Physiological Changes in Older Adults PDF

BPT 17: PHYSIOLOGICAL CHANGES IN OLDER ADULTS Dr. Johanna JOHANNSSON [email protected] PHYSIOLOGICAL CHANGES IN OLDER ADULTS INTRODUCTION AGEING Definition Natural process: Everyone must undergo this phase of life at his or her own time and pace Even the healthiest, aesthetically fit...

BPT 17: PHYSIOLOGICAL CHANGES IN OLDER ADULTS Dr. Johanna JOHANNSSON [email protected] PHYSIOLOGICAL CHANGES IN OLDER ADULTS INTRODUCTION AGEING Definition Natural process: Everyone must undergo this phase of life at his or her own time and pace Even the healthiest, aesthetically fit cannot escape these changes Slow and steady physical impairment and functional disability are noticed resulting in increased dependency in the period of old age According to World Health Organization, ageing is a course of biological reality which starts at conception and ends with death. It has its own dynamics, much beyond human control But also subject to the constructions by which each society makes sense of old age. In most of the developed countries, the age of 60 is considered equivalent to retirement age and it is said to be the beginning of old age AGEING Definition Characterized by TWO main criteria: Age Autonomy Common distinction is made between: 60-74 year-olds: generally mobile, in good health and sometimes still professionally active Independent over 75s >75 who are partially or totally dependent that would benefit from assistance (home adaptation, home help and care, placement in specialized facilities)  AGEING In the World and Luxembourg The proportion of people > 65 year old was highest in Europe: Bulgaria: 21,3% Croatia, Italy and Portugal: ≈20,0% EU (+ Norway, Switzerland, Liechtenstein and Iceland): >18,1% In Luxembourg Society is still young but ageing fast In 10 years : number of elderly aged over 85 have risen by 53,3% and centenarians by 35,8% https://statistiques.public.lu/en/recensement/etre-senior-au-luxembourg.html  In the year 1990: > 280 million people belonging to the age 60 years or over in developing regions of the world, and 58% of the world’s elderly were living in the proportion of elderly in AGEING developing countries is rising more rapidly, in comparison with developed one Speed of population ageing The proportion of elderly in developing countries is rising more rapidly, in comparison with developed one Example France: more than a century for population aged 65 or older to rise from 7 to 14%, whereas many developing countries are growing rapidly in number and percentage of older individuals Dobriansky PJ, Suzman RM, Hodes RJ. Why Population Aging Matters: A Global Perspective. National Institute on Aging, National Institutes of Health, US Department of Health and Human Services, US Department of State; 2007  AGEING Disability Commonly refers to a limitation of certain individual or social abilities in the face of an unsuitable environment Covers variety of situations Disability increases with age with a peak up to 63,3% of respondents aged 85 and over that declare themselves being disabled in Luxembourg https://statistiques.public.lu/en/recensement/etre-senior-au-luxembourg.html  AGEING Types of disability by age group https://statistiques.public.lu/en/recensement/etre-senior-au-luxembourg.html PHYSIOLOGICAL CHANGES IN OLDER ADULTS AGEING PROCESS CHANGES IN NERVOUS SYSTEM Quick revision from BPT 10 - BPT 14 Associated with many neurological disorders, as the capacity of the brain to transmit signals and communicate reduces Loss of brain function is the biggest fear among elderly which includes loss of the very persona from dementia → Alzheimer’s disease: o According to the World Health Organisation (WHO), nearly 5% of men and 6% of women aged 60 years or above are affected with Alzheimer’s-type dementia worldwide. → Multiple other neurodegenerative conditions like Parkinson’s disease or the sudden devastation of a stroke are also increasingly common with age Esopenko C, Levine B. Aging, neurodegenerative disease, and traumatic brain injury: The role of neuroimaging. Journal of Neurotrauma. 2015;32(4):209-220 McKhann GM, Knopman DS, Chertkow H, Hyman BT, Jack CR, Kawas CH, Klunk WE, Koroshetz WJ, Manly JJ, Mayeux R, Mohs RC. The diagnosis of dementia due to Alzheimer’s disease: Recommendations from the National Institute on Aging-Alzheimer’s association workgroups on diagnostic guidelines for Alzheimer's disease. Alzheimer's & Dementia. 2011;7(3):263-269 COGNITION Mild decline in the overall accuracy is observed with the beginning of the 60s that progresses slowly, but sustained attention is good in healthy older adults Cognitive function declines and impairments are frequently observed among the elderly → Changes occur as outcomes of distal or proximal life events, where distal events are early life experiences such as cultural, physical and social conditions that influence functioning and cognitive development Cognition decline results from proximal factors (multiple serial cognitive processes) including processing speed, size of working memory, inhibition of extraneous environmental stimuli and sensory losses. → Threat to the quality of life of those affected individuals and their caregivers Impaired cognition among elderly is associated with an increased risk of injuries to self or others, the decline in functional activities of daily living and an increased risk of mortality Mild cognitive impairment is increasingly being recognised as a transitional state between normal ageing and dementia MEMORY, LEARNING AND INTELLIGENCE Effect of normal ageing on memory may result from the subtly changing environment within the brain → The brain’s volume peaks at the early 20s and it declines gradually for rest of the life → In the 40s, the cortex starts to shrink and people start noticing the subtle changes in their ability to remember or to do more than one task at a time Other key areas like neurons shrink or undergo atrophy and a large reduction in the extensiveness of connections among neurons (dendritic loss) is also noticed During normal ageing, blood flow in the brain decreases and gets less efficient at recruiting different areas into operations → Decreases the efficiency of cell-to-cell communication, which declines the ability to retrieve and learn Also affects the intelligence, especially problem-solving with a novel material requiring complex relations Perceptual motor skills (timed tasks) decline with age SPECIAL SENSES VISION Decline in accommodation, glare tolerance, adaptation, low contrast activity, attentional visual fields and colour discrimination → Presbyopia: beginning in the early to mid-40s, difficulty in seeing clearly at close distances, especially when reading and working on the computer. This is among the most common problems adults develop between ages 41 to 60, that will continue to progress over time. (May need to hold reading materials farther away to see them clearly) → Glaucoma: group of eye conditions that damage the optic nerve that is often related to high pressure in the eye. It is one of the leading causes of blindness for people over the age of 60 → Dry eyes: reduced tear production → Cataracts: lens of the eye becomes progressively opaque, resulting in blurred vision → Age-related macular degeneration: aging causes damage to the macular, esulting in blurred central These numerous changes affect ADLs: reading, balancing and driving 13 SPECIAL SENSES HEARING Conductive and sensory hearing losses: presbycusis Age-related degeneration of the cochlea with the cumulative effects of extrinsic damage: noise and other ototoxic agents Intrinsic disorders: systemic diseases Difficulty in speech discrimination → first have a high tone hearing loss, which has a major adverse effect on communication, particularly in noisy and/or reverberant listening situations 14 SPECIAL SENSES TASTE ACUITY Losing sense of taste is a common problem among adults Taste acuity does not diminish but salt detection declines Perception of sweet is unchanged and bitter is exaggerated. The salivary glands get affected, and the volume and quality of saliva diminish All changes combine to make eating less interesting: physiological decline in the density of the taste acuity and papillae results in a decline of gustatory function Taste perception declines during the normal ageing process Chewing problems associated with loss of teeth and use of dentures also interfere with taste sensation and cause reduction in saliva production (TMJ issues) 15 SPECIAL SENSES SMELL Hyposmia: reduced ability to smell and to detect odours is also observed with normal ageing The sense of smell reduces with an increase in age, and this affects the ability to discriminate between smells. A decreased s ense of smell can lead to significant impairment of the quality of life, including taste disturbance and loss of pleasure from eating with resulting changes in weight and digestion Ageing also causes atrophy of olfactory bulb neurons. Central processing is altered, resulting in a decreased perception and less interest in food Olfactory dysfunction is among the first signs of idiopathic Parkinson's disease R L Doty , S M Bromley, M B Stern. Olfactory testing as an aid in the diagnosis of Parkinson's disease: development of optimal discrimination criteria. Neurodegeneration 1995 Mar;4(1):93-7 doi: 10.1006/neur.1995.0011. 16 SPECIAL SENSES TOUCH Sense of touch often declines due to skin changes and reduced blood circulation to touch receptors or to the brain and spinal cord Minor dietary deficiencies such as the deficiency of thiamine may also be a cause of changes The sense of touch also includes awareness of vibrations and pain Affects simple motor skills, hand grip strength and balance Muscle spindle (sensory receptors within the muscle that primarily detects changes in the length of this muscle) and mechanoreceptor (a sense organ or a cell that responds to mechanical stimuli such as touch or sound) functions decline with ageing, further interfering with balance 17  PHYSIOLOGICAL CHANGES IN OLDER ADULTS CHANGES IN MUSCULOSKELETAL SYSTEM SARCOPENIA/DYNAPENIA BPT 10 revision LOSS OF MUSCLE STRENGTH LOSS OF MUSCLE MASS Manini and Clark 2012 19 SARCOPENIA/DYNAPENIA BPT 10 revision Decrease in bone and muscle mass and an increase in adiposity → lead to risk of fractures, frailty, reduction in the quality of life and loss of independence Functional sarcopaenia or age-related musculoskeletal changes affect 7% of elderly above the age of 70 years, and the rate of deterioration increases with time, affecting over 20% of the elderly by the age of 80 Strength declines at 1.5% per year, and this accelerates to as much as 3% per year after 60 years of age → high in sedentary individuals and twice as high in men as compared with those in women BUT on an average, men have larger amounts of muscle mass and a shorter survival than women → Sarcopaenia potentially a greater public health concern among women than among men 20 SARCOPENIA/DYNAPENIA BPT 10 revision Skeletal muscle strength (force-generating capacity) also gets reduced with ageing depending upon genetic, dietary and, environmental factors as well as lifestyle choices → Causes problems in physical mobility and activity of daily living The total amount of muscle fibres is decreased due to a depressed productive capacity of cells to produce protein → Decrease in the size of muscle cells, fibres and tissues along with the total loss of muscle power, muscle bulk and muscle strength of all major muscle groups Wear and tear or wasting of the protective cartilage of joints occurs → stiffening and fibrosis of connective tissue elements that reduce the range of motion and affect the movements by making them less efficient DNA is more exposed to chemicals, toxins and waste products produced in the body. This whole process increases the vulnerability of cells. 21 SARCOPENIA/DYNAPENIA BPT 10 revision Hormonal disorders can affect the metabolism of bones as well as muscles → Menopause in women marks the aggravation in the deterioration of musculoskeletal changes due to lack of oestrogen that is required for the remodelling of bones and soft tissues Certain systemic conditions like vascular disorders or metabolic disorders, in the case of diabetes, affect the remodelling of tissues as the rate or volume of nutritional delivery for the regeneration of cells is compromised Very important to control the pathological processes to optimise healing and repairing the potential of the musculoskeletal system → Essential vitamins like vitamin D and vitamin C play major roles in the functional growth of muscles and bones → Lack of certain minerals like calcium, phosphorus and chromium can be the result of age-related digestive issues → Imbalance in the production of certain hormones like calcitonin and parathyroid that regulate the serum concentration of vitamins and minerals (due to tumours that are highly prevalent in elderly) or it causes a decreased absorption from the gut. 22  PHYSIOLOGICAL CHANGES IN OLDER ADULTS BODY COMPOSITION CHANGES  After the age of 40, people start losing their lean tissue. Body organs like liver, kidneys and other organs start losing some of their cells BODY COMPOSITION. The tendency to become shorter occurs among the different gender groups and in all races due to changes in the bones, muscles and joints → Loss of 1 cm every 10 years after age 40; height loss is even more rapid after age 70 → Changes can be prevented by following a healthy diet, staying physically active and preventing and treating bone loss Changes in the total body weight vary for men and woman, as men often gain weight until about age 55 and then begin to lose weight later in life → Drop in the male sex hormone testosterone Women usually gain weight until age 67–69 and then begin to lose weight Weight loss later in life occurs partly because fat replaces lean muscle tissue and fat weighs less than muscle → Older people may have almost 1/3 more fat compared to when they were younger → Fat tissue builds up towards the centre of the body, including around the internal organs 24 PHYSIOLOGICAL CHANGES IN OLDER ADULTS OBESITY IN ELDERLY OBESITY PREVALENCE AND PROJECTION 26 OBESITY Obesity occurs when the consumption of calories CAUSES is more than the calorie expenditure Various studies indicate that there is no decline in food intake with advancing age → likely a decrease in energy expenditure that contributes to the increase in body fat Hormonal changes cause an accumulation of fat → Decline in the secretion of growth hormone, serum testosterone → Resistance to leptin: decrease in the ability to regulate appetite downward → Reduced responsiveness to thyroid hormone 27  GENETIC FACTORS Link between obesity and heredity: inherited genes OBESITY Visceral fat is more influenced by the genotype than CAUSES subcutaneous fat ENVIRONMENTAL AND SOCIOLOGICAL FACTORS Physical activity and lifestyle behaviour are all influenced by the environment → Adoption of modern diet over traditional diet → Trend towards ‘eating out’ rather than preparing food in the home → Development of high-rise buildings that often lack sidewalks and a deficit of readily accessible recreation areas Poverty and low education level also appeared as a reason for obesity among elderly → Lack of nutritional knowledge → Purchase of low-cost fat and organ meat → Poor hygienic conditions 28 La Berge AF. How the ideology of low fat conquered America. Journal of the History of Medicine and Allied Sciences. 2008;63(2):139-177 PHYSIOLOGICAL CHANGES IN OLDER ADULTS SKIN CHANGES IN ELDERLY  GENERAL CHANGES Among the most visible signs of aging → Evidence of increasing age includes wrinkles and sagging skin → Whitening or graying of the hair is another obvious sign of aging Role of the skin: → Contains nerve receptors that allow you to feel touch, pain, and pressure → Helps control fluid and electrolyte balance → Helps control your body temperature → Protects you from the environment Three main parts: → The outer part (epidermis) contains skin cells, pigment, and proteins. → The middle part (dermis) contains skin cells, blood vessels, nerves, hair follicles, and oil glands. The dermis provides nutrients to the epidermis. → The inner layer under the dermis (the subcutaneous layer) contains sweat glands, some hair follicles, blood vessels, and fat. 30 CHANGES IN EPIDERMIS Atrophy of the epidermis is most pronounced in exposed areas: face, neck, upper part of the chest, and extensor surface of the hands and forearms BUT the number of cell layers remains unchanged. Number of pigment-containing cells (melanocytes) decreases → Remaining melanocytes increase in size: skin looks thinner, paler, and clear (translucent) → Pigmented spots including age spots or "liver spots" may appear in sun-exposed areas: lentigos Notable flattening of the dermal epidermal junction with effacement of both the dermal papillae and the epidermal reti pegs The turnover rate of cells in the stratum corneum decreases with age and in persons older than 65 it takes 50 percent longer to reepithelialize blistered skin than in young adults Decrease in epidermal cell growth and division attricausally contribute to the increased incidence of decubitus ulcers in older patients 31 CHANGES IN DERMIS Dermal collagen becomes stiffer and less pliable → elastin is more cross-linked and has a higher degree of calcification → cause the skin to lose its tone and elasticity, resulting in sagging and wrinkling: elastosis Age-related decrease in the number of dermal blood vessels also develops → leads to bruising, bleeding under the skin (often called senile purpura), and cherry angiomas → May also play a pathogenetic role in the development of decubitus ulcers Sebaceous glands produce less oil → Men experience a minimal decrease, most often after the age of 80 → Women gradually produce less oil beginning after menopause. This can make it harder to keep the skin moist, resulting in dryness and itchiness. 32 CHANGES IN SUBCUTANEOUS FAT Subcutaneous fat layer thins so it has less insulation and padding → increases risk of skin injury and reduces ability to maintain body temperature → As less natural insulation: risk of hypothermia in cold weather Some medicines are absorbed by the fat layer → Shrinkage of this layer may change the way that these medicines work Sweat glands produce less sweat: → Makes it harder to keep cool → Risk for overheating or developing heat stroke increases. 33 EFFECT OF SKIN CHANGES Increased risk for skin injury Reduced ability to sense touch, pressure, vibration, heat, and cold Rubbing or pulling on the skin can cause skin tears Fragile blood vessels can break easily → Bruises, flat collections of blood (purpura), and raised collections of blood (hematomas) may form after even a minor injury Increased risk of pressure ulcers can be caused by skin changes, loss of the fat layer, reduced activity, poor nutrition, and illnesses Skin repairs itself more slowly than younger skin. Wound healing may be up to 4 times slower. This contributes to pressure ulcers and infections 34  PHYSIOLOGICAL CHANGES IN OLDER ADULTS GASTROINTESTINAL CHANGES IN ELDERLY OESOPHAGUS Age-related changes of esophageal function: presbyesophagus → due primarily to disturbances of esophageal motility The esophagus In an older person may have: → a decreased peristaltic response may lead to dysphagia with a voluntary → a delayed transit time curtailment of caloric consumption → increased nonperistaltic response: found almost exclusively in the elderly. They occur in the lower two thirds of the esophagus and are the cause of the "corkscrew » esophagus seen on barium swallow studies → decreased relaxation of the lower sphincter on swallowing: the basis of achalasia and is more common in the elderly population. 36 STOMACH The incidence of atrophic gastritis increases significantly with age → Scandinavian study: 40% of apparently healthy subjects older than 65 had evidence of atrophic gastritis Atrophic gastritis is divided: → type A which is confined to the body and fundus sparing the antrum: autoimmune disease → type B which is associated with atrophy of both antral and fundic glands: due to local environmental factors such as chronic enterogastric bile reflux Both types increase in frequency with advancing years Severe atrophic gastritis results in achlorhydria: → deficient intrinsic factor secretion → decreased pepsinogen production → in type A, hypergastrinemia due to lack of acid inhibition of gastrin cell secretion Both types of atrophic gastritis are premalignant lesions. 37 COLON Decrease in intestinal motility occurs with age The colon becomes hypotonic: → Leads to increased storage capacity → Longer stool transit time Etiologic factors in the chronic constipation → Greater stool dehydration Laxative abuse is the most common cause of diarrhea in the elderly → A high-fiber diet is the treatment of choice and this can best be achieved by prescribing a diet rich in bran Diverticula are uncommon below the age of 40 but steadily increase thereafter until nearly 50 % of those older than 80 have diverticulosis Symptoms are present in only about 20% to 25 % of those who are affected and severe disease with inflammation and bleeding occurs in a much smaller number 38 SPHINCTER CONTROL Loss of control of the internal and external anal sphincters in the elderly in the presence of essentially normal cognitive function is a most emotionally traumatic and demeaning experience The resulting fecal incontinence is one of the major causes for admission of many otherwise healthy persons to long-term care facilities → Loss of tone of the external rectal sphincter → Biofeedback techniques allowed the regaining of sphincter and bowel control in as many as 70% of a group of patients studied 39 LIVER AND BILIARY TRACT Liver decreases in weight by as much as 20% after the age of 50 BUT attrition is not reflected by a decrease in the usual liver function tests A large number of drugs such as diazepam (anxiety) and antipyrine (fever, anti-inflammatory) are known to be metabolized more slowly by the liver → may be due to a decrease in the appearance, amount or distribution of the smooth endoplasmic reticulum Biliary tract disease is unusual before the third decade and the incidence of cholelithiasis increases greatly with age → In a large autopsy series of subjects older than 70 years, 30% had gallstones and another 5 % had previously had a cholecystectomy → In general, surgical operation is indicated in patients with gallstones, even if asymptomatic, since the risk of complications in an elderly patient is greater than the risk of operation 40  PHYSIOLOGICAL CHANGES IN OLDER ADULTS GENITOURINARY CHANGES IN ELDERLY KIDNEYS (1) Gradual decrease in the volume and weight of the kidneys occurs with aging so that by the age of 90, renal size is about 70% of that of the age of 30 Decline in the total number of glomeruli per kidney from about 1,000,000 below the age of 40 to about 700,000 by age 65 → concomitant age-related decrease in the creatinine clearance and the decline is according to the following equation: C,., (ml/minute) = 135.0-0.84 X age (years) → The serum creatinine concentration, however, changes little with age → Decrease in creatinine production due to a reduction in muscle cell mass that parallels the decrease in glomerular filtration rate Significant consequences for the clinical management of elderly patients: → drugs such as aminoglycosides (antibiotic), digoxin (myocardiac contraction), penicillin and tetracycline (antibiotic) which are primarily cleared by glomerular filtration will have a prolonged half-life in an elderly person even when the dosage is modified through the standard use of the serum creatinine concentration 42 KIDNEYS (2) Although the serum creatinine concentration does not change, there is a small but significant age-dependent increase in the blood urea nitrogen (BUN) concentration and the rate of rise is approximated by the following equation: BUN (mg/dl) = 7.56 + 0.119 X age → not always seen, since there is frequently a decrease in the intake of protein Decline in tubular function → The maximal reabsorption of glucose follows a linear decrease such that the glucose threshold ranges from 130 to 310 mg/dl in elderly persons → Glycosuria may therefore be misleading in the diagnosis and management of diabetes mellitus in older persons → Both the concentrating and diluting ability of the kidneys also slowly deteriorates → May contribute to the increased proclivity for dehydration and hyponatremia seen in older patients although excessive use of diuretics probably plays a more major role → In the absence of congestive heart failure or urinary tract obstruction or infection, the nocturia of old age appears to be primarily of a central nonrenal origin due to a disturbance in the normal diurnal rhythm of excretion 43 BLADDER Urinary incontinence has been found in 17 % of men and 23% of women older than 65 years In about half of the women and a fifth of the men this was due to stress incontinence alone The capacity of the bladder decreases with age from about 500 to 600 ml for persons younger than 65 to 250 to 600 ml for those older than 65 Perhaps more important, in younger persons the sensation of needing to void occurs when the bladder is little more than half filled but in many who are older the sensation occurs much later or sometimes not at all, leading to overflow incontinence These changes appear to be due more often to central nervous system disease than to bladder dysfunction 44 PROSTATE Enlargement of the prostate occurs in most older men; by age 80 more than 90 percent of men have symptomatic prostatic hyperplasia with varying degrees of bladder neck obstruction and urinary retention Prostate surgery is required in 5 % to 10 % of all men at some time Recently the cause of the hyperplasia has been more clearly defined: the increase in concentration of dihydrotestosterone (DHT) in prostatic cells due to two age-related changes: → An estrogen-mediated enhancement of androgen receptors on prostatic cells → A decrease in the intracellular catabolism of DHT → Future treatment of benign prostatic hyperplasia may be endocrinologic, aimed at reducing the intracellular concentration of DHT by competitive steroid antagonists 45  PHYSIOLOGICAL CHANGES IN OLDER ADULTS ENDOCRINE CHANGES IN ELDERLY GLUCOSE HOMEOSTASIS Progressive deterioration in the number and the function of insulin producing beta cells → capacity of these cells to recognize and respond to changes in glucose concentration is impaired A greater proportion of the insulin released into the circulation in response to a glucose challenge is in the form of the inactive precursor proinsulin compared to young Development of progressive peripheral insulin resistance with age → A relative decrease in lean body mass with a relative increase in adiposity → Since little change in the total number of fat cells occurs with age, the increased adiposity appears due to an increase in fat cell size → Adipocytes enlarge they turn down their insulin receptors → Even in nonobese elderly persons there is peripheral insulin resistance due to increased size of adipocytes with a relative decrease in insulin receptors 47 DIABETES The combination of abnormal beta cell function with peripheral insulin resistance leads to increased glucose intolerance in normal aged persons → Nomogram for correcting the glucose tolerance test for the age of the patient, an important consideration in the diagnosis of diabetes in the elderly → Although diabetic ketoacidosis and lactic acidosisvare uncommon in elderly diabetic persons, hyperosmolar nonketotic coma occurs with some frequency As there is a decrease in the renal concentrating function with age as well as a decrease in the maximal reabsorption of glucose: → Mild hyperglycemia may lead to osmotic diuresis → Will cause further hyperglycemia and ultimately dehydration. → Dehydration may lead to vascular insufficiency → This syndrome is frequently precipitated or exacerbated by a myocardial infarction, pneumonia or urinary tract infection 48 OSTEOPOROSIS Skeletal disorder characterized by a decrease in bone mass → Which may result in mechanical failure of the skeleton Linear decline in the 40s in bone mass → Rate of about 10% per decade for women and 5% per decade for men → 30 % to 50% of the skeletal mass may be lost when the person is in its 80s The decrease in bone mass is due to a relative increase of bone resorption over formation but the basis of this is unknown Hormonal factors certainly play a role since women are more susceptible than men and the rate of development of osteoporosis in women accelerates after menopause → low-dose estrogen therapy can arrest or retard bone loss if begun shortly after the menopause 49 MENOPAUSE Occurs because of the disappearance of oocytes from the ovary through ovulation and atresia Several consequences of the menopause: → Vasomotor instability or hot flashes: Two thirds to three quarters of menopausal women will experience flushing, with 80% having the symptoms for longer than one year and 25% to 50% for more than five years Changes in skin temperature, skin resistance, core temperature and pulse rate occur during the flush Besides being a major disturbance while women are awake, the hot flashes may occur during sleep, leading to waking episodes. Insomnia with possible physiologic and psychologic disturbances may thus result. → Arteriosclerotic cardiovascular disease is unusual in women before the menopause The precise protective mechanism of ovarian function is not known, but premenopausal women have a higher ratio of high-density lipoproteins to low-density lipoproteins than do postmenopausal women → Osteoporosis (cf previous slide) → Changes in the skin (cf Skin) 50  PHYSIOLOGICAL CHANGES IN OLDER ADULTS CARDIOVASCULAR CHANGES IN ELDERLY (RESPIRATORY DONE WITH DR. CORBELLINI) CARDIOVASCULAR SYSTEM HEART Cardiac output decreases linearly after the third decade at a rate of about 1% per year Due to the small decrease in surface area with age the cardiac index falls at a slightly slower rate of 0.79% per year The cardiac output of an 80-year-old subject is approximately half that of a 20-year-old May relate to one of several factors: → Senescent cardiac muscle has a decreased inotropic response to catecholamines, both endogenous and exogenous, and, perhaps of more clinical significance is a decreased response to cardiac glycosides → Associated increase in diastolic and systolic myocardial stiffness, perhaps due to increased interstitial fibrosis in the myocardium → Progressive stiffening of arteries with age, particularly of the thoracic aorta, leading to an increased afterload of the heart → As many as 78 % of subjects older than 70 have been shown to have amyloid deposits in the myocardium, predominantly in the atria, but also in the ventricles and pulmonary vessels may lead to congestive failure, often with conduction defects 52 CARDIOVASCULAR SYSTEM HYPERTENSION Progressive increase in blood pressure with grave portents of hypertension for the older age group as well as the young and the potential preventive value of early treatment The elevation with age is more pronounced for systolic than diastolic pressure. When hypertension is defined as a systolic blood pressure of greater than 160 mm of mercury and simultaneously a diastolic of greater than 95 mm of mercury, approximately 16% of the general adult population is hypertensive but about 50 % of those over age 65 are hypertensive High blood pressure is a significant risk factor for stroke, coronary artery disease and congestive heart failure Cardiovascular disease was a more frequent cause of death and morbidity in the hypertensive subjects older than 65 years of age than in the younger subjects 53 PHYSIOLOGICAL CHANGES IN OLDER ADULTS SLEEP CHANGES IN ELDERLY AGEING CHANGES CHECK BPT 10 Sleep cycle that is repeated several times during the night includes: → Dreamless periods of light and deep sleep → Some periods of active dreaming (REM sleep) Sleep patterns tend to change as you age → Harder time falling asleep → Wake up more often during the night and earlier in the morning → Total sleep time stays the same or is slightly decreased (6.5 to 7 hours per night) The transition between sleep and waking up is often abrupt, which makes older people feel like they are a lighter sleeper than when they were younger Less time is spent in deep, dreamless sleep → Older people wake up an average of 3 or 4 times each night. They are also more aware of being awake. Other causes include needing to get up and urinate (nocturia), anxiety, and discomfort or pain from long-term (chronic) illnesses. 55  PHYSIOLOGICAL CHANGES IN OLDER ADULTS PHYSICAL ACTIVITY FOR ELDERLY PHYSICAL ACTIVITY (PA) Protective factor for noncommunicable diseases: → Cardiovascular disease → Stroke → Diabetes → Some types of cancer Associated with improved mental health Delay in the onset of dementia Improved quality of life and wellbeing The health benefits of physical activity are well documented with higher levels and greater frequency being associated with reduced risk and improved health in a number of key areas 57 PHYSICAL ACTIVITY Healthy aging is the ability to maintain independence, purpose, vitality, and quality of life into old age despite unexpected medical conditions, accidents, and unhelpful social determinants of health Exercise, or physical activity, is an important component of healthy aging, preventing or mitigating falls, pain, sarcopenia, osteoporosis, and cognitive impairment A well-balanced exercise program includes daily aerobic, strength, balance, and flexibility components Most older adults do not meet the currently recommended minutes of regular physical activity weekly Counseling by health care providers may help older adults improve exercise habits, but it is also important to take advantage of community-based exercise opportunities 58 BARRIERS AND MOTIVATORS Identifying the difference in barriers and motivators between middle-age and older adults could contribute toward the development of age-specific health promotion interventions Barriers: → environmental factors → Resources Motivators: → Social influences → Reinforcement → Assistance in managing change 59 WHO RECOMMANDATIONS https://iris.who.int/bitstream/handle/10665/337001/9789240014886-eng.pdf Adults aged 65 and over should aim to: be physically active every day, even if it's just light activity (getting up to make a cup of tea; moving around the home; walking at a slow pace; cleaning and dusting; vacuuming; making the bed; standing up do activities that improve strength, balance and flexibility on at least 2 days a week: → do at least 150 minutes of moderate intensity activity (walking aerobics, riding a bike, dance…) a week or 75 minutes of vigorous intensity (running; dance for fitness; any activity increasing breathing and heart rate…) → reduce time spent sitting or lying down and break up long periods of not moving with some activity 60 PERCENTAGE DISTRIBUTION OF CARDIAC OUTPUT DURING EXERCISE TISSUE REST LIGHT MODERATE VIGOROUS Splanchnic 27 12 3 1 Renal 22 10 3 1 Cerebral 14 8 4 3 Coronary 4 4 4 4 Muscle 20 47 71 88 Skin 6 15 12 2 Other 7 4 3 1 61  PHYSIOLOGICAL CHANGES IN OLDER ADULTS IMPORTANT THERAPEUTIC PRECAUTIONS THERAPEUTIC MEDICATIONS CARDIOVASCULAR DRUGS (1) TYPE OF DRUG PRESCRIBED FOR POSITIVE EFFECTS CONSIDERATIONS ACE inhibitor Hypertension PA/Exercise tolerance heart rate and blood pressure Heart failure PA/Exercise capacity in chronic heart response Left ventricular function in failure patient myocardial infarctus PA/Exercise endurance systolic and diastolic blood pressure (SBP and DBP) blood flow to active mucles Oxygen uptake (VO2) Beta-blocker Hypertension SBP and DBP PA/Exercise tolerance Angina heart rate Can PA/Exercise capacity Tachycardia/arrhythmias PA/Exercise tolerance in angina Can peripheral resistance silent myocardial ischemia fall in blood glucose PA/exercise induced arrhythmias hear rate platelet aggregability Hypotension, Fatigue, Lethargy, Dizziness Airways constriction Thermoregulation (cold fingers/toes) 63 THERAPEUTIC MEDICATIONS CARDIOVASCULAR DRUGS (2) TYPE OF DRUG PRESCRIBED FOR POSITIVE EFFECTS CONSIDERATIONS Alpha-blocker Hypertension when not Postural hypotension controlled by other medication Headache Calcium channel blocker Hypertension PA/Exercise endurance in angina Possible in heart rate response Angina metabolic equivalent (MET) scores after PA/Exercise Control of arrhythmias Reduces abnormalities in ST Postural hypotension segment in ECG Headache, Dizziness, Nausea numbers of angina attacks need for nitro-glycerine SBP and DBP workload ability Anti-arrythmia Atrial fibrillation or flutter maximal PA/Exercise tolerance Nausea, Vomiting, Fatigue Slow resting heart rate Nitrate Relief and prevention of angina PA/Exercise tolerance Postural hypotension Heart failure Headache, Dizziness, Nausea 64 THERAPEUTIC MEDICATIONS CARDIOVASCULAR DRUGS (3) TYPE OF DRUG PRESCRIBED FOR POSITIVE EFFECTS CONSIDERATIONS Diuretic Acute heart failure May submaximal PA/Exercise PA/Exercise capacity Short-term use for mild heart duration Possible potassium failure Tiredness Hypertension Muscle weakness and cramps Ventricular arrythmias Diabetes Dehydration in hot weather Inotropic Supraventricular tachycardia Exercise capacity Possible Exercise capacity Atrial fibrillation Endurance Nausea, Vomiting, Fatigue Occasionally for heart failure Slow heart rate 65 THERAPEUTIC MEDICATIONS LIPID-LOWERING DRUGS TYPE OF DRUG PRESCRIBED FOR EFFECT ON FUNCTIONAL CONSIDERATIONS ABILITY Bile-acid binders Reduction of LDL (“bad”) NA Gastrointestinal problems cholesterol Fibrates Reduction of tryglycerides and May result in premature fatigue during Aching legs LDL cholesterol prolonged/moderate intensity Gastrointestinal upset Increase of HDL (“good”) PA/exercise Muscle pain cholesterol Statins Reduction of LDL cholesterol NA Gastrointestinal upset Moderate reduction of tryglycerides Increase of HDL cholesterol 66 THERAPEUTIC MEDICATIONS ANTI-CLOTTING DRUGS TYPE OF DRUG CONSIDERATIONS Warfarin Predisposes to nosebleed during high-intensity PA/Exercise: → Low to moderate intensity preferred Bruising in exercising muscle Perform PA/Exercise at similar time and intensity each day Heparin PA/Exercise duration in angina patients Possible in PA/exercise heart rate, blood pressure and rate pressure product Aspirin Possible in SBP with PA/Exercise Possible modification in blood flow during PA/Exercise Clopidogrel High intensity PA/Exercise may counteract platelet-stabilizing action of this drug 67 THERAPEUTIC MEDICATIONS RESPIRATORY MEDICATION TYPE OF DRUG PRESCRIBED PHYSICAL EFFECTS AND CONSIDERATIONS FOR Bronchondilators Asthma Prevention of exercise induced asthma → Methylxanthines (caffeine) do not appear to affect exercise capacity in asthmatics COPD Exercise capacity dyspnoea → Anticholinergic agents are most effective during steady-state exercise → Methylxanthines: Exercise capacity and endurance Glucocorticoids and Asthma Breakdown of muscle proteins corticosteroids COPD Long term use leads to muscle myopathy Acute use prolongs PA/Exercise endurance Leukotriene modulators Asthma exercise induced asthma Nedocromil and cromolyn Asthma severy and duration of exercise induced asthma (cromoglicate) Antibiotics Asthma May induce feeling of fatigue and physical performance COPD Does not seem to affect aerobic capacity and muscle strength 68 THERAPEUTIC MEDICATIONS MUSCULOSKELETAL DRUGS TYPE OF DRUG PRESCRIBE PHYSICAL EFFECTS AND CONSIDERATIONS D FOR Non-steroidal anti-inflammatory Arthritis Aid recovery from muscular injury BUT may mask pain and thus overuse of drugs injured muscle that could lead to an exercise-induced injury Possible increase in toxicity and gastric problems with prolonged PA/Exercise Biphophanates Osteoporosis May cause musculoskeletal pain Oestrogen Osteoporosis May have a protective role against musculoskeletal damage with PA/Exercise 69 THERAPEUTIC MEDICATIONS TREATMENTS FOR CANCER TYPE OF DRUG PHYSICAL EFFECTS Chemotherapy Peripheral nerve damage Cardiomyopathy Pulmonary fibrosis Anaemia fatigue functional ability and peak oxygen uptake Hormone therapy Muscle weakness Fatigue 70