Chapter 1, Part B
The Biological (Physical) Aspects of Aging

Other Diseases of the Body

Rheumatic Diseases

Rheumatic diseases are "disorders of connective tissue, especially the joints and related structures, characterized by inflammation, degeneration, or metabolic derangement" (MDO n.d.). There are over 100 rheumatic diseases, many of which have historically been lumped under the term rheumatism. The discussion here is limited to those that most commonly occur to people age sixty or older, although they may also occur at other ages.

Osteoarthritis

Osteoarthritis is the most common type of arthritis---70% of those over seventy years old have x-ray evidence of this malady (Srikulmontree 2008). Osteoarthritis chiefly affects the tissue, known as cartilage, which pads the ends of bones within a joint. Osteoarthritis takes place when cartilage begins to wear or fray, sometimes completely wearing away, leaving a bone-on-bone joint (NIAMS n.d.a).

Some predispositions to osteoarthritis are:

·        Age

·        Being overweight or obese

·        Injury and/or stress to the joint(s)

·        Family history of osteoarthritis

Symptoms of osteoarthritis can include the following joint problems (WD 2009):

·        Joint pain or tenderness

·        Joint stiffness, reduced motion

·        Slow, often painful, movement

·        Crunching sound

·        Swollen joints

·        Joints that lock

·        A crunching or grinding sound

Other symptoms can include (WD 2009):

·        Fever

·        Weight loss

·        Fatigue

·        Trouble breathing

·        Rash and/or itch

Osteoarthritis may also cause disability which usually happens when the spine, knees, or hips are affected.

Treatments for osteoarthritis are fourfold:

v    Physical resources:

à       Exercise

à       Support devices

à       Thermal therapy

à       Alternative therapies, e.g., chiropractic, acupuncture, or massage

v    Drug therapy:

à       Topical agents, e.g., capsaicin cream

à       Oral pain relievers, e.g., acetaminophen

à       Nonsteroidal anti-inflammatory drugs (NSAIDs) for swelling and inflammation

à       Narcotics for severe pain

à       Joint injections with corticosteroids or a form of lubricant called hyaluronic acid (HA) derivatives

v    Surgery:

à       Arthroscopy

à       Joint replacement

v    Nutritional supplements:

à       Chondroitin/glucosamine sulfate supplementation is recommended by the National Institutes of Health (NIH 2009), with the caution to consult a pharmacist or physician to avoid drug interactions.

Osteoporosis

Osteoporosis is a disease manifested by a decrease in bone strength; this leads to a greater risk of fractures, or broken bones (NIAMS n.d.b, 1). Osteoporosis is the primary underlying cause of fractures in postmenopausal women and the elderly. Bones of the hip, spine, and wrist more frequently sustain fractures, but any bone can be affected. Some fractures can be permanently crippling, especially if they are in the hip.

The first plan of attack is to aid your clients in preventing osteoporosis. The following are some of the ways an individual can help prevent and/or treat osteoporosis (NIAMS n.d.b, 17ff, 32ff):

·        Adequate calcium consumption (the earlier in life this can be started, the better the result). Calcium needs vary from time to time in one's life; supplements may be beneficial. For adult men and women, the following amounts (in milligrams) are recommended:

19–50 years    1,000

51–70 years    1,200

Over 70 years 1,200

·        Adequate Vitamin D consumption (like calcium, the earlier in life this begins, the better the result); supplements may be helpful. For adult men and women, the following amounts (in International Units) are recommended:

19–50 years    200

51–70 years    400

Over 70 years 600

·        Overall nutrition---a balanced, nutritious diet with a large quantity and variety of fruits and vegetables, plus enough calories

·        Exercising and keeping other facets of a balanced life, including sleep

Pseudogout

Deposits of crystals, calcium pyrophosphate dihydrate (CPPD), in and around joints, cause pseudogout---a type of arthritis (inflammation of joints). The symptoms of pseudogout are the same as those of gout; however, gout is cause by crystals called monosodium urate. These two types of crystals have very different appearances when joint fluid containing them is observed under a microscope, and the treatment is different (MedicineNet n.d.). Almost 50% of people age ninety and older have CPPD crystals in their joints. However, most of them do not experience indications or symptoms of pseudogout (Mayo 2008).

 Calcium Phosphate

         Crystals 

One of the risk factors of pseudogout is older age (Mayo 2008), whereas that is not as true of gout (Mayo 2007).  Other risk factors of pseudogout are:

·        Joint trauma

·        Genetic disorder

·        Excess iron stored in the body (hemochromatosis)  

Polymyalgia Rheumatica

An inflammatory disorder, polymyalgia rheumatica (PMR) causes widespread muscle pain and stiffness, especially in one's neck, shoulders, upper arms, thighs, and hips. Symptoms may appear gradually or very suddenly. The exact cause of PMR is not known, but it is possibly a problem with the immune system; it may involve both genetic and environmental aspects. There may also be a link with particular viruses (Mayo 2008a):

o       Adenovirus, which causes respiratory infections ranging from the common cold to pneumonia

o       Human parvovirus B19, the source of an infection that primarily affects children

o       Human parainfluenza virus

PMR is diagnosed through blood tests: sed rate, rheumatoid factor (RF), C-reactive protein, and other blood tests. Polymyalgia rheumatica will usually resolve itself in one to two years, but symptoms may be improved with medications and self-care strategies.

Symptoms may include:

·        Aching and stiffness in the neck, shoulders, upper arms, thighs, and hips

·        Fatigue

·        Unintentional weight loss

·        General feeling of malaise or weakness

·        A slight fever at times

·        Anemia---low red blood cell count

Risk factors that may increase the likelihood of an individual getting PMR are (Mayo 2008a):

o       Age---that average age of onset is seventy

o       Sex---women are twice as likely to develop PMR as are men

o       Race---anyone can get PMR, but most are white, and people of Northern European and Scandinavian origin are especially at risk

o       Giant cell arteritis---approximately half of those having giant cell arteritis also have polymyalgia rheumatica

Doctors may treat the disease with nonsteroidal anti-inflammatory drugs (NSAIDs) or oral corticosteroid drugs such as prednisone, but they prefer not to use either of these medications over a long period of time because of potential side effects. Other things clients can do to help are:

·        Exercise (surprise, surprise!)

·        Eat a healthy diet (another surprise!)

·        Pace themselves. Try to interchange demanding or repetitious tasks with easier ones to avoid straining painful muscles.

About seven out of one thousand of those over 50 have PMR (WD n.d.), and anywhere from 15-25% of those also have Giant Cell Arteritis (GCA) (Werner 2008), another rheumatic disease. Because of its relatively small percent of incidence, GCA will not be discussed in this course, but healthcare workers are urged to learn more about it "just in case."

Paget's Disease of Bone

Bones, as other parts of the body, continually rebuild themselves. When this happens at an accelerated rate, the bones can become misshapen and soft, a condition called Paget's disease of bone. If a bone has become soft through this condition, it can cause the involved pelvis, spine, hips, thighs, head, or arms to bend and be weak. If the bone is misshapen or enlarged, it is prone to arthritis and fractures and may cause hearing loss and discomfort (Altman 2006).

This is a condition that is seldom diagnosed before age forty, and the frequency of diagnosis increases in each progressive age group to 10% by age 80 (WD n.d.a). For this reason, the symptoms are often assumed to be simply part of the aging process. Fortunately, the condition does not spread from bone to bone and is usually limited to one or a few bones of the pelvis, spine, hips, thighs, head, or arms (Altman 2006). Very rarely, in less than 1% of those with Paget's, it can lead to cancer---osteosarcoma---although this usually happens only after the individual has had Paget's for a long time. Osteoarthritis and congestive heart failure are more common complications of Paget's disease (Mayo 2008b).

The only known risk factors are age and heredity, although men are more likely to get Paget's than are women. It is diagnosed through an alkaline phosphatase blood test, an x-ray---usually taken for unrelated reasons, and/or a bone scan.

Symptoms, if any, will depend on the part of the skeletal system that is involved, and can include (Mayo 2008b):

·        Pain in the affected bone(s)---the most common symptom. It may be a constant, deep ache, and it may be worse at night.

·        Pain, swelling, and/or stiffness in the joints

·        Pain from nerve compression---usually more intense pain than that in the bone

·        Numbness, tingling, weakness, hearing loss, and double vision may occur from nerve compression.

·        Warmth in the skin over the affected area

·        Neurological problems such as headache, hearing loss, and occasionally vision loss

·        Bone deformities (bowed legs, enlarged head)

·        Fractures

·        Loss of bladder or bowel control accompanied by weakness in the legs---this can indicate severe spinal damage

One of two kinds of bone-regulating medications, bisphosphonates and calcitonin, may be prescribed. Nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin may be prescribed for inflammation, and acetaminophen (e.g., Tylenol) may be used to reduce pain. In a very few cases, the patient may need surgery to aid in the healing of fractures, to replace

damaged joints, to realign deformed bones, or to reduce pressure on nerves (Mayo 2008c).

In addition to the anticipated healthy diet and exercise, Paget's patients need to take extra care to avoid falls.

Diabetes Mellitus

Almost twenty-four million Americans are estimated to have diabetes mellitus (ADA n.d.), and more than half of those are over sixty years of age. Of folks over age sixty-five, almost 20% have diabetes (NDIC 2002).

Glucose, or blood sugar, is the body's primary fuel source used to give energy to the cells that comprise the muscles and other body tissues. The pancreas secretes insulin, a protein-type hormone, to convert foods such as sugars and starches into glucose. If an individual has diabetes, there is too much glucose in the blood, although the reasons may differ. Too much glucose can cause serious health problems, such as (Mayo 2009):

·        Cardiovascular disease---if someone has diabetes they are twice as likely to get heart disease such as angina, heart attack, stroke and narrowing of arteries (atherosclerosis)

·        Neuropathy (nerve damage)---tingling, numbness, burning, or pain in fingers or toes that spreads upwards, sometimes ending in loss of all feeling in the affected limbs; neuropathy in the digestive system can cause nausea, vomiting, diarrhea, or constipation, lead to erectile dysfunction for men

·        Nephropathy (kidney damage)---severe damage can have the end results of kidney failure or irreversible end-stage kidney disease, which requires dialysis or even a kidney transplant

·        Eye damage (diabetic retinopathy)--this can lead to blindness

·        Skin and mouth conditions such as bacterial infections, fungal infections and itching

·        Bone and joint problems such as osteoporosis

There are two types of diabetes (Mayo 2009; Inzucchi et al 2007a; Inzucchi et al 2007b):

v    Type 1 diabetes is an immune system problem. Instead of fighting harmful viruses or bacteria, which is the job of the immune system, it attacks and destroys insulin-producing cells in the pancreas, leaving the individual with little or no insulin. This causes the blood sugar to build up in the bloodstream rather than being transported into the cells. Type 1 diabetes most commonly develops during childhood or adolescence, but can develop at any age.

v    Prediabetes is the forerunner of type 2 diabetes in which the cells resist the action of insulin; the pancreas cannot make enough insulin to surmount this resistance. This causes the blood sugar to build up in the bloodstream rather than being transported into the cells, just as in type 1 diabetes. Although the cause of this is unknown, factors seem to include excess fat---particularly abdominal fat---and inactivity. Type 2 diabetes is the most common type. It can develop at any age, and is often preventable.

As a person ages, insulin production tends to decrease because of age-related cell damage (including in the pancreas) causing a reduction of insulin output. Other tissues tend to become less sensitive to insulin.

The risk factors for diabetes include (Mayo 2009):

·        Weight. The more fatty tissue there is, the more resistant the cells become to insulin.

·        Inactivity. Physical activity helps control weight, uses up glucose as energy and makes cells more sensitive to insulin.

·        Family history. Risk increases if a parent or sibling has type 2 diabetes.

·        Race. Although it's unclear why, people of certain races---including blacks, Hispanics, American Indians and Asian-Americans---are at higher risk.

·        Age. The risk increases as one gets older, especially after age 45.

·        Gestational diabetes. If someone developed gestational diabetes when they were pregnant, the risk of developing prediabetes and type 2 diabetes later increases. If birth was given to a baby weighing more than 9 pounds, they're also at risk of type 2 diabetes.

It is most important that your clients be aware of potential symptoms of diabetes (Mayo 2009):

·        Increased thirst

·        Frequent urination

·        Extreme hunger

·        Unexplained weight loss

·        Fatigue

·        Blurred vision

·        Slow-healing sores

·        Frequent infections

The physician may use one or more of the following tests to diagnoses diabetes (Mayo 2009):

·        Fasting blood sugar test---A blood sample is taken after an overnight fast. A blood sugar level from 100 to 125 mg/dL (5.6 to 6.9 mmol/L) is considered prediabetes. If it's 126 mg/dL (7 mmol/L) or higher on two separate tests, the diagnosis will be diabetes.

·        Oral glucose tolerance test, usually used when prediabetes is suspected. A blood sample is taken after a fast of at least eight hours. Then the patient drinks a sugary solution, and the blood sugar level is measured again after two hours. A blood sugar level less than 140 mg/dL (7.8 mmol/L) is normal. A blood sugar level from 140 to 199 mg/dL (7.8 to 11 mmol/L) is considered prediabetes. A blood sugar level of 200 mg/dL (11.1 mmol/L) or higher may indicate diabetes.

·        Random blood sugar test---A blood sample is taken at a random time. Regardless of when the individual last ate, a blood sugar level of 200 milligrams per deciliter (mg/dL)---11.1 millimoles per liter (mmol/L)---or higher suggests diabetes.

As with most classes of diseases, there is some commonality between treatments but specific types of the disease may have special prescriptions and/or regimens. And, as with most of the diseases discussed in this program, for any type of diabetes a healthy diet and exercise should be considered part of the treatment plan. Additionally, someone with diabetes basically needs to monitor their blood sugar and to take insulin as prescribed.

Incontinence

In the elderly population, incontinence is a potentially disabling condition that is both common and disruptive. It is defined as the involuntary loss of urine or stool in an amount large enough to be a social and/or health problem (Kane et al 2004, 173). Urinary incontinence (UI), much more common than stool incontinence, affects 8-34% of the non-institutionalized elderly population (Merck n.d.) and 50-84% of the geriatric population in long-term care facilities (Ogundele et al 2006).

Urinary incontinence is a medical condition with numerous possible causes, but it is not a normal part of aging or, in women, an inevitable consequence of childbirth or change after menopause. It can result in lifestyle changes---changes in activities, work life, social and personal life---and in skin problems and urinary tract infections (Mayo 2007a).

There are several kinds of urinary incontinence (Mayo 2007a):

v    Those that are temporary and can be resolved by a change in habits:

§        Alcohol

§        Over-hydration

§        Dehydration

§        Caffeine

§        Bladder irritation that can be caused by carbonated drinks, tea, coffee (caffeinated or decaffeinated), citrus fruits and juices, and artificial sweeteners

§        Some medications

§        Other illness or injury

v    Those that are caused by easily treatable medical conditions;

§        Urinary tract infections

§        Constipation

v    Those that are caused by factors that lead to chronic incontinence:

§        Pregnancy and childbirth

§        Changes with aging (e.g., aging bladder muscle, blood vessel disease, high blood pressure, overweight)

§        Hysterectomy

§        Interstitial cystitis (rare cause)

§        Prostatitis (not typically a cause)

§        Enlarged prostate

§        Prostate cancer

§        Bladder stones or bladder cancer

§        Neurological disorders (multiple sclerosis, Parkinson's disease, stroke, a brain tumor or a spinal injury can interfere with nerve signals involved in bladder control)

§        Obstruction (urinary stones or a tumor)

There are several risk factors, some that are changeable, and some that are not (Mayo 2007a):

·        Sex---women are more likely to have incontinence, except for men that have prostate gland problems

·        Age

·        Obesity

·        Smoking

·        Vascular disease

·        Kidney disease

·        Diabetes

There are six types of incontinence with their own symptoms (Mayo 2007a):

1.   Stress incontinence. This is loss of urine when one coughs, sneezes, laughs, exercises, or lifts something heavy. When these things are done, pressure (stress) is put on the bladder. Stress incontinence occurs because the sphincter muscle at the bladder is weakened. If the bladder gets too full, the problem will be particularly evident.

2.   Urge incontinence. This is a sudden, intense urge to urinate, followed by an involuntary loss of urine. The bladder muscle contracts and may give a warning of only a few seconds to a minute to reach a toilet. With urge incontinence, one may also need to urinate often. The need to urinate may even wake a person up several times a night. Some people with urge incontinence have a strong desire to urinate when they hear water running or after they drink only a small amount of liquid. Simply going from sitting to standing may even cause urine leakage.

3.   Overflow incontinence. If there is a frequent or continual dribble of urine, overflow incontinence is likely the cause. This is lack of ability to empty the bladder, leading to overflow.

4.   Functional incontinence. Many older people, particularly those in nursing homes, have incontinence because a physical or mental impairment keeps them from getting to the toilet in time. For example, someone with severe arthritis may be unable to unbutton his or her pants quickly enough; a person with Alzheimer's disease may not be able to plan well enough to get to the toilet on time. This type of incontinence is called functional incontinence.

5.   Gross total incontinence. This term describes constant urine leakage, day and night, or intermittent large amounts of urine and uncontrollable leaking. This person's bladder has little or no storage capacity. The person may have been born with an anatomical defect, had a spinal cord injury, or an injury to the urinary system from surgery. A fistula---abnormal opening---between the bladder and a structure next to it, such as the vagina, may also cause this type of urinary incontinence.

6.   Mixed incontinence. If a person experiences symptoms of more than one kind of urinary incontinence, e.g., stress incontinence and urge incontinence, he/she has mixed incontinence. Usually one kind is more of a bother than the other kind is.

Procedures that have a good chance of preventing urinary incontinence are:

·        Maintaining a healthy weight

·        Not smoking

·        Avoiding bladder irritants

·        Eating more fiber

·        Being active

There are a number of treatments for UI, depending on the kind of incontinence the individual has, the severity of the problem, and the fundamental cause of the problem (Mayo 2007a).

v    Behavioral techniques

§        Pelvic floor muscle exercises (Kegel exercises)

§        Bladder training

§        Scheduled toilet trips

§        Fluid and diet management

v    Medications

§        Anticholinergic (antispasmodic) drugs

§        Imipramine (Tofranil)

§        Antibiotics

§        Other medications

v    Electrical stimulation. Electrodes are temporarily inserted into the rectum or vagina to stimulate and strengthen pelvic floor muscles. This can be effective for stress incontinence and urge incontinence, but it takes several months and multiple treatments to work. It can also cause side effects, e.g. abdominal cramps, diarrhea and bleeding. This method is usually used only for people with severe urge incontinence who have been unable to respond to behavioral techniques or medications.

v    Medical devices

§        Urethral inserts

§        Pessaries

v    Surgery

v    Absorbent pads and catheters

Many people do not tell their doctors about the urinary incontinence. They may be "used to it" and assume it is a necessary part of aging, or they may be embarrassed. You will need to be on the lookout for signs---verbal or otherwise---of UI, or you may need to ask in order to help your client find the best resolution to this problem.

Chronic Obstructive Pulmonary Disease (COPD)

A group of progressive diseases---those that get worse over time---chronic obstructive pulmonary disease (COPD) makes it difficult to breathe. Although it is a term for several chronic lung conditions that obstruct the airways in the lungs, it most often refers to obstruction caused by chronic bronchitis and emphysema. These obstructions hinder one's capacity to exhale, trapping air in the lungs---thus making it hard to breathe in normally (Mayo 2007b).

However, COPD is now considered a disease of a multisystemic nature, not just limited to the lungs. Research has found elevated Picture courtesy of A.D.A.M.                                    degrees of systemic inflammation and cardiovascular, neurologic, psychiatric, endocrine system dysfunction, and skeletal muscle dysfunction associated with COPD (Stone and Nici 2007).

Chronic obstructive pulmonary disease is the fourth-leading cause of death in the United States (NHLBI 2009). In most cases, long-term smoking is the cause of COPD. Not smoking or quitting smoking soon enough could prevent COPD. Unfortunately, once symptoms arise, the lung damage cannot be reversed. There is no cure. The primary focus of treatments for COPD is to control symptoms and prevent further damage (Mayo 2007b). The lowest percentage (8.8%) of adults that currently smoke is the elderly, folks age 65 and over (Nazir et al 2007).

However, the mean inpatient, outpatient, and pharmacy costs of patients aged 65+ who have COPD are more than twice those of age- and gender-matched control subjects who do not have COPD (Mapel et al 2000).

Risk factors for COPD are (Nazir et al 2007):

·        Smoking---accounts for 89-90% of the risk in the U.S.

·        Alpha-1 antitrypsin deficiency

·        Occupational, environmental, and domestic air pollution, particularly in developing countries

·        Mucous hypersecretion

·        Possibly airway hyper-responsiveness and asthma

Treatment for COPD includes (Nazir et al 2007):

·        Smoking cessation---most clients will agree with Mark Twain when he said, "Giving up smoking is the easiest thing in the world. I know because I've done it thousands of times."

·        Pharmacologic management---After smoking cessation, pharmacologic treatment focuses on improving symptoms, exercise tolerance, and rates and severity of exacerbations. At this time, no existing medication for COPD has been proven to modify the long-term decline in lung function.

o       Bronchodilators

o       Inhaled corticosteroids

o       Combination therapy of inhaled corticosteroids and bronchodilators

o       Aerosol formulations and delivery devices

·        Nonpharmacologic interventions

o       Long-term oxygen therapy

o       Pulmonary rehabilitation

o       Immunizations for flu and pneumonia

o       Nutrition

For a client that resists quitting smoking, you might try the "5 R's" (PHS 2000; Radin and Cote 2008):

·        Relevancy: "Smoking affects your health and your family."

·        Risks: “Smoking leads to COPD, heart disease, lung cancer.”

·        Rewards: “Cessation will bring better health, money savings, improved taste, better smelling clothes/car/home, reduced aging/wrinkles.”

·        Roadblocks: “We can limit withdrawal effects and weight gain.”

·        Repetition: “I know we've already talked about this, but…”

·        Realism +1: “Yes, quitting is hard, relapses are common, and smoking is one of the best feel-good drugs … but [see 5 R's above] and remember that we can help you.”

Counseling is generally recommended to help a client stop smoking (Radin and Cote 2008). The success for someone trying to stop smoking with no counseling is 13%, whereas intensive counseling has a 22% success rate. Most insurance companies

now reimburse for smoking-cessation counseling visits. There are two types of counseling that seem to be most helpful in smoking cessation: cognitive and behavioral. Cognitive counseling aids clients to reframe the way they think about smoking by using distraction, positivism, relaxation, and mental imagery, as well as offered encouragement and motivation.

Behavioral counseling helps smokers recognize and avoid particular smoking trigger stimuli:

§      Alcohol

§      First morning coffee

§      Stress

§      The influence of other smokers.

There is a powerful correlation between the intensity and duration of the counseling and its effectiveness. Professionally led group counseling sessions are more effective than self-help, and often more than individual counseling. The best choice, however, is a combination of individual and group counseling.

It is also essential that there be continuous social support from spouses, friends, coworkers, and professionals such as the physician or yourself.

Tips for patients trying to quit smoking:

o       Key Steps:

1.   Set a firm quit date, ideally within 2 weeks

2.   Tell friends and family that you wish to quit and ask for their support

3.   Anticipate challenges, limit/abstain from alcohol, and avoid high-risk situations associated with smoking (e.g., social events where alcohol will be served)

4.   Remove all tobacco products and reminders from the home, car, and work place

o       New Skills:

·        Recognize the danger situations for relapse (e.g., being around peer smokers, drinking alcohol, negative moods, time pressure)

·        Develop coping skills for danger situations (e.g., avoid specific settings, alter lifestyle to reduce stress and enhance pleasure/mood)

·        Create new rewards or distractions for times of intensive craving (e.g., use behavior modification techniques to deal with periods of stress)

·        Know what to expect (e.g., withdrawal symptoms such as negative mood, urges to smoke, and difficulty concentrating typically peak within 1–3 weeks)

·        Stay positive (50% of all people who have ever smoked have now quit; treatment is now available)

(Reprinted from JAMA; see Schroeder, 2005)

Although stopping or decreasing the amount of smoking will not promote recovery of lost lung function, it does reduce the rate of decline in the ratio Forced Expiratory Volume (FEV) (the amount of air that a person can forcibly blow out in one second, measured in liters) to Forced Vital Capacity (FVC) (the total amount of air that can forcibly be blown out after full inspiration, measured in liters).

Changes in lung function after age 25 in smokers, nonsmokers, and ex-smokers, based

on FEV₁ (forced expiratory volume in 1 second). (Doherty and Briggs 2004)

"Early diagnosis by spirometry is essential since patients at risk may dismiss telltale symptoms as the normal consequences of smoking. Prompt initiation of smoking cessation therapy can help improve airflow, partially reverse impaired lung function, slow the accelerated annual decline of FEV₁ caused by tobacco smoke, and reduce the premature morbidity and mortality associated with COPD and other tobacco-related diseases. Initiation of appropriate interventions earlier rather than later, especially bronchodilator therapy, can improve symptoms, quality of life, and exercise capacity while decreasing the acute exacerbation rate and perhaps help to slow the progressive accelerated decline in lung function at minimal cost" (Doherty and Briggs 2004).

Oncology in the Aging

The most important risk factor for cancer is aging. The occurrence of common malignancies increases with age; more than 60% of all carcinomas occur in those aged 65 or older and is expected to increase to 70% by 2030 (Balducci and Beghé 2008).

The death rate for surgery and the risk of other complications increase with age; however, even in patients older than eighty, elective surgery seems to be generally safe. The elderly from age 70 on do, however, seem to be greatly more susceptible to complications of emergency surgery, especially those related to the digestive tract. Therefore, a regular screening for colorectal cancer may reduce the need for emergency surgery.

Recent advances in surgery (e.g., fewer surgical excisions, less invasive procedures) and in anesthesia (anesthetics with a shorter half-life and minimal respiratory suppression) have made cancer surgery safer than ever for the elderly. Combined chemotherapy and radiation therapy in the management of cancers of the head and neck, the esophagus, the bladder, and the lung also appear to be well tolerated up to the age of 80 at least (Balducci and Beghé 2008).

Balducci and Beghé (2008) states that the key to effective and safe treatment of elderly patients with cancer is informed decision making. Two components need to be looked at in the decision: the person and the malignancy. He asserts that cytotoxic chemotherapy is generally not indicated in a 90-year-old woman with stage 1 or 2 breast cancer because any benefit would be negligible and the risk of treatment would be considerable. He goes on to report that studies have shown that chemotherapy is of benefit to an 80-year-old woman whose chances of dying of breast cancer are only about 30% and if a 1% reduction in the cancer-related mortality is advantageous.

However, in a 90-year-old woman, the risk of dying of breast cancer must be close to 70% to legitimize the use of chemotherapy. If the same patient has a chemotherapy-responsive disease, such as large cell non-Hodgkin's lymphoma that may shorten her life, then chemotherapy is definitely indicated.

At times, it's best to go with the intuition of the patient. One 83-year-old man with an aggressive form of prostate cancer, in addition to mild cases of high blood pressure, Type 2 diabetes, depression, and angina---all being treated with medication---felt that hormone and radiation therapy was the way to go. Three months after finishing his therapy, blood tests suggested that the malignancy was eradicated (Brody 2009).

More patients over 80 years undergo major cancer (and other) surgeries, when in the past the recommendation would have been to "let nature take its course" (Tampa Tribune 2009). However, doctors often under-treat the elderly for fear of the results of side effects. Other times they over-treat because of pressure from the family.

Things that should influence treatment decisions are (Brody 2009) the patients':

·        Physical and mental health

·        Financial status

·        Living situation

·        Family support system

·        Ability to get to and from the treatment facility

·        Own wishes and desires

Diseases of the Mind

"Diseases of the mind" is, in a sense, a way of referring to the negative side mental health. When an elderly person seems to be "aging successfully" in mental and emotional areas, the social worker's job is largely one of encourager and cheerleader. When this aging is less successful, then the social worker's job is the same as when a physical illness is present: notice, aid the patient in getting professional help if it is needed, and help the client to engage in self-help strategies that might be useful.

Almost 20% of people ages 55 and older suffer mental disorders that are not part of normal aging. The most common disorders, in the order of predominance are: anxiety, severe cognitive impairment (e.g., dementia and Alzheimer's disease), and mood disorders (e.g., depression) (AAGP 2004).  

There is a difference between anxiety as a feeling or experience, and an anxiety disorder as a psychiatric diagnosis---an individual may feel anxious and not have an anxiety disorder. Primarily for this reason, anxiety is not addressed in this course.

Aging and Depression

Depression in the aged is a significant problem.  Changes in physical abilities, illnesses and diseases, the loss of loved ones, lack of a defining activity, and lack of work can all contribute to significant depressive feelings.  Without a feeling of some purpose, many will not feel that getting out of bed in the morning is worth it, and depression can get worse as health declines. 

Everyone, young or old, feels "down in the dumps" at times. But if they have little joy or pleasure from life, and the "down in the dumps" feeling lasts more than a week or two, they probably are depressed. Depression in the elderly needs to be diagnosed and treated. It could be a side-effect of a medication or a disease such as Parkinson's. But no matter the cause it can likely be treated.

The risk of depression in the elderly increases just as other illnesses do. When the inability to function is more limited than before, they are especially at risk. Estimates of major depression in older people who still live in the community range from less than 1% to about 5%, but it rises to 13.5% in those who require home health care and to 11.5% in elderly hospital patients (Hybels and Blazer 2003).

The percentages of people with clinically relevant depressive symptoms, along with age groups are displayed for 2004 in the following table: 

Source: Federal Interagency Forum 2008, Chart 2008-19b

Depression is one of the conditions most commonly associated with suicide in older adults (Conway and Brent 1995). It is widely under-recognized and undertreated. Studies show that up to 75% of older adults who committed suicide visited a physician within a month before death (Conwell 2001). The rate of suicide is highest among the elderly as compared to any other age group; highest of all is the suicide rate for those 85 years and older---twice the overall national rate (AAGP 2004). These statistics show the urgency of learning to recognize and treat depression among older adults.

Depressive symptoms can be different in older adults than younger, often being masked under the resemblance to changes that occur with age. For example, older adults often have a natural tendency for lower appetite and a change in sleep pattern. It is important to do a complete psychosocial assessment, which includes a history of depressive symptoms.

Common symptoms of depression are (Gallo and Katz n.d., MDConsult 2008):

·        Depressed or irritable mood; temper, agitation

·        Fatigue (tiredness or weariness)

·        Loss of interest in self-care and/or following medical advice

·        Little interest in social activities

·        Feeling "empty" inside

·        Trouble sleeping and/or anxiety

·        Trouble concentrating or remembering things

·        Unexplained aches and pains

·        Change in appetite and weight

·        Feeling hopeless about the future

·        Feelings of helplessness

·        Feeling worthless or sad

·        Easily irritated and/or listless

·        Feeling that one is a burden---excessive or inappropriate guilt

·        Abnormal thoughts about death

·        Irresponsible behavior

·        Thoughts about suicide, plans to commit suicide or actual attempts

The cause(s) of clinical depression are not known. No biologic event or gene has been associated with depression; however, if there is a family history of depression, there seems to be an increased risk. Cerebrovascular disease, which is more common among the elderly, appears to play a role in late-onset depression---this has led to the "vascular depression hypothesis" (Conway and Steffens 1999).

Treatment for Depression

Depression may be a result of events (situational) or may have a more neurological or psychological cause. The elderly are at risk for situational depression because of the many losses they suffer (death of loved ones, loss of job, hearing impairment, memory impairment, independence, poor health, etc.). It is important to find out when the depressive symptoms started, how long they have lasted and how severe they are.  You should also find out if there was a precipitating event. The presence of such an event can help direct treatment. The patient should also receive a complete medical examination to determine what illnesses may be contributing to the depression in addition to what medications may be contributing to the symptoms.

The doctor will perform a complete physical examination, obtain laboratory tests, and assess mental status (ability to think clearly, remember, and make plans). The purpose of this workup is to determine if a medical condition or medication may be causing or contributing to the depression.

Treatments for geriatric depression are much like those for the rest of the population:

·        Antidepressants---often a trial and error period is needed to find the antidepressant that works best for the client (NIMH 2009); it may take four to eight weeks for a medication to work best

·        Psychotherapy

Psychotherapy for depression can include (Alexopoulos et al 2001):

§        Cognitive-behavioral therapy (changing pessimistic thoughts and beliefs)

§        Supportive psychotherapy (providing emotional support to help the person cope with and resolve difficulties)

§        Problem-solving therapy (helps the person learn more effective ways to manage problems)

§        Interpersonal therapy (professional works with the person to improve problems in relationships) 

Educating the person and their family about depression are also important interventions.

Cognitive therapy is one of the more common therapies used to help with depression.  If not contraindicated by a client's mental capacity, it can be effective in alleviating or minimizing the depressive symptoms. In cognitive restructuring the professional helps the client replace faulty thinking or misconceptions with beliefs and thoughts that are more aligned with reality, leading to enhanced functioning.  The therapist helps people improve their self-dialogue, educating them that it is this inner dialogue that is affecting their depressed mood. Sometimes, in working with the elderly, much of their dialogue may be pessimistic and negative about the elderly person's life situation, and thoughts that their life has been a failure. 

The following steps are useful in cognitive restructuring (Cormier and Cormier 1979):

1.   Assisting clients to accept that their statements and beliefs affect their emotional reactions to life's events

2.   Assisting clients to identify dysfunctional beliefs and patterns of thoughts that underlie their problems

3.   Assisting clients to identify situations that engender dysfunctional cognitions

4.   Assisting clients to substitute functional self-statements in place of self defeating cognitions

5.   Assisting clients to reward themselves for successful coping efforts

For other guidelines in helping the elderly and their families with depression, go to the following link:

http://www.psychguides.com/Geriatric%20Depression%20LP%20Guide.pdf

Memory Impairment

Often memory suffers with age.  For the majority, this impairment is mild and does not cause problems beyond being a nuisance.  For others, the impairment is more severe and is troublesome both to family and to the patient.  Sometimes the memory impairment creates an issue of safety when stoves are left on or the person wanders and gets lost.  In even more severe cases the senior may not remember significant life experiences and/or lose the ability to identify loved ones, including children and spouse.  Memory impairment that creates issues of safety often leads to the discussion of the need for alternative long term care. 

The following table provides an illustration of the frequency of memory problems among older Americans.  Specifically it reports the percentage of people age 65 and older with moderate or severe memory impairment, by age group.

Source: Federal Interagency Forum 2006, 26

There are different studies that examine what causes memory impairment. According to Marsha K. Johnson (2003), Yale University, source monitoring has great impact in how someone remembers, and this function is processed by the frontal lobes. Being able to process information and then tie these experiences together so they make sense---such as the environment in which the memory occurred---is part of memory. For example, if somebody goes to the beach with friends, they will gather and process information: e.g., the friends there, the sights and sounds of the ocean and the wind, etc. Being able to tie all these details together helps people create accurate memories. Damage to the frontal lobes can cause a person to gather less specific information, resulting in a less accurate memory and even false memories. Johnson elaborates:

"Neuro-imaging experiments along with the patient data suggest that the frontal lobes are important in monitoring the source of memory. So, we . . . know that older adults do less well under certain circumstances in source monitoring tasks than do healthy, young adults. They are poorer on source recognition than on old-new recognition. Investigators have suggested that this occurs because the frontal lobes are among the slower to mature regions, and they are also more likely to show increasing neuropathology with age" (Johnson 2003).

Dementia, Alzheimer's Disease

There are many similarities between dementia and Alzheimer's disease; it is necessary to know what the differences are. Alzheimer's is one kind of dementia---the most common one. In addition to Alzheimer's, dementias related somewhat to age include (Health-cares.net 2005):

·        Vascular dementias (including multi-infarct dementia)---the second most frequent type of dementia, caused by poor circulation to the brain. In multi-infarct dementia multiple mini-strokes (infarcts) take place which cut off the blood supply to parts of the brain. Progress may be slowed by control of blood pressure and diabetes, as well as stopping smoking.

·        Parkinson disease. Not everyone with Parkinson has dementia; it generally occurs when the disease is well-developed. Reasoning, memory, speech, and judgment are most likely to be affected.

·        Lewy body dementia, caused by microscopic deposits of protein in the nerve cells called Lewy bodies. Over time the protein destroys the cells. It can cause symptoms much like Parkinson disease. This type of dementia cannot be reversed or cured.

·        Alcohol-related dementia. Drinking too much alcohol can destroy brain cells, which leads to the dementia. The dementia may not show up until the person is elderly.

Alzheimer's is a progressive and fatal brain disease that gradually destroys a person's memory, ability to learn and make judgments, etc. The disease kills brain cells that eventually will kill a person if they do not die first of something else. The progress of the disease can take from 3-20 years (ALZ 2008). Although a person may have recently been diagnosed with the disease, the progress of the disease may actually be advanced.

Early warning signs of the disease include (ALZ 1999):

v    Memory loss---forgetting recently learned information, forgetting more often and not being able to recall the information later (normal is forgetting names or appointments occasionally)

v    Difficulty performing familiar tasks---e.g., losing track of the steps of preparing a meal, making a phone call, or playing a game (normal is occasionally forgetting why you came into a room or what you planned to say)

v    Problems with language---often forgetting simple words or substituting unusual words (normal is sometimes having trouble finding the right word)

v    Disorientation to time and place---such as getting lost in their own neighborhood, forgetting where they are and how they got there, not knowing how to get back home (normal is forgetting the day of the week or where you were going)

v    Poor or decreased judgment---e.g., dressing improperly for the weather, frequently falling for telemarketers spiels (normal is making a questionable decision occasionally)

v    Problems with abstract thinking---e.g., forgetting what numbers are and how they should be used (normal is finding it challenging to balance a check book)

v    Misplacing things---putting them in unusual places such as a book in the refrigerator or the salt shaker in the medicine cabinet (normal is misplacing keys or a wallet temporarily)

v    Changes in mood or behavior---showing rapid mood swings for no apparent reason (normal is occasionally feeling moody)

v    Personality changes---dramatic changes, becoming extremely confused, suspicious, fearful, mean, or dependant on a family member (normal is slight personality changes with age)

v    Loss of initiative---becoming very passive, sitting in front of the TV for hours---not apparently really watching, sleeping a lot more than usual, not wanting to do usual activities (normal is sometimes feeling weary of work or social obligations)

The changes that occur as a result of Alzheimer's can affect both the diagnosed individual and loved ones. Reactions to these changes can include depression, anxiety, fear, embarrassment, shame, isolation, loneliness, and feeling of loss. In response to these reactions the Alzheimer's Association suggests the following ways a healthcare professional can help (ALZ 1999):

·        Acknowledge feelings and provide an opportunity to talk and ask questions 

·        Refer the individual and/or their family to an Alzheimer's support group

·        Assess for depression and/or suicidal thoughts; short term counseling and medication may be helpful in some cases

·        Refer families to a physician knowledgeable in dementia for evaluation and treatment

·        Encourage the diagnosed individual and the caregiver to take care of their physical and mental health 

Drugs

This is the age of polymedicine which is the direct result of disease states, multiple healthcare providers, inappropriate and/or self prescribing, and numerous prescriptions (Solomon 2000). This has made administering medications for the elderly one of the most difficult areas in their medical care. Major contributing factors are:

o       The increased possibility of numerous illnesses, often with multisystemic involvement

o       The necessity for these patients to take a number of drugs, often prescribed by different doctors

o       The increasing likelihood of changes in the action of the body on a drug over a period of time (pharmacokinetics) and how the drug acts on the body (pharmacodynamics)

Together, these factors add to the heightened frequency of drug interactions and adverse drug responses in these patients (Diasio 2007). Medications no longer include prescription drugs and aspirin over the counter (OTC), but a multiplicity of OTC and herbal remedies as well.

There are a number of reasons for sometimes dramatic pharmacokinetic changes with age. The most basic are:

·        Change in body composition such as the increase in total body fat with attendant reduction in lean body mass, total body water, and decreased albumin

·        Changes in pharmacokinetically important organs such as the liver or kidneys

·        Slower gastric emptying, decreased gastric acidity, impaired intestinal flow causing decreased rate of absorption, slower onset, and delayed peak of action of drugs

The pharmacodynamic changes with age are basically because of alterations in the responsiveness of the target organ. Even if the pharmacokinetics are unchanged, they necessitate using smaller drug doses in the elderly (Diasia 2007).

Medication Management

Because of the difficulties mentioned above, individuals involved in medication management for the elderly, need to be aware of several things. You, as a social worker or therapist, may need to confront a physician regarding these things, as one therapist did---with negative results to herself.

She was a licensed mental health therapist with an M.S. degree in Counseling and Human Resource Development. At one point she was given the assignment to go to a nursing home to do an annual evaluation for the payor of a patient's care. She was to interview the patient, study all of the patient's records at the

necessary to accomplish this.

On reviewing the records she noted the huge numbers of medications being given and that many were prescribed over the phone when nurses called with a new complaint of the patient. The physician had seldom seen the patient. The therapist called the doctor to ask about the medications, but he was curt and unwilling to give adequate answers.

Being a thorough person, the therapist looked every drug up in the Physicians' Desk Reference (PDR) and found that the concurrent use of two of them required a blood test being taken every six months. No blood tests had ever been taken in the more than eighteen months the two medications were used. This was noted in her report, with quotations from the PDR to substantiate it.

The therapist was remanded for practicing medicine without a license, and the center for which she worked changed the rules to only allow therapists whose degree was in psychology to perform these evaluations in the future. (But the patient's blood was checked!)

With this story in mind, be aware---unhesitatingly---of the following information.

First, there are several basic principles that pertain to drug use in the elderly (Diasio 2007):

·        The drugs eliminated by the kidneys may be reduced by 50%

·        Typically, the only drugs that are eliminated by the liver that need adjustment for age are those with high hepatic clearances

·        Only the lowest effective dose should be used

·        The patient's drug history should be reviewed frequently, including prescription medications, OTC medications, and vitamin or herbal preparations, keeping in mind potential adverse drug interactions and responses

Some steps that can be taken to help prevent drug interactions are (Diasio 2007):

·        All of the drugs the patient is taking, or has recently taken---prescription, OTC, herbal---should be documented.

·        Frequently review the patient's drug list to be sure that each drug is still needed.

·        Be very suspicious when medications used have a low therapeutic index with a high risk of drug interactions (anticoagulants, antiarrhythmics, anticonvulsants, Digoxin, Lithium carbonate, oral hypoglycemics, Theophylline)

·        High-risk clinical settings, such as happen with critically ill patients, should get extra attention.

·        Whenever there is a change in the patient's course, the differential diagnoses should consider adverse drug interactions.

It is very important that you know, or know enough to realize you should find the interactions and side effects of the medications your clients are taking, especially those most commonly prescribed to older adults. Make a chart of the interactions and side effects of these 20 medications most often prescribed to older adults (Solomon 2000):

·        Calcium channel blockers

·        Digitalis preparations

·        Antiarthritics, systemic

·        Diuretics

·        Angiotensin-converting enzyme inhibitors

·        Nitrites and nitrates

·        Beta-blockers

·        Cephalosporins

·        Antispasmodics

·        Diabetes, insulin

·        Diabetes, oral

·        K-sparing diuretics

·        Aspirin

·        Codeine and combinations

·        Antihypertensives

·        Xanthines

·        Potassium supplements

·        Corticoids (oral)

·        Benzodiazepines

·        Diuretics, thiazides

Only a relatively small group of drugs causes most of the well-known adverse drug effects---every drug has side effects and can potentially cause an adverse drug response. Even if a particular drug has not had an adverse response reported, the physician needs to be aware that it could still take place. Diasio (2007) lists the following information about clinical presentations associated with adverse drug responses.

·        Some presentations are obvious, such as a rash in someone who has been prescribed a single drug such as penicillin

·        Some are difficult to distinguish from other disease states

·        Sometimes the adverse effect mimics the illness being treated---e.g., depression from an antidepressant, development of an arrhythmia in a person being given an antiarrhythmic drug

Practitioners need to be aware of the drugs that are potentially contraindicated in elderly patients (Col et al 1990):

Note: This chart is from 1990, so it may need to be updated; updated chart not found.

Some drugs and combinations of OTC, prescription, and herbal drugs should be avoided because of potential drug interactions, for example (Col et al 1990):

·        H2 blockers (e.g., Tagamet)

·        Antihistamines (e.g., Benadryl)

·        Gingko with Coumadin, NSAIDs, aspirin

·        St. John's Wort with antidepressants

·        Garlic with Coumadin, NSAIDs, aspirin

·        Echinacea with Coumadin

For a more complete list, go to the University of Michigan Health System's Website at http://www.med.umich.edu/1libr/aha/umherb01.htm.

Compliance Issues

One definition of medication compliance is "the extent to which a person's behavior coincides with medical or health advice" (Coates n.d.).

Patient compliance to a medication procedure has become more of a problem over time. The reasons are multiple, but perhaps fixed income leads the pack.

However good the reason, noncompliance can lead to a number of problems (Coates n.d.):

o       Possible decline in health

o       Need for additional medical treatment

o       Increased hospitalizations

o       Even death

Herrick (2006) has an outstanding booklet with very specific ways and helps to reduce drug costs. He sums some of it up in the following chart:

From Herrick 2006

Kane et al (2004) offers the following strategies to improve compliance in the geriatric population:

1.   Making drug regimens and instructions as simple as possible

a.   Using the same dosage schedule whenever feasible (e.g., once or twice per day)

b.   Timing the doses in conjunction with a daily routine

2.   Instructing relatives and caregivers on the drug regimen

3.   Enlisting others (e.g., home health aides, pharmacists) to help ensure compliance

4.   Making sure the older patient can get to a pharmacist (or vice versa), can afford the prescriptions, and can open the container

5.   Using aids (such as special pillboxes and drug calendars) whenever appropriate

6.   Keeping updated medication records

7.   Reviewing knowledge of and compliance with drug regimens regularly

To give a little different point of view as to how you can help your clients to improve their medication compliance and thus reduce the risk of adverse reactions, Solomon (2000) suggests:

o       Establishing a rapport with these elderly folks

o       Helping them understand that some medications must be continued whether they feel better or not, e.g., antibiotics, blood pressure medications, and cholesterol medications

o       Having them bring in ("brown bag") all of their medications (prescription, OTC, herbal) for review

o       Aiding them in using a medication calendar, medication organizer, or pillbox. There are even pillboxes that will ring an alarm when it is time to take medication

o       Through this, being sure that they know what they are taking and why they are taking them

o       Keeping the regimen simple, and use once-daily dosing when possible.

Alcohol and Substance Abuse Issues among Elderly

The phrase substance abuse brings to mind out-and-out alcoholics, "shoot 'em up" druggers, and other extremes. Although it is estimated that up to 17% of Americans 65 years or older have problems with alcohol (Task Force n.d.), that does not mean they are all alcoholics. Alcohol used in combination with certain medications can cause harmful effects---including impaired coordination and cognition (Breslow et al 2003)---and elders that use these combinations can be defined as substance misusers and are generally classified as substance abusers. That is possibly why the statistics of alcohol and drug abuse are so high.

Besides potential interactions with medications, there are other reasons why seniors should not use alcohol, or use it very sparingly. Elderly men (and women of all ages) have a smaller volume of total body water than younger men, so they reach a higher blood alcohol concentration from the same amount of alcohol consumption (Kalant 1998). Body composition continues to change with age; therefore, the effects of alcohol may be greater for an 80-year-old than for a 70-year-old (Vestal et al 1977). This tends to result in more harm from the same amount of intake as compared to younger people. Other vulnerabilities of the elderly to the effects of alcohol may be raised by age-related changes in functional status, nutritional status, and psychological and cognitive status (Breslow et al 2003).

With these concerns in mind, it is important to note that heavier use (which is not as heavy for the elderly) of alcoholic beverages has been linked with a number of detrimental health consequences, including cirrhosis of the liver, motor vehicle crashes and other unintentional injuries (NIAAA 2000), as well as with hemorrhagic and ischemic stroke (Reynolds et al 2003). Other reports indicate that the consumption of three to five drinks per day over years has been associated with an increase in the death rate (Yee and Williams 2002, 265). On the other hand, light or moderate consumption (one drink per day at most) has been linked with some health benefits, including reduced rates of coronary heart disease (Mukamal et al 2003)---this may be due to the antioxidants and resveratrol content of red wine which can be obtained through safer means (Mayo 2009a).

Moving from alcohol misuse or abuse to drug abuse---again the biggest problem for seniors is drug misuse. A client who does not take medications as prescribed---forgetting to take them or taking extra because "if a little is good for me, a lot must be better"---is a drug misuser. That is why it is so important to oversee and regularly monitor their medication use.

As with other populations, there are situations that tend to motivate some elderly persons to drink. Four factors that may cause the elderly to be susceptible to drinking alcohol or abusing some drugs are (Brody 1980):

·      Retirement and its boredom, role changes, and financial problems

·      Increased concern with death and losses of relatives and friends

·      Poor health and chronic discomfort

·      Loneliness, particularly among older women

Perhaps the greatest situational motivator of all is depression (Whelan 2003), which has been discussed earlier in this course.

When an older person is amenable to treatment for substance use problems, they usually have better success in treatment than do younger people according to Frederic Blow, professor in the Department of Psychiatry at the University of Michigan and a Huss Research Chair on Older Adults and Alcohol/Drug Problems at Hazelden's Butler Center for Research (Hazelden 2006).

If clients or their relatives need help and intervention for substance use, Hazelden has an outstanding pamphlet with information and suggestions, How to Talk to an Older Person

Who Has a Problem with Alcohol or Medications, available at http://www.hazelden.org/web/public/document/ip_talkolderperson.pdf.

Health and Nutrition

Whether you prefer Anthelme Brillat-Savarin's 1826 statement, "Tell me what you eat and I will tell you what you are," or the way the nutritionist Victor Lindlahr put it in 1923, "Ninety per cent of the diseases known to man are caused by cheap foodstuffs. You are what you eat," you recognize the same truth in both statements: the food that a person eats is foundational to the person's state of mind and health---that to be fit and healthy one needs to eat good food (Martin n.d.).

Few people dispute that fact. Any disagreements would be in the areas of what fulfills the category of "good food." What is good for some is not necessarily good for all. And the elderly definitely do have some nutritional needs that are unique to them.

Nutritional Needs of the Elderly

(DOC 1999)

There apparently is no such thing as a "senior's diet." The general consensus is that any diet that improves one's health is not only good for one, it is also an antiaging diet. However, there is some discussion regarding why seniors in particular need to monitor their diet, or have it monitored if they are unable to do so themselves.

While medical advances, particularly in the areas of surgery, have reportedly helped increase the American lifespan, proper nutrition is more critical in slowing the aging process.

For a senior citizen, especially one who lives alone and "cooks" for one, it is easy to depend on simple-to-fix foods, or sometimes fast foods, instead of cooking something that is truly nutritious. In addition to this, many senior's diets contribute to undernourishment because seniors have reduced appetites and slower metabolisms. They also are not as physically active, and they may have side effects of numerous medications.

However, there is also usually a diminished lean body mass, which lessens the body's energy requirements---it is estimated that seniors need about half as much food at 70 as they did at 25--- so the reduced appetite can be a good thing.

On the other hand, if they don't eat as much, it is harder to get all of the nutrition needed in a senior's diet, especially in this day and age of processed foods (foods that need 72 minerals to be the most healthy are grown in soils in which only three of those minerals are added), and foods that are days or weeks between harvest and getting to the consumer's kitchens.

A few of the more nutritionally-serious side effects of some medications are that they can reduce absorption and metabolism of the vitamins and minerals that are in the diet.

As one ages, there are some nutrients that are needed more for the elderly than were needed at younger ages, especially calcium, vitamin E., vitamin D, riboflavins, folate, vitamin B12 and protein. If these nutrients are not ingested in sufficient quantity, the elderly can experience:

·        Bone density loss, causing weak, brittle bones that can lead to disabling fractures

·        Impaired nervous system functioning

·        Slowed wound healing

·        Inability to perform normal daily living activities

·        Weakness and sluggishness

For optimal health, seniors (frankly, everyone) should add food supplements to their diet. Liquid nutrition supplements are best as they are more easily absorbed---especially important for seniors.

Conversely, the need for iron becomes lower as people age. Many people, young and old, use the USDA food pyramid as their guideline:

USDA Food Pyramid

However, Robert M. Russell, M.D., professor of nutrition at Tufts University and associate director of the Jean Mayer USDA Human Nutrition Research Center on Aging, says that the dietary guidelines that go with the USDA food pyramid are not accurate for elderly people because their lives are more sedentary, they are not eating the serving sizes and amounts recommended; as a result they take in fewer nutrients (Sherer 2000). In fact, the pyramid, as presented on MyPyramid.gov, does not include the elderly in its guidelines for specific populations (USDA 2009).

John W. Erdman, Ph.D., of the division of nutritional sciences at the University of Illinois and member of the panel reviewing antioxidants for The U.S. Department of Agriculture (USDA) Dietary Guidelines for Americans 2005, stated that the guidelines are generally designed as a rule of thumb for all Americans and special needs groups, such as geriatric, have only recently been looked at (Sherer 2000).

Among the panels' nutritional recommendations for folks over seventy, Erdman said, "For vitamin D, the recommended intake for [people] over 70 goes up from 10 micrograms to 15 micrograms. There also are some comments about the need for supplements rather than food for things like vitamin B₁₂ because many older individuals lack the intrinsic factor to absorb B₁₂ very well, so they probably need fortified foods and supplements to meet their B₁₂ requirements" (Sherer 2000).

In addition, there are higher recommended Dietary Reference Intakes (DRIs) for calcium and vitamin D for women, who risk greater bone loss during and after menopause.

Russell and his associates created a modified food pyramid that considers the specific food needs and habits of people over seventy.

This modified pyramid uses the official UDSA pyramid as its point of reference, but it adds a layer at the bottom of eight or more servings of water. Russell declared that elderly people have a muted thirst sensation and are therefore prone to dehydration unless they are reminded to drink water.

The next levels up of the Russell pyramid follows the standard pyramid, with some variation in the quantities recommended. However, he added a flag at the top that represents food supplements for calcium, vitamin D, vitamin B₁₂, and several other nutrients.

Russell notes that there are a few nutrients that are problematic no matter which guidelines are followed. As an example he mentioned that the recommendation for vitamin D is 15 micrograms, or 600 International Units---three times as much as for a young adult. To get that amount from milk, for example, one would have to drink a quart and a half. As most older people either can't or won't do that, supplements are recommended.

He went on to say that as many as 15-20% of people over sixty-five have atrophic gastritis, which means they don't generate as much acid and pepsin in the stomach and are thus not able to split vitamin B₁₂ from food proteins. If they can't split if off from the food complex, they can't absorb it. They can absorb it normally if it is in the form of a food supplement.

Because of their sedentary lives reducing energy requirements, they must get all of their nutrients with smaller food quantities. To do this they need foods that are denser---that have more nutrients per calorie than are recommended in the classic USDA food pyramid for adults. Nutrient-dense foods are whole grains, darkly colored fruits and vegetables, and legumes.

Other recommendations that Russell gives are dark green, orange or yellow fresh vegetables for vitamin C, folic acid, vitamin A, and dietary fiber. Beets, kale, cabbage, and broccoli add antioxidant phytochemicals such as indoles, flavones, and isothiocyanates. For adequate fiber intake he emphasizes the need for whole foods rather than juices.

From the dairy group, Russell suggests low-fat products and lactose-free foods to overcome the lactose intolerance of many elderly. He stressed the need for lean meat, suggesting fish as a good substitute since it supplies high-quality protein and fatty acids. There are survey data that show the possibility that if fish are eaten on a weekly basis, the risk of developing cardiovascular disease may be reduced. He pointed out that bean, grain, and vegetable main dishes "provide high-quality protein, add fiber to the diet and---when substituted for meat---help to minimize saturated fat and cholesterol intake" (Sherer 2000).

Russell warns against refined carbohydrates because of their low nutrient density as compared to the naturally occurring counterpart.

Fiber is important for the elderly because it helps prevent constipation, diverticulosis, and diverticulitis, according to Russell. Sources of fiber include whole-grain breads instead of those made with refined flour, brown rice rather than white, whole fruits, legumes instead of meat at least two times a week, cooked vegetables, fresh salads, and high-fiber cereals.

These recommendations are for relatively healthy folks and may need to be adapted somewhat for those who are less healthy. Continuous monitoring for negative effects is also recommended.

Weight Gain and Obesity vs. Weight Loss and Cachexia

Appropriate Weight

Overweight and Obesity

Weight Loss and Cachexia

Protein-Energy Malnutrition

Food Safety

Nutritional Supplements

Exercise

Aging and Sexuality

Age and Sexual Response

Sexuality, Estrogen Replacement and Other Hormone Therapy

Erectile Dysfunction

Sex in Nursing Homes