The fact is that 95% of the elderly population remain at home either living alone or with family and with  minor chronic conditions. Most are still active in the community. We know that the incidence for care needs increases with age, but the need for care increases even more for the prematurely aged. The elderly constitute just 13% of today's population, but they use:

	25% of all prescription drugs
	33% -50% of all hospitalizations

	short-term illness
	the cause is usually known
	the goal is to cure them
	examples: chicken pox, colds, broken bones

1. Before the turn of the last century, people died at home from infectious diseases such as Tuberculosis, pneumonia, flu or cholera. These are acute diseases. The come on quickly, are infectious in nature, and we look for a cure. 

Families often stayed with a family member to nurse them through their illness. People either got better quickly or died. 

1. A chronic condition may or may not be disabling, depending on the type and severity of the condition. Loss of teeth, for example, can be a chronic condition, but is not necessarily disabling. A chronic condition can also be progressive and debilitating like Parkinson's disease. 
   
2. Many elderly persons can have a number of chronic conditions and still be active. For example, a 75 year-old may have mild arthritis, mild diabetes, minor visual impairment, loss of teeth and still may remain active, vigorous and unaffected in a major way by any of them. An older person may become completely bedridden with just one chronic condition. Examples might be a stroke or heart attack. 
   
3. Why are we increasingly dying of chronic diseases? In modern times, we eat more processed and less nutritious foods (higher in fat, salt, sugar and white flour) that affect our vascular system.
   
    We exercise less, carry more weight and stress. These all affect our veins and arteries. Some experts say that we are as old as our veins and arteries. Clogged arteries can lead to a host of chronic illnesses. Besides heart attacks and strokes, arteries clogged from life-style habits can affect our hearing, vision and the circulation through our lungs and feet.
   

The music group Dyer Straits calls chronic diseases "the industrial disease". Do you think they are right? http://www.metrolyrics.com/industrial-disease-lyrics-dire-straits.html

 

Do you remember from previous lectures the difference? Let's review and expand on them.. 

1. Absolute Life Span is the inherent biological limit that is characteristic of every species. When these cells are looked at in lab studies, they only replicate a certain number of times and then stop. Here are some of the theories that try to explain life span:
   

1. Genetic clock theory- For humans the genetic clock has not changed for more than 10,000 years.  According to this theory, each species has it's own clock. For example:
   

	fruit flies     genetic clock is about      40 days
	hamsters                                             3 years
	dogs                                                   20 years
	humans                                               100 years
	tortoise                                              175 years.

2. Free Radical Theory - How many of you take a vitamin "C" or "E" supplements? Do you know why you take it? According to the free radical theory, cells accumulate damage from oxygen metabolism. These so called radicals cause cells to stop functioning. Free radicals are potent chemicals that oxidize and attack cell walls in the body and increase the accumulation of waste products. The use of vitamin "C" or "E"  counteracts the damage from these radicals. 
   
3. Immune Theory: According to the immune theory, there is a  programmed decline in our immune system functions that leads to increased vulnerability to diseases. Researchers in this field look at human growth hormones to increase immune cell production. Growth cells are present when we are young and our immunity is stronger. The goal is to find a way to use these cells to increase immunity as we age. 
   
4. Stress Theory- Cells are subject to wear and tear. According to this theory, the tissue and vital parts of our cells just wear out.

A. Hearing: About one out of every three persons ages 65-74 and about half of those over age 85 have hearing loss that interferes with daily life.  

The picture below is from this site http://deafness.about.com/gi/dynamic/offsite.htm?site=http%3A%2F%2Fwww.hope4hearing.org%2Fanatomy.htm

1. Presbycusis  (pronounced pres by cuss us) is the term for progressive hearing loss associated with old age. It is caused by  the degeneration of hair cells and nerve fibers (the auditory nerve) in the inner ear.
   

1. Presbycusis tends to affect  high-frequency hearing loss, and it becomes harder to distinguish the voices of women and children because of the higher pitch of their voices.   

For this reason, never yell at someone who has a hearing loss due to age. As you yell, the pitch of your voice increases, making it harder for the person to hear you. A man's voice is lower in pitch and easier than a woman' s voice to hear for someone with an age related hearing loss. Someone with presbycusis may be able to hear low rumbles like those of the furnace turning on in the basement.

To learn more about the aging ear, check out this site   http://www.hearform.com/articles/hearing_loss_baby_boomers.htm

2. High-frequency hearing declines steadily, beginning as early as age 20, but most people don't notice any hearing loss until their 60s when voices can become less audible as low- frequency hearing also begins to fade.

1. Although presbycusis is progressive, the rate of its progress varies with the individual.
   
2. Some people at age 80 have much better hearing than others who are just aged 60.

3. Heredity affects how much hearing you lose and how quickly you lose it, as does exposure to loud music, roaring traffic, and other ear- splitting noise. Audiologists (hearing specialists) suggest keeping loud noise, such as kitchen blenders and hair dryers, to a minimum.  If you use these products daily, you might consider a low noise model. 
   
4. Hearing aids can help, but no more than one  out of five older adults who need aids own one, and fewer than half of those over age 75 who own one use it regularly.
   
5. Aids magnify background noise as well as the sounds a person wants to hear. Newer, more expensive, microchip technology can filter out distortion. Volume can also be adjusted. 
   
6. Many people with hearing loss compensate for it by relying more heavily on visual clues, such as facial expressions. Be sure to face someone with a hearing loss when talking to him/her.

B. Eyesight        

Because vision has been shown to compensate for other sensory losses, the effects of its loss are far-reaching. Adjusting to visual loss requires learning new self-care skills, which many elderly fail to accomplish. Most, for example, do not learn how to read Braille. 

Vision loss can be extremely traumatic for those experiencing it. 

	it can limit mobility
	increase the likelihood of accidents
	impede recreational activities
	increase  fear and isolation

1. Presbyopia is the eye change that usually takes place around age 40, when one begins to hold books out at arm's length. 
   
   The changes seem rapid at first, but eventually level off. Near vision is affected as the lens loses its elasticity. Because the lens of the eye bends to focus on objects like the lens  of a camera, presbyopia prevents the now stiff lens from easily adjusting its shape. This makes it difficult to read fine print. What you might notice is your parents or grandparents running around with those little glasses down on the tip of their noses. That is because far away vision is not affected. Someone with presbyopia is able to see distances without glasses, but needs magnifying lenses to see close up. 

Although it's not uncommon for people to notice eye changes after the age or 40, the age and degree of change depends on where you are to begin with. For example:

a. People who start out a little nearsighted tend to have problems later than do farsighted people.

b. There is no cure for presbyopia, but the answer is simple: eyeglasses or contacts.

Cataracts- Please check out this site for information on  cataracts and glaucoma. http://www.glaucoma.org/learn/#poag 

C. Smell

1. Smell is a chemical sense. The receptors are specialized nerves in the nose that lead to the brain. The major nerve is called the olfactory. 
   
   It is thought that olfactory sensory cells are replaced by new cells as they die. If so, there should be no decrease in their number with age.
   
    However, some studies have reported such a decrease. Perhaps not all the sensory cells that degenerate are replaced.
   
   For whatever reason, the sense of smell begins to decline in most people by middle age and continues to decline gradually into old age.
   

D. Taste

1. With aging there is a general decrease in taste perception. It has been suggested that this decline is due to a decrease in the number of taste buds that begins shortly after maturity and continues into old 
   age. However, other studies report little, if any, decline in the number of taste buds until after 75 years of age.
   
   Rather, it is suggested that the diminished taste perception with aging may be due to changes in the processing of taste sensations in the brain (central nervous system).
   
   Another factor that may contribute to the reduction in taste sensation in older persons is a decrease in the volume of saliva secreted. This could interfere with dissolving foods so they can not react with the receptor cells. 

What is commonly considered to be "taste" actually involves the stimulating of olfactory receptors in the nose. This is the reason why food does not have much taste when you have a congested nose and are unable to smell. 

 

E. Touch and Pain

The skin protects the underlying tissues in our bodies from harmful environmental influences and minimizes water loss. It is also important in maintaining the internal temperature of our bodies. 

Age related changes involve the thinning of the top layers (epidermis and dermis layers) of the skin. This results in less blood supply to the skin, fewer nerve endings, and pigment cells that cluster and produce age spots. The skin of an elderly person may also be drier and sweat less. 

Fat that lies under these layers also decreases and the elderly lose important insulation from heat and cold. 

Because of these changes, elderly people have a reduced tactile sense and thus may experience less pain and be less likely to notice injuries or other changes in environmental conditions such as changes in temperature. Declines in the sensation of touch may also result in a loss of balance and may increase the risk of falls. 

It can be difficult for some elderly to maintain body temperature (less insulation from fatty tissue and less blood supply), and the skin is  more prone to tears and prolonged healing time. 

 

Did You Know: Everyone wrinkles, however, smoking decreases the delivery of oxygen to the skin and breaks down the underlying tissues which support the skin. This results in premature aging of skin. 

The abnormal diseases of aging start with minor changes at the cell level of a particular organ and cause microscopic, damaging changes until they can be detected by a variety of tests and warning signs. They then emerge as a disease symptom in the patient.  

Please Refer To Handout - The Increments of Chronic Disease 

Look across the top of the handout and find Emphysema. This is a lung disease that results in diminished lung capacity. 

You have seen people affected by this disease  in society. They usually carry oxygen tanks and take short steps while stopping to rest in between. The disease does not suddenly appear.  It is a chronic disease that has been developing in the person usually with warning signs for years. 

Following The Warning Signs:
On the far left of your handout, look at the age 20 column and intersect it with  emphysema . There you see the person started out as a smoker (this is not the only thing that causes emphysema, but it is the most common). 

At age 30, the person has mild airway obstruction, usually noticed as shortness of breath when trying to keep up with the kids or climb a flight of stairs. At age 40, an x-ray will show that the lungs are changing, and by age 50, the person will feel chronic shortness of breath. 

If smoking continues, by age 60, this person has been in and out of the hospital with lung infections (pneumonia, bronchitis, etc.), and by age 70 if they live that long, find themselves permanently attached to an oxygen tank because they lack the lung capacity to accomplish their daily routine. 

1. Respiratory-  Lung Capacity

Aerobic Capacity is the amount of air you can exchange during exercise. The more you exercise the larger your aerobic capacity becomes. 

The amount of air you can take in and force out reflects a true aging process. However, the normal lung will serve us well into late life.

Lung tissue gets stiffer with age, like a balloon left in the sun, so it won't expand to hold as much air; no matter what size you start with or how much you exercise, your lungs shrink about 40% between ages 20 and 80. To age successfully, one needs to develop a fairly adequate capacity while young. 

The singular most effective measures you can take to maintain healthy lungs is to not smoke, or to quite smoking, and to exercise.

Most men start losing aerobic capacity--the ability to deliver oxygen to muscle during exercise--around the age of 20, and most women in their early 30s. By 65, it declines 30 to 40% in both men and women.

But the decline is much less in people who exercise regularly.

2. Osteoporosis

Osteoporosis means bone (osteo) porous (porosis) or porous bone; caused by  years of life- style-related habits, bones become spongy and soft.  

Many things cause this soft, spongy bone condition: Reduced absorption due to an aging digestive system, cigarette smoking, lack of vigorous physical activity, estrogen deficiency in women, decreased calcium intake, carbonated drinks (the carbonation combines with calcium for eliminating it from the body) and genetics or a family history. Some studies also point to a diet too high in protein as a contributing factor. 

Osteoporosis is a chronic disease and is not a normal part of aging. Loss of bone mass can result in diminishing height, slumped posture, and dowager's hump (that rounding and hump between the shoulder blades seen in some elderly). Bones have a reduction in strength which makes them more susceptible to fractures. 

Bone fractures from falls are epidemic among older people (by age  75, about half of all women have sustained at least one fracture due to osteoporosis).

Hip fractures in the elderly with osteoporosis are a common cause of death. When bones become soft, often just the weight of turning over in bed can break a hip bone. The treatment demands several weeks in bed.

Many bed-ridden elderly  die from pneumonia. When one is confined to bed without movement, fluid accumulates in the lungs. Because of the moist and warm environment in the lungs, it is a perfect place for bacteria to grow. 

This can often be prevented with deep breathing and coughing exercises while one is confined to bed rest. One reason for pneumonia vaccines is to prevent some types of the bacteria, but it does not protect against all types. 

3. Hypertension (high blood pressure), Congestive Heart Failure and Stroke 

I lump these diseases together because they are all caused by the same process- clogged or blocked arteries. In many places around the world, blood pressure doesn't rise with age, but it does in the US.

 While some people are born with a pre-disposition to high blood pressure, others are at risk because they are overweight and sedentary.

Beginning in early adulthood, our arteries become narrower and the walls become more rigid. Of course, this process is excellerated by a lifestyle of inactivity and fatty foods. 

As the walls become narrowed, the passage of blood becomes more difficult. This results in high blood pressure. As the pressure required to force blood through the arterial walls increases, it damages the walls. Platelets adhere to the damaged area and clots form (thrombosis). These clots can completely block the blood flow to critical parts of the body. 

If the block is in the heart, a heart attack results. If it happens in the brain, a stroke results. 

Remember: 
The heart has a blood supply both inside and outside. If you close your fist and look at the vessels on the outside of your hand, that would be somewhat what the coronary arteries look like. It is the blockage of these arteries that cause a heart attack. Inside the heart (peak inside your closed fist), is where the heart receives and pumps blood to the rest of the body. 

Strokes and heart attacks can also be caused by a weakening of the artery walls. An aneurysm ( a broken or leaky artery or vein) results when the wall of the artery pops and leaks blood into the surrounding tissue. It is an immediate cause of death when this happens in the heart and causes severe swelling when it occurs in the brain. Swelling in the brain puts pressure on vital centers and can affect breathing, heartbeat, speech, or other functions. 

In the absence of heart disease, the size of the heart in elderly people remains essentially the same as it was in middle age, or it may become slightly smaller.

The decrease in heart size is mostly due to a reduction in the muscle mass or the size of the muscle (especially in the left ventricle or left side where the pumping action is the strongest). The heart is about the size of your fist and is a muscle. Any muscle not used becomes atrophied and smaller. 

However, because hardening of the arteries (arterioscleroses) is so common in older persons, the heart is more prone to enlargement with age. 

Effects of High Blood Pressure?

Suppose you had a tube three inches in diameter and several feet long. If you poured a gallon of fluid through that tube there would be a flow of pressure at the other end. Now, lets say that tube is now only 1/2 inch in diameter and several feet long. What might happen to the pressure at the other end if you pour the same amount of water through at the same rate? Right, it would be stronger. Thus as arteries clog, the tubes close in resulting in increased pressure.

With increased pressure, the heart has to work harder to pump blood out into circulation. This creates a back pressure and enlarges or stretches the heart much like a balloon that has been over inflated. The muscle then becomes weak and pumps less efficiently. With each beat of the heart, fluid is left in the chambers, and, when full, backs up into the body. 

 

4. Congestive Heart Failure

What I have just described is the mechanism behind congestive heart failure. The heart is no longer able to pump out the blood sent to it from other parts of the body and fluid accumulates in surrounding organs, especially the lungs. A person suffering from congestive heart failure will see early signs such as swelling in the ankles and shortness of breath. Left untreated, the person begins to drown in his/her own fluids. 

So, as you can see, you are as old as your arteries and veins. 

With age there is also a reduction in the heart rate at rest and in the maximum heart rate during strenuous exercise.

Resting heart rate declines steadily from about 140 beats per minute in a newborn to about 70 beats per minutes in a young adult, and generally decreases still more after 60 years of age.

This decrease does not necessarily mean that physical activity needs to be reduced to match the capabilities of an aging cardiovascular system.

Individuals as old as 70 can increase their heart's functioning by following an endurance exercise training program. Always make a sure a physician has cleared an elderly person before beginning an exercise program. There may be underlying health problems that need to be addressed first. 

However, even if a program of regular exercise is not followed, the aging changes that occur in a person's heart generally do not hinder it from functioning adequately to maintain the reduced level of activity characteristic of most older persons.

Only a disease condition reduces the capacity of the heart to maintain normal activities.

E. Cholesterol Levels

Although levels of fats in the blood have little direct connection to age, they do tend to rise as we get older, mostly because of the eating and exercise habits we develop.

You can lower levels of "bad fat " (called low-density lipoproteins  or LDL)) with a low-fat diet and raise levels of "good fat" (called high-density lipoproteins (HDL) ) by exercising, reducing body fat, quitting smoking, and drinking only moderate amounts of alcohol. New research also points to sugar as the main problem. Turns out sugar stimulates the production of cholesterol. http://ngm.nationalgeographic.com/2013/08/sugar/cohen-text

F. Digestive

Although it is true that the aging digestive system may work less efficiently with aging, the changes that occur are usually minor.

Such changes may include:

	slower action of the muscles which move food through the  digestive system
	reduced acid production
	an impaired ability to absorb some nutrients

Because of these changes, older people are more prone to constipation as the food bolus sits in the digestive system longer and water is absorbed from it. This makes the stool harder. 

A diet high in bulk will correct this problem. Bulk is that part of food that does not digest. It gives content to your bowel movement and prevents constipation. Foods that are low in bulk (white flour products, for example) can cause constipation.  

Bulk is obtained by eating fruits, veggies and whole grains. To learn more about nutrition and the elderly, ARC has a great course,  Gerontology 340, Nutrition and the Elderly. 

7. Muscle Mass
   
   The average American adult, a sedentary person, loses about 6 -1/2  pounds of lean body mass every ten years. Most of the loss comes from shrinking muscle. Remember, nature has little tolerance for things that do not continue to grow. When they stop growing, they begin to decline to return to the cycle of life. 
   
   For a variety of reasons--mainly too much sitting around--the rate of loss speeds up after age 45. Building muscle may be the best single strategy for a longer healthy life because it:

	increases your strength, so you move around better
	edges out fat, thus reducing the risk of developing a chronic  disease
	increases metabolism, so you burn calories faster
	fine-tunes the body's ability to use insulin, so you're at lower  risk of diabetes

People aged 80 who run and swim may have a higher proportion of lean 
body mass when compared to others their age, but the proportion is still smaller than 
a 30-year-old's.

	heredity
	environment
	health outlook - what do you believe about your health
	health care
	lifestyle