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Overview of the Aging Process and medical
disorders in the elderly
We Face an Epidemic of Unparalleled
Proportions

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One-third of the years of potential life lost before
age 65 is due to chronic disease.
Four chronic diseases—heart disease, cancer, stroke,
and diabetes—cause almost two-thirds of all deaths
each year.
Mensah: www.nga.org/Files/ppt/0412academyMensah.ppt#18
Leading Causes of Death Age 65+
“Medical Diagnoses”
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Heart Disease
Cancer
Stroke
Chronic respiratory
Flu/Pneumonia
Diabetes
Alzheimer’s
32%
22%
8%
6%
3%
3%
3%
State of Aging and Health 2007 www.cdc.gov/aging; CDC/NCHS Health US, 2002
“Actual Causes of Death”
Behavioral Risk Factors
Behavior
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% of deaths, 2000
Smoking
Poor diet & nutrition/
Physical inactivity
Alcohol
Infections, pneumonia
Racial, ethnic, economic
Disparities
McGinnis & Foege, JAMA, 1993; Mokdad et al, JAMA, 2004
19%
14%
5%
4%
?
Growth of the 85+ Population
Rosen: www.americanhealthcarecongress.org/proceedings/MasterPresentation2005.pdf
When Does Aging Begin?
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Aging begins the day we are
born
No single measure of how “old”
a person is
Aging is highly individualized
Aging proceeds at different
rates in different people, and
within different systems of the
body
Why Do People Age?
Many theories to include:
 Hereditary Factors
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Loss of cellular mass and ability of cells to divide and replicate
Accumulation of waste materials that clog cells and cause
them to die
Changes in structure of connective tissue
Normal Changes of Aging

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Physical changes related to “Normal” aging ARE NOT disease
(be aware of under-reporting)
Changes occur in most body systems to include:
Sensory System
Brain and Central Nervous System
Muscles and Bones
Digestion
Heart/Circulatory System
Respiratory System
Sensory System
Hearing

Loss is usually in ability
to hear high frequency
sounds
2.
Hearing loss can lead to
social isolation and
should be addressed
3.
Hearing aids cannot
address all types of
hearing loss
Lower the pitch of your voice
Speak directly to the person
so that they can see your face
Eliminate background noise
1.

Taste and smell
Some loss in taste and smell as
one ages, but loss is usually minor
and not until after age 70
Vision
Not all older people have impaired vision

Loss of ability to see items that are close up begins in the
40’s

Size of pupil grows smaller with age: focusing becomes less
accurate

Lens of eye yellows making it more difficult to see red and
green colors

Sensitivity to glare increases
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Night vision not as acute
How to help mitigate the effects of vision loss:
1.
Increase lighting
2.
Use blinds or shades to reduce glare
3.
Maintain equal levels of lighting
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Pain and Sense of Touch
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With age, skin is not as sensitive as in youth
Contributing factors include:
1. Loss of elasticity
2. Loss of pigment
3. Reduced fat layer
Safety Implications:
1. Lessened ability to recognize dangerous levels of heat
2. Lessened ability of body to maintain temperature
3. Tendency to develop bruises, skin tears more easily
Brain and Central Nervous System
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Without illness, a person can expect high mental competence
well past age 80
Physical reactions are slowed due to increased “lag” time of
neurons transmitting information :Slowing manifests itself in
the learning process
Unfamiliar or high stress activities cause an older person to
perform more slowly
Throughout adulthood, there is a gradual reduction in the
weight and volume of the brain. This decline is about 2% per
decade..
GOOD NEWS!
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Intellectual functioning defined as “Stored” memory increases with
age
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Problem solving skills increase with age
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Older people are able to learn very well
How to help:
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Allow time
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Minimize distractions
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Use it or lose it
Heart/Circulatory System Changes
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Age changes make the heart less able to contract efficiently
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The limits of the heart to exert itself are reduced with age
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Blood vessels lose elasticity with age making heart have to
contract harder to circulate blood
Medications processed and eliminated differently than in
young adults
Respiratory System Changes
The number of alveoli decreases, and there is a
corresponding decrease in lung capillaries
 lungs also become less elastic-loss of a elastin.
 Changes in the bones and muscles kyphosis/scoliosis
 lung function decreases with age
 airways close more readily
 The cough reflex may not trigger as readily-less
forceful.
 Collapse easily(shallow breathing eg from pain)
 Ciliary dysfunction
 airway secretion less IgA (an antibody that protects
against infection).
Thus, the elderly are more susceptible to pneumonia.
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Common lung problems in the elderly
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decreased ability to
exercise,
abnormal breathing
patterns including
sleep apnea
increased risk of lung
infections
emphysema or lung
cancer.
Kidneys/bladder
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The number of filtering units (nephrons) decreases.
The overall amount of kidney tissue also decreases.
The bladder wall changes with age.
The elastic tissue becomes tough.
Muscles weaken, and the bladder may not empty
completely when urinating
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may affect an elderly person's ability to concentrate
urine and hold onto water
Dehydration occurs more readily - older people
frequently have less of a sense of thirst.
reduces fluid intake in an attempt to reduce bladder
control problems.
Examples of Performance Tests
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Timed-up and go
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6-minute walk Test
“Get up and Go”
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ONLY VALID FOR PATIENTS NOT USING AN
ASSISTIVE DEVICE
Get up and walk 3m, and return to chair
Seconds
<10
<20
20-29
>30
Rating
freely mobile
mostly independent
variable mobility
assisted mobility
Mathias S, Nayak US, Isaacs B. Balance in elderly patients: the “Get-up and Go” test.
Arch phys Med Rehabil. 1986; 67(6): 387-389.
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Timed Up and Go: If greater than 30 seconds, only 23%
independent in tub or shower, only 4% can climb stairs
6-minute walk Test
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One-time measure of functional status
Measures the distance a patient can walk quickly on
a flat, hard surface in a period of 6-minutes
Evaluates the integrated response of all systems
involved during exercise
Assesses sub-maximal level of functional capacity
Using Functional Information
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Use functional status as baseline
Use it to guide recommendations for exercises, PT,
adaptive devices for impairments
Consider home evaluation for highly impaired
Potential marker of caregiver stress
Useful for evaluating risk of & need for placement
Physical Examination
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First contact with patient
level of consciousness,
mobility and gait,
muscle strength,
social interactive ability,
hygiene,
color,
obvious discomfort
Blood pressure
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Up to 30% of patients 75 years and older will have
orthostatic hypotension
systolic blood pressure drops by 20 or more mmHg
with a change in position from supine to standing.
baroreceptors -maintain a fairly constant blood
pressure when a person changes positions or
activities-less sensitive with aging.
Heart rate
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Bradycardia (heart rate < 60 bpm) is common in the
elderly.
Atrial fibrillation.
Atrial Fibrillation in the
Elderly
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The
commonest
sustained
arrhythmia
affecting elderly people.
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Disorganised
atrial
depolarisation-
effective atrial contraction.
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May
be
paroxysmal
persistent or sustained.
(intermittent),
Epidemiology
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Prevalence 0,4% in aged < 65 years; rising
to approximately 10% > 75 years.
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Heart
failure,
hypertension,
valvular
and
heart
advancing
disease,
age,
independently associated with the presence
of AF.
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AF - reduction in cardiac output.
Loss of co-ordinated
emptying.
atrial
filling
and
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Atrial contraction - 30% of cardiac output.
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A rapid, irregular ventricular rate.
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Abnormalities may lead to a reduction in
exercise capacity and symptoms.
Morbidity and Mortality
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AF is associated with
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reduced quality of life;
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increased risk of health problems such
as:

•
heart failure;
•
stroke.
cognitive impairment in older patients.
CLINICAL SIGNS
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An
irregularly
irregular
fibrillation

volume
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rate
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rhythm
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pulse defecit
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varying intensity S1
pulse-atrial
Thrombo-embolism
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Annual risk of a stroke
in lone AF increases
with age, approaching
20% in patients > 80
years.
Risk of death conferred
by AF is at least double
that of age-matched
controls
in
sinus
rhythm.
Table 1. Causes of Atrial Fibrillation (AF)
Factors associated with
the development of AF
Cardiac
Non-cardiac
Hypertension
Increasing age
Coronary heart disease Alcohol excess
Mitral valve disease
Heart failure
Atrial septal defect
Hyperthyroidism
Table 2. Health Problems Due to Atrial
Fibrillation
Cardiac
Non-cardiac
Exercise-intolerance
Thrombo-embolic events
Heart failure
Reduced quality of life
ANTICOAGULATION
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Warfarin substantially reduced the risk of a
thrombo-embolic event, compared with
either aspirin. or placebo.
Risk of haemorrhage with warfarin therapy
is increased in the elderly.
Target INR in this group is 2-3.
Table 4. Risk Factors for Bleeding
Complications with Oral Anticoagulation
Risk factor
Potential clinical
characteristic
History of bleeding
Gastrointestinal blood loss,
epistaxis, haematuria
Drugs which cause bleeding
Non-steroidal antiinflammatory drug therapy
Drugs which potentiate
warfarin effect
Erythromycin, amiodarone
Co-morbid health problems
Heart failure, liver disease
Poor compliance
Cognitive impairment, lack of
carer support
Psycho-social problems
Excess alcohol
Trauma
Recurrent falls
Medical disorders in the elderly
Conditions affecting
Mobility
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Increase incidence of falls with age.
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In
over
65 ” s
falls
are
commonest cause of deaths.
the
sixth
Falls
Self imposed restriction
of activity
Muscle weakness
Increased risk of future
falls
Hip fractures
-mortality at 1 yr (14%36%)
-33-50% do not regain
prev level function
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Cause of falls:
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Impaired balance due to ageing.
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Environmental factors.
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Medical factors:
•
Non-specific illness.
•
Neurological and vision.
•
Cardiovascular
•
musculoskeletal
•
•
Cardiovascular:
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Postural hypotension.
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Arrhythmias.
Drugs:
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Sedatives.
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Alcohol.
•
Locomotor:
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Arthritis.
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Muscle
weakness
/myopathy
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Vertigo:
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Responsible for ±5% of falls.
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Frequently Peripheral Vestibular .
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May be precipitated by
hyperventilation – anxiety,
depression.
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Drugs Salicylates.
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Visual impairment:
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Cataract
- Opacity in the lens.
- Occur earlier in life – poor nutrition or
diabetes mellitus.
- Slowly progressive, painless
decrease in visual acuity.
- Fixed dark spots in their field of
vision and there is a deterioration in
colour vision
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Glaucoma
- Visual field loss, raised intraocular
pressure.
- Raised intraocular pressure causes
ischaemia to the optic nerve head.
- In chronic glaucome – pressure rises
gradually over months and years –
condition frequently goes unnoticed in
early stages.
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Diabetic retinopathy
- Early cataracts.
- Microaneurysms.
- Blot haemorrhages.
- Hard exudates.
- Cotton wool spots.
- Neovascularisation.
MUSCULOSKELETAL
causes of immobility
Osteoarthritis
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Classic example of a degenerative arthritis
Most common form of arthritis in patients > 50 years
12% of patients > 65 years of age have symptomatic
OA
Other Factors
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Muscles and nerves
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Important sensory/motor function for
maintaining joint stability
Shock absorption and coordinating movement
ensuring minimal stress
Crystal arthropathy
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Amplifies cartilage degeneration
Osteoarthritis: Heberden’s and
Bouchard’s nodes
Polymyalgia rheumatica
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common cause of
widespread aching
and stiffness in older
adults
? arthritis - tendency
to involve the
shoulder and hip
joints, and the bursae
(or sacs) around these
joints
Polymyalgia rheumatica: epidemiology
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Onset after age 50 and usually after 60
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Highest incidence in individuals of Northern European
extract
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Female:male ratio 2:1
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Incidence approaches 1% in older populations
Polymyalgia rheumatica: differential
diagnostic possibilities
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Fibromyalgia
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Viral myalgia
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Depression
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Rheumatoid arthritis
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Occult malignancy
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Polymyositis
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Hypothyroidism
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Multiple myeloma
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Osteoarthritis
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Rotator cuff disease
Polymyalgia rheumatica: clinical and
laboratory features
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Pelvic and shoulder girdle aching
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Morning stiffness
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Rapid response to low doses of corticosteriods
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Anemia
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Elevated ESR and C-reactive protein
NEUROLOGICAL
(immobility)
Peripheral neuropathy:
up to 20% of elders will have peripheral neuropathy:
common causes
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diabetes
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alcohol
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neoplasm
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medication
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renal disease
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vitamin B12 deficiency.
vibratory sense
Absence of position sense and heel jerk
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Transient ischemic attacks (TIAs)
A transient ischemic attack (TIA) is: "a neurological
deficit due to vascular disturbance which develops over
minutes and persists for up to 24 hours, with complete
reversal of symptoms".
TIAs and strokes have a similar etiology. For example, an
embolus may cause a TIA instead of a stroke if it breaks
up almost as soon as it has blocked a small artery.
Precede a stroke. The risk is:
- Around 10% in the first year
- Around 5% for each subsequent year
Mark the beginning of progressive mental deterioration over the next 5-10
years
(with silent infarcts or symptomatic strokes leading to vascular dementia

Stroke:
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Sudden neurological deficit of presumed
vascular origin lasting > 24 hrs.
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Transient ischaemic attach ® a stroke that
clinically resolves within 24 hrs.
Major risk factors:
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Age.
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Hypertension.
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Heart disease.
-
Diabetes.
-
Previous stroke.
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Transient ischaemic attack.
Minor risk factors:
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Smoking.
-
Alcohol.
-
Obesity.
Parkinsonism
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Akinesia - slowness of movement,
poverty of movement, fatigue.
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Difficulty in initiating movement.
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Loss of facial expression, infrequent
blinking, monotonous speech, failure to
swing the arms, difficulty in fine
movements, shuffling gait.
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Rigidity – increase in muscle tone “Cogwheel rigidity”.
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Parkinsonism:
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Progressive disorder which starts
with mild unilateral involvement
and
progresses
to
complete
dependency.

Loss of cells in the basal ganglia.
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Cell loss is associated with a
deficiency of Dopamine
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Parkinsonism:
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Tremor – the presenting feature of 70%
of patients with Parkinson’s Disease.
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Pill rolling pattern.
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Usually present at rest and reduced on
intentional movement.
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Parkinsonism:
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Postural instability is a late feature of
the disease, patients presenting with
falls.
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The autonomic nervous system –
- constipation;
- urinary symptoms;
- excess sweating and low blood
pressure with postural fall in blood
pressure.
Muscle
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Elderly people whose mobility is restricted,
particularly those with acute illness or who are
bedridden, lose muscle mass and strength
Vit D
Risk factors for osteoporosis
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Genetics: female, Caucasian/Asian, history of maternal
hip fracture
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Sex hormone deficiency
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Low body mass
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Lifelong low calcium intake
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Sedentary lifestyle, immobility
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Excessive alcohol use
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Cigarette smoking
Osteoporosis
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compromised bone
strength predisposing to
an increased risk of
fracture.

Bone strength-bone
density and bone
quality.
Spinal osteoporosis
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No early warning symptoms
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Height loss
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Dorsal kyphosis
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Paraspinal muscle pain
Osteopenia, compression fractures:
Degenerative disease
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Spinal stenosis
malignancies
Chronic lymphocytic leukemia
Chronic lymphocytic (lymphatic) leukemia (CLL)
accounts for 25% of all cases of leukaemia.
It affects people over the age of 50 with only 5% of
patients aged 30-50 years.
The peak incidence is 60-80 years.
CLL is the most common hematologic malignancy in
older persons.
Multiple myeloma
The annual incidence of multiple myeloma is approximately 3
per 100,000.
The median age for diagnosis of multiple myeloma is 69 years
for males and 71 years for females.
By age 80, the incidence rises to 37 per 100,000.
Multiple myeloma is more common in blacks than whites, and
slightly more common in men
Cancer

Commonest cancers in women are breasts,
skin and lung with lung, skin and prostate in
men.

Chemotherapy:

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More problems with neutropenia.
Radiotherapy

More at risk during radiotherapy – prolonged
supine position and relative immobilisation.

Daily attendance is more difficult for the elderly.
Common Colorectal Cancer
Symptoms
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Bleeding from the rectum
A change in bowel movement pattern that continues
over time
General discomfort in the abdomen (frequent gas
pains, cramping pain, feeling of bloating or fullness)
Vomiting
Constant fatigue
Chronic constipation
Conclusions
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People who live an active lifestyle lose less muscle mass
and flexibility as they age
As a general rule, slight, gradual changes are common,
and most of these are not problems to the person who
experiences them
Steps can be taken to help prevent illness and injury,
and which help maximize the older person's
independence, if problems do occur
There is no need for most people to fear getting older
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Aging is a big issue!
Focus on function
Consider caregivers and abuse
Review medications
Screen for geriatric syndromes:
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falls, incontinence, dementia, depression,
hearing, vision, pain
Get help, use a team when possible
You Can Make A Difference!
"Man becomes great exactly in the degree to
which he works for the welfare of his fellow
man."
-- Mahatma Gandhi