MUSCULOSKELETAL SYSTEM

AGE-RELATED CHANGES IN STRUCTURE AND FUNCTION

(by: Adrianne Erica Tenorio)

Aging process affects the musculoskeletal system in numerous ways. All the changes may
cause pain, impaired mobility, self-care deficits and increased risk of falls for older adults.
 Decreased muscle mass, tone and strength as the actual number of muscle cell decreases
and is replaced by fibrous connective tissue.
 Weaker bones because of the
 decreased elasticity of ligaments, tendons and cartilage
 decreased bone mass
 Loss of 1.5 to 3 inches of height because the intervertebral disks lose water which causes
the narrowing (shrinkage) of the vertebral space.
 Flexion and Extension of the lower back are decreased because of the flattening of the
lordotic or convex curve of the back.
 Posture, which assumes a position of flexion, change as a result of change in the spine.
 There is a shift in the center of gravity because of the changes in posture.
 In men, gait become small stepped with a wider-based stance.
 In women, waddling gait while walking can be observed because of a narrowing
standing base (bowlegged or genus varus).
 The articular cartilage erodes as a result of either the aging process or the wear-and-tear on
the joints.

Falls are the most common cause of accidental death in older adults.
 Falls result in injury and hospitalization which increases the risk of iatrogenic illness and
immobility. This may lead to a downward trajectory and result in death.
 Falls cause a cycle of disuse and occurs after the individual has experienced repeated falls.
 To avoid falls, the individual decreases mobility. With decreased mobility, muscle strength
decreases, joints become stiff and pain develops resulting in disability, loss of
independence and frailty.

Diseases and the decline in the musculoskeletal system may be reduced or prevented through the
use of regular programs of
 active exercise
 resistive muscle strengthening

Gerontologic Assessment Differences

Changes Differences in Assessment Findings
MUSCLE
  Decreased no. and diameter of muscle
cells.
Replacement of muscle cells by fibrous
connective tissue.
 Loss of elasticity in ligaments, tendons
and cartilage.
 Reduced ability to store glycogen
Decreased ability to release glycogen
as quick energy during stress.
 Decreased basal metabolic rate (BMR)
JOINTS
 Increased risk for cartilage erosion that
contributes to direct contact between
bone ends and overgrowth of bone
around joint margins
 Loss of water from discs between
vertebrae
Decreased height of in vertebral spaces
BONE
 Decreased bone density and strength
 Brittleness
 Slowed remodeling process
Biocultural Variations in the Musculoskeletal System
(by: Matthew Gerald Perillo and Jucelle Anne Valerio)
BONE
1. Frontal
2. Parietal/occipital
3. Palate
 Decreased muscle strength and mass
Abdominal protrusion
Flabby muscles
 Increased rigidity in neck, shoulders,
back, hips and knees.
 Decreased fine motor dexterity
Decreased dexterity
Decreased agility
 Slowing of impulse conduction along
motor units
Slowed reaction times and reflexes
Earlier fatigue with activity
 Joint stiffens
Decreased mobility
Limited ROM
Possible crepitation of movement
Pain with motion and/or weight bearing
 Loss of height and shortening of trunk
from disc compression
Posture change
 Loss of height and deformity (e.g.
dowager’s hump on kyphosis) from
vertebral compression and degeneration
 Back pain and stiffness
 More pronounced bony prominences
 Increased risk of osteopenia and
osteoporosis
REMARKS
 Thicker in black men than in white men
 Thicker in white men than in black men;
occipital protuberance palpable in Eskimos
 Tori (protuberances) along suture line of
 hard palate, which is problematic for
denture wearers
Incidence:
Blacks: 0%
Whites: 24%
Asian Americans: up to 50%
Native Americans: up to 50%
4. Mandible  Tori (protuberances) on lingual surface of
mandible near canine and premolar teeth,
which is problematic for denture wearers
 Most common in Asian Americans and
Native Americans; exceeds 50% in some
Eskimo groups
 Torsion or rotation of proximal end with
5. Humerus muscle pull
 Larger in whites than in blacks
 Torsion in blacks is symmetric; torsion in
whites usually greater on right side than on
left
6. Radius/ulna  Length at wrist variable
 Ulna/radius may be longer
Equal length:
Swedish: 61%
Chinese: 16%
Ulna longer than radius:
Swedish: 16%
Chinese: 48%
Radius longer than ulna:
Swedish: 23%
Chinese: 10%

7. Vertebrae  24 vertebrae found in 85% to 93% of all

people; racial and gender differences reveal
23 or 25 vertebrae in select groups (23
vertebrae in 11% of black women; 25
vertebrae in 12% of Eskimo and Native
American men
 Related to lower back pain and lordosis

8. Femur  Convex anterior: Native Americans

Straight: Blacks
Intermediate: Whites

9. Pelvis  Hip width 1.6 centimeters (cm) (0.6 inch)

smaller in black women than in white
women; Asian American women have
significantly smaller pelvises

10. Second tarsal  Second toe longer than great toe

 Incidence:
Whites: 8% to 34%
Blacks: 8% to 12%
Vietnamese: 31%
Melanesians: 21% to 57%
11. Height  Clinical significance for joggers and
athletes
 White men 1.27 cm (0.5 inch) taller than
black men and 7.6 cm (2.9 inches) taller
than Asian-American men
 White women equal to black women
 Asian-American women 4.14 cm (1.6
inches) shorter than white or black women

 Longer, narrower and denser in blacks than

12. Composition of longer bones in whites; bone density in whites greater
than in Chinese, Japanese, Eskimos
 Osteoporosis lowest in black men; highest
in white women

 Responsible for dorsiflexion of foot

Muscle absent: Asian Americans, Native
13. Peroneus tertius
Americans and whites: 3% to 10%
Blacks and Berbers: 10% to 15% (Sahara
Desert): 24%
 No clinical significance because tibialis
anterior also dorsiflexes the foot

 Responsible for wrist flexion

Muscle absent:
14. Palmaris longus Whites: 12% to 20%
Native Americans: 2% to 12%
Blacks: 5%
Asian Americans: 3%
 No clinical significance because three other
muscles are also responsible for flexion

PHYSIOLOGICAL CHANGES IN THE ELDER POPULATION

CARDIOVASCULAR SYSTEM

● As people age, changes occur within the heart. As an individual ages, the chances of comorbid
conditions increase (Meiner, 2015). All over the world, including in Manila, cardiovascular
 diseases pose the biggest threat to people’s health (WHO, 2017). Aging alters cardiovascular
system both structurally and physiologically.
● During rest, the older heart functions in almost the same way as a younger heart, except the heart
rate is slightly lower. Also, during exercise, older people’s heart rate does not increase as much as
in younger people (Gupta and Shea, 2019).
● The heart rate decreases, the left ventricular wall thickens and results in an overall increase in
oxygen demand and increased collagen and decreased elastin in the heart muscle and vessel
walls.
● The size of the left atrium increases and aortic distensibility and vascular tone decrease. These
changes decrease myocardial muscle contraction and, thus, cardiac output and cardiac reserve.
● Age-related changes also included the following:
○ Decrease in diastolic pressure and diastolic filling, and beta-adrenergic stimulation
○ Increase in arterial pressure, systolic pressure, wave velocity, and left ventricular end
diastolic pressure

○ Muscle contraction, muscle relaxation and ventricle relaxation phases are elongated.

● An S4 heart sound commonly occurs in older adults and about 50% of older adults have a grade 1
or 2 systolic murmur.

VASCULAR CHANGES

 We are born with arteries that are elastic, flexible and compliant, allowing optimal cardiac function
and blood flow. During ventricular systole (contraction), blood is ejected into the pulmonary and
systemic circuits and the larger elastic arteries stretch, reducing the resistance to blood flow. As
the body ages, blood vessels, particularly arteries, lose their elasticity and the arterial walls
become stiffer and thicker.
 Tunica intima
- It is the innermost layer of a blood vessel, and consists of two main regions:
o Endothelium – a single layer of cells
o Lamina – a thin layer of connective tissue that anchors the endothelium to the
tunica media (muscle layer) above. This mainly comprises elastin (elastic fibers)
and collagen and undergoes significant changes with age.
- The larger arteries have a high elastin content as they need to stretch in harmony with the
powerful ventricular contractions of the heart to cushion the force of the pulse wave,
smoothing out the flow of blood entering the smaller arteries. These smaller arteries have
much less elasticity and a greater proportion of collagen fibers in their vessel walls
(Steppan et al, 2011).
 Tunica media
- It lies underneath the tunica intima and is made up of layers of smooth muscle cells. It is
controlled by the vasomotor center within the medulla oblongata (the lower part of the
brain stem). The vasomotor center plays an important role in regulating blood pressure by
controlling vasodilation and vasoconstriction (Marieb and Hoehn, 2015).
 With age comes a gradual thickening of the tunica intima and tunica media of large and medium-
sized arteries.
- This is associated with an increase in the number and density of collagen fibers in the
vessel walls (Ferrari et al, 2003). Collagen fibers also undergo a process of cross-linking,
 which makes them less compliant. With age and repeated stretching, elastin – which partly
gives arterial walls their elasticity – undergoes fracture and fatigue (Greenwald, 2007).
- Ageing blood vessels may also display varying degrees of calcification. These events
cumulatively result in a gradual loss of elasticity and stiffening of the arteries, which is
often reflected by increased blood pressure (Bolton and Rajkumar, 2011).

 Endothelium
- The endothelium, the most delicate part of a blood vessel, is in direct contact with the
circulating blood (Marieb and Hoehn, 2015). It is composed of a single layer of squamous
epithelial cells that, in children and young adults, are regular and smooth, minimizing
resistance to blood flow.
- As we age, the endothelium develops irregularly shaped cells and is often thickened due
to the presence of smooth muscle fibers that have migrated from the tunica media. This
thickening contributes to a reduction in arterial elasticity and compliance, and reduces the
lumen size, further increasing resistance to blood flow.

CHEMICAL CHANGES
 Reduced nitric oxide production
- Endothelial cells release various chemical signals that help to regulate blood flow by
controlling the internal diameter of blood vessels. One of the most important of these
chemicals is nitric oxide, which is produced by endothelial cells from the amino acid L-
arginine. This diffuses into the smooth muscle layer of the blood vessels, where it acts as a
powerful vasodilator, expanding the vessels and ensuring good blood flow.
- Damage to the endothelium – be it age-related or due to other causes – results in
reduced nitric oxide generation and therefore blood flow (Greenwald, 2007; Bode-Böger
et al, 2003). This contributes to, and may exacerbate, age-related blood vessel pathologies
including peripheral vascular disease and angina pectoris.
 Increased pro-inflammatory chemicals
 - The concentration of pro-inflammatory chemical mediators circulating in the blood
increases with age. Many are implicated in blood vessel pathology, including
atherosclerotic occlusion and blood vessel wall calcification (Harvey et al, 2015).
 Delayed angiogenesis
- After an injury or infection, new blood vessels can be rapidly produced in a process known
as angiogenesis. This is orchestrated by a variety of chemical signals and growth factors.
Angiogenesis slows with age, and is often significantly delayed (Sadoun and Reed, 2003),
which may help to explain why wound healing generally occurs more slowly in older
people.

CARDIAC CHANGES
 To overcome reduced elasticity and increased resistance to blood flow of aged and occluded
arteries, the heart’s ventricles have to pump with greater force. The myocardium (muscular layer
of the heart) responds by becoming hypertrophied.
 Earlier ultrasound studies suggested the thickness of the left ventricle increases by around 30%
between the ages of 20 and 80 years, with an associated gradual increase in cardiac weight
(Pearson et al, 1991). However, the validity of some of these studies has recently been questioned.
 The amount of collagen deposited in the myocardium also increases with age. Together with the
redistribution of cardiac muscle mass, this typically results in an observable change in the shape of
the heart from the classic elliptical shape to a slightly more spherical appearance (Strait and
Lakatta, 2012; Ferrari et al, 2003).
 Blood pressure
- Systolic blood pressure gradually increases with age – the average in men is around 126
mmHg at 25 years and 140 mmHg at 60. This is thought to reflect the decrease in elasticity
and lumen diameter within the arterial tree, and the associated structural changes to the
heart.
- In addition, small arteries and arterioles become less responsive to vasodilators such as
nitric oxide, further increasing peripheral resistance. Recent research has also
demonstrated a general age-related up-regulation of the renin-angiotensin mechanism.
This results in increased levels of the powerful vasoconstrictor angiotensin II, which
elevates blood pressure (Harvey et al, 2015).
- In the absence of any pathology, diastolic pressure (when the ventricles are relaxed)
changes very little with age and may even be reduced (Steppan et al, 2011).
 Reduced baroreceptor response
- After a change in posture, such as moving from a sitting to a standing position, blood
drains into the lower extremities and blood pressure falls. This hypotension is immediately
detected by the baroreceptors (blood pressure sensors) in the aortic arch and carotid
sinus, causing the cardiac in the medulla oblongata to increase the heart rate. The
vasomotor center, also in the medulla oblongata, initiates vasoconstriction to restore
normal blood pressure, ensuring adequate blood flow to the brain and preventing postural
hypotension and fainting (Marieb and Hoehn, 2015).
- In older people, baroreceptor reflexes are blunted, which often results in an increased
variability of blood pressure throughout the day and may reduce the ability to maintain
blood pressure after blood loss (Monahan, 2007). It is thought that age-related thickening
of the arterial walls may interfere with the ability of baroreceptors to accurately measure
the degree of stretch (blood pressure) within the vessel. This can increase the risk of
postural hypotension, increasing the risk of falls.
CONDUCTION SYSTEM OF THE HEART
 The SA node, AV node and bundle of His become fibrotic with age.
- By the age of 50, the sinoatrial node (SA node), the heart’s natural pacemaker, has lost 50-
75% of its cells.
- While the number of cells in the atrioventricular node remains relatively constant, there is
fibrosis and cellular death in the atrioventricular bundle, also called the bundle of His
(heart muscle cells specialized in electrical conduction).
- These changes may reduce the efficiency of cardiac conduction and contribute to the
decline in maximal heart rate (Ferrari et al, 2003). The reduction in pacemaker cells makes
atrial and ventricular arrhythmias much more likely; an example of this is atrial fibrillation
in older people.
 The number of pacemaker cells located in the SA node decreases with age, which results in less
responsiveness of the cells to adrenergic stimulation.
 If an ECG is conducted, the common aging changes include a notched P wave, a prolonged P-R
interval, decreased amplitude of the QRS complex and a notched or slurred T wave.

RESPONSE TO STRESS AND EXERCISE

 Decreased cardiac output and cardiac reserve decrease the older adult’s response to stress.
 Decreased distensibility of the heart walls, decreased heart rate, and decreased myocardial
contractility affect response to exercise.
 In exercise, the heart increases more slowly. However, once elevated, it takes longer to return to
the resting rate. Nonetheless, this doesn’t exclude older people from participating in exercise
programs.

OTHER COMMON AGE-RELATED CHANGES:

 By age 70, cardiac output has often decreased by one third.
 Hypertrophy of the left ventricle can cause pulmonary edema.
 Decrease in the maximum heart rate by 30-60% by age 85 leads to decreased cardiac output.
 The aortic semilunar valve can become stenotic or incompetent.
 Coronary artery disease and congestive heart failure can develop.
 Aerobic exercise improves the functional capacity of the heart at all ages.
 Reduced elasticity and thickening of arterial walls result in hypertension and decreased ability to
respond to changes in blood pressure.
 Atherosclerosis is an age-related condition.
 The efficiency of capillary exchange decreases.
 Walls of veins thicken in some areas and dilate in others. Thrombi, emboli, varicose veins, and
hemorrhoids are age-related conditions.

HEMATOPOIETIC SYSTEM
NORMAL CHANGES OF AGING

Most of the changes of aging in the hematologic system are the result of the bone
marrow’s reduced capacity to produce RBCs quickly when disease or blood loss has occurred. However,
without major blood loss or the diagnosis of a serious illness, the bone marrow changes of aging are not
clinically significant. At about age 70, the amount of bone marrow in the long bones (where most RBCs are
formed) begins to decline steadily. Additional changes of aging in the hematologic system include the
following:

 The number of stem cells in the marrow is decreased.

 The administration of erythropoietin to stimulate use of iron to form RBCs is less effective
in older adults than in younger people.
 Lymphocyte function, especially cellular immunity, appears to decrease with age.
 Platelet adhesiveness increases with age.
 Average hemoglobin and hematocrit values decrease slightly with age but remain within
normal limits.

Many functions of the hematologic system remain constant in healthy older adults, including
RBC life span, total blood volume, RBC volume, total lymphocyte and granulocyte counts, and
platelet structure and function (Huether & McCance, 2011; NHLBI, 2007; Reuben et al., 2011).The most
apparent change seen in the bone marrow with aging is decreased cellularity. Under normal
circumstances, the bone marrow is the only site of hematopoiesis.

Extramedullary hematopoiesis may occur in the liver, spleen and lymph nodes in pathological
states when the marrow compensatory mechanisms are outstripped. Until puberty the entire skeleton
remains hematopoietically active but by age 18 only the vertebrae, ribs, sternum, skull, pelvis, proximal
epiphyseal regions of humerus and femur remain active sites of blood production, with other medullary
sites infiltrated with fatty tissue. By age 40, the marrow in sternum, ribs, pelvis and vertebrae is composed
of equal amounts of hematopoietic tissue and fat and cellularity declines gradually thereafter. By age 65,
bone marrow cellularity has been estimated to be approximately 30% with a corresponding increase in
marrow fat. Age-associated imbalanced bone remodeling and osteoporosis results in decreased
trabecular bone which itself may contribute to diminished hematopoiesis It has been shown that the
presence of fat correlates with the occurrence and severity of osteoporosis, both of which are evident with
aging

Several age-related qualitative changes have been identified in hematopoietic cells including
skewed X-chromosome inactivation, telomere shortening, accumulation of mitochondrial DNA
mutations and micronuclei formation , any of which could result in cellular dysfunction.

EFFECTS OF AGE RELATED CHANGES

1. Anemia and immune deficiency are observed in late life in individuals without other recognizable
disease, but these are typically mild and associated with minimal morbidity or mortality.
2. With the thymic involution the naïve T cells in the periphery decreases and the memory T cells
reach senescence accounting for the elderly persons having difficulties responding to old and new
antigens and demonstrate impaired reactions to vaccinations.
3. Interventions aimed at reconstituting age-reduced hematologic or immune function are likely to
have consequences in both systems.

LYMPHATIC SYSTEM
Generally, aging is associated with physiological changes that cause stiffness or rigidity and decreased levels
of functioning in many systems. As a result, it is difficult to differentiate age changes that occur simultaneously in
organs throughout the body from specific changes in the immune system. Aging is the result of a lifetime of
cumulative effects of environmental exposures, such as sunlight, radiation, pesticides, and other chemicals, as well as
a lifetime of exposure to illness and stress.
 One of the most important biological changes occurring during human aging is a progressive
decrease in immune functioning, orimmunosenescence. Since regulatory mechanisms also are diminished, the
activation of the immune response is inefficient and poorly controlled. This increases risk for infectious,
autoimmune, neoplastic, cardiovascular, and neurodegenerative diseases and other disorders. Older individuals
have more variation in the effectiveness of their immune system than younger people. However, data that
compare the function of the immune system between the young and old often conflict. Some older people
show relatively little change, and others are severely compromised. There is a trend, however.As the age of a
population increases, the proportion of people with declining humoral and cellular immune function increases
(National Institute of Allergy and Infectious Diseases [NIAID] & National Cancer Institute [NCI], 2007). Within
the individual, there is a decrease in the speed, strength, and duration of both the immune response and the
regulation of immune activities.

A decreased ability to respond to antigenic stimulation by B lymphocytes is a common characteristic

of the aging humoral immune system. Although the secondary immune response of the humoral (B-cell) immune
system may be normal due to the presence of memory cells, the response to new antigens is decreased. More
antigenic material may be needed to prompt antibody production, and the production is slower. A lower
peak antibody concentration may occur, and antibody levels decline faster as the person ages. As a result, risk of an
insufficient humoral immune system response increases with the age at which antigens are first
encountered.Over time, the secondary immune response may also show changes. The number of B cells in the
circulation decreases in some individuals. As a result, tissues are slower to repair and are more vulnerable to disease,
especially infections. A decline in the production of IgE leads to a decrease in allergic or hypersensitivityreactions.
An increase in antibody production that reacts against the person’s own body cells also may occur, contributing to
the development of autoimmune diseases such as rheumatoid arthritis. All changes in B cells develop slowly until the
age of 60, when they begin to occur more rapidly. Therefore, in general, vaccinations should be given by the age of
60 to have the greatest effectiveness; however, exceptions to this rule exist. For example, vaccination with
pneumococcal vaccine is recommended at age 65 with revaccination recommended after 5 years if the initial
dose was administered before age 60, or if the individual was less than age 65 at the time of the first vaccination
(Centers for Disease Control and Prevention [CDC], 2011).There is consensus among investigators that normal
aging, when no pathological conditions exist, is associated with diminished responses by the cell-mediated immune
system, particularly with the T lymphocytes when the body is exposed to some antigens. T lymphocytes mature in the
thymus, which begins to shrink after adolescence. By middle age, it is only about 15% of its maximum size. This is
regarded as a key age-related factor in the gradual reduction in effectiveness of the immune system (National Library
of Medicine [NLM], 2012). A decrease in T-cell proliferation leads to reductions in all the subsequent parts of
the immune response. Cell secretions such as interleukin-2 decline. The ratio of helper T cells (CD4) and cytotoxic T
cells (CD8) to other T cells is often reduced. There is a slower response to delayed hypersensitivity reactions, and
regulation of the immune system is impaired. As a result, the incidence of infectious diseases, cancer, and
autoimmune diseases increases.

AGING INFLUENCES ON THE IMMUNE SYSTEM

■ Overall decrease in:

 Speed and strength of the immune response.

 Neuroendocrine regulation of immune activities.

■ Decrease in humoral immunity:

 The B-cell response to new antigenic stimulation decreases.

 The number of B cells in the circulation decreases.
 The production of IgE declines.
 Antibody production against self increases, which contributes to development of autoimmune diseases.
 The humoral immunity decrease is slow until the age of 60, then occurs more rapidly.

■ Decrease in cellular immunity:

  The key factor in the gradual reduction in effectiveness of the immune system is diminished proliferative
responses by T lymphocytes.
 Reductions in all the subsequent parts of the immune response occur.
 Cell secretions such as interleukin-2 decline.
 Helper T cells (CD4) and cytotoxic T cells (CD8) are often reduced in their ratio to other T cells.
 There is a slower response to delayed hypersensitivity reactions.

■ Regulation of the immune system is impaired. As people age, the immune system becomes less effective in the
following ways:

 The immune system becomes less able to distinguish self from nonself (that is, to identify foreign antigens).
As a result, autoimmunedisordersbecome more common.
 Macrophages (which ingest bacteria and other foreign cells) destroy bacteria, cancer cells, and other
antigens more slowly. This slowdown may be one reason that cancer is more common among older people.
 T cells (which remember antigens they have previouslyencountered) respond less quickly to the
antigens.
 There are fewer white blood cells capable of responding to new antigens. Thus, when older people
encounter a new antigen, the body is less able to remember and defend against it.
 Older people have smalleramounts of complement proteins and do not produce as many of these
proteins as younger people do in response to bacterial infections.
 Although the amount of antibody produced in response to an antigen remains about the same overall, the
antibodies become less able to attach to the antigen. This change may partly explain why pneumonia,
influenza, infective endocarditis, and tetanus are more common among older people and result in death
more often.

These changes may also partly explain why vaccines are less effective in older people and thus why it is important for
older people to get booster shots (which are available for some vaccines).These changes in immune function may
contribute to the greater susceptibility of older people to some infections and cancers.

Factors affecting the aging of Lymphatic System

Many factors can be associated with the aging of the Lymphatic System. It can be directly or
indirectly affected by the following factors:

a. Stress Initiates a physiological fight-or-flight response that evolved over time as a result of threats
to one’s physical well-being.
Psychological threats that come from worrying about bills, work, or relationships,
or traumatic experiences from the distant past, trigger a chronic fight or-flight
response. The extent to which this type of stress has affected the immune system,
and its relationship to disease susceptibility, remains under investigation.It is generally
believed that the stress response, resulting in sympathetic nervous system stimulation and
hormonal changes, can suppress the immune system in older adults. Individuals who
characteristically react more strongly to stress may have greater stress-related effects over
the course of their lives. Older people often have increased psychosocial stressors such
as caring for an infirm spouse or partner. High levels of stress and social isolation have been
reported among caregivers of dementia patients. The stress that accompanies this kind
of caregiving has been equated to multiple and severe long term stressorsAn increase in the
amount of stress perceived by individuals is generally associated with poorer immunity.
However, this relationship is modified by the amount and type of coping used by the
individual. Coping styles are likely to differ among individuals, even when faced with a
similar stressful situation. Successful coping strategies deal with the perceived cause of
the stress.(Seaward, 2012). Psychoneuroimmunology studies the interaction between
psychological processes and the nervous and immune systems of the human body. There is
now sufficient data to conclude that the immune system is modified by psychosocial
stressors that can lead to actual health changes. Changes related to infectious disease
and wound healing have provided the strongest evidence, but it is believed that diverse
 conditions and diseases could result from increased stress. Negative emotions over time
may lead to immune dysregulation.
b. Chronic Illness
The central nervous system, the immune system, the endocrine system, and
the psyche are interrelated. Aberrations in one system can adversely affect another system.
Lymphocytes have receptors on their surface for many neuroendocrine hormones that
consequently have regulatory effects on the lymphocytes. Mood, stress, depression, and
mental illness influence the immune system.3.LifestyleLifestyle factors, such as physical
activity and diet habits, significantly affect the process of immunosenescence Accordingly,
regular exercise training and specific nutrition strategies support successful immune
aging and decrease the risk of maladaptive immune aging.Regular physical exercise has been
associated with increased immunity and may serve as a simple lifestyle intervention to
counteract the deleterious effects of immunosenescence. Some of the positive effects
of exercise for older adults include increased responsiveness to vaccines, greater NK-
cell function, reduced proportions of exhausted/senescent T cells in the periphery,
lower frequency of pro-inflammatory monocytes, enhanced function and number of
anti-inflammatory Tregs, and longer leukocyte telomere lengths.

GASTROINTESTINAL SYSTEM
ORAL CAVITY AND PHARYNX

Changes in the oral cavity have an effect not only on an older person’s well-being, comfort, and health but
also on overall nutrition and digestion.

 Most obvious change is the loss of teethcaused commonly by periodontal disease, which damages
the tissue surrounding the teeth and supporting bones. The surface of the teeth may also be
mechanically worn down (Coleman, 2002).
 It is suggested that about half the people in the Unites States who are 65 years old or older wear
dentures.
 Many other older clients are edentulous(without teeth), and the teeth that are present are
often diseased or decayed.
 Taste buds may atrophywith age, resulting in an inabilityto discriminate among flavors, especially
salty and sweet. This may contribute to decreasedenjoyment of food, resulting in poor eating habits
and nutritional deficiencies(Miller, 2004).
 The amount of saliva produced does not significantly decrease in healthy older adults, but
medications and disease processes do cause 30% of adults to experience xerostomia(dry
mouth).
 Poor oral health and disease conditionshave a significant impact on the older adult’s feelings
of self-esteem and depression.ESOPHAGUSAge-Related Changes
 Decrease in the strength of esophageal contractions, whichmeansdecreased food transit
time.
 Lower esophageal sphincter weaknesscauses older adults to be more prone to reflux of acid
from the stomach, or gastroesophageal reflux, also causing a decreased food transit time.

Changes may lead to:

1. dysphagia
2. heartburn
3. vomiting of undigested foods
4. poor nutrition
5. dehydration
6. decreased food intake

STOMACH
 Age-Related ChangesAge-related changes in the stomach include decreased production of gastric acid,
pepsin, bicarbonate, prostaglandins, and mucus.

 Decrease in pepsinmay hinder protein digestion.

 Decrease in hydrochloric acid and intrinsic factormay lead to malabsorption of iron, vitamin B12,
calcium, and folic acid.
 Altered absorption and decreased gastric acid productionincrease the incidence of
pernicious anemia, peptic ulcer disease, and stomach cancer.
 Decreased elasticity of the stomach wallincreasesgastric emptying time and causes constipation.
 Unable to accommodate large amounts of foodresulting in a feeling of fullness or early satiation.

SMALL INTESTINE

Age-related changes in the small intestine include atrophy and broadening of the villi leading to a decrease
in absorptive surface. This results in a decrease in the absorption of lipids.

 Decrease in the production of lactaseresultsin intolerance to dairy products.

 Increase in the overpopulation of certain intestinal bacterialeadsto bloating, pain, and weight loss
and decrease in the absorption of calcium, folic acid, and iron.
 Deterioration of small intestinecan result to malnutrition.

LARGE INTESTINE

 atrophy of the muscle layers and mucosa.

 These normal changes with aging may lead to a decrease in contraction of the muscle
wallwhen the rectum is filled with feces, resulting in constipation. Constipation
 More water from the food is absorbed into the body.
 Staying hydrated is very important to help prevent constipation.oGet at least 30 minutes of
moderate physical activity four days a week.
 Diverticuli oIncreased in older adults.
 Prevalent nearly half of people older than 60 years (Shaheen, 2006).
 Small outpunching of the colon, where it bulges at weak spots in the intestinal wall.

GALLBLADDER

The gallbladder and bile ducts are unaffected by aging.

 Incidence of gallstonesdoes increase with age.

 Bile may become morelithogenicwith advancing age.
 Increase in biliary cholesterolrelated to diet and hormonal changes.
 Aging affectscholesterol metabolism.
 The bile salt pool also decreases because of a decrease in bile salt synthesis.
 Stone development may occur, along with a tendency for dehydrationin older adults.
 There is an increased incidence of cholelithiasis and cholecystitis.
 The complications of cholelithiasis in older adults:oempyema(condition in which pus gathers in
the area between the lungs and the inner surface of the chest
wall)operforationocholedocholithiasis (calculi in the common bile duct). oThese complications are
often seen in persons older than age 65 and those with diabetes (Lewis et al., 2011).

PANCREAS

Age-Related Changes
 o Fibrosis, fatty acid deposits, and atrophy; weight, but not size, is affected (Lewis et al.,2011).
o The volume of pancreatic secretions (chymotrypsin and pancreatic lipase) decline with age.
o Decrease in enzyme activity affects the digestion of fats and may account for a vague
intolerance of fatty foods in older adults.
o Pancreatic cancer and pancreatitis increases in older adults. LIVERA sturdy organ and retains most
of its functions throughout the life span.
o Liver size decreases after age 50, liver function tests may remain within normal limits.
o Decrease in hepatic blood flowoccurs.
o As hepatic blood flow slows, drug metabolismis reduced, which leaves the aging liver more
susceptible to drugs and toxins.
o Older persons have a decreased ability to compensate for infectious, immunologic, and metabolic
disorders (Lewis et al.,2011).
o Normal aging may adversely affect liver tissue regeneration.
o Generalized slowing of repair or an inadequate response to regeneration of liver tissue.

URINARY SYSTEM
ANATOMICAL CHANGES

A. Pre-renal changes

The most important pre-renal (occurring before the kidney) change affecting kidney
function is vascular degeneration.

· In young adults, renal blood flow is estimated to be approximately 600ml/minute;

· In older people this is often reduced by half (Cukuranovic and Vlajkovic, 2005) primarily
due to normal age-related changes in blood vessels and is often exacerbated in people
with atherosclerosis of the renal artery.

Such blood vessel changes usually lead to ischaemia (reduced oxygenation), particularly in
the outer portion of the kidney (renal cortex). Cells gradually die and are replaced with scar tissue,
giving the outer surface of aged kidneys a granular or mottled appearance. The arterioles leading
to the glomeruli (filtration membranes) show deposition of hyaline (clear cartilage-like material)
and collagen below the endothelium; this reduces the diameter of the vessels, thereby restricting
blood flow. The smallest blood vessels in the kidney, including the capillaries that form the
glomeruli, also progressively degenerate and are replaced with fibrous scar tissue (Musso and
Oreopoulos, 2011).

Aged blood vessels experience a general reduction in the synthesis of the potent vasodilator
nitric oxide (see Part 1 of this series) and this contributes to reducing blood flow to the kidneys
(Weinstein and Anderson, 2010).

Reduced glomerular filtration rate

The glomerular filtration rate (GFR) is a measure of the rate of fluid filtration through the
glomerular capillaries into Bowman’s capsule. It is expressed in milliliters per minute, and is
routinely used to measure the progression of kidney disease. GFR peaks in the third decade of
life, where it may be as high as 140ml/min/1.73m2. Blood vessel changes progressively reduce
renal blood flow and GFR: in normal ageing, it drops by around 8ml/min per decade after the age
of 30. The GFR of people in their 80s may be only 60-70% of what it was when they were young
adults; at 90 years of age it has typically fallen to around 65ml/min/1.73m2.
 Reduced GFR means reduced clearance of waste products. However, age-related decline
in GFR is not observed in all people; indeed many maintain a stable GFR throughout life, which
suggests that variables other than ageing contribute to the decline (Zhou et al, 2008).

B. Renal changes

Both kidney mass and weight decrease significantly after the age of 50 (Zhou et al, 2008).

· The kidneys of people in their 20s weigh 250-270g each;

· In 90-year-olds this has dropped to 180-200g.
· It has been estimated that, between the ages of 40 and 80, approximately 20% of kidney
mass is lost (Choudhury et al, 2016);
· Only 3% of people in their 90s have histologically normal kidney tissue.

There is a gradual increase in collagen deposition, leading to progressive kidney fibrosis.

In old age, whole nephrons (the functional units in the kidneys) are replaced by fatty material or
scar tissue; on average, 70-year-olds have lost 30-50% of their nephrons. Aged nephrons often
show a variety of physical defects (Fig 2).

Glomerular abnormalities

The number of damaged glomeruli (glomerulosclerosis) increases, typically leading to

progressive capillary collapse. Fewer than 5% of glomeruli show sclerosis in people in their 20s
but, by their 80s, this will have risen to around 30% (Weinstein and Anderson, 2010).

Filtration membrane abnormalities

Some nephrons display a progressive thickening and wrinkling of the filtration membrane
in the glomerulus and Bowman’s capsule, decreasing the renal filtering surface area. The filtration
membrane also becomes increasingly permeable, allowing large molecules such as proteins to
collect in the filtrate and appear in the urine (proteinuria).

Tubule abnormalities

Some kidney tubules gradually degenerate and are replaced by scar tissue (tubulo-
interstitial fibrosis). This seems associated with an increasing number of cells showing features of
senescence (Sturmlechner et al, 2017), which reduces the area available for the reabsorption of
useful materials such as glucose, amino acids and salts. The distal convoluted tubules often
shrink and may develop small pouches (distal diverticula), which can in turn become fluid-filled
cysts, increasing the risk of kidney infection and pyelonephritis (Zhou et al, 2008).

Impaired renal repair

In young adult kidneys, around 1% of renal cells can divide and proliferate. This declines
with age, reducing the kidneys’ ability to repair. The chemical signalling pathways that coordinate
cell division and repair in the kidneys also become impaired with age (Bolignano et al, 2014).

Diet and renal ageing

Age-related changes in renal structure and function are thought to occur because of both
genetic and environmental factors (Bolignano et al, 2014). One factor that appears to play a role is
exposure to oxidative stress, which tends to lead to the release of pro-inflammatory mediators.
While most oxidative stress is linked to free radicals produced during cellular metabolism, some of
it comes from diet. Foods cooked at high temperature (particularly fried or roasted) are high in
pro-oxidants; it has been suggested that limiting their intake could reduce oxidative and
inflammatory stress on the kidneys (Vlassara et al, 2009).

Gender differences in renal ageing

Although this is still poorly understood, oestrogens such as 17 beta-estradiol appear to

protect the renal system in women from the effects of ageing, while androgens such as
testosterone increase the risk of renal dysfunction in men. One hypothesis is that androgens
promote fibrosis in the kidney; this may partially explain why chronic kidney disease progresses
more quickly in men (Weinstein and Anderson, 2010).

PHYSIOLOGICAL CHANGES

Renal System Physiological Changes Results

Kidney Decreases in size and weight
Decreased glomerular filtration rate ü
Reduced renal blood flow
Tubular degeneration
Bladder Bladder wall changes
ü May lead to kidney atrophy.
ü Number of filtering units
(nephrons) decreases.
ü Less efficient at concen-trating
urine, therefore a greater volume
of water is required to excrete
toxic waste products.
Reduced clearance of waste
products.
ü Prolonged half-life of drugs.
ü Progressive capillary collapse.
ü Sclerosis may be found in as
many as 40% of the remaining
glomeruli, and fibrous changes in
the interstitial tissues may be
found in older adults without
kidney disease.
ü Usually lead to ischemia
particularly in the renal cortex.
ü Reduction in the synthesis of the
potent vasodilator – nitric oxide.
ü Less efficient at clearing
acidic/basic metabolites/ions
ü This is problematic in older
people with diabetes, as acidic
molecules such as ketones may
accumulate in the blood, leading
to life-threatening ketoacidosis.
ü Decreased reabsorption of
glucose
ü Electrolyte imbalance
ü Loss of elasticity
ü Bladder capacity decreases.
ü May lead to urinary frequency,
urgency, and nocturia.
 ü Incomplete emptying during
micturition (urination).
Decrease muscle strength ü Sphincter muscle lose tone
leading to incontinence
Ureters Do not change much with age -----
Urethra Shortens and its lining becomes ü Decrease the ability of the
thinner urinary sphincter to close tightly
ü Increasing the risk of urinary
incontinence
Changes in length and elasticity ü Shorter in women, it often
becomes colonized with bacteria
ü Risk for recurrent urinary tract
infections (UTI)
Urinary Lessening of the strength of the ü Less effective at voluntarily
Sphincter sphincter muscle retaining urine
ü May lead to urinary incontinence,
often involving a slow leakage of
urine
Prostate Gland Benign enlargement of the prostate ü Benign prostatic hyperplasia
gland ü Gradual compression of the
urethra, making micturition more
difficult
ü If untreated, blockage may
become nearly complete or
complete, causing urinary
retention and possibly kidney
damage
ü Onset of prostate cancer is also
marked by an increase in
prostate size
ü Reduction in strength of the
urine stream
ü Difficulty urinating or starting to
urinate; a weak stream; dribbling
at the end of urination; frequent
urination; sudden, strong urges
to urinate; and urinating several
times at night (nocturia)
ü Makes it harder to empty bladder

PLAN OF CARE FOLLOWING ASSESSMENT

A good assessment will help to identify any underlying causes of the incontinence and
enable appropriate treatment to be initiated. The options should be discussed with the older
person and their willingness and ability to participate in self-help strategies assessed and a clear
explanation should be given to the individual and/or carer.

Patients’ preferences for care must be established and the care plan individualized with
patient-centered goals (Fonda et al, 2005). In frail older people some interventions may be
inappropriate, but advanced age alone should not preclude treatment if the assessment identifies
that it is necessary (Fonda et al, 2005).

NURSING CONSIDERATIONS:

1. Frequency of voiding is common (decreased muscle tone of the bladder with impairment of
the bladder emptying capacity; increased residual, urine infection)
 lifestyle changes – such as reducing caffeine intake (including green tea), stopping
smoking and losing weight
 pelvic floor muscle training – this technique strengthens the pelvic floor muscles and
is an effective treatment for stress incontinence, especially if the muscle has been
damaged.
 bladder training – bladder training involves learning techniques to increase the length
of time between feeling the need to urinate and passing urine. The course usually lasts
for at least six weeks and can be combined with the Kegel exercises. Some individuals
may find that timed toileting is helpful, particularly people with a learning disability or
cognitive impairment..
 Treatment and management plans for urinary incontinence are determined on an
individual basis. Interventions are individually selected in relation to the type of
incontinence, duration of symptoms, and abilities of the client. For example, consider:
o Is the elder aware of the need to void?
o Can he or she communicate that need?
o Is the elder able to fully empty the bladder when assisted to the toilet?
o Is he or she functionally able to successfully use the toilet or commode?

2. Older men with benign prostate disease:

 may be managed with medication for example alpha–blockers.
 Those with early prostate cancer may carefully monitored with regular blood tests for:
o PSA (prostate specific antigen)
o digital rectal examination
o observation of symptoms
 Other treatment options include surgery and radiotherapy.
 Advanced prostate cancer may be treated with hormonal therapies and monitoring of
symptoms.

3. Older women related interventions:

 Relaxation of the perineal muscles in elderly women interferes with complete emptying
of the bladder (UTI)
o NICE (2006) recommends the use of topical estrogen for vaginal atrophy and report
that it can also improve symptoms of frequency, dysuria, urge or stress urinary
incontinence.
 Involutional changes in the lining of the vagina lead to decreased resistance to
organism (infection with discharge)

4. Urinary incontinence which may lead to infection

 Promote continued mobility because this helps decrease the risk of developing UTI.
  To those patients who can urinate by themselves, ask them to cleanse perineal area
and keep it dry. To those patients who are catheterized, provide catheter care as
appropriate. Proper perineal hygiene decreases risk of skin irritation or breakdown and
development of ascending infection.
 Maintain an acidic environment of the bladder by the use of agents such as Vit.C,
Mandelamine (a urinary antiseptic) when appropriate to prevent the occurrence of
bacterial growth.
 Encourage adequate fluid intake (2–4 L per day), avoiding caffeine and use of
aspartame, and limiting intake during late evening and at bedtime. Recommend use of
cranberry juice/vitamin C. Sufficient hydration promotes urinary output and aids in
preventing infection. These also help improve renal blood flow.
 Note: When patient is taking sulfa drugs, sufficient fluids are necessary to ensure
adequate excretion of drug, reducing risk of cumulative effects.
Note: Aspartame, a sugar substitute (e.g., Nutrasweet), may cause bladder irritation
leading to bladder dysfunction.
 Encourage the client to void every 2-3 hours to prevent the accumulation of urine thus
limiting the number of bacteria.
 Palpate the client’s bladder every 4 hours to determine the presence of urinary
retention.
 Observe for cloudy or bloody urine, foul odor. Dipstick urine as indicated. These are
signs of urinary tract or kidney infection that can potentiate sepsis. Multistrip dipsticks
can provide a quick determination of pH, nitrite, and leukocyte esterase suggesting
presence of infection.

5. Prolonged half-life of drugs because of decreased GFR

 Your doctor may choose to carry out some further investigations:
o Blood tests may be taken to see what your hemoglobin levels and white cell counts
are, to monitor the balance of your electrolytes and waste products the kidney normally
excretes.
o Urine samples are obtained, that are tested with a dipstick and also analyzed to see if
there is any protein or other abnormalities present.
 Imaging of the kidneys through procedures such as an ultrasound test. This can provide
an idea of the size of the kidneys, how your urinary tract looks and whether there is
any obstruction present.
 Some drugs depend on the kidneys to be excreted from the body. These medications
should all be monitored closely and adjusted as necessary. Medications that are known to
be toxic to the kidney should be avoided.
 Lifestyle factors that contribute to your risk of disease of the heart and major blood vessels
should be identified and optimized. These include: quitting smoking, adhering to a healthy
diet low in fats and salts, limiting alcohol consumption and regular exercise. You should
have your blood pressure checked regularly by your local GP. Your local doctor may start
some blood pressure medications that can be beneficial to your kidneys.
 NERVOUS SYSTEM
Physiological Changes of Aging in the Autonomic Nervous System The slowing of Autonomic Nervous
System response is a result of structural changes in basal ganglia.
1. Lower blood pressure | Orthostatic Hypotension |Syncope
2. Slower heart rate ‘bradycardia’ | shortness of breath
3. Lower body temperature ‘hypothermia’
4. Slower digestion
5. Decreased metabolism
6. Imbalance in fluids & electrolytes
7. Decreased sweat production
8. Watery eyes
9. Decreased saliva production
10. Urinary incontinence
11. Constipation
12. Sexual dysfunction
NEURON

The neuron, also called nerve cell, is the basic unit of the CNS and functions to transmit impulses.
Some neurons are motor neurons, and some are sensory neurons. Each neuron has a cell body (soma),
dendrites, and a single axon. Synapses are structural and functional junctions between two neurons. These
are the points at which the nerve impulse is transmitted from one neuron to another or from neuron to
efferent organ. The two types of synapses are electrical and chemical. Significant cellular and structural
changes in neurons:

 Shrinkage in neuron size and gradual decrease in neuron numbers

 Structural changes in dendrites
 Deposit of lipofuscin granules, neuritic plaque, and neurofibrillary bodies within cytoplasm and
neurons
 Loss of myelin and decreased conduction in some nerves, especially peripheral nerves

NEUROTRANSMITTERS

Neurotransmitters are chemical substances that enhance or inhibit nerve impulses. These
substances are necessary in the synaptic transmission of information from one neuron to another. In aging
the function of these substances is altered because of the decrease of neurons. With aging, the number of
neurons in various areas of the brain also decreases, and abnormal substances are deposited on the
neuronal cellular structure (dendrites) (Sugarman & Huether, 2012). The loss of neurons is not as extensive
in the process of aging as previously believed. In actuality, large neurons appear to shrink and few are lost.
The changes in neuron function are associated with accumulation of lipofuscin (dark fluorescent pigment)
granules and neuritic plaques in the cell body of some neurons and some cellular debris in neuroglia cells
(Keller, 2006). Significant cellular and structural changes in neurotransmitters:

 Changes in precursors necessary for neurotransmitter synthesis

 Change in receptor sites
 Alteration in enzymes that synthesize and degrade neurotransmitters
 Significant decreases in neurotransmitters, including ACh, glutamate, serotonin,
dopamine, and gammaaminobutyric acid

NEUROGLIA AND SCHWANN CELLS

 Neuroglia and Schwann cells are the supportive cells of the CNS, making up approximately half of
the brain and spinal cord tissue. Their role is to protect the neurons. As individuals age, the number of
these protective cells increases. Each of these cells serves a different function. Neuroglia cells vary in size
and shape and are divided into two main classes: the microglia and the macroglia. The microglial cells are
phagocytic scavenger cells related to macrophages that respond to infection or trauma to the CNS. The
macroglial cells include astrocytes, oligodendrocytes, and ependymal cells.

 Astrocytes (astroglia) are star-shaped cells that provide the physical support for the
neurons. They also regulate the chemical environment and nourish the neurons. These
cells respond to brain trauma by forming scar tissue.
 Oligodendrocytes and Schwann cells produce myelin within the CNS and peripheral
neurons, respectively.
 Ependymal cells form the lining of the ventricles, choroid plexuses, and central canal of
the spinal cord. These cells help in the regulation of cerebrospinal fluid (CSF) and the
blood–brain barrier.

CEREBROSPINAL FLUID AND VENTRICULAR SYSTEM

CSF is a clear, colorless fluid. Approximately 135 ml of CSF circulates through the ventricles and
within the subarachnoid space. The brain and the spinal cord float in CSF, which absorbs shocks, cushions
the CNS, and prevents the brain from tugging on meninges, nerve roots, and blood vessels. The choroid
plexus (CP) is a group of blood vessels (capillaries) covered with a thin layer of epidermal cells. The CP is
responsible for producing approximately 500 mL of CSF per day. Several physiologic changes known to
occur in the CNS of aging individuals include:

● difficulty retrieving explicit memories

● altered vision, hearing, taste, and smell

● vibratory sensations

● position sense

As a result of neurotransmitters and hypothalamic changes in the aging process, the reticular
activating system (RAS) that controls arousal and consciousness from the brainstem to the cerebral cortex
is also altered. The neuroendocrine system plays a vital role in the function of the hippocampus. When any
alteration occurs in this system, gradual changes in memory may be seen.

HIPPOCAMPUS AND THE HYPOTHALAMIC–PITUITARY–ADRENAL AXIS

The hippocampus is a part of the temporal lobe that plays an important role in memory and
learning. Normal aging is associated with changes in the ability to consciously learn and retain new
information easily. This occurs as a result of structural changes, synapse loss in the neurons, decreased
microvascular integrity, reduction in glucose metabolism, and alterations in the neuroglia cells with aging.
As a result of changes in the secretory pattern of the hypothalamic–pituitary–adrenal (HPA) axis,
additional alterations occur in the hippocampal area of the brain. The hippocampal area is strongly
influenced by HPA hormones. The specific aspects altered by the aging process are the:

● explicit memory (e.g., delayed recall)

● the ability to learn new information quickly

● memory storage

● memory retrieval
Balance and Motor Function

● Age-related neurodegenerative and neurochemical changes in the cerebellum are believed to be the
underlying cause of decline in motor and cognitive function. The neurodegenerative and neurochemical
changes, combined with inner ear and vestibular changes, cause many older adults to experience changes
in balance.

● These changes may further contribute to postural hypotension because of an inability to quickly respond
to changes in position. The symptoms of postural hypotension are dizziness or lightheadedness when
changing positions rapidly. However, compensatory processes in the cortex and subcortical areas of the
brain help aging individuals maintain relatively normal motor performance (Heuninckx, Wenderoth, &
Swinnen, 2008).

Sensorimotor Function

The nervous system gathers information about the internal and external environment by
depending on specialized sensory receptors. These specialized sensory receptors include those needed for
vision, hearing, smell, touch, equilibrium, and pain sensation.

Significant vision changes occur with aging that lead to gradual decrease in color perception,
potentially affecting the ability of older individuals to distinguish between blues, greens, and violets. These
changes are the following:

 Thickening of the lens reduces the amount of light passing through the lens .
 As the lens becomes less elastic, it loses its ability to focus on close objects.
 Change in elasticity narrows the visual field and diminishes depth perception.
 Yellowing of lens and changes in size & thickening of cornea results in difficulty seeing at night. ○
As the fluid of the eye becomes cloudy, it reduces light sensitivity.
 Presbycusis is the hearing loss associated with the aging process.
 Older persons are unable to hear high frequencies
 Unable to clearly hear consonant sounds such as f, g, s, z, t, sh, and ch.
 Other changes involve collapse and narrowing of the canal and thickening of earwax, which
increase hearing ability.
 Number of taste and smell receptors decrease and nerve transmissions become slower.
 Loss of taste and smell receptors = not appetizing to older adults
 Would less likely detect bad taste or smell of spoiled food.
 Unable to rapidly detect smoke, gas leaks, or other toxic fumes.
 Somatic receptors respond to touch, pressure, cold, pain, and body position that it becomes less
sensitive as aging occurs. Therefore decreased ability to feel pain and cope

Reticular Formation and Sleep Patterns

● The Reticular Formation is a set of neurons that extends from the upper level of the spinal cord through
the brainstem up to the cerebral cortex.

● The RF contains both motor and sensory tracts that are closely connected with the thalamus, basal
ganglia, cerebellum, and cerebral cortex. This group of neural fibers has both excitatory and inhibitory
capability.

● The RF contains a physiologic element, the RAS, which regulates sensory impulses that are transmitted
to the cerebral cortex. The lower portion of the RAS in the brainstem assists in the regulation of the wake–
sleep cycle and consciousness. Sleep disorders are common in aging individuals. Risk factors for sleep
disturbances include physical illness, medications, changes in social patterns (e.g., retirement or death of a
spouse or loved one), and changes in circadian rhythm. Some sleep disturbances may also be part of the
normal aging process resulting from neural changes in the RAS. Normal sleep is organized into different
stages that cycle throughout the night. The sleep stages are classified into the following categories
(Brannon, Carroll, Vij, & Gentili, 2008; National Institute on Aging [NIA], 2012e): 1. Rapid eye movement
(REM) sleep. This is the stage of sleep during which muscle tone decreases significantly. In advanced aging
REM sleep is maintained without much decline. 2. Non-REM sleep. This is subdivided into four stages.

● Stages 1 and 2 = light sleep (duration and shifts increases)

● Stages 3 and 4 = deep sleep or slow-wave sleep. (decreases or disappear completely)

● Some older women have normal or even increased stage 3 sleep, whereas men have normal or reduced
stage 3 sleep. As individuals age, they spend more time in bed to get the same amount of sleep they
obtained when younger; however, the total sleep time is only slightly decreased, with an increase in
nocturnal awakenings and daytime napping. Hence older persons often report having earlier bedtimes and
increased sleep latency (time to fall asleep), with women taking longer than men, a 16% and 36%
difference (NIA, 2012e).

● Excessive daytime somnolence is not part of normal aging. Somnolence indicates the presence of a
pathologic condition.

● Sleep apnea and certain movement disorders are serious sleep disorders, and older adults should be
tested for these if they are having trouble with insomnia.

● Movement disorders, including restless leg syndrome, rapid eye movement sleep behavior disorder, and
periodic limb movement disorder, are common among older adults (NIA, 2012e)

SENSORY SYSTEM
I. Sensory Loss and Sensory Deprivation

Sensory loss is when one of your senses; sight, hearing, smell, touch, taste and spatial awareness, is
no longer normal. It can often be compensated for by assistive devices such as glasses and hearing
aids. In contrast, sensory deprivation is the absence of stimuli in the environment or the inability to
interpret existing stimuli. It can lead to boredom, confusion, irritability, disorientation, and anxiety.
Meaningful sensory stimulation provided to the older person is often helpful in correcting this
problem.

II. Visual

1. Age-related changes in structure and function

Eyelids Lose tone and become lax, which may result
in ptosis of the eyelids, redundancy of the
skin of the eyelids, and malposition of the
eyelids.

May turn gray and become coarser in men,

with outer thinning in both men and women.
Eyebrows

Thins and yellows in appearance. This

membrane may become dry because of
Conjunctive diminished quantity and quality of tear
production.

May develop brown spots.

Yellows and develops a noticeable

Sclera surrounding ring, made up of fat deposits,
called the arcus senilis.

Cornea
Decreases in size and loses some of its
ability to constrict. Changes related to aging
that decrease the size of the pupil and limit
the amount of light entering the eye also
occur in the iris.
Pupil

Increases in density and rigidity, affecting

the eye’s ability to transmit and focus light.
Peripheral vision decreases, night vision
diminishes, and sensitivity to glare
increases. The yellowing of the lens results
in difficulty identifying certain colors,
especially cool colors such as blue, green,
and violet.
Lens

Ophthalmoscopic examination of the retina

may reveal the following changes: blood
vessels have narrowed and straightened;
arteries seem opaque and gray; and drusen,
localized areas of hyaline degeneration, may
be noted as gray or yellow spots near the
macula.
 Retina

2. Common Complaints

FLOATERS AND FLASHERS

Floaters appear as dots, wiggly lines or clouds that a person may see moving in the field of vision. It occurs
more often after the age of 50 as tiny clumps of gel or cellular debris float in the vitreous humor in front of
the retina. They are caused by degeneration of the vitreous gel and are more common in older adults who
have undergone cataract operations or yttrium-aluminum-garnet (YAG) laser surgery.

Flashers occur when the vitreous fluid inside the eye rubs or pulls on the retina and produces the illusion of
flashing lights or lightning streaks. Flashers that appear as jagged lines, last 10 to 20 minutes, and are
present in both eyes are likely to be caused by a spasm of blood vessels in the brain called migraine.

In general, floaters and flashers are normal and harmless. But they may be a warning sign of a more serious
condition, especially if they increase in number and if changes in type of floater, light flashes, or visual
hallucinations are noted.

DRY EYES

Dry eyes result as a quantity and quality of tear production diminish with aging. Stinging, burning,
scratchiness, and stringy mucus are some of the symptoms. Although this may be surprising,
increased tearing may be a symptom of dry eyes. If the tear section is below normal, excess tears
are produced by the lacrimal gland in response to irritation. If no foreign body is found, the
condition is called dry eye syndrome.

3. Common Problems

PRESBYOPIA

The most common complaint of adults older than age 40 is a diminished ability to focus clearly
on close objects (arm’s length) such as a newspaper. In presbyopia, the lens loses its ability to
focus on close objects. Accommodation is impaired as the lens thickens and loses its elasticity. The
ciliary muscles weaken the lens’s ability to contract.

Treatment:

❏ wearing reading glasses or bifocals (two-part lenses that correct near and distant vision)
Prognosis:

For corrected vision is excellent.

Nursing care:

❏ Encouraging the patient to adjust to the glasses by wearing them and following up with a
visit to the ophthalmologist every 2 years. Patients may be provided with an “Aging and
Your Eyes” pamphlet for information about presbyopia. Also, patients and their families
can be taught eye health promotion and prevention techniques.

ECTROPION AND ENTROPION

Ectropion and entropion are external eye conditions; specifically, they are malpositions of the
lower lid, which irritate the eye. Both conditions are caused by tissue laxity and scarring of the
eyelids from infection.

Ectropion (turning outward) prevents normal closure, affects tear drainage and production, and
causes redness and tearing of the eyeball.

Entropion (turning inward) results in the eyelashes rubbing against the eye, causing corneal
abrasion. The lower lashes may not be visible and may cause watering and redness of the eye.

Treatment:

❏ Both can be treated with minor, same-day outpatient surgery performed by an

ophthalmologist.

Prognosis:

❏ For complete recovery and cessation of symptoms is excellent.

BLEPHARITIS

Blepharitis is chronic inflammation of the eyelid margins that is commonly found in older adults. It
may be caused by seborrheic dermatitis or infection. The use of antihistamines, anticholinergics,
antidepressants, and diuretics may exacerbate this condition because of the drying effects of these
medications. In addition, the deficiency in tear production with aging may lead to infection.

Symptoms:

Red, swollen eyelids; matting and crusting along the base of the eyelash at the margins; small
ulcerations along the lid margins; and complaints of irritation, itching, burning, tearing, and
photophobia.

Treatment:

❏ Aimed at removing the causative bacteria and healing the affected areas.
 ❏ Physicians may prescribe topical antibiotics or steroids. However, the nurse can play a
significant role in the treatment of this condition by teaching a patient certain interventions
described later.
❏ The patient must be taught scrupulous eye hygiene, including good hand washing habits.
Mild soap (e.g., Ivory, Neutrogena) should be used.
❏ Contact lens wearers must be taught proper cleaning and storage techniques to prevent
contamination of the eye, lens, lens solution, and lens case.
❏ Because cosmetics are a common source of bacterial contamination, eye makeup products
should be replaced every 3 to 6 months to avoid bacterial growth. It is also important that
patients know how to apply makeup with cotton balls and cotton-tipped applicators and
understand the importance of discarding the applicators after each use. Mascara should be
water resistant, free of lash-extending fibers, and not applied to the base of the lashes.
Eyeliner should be a medium-hard pencil and not be applied to the inner margin of the
eyelid.
❏ Patients should avoid the use of aerosol hairsprays because these may irritate the eyes.

Inflammation caused by blepharitis will be resolved and the patient’s comfort level will improve
after a week of these hygiene measures.

GLAUCOMA

Glaucoma is one of the leading causes of blindness for people over the age of 60. Although
glaucoma may occur at any age, those most at risk are adults older than age 60. The most common
form has few, if any, symptoms and may cause partial vision loss before it is detected.

Glaucoma results from a blockage in the drainage of the fluid (the aqueous humor) in the anterior
chamber of the eye. Normally, this fluid drains through the Schlemm canal and is transported to the
venous circulation system. If the fluid is formed in the eye faster than it can be eliminated,
intraocular pressure (IOP) increases. Pressure is then transferred to the optic nerve, where
irreparable damage, possibly even total blindness, may result. Three types of glaucoma are found
in older adults: chronic open-angle glaucoma, closed-angle glaucoma, and secondary
glaucoma.

1. Chronic Open-Angle Glaucoma

The most common type (making up 90% of all primary glaucoma), develops slowly.
Degenerative changes in the Schlemm canal obstruct the escape of aqueous humor,
resulting in increased IOP. This type of glaucoma may damage vision so gradually and
painlessly that a person is unaware of a problem until the optic nerve is badly damaged.
Visual loss begins with deteriorating peripheral vision.

2. Closed-Angle Glaucoma

This is acute glaucoma that occurs suddenly as a result of complete blockage. It requires
prompt medical attention to avoid severe vision loss or blindness. The following symptoms
of closed-angle glaucoma occur rapidly:
 - Severe eye pain
- Redness in the eye
- Clouded or blurred vision
- Nausea and vomiting
- Bradycardia
- Rainbow halos surrounding lights
- Pupil dilation
- Steamy appearance of cornea

3. Secondary Glaucoma

Secondary Glaucoma Secondary glaucoma occurs when the drainage angle is damaged by
eye injury or other specific conditions such as medication use (e.g., use of steroids), tumors,
inflammation, or abnormal blood vessels.

NURSING MANAGEMENT:

❏ Assessment

Patients with glaucoma may complain of dull eye pain, or they may experience no early
symptoms. Visual field testing reveals a loss of peripheral vision (tunnel vision), and
increased IOP is seen on ophthalmologic examination.

❏ Diagnosis

Potential nursing diagnoses for the patient with glaucoma include the following:

❏ Deficient Knowledge, related to lack of exposure and inexperience with regard to

glaucoma causes and treatments
❏ Pain, related to increased IOP
❏ Risk for Infection, related to eye drop instillation
❏ Dressing Self-Care Deficit, related to visual impairment

❏ Planning and Expected Outcomes

Expected outcomes for the patient with glaucoma include the following:

1. The patient will have no further loss of vision.

2. The patient will follow prescribed glaucoma care guidelines daily.
3. The patient will state that eye pain is decreased.
4. The patient will be free from eye infection.
5. The patient will be able to perform activities of daily living (ADLs) safely and
independently.
 ❏ Intervention

Nursing management is aimed at teaching the patient that glaucoma is a chronic condition
requiring lifelong medical treatment. If medication fails to control rising IOP, surgical
intervention may be necessary. Trabeculoplasty is usually performed on an outpatient
basis. It requires an IOP check 3 to 4 hours after surgery. A sudden rise in IOP may occur
immediately after surgery. A 4- to 8-week wait is necessary to determine whether the
procedure was effective. However, continual use of glaucoma medications is necessary.

Postoperative nursing care for the patient who has had a trabeculectomy includes:

1. routine postanesthesia care

2. protection of the operated eye with an eye patch or a shield, proper positioning of
the patient on the back or on the side of the non operated eye, and the use of a call
light and side rails
3. administration of pain medications and cold eye compresses to maintain comfort
4. monitoring of the eye for increased IOP, bleeding, or infection
5. assistance and teaching of safe, independent performance of ADLs

❏ Evaluation

Evaluation includes documentation of the achievement of the expected outcomes, no

further vision loss, and the independent performance of ADLs.

❏ It is imperative that the patient and family understand the chronic nature of this
disease and its treatment.
❏ The patient must be able to state the name and dosage of the prescribed eye
medications and describe their daily use, even during periods of travel or
hospitalization.
❏ The patient must also be able to identify significant signs and symptoms so that they
can be reported to the ophthalmologist.

CATARACTS

Cataracts are the most common disorder found in the aging adult. The highest incidence is found
in adults older than age 55; cataracts are found in virtually all adults older than age 80.

A cataract is a clouding of the normally clear and transparent lens of the eye. The lens focuses light
on the retina to produce a sharp image. When a cataract forms, the lens may become so opaque that
light cannot be transmitted to the retina.

Cataracts result from changes in the chemical composition of the lens; these changes may be
caused by aging, eye injuries, certain diseases, and heredity. In addition, different types of cataracts
exist.
 1. The normal aging process may cause the lens to harden and turn cloudy. These cataracts are
called senile cataracts and may occur as early as age 40.
2. Eye injuries such as a hard blow, puncture, cut, or burn may damage the lens and result in a
traumatic cataract.
3. Secondary cataracts may be caused by certain infections, drugs, or diseases

The size and location of a cataract determine the amount of interference with clear sight. A cataract
located near the center of the lens produces more noticeable symptoms such as the following:

❏ Dimmed, blurred, or misty vision

❏ The need for brighter light to read
❏ Glare and light sensitivity
❏ Loss of color perception
❏ Recurrent eyeglass prescription changes

These symptoms develop slowly and at different rates in each eye.

NURSING MANAGEMENT

❏ Assessment

Subjective complaints include having trouble reading and the necessity for constantly
cleaning the glasses (the vision difficulties are thought to be caused by dirty glasses). Lens
opacity may be visible on external or internal eye examination.

❏ Diagnosis

Nursing diagnoses for the patient with cataracts include the following:

❏ Anxiety, related to uncertain surgical outcome

❏ Deficient Knowledge, cataracts related to lack of exposure
❏ Risk for Injury, related to changes in visual acuity
❏ Dressing Self-Care Deficit, related to inability to see body and face clearly enough
to maintain appearance of clothes and cosmetics

❏ Planning and Expected Outcomes

Expected outcomes for a patient with cataracts include the following:

1. The patient will have cataract surgery when it is recommended by an

ophthalmologist.
2. The patient will ask questions about preoperative and postoperative care and report
satisfaction with information.
 3. The patient’s affected eye will be free from increased IOP, stress on the suture line,
hemorrhaging, and infection.
4. The patient will verbalize appropriate home care activities to avoid and activities to
do after cataract surgery.
5. The patient will demonstrate correct administration of eye drops.
6. The patient will avoid falling, bumping into objects, and having automobile
accidents before and after surgery.
7. The patient will dress and groom himself or herself when vision returns.

❏ Intervention

Nursing management for a patient with cataracts focuses mainly on preoperative and
postoperative surgical care because surgery is the only method for treating cataracts.
However, asymptomatic patients do not require referral. Most cataract surgery is performed
as outpatient surgery with the administration of a local anesthetic; this makes preoperative
teaching difficult because patients arrive just hours before surgery. Many ambulatory
centers conduct preoperative assessment and teaching via phone calls a week before
surgery.

Preoperative care involves administering eye drops and a sedative, as ordered.

Postoperative care requires teaching the patient and family home care procedures for the
period after cataract surgery, including the correct method for instilling eye drops.

The home care instructions need to include special precautions recommended by the
ophthalmologist based on the type of surgery performed. If a lens implant has not been
inserted, patients need to wear contact lenses or cataract glasses. Patients wearing cataract
glasses experience loss of depth perception and distorted peripheral and color vision. They
need to be taught that objects are magnified by 25% and appear larger and closer than they
really are; this requires home safety measures and the modification of dressing and
cosmetic application after surgery.

❏ Evaluation

Evaluation includes documentation of the achievement of the expected outcomes. Patients

who have had successful cataract surgery will be free from complications and will have
improved vision. Additionally, they will report performance of their usual daily activities
with the use of lens implants, contact lenses, or corrective glasses. The patient and family
will arrange assistance with ADLs for the first 24 to 48 hours after surgery, or they will
notify the home health agency.

4. Retinal Disorders

Three common disorders that affect the retina of an older adult are macular degeneration, diabetic
retinopathy, and retinal detachment.
AGE-RELATED MACULAR DEGENERATION

Age-related macular degeneration (AMD) is the leading cause of blindness among older adults in
the United States. It does not cause total blindness but results in loss of close vision. AMD is a
poorly understood disease that causes damage to the macula, the key focusing area of the retina.
The cells within the macula diminish in functional ability with age, and replacement of the
damaged cells is decreased, causing irreversible damage to the macula (Roach, 2005). As a result,
central visual acuity declines, which makes performance of daily tasks requiring close vision
nearly impossible. Peripheral vision is retained. AMD is viewed as a disease that is becoming an
epidemic among older adults.

Types of AMD include the following:

• Dry macular degeneration. Also known as involutional macular degeneration, this condition is
caused by breakdown or thinning of macular tissue related to the aging process. Vision loss is
gradual.

• Wet macular degeneration. Also known as exudative macular degeneration, this type of AMD
results when abnormal blood vessels form and hemorrhage on the retina. Vision loss may be rapid
and severe.

Symptoms of macular degeneration include the following:

• Difficulty performing tasks that require close central vision, such as reading and sewing

• Decreased color vision (i.e., colors look dim)

• Dark or empty area in the center of vision

• Straight lines appearing wavy or crooked

• Words on a page looking blurred

DIABETIC RETINOPATHY

Loss of visual function is one of the most common complications of diabetes. Altered circulation to
the eye may result in retinal edema, degeneration, or detachment. This condition is a complication
of diabetes that affects the retinal capillary circulation. Ballooning of these tiny vessels leads to
hemorrhaging, scarring, and blindness. These vascular changes, in and around the retina, lead to
macular edema which causes the retina to swell. No symptoms of early retinal changes exist, and
no symptoms may be apparent even when the retinopathy is advanced. Early detection requires a
complete ophthalmoscopic examination; therefore, patients with diabetes should have yearly
examinations by an ophthalmologist.
RETINAL DETACHMENT

Retinal detachment occurs when the sensory layer of the retina separates from the pigmented layer.
Tears or holes occur in the retina as a result of trauma, aging (degeneration), hemorrhaging, or the
presence of a tumor. When a tear occurs, fluid seeps between the layers which causes detachment.
The usual symptoms include the following:

• Light flashes

• A shower of floaters that resembles spots, bugs, or spider webs

• Loss of vision

• Veil or curtain obstructing vision

5. Visual Impairment

Visual impairment is the most common sensory problem faced by older adults. The visually
impaired population includes those with low vision (20/50 to 20/200) and those who are legally
blind (visual acuity of 20/200 or worse in the better eye with the aid of the best possible correction
with the use of spectacles or contact lens) (Kollarits, 2007). Blindness in older adults results from
diabetic retinopathy, glaucoma, cataracts, and macular degeneration, and its incidence has
increased as the number of adults age 65 or older grows.

III. Hearing and Balance

In older adults, the inner and outer ear structures change and their functions decline. Their
ability to pick up sounds decreases and may have balance maintenance problems when sitting,
standing and walking.

COMMON PROBLEMS AND CONDITIONS IN HEARING

1. Pruritus

- Pruritus is defined as an unpleasant sensation that provokes the desire to scratch. Certain systemic
diseases have long been known to cause pruritus that ranges in intensity from a mild annoyance to
an intractable, disabling condition.

2. Cerumen Impaction

- Cerumen impaction is a reversible cause of conduction hearing loss in the elderly. Risk factors
include ear canal hairs, hearing aids, bony growths secondary to osteophyte or osteoma, and a
history of impacted cerumen..

3. Tinnitus
- Persistent, abnormal ear noise is another common problem in older adults. Causes of tinnitus may
include wax buildup or medicines that damage structures inside the ear.

4. Presbycusis (Hearing Loss)

- Age-related hearing loss is called presbycusis. It affects both ears. Hearing, often the ability to
hear high-frequency sounds, may decline. Older adults with presbycusis may have trouble telling
the difference between certain sounds. Or, they may have problems hearing a conversation when
there is background noise.

COMMON PROBLEMS AND CONDITIONS OF BALANCE

1. Dizziness and Disequilibrium

- Although the causes of dizziness in older people are multifactorial, peripheral vestibular
dysfunction is one of the most frequent causes. Benign paroxysmal positional vertigo is the most
frequent form of vestibular dysfunction in the elderly, followed by Meniere's disease.

2. Meniere’s Disease

- It is caused by pressure within the labyrinth of the inner ear, which is a result of excess
endolympha that causes swelling in the cochlea. The three major characteristics are vertigo,
tinnitus and hearing loss.

Behavioral Clues Indicating Difficulty Hearing

● Difficulty hearing over the telephone

● Trouble following conversation when two or more persons are talking at the same time
● Turning up the volume on the television
● Leaning forward to hear better straining to understand conversations
● Complaining about people mumbling
● Difficulty understanding women and children talking
● Asking for frequent repetition and answering questions inappropriately
● Losing sense of humor or becoming grim

Client/Family Teaching

STRATEGIES TO IMPROVE COMMUNICATION WHEN THERE IS HEARING LOSS

1. Provide good visual contact with clients. Hearing, impaired individuals need to supplement
hearing with lip reading. They need to be able to see the speaker's face and lips. Avoid
situations where there is glare or shadows on the client's field of vision.
2. Reduce or eliminate background noise.
 3. Speak at a normal rate and volume. Do not over articulate or shout.
4. Use short sentences, and pause at the end of each sentence.
5. Use facial expressions or gestures to give useful clues.
6. Ask how you can help the listener.
7. Be patient, and stay positive and relaxed.

ASSISTED-LISTENING DEVICES

These devices are designed to amplify sound or transform sound into tactile or visual signals.
These systems allow a hearing impaired person to communicate more effectively and function
more independently.

● Microphones placed close to sound source

● Amplifiers for the telephone, television, or radio
● Closed-captioned television
● Teletypewriters
● Doorbell and telephone that light as well as ring
● Flashing smoke detectors and alarm clocks

IV. Taste and Smell

The taste and smell senses of older adults also changes. As we all know, there are four
basic tastes namely: sweet, sour, salty and bitter. The sweet tastes are the first to be particularly
dulled in older adults. Also, blunted taste may be present which explains why most older adults
prefer salty, highly seasoned food which is not good for their health. Substitution of the salt in
flavoring food can be possible with the use of herbs, onions, garlic and lemon.

The changes in the sense of smell are usually related to the cell loss in the nasal passages
and in the olfactory bulb in the brain. Some that may contribute to cellular damage are
environmental factors such as long-term exposure to toxins like dust, pollen, and secondhand
smoking.

COMMON PROBLEMS AND CONDITIONS

1. Xerostomia (Dry Mouth)

2. Burning of the Oral tissues and tongue

3. Cracking of the lips

4. Abnormal taste sensations

5. Sore gums and tissues and denture slippage from loss of saliva flow
 6. Decrease in salivary flow which interferes with swallowing and chewing

7. Recognition of odors dramatically declines with age

XEROSTOMIA

Xerostomia, or dry mouth, is referred to as a subjective sensation of abnormal oral dryness.

Dry mouth is usually may be caused by certain factors like taking medications (sedatives,
antihistamines, diuretics, anticholinergics, chemotherapy), diseases (depression, Alzheimer’s
disease) and other conditions (mouth breathing, radiotherapy of the head and neck). Dry mouth in
older adults can lead to increase risk of having serious respiratory function, impaired nutritional
status, and reduced ability to communicate.

Clinical manifestations of Xerostomia include red, inflamed, cracked, dry, bleeding lips,
and the tongue has red areas and a coated base; it’s thicker, with prominent lingual groove and
papillae. The lining of the mouth and gums and the mucous membrane of the palate may appear
dry, red and edematous. The saliva is scant, ropy and viscid. The client’s voice may also be raspy
and dry and may complain of difficulty articulating words.

V. Touch

Touch is the most developed sense. It involves tactile information on pressure, vibration, and
temperature.

A. Age-related changes
1. Sensitivity to light touch diminishes
2. Tactile vibratory thresholds progressively increases
3. Warm-cold difference threshold increases
B. Most Common Disorders
1. Cerebrovascular Accident
2. Peripheral Vascular Disease
3. Diabetic Neuropathy
❏ These conditions involve changes in the vascular system that result in decreased
blood flow to various parts of the body.
❏ Nursing interventions are directed toward preventing accidental trauma and injury
in the affected limbs.
❏ Client education focuses on skin, leg and foot care.

REPRODUCTIVE SYSTEM
Neuroendocrine Function
● Reproductive axis: integration of hypothalamus, pituitary, and ovaries; it
controls reproductive hormones and ovulatory cycles.
● Reproductive function relies heavily on hormone signaling from the ovaries to the
hypothalamus and pituitary as demonstrated by FSH secretion in the development
 of mature oocytes.
● Age-related changes in neuroendocrine function includes change in gonadotropin
levels, which occurs before ovarian age-related changes.
○ FSH levels begin increasing before menopause occurs and continue to
increase throughout and after menopause.
○ Estradiol levels tend to increase right before and while transitioning
into menopause and then drastically decrease during menopause.
○ Inhibitin B, a glycoprotein that usually suppresses FSH, also decreases in older
women.
○ Age-related changes in circulating hormones (estrogen & progesterone)
strongly affect hypothalamic and pituitary responses to positive & negative
hormone
feedback systems.
● Age-related decline in estrogen affects the brain, resulting in some cognitive
changes, insomnia, or even depression.
○ It also affect other areas of the body that contain estrogen receptors
& estrogen-dependent tissues:
■ Skin contains less collagen & becomes thin.
■ Sweat & sebaceous glands become dry.
■ Hair follicles begin to dry.
■ Bones lose calcium & undergo increased bone resorption.
■ Breasts lose connective tissue but gain adipose tissue
■ Bladder function decreases.
■ Cardiovascular function & blood pressure change.
■ Absorption & metabolism of nutrients become less efficient.
○ Majority of the emphasis concerning estrogen has been on neuroprotective
effects, including delay of onset in Alzheimer's disease & Parkinson’s disease, as
well as protection against nerve cell death & brain injury.
Systemic Changes
● Ovaries
○ Atrophy to such a small size that they can become impalpable during an exam.
○ Number of ovarian follicles decreases with age leading to a decline in
fertility; usually begins in 30s or 40s and more rapid decline occurs after age
35.
■ Ovarian follicles that remain through these declining years tend to be
underdeveloped & only a few follicles ovulate & form a corpus
luteum.
■ By the age of 50-65 years old, a woman will have no remaining viable
follicles.
○ Around age 45, when fertility declines, FSH levels tend to increase earlier in
follicular phase than they do among younger women; this is attributed to
the
drastic age-related decline in Inhibin-B; this is the earliest age-related changes in
ovaries.
○ Reproductive aging causes a decline in estrogen due to a decrease in
ovarian follicles.
○ These changes in the ovaries, including ovarian failure & oocyte depletion,
are causally linked to the triggering of menopause.
● Uterus
○ Age-related decreases in uterine endometrial thickening during menstrual cycles
occur as the result of decreased estrogen and progesterone levels
- leads to a decline in menstrual flow and causes missed menstrual cycles
and permanent cessation of ovulation and menstruation.
○ Supporting ligaments attached to the uterus are weakened with age
- causing the uterus to tilt backward.
○ Over the postmenopausal period the uterus decreases in size by as much as 50%
- become so small as to be impalpable in women over the age of 75.
○ The cervix (the structure at the opening of the uterus)
- may also be unidentifiable upon physical exam in postmenopausal women
because of stenosis and possible retraction

● Fallopian tubes
○ Fallopian tubes are the site of fertilization and are responsible for transporting
the fertilized ovum to the uterus, these changes contribute to the age-related
reduction in fertility, and may explain why older women are at increased risk of
ectopic pregnancy
 ○ Age related changes: Shrinkage in the length of the Fallopian tube, loss of
ciliated epithelia, loss of mucosa
● Vagina

Structural changes

○ Thinning of the vaginal walls and loss of elasticity - increases the chances
for the vaginal injury in the older female
○ Loss of mucosal layers; large decrease in discharge - loss of
lubrication; dry vagina causing sexual intercouse to be painful
○ Decreased glycogen levels in vaginal tissue, which results in an environment
where microbes flourish - vaginal pH levels shift from acidic (3.8-4.2) to
alkaline environment (6.5-7.5)
○ Shrinkage of the labia majora - exposes a greater surface area
upon which microbes and infectious agents can nest
Menopause

● The perimenopause
○ First episode of menstrual bleeding (menarche) marks the onset of puberty.
○ Before the menopause, when menstruation ceases, and women become
infertile - hormones that drive the menstrual cycle start to fluctuate
○ Perimenopausal phase - lasts 2-10 years. Often accompanied by increasing
irregularity of the menstrual cycle. Women are still fertile; pregnancy
becomes more difficult
● Menopause
○ Menopause is classified as the complete cessation of menstrual cycles for a
period of at least 1 year.
○ 51 years of age – average age where menopause usually begins but the
reproductive changes described in this section begin years earlier.
○ 35 years of age - late reproductive stage begin with a decrease in fertility
marked by a decrease in inhibin B, decrease in an increase in FSH
○ Menopause is usually causally linked with ovarian failure and complete
oocyte depletion, but recent research also implicates the hypothalamus
and pituitary via a decline in estrogen negative feedback on LH releases.
○ Some studies have shown that there are slight declines in testosterone
levels during and after menopause, others have shown no change in
testosterone levels. Thus, the question of whether androgen deficiency
occurs in older women remains unanswered.
○ Physical symptoms that are often described by menopausal women include:
■ hot flashes - described as a rapid heat increase, particularly in the
face, neck, and chest, often with sweating and palpitations. Related
to increased levels of FSH and decreased levels of estrogen.
Compiled by: HABACON, Gabrielle Anne J.