Let’s DiscussCommon neurosensory, systemic changes with aging

Symptoms of illness in aging differ from younger age

Atypical disease presentation

Clinical features associated with frailty

Research shows older people have…

SHORTER clinic visits

FEWER tests

LESS screening

LESS specialist referral

MORE untreated pain

Remember Your Senses

How do our senses change as we age?

CORNELL VIRTUAL HOUSE As you go through the house answer these 3 questions:

1. What sensory impairment is the most fearful to you?

2. What is the best something you learned that will help you in your practice?

3. Can you think of any personal experiences…

A

G

I

N

G

http://www.environmentalgeriatrics.org

Multimedia Course: 3D Animated Virtual Home

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Physical Changes in the EyeLoss of eye lid tone, decreased orbital fat,

receding eye ball

Changes in Hearing

Hearing occurs after sound vibrations cross the eardrum to the inner ear.

The vibrations are changed into nerve signals in the inner ear and carried to the brain by the auditory nerve.

Your ears have two jobs:

Hearing

Maintaining Balance

Changes Interfere With HearingExternal ear canal: Walls thin

Cerumen (Wax): Becomes drier, more tenacious, reduced activity and number of cerumen glands

Eardrum: Thickens and appears duller

Cochlea: Hair cells are lost, basilar membrane stiffens, auditory structures calcify, cochlear neurons are lost

Brain: Atrophic changes in temporal auditory cortex

Hearing Loss

0

5

10

15

20

25

Age 65-75 Age >75

10

25

Smokers have higher rates of hearing loss

% o

f p

op

ula

tio

n

Prevalence increases with age

Impact of Hearing Loss

Often considered benign, but affects quality of life

May contribute to family discord, social isolation,

loss of self-esteem, anger, depression

Treatment can improve quality of life by facilitating

interaction with family, friends, and caregivers

Improving Communication with Hearing Impaired

Have the person’s attention

Speak face-to-face

Repeat by paraphrasing

Speak normal to slightly

louder

Speak little more slowly

Stand within 2 - 3 feet

Reduce background noise

Pause at end of sentences

Avoid appearing frustrated

Write down key words if

the person can read

Have the person repeat to

be certain message was

understood

Use a deeper tone when speaking

A. Shortening of hair follicles

B. Increased cerumen production

C. Reduced activity of cerumen glands

D. Increased tortuosity of external canal

Which of the following changes in the external auditory canal contributes to an

increased incidence of cerumen impaction with increasing age?

HAVE EAR WAX REMOVED! C. Reduced activity & number of cerumen glands

CHANGES IN SMELL

S

M

E

L

LDensity/Sensitivity of nerve endings decrease

starts age 2 and continues until death

CHANGES IN SMELL

S

M

E

L

L

Ability to smell odors is blunted

Mucous membranes become thinner with fewer mucous secreting cells, nasal dryness and epistaxis

There is increased sensitivity of the parasympathetic vasomotor secretory fibers, increased rhinorrhea (runny nose)

Effects elderly –Smell and taste play a role in enjoyment and safety

Changes in the Oral Cavity

Decreased density & sensitivity of taste buds

Changes in the Oral CavityXerostomia (dry mouth)

Eduntulism (missing teeth)

Periodontal disease

Co-morbid illness

Medications

Oral devices

Changes in the Oral Cavity

The number of taste buds decreases

Remaining taste buds lose mass

Sensitivity to taste often declines after age 60

Mouth produces less saliva

Causes dry mouth, can affect taste

How do changes in the oral cavity effect taste?

Decreased appetite

Weight loss

Social isolation

Taste declines:

Bitter

Sour

Salt

Sweet

DECREAS

E

Changes in Skin

How do changes in skin effect the

sense of touch?

Reduced tactile sensation

Complicated by arthritis

Changes in Skin

↓collagen/elastin

↓tensile strength/elasticity

↓glands & blood vessels

↓ thermoregulation and healing

↓neural elements

↓sensation and ↑pain threshold

↓ subcutaneous fat

↓keratin and melanocytes

↓UV protection

↓vitamin D production

Decreased Skin Thickness

Loss of thickness in all three layers

Loss of elastin (tenting no longer reliable measure)

Flattening of dermal-epidermal junction

Decreased sensation of pressure related discomfort

Why do older people seem to get pressure sores so often?

A. Altered sense of touch

B. Altered sense of smell

C. Diminished appetite

D. Carbohydrate cravings

Which of the following increases risk for

foodborne illness in older adults?

B. Altered sense of smell

Cardiac Output

30%

Average

Vital Capacity,

Renal Blood Flow

50%

Decline

Max Breathing Capacity, Oxygen Uptake

60-70%

Age

30 to 80

Musculoskeletal Changes

Decreased bone mass

decreased osteoblast and

osteoclast activity

Altered cartilage composition

chondrocyte dysfunction

bony proliferation within

the joint

Muscle Mass Decreases

50

60

70

80

90

100

110

20 30 40 50 60 70 80 90Mu

sc

le M

as

s %

From age 20 to 70 strength decreases by50% in the legs

Age in years

Large Arteries Stiffen

Collagen & elastin changes

Stiffer arteries provide less

cushioning function

Diameter/length of aorta

increases

400

500

600

700

800

900

1000

1100

10 30 50 70 90

ST

IFFN

ESS (

PW

V IN

CM

/SEC

)

AGE (YEARS)

Why is systolic hypertension more common?

Lower Creatinine Clearance

Decreased:

1. concentrating &

diluting

2. renal blood flow & mass

3. drug clearance

How does kidney function deteriorate with age?

70

80

90

100

110

120

130

140

30 40 50 60 70 80

Progressive linear decline in creatinine clearance from 140 at age 30 to 97 at age 80

What is not

normal about

aging?

Cognitive Changes

Geriatric SyndromeDementia

Delirium

Falls

Incontinence

Constipation

Elder Abuse

Polypharmacy

Depression

Malnutrition

Dizziness & Syncope

Insomnia

Skin Breakdown

Osteoporosis

Substance Abuse

Disability

Diagnosis with multiple causes, frequently seen in older population

Geriatric ComplaintsConstipation

Insomnia

Pain

Weight Loss

Dizziness

Hearing Loss

Visual Impairment

Why is it so hard to diagnose disease

in the older population?

Heterogeneity

Homeostenosis

Higher function = longer the life expectancy

Disease Presentation in Old Age

Doctor may share patients’ views on aging

May attribute treatable conditions to aging

Prevalence of disability increases with age

1.6 to 2.3 times more likely Vitamin B12

deficiency

3.7 to 4 times more likely Vitamin D

deficiency

Disease Presentation in Old Age

Traditional model for medical practice

Mainly from presentation younger people

Account abnormality to single diagnosis

Deviation from traditional model

Multiple diseases often co-exist

Atypical presentation of disease

Disease in one organ may precipitate decompensation in

another organ

Atypical Disease Presentation

Late or silent presentations

Disease one site limits symptoms at another

Disease often presents in advanced state

Misinterpret symptoms as aging

Mobility problems limit activity

Dyspnea may not occur until heart failure is very advanced

Signs of illness in the

older patient…

Illness in General…An acute change in the patients functional

status or ability to perform daily activities

Abnormal temperature

Tachycardia or hypotension

Altered mental status

Unexplained dehydration and poor appetite

Fatigue with increased aches and pains

Fever & Pain

Many illnesses do not present

with pain

Patients with chronic pain,

may complain of acute

exacerbation of their pain

when sick

“Old men have little innate heat… for

this reason too, the fevers of old men

are less acute than others, for the body

is cold.”

Hippocrates

Nearly 20-30% of elderly with a bacterial or viral illness have NO temperature elevation

FRAILTY,

A COMMON

END?

Frailty

Biologic syndrome, decreased reserves in

multiple organ systems

It is initiated by physiologic changes of aging,

disease, lack of activity, or inadequate

nutritional intake

Decreased ability maintain homeostasis in stress

Statistics

20-25% older than 80 are frail

Frail elders at higher risk for:

Falls

Hospitalization

Disability

Increased Mortality

Post-operative complications

Fried’s Criteria

The clinical presentation of frailty is

measured by having three of the following:

Sarcopenia

Unintentional weight loss

Decreased caloric expenditure

Slow walking speed

Exhaustion

What Contributes to Frailty?Age-related changes

Medications

Chronic disease

Smoking

Depression

Physical inactivity

Social isolation

Environment

Obesity

Frail patients are more

likely to be socially

isolated and develop

depression

Frailty is associated with

decreased cognition and

increased brain plaques

OSTEOPENIA

ANOREXIA

SICKNESS BEHAVIOR

ALBUMIN

SYNTHESIS

SARCOPENIA

LOSS OF NITROGEN

ATHEROSCLEROSIS

EXTRAVASATION

OF ALBUMIN INTO

EXTRAVASCULAR SPACE

FRAILTY

IMPAIRED FUNCTION

IL-1

IL-2

IL-6

TNFa

Immunomodulation

Anemia

COGNITIVE DECLINE

INCREASED MORTALITY

Cytokines & Frailty

Besse Cooper 116 year

Birthday Party

Besse’s secrets to longevity

Minding your own businessNot eating junk food

Preventive Strategies to Slow the Onset of Frailty

Food intake maintained

Resistance exercises

Atherosclerosis prevention

Isolation avoidance

Limit pain

Tai Chi or other balance exercises

Yearly checks for deficiencies

A. It is genetically determined

B. It is related to his level of physical activity

C. It is most strongly related to losing weight

D. Make a lot of money

Your family member asks you what can he do to make his "golden years really golden?" Which of the following describes his best chance of living a long and healthy life?

B. It is related to his level of physical activity