PHYSICAL CHANGES OF AGING

Physiologic aging may be the most significant factor challenging quality of life. It is not known exactly how and why people change as they get older, and there are many theories about it. Most gerontologists believe that aging is due to the interaction of many lifelong influences, including heredity, environment, culture, diet, exercise, leisure, and past illnesses, to name a few.

Some body systems begin aging as early as age 30. Other aging processes are not common until much later in life. Some changes always occur with aging, but they occur at different rates and to different extents. There is no way to predict exactly how any given individual will age (CDC, 2020b).

Musculoskeletal Changes

The musculoskeletal system is comprised of bone, muscle, joints, tendons, ligaments, and cartilage. Musculoskeletal disorders that are common among older patients consist of the following triad: loss of muscle mass and function, tendinopathies, and arthritis. Their common shared trait is progressive loss of neuromuscular performance with a risk of adverse outcomes, including pain, mobility disorders, increased risk of falls and fractures, and disability or impaired ability or to perform activities of daily living.

Bone mass decline is approximately 0.5% per year in healthy older people, and age-related changes in women are compounded by menopausal changes in bone mass and function. The increased proinflammatory environment in healthy older adults promotes bone loss (osteoporosis). Vitamin D deficiency, common in older people, further accelerates this loss. Osteoporosis increases the risk for bone fractures and slows the rate of repair once a fracture occurs.

Height changes occur as the vertebrae lose some of their mineral content, making each bone thinner. Vertebral discs gradually lose fluid and become thinner. The spinal column becomes curved and compressed, making the middle of the torso shorter. Foot arches become less pronounced, and overall height decreases. Posture may become stooped, and postural hyper- kyphosis may occur, creating what is referred to as a “Dowager’s hump.” Knees and hips become more flexed, and the neck may tilt backward. The shoulders may narrow, while the pelvis becomes wider. Bones in the arms and legs thin but do not change in length, making them appear longer in comparison with the shortened trunk.

Bone spurs caused by aging and overall use of the spine may form on the vertebrae, narrowing the space that contains the spinal cord. These may pinch the spinal cord or its nerve roots and cause weakness or numbness in the arms or legs. Compression fractures of the vertebrae can cause pain and reduce mobility (LibreTexts, 2020).

With aging, muscle mass decreases in relation to body weight by about 30% to 50% in both men and women. Loss is greater in the legs than the arms, and the loss accelerates with increasing age. Lost muscle tissue may be replaced with a tough, fibrous tissue, most noticeably in the hands, which may appear thin and bony.

The loss of muscle is associated with decreased strength, slower movement, and movement limitations. It also contributes to age-related insulin resistance, age-related changes in body composition, and volumes of distribution for water-soluble drugs.

Lipofuscin (an age-related pigment left over from breakdown and absorption of damaged blood cells) and fat are deposited in muscle tissue. Infiltration of fat (myosteatosis) and connective tissue decreases muscle quality.

Recovery of older muscle after injury is slowed and frequently incomplete, and muscle contractions may occur in those who are unable to move on their own or who do not stretch their muscles with exercise.

Tendons attaching muscle to bone begin to shrink and lose mass, and a decrease in water content results in tissue stiffness and less ability to tolerate stress (NIH, 2020a).

Joint changes may lead to inflammation, chronic pain, stiffness, and deformity and may result in functional disability. Joint changes affect almost all older people, ranging from minor stiffness to severe osteoarthritis.

As joints age, they become stiffer and less flexible. Joint fluid decreases, and cartilage may begin to rub together and wear away. Minerals may deposit in and around some joints, commonly in the shoulder. Degenerative changes occur in the hip and knee joints. Finger cartilage and bone thicken slightly. Changes in the finger joints are more common in women.

Ligaments tend to shorten and lose some flexibility, resulting in joint stiffness, which increases the probability of injuries including sprains and ruptures caused by low-energy trauma or joint use. Rate of ligament healing declines with aging.

Gait becomes slower and shorter. Walking may become unsteady and there is less arm swinging, Risk for injury increases from falls due to gait changes, instability, and loss of balance (NIH, 2020a).

Foot problems are common with aging, all of which may interfere with functioning and daily activities. Common age-related changes may include hallux valgus, also known as a bunion, in which the great toe moves out of alignment, deviates, and rotates. Other problems may include hammer toe (hyperflexion of the proximal interphalangeal joint) and claw toe (hyperflexion of the proximal and distal interphalangeal joints). Toe deformities may result from wearing ill-fitting shoes or from rheumatoid arthritis, diabetes, or neurologic disorders (Judge, 2019; Besdine, 2019).

ASSESSMENT

Assessment of the aging musculoskeletal system poses the challenge of distinguishing between the normal effects of aging and the first signs of disease. For example, a problem in one joint can mean trauma, while a problem in more than one can mean a systemic condition.

The joints are examined for tenderness, swelling, subluxation, crepitus, warmth, redness, and other abnormalities, which may be indicative of a disorder such as osteoarthritis or chronic rheumatoid arthritis.

Active and passive range of joint motion should be determined, and the presence of contractures should be noted. Variable resistance to passive manipulation of the extremities sometimes occurs with aging.

Older patients should be asked about gait-related issues such as difficulty with walking, balance, or both, including whether they have fallen or fear that they might fall. Specific capabilities should be assessed and patients asked whether they can:

• Go up and down stairs
• Get in and out of a chair, shower, or tub
• Walk as needed to purchase and prepare food and do household chores

Physical examination of the older adult should include:

• Lower extremity strength: Can the patient get out of a chair without using their arms?
• Gait assessment with and without assistive devices (if applicable) including:
  • Gait speed
  • Cadence
  • Step length, height, and swing
• Balance assessment

Gait speed, chair rise time, and ability to successfully maintain tandem stance (standing heel-to-toe without losing balance for 10 seconds) are independent predictors of the ability to perform instrumental activities of daily living as well the risk of nursing home admission and death (Judge, 2019). Other testing may sometimes be required, including a brain CT or MRI, if a patient presents with poor gait initiation, chaotic cadence, or a very stiff-appearing gait.

MANAGEMENT AND PREVENTION

Common management strategies for musculoskeletal disorders include physical exercise, either alone or in combination with nutritional intervention. High-intensity resistance training can improve strength and mass of skeletal muscles and may counteract age-related decline in muscle size and function. A balanced program of both endurance and strength exercises performed on a regular schedule is usually recommended. Nutritional supplements may be advised, including vitamin D.

• Management of tendinopathies includes exercise, corticosteroid or platelet-rich plasma injections, physical therapy evaluation/treatment, and topical glyceryl trinitrate (nitroglycerin).
• Management of osteopenia or osteoporosis involves obtaining bone density measurements, encouraging exercise, a diet high in calcium and vitamin D, and bisphosphonate medications such as alendronate (Fosamax) orally or zoledronic acid (Reclast) IV infusions.
• Arthritis alters the joints biochemically, structurally, and physiologically. Recommendations include self-management, weight loss, and an exercise program to strengthen joints and supporting structures, as well as optimizing joint mobility. Physical therapy and supervised progressive exercise programs are often encouraged. Aquatic exercises may be beneficial as well as assistive devices for ambulation, braces, splints, and taping (if indicated) for comfort or to provide mechanical support.
• Interventions for managing arthritis may also include physical modalities, such as heat and cold, techniques to manage or control edema and inflammation, therapeutic activities and exercises, or provision of custom or prefabricated orthotic devices.
• Pharmacological treatment for arthritis varies, the most common being acetaminophen following by NSAIDS. Interventions for osteoarthritis typically begin with intra-articular injections and can escalate to total joint replacement.

Falls are the most common cause of fractures in older people. Most falls that occur are fragility fractures in those who have multiple comorbidities and functional impairments. Fragility fractures usually occur in the hip, spine, wrist, pelvis, humerus, rib, and ankle. These fractures can lead to functional decline, institutionalization, and death. Management depends upon the site of fracture, risks and benefits of nonsurgical versus surgical intervention, and the patient’s goals of care. Most older adults can benefit from targeted programs to prevent falls and optimize bone health (Minetto et al., 2020). (See also “Fall Prevention Interventions” later in this course.)

Integumentary Changes

The integumentary system, which includes the skin, hair, nails, and glands, is the largest organ of the body.

Skin changes are the most visible signs of aging. Growths such as skin tags, warts, rough patches (keratoses), and other blemishes are more common. More than 90% of all older people have some type of skin disorder, such as xerosis, pruritus, eczematous dermatitis, and purpura (NIH, 2020b).

As the skin ages, the epidermal layer thins; however, the number of cell layers remains unchanged. Decreased concentration of 7-dehydrocholesterol in the epidermis results in decreased synthesis of vitamin D necessary for bone health. Ability to sense touch, pressure, vibration, heat, and cold may decrease.

As the dermis ages, there is reduction in the ability to regenerate, leading to slower wound healing. Wrinkling of the skin results from weakening of muscles under the skin, decreased collagen and elastin production in the dermis, and decreased ability of skin to retain moisture. Blood vessels of the dermis become more fragile, leading to bruising, bleeding under the skin (senile purpura), cherry angiomas, and similar conditions. The activity of accessory structures in the dermis decreases, generating thinner hair and nails. Reduced sweating can lead to heat intolerance. Sebaceous glands produce less sebum and cerumen, resulting in dryness and itchiness.

As the subcutaneous or hypodermal layer thins, less insulation and padding are provided, increasing the risk of skin injury and reducing the ability to maintain body temperature, which increases the risk of hypothermia. Loss in the fat layer also reduces absorption of medications by the skin. Pressure injuries (ulcers) may develop from reduced activity, poor nutrition, and illnesses.

Nails grow more slowly and become dull, brittle, yellowed, opaque, and thickened, and ingrown toenails become more common. Hair color changes due to decreased follicular production of melanin. Hair thickness changes, and rate of hair growth slows. Male-pattern and female-pattern baldness may develop (NIH, 2020b).

ASSESSMENT

The assessment of the skin of an older adult is the responsibility of all members of the team. Some providers may do a more in-depth assessment than others, but all should be aware of the need to protect the integrity of the skin.

Assessment begins with collecting data about patient concerns, such as rate of wound healing, bruising, falls, incontinence, ability to change position without assistance, and self-care abilities. Skin should be examined for:

• Impaired integrity (particularly of the skin covering bony prominences), roughness, sloughing, complaints of pruritis
• Suspicious lesions such as keratoses and moles. Suspicious lesions should be evaluated for possible premalignancy and malignancy using the ABCDE rule (see table below).
  (Fraser, 2020; Besdine, 2019; Nursecepts, 2018)

ABCDE RULE FOR SKIN LESIONS

Label	Characteristic	Description
(Prevent Cancer Foundation, 2020)
A	Asymmetry	When the shape differs from side to side
B	Border	Irregular or uneven
C	Color	Irregular, with patches of black, brown, red, blue, or white
D	Diameter	Larger than 1/4 inch (6 mm)
E	Evolving	Any change in size, shape, color, or texture, or any new symptoms such as itching, bleeding, or crusting

MANAGEMENT AND PREVENTION

Maintaining skin integrity in the older adult is essential and requires a holistic and interdisciplinary approach. Skin basics include:

• Educating patients and caregivers
• Performing regular skin assessments
• Maintaining mobility
• Relieving pressure
• Using safe manual handling techniques
• Providing skin care, paying attention to high-risk areas
• Encouraging good nutrition and hydration

Older patients and caregivers should be encouraged to inspect feet daily for skin color, dryness, swelling or tenderness, blisters, cracks, sores, ulcers, corns, ingrown toenails, paresthesia, or pain. Other common foot problems in older individuals include calluses, foot deformity, fungal infection, and warts. Many of these are often the result of inappropriate or inadequate foot care, mechanical causes, infection, as well as underlying problems such as diabetic vascular disease, or congenital foot deformities. Podiatry consult may be recommended (Fraser, 2020; EHS, 2018).

Because many older adults had chicken pox as children, they are at risk for reactivation of the varicella zoster virus, which causes shingles, and should obtain a vaccine if there are no contraindications (Fraser, 2020; MSKL, 2020).

Dry skin, skin tears, moisture-related skin damage, and pressure injuries are the most common skin problems experienced by older people. Skin integrity assessment should be conducted on admission to any facility and at least daily depending on the individual’s circumstances. High-risk patients require skin inspection at least once per shift in addition to admission or transfer to another facility (Fraser, 2020; Todd, 2018).

Mobility is important for circulation and in reducing prolonged exposure to external forces such as pressure, shear, and friction that are implicated in pressure injury formation. Interventions may be required to limit exposure to such forces if the patient has reduced mobility, loss of protective sensation (e.g., diabetic neuropathy), is at nutritional risk or malnourished, acutely ill, or has any condition that decreases the capacity to respond to pressure and/or reduces tissue tolerance to pressure.

Pressure-relieving surfaces may be required, such as pressure-relieving mattresses and pressure-redistribution seating cushions. Other devices might include heel wedges and off-loading shoes or boots to reduce pressure to heels and free-standing self-help poles (“monkey bars”) and/or side bars to assist a person to reposition in bed.

Safe manual handling techniques and use of appropriate manual handling equipment facilitates safe patient/resident transfer, reducing risk of injury. Slide sheets, additional assistance, or a lifter aid (e.g., a Hoyer mechanical lift) can be used for the safe transfer of patients.

Skin is cleansed (avoiding hot water), dried thoroughly, and moisturized daily to reduce the risk of excoriation. Using non-soap cleansers and shampoos with a pH close to 5.5 helps protect the acid mantle and prevent skin from drying out, while moisturizers applied twice a day or more often hydrate the skin. If the person is incontinent, any continence aid is checked and changed regularly and exposed skin cleansed, carefully dried, and moisturized. Protective skin barriers may reduce associated dermatitis. In patients with high BMI, particular attention is paid to creases and skin folds.

Adequate fluids must be taken to avoid dehydration, which can put the person at risk for compromised skin integrity and reduced tissue tolerance to pressure. A referral to a dietitian may be ordered for determining appropriate nutrition.

Referral to a physical therapist and occupational therapist may also be ordered to ensured the best possible outcome for the patient (Fraser, 2020; Todd, 2018).

Cardiovascular Changes

Cardiac aging is associated with left ventricle hypertrophy, fibrosis, and diastolic dysfunction, resulting in reduced cardiac output. Hypertrophy is an adaptive mechanism to maintain cardiac function in response to age-induced structural changes, causing the heart to enlarge and develop thicker walls and slightly larger chambers mainly due to an increase in the size of individual muscle cells. These changes result in reduced left ventricular filling, which can lead to heart failure, especially in older people with other diseases such as hypertension, obesity, and diabetes.

The walls of the arteries and arterioles also become harder and thicker (arteriosclerosis). Deposits of yellowish plaque containing lipids and cholesterol (atherosclerosis) build up on the artery walls, narrowing the lumen. Since arteries and arterioles become less elastic, blood pressure cannot adjust quickly when people stand, putting them at risk for dizziness or fainting. And because blood vessels become less elastic with age, they do not relax quickly, causing blood pressure to increase during systole (Gupta & Shea, 2019; Fajemiroye et al., 2018).

Approximately 80% of deaths attributed to acute coronary syndromes occur in patients 65 years of age and older. Older adults are also at increased risk of major complications from therapeutic interventions. The prevalence of peripheral arterial disease increases progressively with age and is often predictive of the presence of coronary artery and cerebrovascular disease.

Heart rate at rest does not change significantly during the aging process but does not increase as much during physical activity as it did when younger. One reason for this is the depression of spontaneous electrical activity of the heart’s natural pacemaker, the sinoatrial node, that results from ischemia or necrosis of the pacemaker cells due to decreased perfusion.

The prevalence and complexity of cardiac arrhythmias also increases with age (Kyriazis & Saridi, 2020; Harper et al., 2019).

ASSESSMENT

Geriatric assessment of the cardiovascular system focuses on common problems among that population. Fatigue and breathlessness are signals that the heart is not functioning as well as it should. Most often heart failure is the result of coronary artery disease or heart attack, but faulty heart valves, long-standing high blood pressure, or genetic disease may also be the cause. The mnemonic FACES can be used to quickly spot symptoms of heart failure.

FACES MNEMONIC

Label	Description
F	Fatigue
A	Activity limitation
C	Congestion resulting in coughing, wheezing, breathing difficulty
E	Edema or ankle swelling
S	Shortness of breath

Important tools for diagnosis include an echocardiogram, stress test, and blood test for B-type natriuretic peptide, which is released when the heart is under stress.

Atrial fibrillation (AF) is the most common sustained dysrhythmia in the geriatric population. Over 50% of all patients with AF are 75 years or older. Atrial fibrillation is correlated with an increased risk of thrombosis, resulting in a four-times greater risk of imminent stroke. ECG is the primary tool for diagnosing AF. Holter monitor may be used to assess heart rhythm for 24 hours. Echocardiogram may be used to diagnosis thrombosis.

Age-related changes in blood pressure regulation lead to greater variability in blood pressure and postural changes. Multiple blood pressure readings, including orthostatic measurements, may be part of the assessment to accurately diagnose and safely manage hypertension. Orthostatic blood pressures give clues about fluid status, medication effects, and causes of dizziness or falls.

Peripheral vascular disease is more common in the aging population. Symptoms of peripheral artery disease include pain, achiness, fatigue, burning, or discomfort in muscles of the feet, calves, or thighs which most often appear during walking or exercise, and diminish after several minutes of rest.

Chronic venous insufficiency is commonly due to malfunctioning valves in the veins resulting in stasis dermatitis, varicose veins, and ulcers that are slow to heal on legs or ankles (Harper et al., 2019; NIH, 2020c; Harvard Health Publishing, 2019).

MANAGEMENT AND PREVENTION

Management and prevention of cardiovascular issues in the older adult include patient education regarding modifying controllable risk factors such as diabetes, hypertension, overweight, diet, exercise, smoking, and alcohol intake. This includes instruction on signs and symptoms of acute myocardial infarction; routine exercise; and nutrition and low-fat, low-cholesterol, and low-sodium diets.

Hypertension management also requires lifestyle changes and pharmaceutical therapy, which is often started low and increased, if indicated. Education on stress management and encouragement of some form of relaxation technique are also recommended.

The goal of therapy for atrial fibrillation is the prevention of thromboembolism, which is often managed with anticoagulation therapy, such as warfarin (Coumadin) or apixaban (Eliquis). Education is provided regarding emergent issues and instructions are given for seeking treatment of anticoagulant side effects.

Management of peripheral vascular disease includes general prevention measures such as avoiding prolonged standing or sitting, exercising on a regular basis, other lifestyle recommendations, and strategies to better manage other chronic medical conditions that directly affect progression of peripheral vascular disease, including hypertension, diabetes, dyslipidemia, and obesity.

Pharmaceutical therapy includes antiplatelet or anticlotting agents, statins, and medications that increase blood supply. Nonpharmaceutical therapy includes extremity elevation, compression stockings, exercise, and wound care for ulcerations caused by chronic venous insufficiency (Cash & Glass, 2019).

Thermoregulatory Changes

Changes in thermoregulation control with aging are associated with a decreased physiologic ability to dissipate heat. This has been attributed to a combination of factors, including alterations in sweating, skin blood flow, body fat, and muscle mass, as well as age-related changes in cardiovascular function (Balmain et al., 2018; Abutair et al., 2018).

Older adults have an increased threshold for the onset of sweating and a diminished response when sweating occurs. Because the older body loses body fat and becomes less efficient at generating heat, resistance to cold temperatures is reduced, increasing the risk for hypothermia.

It is important to consider impaired regulatory response in older adults because it may contribute to heat-related illness or hypothermia and adversely affect outcomes during daily activities. Because of an altered response to hot environments and diminished perception of discomfort despite being physiologically challenged, older adults are more likely to have heat- and cold-related illnesses. Older adults report feeling cool or cold even in very warm environments and generally prefer environmental temperatures that are at least 75 °F. Half of the older people who develop hypothermia die before or soon after being found (Balmain et al., 2018; Johns Hopkins Medicine, 2020).

Older people are also at high risk for hypothermia because they often have other illnesses or take medications that interfere with the body’s ability to regulate its temperature. Substandard living conditions and poor nutrition have been associated with hyperthermia and hypothermia. Social isolation increases risk, as older people are rarely able to self-report these conditions. Living alone and having dementia may increase risk if cognitive skills do not allow for adjustment of a thermostat, wearing of proper clothing, or the ability to recognize symptoms and call for help (Abutair et al., 2018).

Hyperthermia can be caused by excessively high environmental temperatures, cardiovascular disease, fluid or electrolyte imbalance, alcohol and medications, or increased heat production caused by exercise, infection, or hyperthyroidism. Individuals with chronic lung disease (e.g., asthma, COPD) may be particularly vulnerable to heat-related conditions. Those most prone to heat exhaustion are older adults, those with hypertension, and those who are active in a hot environment (CDC, 2018; Raza, 2020; Helman, 2019).

Urinary System Changes

KIDNEYS

Aging changes that occur in the kidneys include a decrease in the volume of kidney tissue. Over an average lifespan nephrons are reduced by half, and by age 75 atherosclerosis of renal arteries reduces renal blood flow by half. Glomerular filtration rate and maximum excretory capacity are reduced by the same proportion.

The kidneys can still maintain normal homeostatic mechanisms and waste disposal within limits, but they are less efficient, need more time, and their reserves may be minimal. Therefore, relatively minor degrees of dehydration, infection, or impaired cardiac output may lead to kidney failure. Loss of renal reserve increases the risk for toxic accumulation of renally cleared medications.

The kidneys have a central role in maintaining normal levels of most electrolytes. Reduced diluting capacity of the kidney increases the risk of hyponatremia in older patients, particularly those on a low-protein diet. Kidneys demonstrate impaired renal conservation of sodium in response to an acute reduction of sodium intake as well as impaired ability to rapidly excrete a large sodium load. Inability to remove potassium from the blood may lead to abnormal heart rhythms and sudden death (Physiopedia, 2021c).

The kidneys play a role in glucose homeostasis. Under normal circumstances, the kidneys filter and reabsorb 100% of glucose. In addition, they produce glucose by gluconeogenesis, contributing 20% to 25% of circulating glucose (Bhimma, 2018).

Diabetes mellitus is the most common cause of chronic kidney disease. Hyperglycemia damages the glomeruli within each kidney, resulting in an increased glomerular filtration rate. About 10% to 40% of those with type 2 diabetes will eventually develop end-stage renal failure.

The kidneys also produce erythropoietin, a hormone that stimulates stem cells in bone marrow to produce red blood cells. Kidney disease leads to a decline in production of erythropoietin, which is one of the causes of unexplained anemia in older adults. Most people with kidney disease will develop anemia (NKF, 2020; Artz, 2019).

Renal Function Assessment

Physical assessment begins with the patient’s overall appearance. Chronic renal disease can cause yellowing of the skin, brown nail beds, excoriation from chronic pruritus, and volume excess resulting in edema and distention of vessels in the neck. Symptoms of kidney failure include weakness, shortness of breath, lethargy, edema, pruritis, loss of appetite, sleep disturbances, and confusion.

Laboratory tests may include electrolytes, complete blood count, serum creatinine (the end product of muscle and protein metabolism), and blood urea nitrogen (BUN) (which measures the renal excretion of urea nitrogen, a by-product of protein metabolism). Renal disease results in increased creatinine levels and does not increase until at least 50% of the renal function is lost.

When liver and kidney dysfunction are both present, BUN levels actually decrease, reflecting liver failure but not kidney failure. BUN level is not always elevated with kidney disease but is highly suggestive of kidney dysfunction (NKF, 2020; UM, 2020; Devu, 2018).

BLADDER AND URETHRA

Aging increases bladder dysfunction, including reduction in bladder capacity, uninhibited contractions, and decreased urinary flow rate. Urinary tract infections common in older people have more systemic effects. They are commonly seen in older adults admitted to hospital because of a fall or acute confusion.

The urethra can become blocked. In women this can be due to weakened muscles caused by bladder or vaginal prolapse, and in men by an enlarged prostate gland. Benign nodular hyperplasia (BPH) of the prostate is present in 75% of males over 80 years of age. Histological (latent) prostatic carcinoma is present in most males above the age of 90 (Physiopedia, 2021c).

Urinary incontinence is a significant health problem for older adults, both physically and psychologically. Women are disproportionately affected, with up to 50% over age 60 experiencing incontinence at least once per week. Common age-related physiologic changes predisposing to incontinence include decreased bladder capacity, benign prostatic hyperplasia in men, and menopausal loss of estrogen in women. Other risk factors include immobility, certain types of medications, obesity, smoking, malnutrition, delirium, depression, sensory impairment, and environmental barriers (NIH, 2020d; Dowling-Castronov & Spiro, 2020).

Bladder and Urethra Assessment

Assessment includes a history and physical. Urinalysis is done to check for infection or blood or other abnormalities.

Urinary tract infections (UTIs) can cause sudden confusion (delirium) in older people and people with dementia. If the person has a sudden and unexplained change in behavior, such as increased confusion, agitation, or withdrawal, it may be due to a UTI. Dehydration should also be ruled out as a cause for these changes.

Urethral irritation is suspected when the patient reports discomfort with urination. BPH is also common in older men and can cause uncomfortable symptoms such as frequency or urgency, difficulty initiating urine stream, weak or intermittent urine stream, dribbling at the end of urination, and inability to completely empty the bladder. Postvoid residual measurement may be done to determine the amount of urine remaining in the bladder after urination. If further information is necessary, urodynamic testing and ultrasound may be done (Devu, 2018).

Patients with a complaint of incontinence may be asked to maintain a bladder diary for several days that records fluid intake, urination times and amounts, urge to urinate, and number of urinary incontinence episodes. It is also important to determine whether the person is not self-dehydrating for fear of having an accident.

Bladder and Urethra Dysfunction Management

Patients presenting with symptoms of urinary tract infection should be placed on an appropriate antibiotic.

Urinary retention is most commonly caused by benign prostatic hypertrophy (BPH), whose main treatments include:

• Active surveillance by a urologist
• Medications: Alpha blocker tamsulosin (Flomax) and 5-alpha reductase inhibitor finasteride (Proscar)
• Less invasive procedures, such as a prostatic urethral lift (PUL) that lifts and compresses the prostate to prevent urethral blockage; water vapor thermal therapy and transurethral microwave therapy (TUMT) that destroys prostate cells; and catheterization, intermittent or indwelling
• Invasive surgical procedures, including transurethral resection of the prostate (TURP)
  (AUA, 2020)

Management of urinary incontinence depends on the type of incontinence, severity, and underlying cause, and a combination of treatments may be used (see table).

INTERVENTIONS FOR URINARY INCONTINENCE

Type	Interventions
(Mayo Clinic, 2019a; Cunningham & Valasak, 2019)
Lifestyle changes	Weight loss Smoking cessation Alcohol avoidance Decreased caffeine intake Prevention of constipation Avoiding heavy lifting
Behavioral techniques	Scheduled or delayed timed urination Double voiding
Physical therapy	Pelvic floor exercises (e.g., Kegel’s) Muscle-strengthening exercises Electrical stimulation Biofeedback
Occupational therapy	Bladder retraining Modifications to food and fluids Relaxation techniques Support for integration of training
Medications	Anticholinergics Alpha blockers for men Topical estrogen for women
Medical devices	Vaginal rings and urethral inserts
Surgery	Single sling procedures Bladder neck suspension Prolapse surgery Artificial urinary sphincter implants
Supportive interventions and devices	Absorbent pads Protective undergarments, modified clothing Intermittent catheterization Condom catheter for men Urethral plugs and penile clamps

Respiratory Changes

Aging of the respiratory system reduces the capacity of all pulmonary functions, which may lead to decompensation when the system is stressed. The changes contribute somewhat to an older person’s reduced ability to do vigorous exercise, especially intense aerobics, but these changes seldom lead to symptoms. They are compounded, however, by the effects of heart and lung disease, especially those that result from smoking.

The effects of aging in other areas of the body affect the lungs. These include changes in the bones and muscles of the chest and spine. Bones become thinner and change shape and can alter the shape of the ribcage, resulting in decreased expansion and contraction while breathing. The diaphragm becomes weakened, and this may impair both inhalation and exhalation. These changes may lower the oxygen level in the body and raise carbon dioxide levels, resulting in tiredness and shortness of breath.

Muscles and other tissues adjacent to the airways may lose the ability to keep airways completely open, and progressive calcification of the walls of the trachea and bronchi causes increasing rigidity, resulting in a gradual decrease in maximum breathing capacity. Aging also causes the walls of the alveoli to deteriorate, lose shape, and become baggy. Dead space increases with age as larger airways increase in diameter. These changes can allow air to become trapped in the lungs, making it hard to breathe and impairing gas exchange.

The nervous system, which monitors respiratory volume and blood gas levels and regulates respiratory rate, may lose some of its function. Breathing may become more difficult and gas exchange impaired. Nerves in the airways that trigger the protective cough reflex become less sensitive, resulting in contamination of the lower airway through aspiration, silent or otherwise. Dysphagia or impaired esophageal motility, also common in old age, may exacerbate the tendency to aspirate.

Decline in effectiveness of the immune system means the body is less able to fight lung infections and less able to recover following exposure to smoke or other harmful substances (NIH, 2020e). The onset of pneumonia in the older patient can often be rapid, and prognosis is poor in severe pneumonia.

Normal aging results in a number of changes to the structure and function of the respiratory system (see table).

AGE-RELATED CHANGES IN THE RESPIRATORY SYSTEM

Respiratory Function	Pathophysiological Changes	Clinical Presentation
(Meiner & Yeager, 2019)
Mechanics of breathing	Increased chest wall compliance Loss of elastic recoil Decreased respiratory muscle mass and strength	Decreased vital capacity Increased reserve volume Decreased expiratory flow rate
Oxygenation	Increased ventilation-perfusion mismatch Decreased alveolar surface area for gas exchange Decreased CO2 diffusion capacity	Decreased PaO2 Increased A-a (alveolar-arterial) oxygen gradient
Control of ventilation	Decreased responsiveness of central and peripheral chemoreceptors to hypoxemia and hypercapnia	Decreased tidal volume (Vt) Increased respirator rate Increased minute ventilation
Lung defense mechanism	Decreased number of cilia Decreased effectiveness of mucous clearance Decreased cough reflex Decreased cellular immunity Decreased immunoglobulin A (IgA), which neutralizes viruses	Decreased ability to clear secretions Increased susceptibility to infections Increased risk of aspiration
Sleep and breathing	Decreased ventilatory drive Decreased upper airway muscle tone Decreased arousal	Increased frequency of apnea, hypoxemia, and arterial oxygen desaturation during sleep Increased risk of aspiration Snoring Obstructive sleep apnea
Exercise capacity	Muscle deconditioning Decreased muscle mass Decreased efficiency of respiratory muscles Decreased reserves	Decreased maximum O2 consumption
Breathing pattern	Decreased responsiveness to hypoxemia and hypercapnia Change in respiratory mechanics	Increased respiratory rate Decreased tidal volume (Vt)

ASSESSMENT

A history can reveal previous illnesses, occupational and environment exposures, family history, travel history, and symptoms of dyspnea, chest pain, wheezing, stridor, hemoptysis, and cough. When more than one symptom occurs concurrently, such as fever, weight loss, and night sweats, the focus is on the primary symptom.

Physical exam includes assessment of general appearance, presence of discomfort and anxiety, alterations in body shape, and chest wall deformities (CDC, 2020c).

When an older person has an infection, the body may not be able to produce a higher temperature, and it is therefore important to check other vital signs as well as look for any symptoms and signs of infection, such as confusion or productive cough. Respiratory infections in older adults include:

• Upper respiratory infections, including influenza
• Lower respiratory infections such as pneumonia and bronchitis
• Increased risk of becoming seriously ill from COVID-19 (older adults have the highest rate of fatalities from this virus)
  (CDC, 2020c)

MANAGEMENT AND PREVENTION

Because older people are at highest risk of developing pneumonia, influenza and pneumococcal pneumonia vaccines are highly recommended.

Common respiratory diseases experienced by older persons include chronic obstructive pulmonary disease (COPD) and emphysema. There is a greater prevalence of COPD in older adults as a result of smoking. Management can be difficult because of those coexisting medical problems, requiring geriatric care and attention from a team of providers.

Risk for COPD and emphysema can be reduced through lifestyle management that includes encouraging older adults to stop smoking, avoid air pollution, and reduce weight to improve diaphragm function. Pulmonary function does not respond to exercise training, however; aging, therefore, may become an increasingly important limiting factor for physical activity (NIH, 2020e).

COPD affects the well-being of the older adult both physically and socially, increasing disability and dependency. The main treatment for COPD is inhaled medications, including steroids. Impact of using long-term inhaled steroids must be considered in this population. Bone density, diabetes management, and increased risk of pneumonia are monitored and managed appropriately. Therapies that have a proven impact on mortality include smoking cessation and oxygen therapy (Gill, 2017).

Emphysema, a form of COPD, can be treated with the Zephyr valve, a one-way valve placed in 3 to 5 airways that reduces hyperinflation of a portion of the lung (Dransfield et al., 2020).

Endocrine Changes

The endocrine system consists of organs and tissues that produce hormones that control the function of target organs. Aging results in changes in the way body systems are controlled, with some target tissues becoming less sensitive to their controlling hormones. Also, the amounts of hormone production may change. Many of the organs that produce hormones are controlled by other hormones, and aging also changes this process (van den Beld et al., 2018).

The thyroid gland produces hormones that help control metabolism, and with aging, metabolism slows. This reduces body heat production and increases levels of body fat. There is an increased risk of hypothyroidism with aging, and hyperthyroidism may increase the risk of death due to cardiovascular disease.

Parathyroid gland hormone affects calcium and phosphate levels. This hormone’s level rises with age, contributing to osteoporosis (common in both older males and females), leads to kidney stones and renal failure, and can significantly decrease the quality of life.

Insulin is produced by the beta cells in the pancreas, and after age 50, cells become less and less sensitive to its effects. An increase in fibrosis and fatty deposits increases glucose intolerance and decreases sensitivity to insulin. Type 2 diabetes is the most common type of diabetes among this age group and is on the rise due to increasing obesity and failure to remain physically active, both of which contribute to insulin resistance.

Normal aging results in subtle changes in adrenal secretion of both ACTH and cortisol, most significantly an increase in cortisol levels. Glucocorticoid excess can have serious consequences in the integrity of both the structure and function of various areas in the brain, leading to impairment in normal memory, cognitive function, and sleep cycles. The increase also impinges on the normal stress response, leading to an impaired ability to recover from stressful stimuli. In addition to effects on the brain, cortisol excess is associated with other changes, including loss of muscle mass, hypertension, osteopenia, visceral obesity, and diabetes.

Melatonin is a hormone secreted by the pineal gland in response to darkness. A decline in melatonin level is believed to play a role in the loss of normal sleep-wake cycles with aging (NIH, 2020f).

Gonads, the main source of sex hormones, begin to secrete less estrogen in the female and less testosterone in the male, increasing the risk for atherosclerosis and osteoporosis in both genders. Less estrogen leads to menopause, the decline of ovarian function in the female, and changes in the uterus and vaginal tissues that may interfere with sexual satisfaction. For males, reduction in levels of testosterone occurs gradually during andropause. This decline in hormone may increase the risk of sexual dysfunction; however, age does not predict male fertility (Morley, 2019; NIH, 2020g).

Among other medical issues, older adults with the diagnosis of HIV/AIDS may develop endocrine problems specific to HIV infection and its treatment. These may include gonadal dysfunction, osteoporosis with increased fracture risk, and dyslipidemia with increased cardiovascular risk (Zaid & Greenman, 2019).

ASSESSMENT

Assessment for endocrine problems may be challenging because of the effects of aging. Manifestations of endocrine disorders in older persons are often atypical and present as nonspecific geriatric syndromes (e.g., weight loss, weakness, functional decline, falls, depression, confusion, and cognitive impairment) that are often attributed to “old age” by patients. These manifestations may also be mistakenly attributed to worsening of comorbid illnesses or medications by clinicians. Older patients with endocrine disorders often have multiple chronic medical conditions that can complicate and confound clinical manifestations, evaluation, and management.

Clinicians use the history, physical examination, and simple laboratory tests (e.g., blood glucose) to actively screen for endocrine-related disorders that occur more commonly in older patients.

MANAGEMENT AND PREVENTION

Taking a history and listening to the patient’s presenting complaints is important in guiding management. Treatment of endocrine disorders can be complicated, as changing one hormone level can affect another. Management takes into account coexisting medical illness, medications, alterations in clearance rate of hormones, and changes in target organ sensitivity with older age.

Patient-centered management and goals of care focus on improvement of function and quality of life within the patient’s social context and care setting. Interdisciplinary care models provide for optimal care and typically include an endocrinologist, pharmacist, physical therapist, and occupational therapist.

Hyperthyroidism and Hypothyroidism

Patients with hyperthyroidism may be started on antithyroid medications such as methimazole or beta blockers to help control symptoms. For those with hypothyroidism, thyroid replacement medication such as levothyroxine may be started (Cleveland Clinic, 2020).

Diabetes Mellitus

For patients with diabetes, guidelines stress the importance of considering overall health, comorbidities, cognitive and physical status, hypoglycemia risk, and life expectancy to guide glycemic goal setting. Lifestyle modification is important, including diet and exercise, and when such modifications alone are unable to maintain target treatment goals, antihyperglycemic pharmaceutical agents are considered (Leung et al., 2018).

Hyperparathyroidism

Hyperparathyroidism, the most common cause of hypercalcemia, increases with age. Older patients, however, are underdiagnosed and undertreated because hypercalcemia is often missed on routine labs, the diagnosis is not considered, and the diagnosis requires an ability to interpret the relationship between calcium and parathyroid hormone levels—a complex calculation requiring expert assistance. Surgical treatment substantially improves quality of life and is more cost-effective than medical management (Dombrowsky et al., 2018).

Excess Adrenal Cortisol Secretion

Management of excess adrenal secretion of cortisol involves recommending participation in physical activity that improves physical performance in order to attenuate the negative impact of chronic stress and normalize adrenal secretion of cortisol (Tortosa-Martinez et al., 2018).

Menopause and Andropause

Many older adults wish to maintain an active, healthy sex life. With the decline in sex hormones, both men and women face organic changes that can affect sexual functioning. For women it may include vaginal dryness, irritation/itching, inadequate lubrication, and dyspareunia (painful intercourse). For men, erectile dysfunction prevalence increases with age, and some men develop testosterone deficiency that can severely reduce libido.

Recommended treatments for the symptoms of menopause include vaginal moisturizers and lubricants, vaginal estrogens, and oral or transdermal hormone therapy.

The best way to manage and prevent erectile dysfunction (ED) is to recommend that older men make healthy lifestyle choices, manage any existing chronic health conditions, and be screened for depression or other possible psychological causes of ED. Exercise, especially moderate to vigorous aerobic activity, has been found to improve ED. Other treatments may include oral, rectal, or injected drugs; testosterone replacement; penis pumps; and penile implants.

Testosterone replacement for men can be recommended as long as maintenance of fertility is not desired. Testosterone replacement can restore lean body mass, physical strength, erectile function, and libido as well as improve mood, bone mineral density, and quality of life (Jannini & Nappi, 2018; Mayo Clinic, 2020a).

Gastrointestinal Changes

Age-related changes in the digestive system begin in the mouth and can affect virtually all aspects of the digestive system.

• Taste buds become less sensitive, and food becomes less appetizing.
• Decreased salivary gland secretion results in xerostomia, which occurs in up to 40% of patients over 65, primarily due to adverse effects of medications.
• Dental conditions associated with aging may include root and coronal caries and periodontitis. Receding gums are common, exposing base or root of a tooth, making it easy for bacteria to build up and leading to inflammation and decay (ADA, 2019).

Contractions of the esophagus and tensions in the upper esophageal sphincter decreases, but the movement of food is not impaired. Some older adults, however, can be affected by diseases or disorders that interfere with esophageal contractions.

The stomach lining’s capacity to resist damage decreases, which in turn may increase risk of peptic ulcer disease, especially in those who use aspirin or NSAIDs. Mucus membrane thins, resulting in lower levels of mucus, hydrochloric acid, and digestive enzymes. With age, the stomach cannot accommodate as much food due to decreased elasticity, and the rate of emptying into the small intestine decreases. These changes, however, typically cause no noticeable symptoms.

Minor changes occur in the structure of the small intestine, so movement of contents and absorption of nutrients do not change. However, lactase levels decrease, leading to intolerance of dairy products by many older adults. Excessive growth of certain bacteria becomes more common with age and can lead to pain, bloating, and weight loss. This may also lead to decreased absorption of certain nutrients, such as vitamin B₁₂, iron, and calcium.

The large intestine does not undergo many changes with age. The rectum does enlarge somewhat, and constipation becomes more common related to a slight slowing in movements of contents through the large intestine, a modest decrease in contractions of the rectum when filled with stool, frequent use of drugs that can cause constipation, and less exercise or physical activity.

The number of secretory cells in the pancreas decreases with age, resulting in a decrease in the level of fat digestion. The liver reduces in size, and metabolism of many substances decreases. This is important when considering medications whose dosages often need to be decreased in older people. Production and flow of bile decreases, and as a result, gallstones are more common (Ruiz, 2020).

ASSESSMENT

Assessment begins with a thorough history of any abdominal or gastrointestinal complaints; assessment of nutritional status and elimination pattern; past history of previous disorders or abdominal surgeries; and a review of medications, including prescription, over-the-counter meds such as aspirin and NSAIDs, herbs or other supplements, and use of enemas and laxatives.

Patients with symptoms may be assessed using blood and diagnostic tests, including fecal occult blood test, lactose tolerance test, as well as GI diagnostic exams using endoscopy and ultrasound.

GI diseases and disorders can manifest with various signs and symptoms, including changes in appetite, weight gain or loss, dysphagia, intolerance to certain foods, nausea and vomiting, changes in bowel habits, and abdominal pain. Abdominal pain may be chronic or acute and related to inflammation, infection, allergy, or food intolerance. It can also result from trauma or obstruction.

Detailed history and video fluoroscopy help diagnose dysphagia, which is described as a sensation of difficulty chewing food or initiating swallowing. Common signs are cough with swallowing, food sticking in the throat, and nasal regurgitation, all of which increase the risk of aspiration (Maryniak, 2019).

MANAGEMENT AND PREVENTION

It is frequently confusing to know which changes in GI function represent a part of normal aging processes and which are pathological results of a disease process. Management is complicated by the frequent presence of comorbidities and polypharmacy, all of which predispose the older patient to a more complex clinical course and increased probability for development of complications.

The most commonly reported oral complaints, including xerostomia, taste disturbances, and burning mouth syndrome, can be managed by discontinuation of offending medications and salivary supplements.

Management of dysphagia with risk of aspiration may require artificial modes of feeding due to the irreversible nature of the underlying disease.

Stomach disorders can be managed by encouraging bland foods high in vitamins and iron. Decreased lipase results in decreased fat absorption and digestion. Small, frequent feedings are encouraged.

Decreased sensation to defecate can result in postponement of bowel movements, leading to constipation and impaction. Interventions that increase the sensation of the need to defecate include a high-fiber diet, 1,500 ml of fluid intake daily if not contraindicated, and as much activity as tolerated (Maryniak, 2019). Stool softeners may be indicated for patients who have limited mobility or are at risk for constipation due to medications.

Sensory Changes

Sensory changes in later life affect how people perceive and experience the world and can have an enormous impact on independence, safety, and quality of life. All five senses—vision, hearing, taste, smell, and touch—diminish in acuity with age. Aging raises the threshold of the amount of stimulation necessary to become aware of a sensation, with stimulation required. Sensory changes can affect lifestyle by causing difficulties with communication, enjoyment of activities, and staying involved with others, which can lead to isolation (NIH, 2020h).

VISION / EYES

Vision is affected by changes in all of the eye structures. The cornea become less sensitive, making eye injuries less noticeable. By age 60, pupils may decrease to about one third the size they were at age 20. Pupils react more slowly to darkness and bright light. The lens becomes yellowed, less elastic, and slightly cloudy. Eye muscles become less able to fully rotate the eye.

Eyes become less able to tolerate glare, and problems with glare, brightness, and darkness may lead to impaired night vision and reduced color discrimination.

Visual acuity gradually declines, causing difficulty focusing on close-up objects (presbyopia). Reading glasses, bifocal glasses, or contact lenses are required to help correct acuity. Also, with aging, the vitreous starts to shrink, creating small particles called floaters that dart back and forth across the field of vision.

Aging eyes may fail to produce enough tears, leading to dry eyes, and if not treated, infection, inflammation, and scarring of the cornea can occur. Eye drops or artificial tears can alleviate this problem (NIH, 2020h).

Other common eye disorders affect older adults, although they are not considered normal effects of aging. These may include:

• Cataracts are cloudy areas in the lens of the eye that cause blurred or hazy vision and that may require surgical removal. Corneal diseases and conditions can present with redness, watery eyes, pain, problems with vision, or a halo effect. Complaints of burning, a sandy feeling as if something is in the eye, or other discomfort may be due to dry eye, especially in women (NIA, 2017a).
• Glaucoma is a group of eye conditions that damage the optic nerve by increasing ocular pressure. Many forms of glaucoma, one of the leading causes of blindness for those over 60, have no warning signs; the effect is so gradual the person may not notice any change in vision until the condition is at an advanced state. Patients also often have no early symptoms of pain. If glaucoma is recognized early, vision loss can be slowed or prevented. Patients with open-angle glaucoma may present with patchy blind spots in peripheral or central vision, often in both eyes, and tunnel vision in the advanced states. Acute-closure glaucoma presents with severe headache, eye pain, nausea and vomiting, blurred vision, halos around the eyes, and eye redness (Mayo Clinic, 2020b).
• Age-related macular degeneration (AMD) is caused by damage to the macula of the retina, leading to loss of central vision. It is the leading cause of severe and permanent vision loss in older adults. Early AMD is often asymptomatic, but patients may complain of a gradual loss of vision in one or both eyes, first noticed as difficulty reading or driving, or a need for brighter light or magnifying lens for fine visual acuity. Others may experience distortion of straight lines (Arroyo, 2020).
• Retinopathies: Hypertensive retinopathy is caused by chronic high blood pressure that damages the retina. Diabetic retinopathy occurs when too much glucose damages the blood vessels in the retina, stimulating the growth of scar tissue, which can pull the retina away from the back of the eye (NIH, 2020h).

Assessment, Management, and Prevention

It is important to remind older patients to follow the recommendation of the American Academy of Ophthalmology for a comprehensive vision exam every year or every other year, which can assure that the patient has the proper eyeglass or contact lens prescription and to check for common eye disorders (Boyd, 2020).

Vision assessment includes testing visual acuity, often by using a Snellen chart. Tonometry to test for ocular pressure is occasionally done in primary care, but normally is done by an ophthalmologist or optometrist as part of a routine eye exam or when a patient is referred for clinically suspected glaucoma. Ophthalmoscopy is performed to check for cataracts; optic nerve or macular degeneration; and evidence of glaucoma, hypertension, or diabetes (Besdine, 2019).

Regular eye exams include measurements of ocular pressure so that a diagnosis of glaucoma can be made in its early stages and treated appropriately. If left untreated, glaucoma will eventually cause blindness. Even with treatment, about 15% of people with glaucoma become blind in at least one eye within 20 years (CDC, 2020b).

Falls are linked to poor eyesight, so it is important to ensure that floors are kept free of clutter, rooms are well-lit, and night lights are installed in strategic locations. Assistive devices in addition to eyeglasses include magnifiers. It is important to ensure that eyeglasses are kept clean and that the person is wearing them.

HEARING / EARS

Aging results in changes in the structures inside the ear, causing a decline in function and causing a major impact on independence, safety, and quality of life. The ears have two functions: hearing and maintaining balance. With aging, the ability of the ear to pick up sounds decreases, and problems with maintaining balance may also occur.

Assessing and Managing Hearing Changes

Age-related hearing loss (presbycusis) affects both ears. Hearing, often the ability to hear high-frequency sounds, may decline. There may be problems in differentiating between certain sounds or with hearing a conversation in the presence of background noise.

Persistent abnormal ear noise (tinnitus) is another common problem in older adults; causes may include cerumen buildup or medications that damage structures in the ear (NIH, 2020g).

Hearing assessment includes observing and listening to the person for evidence of hearing problems, including tilting the head or leaning toward the speaker when listening. The person may also misinterpret questions or comments, or fail to respond at all, which might be interpreted by the examiner as cognitive impairment.

Assessment includes examination of the external auditory canal for an accumulation of cerumen, especially if a hearing problem was noted during interview. If the patient is wearing a hearing aid, it should be removed and examined to determine whether the ear mold or plastic tubing is plugged with wax or the battery is dead.

To evaluate for possible hearing problems, the whisper test (although not a standardized test) can be used to assess the functionality for one-on-one conversations. This test involves the examiner whispering 3 to 6 random words or letters into each of the patient’s ears while keeping their face out of the patient’s view. If the patient correctly repeats at least half of those words for each ear, hearing is considered functional for one-on-one conversations.

Patients with age-related hearing loss are more likely to report difficulty in understanding speech than in hearing sounds. Evaluation with a portable audiometer, if available, is recommended, as these testing sounds are standardized.

Assessment also includes a determination of how the patient’s hearing loss interferes with social or family functioning. This can be done by having the patient complete the Hearing Handicap Inventory for the Elderly (HHIE). If the test score is positive, the patient is referred for formal audiological testing (Besdine, 2019; NIH, 2020i).

While hearing loss in older adults is usually permanent, there are ways to manage the condition using adaptive techniques and assistive devices. Adaptive techniques include making sure to have the person’s attention by directly facing the person when speaking, using a normal tone of voice, and enunciating clearly. The clinician rephrases sentences rather than repeats them and avoids covering the mouth with the hand (NIH, 2020h).

Assistive devices and other options include:

• Hearing aid: An adaptive device worn either behind or inside the ear that amplifies sound
• Cochlear implant: A device implanted surgically in the ear that sends sound directly to the acoustic nerve
• Surgery: Used for problems with the eardrum or in the bones of the middle ear

It is essential when caring for patients with hearing deficits that any hearing aid device be kept clean and functioning and to make certain the hearing device is being worn (NIH, 2020i).

Older adults with profound, uncorrectable hearing loss can benefit from a TTD/TTY phone line and other signaling devices (alarm clocks, smoke alarms, doorbells) that use flashing lights rather than sound. These adaptations not only help people with hearing loss stay connected with family and friends but are also critical safety measures for those living alone. Other assistive devices include amplifiers for telephones and earphones for watching TV.

Prevention measures include management of hypertension and diabetes; smoking cessation; limiting alcohol use; avoiding ototoxic drugs whenever possible; eating foods high in vitamins A, C, E, and especially B₁₂; and wearing hearing protection in noisy environments (NIH, 2020h).

Vestibular Function

Vestibular function requires reliable sensory input. The vestibular system is another sensory system that can also decline with age, leading to a diminished quality of life. The vestibular system constitutes part of the inner ear and detects position and movement of the head as well as the direction of gravity. This is important to the brain’s ability to control balance in standing and walking and also to control certain types of reflexive eye movements that make it possible to see clearly while walking or running (VEDA, 2021).

Both the number of nerve cells in the vestibular system and decreased blood flow to the inner ear decrease with age. Idiopathic bilateral vestibular loss becomes more severe as age progresses, which may first be noticed as difficulty walking and standing, and the person begins to experience dizziness and balance problems (VEDA, 2021).

Healthcare providers screen older adults for symptoms of vestibular changes and make a referral to a vestibular specialist (such as a physical or occupational therapist) if problems are suspected. Symptoms may include:

• Staggering when walking
• Teetering or falling when standing up
• Dizziness or vertigo
• Falling or feeling as if falling
• Lightheadedness, faintness, or a floating sensation
• Blurred vision or bouncing vision
• Confusion or disorientation
• Problems with concentration and memory

Other symptoms may include nausea, vomiting, diarrhea, changes in heart rate and blood pressure, fear, and anxiety (VEDA, 2021).

TASTE AND SMELL

Taste and smell work together to detect the aesthetics and safety of the environment. The number of taste buds declines with age, and each remaining taste bud begins to shrink. In addition, salivary glands produce less saliva, causing dry mouth, which can affect the sense of taste. After age 70, the sense of smell may diminish, possibly due to loss of nerve endings and less mucus production in the nose. Mucus helps odors stay in the nose long enough to be detected and helps clear odors from the nerve endings.

The speed of loss of taste and smell can be increased as a result of certain diseases, smoking, and exposure to harmful particles in the air. Taste may be affected by infections and inflammatory causes; drugs; exposure to chemicals, toxins, and metals; nerve damage; vitamin and mineral deficiencies; metabolic and endocrine disorders; and neurological disorders such as Parkinson’s disease and Alzheimer’s disease.

Loss of the sense of smell disrupts almost every aspect of life, from concerns about personal hygiene, loss of ability to link smells to happy memories, and loss of interest and enjoyment in eating—subsequently impairing nutritional and immune status. In addition, it impairs ability to detect spoiled foods, gases, and smoke.

Alzheimer’s disease impairs olfactory function, including defective odor identification and discrimination and altered detection thresholds. As the disease progresses, odor detection typically becomes markedly impaired (NIH, 2020h). Sudden loss of taste and smell have been reported as presenting symptoms in some patients with COVID-19 (Lafreniere, 2020).

Assessment for taste and smell complaints can involve a variety of tests, including those that directly assess smell and taste as well as more general tests such as imaging and laboratory studies. The majority of patients with loss of smell may be unaware and therefore remain undiagnosed and untreated.

For patients with diminished or absent sense of taste or smell, treatments usually depend upon the cause; however, there is no treatment for loss due to the aging process.

Medication regimens are assessed for possible olfactory side effects, and alternative drugs or reduced dosages may preserve the sense of smell. Patients are encouraged to stop smoking.

To help enhance the dining experience, recipes can be altered to include more flavorful spices and herbs. Older adults can also be encouraged to make meals a social time whenever possible. Studies have shown that the presence of others during meals also increases the duration of the meal, resulting in increased intake (NIH, 2020h).

TOUCH

Sense of touch allows for awareness of pain, temperature, pressure, vibration, and body position. With aging, sensations may be reduced due to decreased blood flow to nerve endings or to the spinal cord or brain. Certain health conditions can affect the ability to sense touch, such as skin or nerve damage caused by diabetes, neurological disorders, mental illness, and brain disorders. Certain medications and treatments can also affect touch sensation.

With changes in temperature sensitivity, there is an increased risk of injury from frostbite, hypothermia, and burns. Reduced ability to detect vibration, touch, and pressure also increases the risk of injuries, including pressure ulcers. After age 50, many people have reduced sensitivity to pain, making it easy to ignore a severe injury. Problems may develop due to reduced ability to perceive where the body is in relation to the floor, increasing the risk of falling.

Peripheral neuropathies can prevent older people from noticing foot infections and injuries and can lead to falls and gait disorders, contributing to loss of autonomy and independence. Causes include physical injury, diabetes, vascular and blood problems, systemic autoimmune disease, hormonal imbalances, kidney and liver disorders, nutritional or vitamin imbalances, alcoholism, exposure to toxins, certain cancers and benign tumors, chemotherapy drugs, or infections (NIH, 2020h; NINDS, 2020).

Assessment, Management, and Prevention

Assessment of sensation includes touch (using a skin prick test), cortical sensory function (e.g., graphesthesia, stereognosis), temperature sense, proprioception (joint position sense), and vibration sense testing. Many patients report numbness, especially in the feet, and many older people lose vibratory sensation below the knees. Patients with numbness should be checked for systemic diseases that can cause nerve damage (such as diabetes) and tested to identify any neuropathic disorder that may be causing peripheral neuropathies. In many patients, no cause of numbness can be identified (Besdine, 2019).

Management of changes in sensation often focus on safety issues. The following are ways patients can be instructed to manage symptoms:

• Lower water heater temperature to no higher than 120 °F to avoid burns.
• Inspect skin, especially the feet, for injuries. If there is an injury, it should be treated and never assumed not to be serious because there is no pain.
• Wear socks and well-fitting, protective shoes and never go barefoot.
• Avoid sunburn.
• Protect hands in cold weather.
  (Saint Luke’s, 2020)

Nutritional Changes

Older adults generally require fewer calories because they are not as physically active as they once were and their metabolic rate slows down. Nevertheless, their bodies still require the same or higher levels of nutrients for optimal health outcomes.

Changes that occur with aging that affect the nutrition of the older adult involve a combination of physical, social, and psychological issues, including:

• Increased likelihood of isolation at mealtimes
• Illnesses such as malignancy that contribute to decline in appetite
• Medicines that can change the taste of foods, make the mouth dry, take away appetite, or reduce the ability to absorb nutrients
• Financial limitations affecting food acquisition
• Age-related diminished sense of smell and taste, early satiety, and delayed gastric emptying
• Impaired ability to eat, including difficulty chewing or swallowing, poor dental health, or impaired ability to feed oneself
• Dementia, which can result in forgetting to eat, not buying groceries, or other irregular food habits
• Depression related to grief, loneliness, failing health, or lack of mobility
• Alcohol misuse, which can interfere with digestion and absorption of nutrients and contribute to poor decisions about nutrition

Malnutrition is not synonymous with thinness. Some obese persons are also malnourished; they consume more than enough calories but insufficient nutrients essential to good health. Obesity is the most common nutritional disorder in the older adult living in the community, and malnutrition is most common in those in acute and long-term care facilities.

Malnutrition in older adults can lead to various health problems, including:

• A weak immune system, which increases the risk of infections
• Poor wound healing
• Muscle weakness and decreased bone mass, which can lead to falls and fractures
• A higher risk of hospitalization and risk of death
  (Mayo Clinic, 2020c)

ASSESSMENT

There are four components of a nutritional assessment:

• Nutritional history and screening using a validated tool
• Food intake diary of 1 to 3 days
• Physical assessment, including anthropometric measurements and signs of nutritional deficiencies
• Biochemical markers, if applicable

Nutritional History

Nutritional history includes:

• Medical diagnoses
• Hospitalizations
• Changes in appetite
• Availability and preparation of food
• Medications
• Details regarding weight change
  (Hood, 2020)

Screening is done using a standardized tool. There are a number of nutrition screening and assessment tools available for use with older adults. The Nutrition Health Checklist and the Mini Nutritional Assessment Instrument (see table) are the two most often used. Others are:

• DETERMINE checklist: Helps identify a person at nutritional risk
• Malnutrition Screening Tool (MST): Suitable for residential care facilities
• Malnutrition Universal Screening Tool (MUST): Suitable for adults in acute and community settings
• Subjective Global Assessment (SGA): Useful in acute, rehab, residential care, and community settings
• Seniors in the Community: Risk Evaluation for Eating and Nutrition (SCREEN)
  (NCOA, 2020)

MINI NUTRITIONAL ASSESSMENT INSTRUMENT

Assessment Question	Scoring
(Hood, 2020)
Has food intake declined over past 3 months due to: Loss of appetite Digestive problems Chewing or swallowing difficulties	0 = Severe decrease 1 = Moderate decrease 2 = No decrease
Weight loss during the last 3 months	0 = Weight loss less than 6.6 lbs 1 = Does not know 2 = Weight loss between 2.2 and 6.6 lbs 3 = No weight loss
Mobility	0 = Bed or chair bound 1 = Able to get out of bed/chair but does not go out 2 = Goes out
Psychological stress or acute disease in past 3 months	0 = Yes 2 = No
Neuropsychological problems	0 = Severe dementia or depression 1 = Mild dementia 2 = No psychological problems
Body mass index (BMI)	0 = Less than 19 1 = 19 to less than 21 2 = 21 to less than 23 3 = 23 or greater
If BMI not available, calf circumference	0 = Less than 31 cm 3 = 31 cm or greater
Screening Score (maximum 14 points)	12–14: Normal nutritional status 8–11: At risk of malnutrition 0–7: Malnourished

Food Diary

A dietary assessment involves a three- or four-day food diary that contains a complete record of foods and beverages consumed over those days. A food diary allows the clinician to highlight foods that need to be changed in addition to any beneficial choices that should be continued. The diary can be an excellent tool to help patients increase awareness of eating habits and to encourage compliance with recommended dietary changes. Also, patients may alter what they consume and increase their awareness of intake because they were asked to write it down (Olendzki, 2019).

Physical Assessment

Physical assessment of nutrition involves a search for medical conditions that may be contributing to weight loss or other nutritional health conditions.

Signs and symptoms of malnutrition include:

• Unintended weight loss
• Loss of muscle mass and subcutaneous fat
• Loss of appetite
• Wounds that are slow to heal
• Memory issues or oncoming dementia
• Lack of energy
• Trouble chewing, swallowing or feeding oneself
• Muscle weakness
• Getting sick often
• Bruised or dry, cracked skin
• Weakness

Body mass index (BMI) measurement is not an accurate means to determine obesity in the older adult. The BMI may not change, but fat-stores increase. Also, with aging, people often become shorter due to osteoporosis and spinal vertebral issues. This alters the BMI, which is calculated using height and weight. Determining waist circumference, however, can be a valuable measurement, since aging increases abdominal fat accumulation while muscle mass deteriorates. Calf circumference and mid-upper-arm circumference have also been found to be more effective than BMI in predicting long-term mortality risk (Kennedy-Malone et al., 2019; Schaap et al., 2018).

Biochemical Markers

There is no gold standard for biomarkers of nutritional deficiencies in the older adult, but some indicators include:

• Prealbumin
• Transferrin
• Albumin
• Chemistries
• CBC
• Vitamin B₁₂
• Folate
• Vitamin D (25 OH)
• Thyroid panel

A C-reactive protein can help determine if malnutrition is the result of lack of intake or due to inflammation and hypercatabolism (excessive metabolic breakdown of substances such as protein) (Kennedy-Malone, 2019).

MANAGEMENT AND PREVENTION

Interventions for patients who are malnourished are directed at the underlying cause (e.g., treatment for depression) as well as dietary modification. Nutritional restrictions are lifted for patients with diabetes who may do well with a regular diet and adequate monitoring. High-calorie foods are recommended. Oral nutritional supplementation for patients who do not regain weight are also recommended, with adjustments in meal preparation and diet.

Advice regarding weight loss of the overweight older person is tailored to the individual, assessing the impact of excess weight on quality of life, and includes the need for regular exercise. It is not recommended that people over the age of 80 who are slightly obese be placed on calorie-restricted diets. The best option is to eat at least three meals a day that provide 30 grams of protein each, and to engage in two or three weekly sessions of resistance training that taxes all the large muscle groups in order to preserve muscle mass (Ritchie & Yukawa, 2020).

The Academy of Nutrition and Dietetics outlines special nutrient needs:

• Older adults require more calcium and vitamin D to help maintain bone health. Good sources for calcium include dark green leafy vegetables, canned fish with soft bones, and fortified cereals. Good sources of vitamin D include fatty fish, eggs, and fortified foods and beverages. Supplements may be recommended.
• Some adults older than 50 may not be able to absorb enough vitamin B₁₂. Fortified cereal, lean meat, and some fish and seafood are good sources. Supplements may be recommended.
• Dietary fiber helps with maintaining bowel regularity and may also reduce risk of heart disease and type 2 diabetes. Whole-grain breads, cereals, beans and peas, along with fruits and vegetables provide fiber.
• Consuming adequate potassium, along with limiting sodium intake, lowers risk of hypertension. Good sources of potassium include fruits, vegetables, beans, and lower-fat dairy products. Flavor can be added to food with herbs and spices rather than salt.
• Other minerals include phosphorus, magnesium, sodium, chloride, and a small amount of trace minerals, including iron, manganese, copper, iodine, zinc, cobalt, fluoride, and selenium.
  (AND, 2020)

The National Institutes of Health (2020j) offers the following recommendations for those who are having difficulty meeting nutritional needs:

• For those who eat alone, organize potluck meals or cook with a friend. Older adults can also look into having some meals at a nearby senior center, community center, or religious facility.
• See a dentist to check for oral problems and solutions.
• If having trouble swallowing, drink plenty of liquids with meals.
• If having trouble smelling and tasting food, add color and texture to make food more interesting.
• If not eating enough, add healthy snacks throughout the day to help get more nutrients and calories.
• If illness is making it hard to cook or feed oneself, consider obtaining an occupational therapy referral.

Sleep Changes

Older adults need about the same amount of sleep as younger adults, which ranges from 7 to 9 hours daily (Olson, 2019). Sleep normally occurs in several stages. The sleep cycle includes periods of light sleep, deep sleep, and active dreaming (REM) sleep. This cycle is repeated several times during the night. Sleep architecture (how people cycle through the different stages of sleep) often changes with aging. Alterations in sleep architecture are common among older adults, who may experience:

• Increased sleep latency (a delay in the onset of sleep)
• Waking more often during the night
• Waking earlier in the morning
• Total sleep time that remains the same (7 to 9 hours) or is slightly decreased (6.5 to 7 hours per night)
• A more abrupt transition between sleep and waking, making older people feel like they are a lighter sleeper than when they were younger
• Spending less time in deep, dreamless sleep
  (NIH, 2020k)

Because older adults sleep more lightly and wake up more often, they may feel deprived of sleep even when their total sleep time has not changed. Sleep deprivation can eventually cause confusion and other mental changes.

Insomnia is one of the more common sleep problems in older people, which may be caused by a variety of overlapping factors, but can improve with treatment.

Sleep apnea can cause pauses in breathing during sleep. These pauses are related to a repeated collapse or partial collapse of the upper airway. Sleep apnea causes fragmented sleep and can affect oxygen levels in the body, leading to headaches, daytime sleepiness, and difficulty thinking clearly.

Restless leg syndrome results in an urge to move the legs while resting or sleeping, causing involuntary movements, mostly commonly in the feet.

REM sleep behavior disorder (RBD) primarily affects older people. RBD decreases or stops the temporary paralysis of muscles during REM sleep and can cause people to act out their dreams, sometimes violently.

Mental and physical health conditions may also interfere with sleep, including depression, anxiety, heart disease, diabetes, and conditions that cause pain, such as arthritis. Sleep issues may also be related to the side effects of medications, and taking multiple medications may cause unanticipated effects on sleep (NIH, 2020k).

ASSESSMENT

Evaluation of sleep in older adults begins with a complete sleep history. A good sleep history includes questions relating to:

• Typical sleep pattern
• Daytime functioning
• Presence of medical conditions
• Intake of caffeine, alcohol, drugs, or food before bedtime
• History of psychiatric and mood disorders

It is also important to investigate sleep-related problems patients may have, including disorientation, delirium, impaired intellect, decreased cognition, psychomotor complaints, and increased accidents and falls. The most frequent sleep-related complaints in older patients are problems initiating or staying asleep.

Whenever possible, it is advisable for the patient to maintain a sleep diary for several weeks before arriving for assessment and to interview the patient’s bed partner, who may notice problems of which the patient is unaware.

A physical exam, neurological exam, and mental status exam may provide clues to the causes of sleep disturbance (Xiong, 2019).

Review of Medications

The geriatric population is the largest age group to use hypnotic drugs. The use of these medications has been associated with falls, hip fractures, and daytime carryover symptoms. When evaluating a patient for sleep problems, a review of medications is performed to help determine causes of insomnia. Such medications can include:

• Alpha blockers
• Beta blockers
• Corticosteroids
• SSRI antidepressants
• ACE inhibitors
• H1 antagonists
• Glucosamine/chondroitin
• Statins

A ferritin blood level may be drawn for patients with restless leg syndrome. A low level has been found to be associated with this complaint (Xiong, 2019).

Sleep Apnea

Signs and symptoms that may be present in those with obstructive sleep apnea include:

• Excessive daytime sleepiness
• Loud snoring
• Observed period of apnea during sleep
• Abrupt awakenings accompanied by gasping or choking
• Dry mouth or sore throat on awakening
• Morning headache
• Difficulty concentrating during the day
• Mood changes, e.g., depression or irritability
• Hypertension
• Night-time sweating

Following initial assessment, it may be necessary to refer the patient to a sleep disorders center for evaluation of sleep apnea. Portable recorders may be used as screening tools. These devices are placed on the patient in the afternoon, who is then sent home to sleep at night (Mayo Clinic, 2019b).

MANAGEMENT AND PREVENTION

If initial history and physical exam do not reveal a serious underlying cause, a trial of improved sleep hygiene is recommended:

• Maintain a regular bedtime and wake-up time; avoid sudden changes in sleep schedules.
• Decrease or eliminate daytime naps.
• Exercise daily but not immediately before bedtime. (Those who exercise regularly fall asleep faster, sleep longer, and report better quality of sleep.)
• Use the bed only for sleeping and sexual activity.
• Reduce bedroom distractions such as television, cellphones, and bright light; move electronics out of the bedroom.
• Do not use bedtime as “worry time.”
• Avoid heavy meals at bedtime, and eat dinner at least four hours before bedtime.
• Limit or eliminate alcohol, caffeine, and nicotine before bedtime.
• Develop and maintain a bedtime routine that helps with relaxation.
• Control environment with comfortable temperature, quietness, and darkness.
• If unable to sleep within 30 minutes, get out of bed and perform a soothing activity, but avoid exposure to bright light.
  (Xiong, 2019)

Those who are overweight and snore loudly may improve with weight loss and should avoid sleeping supine.

Psychiatric consultation for severe depression and pulmonary or surgical consultation for obstructive sleep apnea may be helpful.

Older people respond differently to medications, and it is best to avoid sleep medicines if possible. However, antidepressant medicines can be very helpful if depression affects sleep. Medication on a short-term basis together with sleep hygiene is appropriate for transient insomnia (e.g., secondary to bereavement) (Xiong, 2019).

Patients diagnosed with sleep apnea may need to sleep with a continuous positive airway pressure (CPAP) device and are advised to keep a regular routine of use. Regular maintenance of the machine and evaluation of its effectiveness are also important considerations. Common problems include a leaky mask, trouble falling asleep, stuffy nose, and dry mouth. When patients are first introduced to this device, it is helpful for them to wear it for short periods while awake. Once the patient is used to how it feels, the device is worn for sleeping, including naps (Mayo Clinic, 2018).