least one year. These services can include telephone calls, visits, written materials about grieving, and support groups. Individual counseling may be offered by the hospice, or the hospice may make a referral to a community resource.
For some people, hospice expenses are paid by health insurance plans (either group policies offered by employers or individual policies). Information about the types of medical costs covered by a particular policy is available from an employee’s personnel office, a hospital or hospice social worker, or an insurance company. Medical costs that are not covered by insurance are sometimes tax-deductible (NCI, 2006).
Medicare—a health insurance program for elders and the disabled that is administered by the Centers for Medicare and Medicaid Services (CMS) of the federal government—provides payment for hospice care. When a patient receives services from a Medicare-certified hospice, Medicare insurance provides substantial coverage, even for some services that would not be covered outside a hospice program (NCI, 2006).
The Medicare hospice benefit was initiated in 1983 and is covered under Medicare Part A (hospital insurance). Medicare beneficiaries who choose hospice care receive a full range of medical and support services for their life-limiting illness. Hospice care also supports the family and loved ones of the dying person through a variety of services (Caring Connections, n.d.b).
More than 90% of hospices in the United States are certified by Medicare. Eighty percent of people who use hospice care are over the age of 65, and are thus entitled to the services offered by the Medicare hospice benefit. This benefit covers virtually all aspects of hospice care with little expense to the person or family. In addition, most private health plans, plus Medicaid in 47 states and the District of Columbia, cover hospice services (Caring Connections, n.d.b).
Medicaid, a federal program that is part of CMS and is administered by each state, is designed for patients who need financial assistance for medical expenses. Information about coverage is available from state welfare offices, state public health departments, state social services agencies, or the state Medicaid office. In addition, local civic, charitable, or religious organizations may be able to help patients and their families with hospice expenses. Hospice will also work with the person and their family to ensure that needed services be provided (NCI, 2006).
If a patient’s health improves or their illness goes into remission, their physician may decide hospice is no longer needed. The patient may also choose to terminate hospice services at any time. When hospice services are stopped, the patient will receive the type of Medicare coverage received before hospice care. If patients are eligible, they may go back to hospice care at any time (Caring Connections, n.d.b).
In order to be eligible for Medicare hospice benefits, a patient must:
Medicare will continue to pay covered benefits for any health needs that are not related to the life-limiting illness.
The number of older American adults is unprecedented in the history of our country because of longer lifespans and the aging of the baby boomers.
Much of the twenty-first century will be defined by the aging of the population. Today about thirteen percent of Americans are over age 65. By the year 2025 this number is expected to grow to over twenty percent, as life span extends well into the eighth decade. Health professionals must separate changes observed in old age that are due to the inevitable aging process from those that are manifestations of pathology. Health professionals must also help to extend the years of productive life through improved health, lifestyle, and psychosocial status.
The challenge for the twenty-first century will be to make these added years as healthy and productive as possible and to continue the current trend of decline in disability across all segments of the population.
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