Aging and Long-Term Care (10 Hours) > Chapter 2, Part A

Chapter 2 Part 1: The Biopsychosocial

Aspects of Aging

Biological (Physical) Aspects of Aging



One of the most notable areas of change that occur as we age is our bodies. George Bernard Shaw declared, "Youth is wasted on the young." In other words, young folks have everything still going for them physically, health-wise, and mentally. But they have not yet developed the patience, understanding, and wisdom that would save a lot of effort. Once those qualities are nurtured, the physical and mental energy can be used to their full extent.

This is probably understood only by those who no longer qualify as young; there is likely nothing the aged miss more than a young and healthy body. Even those in the best of shape find themselves running a little slower, jumping a little lower, and recovering slower still. Aches no longer come and go, they come and linger. For some, the aches include severe pain that is a constant companion. A lack of physical control is often in attendance. As Bette Davis said, "Old age is no place for sissies." The following are common physical and biological concerns that face the aging.

Activities of Daily Living


1. Reduced Endurance and Strength


As one ages, especially after age 75, there is a gradual decline in endurance and strength. But the individual generally does not experience a decline in his or her desire to remain as independent as possible. Many sources advise older people to exercise regularly at a level suitable for their age and health in order to try to limit the fatigue and weakness that often contribute to their inability to care for themselves.

This is generally good advice, although there are several causes of a decline in muscle strength: diseases, nutrition deficiency, general reduction in normal activity, or just plain aging (Hyatt et al 1990). Potentially crucial levels for disability in activities of daily living (ADL) may relate to knee extensor strength and maximum walking speed (Sonn et al 1995).

The rehabilitation specialist must plan a program for an elderly client that balances the goal of cultivating full range of motion (ROM) and maximum independence with work simplification techniques to reduce enervation.

Some of the energy conservation and work simplification techniques that may be used include (Hills 2002, 43):

  • Review the normal scheduled activities; eliminate unnecessary ones.
  • Determine whether combining, rearranging, or simplifying procedures can enhance work efficiency.
  • Plan activities so there is a balance of heavy and light tasks throughout the day, week, and month.
  • Alternate work sessions with sufficient rest periods to avoid overfatigue. Maintain good posture. Site rather than stand. Avoid bending and stooping whenever possible.
  • Avoid rushing, which increases tension and fatigue. A moderate steady pace is more productive.
  • Utilize proper body mechanics at all times.
  • Organize storage and work areas according to function. Assemble all necessary supplies and equipment before beginning a task.

2. Decreased Joint Mobility


Many elderly people have joint deterioration, causing diminished mobility and discomfort. The most common causes for joint deterioration are rheumatic diseases, especially the many forms of arthritis. Any disease that causes pain, stiffness and swelling in joints or other supportive body structures (muscles, tendons, ligaments, and bones) is a rheumatic disease (Spectrum n.d.).

Four important principles for joint protection are (Hills 2002, 44):

  • Actively move every joint through its full ROM during daily activities. For example, store light objects at heights that will encourage full ROM when reaching them. Use smooth, long, sweeping motions when dusting a floor.
  • Avoid unnecessary pressure on joints, using the largest joint whenever possible. For example, carry large objects with the arms rather than the hands. Jar openers and other kitchen equipment and utensils should have enlarged handles to reduce stress on fingers caused by a tight grip.
  • Use correct body mechanics when lifting or pushing objects to reduce strain on joints.
  • Avoid static movements that need continuous muscle contractions over a long period of time---they are very tiring. Instead of holding a book, for example, use a book holder---or a telephone holder for the phone.

3. Increase Danger of Accidents


Elderly adults are at a greater risk of household accidents. When the reduced endurance and strength and the decreased joint mobility already mentioned are combined with decreased vision and/or hearing, plus a slowed reaction time, it is easy to see why this is true.

Areas of the home that can be hazards are:

  • Slippery or uneven surfaces
  • Stairs or steps
  • Kitchen
  • Bathroom


All people, but especially the elderly, are a danger to themselves. While they may be careful to avoid walking on icy sidewalks, they may decide to stand on a chair to change a light bulb. Encourage safety by assisting them to find someone who can help with these kinds of tasks at a time that is convenient for both. Perhaps they can trade a service, such as baking, in exchange for jobs that are too risky (Hills 2002, 44).

A few simple, inexpensive fixes, from lowering the water heater temperature to getting brighter light bulbs, can go a long way toward minimizing the risk of accidents for seniors.

Here are a few more ideas you can give to clients (Vancouver 2007):

Throughout the house:
  • Put a night light in every room, near floor level.
  • Remove small scatter rugs, or at least trim fringes and add non-skid padding. Use double-sided tape between rug and pad.
  • Put handrails on both sides of all steps, and non-skid tape or rubber treads on uncarpeted stairs.
  • Bright, glare-free lighting is important, especially near stairs and work areas. Frosted bulbs and dimmers can reduce glare.
  • Eliminate extension cords, or at least be sure they are not used where one could trip over them.
  • Install smoke and carbon monoxide alarms on each floor; use alarms with strobe lights for the hearing-impaired.
  • Replace doorknobs and sink faucets with lever-style handles that are easier to turn.
  • Set water heater temperature at 120 degrees to avoid scalding.


Entrance Way:
  • Have a porch light bright enough for adequate illumination and security.
  • Put a bench in the foyer and outside the front and back doors for resting or setting down packages.


Bedroom:
  • Have a lamp and telephone within reach of the bed.
  • Install lights in each closet and lower clothing rods if necessary.


Bathroom:

  • Install grab bars in the tub or shower enclosure. Bars are also helpful near the toilet.
  • Use non-skid tub strips or a rubber suction mat to avoid slips.
  • A bench or fold-down seat and a handheld shower attachment can make showering easier.
  • Replace glass or porcelain cups and accessories with unbreakable plastic or metal.
  • Label medications clearly; always discard expired and unnecessary prescriptions.
Kitchen:
  • Swap cabinet and drawer knobs with easy-to-use pulls.
  • Put frequently used items close at hand; consider getting rid of dishes, utensils and gadgets rarely used.
  • Store pans, platters and other heavy objects within easy reach and lighter things higher up.
  • Get a sturdy step stool---never use a chair or box; it should have wide steps and a steady hand grip.

A physical therapist can evaluate ambulation problems and then recommend correct equipment. Care must be taken that any equipment purchases (canes, walkers, crutches) are properly fitted and that training in using them is given. If the person lives alone, help arrange for a family member or volunteer to check regularly on the person's welfare by telephone or visit (Hills 2002, 44). Another help is to encourage the person to wear a medical alarm system necklace; these can often be obtained through a local hospital.

A cautious plan for safety measures is wise, since elderly folks often have a longer recovery time after an injury than younger people do. However, there needs to be a balance between safety and independence issues.

Changing Sphere of the Senses


Vision


Vision loss among the elderly is a major health care problem. In the U. S. Department of Health and Human Services' (HHS) Older Americans 2008, Key Indicators of Well-Being, 17% of respondents reported vision problems in response to the question, "Do you have any trouble seeing, even when wearing glasses or contact lenses?" (Federal Interagency Forum 2008, 28)
The most common causes of vision loss among the elderly are (Quillen 1999):
  • Age-related macular degeneration (loss of central vision)
  • Glaucoma (leads to blindness by damaging the optic nerve)
  • Cataracts (clouding of the eye's lens)
  • Diabetic retinopathy (damage to the retina caused by complications of diabetes mellitus)


[QN.No.#1.The most common causes of vision loss among the elderly are:]

Signals of vision loss in the elderly include blurred vision, image distortion, difficulty reading, decreased night vision and visual field loss. Slower adaptation when moving from sunlight to indoors or change of focus between closer objects and those more distant are also vision problems. Sensitivity to glare and decline in peripheral vision greatly affect the ability to drive (Life Alarm 2009).

Vision loss can affect many previously enjoyed activities, such as reading, watching television, and attending the theater or sporting events. Depending on the severity of the vision trouble, it can also impede facial recognition, transportation issues (reading street signs or various public transportation signs), as well as communication---especially non-verbal cues.

Regular visual check-ups are needed to catch the problems early on when there is the best chance of correcting them.

Hearing


As we age hearing often declines. Difficulty with hearing can be especially frustrating to both the elderly and to those around them. The ability to hear impacts speaking as well as equilibrium, so a person who has trouble hearing may also have difficulty speaking, or feel off balance or dizzy. In a national survey of people 65+, 48% of men and 35% of women reported having trouble hearing (Federal Interagency Forum 2008, 28).



This can result in difficult social situations. Some say, "As you lose hearing you lose people." In social gatherings it is difficult to stay engaged in conversations when not all the comments are heard. Frustration over not being able to hear comments can produce anger displaced on those who are speaking. Communication becomes more laborious and, after time, avoidance of communication can occur.

A famous audiologist, Mark Ross, once said, "When someone in the family has a hearing loss, the entire family has a hearing problem” (Kricos, n.d.). That is very accurate, because it affects every member of the family, not just the person who’s hard of hearing.

Basic learned hand gestures used between the hearing impaired and loved ones can help increase communication. This may vary from levels of deaf sign language to just basic "homemade" gestures that are shared and understood for communication. Since a great majority of communication is non-verbal, there is still much that can be communicated, especially with those familiar with the hearing impaired.

"Communication in general is a process of sending and receiving messages that enables humans to share knowledge, attitudes, and skills. Although we usually identify communication with speech, communication is composed of two dimensions---verbal and nonverbal.

"Nonverbal communication has been defined as communication without words. It includes apparent behaviors such as facial expressions, eyes, touching, and tone of voice, as well as less obvious messages such as dress, posture and spatial distance between two or more people" (Fort Hayes, n.d.).

Some who have lost hearing find comfort in the ability to communicate and interact with people through e-mailing and Internet message boards. This provides opportunity to exchange ideas and communicate without the usual frustrations. Because of the more recent access to computers, many of the elderly have avoided its use. The healthcare professional can help elderly clients overcome their fear or indifference by showing them basic steps of communication over a computer. Of course, this does not supplant emotionally important personal interactions, but it can provide a feeling of competence and satisfaction lost in face-to-face interactions.

The advanced technology of hearing aids has also helped the elderly suffering from hearing loss to maintain good social interaction. Early hearing aids only amplified all sounds without distinguishing volume or wave levels between things such as the human voice or cars on the road. They also did not allow the hearer to distinguish the direction from which the sound was coming. Newer hearing aids are able to do these things and have greatly improved the quality of social interactions and of life for those having difficulty hearing.

Edentulousness: Loss of Teeth


The same survey that inquired regarding older persons' sight and hearing also surveyed to find how many are affected by the loss of teeth. The respondents were asked if they had lost all of their upper and lower teeth. Twenty-seven percent of men and twenty-five percent of women reported having no natural teeth (Federal Interagency Forum 2008, 101).

Obviously, periodontal disease and tooth decay, with the complication of loss of teeth, are major health concerns for the elderly population. However, the majority of the cases of edentulousness have no apparent reason, no underlying cause or origin, other than a symptom of the aging process (Cadena 2008).

In a six-year study, it was shown that edentulous elderly in nursing homes who had no dentures had a significant deterioration of their systemic health compared to those who had twenty or more teeth. Their mortality rate was also decidedly higher. At least a major reason from this is that the loss of teeth is known to influence the mastication of foods, endangering nutritional status (Shimazaki et al 2001).


Tooth loss has also been identified as a significant risk factor for head and neck, esophageal, and lung cancers. Efforts to preserve the teeth may decrease the risk of these cancers (Hiraki et al 2008).


[QN.No.#2.Efforts to preserve the teeth may decrease the risk of:]

Another study, using self-assessed chewing ability rather than number of teeth, found that the 80-year-old subjects able to chew four foods or less ranged from 2-7 times more dissatisfied with their social interactions, physical condition, meals, and daily living (Takata et al 2006).

Apparently the functional and psychological problems can be offset to some extent if the way the elderly person looks can be satisfactorily improved. A group of elderly who were studied were interested in surgical, restorative, and rehabilitation procedures, to the detriment of preventive actions and promotion of health. This suggests that there needs to be plans to educate the elderly client in the essentiality of oral health (Unfer et al 2006).

Technological advances in dentistry have benefitted the elderly. The elderly have even better results with oral implants than younger individuals (Bryant 2005). However, some seniors may need to be reminded that having dentures or oral implants still requires care for oral cleanliness.

Speech


Slow speech and thought processes usually represent an aging change, although some diseases such as depression and Parkinson's can also cause these (Kane et al 2004).


Changes in Motor Processes


As a person ages, there are numerous anatomic and physiologic changes in their body. Several of these can affect a person's speech (Cherney 2002, 49):

  • Respiration (breath under lung pressure)
  • Phonation (opening and closing of the glottis; with Respiration, sound is produced)
  • Resonance (the sizes of interrelated cavities in the head, chest, and throat that influence volume and quality of speech sounds)
  • Articulation (the changes in shape and movements of speech organs, particularly the tongue and throat, that cause a particular verbal sound to be made)

Respiration


Expired air is the foundation for all speech. Of course, the health of the lungs is the primary aspect of respiration. However, changes in the rigidity of the spinal cord, vertebral column and disks, and rib cartilage can restrict the ability of the lungs to inhale and express air.

This can affect voice volume, the ability to adequately make some sounds, changing the voice quality to a breathless characterization; it can disturb the natural rhythm or flow of speech because the individual may need to catch his or her breath more often when speaking.

Phonation


Physical changes that can affect phonation include changes in the structure and physiology of the pharynx such as calcification of the cartilage and fatty degeneration of tissue. Either or both of the two pairs of folds called vocal cords can bow, atrophy, or swell with water retention; the laryngeal mucous glands may also atrophy. Reduced blood flow to the laryngeal muscles can affect speech, as can stiffening of laryngeal ligaments. These sorts of physical changes cause an elderly person's voice to sound hoarse, tremulous, rough, or breathy. Men's voices may take on a higher pitch, while women's tend to sound lower.

Resonance


Nasality and denasality are determined by the size and shape of the pharynx and the nasal and oral cavities. Although such changes in these structures are not common through normal aging, other causes have been noted to affect resonance: loss of teeth (some or all), lower jaw structural changes, and decreased function of the pharynx.

Articulation

There are a number of oral-facial changes that take place as a person ages---loss of teeth, bone alterations, changes in muscles used for chewing, weakening of the facial muscles (primarily affecting the firmness of the skin), and acquiring "extra chins" through fat accumulation. These usually do not significantly alter the articulation of sounds. Sometimes if an elderly person just doesn't feel well, or if they have a disease such as Parkinson's, they may just not care to work at speaking well. If clients are becoming more unintelligible, a speech-language pathologist may be able to assist them. On the other hand, if it is severe, dysarthria must be considered (see below, Changes in Neurological Processes).

Changes in Neurological Processes


Aphasia


The term aphasia has replaced the earlier term "dysphasia" to prevent confusion with the swallowing disorder dysphagia. According to the National Aphasia Association (NAA), "aphasia is an acquired communication disorder that impairs a person's ability to process language, but does not affect intelligence. Aphasia impairs the ability to speak and understand others, and most people with aphasia experience difficulty reading and writing" (NAA 2009). Aphasia is caused by brain damage, usually from a stroke or head trauma.

The NAA recommends several things people can do to aid communication with someone suffering from aphasia:

  • Wait: Give them time to speak. Resist the urge to finish sentences or offer words unless there is a clear signal that a suggestion is welcome.
  • Be sensitive to noise. Turn off competing sounds (like radios, TVs, appliances). Keep your own voice at a normal level---shouting does not help.
  • Be open to different ways of getting and sending messages like drawings, gestures, writing, and facial expressions. Shared understanding is more important than perfect grammar.
  • Confirm that you are communicating successfully. Verify that your partner uses "yes" and "no" consistently, then use yes/no questions to check key points.

Dysarthria


Dysarthria is the name for slurred, slow, distorted speech. It is cause by lack of ability to control or coordinate the muscles used in speaking. Mayo Clinic lists the following common causes (Swanson 2008):

  • Stroke
  • Traumatic brain injury
  • Brain tumor
  • Degenerative disorders such as Parkinson's disease, amyotrophic lateral sclerosis (ALS) and multiple sclerosis
  • Conditions that cause facial paralysis or weakness, such as Bell's palsy
  • Excessive use of alcohol
  • Certain medications, such as sedatives or narcotics


[QN.No.#3.Common causes for Dysarthria is:]

The severity of the dysarthria is the guide for what treatments to use. If the individual has a mild or moderate form of the disorder, he or she can learn methods to make their speech more intelligible. Training and work towards improving physiological support for articulation, resonance, and respiration should be tried before compensatory methods are used. Compensatory techniques are those that help the individual make good use of whatever physiological abilities they still have to speak understandably.

A speech-language pathologist should be the one to guide the treatment. Possible goals of treatment are suggested by the American Speech-Language-Hearing Association (ASHA 2009):

  • Slowing the rate of speech
  • Improving the breath support so the person can speak more loudly
  • Strengthening muscles
  • Increasing mouth, tongue, and lip movement
  • Improving articulation so that speech is more clear
  • Teaching communication strategies to caregivers and family members
  • In severe cases, learning to use alternative means of communication (e.g., simple gestures, alphabet boards, or electronic or computer-based equipment)

Taste and Smell


Taste and smell are often spoken of as if they were one unit. To a great extent that is true. Approximately 80-90% of what we perceive as "taste" actually is due to the sense of smell (Kalamuck n.d.). Because our tongues only discern five true "taste sensations" (sweet, sour, bitter, salty, and umami (the taste elicited by glutamate, which is found in chicken broth, meat extracts, and some cheeses) (NIDCD n.d.), smell is the means by which we savor the complex, wide range of flavors that make our mouths water or cause us to turn up our noses.

It is rare to have a true loss of taste. When one perceives a taste loss, it is usually instead caused by a smell loss (NIDCD n.d.).

In the first massive study of loss of smell, Doty and others (1984) found that the average ability to identify odors usually peaks between twenty and forty years of age. From that point on, it begins to decline in a constant monotonic manner. They also discovered that more than 80% of those tested over age eight showed major olfactory damage. In fact nearly half of them had essentially total loss of smell. More than 60% of those individuals in the test groups between ages 65 and 80 also showed major olfactory damage, with nearly one-fourth of them being anosmic.

This study also indicated that there is compelling circumstantial evidence that these changes in smell may be due to degenerative processes within the olfactory epithelium, as well as changes in more central neural pathways.

In addition to these possibly untreatable causes, other causes include (Takahashi 2007):

  • Nasal and sinus problems (e.g., allergies, sinusitis and nasal polyps)
  • Certain medications (e.g., some antibiotics, high blood pressure medications and chemotherapy)
  • Mouth sores, tooth decay, or poor dental hygiene
  • Head injury
  • Cigarette smoking
  • Neurodegenerative diseases (e.g., Parkinson's disease and Alzheimer's disease)

Effects of loss of taste and smell can have critical impact on an elders' quality of life:

  • Decreased nourishment because of recduced appetite since the food lacks flavor or because of depression caused by bland-tasting food
  • Unable to tell if foods or beverages are spoiled, or if they are a food the individual is allergic to
  • Problem for folks with high blood pressure or diabetes because of using too much salt or sugar
  • Safety problem because they may not be able to detect life-threatening fires and gas leaks in the home

Some of the things that can be done for safety nd to make meals more palatable for an elder with reduced taste or smell are (Hills 2002a, 99):

  • Choose foods that accent appearance and texture
  • Hot foods should be hot, and cold foods should be cold
  • Use spices and herbs to increase flavor choices---use as liberally as necessary
  • Emphasize social aspects of mealtimes, including table settings, lighting, and pleasant company
  • Engage family members or friends to check pilot lights, stored food, etc. for safety problems

Touch


Touching is usually taken for granted, but it is an amazing and essential sense. We think of the sense of touch as involving only the skin, but there are also receptors that detect touch, temperature, pain, pressure or vibrations in the muscles, tendons, joints, and internal organs (Cohen 2007).

Because of changes in the amount of fat beneath the skin and fewer nerve endings, the skin becomes less sensitive as we age, and therefore the sense of touch diminishes (Kemmet and Brotherson 2008).
Causes for the loss of touch have been given as:
  • Decreased blood flow to touch receptors
  • Decreased blood flow to the brain or spinal cord
  • Nutritional deficiencies
  • Decrease in density and distribution of particular corpuscles and discs in the skin (RNIB 2009)

Because of this loss, which deprives them of some ordinary defense mechanisms, the elderly person:

  • May not wear clothing suitable to the temperature
  • May not feel pain until the skin has been injured
  • May not notice a cut, blister or other injury that can lead to infection
  • May not notice the presence of pressure ulcers
  • May have difficulty with small motor skills such as writing or picking up small objects

Some of the safety recommendations to aid in coping with reduced touching sensations are (Cohen 2007):

  • Limit the maximum water temperature in the house to reduce the risk of burns.
  • Teach the clients to look at the thermometer to decide how to dress rather than waiting until they feel overheated or chilled.
  • Encourage the elderly to inspect their skin (especially the feet) regularly, and if an injury is found, see that it is treated---they should not assume that because the area is not painful it is not a significant injury.

Balance and Dizziness


Of grave concern for many people ages 65 and over is the possibility of falling. Problems in balance and/or dizziness can cause falls. Physical characteristics or problems that can affect balance are (VEDA 2008):
  • Those that affect vision: cataracts, glaucoma, diabetic retinopathy, macular degeneration, and wearing the wrong prescription for glasses
  • Peripheral neuropathy
  • Vestibular-system degeneration
  • Muscle weakness
  • Decreased joint mobility

Vestibular disorders cause about half of dizziness problems, although problems with the central area of the brain, vision and neuropathy problems, and psychological problems can also cause dizziness.


Vestibular System, Wikipedia
Commons: Public Domain
Those problems caused by degeneration of the vestibular system can be reduced through two means. The first is the Canalith Repositioning Procedure (CRP)---also called the Epley maneuver, which can be done in the doctor's office by a trained professional. Through a series of head and trunk movements, the CPR moves excessive calcium masses, often called otolithic debris or canaliths, from the semicircular ducts to the utricle, where they don't send false signals to the brain about spatial movement (VEDA 2007a).

The second is Vestibular Rehabilitation Therapy (VRT). VRT's goal is to re-educate the brain to identify and process signals from the vestibular system, coordinating them with information from vision and the body's perception of movement and spatial orientation.

[QN.No.#4.Balance and Dizziness problems for elder persons caused by degeneration of the vestibular system can be reduced through:]
[QN.No.#5.To re-educate the brain to identify and process signals from the vestibular system, coordinating them with information from vision and the body's perception of movement and spatial orientation is known as:]

Musculoskeletal Changes with Age


The causes of loss of flexibility as one ages are several (Lewis 2002, 104ff):

  • A biologic cause: change in collagen
  • A functional cause: decreased activity or hypokinesis
  • A pathologic cause: arthritis
  • A nutritional cause: dietary deficits

The results of loss of flexibility can be:

  • Difficulty in walking
  • Difficulty in carrying out daily activities
  • Pain
  • Inability to increase strength


The American College of Sports Medicine (ACSM) has long advocated incorporating flexibility exercises into overall fitness programs. Their recommendations are stated for healthy adults, so they may need to be adjusted a bit for the elderly. They state that these programs should be designed to adequately develop and maintain range of motion (ROM), and stretch the major muscle groups. They stress that they should be performed a minimum of two to three days a week. They recommend using both dynamic and static techniques (ACSM 1998).

According to the BríanMAC Sports Coach Website (2009), dynamic stretching exercises are "slow controlled movements through the full range of motion" and are most suitable for warming up. Static stretching exercises are "for cooling down at the end of a training session when stretches are held for 10 seconds or to improve the mobility and range of movement when stretches are held for 30 seconds." The 30 second movements are the most basic ones for the elderly, although the "30 seconds" may need to be reduced, especially when beginning a flexibility exercise program.

Loss of Strength


A number of researchers have documented that many older adults experience changes in the musculoskeletal system, usually associated with decline of muscle strength, although occasionally there were gains in strength. Gains cause no problems, but declines can. Endurance, the ability of the muscle to contract steadily at levels below what the individual is maximally capable of, also decreases with age, but generally not as much as muscle strength (Shumway-Cook and Woollacott 2006, 219).

Although it has been shown that there is a major association between strength and physical function, it has more recently been shown that muscle power is even more important to physical function (Shumway-Cook and Woollacott 2006, 220). Exercises in muscle power include jumps, marches, twists, and medicine ball exercises rather than strength training with weights (ExRx.net n.d.).

Poor Posture


Posture changes with age as muscles, tendons, ligaments, nerves, and bones undergo degenerative change (Heary and Albert 2007, 59). Typical changes are (Lewis 2002, 114):

  • The head tends to extend forward
  • Shoulders may be rounded
  • The upper back may have a slight kyphosis---often referred to as a "hump back"
  • Flatter lumbar spines if the person is apt to sit for long periods of time
  • The lordotic curve at the waist may either be flatter or more pronounced
  • The knees and hips may be slightly flexed


The main causes for these posture changes are:

  • Osteoporotic wedging of the thoracic vertebra
  • Loss of lumbar disk height
  • Greatly diminished muscular function or mobility


If the spine cannot adapt to these changes, the hips and legs try to compensate by hip extension, knee flexion and posterior pelvic angulation (Heary and Albert 2007, 60). These changes often require other parts of the spine to make their own compensatory changes. It is like the fall of dominoes, only usually in very slow motion.

One study found that the severity of flexed posture in elderly female patients who had no other physical condition was not related to osteoporosis, but rather to (Balzini et al 2003):

  • The severity of vertebral pain
  • Emotional status
  • Muscular impairments
  • Motor function

Rehabilitation interventions should address muscular impairments, posture, and behavior modification. Exercises should include those that (Kolt and Snyder-Mackler 2003, 80):

  • Encourage diaphragmatic breathing
  • Strengthen the hips
  • Strengthen the neck and back extensors and the scapula retractors
  • Stretch the major upper and lower arm and leg muscles
  • Stabilize the trunk and limb girdles by using a medicine ball or other stability balls such as bosu balls, and other balance equipment like balance boards
  • Stimulate thoracic extension by lying in a prone or prone-on-elbows position

Changes in Gait


Gait is a person's particular manner of walking, or other movement on foot. To walk most effectively and with minimal effort a person makes good use of both gravity and momentum. In fact, many problems caused by loss of balance and its recovery are related to the lack of ability to make the most of momentum and gravity (Lewis 2002, 117-8). Ways in which a person's gait may change as they age include:
  • Having less body motion, e.g. arm swing will be less
  • Less able to use gravity so muscles have to work harder
  • Reduced velocity
  • Shorter steps are taken, often to provide safety
  • Feet are farther apart to affect a more stable base
  • Decrease in heel-to-floor angle
  • Rotating the hips and shoulders less

Topics discussed earlier (reduced flexibility, decreased muscle strength/tone, posture limitations) all affect these gait changes. Bony changes in the foot or ill-fitting shoes can also influence gait. Other things essential for walking are good equilibrium, ability to begin and maintain rhythmic stepping, functioning joints, adequate vision, as well as the vestibular, auditory, and sensorimotor systems (Molson Medical 1999).

There are several approaches to exercising to improve the client's gait. The first is a regular routine of exaggerated movements of hip extension and rotation, and arm movements (Lewis 2002, 119). A second approach is to use ankle weights for hip flexion, knee extension, plantar flexion, and dorsiflexion---working up to two sets of ten to fifteen repetitions, 2-3 times a week (NCPAD 2007).

Chronic Pain


Everyone has experienced pain of some sort. However, as one ages chronic pain often becomes part of daily life. This is because the number of cells that secrete enkephalin, one of the body's natural painkillers that block pain signals in the spinal cord (Medical Discoveries n.d.), is reduced with age. As a result, the output and release of enkephalin are decreased, causing chronic discomfort (Herr and Mobily 1991).

Because most older people don't want to seem to be complaining "all the time," they tend to avoid reporting pain as often as younger people do (Lewis 2002, 122). Musculoskeletal disorders are the most common complaints of pain among the elderly, especially the joints. In the U.S., about 20% of elderly take analgesics at least several times a week; two-thirds of these people take prescription analgesics for more than six months (Merck 2005).


Other problems that chronic pain leads to include (Merck 2005):

  • Social isolation
  • Depression
  • Polypharmacy
  • Decreased functional status
  • Under utilizing musculoskeletal tasks, leading to deconditioning


Social workers, physicians, and others working with the elderly can help by:

  • Asking about the elderly person's pain
  • Offering psychosocial support and nondrug treatments that reduce pain, helping to avoid the elderly's increased risk of adverse drug effects and drug-drug interactions of analgesics
  • Knowing that if analgesics must be used, for mild to moderate chronic pain not due to inflammation, acetaminophen is usually safer than NSAIDs
  • Facilitation patient/caregiver education and active caregiver involvement---these can help reduce pain and thus improve quality of life

Instability and Falls


Although instability and falls have been mentioned in regards to balance/dizziness, muscle weakness, and gait, they are enough of a problem to deserve special attention. There are various age-related elements that contribute to instability and falls (Kane et al 2004, 220-1).


  • Age-related changes in neuromuscular function, gait, and postural reflexes
  • Impaired vision and/or hearing
  • Medical and neuropsychiatric conditions (e.g., degenerative joint disease, orthostatic hypotension, dementia)
  • Environmental hazards (unstable and low-lying furniture, inappropriate height of beds and toilets, grab bars not handy or available, uneven stairs and inadequate railing, throw rugs, frayed carpets, cords/wires, slippery floors and bathtubs, inadequate lighting, glare, cracked and uneven sidewalks)
  • Medications and especially combinations of medications
  • Improper prescription and/or use of assistive ambulation devices


Meta-analyses of studies targeting interventions to reduce the rate of falls found that these interventions usually did reduce the overall rate of falling, but not the number of falls with serious consequences. Successful interventions included exercising (must be sustained for at least six months), environmental modifications, attention to drug regimens, and education of caregivers; the most success was attained when all of the interventions were included in the plan. Kane and others (2004, 242) sums these in more detail:

1. Among older persons who live in the community:

  • Gait training and advice on appropriate assistive devices
  • Review and modify medication, especially psychotropics
  • Exercise programs that include balance
  • Treat postural hypertension
  • Modify environmental hazards
  • Treat cardiovascular disorders, including arrhythmias
2. Among older persons who live in long-term care and assisted-living settings:

  • Staff education programs
  • Gait training and advice on appropriate assistive devices
  • Review and modify medication, especially psychotropics

Chronic Diseases and Causes of Death



A chronic disease is one that lasts for a long time. The U.S. National Center for Health Statistics has defined a chronic disease as one that last three months or more. Vaccines usually cannot prevent these diseases, nor can medications cure them; they also don't just disappear. As of 1998, 88% of Americans age 65+ have at least one chronic health condition. Major contributors to these diseases can be lumped under health damaging behaviors---specifically tobacco use, lack of physical activity, and poor eating habits (MedicineNet.com 2004).

Chronic diseases are inclined to become more prevalent with age. The leading chronic diseases in the United States (in alphabetical order) are:

  • Arthritis
  • Cardiovascular diseases, including heart attacks and strokes
  • Cancer
  • Diabetes
  • Obesity


Chronic disease, other illness, or injuries may limit physical and mental abilities. There are important limitations for work and retirement policies, health and long-term care needs, and the social well-being of the elderly that are impacted by changes in functional limitations. The chart below shows what percentages of Medicare enrollees have these impactive limitations.

Source: Federal Interagency Forum 2008, 32

Six of seven leading causes of death among older Americans are chronic diseases---long-term illnesses that are seldom cured. These conditions adversely affect quality of life and contribute in a major way to worsening functionality and the inability to maintain independence (Federal Interagency Forum 2008, 27).


Age-Related Diseases


Although no disease is limited to the elderly, there are some that are predominantly age-related. Basic, clinical, and epidemiologic research is performed daily to develop creative, safe, and productive ways to prevent and treat age-related diseases, disorders, and disabilities (NIH 2009b). The goals of these studies are to:

  • Improve vaccine and drug development
  • Lessen the disabling effects of disease
  • Delay onset or progression of disease
  • Enhance pain management


[QN.No.#6.Which of the following is NOT a goal of epidemiologic research?]

Diseases that these studies target are primarily in the following categories:

  • Alzheimer's disease
  • Cardiovascular diseases
  • Cancer
  • Osteoporosis, osteoarthritis, and other bone, muscle, and joint disorders
  • Sensory disorder, including vision and hearing
  • Diabetes
  • Incontinence


[QN.No.#7.Which of the following diseases are considered primarily age related?]

The leading cause of death in 2004 among people age 65 and over was heart disease, followed by cancer, stroke, chronic lower respiratory diseases, Alzheimer's disease, diabetes mellitus, and influenza and pneumonia. Death rates for heart disease and stroke declined by approximately 44% since 1981; however, deaths from diabetes increased by 38% and death from lower respiratory diseases also increased by 53% (Federal Interagency Forum 2008, 26).


Please note that the information on age-related diseases in this course is to aid you in understanding your clients' needs. Treatment options are for your information only; clients with any of these problems should be under a physician's care. You also need to be aware that diminished physical and/or mental ability may make it hard for a client to follow a treatment plan; limited financial resources may affect the choice and use of medication (NDIC 2002).

Cardiovascular Diseases (CVD)


An estimated one in three American adults has one or more types of cardiovascular diseases (CVD). These diseases are the No. 1 killer in our nation. The diseases that are collectively known as CVD are high blood pressure, coronary heart disease (which includes heart attacks and angina), heart failure, stroke, and congenital cardiovascular defects.

The American Heart Association (2009) shows the prevalence of CVD in adults by age and sex (these data include coronary heart disease, heart failure, stroke and hypertension)---



--- and the percentage breakdown of deaths from cardiovascular diseases from the most recent statistics available (AHA 2009a):


*Not a true underlying cause

High Blood Pressure

The official definition of high blood pressure (HBP) is systolic pressure of 140 mm Hg or greater and/or diastolic pressure of 90 mm Hg or higher, taking antihypertensive medicine, or being told at least twice by a physician or other health professional that you have high blood pressure. If you have a hard time remembering which number is systolic and which is diastolic, think of the initials of South Dakota---S (or systolic) comes before D (or diastolic).

Up to age 45, more men than women have HBP. For the next nine years, until age 54, the percentage of men and women is similar. After that, a much higher percentage of women than men have the problem (AHA 2009a).

The major problems of HBP are that the relative risk for stroke is about four times greater than for those with normal blood pressure, the likelihood of developing heart failure is two to three times higher, and there is a shorter life expectancy.


Coronary Heart Disease

Coronary heart disease (CHD), also known as coronary artery disease (CAD), is a narrowing of the small blood vessels that supply blood and oxygen to the heart. This narrowing disallows an adequate amount of blood to get to the heart, and may cause a variety of symptoms (Weinrauch 2008a):

  • Chest pain (angina)
  • Shortness of breath
  • Heart attack---transient ischemic attack (TIA)---sometimes the first sign of CHD
  • Fatigue with activity (exertion)


A number of risk factors for CHD have been identified (NHLBI n.d.a) including:

  • Unhealthy blood cholesterol levels---high LDL cholesterol ("bad cholesterol") and low HDL cholesterol ("good cholesterol")
  • High blood pressure
  • Smoking. This can damage and constrict blood vessels, raise LDL cholesterol and blood pressure; it prevents sufficient oxygen from reaching the body tissues
  • Insulin resistance, a condition that develops when the body can't use its own insulin correctly
  • Diabetes, a disease in which the body's blood sugar level is high because the body doesn't make enough insulin or there is insulin resistance
  • Overweight or obesity
  • Metabolic syndrome, a group of risk factors linked to overweight and obesity
  • Lack of physical activity
  • Age
  • Family history of heart disease. Risk increases if a father or a brother was diagnosed with CAD before age 55, or if a mother or a sister was diagnosed with CAD before age 65


[QN.No.#8.Which of the following is NOT a risk factor for coronary heart disease (CHD)?]

However, another group found nine easily measured risk factors, many found on the above list. The big news is that most are something one can potentially control and thus reduce risk for CHD (Yusuf 2004). Most people can probably name them:

  • Cigarette smoking
  • Lack of physical activity
  • Low daily fruit and vegetable consumption
  • Alcohol overconsumption
  • Abdominal obesity
  • Stress
  • Diabetes
  • High blood pressure
  • Abnormal blood lipid levels (which cause high cholesterol levels).

The prevention? Common sense should enable one to figure out what is on the list if they don't already know, a list that is perhaps easier said than done, but still doable:

  • Watch the diet (reduce refined carbohydrates, increase fiber, eat the recommended 5-6 daily servings of fruits and vegetables)
  • Exercise
  • Get enough sleep


Angina pectoris

Angina pectoris is often labeled just plain angina. However, there are more anginas than just the one related to the heart. Angina pectoris is a chest pain or discomfort that is the most common symptom of coronary heart disease. The pain is felt when the heart is not getting enough blood or oxygen. The severity of the pain varies from person to person; in fact it often varies from time to time for the same person.

There are two kinds of angina pectoris: stable and unstable.

Stable angina, also called chronic angina, is pain or discomfort that is usually caused by activity or stress. The pain typically starts slowly and worsens over a few minutes before going away. Medications or rest bring it to an end, but with further activity or stress it may return (Weinrauch 2007a).

Unstable angina is a sudden or severe chest pain that happens when not enough oxygen reaches the heart. It can be a warning sign of impending heart attack (Weinrauch 2007b).

[QN.No.#9.Which kind of angina can be a warning sign of impending heart attack?]

The pain is most commonly in the chest, but it can appear almost anywhere in the chest or abdomen, the back or arms. This makes it very difficult to recognize, but if it happens repeatedly or if it is quite severe or lasts for 30 minutes or more, it is time to summon immediate medical aid.


Note: Rate for women age 45-54 considered unreliable

Angina pectoris results in nine to ten deaths every week in the U.S. (Lloyd-Jones 2009, e60).

Transient Ischemic Attacks (TIAs)

When enough of the flow of blood to a section of the heart becomes blocked, a heart attack---transient ischemic attack (TIS)---takes place. The longer it takes to restore the blood flow, the more likely the heart muscle becomes damaged from insufficient oxygen and begins to die. This heart damage may not be noticeable, or it may cause serious or long-lasting problems.

Although CAD is by far the most common cause of heart attacks, they can also be caused by a severe spasm, or tightening, of a coronary artery, cutting off the blood supply to the heart just as CAD does. These spasms can happen in coronary arteries that have no CAD. Potential causes of this tightening include: taking certain drugs such as cocaine; emotional stress or pain; exposure to extreme cold; and cigarette smoking (NHLBI n.d.b).

In addition to angina, symptoms of having a heart attack may include (NHLBI 2008):

  • Upper body discomfort in one or both arms, the back, neck, jaw, or stomach.
  • Shortness of breath may occur with or before chest discomfort.
  • Vomiting
  • Lightheadedness or fainting
  • Breaking out in a cold sweat.


If it appears an individual may be having a heart attack:

  • Call 9-1-1 within a maximum of five minutes of the start of symptoms.
  • If the symptoms stop completely in less than 5 minutes, still call the doctor.
  • Only take an ambulance to the hospital; going in a private car can delay treatment.
  • Have the individual take a nitroglycerin pill if the doctor has prescribed this type of medicine.


Every year, approximately 1.5 million people in the United States have heart attacks, and more than half of them die. CAD, which often results in a heart attack, is the leading killer of both men and women in the United States (AHA 2009a).



Heart attacks occur with no previous symptoms in 50% of men and 64% of women who die suddenly from the attacks. (Lloyd-Jones 2009, e60). Many more people could recover from heart attacks if they got help faster. Of the people who die from heart attacks, about half die within an hour of the first symptoms and before they reach the hospital (NHLBI 2008).

Stroke

Because a stroke is a vascular (cerebrovascular) disease it is often included as a CVD.

On average, every 3-4 minutes someone dies of a stroke. Stroke accounted for about one of every seventeen deaths in the United States in 2005. When considered separately from other cardiovascular diseases, stroke ranks No. 3 among all causes of death, behind diseases of the heart and cancer (AHA 2009b, 14).

Stroke risk factors include (AHA 2009b, 15):

  • High blood pressure, the most important risk
  • Smoking, increases the risk to about twice that of non-smokers
  • Atrial fibrillation, increases the risk about five times
  • Among postmenopausal women in one study, taking estrogen plus progestin (PremPro) increased ischemic stroke risk by 44%, with no effect on hemorrhagic stroke.
  • In the Framingham Heart Study, among participants younger than age 65, the risk of stroke was 4.21 times higher in subjects with symptoms of depression.


The best stroke prevention is physical activity.

Congestive Heart Failure

More than five million Americans have been diagnosed with congestive heart failure (CHF)---also known as heart failure (AHA 2009b).



This is a progressive condition when a heart has been damaged, leading to a weakened cardiovascular system. The heart is unable to pump enough blood to the body's other organs. Sometimes this is because the heart cannot be filled with enough blood (diastolic failure); other times it is because the heart can't pump with enough force to send the blood to other parts of the body (systolic failure) (NHLBI 2007).

Once the heart has been injured, the body tries to make up for lessened blood flow. Unfortunately, many of the compensations actually escalate strain on the heart and aid heart failure to further develop (HFO 2006).

Right- vs. Left-Sided Heart Failure (HFO 2006; Weinrauch 2008b,c)

  • Right Heart Failure---This occurs when the right side of the heart is unable to sufficiently pump venous blood into the pulmonary circulation. The lungs may not receive enough blood. All of this results in a back-up of fluid in the body, producing edema and congestion that may affect the liver, the gastrointestinal tract, and the limbs.
  • Left Heart Failure---The left side of the heart gets blood directly from the lungs, where it has been oxygenated. If it is unable to adequately pump that blood into the rest of the body, then the rest of the body does not have enough oxygen, resulting in fatigue, shortness of breath, and pulmonary edema.


Causes of congestive heart failure include (HFO 2006):

  • Coronary artery disease (CAD)
  • Hypertension (high blood pressure)
  • Valvular heart disease
  • Cardiomyopathy (one of several diseases of the heart muscle)
  • Family history of heart failure
  • Diabetes
  • Marked obesity
  • Heavy consumption of alcohol, or drug abuse
  • Failure to take medications
  • Large salt intake in diet
  • Sustained rapid heart rhythms
Symptoms of heart failure can be:

  • Swollen ankles or legs
  • Shortness of breath
  • Angina
  • Fatigue
  • Weight gain or loss
  • Loss of appetite


Although no heart failure patient should ever begin or alter a course of physical training without the explicit instructions and observation of a health care professional, moderate to light aerobic activity and mild weight training seem to aid in preventing progression of heart failure (Mayo Clinic Health Letter 2008).

Arrhythmias

A disorder of the regular, rhythmic beating of the heart is called an arrhythmia. They are common disorders; the American Heart Association indicates that 2.2 million Americans are living with one type of rhythm problem---atrial fibrillation. Arrhythmia (Wikipedia Commons, Public Domain)

Arrhythmias can occur in a healthy heart and be of minimal consequence. They also may indicate a serious problem and lead to heart disease, stroke or sudden cardiac death (AHA 2009c).

The rhythmic beating of the heart is controlled by electrical signals. The sinoatrial (SA) node of the heart (also called the "sinus node") sends an electrical impulse through the heart, initiating impulses for the heart beat. The heart contracts ("beats") when it receives this impulse.

This begins the normal electrical sequence through the heart. It begins in the right atrium, and spreads throughout the atria to the atrioventricular (AV) node. From there the electrical impulses travel down the His-Purkinje system---a group of fibers designed to take the electrical signals to all parts of the ventricles.

The heart pumps correctly when this exact route is followed. This means that the heart pumps and beats at a regular pace, about 60 to 100 times a minute for an adult. To see a graphic explanation of how the heart pumps, go to http://www.youtube.com/watch?v=P66lNH0f1HY. If arrhythmias are so fleeting, such as a premature beat or a temporary pause, that the heart's rhythm is barely affected, there is no problem. However, if it lasts for a longer time, the heart may pump less efficiently because the heart rate has slowed down too much, sped up too much, or the rhythm has become erratic; then the problem could be severe. For a lengthy, but excellent discussion, see Heart Rhythm Abnormalities, Part 1 (http://www.youtube.com/watch?v=E5OQL6KY_2g) and Part 2 ( http://www.youtube.com/watch?v=FBvAOiSJlUo).

A fast heart rate (more than 100 beats per minute in adults) is called tachycardia; a slow heart rate (less than 60 beats per minute) is called bradycardia. Other common arrhythmias are fibrillation (quivering beat), and premature contraction (early beat) (AHA 2009c).

Arrhythmias can produce a broad range of symptoms. Some may be barely noticeable; others may be at the opposite extreme: cardiovascular collapse and death. For example, not likely to be serious:

  • A single premature beat that may be felt as a "palpitation" or "skipped beat."
  • If premature beats take place frequently or in rapid succession, a person may become more aware of heart palpitations or a "fluttering" feeling in the chest or neck.


If these arrhythmias last long enough to alter how well the heart works, the following---more serious---symptoms may develop:

  • Fatigue
  • Dizziness
  • Lightheadedness
  • Fainting or near-fainting spells
  • Rapid heartbeat or pounding
  • Shortness of breath
  • Chest pain
  • In extreme cases, collapse and sudden cardiac arrest


Most arrhythmias are not treated because they are thought to be harmless. Once the doctor has determined whether the arrhythmia is clinically significant or not, he/she will set a treatment plan with the following goals (AHA 2009c):

  • Prevent blood clots from forming to reduce stroke risk
  • Control the heart rate within a relatively normal range
  • Restore a normal heart rhythm, if possible
  • Treat heart disease/condition that may be causing arrhythmia
  • Reduce other risk factors for heart disease and stroke


Valvular Heart Disease

Heart valve disease is when the heart's valves don't work the way they are supposed to---they may be constricted so that they don't open wide enough for an adequate amount of blood to go through during each heart beat (stenosis); conversely, they may flap too much and not close tightly so blood is allowed to "leak" backwards between contractions (insufficiency or regurgitation).

The heart valves are one-way valves. They are placed at the exit of each of the four heart chambers to prevent this backward leakage.

Valvular stenosis makes the heart work hard to pump blood through it. This can lead to heart failure, and other problems. The heart also has to work harder in valvular insufficiency to make up for the leaky valve; also less blood may be pumped to the rest of the body.

There are a number of potential causes of valvular heart disease (MedicineNet.com n.d.):

  • Congenital valve disease where, before birth, the valve was the wrong size, had misshapen or misattached leaflets.
  • Rheumatic fever---a bacterial infection, usually strep throat. Not as common now with newer antibiotics, children have the disease but may not be aware of the heart problem for 20-40 years, when the heart valves become inflamed, the leaflets stick together and become misshapened: scarred, rigid, thickened, and/or shortened.
  • Endocarditis---bacteria or other germs get in the bloodstream and attack the heart valves, causing growths and holes in the valves and/or scarring.
  • Coronary artery disease
  • Heart attack
  • Cardiomyopathy (heart muscle disease)
  • Syphilis
  • High blood pressure
  • Aortic aneurysms
  • Connective tissue diseases


The primary symptoms of valvular heart disease are (MedicineNet.com n.d.):

  • Shortness of breath and/or difficulty catching one's breath
  • Weakness or dizziness
  • Chest discomfort
  • Heart palpitations
  • Edema, swelling of ankles, feet, or abdomen
  • Rapid weight gain, from edema


The doctor will usually try to treat valvular disease with medication as long as possible: diuretics for water retention, antiarrhythmic medications for heart rhythm problems, vasodilators to lessen the heart's work, ACE inhibitors to treat high blood pressure and heart failure, beta blockers to slow the heart's rhythm and allow more time for the blood to flow through the valves, and anticoagulants to thin the blood and prevent blood clots from developing on the valve.

When the medication can no longer control the problem, surgery is considered. Some valves may be repaired, others must be replaced. The older person can use the slightly shorter-lived animal valves and thus may not need lifetime anticoagulants. Traditional open-heart surgery may be performed, but more and more minimally-invasive procedures are being used. Percutaneous balloon valvotomy may be used for some problems.

[QN.No.#10.Biological concerns for the Elderly include:]

 
Aging and Long-Term Care (10 Hours) > Chapter 2, Part A
Page Last Modified On: February 18, 2015, 07:11 AM