Normal Aging

Normal Aging

Universal Changes

In spite of the differing rates of aging from person to person, there are some universal changes noted in organ systems. This summary, based on data collected by the Baltimore Longitudinal Study of Aging, comes from Aging Under the Microscope (NIH, 2002). More specific changes to selected systems will follow in this chapter.

Heart

As we age, the heart muscle thickens. The maximum oxygen consumption in men during exercise decreases by about 10 percent with each passing decade. IN women the decrease is approximately 7.5 percent. The reason for the decrease in oxygen consumption is that there is diminution of the heart's maximum pumping rate and the body has less ability to extract oxygen from the blood.

Arteries

As we age, arteries become stiff and more resistant to blood being pushed through blood vessels by the heart. In turn, the heart must work harder to propel the blood. This results in higher systolic blood pressure, increased load on the heart, and enlargement of the left ventricle.

Lungs

About 40 percent of lung function is lost between the ages of 20 and 80. This function may be decreased even more if smoking or disease is present. The decreased function can be attributed to more rigidity in the chest wall, decreased respiratory muscle strength, loss of elasticity in the lung tissue, and loss of gas exchange surface area.

Brain

Some of the axons, the connecting links between nerve cells, are lost with age. The function and amount of nerve cells themselves may also decrease with age. It is believed that the system is capable of producing new neurons, but the conditions under which this may happen is unknown.

Kidneys

During the aging process, the kidneys become less proficient in removing wastes from the circulating blood. This is especially significant in the excretion of byproducts of medication breakdown. If these byproducts aren't satisfactorily removed, they build up in the body, leading to accentuated actions and adverse reactions or possible kidney damage.

Bladder

The capacity of the bladder declines with age. Urinary incontinence may occur with atrophy of tissues. This is problematic in women, but exercise and behavioral techniques may be helpful in managing it.

Body Fat

The typical pattern is for body fat to increase gradually until middle age, stabilize, and then decline in old age as weight decreases. Muscle loss accompanies this weight and fat decrease. As we age, the fat distribution in our bodies changes by migrating from just under the skin to deposits around deeper organs. Men usually have a lower percentage of body fat than women, with distribution in the abdomen as opposed to fat on the hips and thighs of women. This distribution may be a factor in women being less susceptible to heart disease and other conditions.

Muscles

There is a 22 percent decline in muscle mass in non-exercising women and a 23 percent decline in non-exercising men between the ages of 30 and 70. Exercise can slow the rate of muscle mass loss.

Bones

Throughout early life, bone mineral is lost and replaced in balanced amounts, but beginning at around age 35 there is more loss than replacement of bone cells. This loss is accelerated in women at the time of menopause, leading to the possibility of osteoporosis and fractures. Bone loss can be decreased by regular weight-bearing exercise such as walking, running, and strength training.

Vision

There is noticeable change in close-up vision in the mid-40's. Increased susceptibility to glare becomes apparent in the 50s, including decreased vision with low light levels, and more difficulty detecting moving objects. By the 70s there may be a decline in the ability to distinguish fine details.

Hearing 

The ability to hear high frequencies decreases with age. There may be some difficulty understanding speech, especially when background noise is present. Men notice a decline in hearing more than women.

Sensory Changes

Our sense of hearing, vision, taste, smell, and touch are the means with which we connect with our world. When there is a decrement in one of the senses, we attempt whenever possible to compensate for the loss through one of the other senses.

Hearing

Hearing loss is a common impairment, especially in older adults. It affects more than 28 million Americans, but one in three persons over age 60 and half of those 85 and older have significant loss. Untreated hearing loss results in misunderstood communication. It can also lead to depression, isolation, irritability, and a decreased quality of life (National Academy on an Aging Society, 1999). A review of the ear's anatomy and function will help you better understand hearing loss and its impact on the senior client.

The ear has three main parts: 

  • The outer ear includes the pinna and the ear canal.
  • The middle ear includes the eardrum and three bones (ossicles) commonly referred to as the hammer, anvil, and stirrup. These bones are suspended in an air-filled cavity.
  • The inner ear is called the cochlea and includes nerve endings that allow us to hear. It also is the organ that helps us control our physical balance.

Sound is gathered by the pinna, then travels through the ear canal, striking the eardrum and causing it to vibrate. This in turn causes the ossicles to vibrate and mechanically conduct sound through the middle ear to the inner ear. The sound moves fluid over nerve endings (hair cells) in the inner ear and then travels as electrical impulses to the brain. Although any senior is susceptible to hearing loss, men are most often affected, as well as farmers, construction workers, musicians, and others exposed to long-term noise.

The most common age-related hearing loss is called presbycusis. This is a sensor neural disturbance caused by death of the hair cells in the inner ear. Sounds in the high frequency range are lost first, followed by those in the middle frequencies. Since most speech sounds are in the middle range, presbycusis results in speech sounding distorted and occasionally unintelligible. Words sound fuzzy and the listener frequently accuses speakers of mumbling. The sounds of c, ch, f, s, z and th are most easily misunderstood; vowels are usually heard better because they occur in the lower frequencies (Olson, 2004).

Presbycusis is especially troubling because the senior may hear a part of the conversation, but not enough of it to understand the meaning. The senior, either out of pride or self-consciousness, may hesitate to ask for the words to be repeated. So the speaker may assume that all was heard and not realize the communication was incomplete. Some seniors may compensate by lip-reading but others do not.

Conductive hearing lossis a result of sounds waves not passing satisfactorily to the inner ear. Common cause of this are wax buildup in the ear canal, perforated eardrum, fluid in the middle ear, or damage to the ossicles. Other hearing losses may be a combination of both conductive and sensor nueral.

Tinnitusis a condition frequently referred to as "ringing in the ears", but it actually may sound like bussing, chirping crickets, blowing, roaring, or popping. The noise level of the tinnitus may be quite variable, and tinnitus infections, injuries, allergies, tumors, or unknown reasons. It is estimated that 50 million Americans have the condition, 2 million so severely that it interferes with day-to-day functioning. Treatment options include amplification products, biofeedback, medications, masking techniques, and retraining exercises that desensitize the brain to the noise (NIA, 2002).

Seniors may occasionally complain of dizziness or vertigo. This may be associated with high blood pressure, inflammation in the inner ear, or unknown causes. A major concern, in addition to the extreme discomfort felt by the client, is its contribution to falling and potential injury.

Vision

Our eyes are remarkable organs and usually serve us well over the years. The aging changes taking place in the eye frequently are so subtle and slow that we are able to adapt to the changes that occur and make the modifications necessary. To better understand these changes one must know the structures of the eye.

These structures constitute the basic anatomy of the eye:    

  • The cornea takes light rays from varying angles and bends them toward the pupil.
  • The pupil is a dark round opening in the center of the iris, through which light enters the eye. The pupil adjusts in size according to the amount of light present.
  • The lens, located behind the pupil, bends light rays as they enter, so that they are focused on the retina.
  • The retina is a membrane on the back wall of the eye that contains photoreceptor nerve cells. These cells change the light rays into electrical impulses and send them to the brain via the optic nerve. The impulses are then assembled into an image by the brain

The majority of normal vision changes result from alterations in the structures of the eye. This includes the lens becoming yellowed, opaque, and less flexible; pupils shrinking; and decreased response of the pupils to dim light.

A readily noticed change, and a common one involving almost everyone over the age of 40, is that of presbyopia, or farsightedness. This is a condition in which the lens loses flexibility and is less able to focus on objects that are close. One of the first indicators is moving objects farther away from the eyes when reading in an attempt to see images better. The treatment for presbyopia is to use reading glasses or bifocals, but some seniors may also use large print books or magnifying glasses (NIA, 2002).

Yellowing of the lens results in distorted color vision, usually so subtle that it may not be readily apparent. As we age it becomes more difficult to discern the color intensities, particularly the cool colors of blue, green, and violet, which are filtered out. As a result, a person may not be able to discriminate between the various shades of these colors. An item similar in color to its back drop may blend into it and not be readily distinguishable. Yellow, red, and orange are seen more readily. Sharper color contrasts must be used to make the colors stand out from each other.

Opaqueness of the lens means that less of the light entering the eye reaches the photoreceptors. By age 60 this amount is only a third of what it was at age 20, and by age 70 it decreases to 12 percent. Most seniors compensate for this by increasing illumination. Seniors may also complain of glare, a result of increased scattering of light by the lens.

Diminished diameter of the pupils, accompanied by decreased ability of the pupils to change size quickly and chemical changes in retinal structure, results in difficulty adjusting quickly between areas of dim and bright light. This results in more problems with night driving. After confronting the bright lights of an oncoming car, the structures don't adapt quickly enough to the lights of an oncoming car, the structures don't adapt quickly enough to the decreased amount of light after the car has passed. The difficulties in distinguishing roadside features dim light adds to the concern with night driving (Olson, 2004).

Many seniors notice a diminishing of peripheral vision as they get older and don't see objects off to the side as readily. This is especially an issue in driving, when the decreased peripheral vision combined with the normal blind spot impairs seeing cars in an adjacent lane. The senior must compensate by turning the head completely to the side instead of just looking out the corners of the eye.

A common complaint of seniors is that they see floaters, or specks, in the field of vision. Floaters are small, dark shapes, resembling spots, threads, or squiggly lines. The floaters seem to dart around like small flies when the eyes move. Floaters are common as we age and are due to shrinkage of the vitreous, the gel-like substance that fills 80 percent of the eye. With shrinkage, the vitreous becomes stringy, and these stringy strands cast shadows on the retina. These shadows are the floaters.

Taste and Smell

Numbers of taste buds, found on the tongue, pharynx, and lining of the mouth, begin to decline after age 20 and drop off dramatically after age 70. There are four different taste sensations-sweet, sour, bitter, and salty. Greatest decline is noted in the sweet and salty buds, resulting in older persons frequently using heavier amounts of sugar on cereal or in coffee and generously salting other foods.

Smell is more sensitive than taste and also shows a decrease in acuity as we age. By age 80 four of five persons demonstrate major dysfunction in smell, resulting in not only a loss of the sense, but difficulty in discriminating between smells. Medications that alter taste and smell sensations complicate the issue. The close relationship between smell and taste-smell is responsible for 75 percent of our sense of taste-has implications for creating appetite and an enjoyment of food. But there are more serious implications as well in that ability to detect noxious odors, such as natural gas, plays a large role in our being safe in our environment.

If you are providing food at activities for senior clients, make an effort to provide an assortment of herbs and spices to enhance flavors in place of the less healthy sweet and salty items. Aromas of freshly baked bread and freshly brewed coffee are also appealing to the sense of smell.

Skin Changes

As a society we are frequently overly concerned about how our skin looks. Society attaches great value to skin that is soft and unwrinkled; so many seniors tend to be self-conscious about the appearance of their skin and what it says about their age.

While not a major health issue, aging skin does cause inconvenience and sometimes discomfort. Two-thirds of persons over age 70 consult a physician about problems related to skin-dryness, itching, calluses, corns, and changes in nails.

As we age there are changes in the elastin and collagen, the connective tissue that gives skin its firmness and elasticity. The changes in the elastin and collagen result in less elastic and drier skin. Then the fat padding underneath the skin begins to disappear, leaving a sagging appearance in the skin. This leads to wrinkles, dryness, and slower healing of cuts. Sun exposure and a history of cigarette smoking contribute further to the skin changes.

Other changes in the skin explain common concerns among seniors. The fat layer acts as a shock absorber and controls loss of body heat. Loss of the fat on the face and hands leads to increased susceptibility to bruising, while in the feet, fat loss may be a reason for increased trauma in walking and complaints of foot problems. Reduction in density of small blood vessels under the skin may be responsible for older people needing higher room temperatures to be comfortable. Nerve cells in the skin lose efficiency with age and may lead to seniors being less sensitive to skin pain and having a reduced sense of touch. Reduced sensitivity to both pain and heat increases the withdrawal reaction time. Seriousness of burns in seniors may be a result.

Sleep Changes

Mary Margaret is a 73-year-old professional, retired for only three years. Single, she lives with her brother and sister-in-law, also retired, in their home in a large Midwestern city. All during her career Mary Margaret was accustomed to arising at 4 a.m., napping at intervals during the day, and retiring by 9 p.m. Her usual schedule even in retirement is to continue getting up at 4 o'clock. Feeling mentally and physically alert in the early morning, she spends the next three to four hours typing the draft of a book she is writing about her lifelong work with disadvantaged children in the inner city. About 8 a.m., she gets sleepy, so she has a light breakfast and naps until 9:30. Upon waking from her nap, she continues working on her book until she stops for lunch at noon. Then it's time for an hour's nap. Finding that her alertness is diminished by afternoon, she spends the time until supper on lighter activities-working crossword puzzles, watching TV, or playing solitaire. After supper she watches more TV. Bedtime for her is around 9 p.m., though she may have already fallen asleep on the couch in front of the TV set. She prepares herself for bed and the next day starts her routine all over again. Although this pattern of sleeping and waking may seem unorthodox to some, it is a pattern that has worked well for Mary Margaret for many years and continues to work for her now. 

 Although many seniors have minimal problems with sleep, many others feel they are not getting the sleep they would like. According to the National Institute on Aging, sleep patterns change as we age, but disturbed sleep and waking up tired every day is not a normal part of aging (NIA, 2002). Disturbed sleep may be an indication of either physical or emotional problems and should be discussed with a physician.

The quality of sleep may decrease slightly as we age for several reasons. Our bodies secrete lesser amounts of the chemicals that regulate the sleep-wake cycles. Melatonin, which promotes sleep, and growth hormone, also a factor in sleep, decrease. IN addition, changes in the body temperature cycle, daytime inactivity or lack of exercise, daytime napping, and decreased mental stimulation may have some responsibility. During the night an aging bladder or pain may awaken a person.

There are two kinds of sleep in a normal sleep cycle-rapid eye movement (REM), or dreaming sleep, and quiet (non-REM) sleep. Everyone has about four or five cycles of REM and non-REM sleep a night. For older people, the amount of time spent in the deepest stages of non-REM sleep decreases and may explain why older people are thought of as light sleepers. Although the amount of sleep each person needs varies widely, the average range is between seven and eight hours a night. As we age, the amount of sleep we can expect to get at any one time drops off. By age 75, for many reasons, some people may find they are waking up several times each night (NIA, 2002).

At any age, insomnia is the most common sleep complaint. Insomnia includes such manifestations as:

  • Taking a long time to fall asleep (more than 30 to 45 minutes);
  • Waking up many times each night;
  • Waking up early and being unable to go back to sleep;
  • Waking up feeling tired.

Insomnia is usually a symptom of a problem and not the problem itself. It can be linked with other sleep disorders such as sleep apnea, a common problem that causes breathing to stop for periods of up to two minutes many times each night.

There are two kinds of sleep apnea:

  • Obstructive sleep apnea is an involuntary pause in breathing-air cannot flow in or out of the person’s mouth or nose
  • Central sleep apnea is less common and occurs when the brain doesn’t send the right signals to start the breathing muscles.

In either case, the sleeper is totally unaware of his or her difficulties breathing. Daytime sleepiness combined with loud snoring at night are clues that there may be sleep apnea. A doctor specializing in sleep disorders can make a diagnosis and recommend appropriate treatment that may include devices that keep the airway open, surgery, or medication.

Here are some suggestions seniors can follow to get a good night’s sleep:

  • Follow a regular sleep schedule and avoid napping if possible.
  • Exercise at a regular time each day.
  • Try to get some natural light in the afternoon.
  • Avoid caffeine, heavy snacks, alcohol, or nicotine before bedtime.
  • Create a safe and comfortable sleep area with an accessible lamp and phone, a dark but well-ventilated and quiet room, smoke alarms, and locks on all doors.
  • Follow a bedtime routine to communicate to your body that it’s bedtime-bath, reading, or TV.
  • Use your bedroom only for sleeping-not for office work or TV. If you’re not drowsy after 15 minutes in bed, get up. When sleepy, go back to bed.
  • Excess worry about sleep may keep you awake. Use mental exercises to help you fall asleep.

Energy, Bone, and Muscle Changes

Age-related changes in bones, muscles, and joints have an impact on our activity level. While some seniors are able to maintain many of their previous activities, others are hampered by the effects of muscle wasting, joint restriction, and porous bones. Regardless of the changes present, exercise and diet play a large role in keeping a senior functioning at a high level in spite of aging changes.

As we age, muscles begin to shrink and lose mass because of decreases in number and size of fibers. This leads to several noticeable results-it takes our muscles longer to respond, our handgrip decreases in strength, and we tire more quickly since the heart muscle isn’t as effective.

Additionally, our tendons, the cord-like tissues attaching muscles to bones, lose water content. This makes us stiffer and less able to tolerate stress. Cartilage in joints is also affected by this water loss, so joints become inflamed as bone rubs against bone. Concurrently our metabolic rate slows, leading to increased obesity and cholesterol levels (American Academy of Orthopedic Surgeons, n.d.)

Loss of bone tissue is a formidable issue for aging women, although mean can be affected to a lesser degree. Throughout life a constant process of absorption and formation takes place in the bone. This process called remodeling, keeps bones strong until the mid-30’s, when the balance changes and more bone is lost than is formed new. Gradually this can lead to osteopenia (low bone mass) or osteoporosis (porous bones). According to the NIA (2002), 10 million Americans (8 million of them women) have osteoporosis. Thirty-four million more have osteopenia. One of the effects of osteoporosis is a dowager hump, caused by collapse of vertebrae. This results in decreased height of the individual.

But the unfortunate consequence of osteoporosis is that of fracture. Half of women and one in four men over 50 will experience some type of fracture0hips, vertebrae, and wrists are more common-attributable to osteoporosis. A hip fracture has a particularly negative outcome. About a fourth of those sustaining a hip fracture will require long-term care, and worse, the person’s risk of dying within a year of the fracture increases substantially.

Fortunately there are ways to head off some of this damage. A healthy diet with balanced nutrients, especially the minerals, is important. Medications are available to slow down the process of bone loss. Hormones are known to have a positive impact on bone structure and to reduce fracture rates, but many postmenopausal women have discontinued taking them amid fears of heart attack, stroke, and breast cancer. Exercise is the one variable that seems to have greater effect in slowing the impact of the bone loss and promoting bone strength.

There are simple tests that measure bone density in various sites of the body. A bone density test can detect osteoporosis before a fracture occurs and predict one’s chances of a fracture in the future. Requiring only a few minutes, it can be done annually to determine rate of bone loss and monitor effectiveness of treatment.

Falls

Falls are a major concern for seniors because of the life change a fracture and disability may bring. Falls are due to numerous factors-decreased coordination, reflexes, and muscle strength, and poor vision or hearing. Medications, high blood pressure, or other disease processes may impair a person’s balance and ability to right oneself quickly.

However many falls can be prevented by making some changes in the home or in behaviors: 

  • Have medications evaluated regularly for side effects, interactions, and reduction of dosage to the lowest possible that will control symptoms.
  • Rise slowly from a lying or sitting position. Orthostatic hypotension is a condition in which blood pressure drops dramatically when getting up. Go from lying to sitting to standing over a longer period of time.
  • Use sturdy shoes for walking. Avoid doing barefoot or in stocking feet. Use a cane or walker to aid in balance.
  • Have a regular exercise program. Tai chi and yoga can be helpful in maintaining balance and improving muscle tone.
  • Keep floors free of clutter. Remove throw rugs. Avoid having electrical or phone cords in walking areas.
  • Install handrails in stairwells and have light switches at both top and bottom of stairs.
  • Install grab bars above tubs, in showers, and beside toilets.
  • Place a nonskid mat in the shower or use a shower chair.
  • Use nightlights throughout the house

Cognitive and Perception Changes

Although some changes in cognition occur as we age, there are so many areas of variability that generalizations are not appropriate. For example, in the Baltimore Longitudinal Study of Aging, performance on tests of logic decreased for most participants after age 70, but in some participants there was no change. Individuals with no decline in mental task performance were found in every age group, including the oldest. Ability to learn oral material decreased only in those over age 70. Vocabulary scores did not change with age.

Some consistencies have been found, however. Short-term memory appears to shorten with age. Visual memory, measured by ability to reproduce geometric designs from memory, declines slightly between ages 50 and 60 but rapidly after age 70.

Many seniors are very capable of not only maintaining cognitive skills but learning new ones as well. Strategies used to do so include reading, crossword puzzles, card playing, and taking classes. Recent research is suggesting that exercise, especially walking, does play a role in increasing cognitive ability.

Perception is the process of assigning meaning to information collected by our sense. As we age it appears there is a decrease in the speed of evaluating the information and reacting to it. A reason may be that aging affects the speed with which the nervous system processes one stimulus before acting on another. Older persons also become less capable of making a decision regarding a stimulus, thereby appearing less decisive. However, neither of these slowed functions has a serious impact until later years (Atchley & Barusch, 2004).

Sexual Changes

Normal aging brings sexual changes in both men and women. These changes may affect one’s ability to have and enjoy sex with another person.

Menopause usually begins for women sometime in their 40’s. Menopause is a mixed blessing for many women, as decline in hormone production signals the end of both fertility and fears of unwanted pregnancy. This may actually increase a woman’s enjoyment of sexual activity (NIA, 2002). But there are some physical changes that may be uncomfortable, although not untreatable. The vagina shortens and narrows, vaginal walls become thinner and stiffer, and there is less vaginal lubrication. These changes may reduce sexual pleasure if pain is present. Gels and lubricants can help.

Hot flashes and night sweats often accompany menopause, but do not affect all women equally. Women may note other changes at the time of menopause-more fat around the waist and hips, stiffening of joints, and occasional mood changes. Consultation with a physician is appropriate to address these issues. Both prescription medications and some alternative therapies may be effective in reducing symptoms.

A man may find it takes longer to achieve an erection, amount of ejaculate may be smaller, and there may be a greater interval before another erection is possible. Men, also, should be encouraged to consult their physicians for advice.

In both men and women, illness, disability, or medications taken for other health problems can affect the ability to have and enjoy sex. But even the most serious health problems don’t need to deter one from a satisfying sex life. Factors that may require modification of sexual activity include arthritis, chronic pain, diabetes, heart disease, incontinence, and stroke.

Most seniors desire and maintain a satisfying sex life throughout the aging process in spite of the above changes. Important to persons as they age is the intimacy, affection, and closeness that a relationship with a partner provides. How that relationship is expressed depends on the ability to communicate desires and make accommodations necessary so that both persons in the partnership feel their needs are met.

The information above is reprinted from Working with Seniors: Health, Financial and Social Issues with permission from Society of Certified Senior Advisors® . Copyright © 2009. All rights reserved. www.csa.us