Gerontology and Aging

The Influence of Aging on Occupational Performance

Overview of Aging

• Young-old adults are 65-74 years old.
• Middle-old adults are 75-84 years old.
• Oldest-old adults are 85 years and older.
• Professional identity influences aging.
• Financial changes, like income, medical expenses, and food insecurity, influence aging.

Environmental Factors

• Common living arrangements for older adults include aging in place and independent living.
• Other living arrangements are assisted living and memory care units.
• Living arrangements also include skilled nursing facilities, alone, or with others.
• Changes in relationships impact aging through role changes.
• Social isolation and loneliness impact aging.
• Support from family, caregivers, and pets also impacts aging.

Physical Factors of Aging

• Typical central nervous system changes include decreased short-term memory.
• Slower processing speed is a typical central nervous system change.
• Reduced reaction time is another sign of aging.
• Common visual system changes include presbyopia, which makes it difficult to see close objects.
• Decreased tear production is a common visual system change.
• Reduced sensitivity to light and changes in color perception occur.
• Main auditory system changes include hearing loss, also known as presbycusis.
• Presbycusis is age-related hearing decline.
• Dual sensory impairment can also occur.
• The musculoskeletal system changes with age via osteopenia, osteoporosis, and decreased muscle strength.
• The vestibular system changes with aging, resulting in presbystasis, which is age-related balance decline.
• Common skin and integumentary system changes include wrinkles, age spots, and skin thinning.
• Increased susceptibility to heat also happens with aging plus thinning fingernails and thickened toenails.

Health Conditions in Older Adults

• Common chronic conditions include frailty, osteoporosis, and sarcopenia.
• Low vision and hearing loss can happen, as well as depression.
• Risk factors for falls include decreased physical function.
• Fear of falling is a risk factor.
• Environmental hazards increase risk, too.
• Interventions to prevent falls include the STEADI (Stopping Elderly Accidents, Deaths, and Injuries) program.
• environmental modifications can prevent falls.
• Physical activity to improve strength and balance also helps.

Cognitive Changes in Aging

• Attention changes, leading to a decreased ability to sustain and divide attention.
• Memory changes can result in a decline in working memory.
• Episodic and autobiographical memory decreases.
• Crystallized intelligence remains stable or improves.
• Fluid intelligence declines.

Occupational Therapy Interventions for Aging Adults

• Common models used in occupational therapy for aging are the OTPF-4 and The KAWA Model.
• Models involve the Model of Human Occupation (MOHO) and Model of Cognitive Disability.
• Common interventions include ADLs like bathing, dressing, grooming, feeding, and sexual activity.
• IADLs like pet care, financial management, and meal preparation are also targets.
• Health Management: Focuses on medication management and physical activity.
• Work & Social Participation: Volunteer roles and adapted leisure activities can improve with OT.
• Occupational therapists support occupational engagement by promoting productive aging.
• Productive aging involves maintaining function in daily tasks.
• Activities are adapted to match physical and cognitive abilities.
• Social isolation is addressed by encouraging community participation.

Aging Trends and Concepts

Key Terminology

• Gerontology is the study of the aged and the aging process.
• Geriatrics specialty is focused on treating older adults.
• A cohort is a group of people born during a specific period who share common historical and social experiences. Ageism means stereotyping and discriminating based on age.
• Chronic illness is a long-term health condition that cannot be cured, but can be managed through medication, diet, exercise, and technology.

Stages of Aging

• Young-old (65–74 years): Recently retired, often active in volunteer work and leisure activities, may have chronic conditions.
• Middle-old (75–85 years): Simplify lifestyles, rely on community support (e.g., Meals on Wheels).
• Old-old years (85 plus): Increased reliance on others for care, may need adult day care, home care, or nursing home placement.
• The Program for All-Inclusive Care of the Elderly (PACE) provides medical and support services to keep older adults in their homes.
• Centenarians, and factors that contribute to longevity include the factors genetics, lifestyle, environment, social connections, resiliency, and adaptability in people over 100 years.

Health, Illness, and Chronic Conditions

• Health defined occurs when functioning optimally without evidence of disease or abnormality.
• Common chronic illnesses in adults over 65 include hypertension, arthritis, heart disease, cancer, and diabetes.
• Chronic illness affects minority populations via conditions like hypertension and diabetes, which are more prevalent among Black older adults than White older adults.

Client-Centered Therapy

• Client-centered therapy is collaborative with occupational therapists and OTAs working with older adults to determine therapy goals based on their personal needs and interests.
• This therapy increases their investment in therapy, enhancing their quality of life, and improve engagement in meaningful occupations.

Living Arrangements and Financial Trends

• Common living arrangements include aging in place, assisted living, low-income housing, nursing homes, and retirement communities.
• Aging in place refers to older adults remaining in their homes with modifications to improve safety and accessibility.
• Financial challenges include expensive long-term care costs and are not covered by Medicare.
• Medicaid covers only institutional care, and many elders rely on long-term care insurance.
• Older women face higher poverty rates.
• Minority groups experience greater financial disparities.
• Social Security provides retirement income, but funding changes may impact future benefits.

Additional Aging Trends & Occupational Therapy

• Aging trends include older adults staying in the workforce; the increased use of technology reduces isolation and improves access to services; and more grandparents taking on parenting roles.
• Technology reduces isolation, supports telemedicine, provides learning opportunities, and helps those with disabilities (e.g., adaptive computer programs).

Generational Cohorts & Intergenerational Concepts

• Understanding the characteristics of generational cohorts is important in occupational therapy because different generations have unique life experiences that affect how they engage in therapy.
• Key traits of Traditionalists (Silent Generation, 1928–1945) are: hard workers, respect healthcare teams, value formal communication.
• Key traits of Baby Boomers (1946–1964) value teamwork, personal gratification, lifelong learning, and active engagement in occupations.

Ageism and Respectful Communication

• Elderspeak is using condescending terms like "dear" or "sweetie" instead of addressing older adults respectfully; it should be avoided.
• Promoting positive interactions helps address clients by their preferred name/title; encourage active participation in decision-making; and avoid a protective attitude that limits their independence.

Biological and Social Theories of Aging

Key Terminology

• Senescence is the natural aging process involving gradual deterioration of function.
• Genetic aging is aging determined by programmed biological factors, such as genetic coding.
• Nongenetic aging is aging influenced by environmental and lifestyle factors rather than genetics.
• Programmed aging is aging that follows a genetic "clock" with a limited number of cell divisions.
• Nonprogrammed aging is aging resulting from accumulated damage and external factors.

Biological Theories of Aging

• The main categories of biological aging theories are genetic theories (biological programming) and nongenetic theories (external/environmental damage).
• The programmed aging theory suggests that organisms live a predetermined period based on their genetic code.
• The Hayflick limit signifies cells having a predetermined number of divisions before they stop replicating, contributing to aging.
• The mutation theory states random mutations accumulate over time, altering genetic sequences and potentially leading to diseases like cancer.
• The free radical/oxidative stress theory explains that highly reactive molecules (free radicals) cause cellular damage, leading to system-wide dysfunction.
• The neuroendocrine theory states the central nervous system (CNS) regulates aging, and hypothalamic dysregulation leads to increased disease susceptibility.
• Wear and tear theory suggests that body tissues and organs deteriorate over time due to daily use and accumulated damage.

Psychosocial Theories of Aging

• Disengagement theory states that older adults naturally withdraw from roles, responsibilities, and social interactions.
• Criticisms of the disengagement theory note it assumes withdrawal is universal and inevitable, but not all individuals experience aging this way.
• Activity theory of aging suggests that older adults need social roles and activities for life satisfaction.
• Continuity theory notes that older adults maintain continuity by adapting and using past experiences to navigate aging.
• Internal continuity links past experiences with present ones.
• External continuity continues interactions with familiar people and environments.
• The life span or life course perspective examines developmental changes and adaptations in cognition, emotions, and behavior throughout life.
• The life course theory considers cultural, historical, and social influences on an individual's lifespan.

Application of Aging Theories in OT

• Occupational therapy integrates aging theories by practitioners assessing client needs combining biological, social, and psychological theories into a client-centered approach.
• OT considerations include a client's physical, cognitive, and emotional abilities.
• Evaluation includes the client's ability to complete daily activities. This also includes established routines and habits, as well as social and physical influences on aging.

Tremors

Introduction to Tremors

• A tremor is a rhythmic, oscillatory involuntary movement that affects various body parts.
• Tremors affect the hands, arms, head, face, voice, trunk, and legs (most common in hands).

Causes of Tremors

• Major causes can be problems in specific areas of the brain.
• Medical conditions can affect the nervous system.
• Other factors can be substance use, stress, or metabolic disorders.
• Medical conditions that can cause tremors include stroke, traumatic brain injury (TBI), multiple sclerosis (MS), and diseases affecting the cerebellum or brainstem.

Types of Tremors

• Main types are resting, postural, and action tremors.
• When is the tremor present (at rest, during movement, or while maintaining posture)?
• Which body parts are affected?

Detailed Overview of Tremor Types

• A resting tremor occurs when the hands or body part are at rest.
• Parkinson's disease is associated with this particular tremor.
• The hands and fingers are often affected by resting tremors.
• Postural tremors appear when the body is positioned against the effect of gravity (e.g., holding arms outstretched).
• Common causes of postural tremors affect people with essential tremors.
• Other causes are substance abuse-related tremors (e.g., alcohol withdrawal) and exaggerated physiological tremors (e.g., anxiety, stress).
• Action tremors occur when the affected body part is moving.
• Cerebellar disease is associated with this type of tremor.

Miscellaneous Tremors

• Kinetic, intention, task-specific, and isometric tremors are the four main types.
• Kinetic tremors appear during the movement of a body part.
• Intention tremors appear when completing a purposeful movement toward a target (e.g., reaching for an object).
• Task-specific tremors occur in people during high-level goal-oriented tasks (e.g., writing, playing an instrument).
• Isometric tremors occur due to voluntary muscle contraction without movement (e.g., holding a heavy object).

Essential Tremor vs. Parkinsonian Tremor

• An essential tremor is a neurological disorder with rhythmic, involuntary shaking, often affecting the hands.
• Essential tremor is more noticeable during action or postural movements, while Parkinson's tremor is more prominent at rest.
• Essential tremor mainly affects the hands, head, and voice.
• A parkinsonian tremor is associated with Parkinson's disease, occurring at rest and often affecting one side of the body first.

Occupational Therapy Considerations

• Therapy helps with this condition by using weighted utensils, built-up handles, and stabilizing devices.
• Reducing fine motor demands by improving a client's grip strength is key.
• Adaptions include larger, controlled movements instead of small, precise ones.
• OT empathize's with people by understanding both the physical and emotional impacts of tremors, providing support and reassurance while teaching adaptive strategies, and encouraging independence and self-confidence during daily activities.

Hearing Impairments in Elders

Key Terminology

• Sensorineural hearing loss is hearing loss due to damage to sensory hair cells, auditory nerve fibers, or cochlear membranes; and it's gradual, affecting high-frequency sounds first.
• Conductive hearing loss is an inability of the outer or middle ear to conduct sound property to the inner ear.
• Common cause of conductive hearing loss: Earwax buildup, fluid in the middle ear, or those treatable with cleaning, medications, or surgery.
• Tinnitus is a condition where individuals experience ringing, buzzing, or hissing sounds that can be linked to Meniere's, otosclerosis, or earwax buildup.
• An assistive listening device (ALD) amplifies sound while reducing background noise, often used with microphones or headsets.
• An audiologist evaluates, diagnoses, and treats hearing disorders.

Statistics on Hearing Loss

• By 2050, 52.9 million people are expected to have hearing impairment.
• About one-third of individuals aged 65-74 experience hearing loss.
• Eighty-five to 90% of nursing home residents have some degree of hearing impairment.
• Hearing loss impacts elders' physical health by producing balance problems, ambulation, and increased risk of falls.

Types and Causes of Hearing Loss

• Types are sensory, neural, and mechanical loss.
• Sensory loss involves damage to hair cells in the cochlea, causing high-frequency hearing loss.
• Neural loss results in loss of auditory nerve fibers, leading to difficulty distinguishing speech sounds.
• Mechanical loss comes from the degeneration of the cochlear membrane, making sound discrimination difficult.
• Sensorineural hearing loss results from aging (presbycusis), prolonged exposure to loud noise (headphones, concerts), and genetic predisposition.
• Conductive hearing loss occurs from a blockage of the external or middle ear with earwax buildup and fluid accumulation.
• Conductive hearing loss will be treated with cleaning and medications.

Tinnitus

• Causes include earwax buildup, cardiovascular diseases, neurological conditions, and exposure to loud sounds.
• Hearing loss affects elder's mental health leading to social withdrawal, loneliness, and isolation.
• Difficulty following conversations, making elders reluctant to engage in social settings can occur.
• Can lead to paranoia, misunderstandings, and frustration.
• Hearing loss impacts safety to hearing aids by missing alarms, doorbells, or phone calls.
• Elevated risk arises due to balance difficulties.
• Greater vulnerability to accidents or emergencies comes with increased risk.

Signs and Symptoms of Hearing Loss

• Common behaviors that may indicate hearing impairment include speaking in an inappropriately loud voice; turning the TV or radio volume excessively high; frequently asking for repetitions in conversation; not responding to questions or seeming confused; and withdrawing from social interactions.

Rehabilitation and Communication Strategies

• Primary goals of hearing rehabilitation include restoring functional communication.
• Improve social participation.
• Modify home and work environments for better hearing accessibility.
• Success includes factors like age of onset of hearing loss and any sensory impairments.
• Any support from family and caregivers helps, as well as motivation and willingness to use assistive devices.
• A COTA helps modify environments to improve hearing accessibility; they teach communication strategies; they assist in training elders to use assistive listening devices (ALDs).

Environmental Modifications for Improved Hearing

• Reduce background noise in a home or institution by using carpets, curtains, and upholstered furniture to absorb sound.
• Also, by reducing open spaces that amplify sound.
• Minimize background noise from TVs, music, or loud conversations.
• Safety recommendations for hearing-impaired elders include installing fire alarms with flashing lights; using telephones with text capabilities; and ensuring clear lighting to improve lip reading and visual cues.

Assistive Devices for Hearing Loss

• Hearing aids amplify sounds, requiring functioning hair cells and auditory nerves.
• Cochlear implants convert sound waves into electrical impulses to stimulate the auditory nerve.
• Benefits of hearing aids includes improves hearing clarity; modern devices are small and discreet.
• Challenges involves the cost of batteries, maintenance, and background noise amplification.
• Assistive listening devices (ALDs) use a microphone, amplifier, and headset to reduce background noise and enhance speech clarity.

Strategies for Better Communication with Hearing-Impaired Elders

• Speak slowly and distinctly with a lower-toned voice.
• Face the elder directly and ensure good lighting.
• Use visual aids like closed-captioned TVs.
• Avoid talking from another room or approaching from behind.
• Encourage self-confidence in using assistive devices.
• Age-related hearing impairments can cause elders withdraw from conversations, feel frustrated or embarrassed, and experience isolation.
• Elders might prefer not to use a hearing aid as costly batteries, discomfort, difficulty adjusting to amplified background noise.
• Cochlear implants improve hearing by replacing damaged hair cells.
• ALDs improve hearing by sending electrical signals directly to the auditory nerve.
• COTAs can reduce background noise, enhance speech clarity, and help elders adjust to amplified sound environments.

Vision Impairments in Elders

Key Terminology

• Cataracts are a condition where the lens becomes cloudy, preventing light from reaching the retina, leading to blurred vision and difficulty with night vision.
• Macular degeneration is a leading cause of vision loss in older adults, affecting fine detail recognition.
• Two types of macular degeneration can occur: build up of yellow deposits (drusen) under the macula (Dry), or Growth of abnormal blood vessels that leak and cause scarring (Wet).
• Glaucoma is defined by increased pressure in the eye due to fluid buildup, leading to optic nerve damage and peripheral vision loss.
• Open-angle glaucoma and closed-angle glaucoma are the two types.
• Diabetic retinopathy is a diabetes-related condition causing damage to retinal blood vessels, leading to blurry vision and potential blindness.
• Contrast sensitivity is the ability to distinguish objects from their background, facilitating the navigation of stairs and reading.
• Strabismus occurs from misalignment of the eyes, often due to neurological damage.
• Visual acuity refers to the sharpness of vision, measured using an eye chart.

Statistics on Vision Impairment

• One of six adults over 65 has a visual impairment.
• One of four adults over 75 has moderate to severe vision loss.
• Forty to seventy-five percent of individuals with head trauma or stroke have visual impairments.

Normal Age-Related Vision Changes

• Common vision changes: Loss of retinal neurons or presbyopia.
• Loss of elasticity in the lens is a major cause of presbyopia, making near vision difficult.
• Yellowing of the lens affects color differentiation.
• Reduced contrast sensitivity and adaptation to lighting/darkness.
• Changes affect daily function by creating difficulty reading, driving at night, recognizing faces, and object detection.

Common Ocular Diseases

• Cataracts comes with blurred vision, night vision difficulty, and increased glare sensitivity.
• Surgical lens replacement is the treatment for cataracts.
• Functional limitations of macular degeneration include loss of central vision, difficulty with reading, and fine motor tasks.
• Treatments offer eye drops to reduce eye pressure, laser therapy or surgery.
• Potential options for vision correction are medications (injections for wet AMD) and low-vision rehabilitation involving magnifiers, contrast enhancement, and adaptive strategies.
• Gradual loss of peripheral vision marks glaucoma.
• Treatments: Laser therapy, injections, and vitrectomy surgery.

Neurological Causes of Vision Impairment

• Stroke (CVA), Traumatic brain injury (TBI), Multiple sclerosis (MS) are among leading causes.
• Brain tumors also trigger vision loss.
• Neurological conditions affects vision by impairing Eye movement, double vision (diplopia).

Visual Perception & Occupational Therapy

• Hierarchy of visual perceptual skills include visual cognition, visual memory, pattern recognition, scanning, and visual attention.
• Also is oculomotor control, visual fields, and acuity.
• Visual scanning is important for reading, driving, and locating objects.
• Visual deficits are aided by referrals to specialists (ophthalmologists, low-vision therapists).
• Use high-contrast colors (e.g., dark plates on a light table).
• Update eyeglasses or use magnification devices.
• Improve lighting (full-spectrum lighting).
• Visual field loss uses eccentric viewing (shifting gaze to the side).
• Improve mobility safety (reduce clutter, add contrast to steps and edges).
• Effective environmental modifications include reduces clutter and organizes items.
• Consistent environmental modifications are use contrasting colors for safety (e.g., bright tape on stairs).
• Ensure proper lighting in key areas.
• The use of color filters and proper lighting.
• Technology and Assistive Devices include electronic magnifiers.
• OT's also refer clients to screen readers (text-to-speech software).
• OT's provide phones with large buttons or voice commands.

Chapter Review Questions

• Smartphone apps promote voice navigation.
• OTA's also utilize talking clocks, motion-sensor lights, and large print materials.
• Settings for vision rehabilitation include geriatric rehab, inpatient and outpatient rehab, and home health.
• OTAs will also work in low-vision rehabilitation climates.
• OTAs collaborate with optometrists, ophthalmologists, low-vision specialists, and rehabilitation teachers to create personalized therapy plans.
• Three primary ocular conditions leading to low-vision rehab referrals include macular degeneration.
• Conditions leading to total blindness include severe glaucoma and advanced diabetic retinopathy.
• Oculomotor Control, visual fields, and visual acuity is a foundational vision ability on the vision chart.
• Visual Skills: Loss of peripheral vision and impaired vision acuity.
• Environmental adaptations include increased lighting, high contrast, and reducing clutter.

The Vision Treatment Team

• Key professionals in vision rehabilitation.
• The ophthalmologist is a medical doctor specializing in eye diseases.
• The optometrist evaluates vision and prescribes glasses.
• Other members of the team include the CLVT, trains clients on using assistive devices.
• The OT Practitioner focuses on compensatory strategies and adaptive equipment.
• Vision loss affects mental health by causing a loss of independence, leading to depression, anxiety, fear of falling, and social isolation.
• An OTA plays an integral role in vision by providing emotional support to clients/caregivers.

Vision and Visual Perception

The Visual System

• The visual system functions to allows the brain to process visual information and integrate it with other sensory inputs for occupational performance.
• Key anatomical structures Fovea Provide the sharpest vision, Macula: fine-detail vision, and the retina: converts images into signals for the brain.
• Additional structures are the choroid(supplying blood), and the Sclera , White outer layer of the eye.

The Visual Pathway

• Cranial nerves CN II (Optic Nerve) transmits visual information to the brain.
• Cranial Nerve: CN III (Oculomotor Nerve) and CN IV (Trochlear Nerve).
• CN III moves eye muscles, controls the Pupil and eyelid elevation.
• CN IV controls the superior oblique muscle.

Visual Acuity and Fields

• Visual acuity is defined as vision which affects their ability to read.
• Loss is an effect or condition of homonymous hemianopsia (Vision loss in one field.)
• Homoymous hemianopia loss is of the SAME HALF of visual field in both eyes.

Neurological Visual Deficits

• The Difference between : visual field deficits (VFD) and inattention, also known as neglect.

Visual Acuity and Fields

• What visual perceptual and processing skills include interpreting something or giving meaning to something.
• Visual processing is all about giving meaning to visual data.

Low Vision Conditions

• Conditions that can affect people include macular degeneration(Center vision) , Diabetic problems- Blind spots, and peripheral loss issues.
• Macular Degeneration (MD) affects Macaula (Center Vision).
• Diabetic Vision issues affects retina.
• Glaucoma affects visual periphery and is affected by lack of eye pressure.