Chapter 4: Physiological Changes

THE INTEGUMENT (skin, hair, nails) I. Skin -protects internal organs -regulate body temp -serves as vehicle for salt excretion, water, & organic waste -stores fat -provides protection from UV rays -makes vitamin D Causes of skin changes Extrinsic factors: environmental (exposure to pollutants, chemicals, solar radiation); sun exposure (increases extent & speed of normal skin aging) Intrinsic factors: occurs over time. Related to oxidation & cross-link theories of aging Epidermis (outer layer) -normally is in constant state of renewal thru regeneration, cornification, & shedding Physiological Changes: epithelial renewal in young adults is every 20 days, whereas for older adult (OA), it takes 30-50% longer because keratinocytes become smaller & regeneration slows number of melanocytes decrease 10-20% per decade, resulting in lighter skin tone and therefore decreasing the amount of protection from UV rays pigment spots (nevi & freckles) enlarge with age & become more numerous with increased exposure to natural & artificial light lentigines (age/liver spots) common in older, lighter skinned people Dermis -provides stretch, recoil & tensile strength -supports blood vessels; nerves; hair follicles; & sebaceous (oil), eccrine (sweat-moisture) & aprocrine (sweat-odor) glands Physiological Changes: dermis loses 20% thickness (which makes the skin more transparent & fragile) dermal blood vessels are reduced resulting in skin pallor & cooler skin temp collagen synthesis decreases, causing skin to tear more easily less elastic & resilience causing a sagging appearance sebum production decreases, causing drier skin & risk for cracking, and xerosis reduced sweat gland activity Hypodermis -contains connective tissues, blood vessels, nerves, but major component is subcutaneous fat (adipose tissue). Purpose of the fat is to store calories & thermoregulation -Helps give the body shape & act as a shock absorber

Physiological Changes: lean muscle is replaced by fat tissue in some areas of the body subcutaneous fat reduced. Loss of fat around orbit of eye creates a sunken appearance. Landmarks become more prominent. Muscle contours easily IDd risk of hyperthermia is elevated because the eccrine glands are not as efficient (become fibrotic & surrounding connective tissue becomes avascular, resulting in the decline in bodys ability to cool itself thru perspiration) risk of hypothermia (sebaceous glands secrete less oil, moisture evaporates more readily; cold weather accelerates loss of body heat by evaporation) II. Hair Physiological Changes: becomes thinner becomes gray due to diminishing melanocytes diffuse hair loss (alopecia) in men & women axillary, extremity & pubic hair diminishes (sometimes disappears) in men & women amount of hair increases in the ears, nose, & eyebrows III. Nails Physiological Changes: nails become more brittle, flat, or concave with longitudinal striations cuticle becomes less thick & wide due in part to decreased circulation, fingernails & toenails thicken, change shape & color. NOT a normal process of aging, but are common in OA: onychogryphosis (thickening & distortion of nail plate) and fungal infection onycholysis

MUSCULOSKELETAL SYSTEM I. Structure & Posture Physiological Changes: shortening of the trunk due to the thinning of vertebral disks as a result of gravity & dehydration. Combined with slight curving of cervical vertebra, height is lost. stooped, slightly forward-bent posture is common these changes occur because of age-related bone calcium loss and atrophic cartilage & muscle shoulder width decreases because of shrinkage of the deltoid muscles & acromion processes. Chest width & pelvic width increase, and abdominal length decreases while its girth increases. II. Bones -ongoing & cyclic resorption (into the bloodstream) and renewal (into the bones) of minerals, esp. calcium.

Physiological Changes: resorption is more rapid than renewal, resulting in reduced bone mineral density (BMD) increased risk of fall-rated fractures (this is the most important issue related to osteoporosis) [Reduced BMD is 4x more common in older women than in men. Its due to hormonal changes following menopause. In men, reduced BMD is primarily due to prolonged steroid use.] III. Joints, Tendons, Ligaments -joints responsible for movement -tendons & ligaments are connective tissue that bind bones to each other & allow joints to articulate -cartilage lines the joints & supports specific body parts (eg. ears & nose) Physiological Changes: changes in articular cartilage. As cartilage in joints dries up, it becomes thinner, resulting in less fluid movement or pain as bone rubs on bone. tendons may shorten & move from usual positions IV. Muscles -three types of muscles: 1. Skeletal: for movement, posture, & heat production. Voluntary control 2. Smooth: throughout body, primarily in lining or organs & red blood vessels 3. Cardiac: heart muscle Physiological Changes: sarcopenia: decrease of muscle mass (atrophy). Seen mostly in skeletal muscle. Loss is caused by physical inactivity, change in central & peripheral nervous systems, & reduced skeletal protein synthesis CARDIOVASCULAR SYSTEM Responsible for the transport of oxygen & nutrient rich blood to organs & transport of metabolic waste products to the excretory organs Most relevant age-related changes: -myocardial & blood vessel stiffening -decreased beta-adrenoceptor responsiveness -impaired autonomic reflex control of the heart rate -left ventricular hypertrophy -fibrosis I. Heart -catecholamines & certain enzymes that influence force & speed of heart contractions diminish in concentration, resulting in longer interval betw contractions, weakened cardiac force, & more energy demand on heart muscle

-presbycardia/reduced cardiac reserve: decreased maximal heart rate, stroke volume, cardiac output, ejection fraction, & oxygen uptake. Healthy older heart is still able to function well despite these limitations. Presbycardia becomes significant only when the person in physically or mentally challenged

Valves -four valves control blood flow in, out, & within heart -when a valve is compromised, some blood may leak backward (regurgitate) during the hearts contraction or relaxation. The sound of backflow is a murmur -normal aging: valves may be thicker & stiffer from lipid deposits & collagen crosslinking, making mild systolic murmurs an expected finding. Conductivity -heart contracts & relaxes on its own. Stimulation starts in pacemaker cells in SA node, AV node & bundle of His. The bundle splits into right & left bundle branches. Beating movement produces the S1 & S2 sounds. The aging heart is able to adapt to changes: -number is SA node cells decrease significantly in the 6th decade of life -AV node & bundle of His lose a number of conductive cells in 4th decade of life -left bundle loses cells betw 5th & 7th decades -resting heart rate unchanged with age, but max heart rate is achieved thru decreased activity -sinus rates <60 beats/min are common in elderly & dont necessarily mean disease in SA node II. Blood Vessels -most significant age-related change is reduced elasticity & lumen; increased peripheral resistance -systolic BP increases with age RESPIRATORY SYSTEM Risk for respiratory infection is higher in OA due to structural changes in the respiratory system (along with lower immune system). (Cilia, which are normally responsible for pushing foreign bodies and mucus out of the body, are fewer in number & less effective. Compounded by diminished cough reflex) Specific age-related changes: -loss of elastic recoil -stiffening of chest wall -inefficiency in gas exchange -increased resistance to airflow

[IMPORTANT: instead of typing the entire table, please see Table 4-1 on pg 51 for more age-related changes. It includes some of the points from the PowerPoint] I. Airways Physiological Changes: Nose: nose droops downward (esp. in men), restricting airflow Trachea & Larynx: stiffening on larynx & tracheal cartilage, resulting from calcification & cross-linking. NOT a normal part of aging: breathlessness in speech resulting from air escaping thru incompetent glottis II. Chest Wall & Lung Physiological Changes: ossification or rigidity of costal cartilage & downward slant of the ribs create a less compliant, more rigid rib cage limiting chest expansion RENAL & UROLOGICAL SYSTEMS Responsible for excreting toxins, regulating water & salt, maintain acid-base balance in blood. I. Kidneys Physiological Changes: size & function begin to decrease in 4th decade, and even more so by the 6th decade. Kidneys are 20-30% smaller by 8th decade II. GFR Physiological Changes: decline of GFR begins around 40 yrs old; may be reduced by 50% by 75 yrs old ability to concentrate urine decreases: OA cant tolerate dehydration or fluid overflow. As a result, hyperkalemia is common. sudden changes in pH or fluid overload can lead to hypervolemia or hypovolemia change in GFR also changes the way drugs are metabolized & excreted III. Ureters, Bladder, Urethra Physiological Changes: some tone & elasticity are lost. total bladder capacity decreases from 600mL to 300 mL (powerpoint slide states from 500-600mL to 250mL) weakened contractions during emptying can lead to postvoid residual & increased risk for baldder infection IV. Renal Vessels Physiological Changes: renal blood flow decreases by 50% by age 80 or 10% per decade of adult life

ENDOCRINE SYSTEM Produce & secrete hormones. Hormones control reproduction, growth & development, maintain homeostasis, response to stress, nutrient balance, cell metabolism, energy balance. Primary glands in endocrine syst: thyroid, parathyroid, adrenal, pituitary, pineal, & thymus. I. Thyroid gland (influence metabolic rate & produces body heat) Physiological Changes: diminished T4 (thyroxine) & decreased T3 (plasma triiodothyronine) are agerelated decreased thyroid gland activity & secretion of hormones II. Adrenal Glands Physiological Changes: these glands become more fibrous with age ACTH secretion decreases with age hormones influenced by adrenals are reduced III. Endocrine Pancreas Physiological Changes: decreased sensitivity to insulin DIGESTIVE SYSTEM I. Mouth & Teeth Physiological Changes: teeth lose enamel & dentin becoming more vulnerable to cavities gums more susceptible to periodontal disease taste buds & sense of smell decline, leading to decreased ability to taste less saliva leading to dry mouth (xerostomia) II. Esophagus Physiological Changes: presbyesophagus: in aging, contractions increase in frequency but more disordered with less effective propulsion III. Stomach Physiological Changes: decreased gastric motility & volume and reductions in bicarbonate & gastric mucus. Reductions are caused age-related gastric atrophy that results in hypochlorhydria (insufficient hydrochloric acid) decreased production of intrinsic factor (which can lead to anemia if stomach isnt able to digest B12 vitamins) more susceptible to peptic ulcer disease (because the protective alkaline mucus of stomach is lost due to increase in stomach pH)

loss of smooth muscle in stomach delays emptying time, which can lead to anorexia/weight loss as a result of distention, meal induced fullness, & premature satiety

IV. Small Intestine Physiological Changes: villi become broader, shorter, less functional; blood flow decreases nutrient absorption slows down [proteins, fats, minerals (calcium), vitamins (B12), & carbs (lactose)] V. Large Intestine Physiological Changes: peristalisis slows down [fyi: constipation is more the result of side effects of meds, life habits, immobility, inadequate fluid intake] VI. Liver & Gallbladder Physiological Changes: liver decreases in weight/mass (which results in decrease in liver blood flow, which in turn, effects drug metabolism) no specific age-related changes in the gallbladder, BUT incidence of gallstones increases VII. Exocrine Pancreas Physiological Changes: with age, the pancreas become more fibrotic, has increased fatty acid deposits, & atrophies slightly (but these changes dont affect function)

NERVOUS SYSTEM Includes the central nervous system (CNS) and peripheral nervous system (PNS). Working with the endocrine system, its responsible for maintaining homeostasis. Neurons generate electrical & chemical impulses; neurotransmitters are the chemicals that allow transmission of signals from one neuron to another. Although neurophysiological changes occur with aging, they dont occur in all older adults and dont always have the same effect. I. CNS Physiological Changes: reduction in the number of neurons, cerebral blood flow, & metabolism loss of neurons, along with cellular changes, is related to slowed responses to sensory stimuli slower reflexes, delayed responses, and changes in balance

II. PNS Physiological Changes: functioning of PNS slows down & prolonged recovery phases after activation, especially of the ANS kinesthetic perception (ability of a person to automatically respond to changes in environmental stimuli) becomes less reliable [IMPORTANT: see Table 4-2 on pg 55 for more age-related changes. One of the powerpoint slides only listed the changes, but it does not explain specifically what the changes are. The table explains it.] SENSORY I. Smell Physiological Changes: sense of smell declines & therefore can affect taste acuity. Safety implications are also involved if an older adult is unable to smell toxic substances (smoke or gas) in the environment II. Taste Physiological Changes: taste perception declines (thats why some OA pile on the salt on their food) III. Touch Physiological Changes: Somateshesia (tactile sensitivity) decreases because of skin changes. Ability to sense pressure & pain and differentiate temperature is reduced. IV. Sight A. Extraocular changes eyelids lose elasticity & drooping (senile ptosis) may result. In extreme cases, it can interfere with vision entropion (lower lid may turn inward. When this happens, the eyelashes cause irritation and scratch the cornea) ectropion (lower lid turns out. When this happens, tears run down the cheek instead of bathing the cornea, which can lead to dry eyes) B. Ocular changes With aging, cornea becomes flatter, less smooth, thicker, loss of sparkling transparency resulting in increased incidence of astigmatism With aging, the anterior chamber decreases slightly in size & volume capacity because of lens thickening. Resorption of intraocular fluid becomes less efficient, and if change is great it can lead to glaucoma. With age, color of iris becomes paler as result of pigment loss & increase in density of collagen fibers.

From the powerpoint slide, changes in vision: Presbyopia (decreased near vision) Narrowing of visual field Less pupil response to light Hardening of the pupil Reduced pupil size High prevalence of cataract development Yellowing of the lens V. Hearing Physiological Changes: A. Outer ear: with aging, pinna loses flexibility & becomes longer & wider. Ear lobe sags, elongates, & develops wrinkles. Tragus becomes larger in men. Cerumen glands atrophy, making ear wax thicker & dryer & harder to remove. As a result, impaction may occur & can cause conducive hearing loss. B. Middle ear: with aging, tympanic membrane becomes dull, less flexible, a little retracted, reducing sound transmission From slide: Progressive hearing loss can distort speech [IMPORTANT: see Table 4-4 on pg 58 for Changes in Hearing caused by Aging] REPRODUCTIVE SYSTEM I. Female Physiological Changes: Perimenopause: period of time 5-10 years before cessation of menses. Follicular loss slowly accelerates. Changes may/may not be accompanied by mood swings, hot flashes, night sweats. Ovulation is variable. Menopause: occurs around 51 yrs of age. Cessation of menses. Other age related changes occur: ovaries/uterus atrophy; vagina shortens, loses elasticity; vaginal dryness; pH of vaginal epithelium rises; menopause often accompanied by lower libido II. Male Physiological Changes: Fertility is reduced because of higher number of sperm lack motility or due to structural abnormalities Erectile changes: more stimulation needed Enlarged prostate IMMUNE SYSTEM Decreased immune functioning as we age is associated with interrelated factors: decrease in Tcell function & cell-mediated response to infectious agents & other foreign substances. Thymus decreases in size & volume over time. These changes are called immunosenescence.

From the powerpoint slide (immune system changes): Skin is thinner & less resistant to bacterial invasion Reduced number of cilia in lungs leads to increased risk for pneumonia Friability of urethra increases risk for urinary track infection Reduced immunity at cellular level Average temp for OA is 95-97F; a low grade fever of 98.6F can signify a serious illness. CHANGES IN THE MIND (powerpoint slide) Psychological changes are influenced by general health status, generic factors, education, and activity Basic personality does not change Retrieval of long term memory info can be slower Basic intelligence is maintained More factors interfere with ability to learn Older adults more easily distracted