Gerontology is complex, because it encompasses three levels of complexity: Normal aging changes Chronic diseases Acute exacerbations of chronic diseases (major killers) It is important to be able to recognize the changes of normal aging versus the effects of disease. Untreated disease can result in "excess disability" and reduce the quality of life of individuals. Healthy aging is an issue of increasing importance as the size of the older population continues to grow. It is chronic diseases that can make old age miserable, not the normal changes of aging. Poor health in older life is not inevitable. Much of the illness and disability associated with aging is related to modifiable lifestyle factors that are present in middle age. The rate of physical decline can be modified by lifestyle. The normal changes of aging reduce the older person’s reserve capacity. This makes them more vulnerable to injury or infection. Can cause disability and dependency. One acute illness can cause a “cascade of health problems” not seen in younger people. Aging results in diminished ability to maintain homeostasis and regulate the body systems. As an example, older adults are more vulnerable to hypothermia and hyperthermia. Everyone ages differently and the rate of aging can vary markedly in individuals. Age-related changes in one system are not predictive of changes in other systems. The rate of changes in function of organ systems can even vary markedly within individuals.
As a person gets older, changes occur that can be classified as resulting from aging itself (“normal aging”) and those that result from diseases. In normal aging, many physiological functions are altered, but do not progress to disease. For instance, some degree of glucose intolerance is thought to be a part of normal aging, but diabetes, though very common, is considered a disease. Some common age-related changes might not be considered a part of “normal aging.” Instead, we see a high correlation of these conditions the older a person gets, such as osteoarthritis, hypertension, cataracts, osteoporosis, and Alzheimer’s disease. Most of the normal changes of aging have no impact on normal functioning. These changes will become apparent when the body is place under stress (such as acute illness, physical exertion).
Living is a process of continual change. Infants become toddlers, pubescent children blossom into young men and women, and dependent adolescents develop into responsible adults. The continuation of change into later life is natural and expected. The type, rate, and degree of physical, emotional, pyschological, and social changes experienced during life are highly individualized; such changes are influenced by genetic factors, environment, diet, health, stress, lifestyle choices, and numerous other elements. The result is not only individual variations among older persons, but also differences in the pattern of aging of various body systems within the same individual. Although some similarities exist in the patterns of aging among individuals, the pattern of aging is unique to each individual. Generally, each body system is affected by aging. Some of the changes can begin in the 20s and 30s. “Plastic” or modifiable changes can be slowed by exercise, good nutrition, and other elements of a healthy lifestyle. Normal aging consists of those universal changes that occur in all older people.
Organ and system changes can be traced to changes at the basic cellular level. The number of cells is gradually reduced, leaving fewer functional cells in the body. Lean body mass is reduced, whereas fat tissue increases until the 6th decade of life. Total body fat as a proportion of the body’s composition increases. Cellular solids and bone mass are decreased. Extracellular fluid remains fairly constant, whereas intracellular fluid is decreased, resulting in less total body fluid. This decrease makes dehydration a significant risk to older adults.
The quality of life of elderly depends largely on physical mobility, mental alertness, and normal cognitive ability. Adequate water intake is essential to attain and maintain such quality elements.
Many physical changes of aging affect a person’s appearance. Some of the more noticeable effects of the aging process begin to appear after the fourth decade of life. It is then that men experience hair loss, and both sexes develop gray hair and wrinkles. Subcutaneous body fat atrophies. The body’s contours gain a bony appearance along with a deepening of the hollows of the intercostal and supraclavicular spaces, orbits, and axillae. The loss of subcutaneous fat content is responsible for a decline in the body’s natural insulation, making older adults more sensitive to cold temperatures. Older adults are more vulnerable very cold or very hot weather because they are unable to adapt their body temperature as effectively. Elongated ears, a double chin, and baggy eyelids are among the more obvious manifestations of the loss of tissue elasticity throughout the body. Skin-fold thickness is significantly reduced in the forearm and on the back of the hands. The loss of subcutaneous fat content is responsible for the decrease in skin-fold thickness. Stature decreases, resulting in a loss of approximately 2 inches in height by 80 years of age. Body shrinkage is due to reduced hydration, loss of cartilage, and thinning of the vertebrae. The decrease in stature also causes the long bones of the body, which do not shrink, to appear disproportionately long. Any curvature of the spine, hips, and knees that may be present can further reduce height. These changes in physical appearance are gradual and subtle. Further differences in physiologic structure and function can arise from changes to specific body systems.
Ectropion is the medical term used to describe sagging and turning out of the lower eyelids and eyelashes. As a result, the elder’s eyelids don’t close or function properly.
Decreased skin turgor is a normal finding in elderly patients, making it an unreliable indicator of dehydration. To accurately assess skin turgor in an elderly patient, try squeezing the skin of the sternum or forehead instead of the forearm.
Respiratory function is one of the best predictors of functionality and mortality in old age. This is because the respiratory system reflects changes in many other body systems, including the cardiovascular, nervous, and musculoskeletal systems. Various structural changes occur in the chest with age that reduce respiratory activity. The calcification of costal cartilage makes the trachea and rib cage more rigid; the anterior-posterior chest diameter increases, often demonstrated by kyphosis; and thoracic inspiratory and expiratory muscles are weaker. There is a blunting of the cough and laryngeal reflexes. In the lungs, cilia reduce in number and there is hypertrophy of the bronchial mucous glands, further complicating the ability to expel mucous and debris. Cilia protect against infection by clearing irritants and obstruction. Alveoli reduce in number and stretch due to a progressive loss of elasticity – a process that begins by the 6th decade of life. The lungs become smaller and more rigid and have less recoil. This reduces maximal oxygen intake. The sum of these changes causes less lung expansion, insufficient basilar inflation, and decreased ability to expel foreign or accumulated matter.
Total lung capacity is relatively constant across the life span. Vital capacity is the amount of all that can be forcibly exhaled and this decreases because residual volume, which is the amount of air that remains in the lungs after maximal expiration, increases. Reduced reserve capacity and increased vulnerability to respiratory disease. The lungs exhale less effectively, thereby increasing the residual volume. As the residual volume increases, the vital capacity is reduced; maximum breathing capacity also decreases. Immobility can further reduce respiratory activity. With less effective gas exchange and lack of basilar inflation, older adults are at high risk for developing respiratory infections. Endurance training can produce a significant increase in lung capacity of older adults. Key Concept: The reduced respiratory activity associated with advanced age puts older adults at increased risk for developing pneumonia easily, especially when they are immobile. Older adults need to seek medical help sooner than later – At greater risk for mortality from acute respiratory problems.
In the normal aging lung, alveolar surface area decreases by up to 20 percent which reduces our maximal oxygen uptake (the volume of air that can be moved in and out by forced voluntary breathing) by as much as 55% by age 85. Thus, over time our exercise capacity declines because we have less "reserve". In addition, the alveoli of older adults tend to collapse sooner on expiration than in younger peoples. This tendency is exacerbated by reduced mobility, illness, and hypoventilation and increases the risk for respiratory diseases such as atelectasis. The BLUE represents the amount of air inhaled at any time by a person. The RED represents the Lungs. The PINK (below the Lungs) represents the diaphram. Older adults are less efficient in monitoring and controlling breathing. Older adults may be at greater risk for dying from acute lung problems if they seek medical care later rather than sooner
c. Increase in residual volume and reduction in vital capacity As residual volume increases, the vital capacity is reduced, and maximum breathing capacity decreases placing older adults at high risk for developing respiratory infections
Key concept: Age-related cardiovascular changes are most apparent when unusual demands are placed on the heart. The maximum heart rate of older adults is lower than that of younger adults. However, the resting pulse of a younger and older adults would not show this change. Some cardiovascular changes commonly attributed to age actually result from pathological conditions. Heart size does not change significantly due to age; rather, enlarged hearts are associated with cardiac disease, and marked inactivity can cause cardiac atrophy. There is a slight left ventricular hypertrophy with age, and the aorta becomes dilated and elongated. Atrioventricular valves (mitral, tricuspid) become thick and rigid as a result of sclerosis and fibrosis, compounding the dysfunction associated with any cardiac disease that may be present. There may be incomplete valve closure resulting in systolic and diastolic murmurs. Extra systolic sinus bradycardia and sinus arrhythmia can occur in relation to irritability of the myocardium. Age-related physiologic changes in the cardiovascular system appear in a variety of ways. Throughout the adult years, the heart muscle loses its efficiency and contractile strength, resulting in reduced cardiac output under conditions of physiologic stress. Pacemaker cells become increasingly irregular and decrease in number, and the shell surrounding the sinus node thickens. The isometric contraction phase and relaxation time of the left ventricle are prolonged; the cycle of diastolic filling and systolic emptying requires more time to be completed. Usually, adults adjust to changes in the cardiovascular system quite well. When unusual demands are placed on the heart (e.g., shoveling snow for the first time of the season, receiving bad news, running to catch a bus), the person feels the effects. The same holds true to older individuals who are not severely affected by less cardiac efficiency under non-stressful conditions. When older persons are faced with an added demand on their hearts, however, they note the difference. Although the peak rate of the stressed heart may not reach the levels experienced by younger persons, tachycardia in older persons will last for a longer time. Stroke volume may increase to compensate for this situation, which results in elevated blood pressure, although the blood pressure can remain stable as tachycardia progresses to heart failure in older adults. The resting heart rate is unchanged. Maximum exercise capacity and maximum oxygen consumption vary among older people. Older adults in good physical condition have comparable cardiac function to younger persons who are in poor condition. Blood vessels consist of three layers, each of which is affected differently by the aging process. The tunica intima, the innermost layer, experiences the most direct changes, including fibrosis, calcium and lipid accumulation, and cellular proliferation. These changes contribute to the development of atherosclerosis. The middle layer, the tunica media, undergoes a thinning and calcification of elastin fibers and an increase in collagen, which cause a stiffening of the vessels. Impaired baroreceptor function and increased peripheral resistance, leading to a rise in systolic blood pressure, result. The outermost layer (the tunica adventitia) is not affected. Decreased elasticity of the arteries is responsible for vascular changes to the heart, kidney, and pituitary gland. Reduced sensitivity of the blood pressure-regulating baroreceptors increases problems with postural hypotension and postprandial hypotension (blood pressure reduction of at least 20 mm Hg within 1 hour of eating). The reduced elasticity of the vessels, coupled with thinner skin and less subcutaneous fat, causes the vessels in the head, neck, and extremities to become more prominent.
GI = mouth, esophagus, stomach, small & large intestines, live, gallbladder, and pancreas. Generally, physiological changes of aging in the digestive system are minor. Although not as life-threatening as other body systems, GI symptoms may be of more concern to older persons. This system is altered by the aging process at all points. Changes in the teeth and mouth and accessory structures such as the liver also affect GI function. Tooth enamel becomes harder and more brittle with age. Dentin, the layer beneath the enamel, becomes more fibrous and its production is decreased. The root pulp experiences shrinkage and fibrosis, the gingiva retracts, and bone density in the alveolar ridge is lost. Increasing numbers of root cavities and cavities around existing dental work occur. Flattening of the chewing cusps is common. The bones that support the teeth decrease in density and height, contributing to tooth loss. Tooth loss is not a normal consequence of growing old, but poor dental care, diet, and environmental influences have contributed to many of today’s older population being endentulous (loosing teeth). After 30 years of age, periodontal disease is the major reason for tooth loss. More than half of all older adults must rely on partial or full dentures, which may not be worn regularly because of discomfort or poor fit. Taste sensations become less acute with age because the tongue atrophies, affecting the taste buds. Sweet sensations tend to suffer a greater loss than sensations for sour, salt, and bitter flavors. Excessive seasoning of foods may be used to compensate for taste alterations and could lead to health problems for older individuals. Older adults produce approximately one third of the amount of saliva they produced in younger years. This can lead to dry mouth (xerostomia), which can interfere with desire for food and nutrition. Esophageal motility is affected by age. The esophagus tends to become slightly dilated, and esophageal emptying is slower, which can cause discomfort because food remains in the esophagus for a longer time. Relaxation of the lower esophageal sphincter may occur; when combined with the older person’s weak gag reflex and delayed esophageal emptying, aspiration becomes a risk. Stomach has reduced motility in old age, along with decreases in hunger contractions. The gastric mucosa atrophies. Hydrochloric acid and pepsin decline with age; the higher pH of the stomach contributes to an increased incidence of gastric irritation in the older population (gastritis, ulcers). Atrophic gastritis – a stomach disorder unique to the elderly. Thinning of stomach lining. Brings on achlorhydria – Also, common cause of vitamin B12 deficiency. Atrophy small and large intestines; fewer cells present on the absorbing surface of intestinal walls. Fat absorption is slower. Absorption of vitamin B, B12, D, calcium, and iron is faulty. The large intestine has reductions in mucous secretions and elasticity of the rectal wall. Normal aging does not interfere with the motility of feces through the bowel, although other factors that are highly prevalent in late life do contribute to constipation. Liver has reduced weight and volume. Metabolism of drugs is generally slower in older adults. This can cause a higher build up of the drug in the body, causing adverse effects. The older liver is less able to regenerate damaged cells. Liver function tests remain within normal range. Less efficient cholesterol stabilization and absorption causes an increased incidence of gallstones. The pancreatic ducts become dilated and distended, and often the entire gland prolapses.
Liver – Altered clearance of drugs. Half lives of certain drugs such as benzodiazepines may be doubled due to decreased metabolism of liver.
True. Absorption of vitamin B, vitamin B12, vitamin D, calcium, and iron is decreased in the intestine of the older adult.
The urinary system is affected by changes in the kidneys, ureters, and bladder. The renal mass becomes smaller with age. Renal tissue growth declines, and atherosclerosis may promote atrophy of the kidney. These changes can have a profound effect on renal function, reducing renal blood flow and the glomerular filtration rate by approximately one-half between the ages of 20 and 90 years. Tubular function decreases. There is less efficient tubular exchange of substances, conservation of water and sodium, and suppression of antidiuretic hormone secretion in the presence of hypo-osmolarity. Although these changes can contribute to hyponatremia and nocturia, they do not affect specific gravity to any significant extent. The decrease in tubular function also causes decreased reabsorption of glucose from the filtrate, which can cause 1+ proteinurias and glycosurias not to be of major diagnostic significance. Urinary frequency, urgency, and nocturia accompany bladder changes with age. Bladder muscles weaken and bladder capacity decreases. Emptying of the bladder is more difficult; retention of large volumes of urine may result. The micturition reflex is delayed. Although urinary incontinence is not a normal outcome of aging, some stress incontinence may occur because of a weakening of the pelvic diaphragm, particularly in multiparous women.
The glomerular and tubular basement membranes thicken with age, also reducing filtrating ability. The number of glomeruli and their surface area decrease. The tubular changes result in a decreased ability to concentrate urine. This figure shows the difference in glomerular filtration rate (GFR) for a young and an old kidney. The older kidney has a lower concentration of the urine (lighter yellow with fewer particles in it). Aging clients have decreased thirst mechanism, and since their kidneys do not concentrate urine as efficiently, the elderly are more at risk for dehydration. The aging bladder is characterized by a decrease in capacity and urinary flow, and an increase in urgency and amount of residual urine. This is because the bladder muscle, the detrusor muscle, becomes less elastic with age and the urinary sphincters become weaker. The changes contribute to a increase in nocturia (frequent urination at night), increased urgency and incontinence, as well as a higher rate of urinary tract infections among the elderly. Which change in renal functioning as a result of the normal aging process will increase the older client’s risk for infection? Urinary retention as a result of detrusor muscle being less elastic.
“A” Because of age-related changes in the immune system, a sudden change in behavior is one of the best indicators of a urinary tract infection in adults 80 years of age and older. Urinary tract infections in older adults may present as confusion, falls, new onset incontinence, and decrease in appetite. Often there is no fever, pain, or discomfort.
As men age, the seminal vesicles are affected by smoothing of the mucosa, thinning of the epithelium, replacement of muscle tissue with connective tissue, and reduction of fluid-retaining capacity. The seminiferous tubules experience increased fibrosis, thinning of the epithelium, thickening of the basement membrane, and narrowing of the lumen. The structural changes can cause a reduction in sperm count in some men. Venous and arterial sclerosis and fibroelastosis of the corpus spongiosum can affect the penis with age. The older man does not lose the physical capacity to achieve erections or ejaculations. There is some atrophy of the testes. Prostatic enlargement occurs in most older men. The rate and type vary among individuals. Three fourths of men aged 65 and older have some degree of prostatism, which causes problems with urinary frequency. Although most prostatic enlargement is benign, it does pose a greater risk of malignancy and requires regular evaluation. The female genitalia demonstrate many changes with age, including atrophy of the vulva from hormonal changes, accompanied by the loss of subcutaneous fat and hair and a flattening of the labia. The vagina of the older woman appears pink and dry with a smooth, shiny canal because of the loss of elastic tissue and rugae. The vaginal epithelium becomes thin and avascular. The vaginal environment is more alkaline in older women and is accompanied by a change in the type of flora and a reduction in secretions. The cervix atrophies and becomes smaller; the endocervical epithelium also atrophies. The uterus shrinks and the endometrium atrophies; however, the endometrium continues to respond to hormonal stimulation, which can be responsible for incidents of postmenopausal bleeding in older women on estrogen therapy. The fallopian tubes atrophy and shorten with age, and the ovaries atrophy and become thicker and smaller. Despite these changes, the older woman does not lose the ability to engage in and enjoy intercourse or other forms of sexual pleasure. Estrogen depletion also cause a weakening of the pelvic floor muscles, which can lead to an involuntary release of urine when there is an increase in intra-abdominal pressure.
By the time we reach age 80, most of us will lose an average of about 2 inches of height. The primary factors contributing to this reduction in height include compression of vertebrae, changes in posture, and increased curvature of the hips and knees. The kyphosis, enlarged joints, flabby muscles, and decreased height of many older persons result from the variety of musculoskeletal changes occurring with age. Along with other body tissue, muscle fibers atrophy and decrease in number, with fibrous tissue gradually replacing muscle tissue. Overall muscle mass, muscle strength, and muscle movements are decreased; the arm and leg muscles, which become particularly flabby and weak, display these changes well. Because the variability in the rate of these changes could suggest they result from inactivity rather than aging, the importance of exercise to minimize the loss of muscle tone and strength cannot be emphasized enough. For various reasons, muscle cramping frequently occurs. Muscle tremors may be present and are believed to be associated with degeneration of the extrapyramidal system. The tendons shrink and harden, which causes a decrease in deep tendon reflexes. Reflexes are lessened in the arms, are nearly totally lost in the abdomen, but are maintained in the knee. Bone mineral and mass are reduced, contributing to the brittleness of the bones of older people, especially older women. There is diminished calcium absorption, a gradual resorption of the interior surface of the long bones, and a slower production of new bone on the outside surface. These changes make fractures a serious risk to the older adults. Although long bones do not significantly shorten with age, thinning disks and shortening vertebrae reduce the length of the spinal column, causing a reduction in height with age. Height may be further shortened because of varying degrees of kyphosis, a backward tilting of the head, and some flexion at the hips and knees. A deterioration of the cartilage surface of joints and the formation of points and spurs may limit joint activity and motion. Key concept: Regular exercise helps maintain muscle strength and tone and reduces some of the negative functional consequences of aging.
It is difficult to identify with accuracy the exact impact of aging on the nervous system because of the dependence of this system’s function on other body systems. For instance, cardiovascular problems can reduce cerebral circulation and be responsible for cerebral dysfunction. There is a decline in brain weight and a reduction in blood flow to the brain; however, these structural changes do not appear to affect thinking and behavior. Brain cells decline by 1% yearly, the cerebral cortex undergoes approximately a 20% loss of neurons, and there is some decrease in brain size. Declining nervous system function may be unnoticed because changes are often nonspecific and slowly progressing. A reduction in neurons, nerve fibers, and cerebral blood flow and metabolism are known to occur. The nerve conduction velocity is lower. These changes are manifested by slower reflexes and delayed response to multiple stimuli. Kinesthetic sense lessens. There is a slower response to changes in balance, a factor contributing to falls. The hypothalamus regulates temperature less effectively. Because the brain affects the sleep-wake-cycle, and circadian and homeostatic factors of sleep regulation are altered with aging, changes in the sleep pattern occur, with stages III and IV of sleep becoming less prominent. Frequent awakening during sleep is not unusual, although only a minimal amount of sleep is actually lost.
A. Decline in the weight of the brain There is a decline in brain weight and a reduction in blood flow to the brain. Stages III and IV sleep become less prominent. Nerve conduction velocity is lower which causes slower reflexes and delayed response to multiple stimuli.
Perhaps the sensory changes having the greatest impact are changes in vision. Presbyopia, the inability to focus or accommodate properly due to reduced elasticity of the lens, is characteristic of older eyes and begins in the 4th decade of life. This vision problem causes most middle-aged and older adults to need corrective lenses to accommodate close and detailed work. The visual field narrows, making peripheral vision more difficult. There is difficulty maintaining convergence (movement of the two eyes so coordinated that the images of a single point fall on corresponding points of the two retinas) and gazing upward. The pupil is less responsive to light because the pupil sphincter hardens, the pupil size decreases, and rhodopsin content in the rods decreases. (The pigment in the rod cells of the retina of the eye which is responsible for the visual process; helps the eye adjust to drastic changes in environmental lighting.) Changes in the retina and retinal pathway interfere with critical flicker fusion (the point at which a flickering light is perceived as continuous rather than intermittent). As a result, the light perception threshold increases and vision in dim areas or at night is difficult; older individuals need more light than younger persons to see adequately. Alterations in blood supply of the retina and retinal pigmented epithelium can cause macular degeneration, a condition in which there is a loss in central vision. Common eye disorders in the elderly (changes that are NOT normal) include cataracts, glaucoma, senile macular degeneration, and diabetic and hypertensive retinopathy
The density and size of the lens increases, causing the lens to become stiffer and more opaque. Opacification of the lens leads to the development of cataracts, which increases sensitivity to glare, blurs vision, and interferes with night vision. Exposure to the ultraviolet rays of the sun contribute to cataract development. Yellowing of the lens (possibly related to a chemical reaction involving sunlight with amino acids) and alterations in the retina that affect color perception make the older people less able to differentiate the low tone colors of the blues, greens, and violets. Depth perception becomes distorted, causing problems in correctly judging the height of curbs and steps. Dark and light adaptation takes longer, as does the processing of visual information. Less efficient reabsorption of intraocular fluid increases the older person’s risk for developing glaucoma. The ciliary muscle gradually atrophies and is replaced with connective tissue. The appearance of the eye may be altered; reduced lacrimal secretions can cause the eyes to look dry and dull, and fat deposits can cause a partial or complete glossy white circle to develop around the periphery of the cornea (arcus senilis). Corneal sensitivity is diminished, which can increase the risk of injury to the cornea. The accumulation of lipid deposits in the cornea can cause a scattering of light rays, which blurs vision. In the posterior cavity, bits of debris and condensation become visible and may float across the visual field; these are commonly called “floaters.” Vitreous decreases and the proportion of liquid increases, causing the vitreous body to pull away from the retina; blurred vision, distorted images, and floaters may result. Visual acuity progressively declines with age due to decreased pupil size, scatter in the cornea and lens, opacification of the lens and vitreous, and loss of photoreceptor cells in the retina. Visual acuity (VA) is acuteness or clearness of vision, especially form vision, which is dependent on the sharpness of the retinal focus within the eye and the sensitivity of the interpretative faculty of the brain.
“B” The pupils become smaller with age, which limits the amount of light reaching the retina. The older adult, therefore, has greater difficulty seeing objects in dim light. Other normal age-related changes in vision include decreased lacrimation, presbyopia (difficulty focusing on near objects), yellowing of the lens, and increased sensitivity to glare.
Hearing loss is common in older adults. A significant number of older people, including a majority of those residing in nursing homes, have some degree of hearing loss, resulting from a variety of factors in addition to aging. In fact, hearing loss related to normal aging is the most common cause of sensory impairment. Over 30% of persons age 65 to 74 and 50% over 75 have some degree of hearing loss. Older men of all ages are more likely to be hearing impaired than older women. White men and women are more likely than AA men and women to report hearing problems. Complete deafness in both ears accounts for a little over 20% of all hearing impairments in older people. About 3 million people in the United States wear hearing aids in one or both ears. Exposure to noise from loud music, jets, traffic, heavy machinery, and guns cause cell injury and loss. The higher incidence of hearing loss in men may be associated with their more frequent employment in occupations that subject them to loud noise (e.g., truck driving, construction work, heavy factory work, military service). Recurrent otitis media and trauma can damage hearing. Cumulative damage to eighth cranial nerve: hearing loss, vertigo, loss of equilibrium, motion sickness, tinnitus Certain drugs ototoxic: aspirin, loop diiuretics, aminoglycoside antibiotics (those ending in –mycin). The delayed excretion in many older persons promotes this effect. Need trough after third dose. Diabetes, tumors of the nasopharynx, hypothyroidism, syphilis, other disease processes, and psychogenic factors also can contribute to hearing impairment. Particular problems affect the ears of the older person. Vascular problems, viral infections, and presbycusis: inner ear damage. Tinnitus, a ringing or buzzing, chirping sound in the ear; associated with age-related hearing loss, ear injury, medications, or cardiovascular disease. Hearing can be further jeopardized by an accumulation of cerumen in the middle ear. Cerumen becomes harder and drier with age, and may occlude the ear canal. Hearing can be further jeopardized by an accumulation of cerumen in the middle ear. The most common cause of hearing loss. Your ears have two jobs. One is hearing and the other is maintaining balance. Hearing occurs after vibrations cross the eardrum to the inner ear. They are changed into nerve impulses and carried to the brain by the auditory nerve. Balance (equilibrium) is controlled in a portion of the inner ear. Fluid and small hairs in the semicircular canal (labyrinth) stimulate the nerve that helps the brain maintain balance. In addition to hearing problems, equilibrium can be altered because of degeneration of the vestibular structures and atrophy of the cochlea, organ of Cortia, and stria vascularis.
Presbycusis is progressive hearing loss that occurs as a result of age-related changes to the inner ear, including loss of hair cells. It is the most common cause of hearing loss in the elderly and the most serious problem affecting the middle ear. It is characterized by progressive hearing loss and sound discrimination. Tiny hairs inside your ear help you hear. They pick up sound waves and change them into the nerve signals that the brain interprets as sound. Hearing loss occurs when the tiny hairs inside the ear are damaged or die. The hair cells do not regrow, so most hearing loss is permanent. A variety of factors, including continued exposure to loud noise, may contribute to the occurrence of presbycusis. This problem causes speech to sound distorted as some of the high pitched sounds (s, sh, f, ph, ch) are filtered from normal speech and consonants are less able to be discerned. The loss of hearing occurs slowly over time. It is most difficult to hear high-frequency sounds, such as someone talking. As hearing gets worse, it may become difficult to hear sounds at lower pitches. Symptoms include: Difficulty hearing high frequencies High-pitched sounds such as "s," “sh,” “ch,” or "th" are hard to distinguish from one another Men's voices are easier to hear than women’s. Other people's voices sound mumbled or slurred Inability to distinguish directions of sound Certain sounds seem overly loud Difficulty hearing things in noisy areas Ringing in the ears
Cerumen impaction is one of the most common and reversible causes of conductive hearing loss in elderly adults. Nearly 35% of community-residing older adults have cerumen impaction in one or both ears, and the rate of impaction in the institutionalized elderly is thought to be much higher. As described earlier, cerumen becomes harder and drier with age, and may occlude the ear canal. Recommended aural hygiene involves gentle cleansing of the auricles (outside of the ears) during bath or shower. The use of cotton-tipped applicators to cleanse the ear canal is not recommended because the applicator may push the cerumen deeper into the canal and thus increase the risk of impaction, as well as traumatize the canal wall and tympanic membrane. An occlusion of cerumen can greatly affect hearing, as sound is unable to reach the inner ear. Examination of the ear canal for cerumen impaction is recommended as part of routine preventive heatlhcare screening for older adults. The person with cerumen impaction may complain of a feeling of fullness or itching in the ear canal. In addition to hearing loss, cerumen may also cause tinnitus, ear pain, or vertigo. Contraindications for cerumen removal include perforated tympanic membrane, ear trauma, tumors, and cholesteatoma. Use extreme caution in patients with diabetes due to the increased risk of infection.
Sensorineural hearing loss involves damage to the inner ear, auditory nerve, or the brain. This type of hearing loss may or may not respond to treatment, but function can be helped by hearing aids. Conductive hearing loss occurs when sound has problems getting through the outer and middle ear to the inner ear.
Contraindications to ear lavage or irrigation include history of ear surgery and history of otitis media (swimmer’s ear). It is safer to make a referral to an ear, nose, and throat specialist.
The first action in caring for someone with a hearing deficit should be to encourage audiometric examination. Hearing impairment should not be assumed to be a normal consequence of aging and ignored. It would be most sad and negligent if the cause of the hearing problem was easily correctable (e.g. removal of cerumen or a cyst) but was allowed to limit the life of the affected individual. Although sometimes the underlying cause of the hearing problem can be corrected, frequently, older persons must learn to live with varying degrees of hearing deficits. It is not unusual for individuals with a hearing impairment to demonstrate emotional reactions to their hearing deficits. Unable to hear conversations, patients may become suspicious of those around them and accuse people of talking about them. Anger, impatience, and frustration can result from repeatedly unsuccessful attempts to understand conversation. Patients may feel confused or react inappropriately on receiving distorted verbal communications. Limited ability to hear danger and protect themselves may make them feel insecure. Being self-conscious of their limitation may make them avoid social contact to escape embarrassment and frustration. Social isolation can be a serious threat; people sometimes avoid an older person with a hearing deficit because of the difficulty in communication. Physical, emotional, and social health can be seriously affected by this deficit. Helping older adults live with hearing deficits is a challenge but an important responsibility in gerontological care. A neighbor should be alerted to the individual’s hearing problem so that he or she can be protected in an emergency. In an institutional setting, such patients should be located near the nurses station. People with hearing loss should be advised to request explanations and instructions in writing so that they receive the full content. When talking with individuals with high-frequency hearing loss, the speaker should talk slowly, distinctly, and in a low-frequency voice. Raising the voice or shouting will only raise the sounds to a higher frequency and compound the deficit. Methods for promoting more accurate and complete communication include talking into the less impaired ear, facing the individual when talking, using sign language, gestures, and facial expressions, allowing the person to lip read, using a stethoscope to amplify sounds, and using flash cards or similar aids.
Hearing aids can benefit persons with some hearing disorders, but they may not solve all hearing problems. The otologist can determine if the specific hearing problem can be improved by using a hearing aid and can recommend the particular aid best suited to the patient’s needs. A hearing aid should never be purchased without being specifically prescribed. Sometimes, older persons will attempt to improve hearing by purchasing an aid through a private party or a mail-order catalog, which often results in disappointment and a waste of money from an already limited budget. The nurse is in a key position to educate the older individual on the importance of consulting an otologist before purchasing a hearing aid. Patients must understand that, even with a hearing aid, their problems will not be solved. Although hearing will improve, it will not return to normal. Speech may sound distorted through the aid because when speech is amplified, so are all environmental noises, which can be most uncomfortable and disturbing to the individual. Sounds may be particularly annoying in areas where reverberation can easily occur (e.g., a church or large hall). Some persons never make the adjustment to a hearing aid and choose not to wear the appliance rather than to tolerate these disturbances and distortions. New hearing aid user need support during the adjustment phase and should be advised to wear the aid for progressively longer periods each day until comfort is gained and to avoid its use in noisy environments, such as airports, train stations, and stadiums. The aid must be checked regularly to ensure that the earpiece is not blocked with cerumen and that the battery is working.
“A” Presbycusis is a type of sensorineural hearing loss associated with normal aging. This condition causes a decreased ability to hear high frequency sounds, such as the consonants g, f, s, sh, t, and z. It is easier for older people with presbycusis to hear low frequency sounds, such as the vowels.
Taste – Approximately half of all older persons experience some loss of their ability to smell. The sense of smell reduces with age because of a decrease in the number of sensory cells in the nasal lining and fewer cells in the olfactory bulb of the brain. By age 80, detection of scent is almost half as sensitive as it was at its peak. As most of taste acuity is dependent on smell, the reduction in the sense of smell alters the sense of taste. Atrophy of the tongue with age can diminish taste sensations, although there is not conclusive evidence that the number or responsiveness of taste buds decreases. A decrease in taste perception of food is thought to be related to a perceptual loss of taste. Reduced saliva production, poor oral hygiene, medications, and conditions such as sinusitis can also affect taste. Touch – Tactile sensation is reduced, as observed in the reduced ability of older persons to sense pressure and pain and differentiate temperatures. These sensory changes can cause misperceptions of the environment and, as a result, profound safety risks.
With age, the thyroid gland undergoes fibrosis and has more nonfunctioning nodules. The resulting decreased thyroid gland activity causes a lower basal metabolic rate, reduced radioactive iodine uptake, and less thyrotropin secretion and release. Protein-bound iodine levels in the blood do not change, although total serum iodide is reduced. The thyroid gland progressively atrophies, and the loss of adrenal function can further decrease thyroid activity. Secretion of thyroid-stimulating hormone (TSH) and the serum concentration of thyroxine (T4) do not change, although there is a significant reduction in trriodothyronine (T3), believe to be a result of the reduced conversion of T4 to T3. Overall, thyroid function remains adequate. Much of the secretory activity of the adrenal cortex is regulated by adrenocorticotropic hormone (ACTH), a pituitary hormone. As ACTH secretion decreases with age, secretory activity of the adrenal gland decreases also. Less aldosterone is produced and excreted in the urine of older persons. Less aldosterone levels may cause orthostatic hypotension – increased risk of falls. The secretion of glucocorticoids, 17-kerosteroids, progesterone, androgen, and estrogen, also influenced by the adrenal gland, are reduced as well. The pituitary gland decreases in volume by approximately 20% in older persons. Somatotropic growth hormone remains present in similar amounts, although the blood level may be reduced with age. Decreases are seen in ACTH, TSH, follicle-stimulating hormone, luteinizing hormone, and luteotropic hormone to varying degrees. Gonadal secretion declines with age, including gradual decreases in testosterone, estrogen, and progesterone. With the exception of alterations associated with changes in plasma calcium level or dysfunction of other glands, the parathyroid glands maintain their function throughout life. There is a delayed and insufficient release of insulin by the beta cells of the pancreas in older people, and there is believed to be a decreased tissue sensitivity to circulating insulin. The older person’s ability to metabolize glucose is reduced, and sudden concentrations of glucose cause higher and more prolonged hyperglycemia levels; therefore, it is not unusual to detect higher blood glucose levels in nondiabetic older persons. Insulin resistance also increases as people age, and this will also contribute to higher blood glucose levels. Key concept: Higher blood glucose levels than are normal in the general adult population are not unusual in non-diabetic older people.
Diet, general health, activity, exposure, and hereditary factors influence the normal course of aging of the skin. This system’s changes are often the most bothersome because they are obvious and clearly reflect advancing years. Flattening of the dermal-epidermal junction, reduced thickness and vascularity of the dermis, slowing of epidermal proliferation, and an increased quantity and degeneration of elastin fibers occur. Collagen fibers become coarser and more random, reducing skin elasticity. The dermis becomes more avascular and thinner. As the skin becomes less elastic and more dry and fragile, and as subcutaneous fat is lost, lines, wrinkles, and sagging become evident. Skin becomes irritated and breaks down more easily. There is a reduction in the number of melanocytes, and those present cluster causing skin pigmentation, commonly referred to as age spots: these are more prevalent in areas of the body exposed to the sun. The reduction in melanocytes cause older adults to tan more slowly and less deeply. Skin immune response declines, causing older people to be more prone to skin infections. Benign and malignant skin neoplasms occur more with age. Scalp, pubic, and axillary hair thins and grays due to a progressive loss of pigment cells and atrophy and fibrosis of hair bulbs; hair in the nose and ears becomes thicker. By age 50, more white men have some degree of baldness and about half of all people have evidence of gray hair. Growth rate of scalp, pubic, and axillary hair declines; the growth of facial hair may occur in older women. An increased growth of eyebrow, ear, and nostril hair occurs in older men. Fingernails grow more slowly, are fragile and brittle, develop longitudinal ridges, and experience a decrease in lunula size. Perspiration is slightly reduced because the number and function of the sweat glands are lessened.
The depressed immune response of older adults causes infections to be a significant risk for this age group. Sometimes infections are difficult to diagnose. The febrile response that signals infections may be blunted in the older person. The baseline body temperature in older people is approximately 1 F lower than the normal temperature in younger people. Therefore, a rise in body temperature may not be immediately evident. Other classic signs and symptoms of infection, such as redness, swelling and pain, may also be altered. After midlife, thymic mass decreases steadily, to the point that serum activity of thymic hormone is almost undetectable in the aged. T-cell activity declines, and more immature T cells are present in the thymus. A significant decline in cell-mediated immunity occurs, and T lymphocytes are less able to proliferate in response to mitogens (a substance or agent that induces mitosis). Changes in the T cells are witnessed in many older individuals. Cell-mediated immunity is an immune response that does not involve antibodies or complement but rather involves the activation of macrophages, natural killer cells (NK), antigen-specific cytotoxic T-lymphocytes, and the release of various cytokines in response to an antigen. Serum immunoglobulin concentration is not significantly altered; the concentration of IgM is lower, whereas the concentrations of IgA and IgG are higher. An increase in antibody production that reacts against the person’s own body cells also may occur, contributing to the development of autoimmune diseases such as rheumatoid arthritis. Responses to influenza, pneumonia, and tetanus vaccines are less effective (although vaccination is recommended because of the serious potential consequences of infections for older adults.) Inflammatory defenses decline and, often inflammation presents atypically in older individuals (e.g., low-grade fever, minimal pain).
“B” Atypical presentation of illness in older adults includes absence of fever and cough, anorexia, confusion, dizziness, falls, fatigue, new-onset incontinence, lethargy, level of consciousness changes, malaise, self-neglect, and unexplained weight loss.
Normal body temperatures are lower in later life than in younger years. Mean body temperature ranges from 96.6 F to 98.3 F orally and 98 F to 99 F rectally. Rectal temperatures are the most accurate and reliable indicators of body temperature in older adults. There is a reduced ability to respond to cold temperatures due to inefficient vasoconstriction, decreased cardiac output, diminished shivering, and reduced muscle mass and subcutaneous tissue. At the other extreme, differences in response to heat are related to impaired sweating mechanisms and decreased cardiac output.
True. Normal body temperatures are lower later in life than in younger years.
Psychological changes can be influenced by general health status, genetic factors, educational achievement, activity, and physical and social changes. Sensory organ impairment can impede interaction with the environment and other people, thus influencing psychological status. Feeling depressed and socially isolated may obstruct optimum psychological function. Recognizing the variety of factors potentially affecting psychological status and the range of individual responses to those factors, some generalizations can be discussed. Personality – Drastic changes in basic personality normally do not occur as one ages. Excluding pathologic processes, the personality will be consistent with that of earlier years. Personality in late life is a reflection of lifelong personality. Memory – The three types of memory are short-term, long-term, and sensory. Retrieval of information from long-term memory can be slowed. Working memory function (the ability to retain information in the consciousness while manipulating other information) is reduced. Intelligence – Some research shows bias. Basic intelligence is maintained; one does not become more or less intelligent with age. The abilities for verbal comprehension and arithmetic operations are unchanged. Crystallized intelligence, which arises from the dominant hemisphere of the brain, is maintained through the adult years. This form of intelligence enables individuals to use past learning and experiences for problem-solving. Fluid intelligence, emanating from the non-dominant hemisphere, controls emotions, retention of non-intellectual information, creative capacities, spatial perceptions, and aesthetic appreciation. This type of intelligence is believed to decline in later life. High levels of chronic psychological stress are associated with increased mild cognitive impairment. Learning – Learning ability is not altered with age. Other factors can interfere with the ability to learn, such as motivation, attention span, delayed transmission of information to the brain, perceptual deficits, and illness. Older persons may display less readiness to learn and depend on previous experience for solutions to problems rather than experiment with new problem-solving techniques. Early phases of learning process tend to be more difficult for older persons than younger individuals. After a longer early phase, they are able to keep equal pace. Slower response and reaction time – Allow adequate time for elder to respond, process information, perform tasks. Older adults maintain the capacity to learn, although a variety of factors can easily interfere with the learning process. Learning occurs best when the new information is related to previously learned information. Little difference in verbal and abstract ability. Older persons do show some difficulty with perceptual motor tasks. Greater problem to learn new habits when old habits exist (and must be unlearned, relearned, or modified). Attention span – Older adults demonstrate a decrease in vigilance performance (the ability to retain attention longer than 45 seconds). They are more easily distracted by irrelevant information and stimuli and are less able to perform tasks that are complicated or require simultaneous performance.
A, B, E
Common aging changes_spring 2014 abridged
Common Aging Changes
NURS 4100 Care of the Older Adult
Joy Shepard, PhD(c), MSN, RN, CNE,
• List common age-related changes at the
cellular level; in physical appearance; and
to various body systems, the sensory
organs, and thermoregulation
• Discuss risks and nursing considerations
associated with age-related changes
• Identify signs of and nursing interventions
for older adults with hearing impairment
• Changes of aging highly
• Changes also different in various
body systems of the individual
• Changes influenced by:
– Genetic factors, environment, diet,
health, stress, and lifestyle choices
Changes in the Body: Cells
• Changes start at cellular
• Cell numbers reduced
• Decreased lean body
• Increased total body fat
• Decreased fluid (cells)
• Risk for dehydration
Checking Skin Turgor?
Not on back of hand or forearm
for an elder client
Forehead, collarbone, or sternum
Changes in the Body:
• Reduction respiratory
• Increased rigidity of
• Increased anterior-posterior
diameter of chest
• Blunted cough reflex,
• Less lung expansion
Changes in the Body:
• Increased residual
volume (increased air
remaining in lungs after
the most complete
• Reduced vital capacity
(decreased capacity to
inhale, hold, & exhale
• High risk for respiratory
• Which of the normal age-related changes in the
respiratory system can increase the risk of
infection in the older adult population?
– A. Decrease in the anterior-posterior diameter of
– B. Increased strength of the thoracic musculature
– C. Increase in residual volume and reduction in
– D. Decreased calcification of costal cartilage
Changes in the Body:
• Heart size unchanged (in
absence of pathology)
• Valves thick & rigid
• Heart muscle loses
Reduced cardiac output
under physiologic stress
• Reduced elasticity of blood
• Increased peripheral
HTN not normal part of
• Is the following statement true or false?
• Atrophy of the small and large intestine,
with fewer cells present on the absorbing
surface of the intestinal wall, causes
certain vitamins and minerals to have a
decreased rate of absorption
Changes in the Body: Urinary
• Reduction renal blood
flow & filtration
• Reduced bladder
– Urinary frequency,
urgency, & nocturia
– UTI = confusion
• Incontinence not a
normal part of aging
Changes in the Body:
• Atrophy of muscles
• Tendons shrink &
• Reduction in bone
mineral & mass
• Loss of height
• Joint activity & motion
• Increased risk fractures
Changes in the Body:
• Reduction: nerve cells,
cerebral blood flow, &
• Slower reflexes, delayed
responses, & changes in
Increased risk falls
• Nervous system affected by
all other body systems
• Changes: sleep patterns
(stages III & IV)
• Which of the following is a normal
age-related change of the nervous
• A. Decline in the weight of the brain
• B. Increase in cerebral blood flow
• C. Stage I and II sleep are interrupted
• D. Higher nerve conduction velocity
Changes in the Body: Sensory
• Presbyopia – normal
change of aging
• Narrowing of visual field;
decreased peripheral vision
• Pupil less responsive to
• Potential for macular
• Common eye disorders in
the elderly are NOT normal:
macular degeneration, &
Changes in the Body: Sensory
Organs— Vision (cont’d)
• Opacification/ yellowing
of lens: potential for
• Distortion in depth
• Dry eyes
• Arcus senilis –
white/gray ring around
• Decline visual acuity
• Normal age-related changes in vision
include which of the following?
• (A) Difficulty focusing on far-away objects
• (B) Greater difficulty seeing objects in dim light
• (C) Greater ease with seeing objects up close
• (D) Blurry vision from increased lacrimation
• (E) A gradual loss of central vision
Changes in the Body: Sensory
• Causes: age-related changes; loud
noises; diseases; trauma; medications
Ototoxic medications: aminoglycoside abx;
loop diuretics; aspirin (review, p. 370)
• Inner ear problems
• Damage to 8th cranial nerve
• Alteration in equilibrium (balance)
• Presbycusis (sensorineural loss)
• Accumulation of cerumen; impaction
Presbycusis (p. 62)
• Part of normal aging – most common cause of hearing loss in elderly
• Characteristics: bilateral, symmetric, progressive
• 75% people over age 60
• Sensorineural loss
Loss of hair cells in cochlea
Degradation of neurons
• Gradual, bilateral, impaired ability to hear high-pitched tones
High-pitched sounds such as "s" or "th" are hard to distinguish
Unable to distinguish directions of sound
• No interventions to slow progression
• Rarely causes severe hearing loss/ deafness
• One of most common, reversible causes of
conductive hearing loss in elderly adults
• 35% community-residing older adults
• Can greatly affect hearing
• Feeling of fullness, itching in ear canal
• Recommended aural hygiene
– Gentle cleaning of auricles
– Use of cotton-tipped applicators to cleanse ear canal
Care of the Person With a
• Encourage audiometric testing
– May not be age-related; could be
• Learning to live with hearing deficit
• Emotional reactions to hearing
• Nursing interventions (review, p. 372)
• Hearing Aid Care Box 26-3 (review, p. 372)
• Hearing aids benefit some, not all
• Examination by otologist
• Purchase only by prescription
• Hearing improves but does not return to
• Difficulties with hearing aid
• It is more difficult for older people
• (A) High pitched consonants
• (B) Low pitched consonants
• (C) High pitched vowels
• (D) Low pitched vowels
• (E) All low frequency sounds
Changes in the Body: Sensory
Organs— Smell & Taste
• Loss of ability to
• Altered sense of
• Reduction in tactile
• Potential risk related
to safety issues
Changes in the Body:
• Decreased thyroid
• Decreased ACTH,
• Delayed & insufficient
release of insulin
• Decreased tissue
sensitivity to insulin
• Reduced ability to
– Higher blood glucose
Changes in the Body:
• Skin less elastic,
more dry, & more
• Age spots (solar
• Increased skin cancer
• Thinning & graying of
• Reduced sweat gland
Changes in the Body:
• Depressed immune response:
– Decreased fever response
– Thymus gland shrinks, T-cell activity
– Decline in cell-mediated immunity
– Increased risk for infection, cancer
– Potential for reactivation of dormant
varicella-zoster (shingles) & tuberculosis
• Because illness in older adults is complicated
by the normal changes of aging and multiple
chronic conditions, many older adults do not
display the usual signs and symptoms of illness.
Atypical presentation of illness in older adults
includes all of the following EXCEPT:
• (A) Anorexia
• (B) Cough
• (C) Confusion
• (D) Falls
• (E) Incontinence
Changes in the Body:
• Lower normal body temperatures
• Rectal most reliable
• Reduced ability to respond to cold
• Differences in response to heat
• Is the following statement true or
• Mean body temperatures of the older
adult range from 96.9°F to 98.3°F
Changes in the Mind
• Psychological changes – explore causes
• Personality remains consistent
• Changes in memory
• Intelligence & aging
• Learning ability & aging
• Attention span
Nursing Implications of
• Understanding aging changes essential for
competent gerontological nursing practice
• Health promotion
• Acknowledgment of factors altering function with
• Emphasis on capabilities and assets
– Table 5-1 (pp. 66-67)
– pp. 370-371 (interventions for hearing
• When talking with elders with highfrequency hearing loss, the nurse should:
• A. Raise the voice or shout
• B. Face the client when talking
• C. Avoid using hand signals
• D. Do not talk directly into the ear
• An elder client complains to the nurse that he is
having difficulty seeing colors. To assist the
client in seeing colors better, the nurse should
suggest increased use of which of the following
• A. Blue
• B. Green
• C. Violet
• D. Red
• The teaching plan for an elder client with
decreased taste and smell sensation would
include which of the following (select all that
• A. Add more spices and herbs to food
• B. Serve food attractively
• C. Add salt and sugar to food as needed
• D. Limit consumption of fluids
• E. Maintain adequate diet intake
• Which of the following is an age-related
change in the neurologic system?
• A. Increased intracranial pressure
• B. Prolongation of REM sleep
• C. Mild confusion
• D. Hypertonic reflexes
• E. Delayed response to stimuli
• Nursing interventions for the drier oral cavity
that occurs with aging includes which of the
• A. Have patient drink before swallowing tablets
• B. Discourage fluids during meals
• C. Lemon and glycerin swabs
• D. Encourage mouth wash rinses