1. Aging Population

Older age & employment

Growth in amount of employed older adults estimated to grow — Trend reversal

Difference of 65+ age group

- Increased incidence of iatrogenic illness

- Higher need of social support

- Different goals of therapy

- Heterogeneity

Aging & organ systems

Organ systems lose function ~1% per year beginning at age 30

When are age changes evident?

4-5th decade

Normal changes of aging — Vision

- Presbyopia d/t increased thickening of lens

- Keratitis sicca d/t decline in tear production

- Decreased pupil diameter

Clinical significance of decreased pupil diameter in older adults

Impaired dark adaptation — AVOID driving in dark & line house with motion censored lighting

When does increased thickening of the lens occur (presbyopia)?

After age 40

Pathophys of presbyopia

Gradual hardening of lens w/ decreased muscular effectiveness of ciliary body

Eye examination recommendation of American Academy of Ophthalmology

Comprehensive eye exams w/ dilation every 1-2 years for age ≥65

What other eye abnormalities worsen with age?

Macular degeneration, glaucoma, cataracts

MCC of irreversible blindness of older adults in developed countries (+ 2nd MCC)

Macular degeneration; then glaucoma

What age is associated with high occurrence of cataracts?

Age >75

Prevention of cataracts

Wear sunglasses, protective eyewear, eye exams (esp. if over 40)

Normal changes of aging — Hearing

- Bilateral loss of high-frequency tones

- Difficulty discriminating source of sound

Age of hearing decline

50 years old

Risk factors associated with hearing loss

Depression, pseudo-dementia, smoking

Management of hearing loss

Hearing aids w/ gradual reintroduction to sound for 2 weeks

Normal changes of aging — Taste

Blunting of salty & sweet

Clinical significance of changes to taste perception in older age

Blunting of salt / sweet → Over salting food / sweet cravings

Medications & taste

Diminished saliva flow → impaired taste perception

Aging & salivary function

Regressive histological changes of major salivary glands W/O change in saliva production

Causes of dry mouth (4)

Drugs w/ anticholinergic effects — TCAs, opioids, anti-histamines, anti-arrhythmics, anti-HTN

Local diseases — Salivary tumors & blocked ducts

Systemic diseases — Sjögren's, depression, DM, hypothyroid

Therapeutic irradiation — Of head & neck

Normal changes of aging — Smell

Declines by 50% with age

Clinical significance of decline of olfactory function

Risk of consumption of spoiled food, gas leaks, domestic fires

Management of decline of olfactory function

- Date on everything in fridge

- Weekly clean out

Demographic associated with increased loss of smell

Male (vs. female)

Normal changes of aging — Thirst

Decreased thirst drive

Clinical significance of decreased thirst drive in older age

Water consumption helps prevent growth of bacteria / oral infections

Normal changes of aging — Urinary

- Incomplete bladder emptying

- Increased post-void residuals

Normal changes of aging — Joint

- Disordered cartilage

- Decrease in fluid in joints

- Increased stiffness / flexibility

Normal changes of aging — Bone

- Slow healing of fractures

- Decreased bone mass (men and women)

USPSTF recommendation for osteoporosis screening

Women age ≥65

Normal changes of aging — Renal

- Decreased CrCl & GFR 10 mL/decade

- Decrease of 25% renal mass

Effect of increased age on serum creatinine

Pseudo-normal serum Cr in elderly d/t decrease in lean muscle mass & Cr production

**CrCl NOT good indicator of renal function as compared to younger ages

Management of renal changes with older age

Adjust medications cleared by kidney

Normal changes of aging — Height

Shortening of trunk d/t thinning (loss of mineral content) / loss of fluid of intervertebral discs

Normal changes of aging — Muscle

- Decrease in muscle mass d/t loss of muscle fibers — Higher decline in legs vs. arms

- Infiltration of fat into muscle bundles

- Increased fatiguability

- Decrease in BMR

At what ages are muscle changes seen?

Men — 20s

Women — 40s

When do changes in BMR begin?

Decrease 4% per decade, after age 20

Management of decline in muscle mass & BMR in older age

- Weight train

- Nutrition

Normal changes of aging — GI

- Decreased liver side & blood flow

- Impaired liver clearance of drugs

- Decline of intestinal motility

Normal changes of aging — CV

- Unchanged resting HR w/ decline in max HR

- Decreased max CO

- Dropout of placement cells in SA node

- Increased peripheral vascular resistance (stiffness)

- Increased LV wall thickness

Normal changes of aging — BP

Increased sBP & unchanged dBP

Normal changes of aging — Pulmonary

- Decreased elastic recoil, vital capacity, FEV, FVC

- Less effective ciliary action & cough

- Decreased lung mass

- Decreased respiratory muscle strength

- Decreased exercise tolerance

Intubation & risk of pulmonary

Incentive spirometry — Forced major inspiration & expiration (cough reflex) to strengthen diaphragm → Exercises increase likelihood of recovery in the case of intubation / extubation & reduces risk of infection

Management of pulmonary decline of older age

Open chest, deep breaths to flatten diaphragm → stretching of alveoli w/ cough reflex to expel pathogens

Normal changes of aging — Endocrine

- Decreased production of vitamin D

- Impaired glucose tolerance

Normal changes of aging — Skin

- Loss of skin elasticity (d/t increased collagen cross-links & decreased elastin)

- Hair follicle atrophy

- Greying hair (d/t loss of melanocytes at base)

Clinical significance of baldness

Hair is protective factor — Sun & direct trauma to skin

Risk factors for dental decay

- Frequent ingestion of sticky foods w/ high sucrose

- Infrequent dental visits

- Limited lifetime fluoride

Risk factors of older age that contribute to poor oral hygiene

- Impairment of visual acuity

- Manual dexterity

- UE flexibility

- Diminished salivary flow

Normal changes of aging — PNS

- Decreased thermal sensitivity (burn at lower temps / frostbite → injuries)

- Decreased vibratory sensation (esp in feet)

Normal changes of aging — CNS

- Decrease in brain mass

- Decrease in brain blood flow

- Slowed central processing & reaction time

Leading causes of death

1. Cardiac disease

2. Malignant neoplasms

3. Cerebrovascular disease

5. Alzheimer's

Dementia

- Acquired syndrome of decline in memory & cognitive functions sufficient to affect ADL

- NOT inherent aspect of aging

Prevalence of Alzheimer's disease

Age >65 — 10%

Age >85 — 50%

Clinical significance of cognitive impairments

Increased risk for accidents, delirium, medical non-adherance, disability

Methods of cognitive assessments

- Recall 3 items

- Folstein Mini-MSE

- Tests of executive control (clock, 4-legged animals)

Folstein Mini-MSE (cognitive assessment)

Tests orientation, registration, recall, attention, calculation, language, visuospatial skills

**Widely used

Tests of executive control (cognitive assessment)

- Clock-drawing test

- Listing 4-legged animals

Life expectancy of Alzheimer's Disease

8-10 years after onset of symptoms

S/S of Alzheimer's

- Behavior & mood changes

- Difficulty learning & retaining new information

- Aphasia, apraxia, disorientation, visuospatial dysfunction

- Impaired executive function & judgement

- Delusions, hallucinations, aggression, wandering

Rate of physiological decline in older ages

Can be modified!