Physiology of Aging

John Puxty, Queens University

puxtyj@post.queensu.ca
 Learning Objectives
By the end of this section, the student will
appreciate the importance of
– physiological and psychological factors that
contribute to normal aging,
– the difference between normal aging and the
diseases of aging.
– frailty and co-morbidity in the presentation of
disease in the elderly
 Normal Aging
 Despite stereotype most of the elderly age
well!
 Normal Aging
 Despite stereotype most of the elderly age well!
 Most of our images are based on the frail sub-set
who frequently use medical services
 Normal Aging
 Despite stereotype most of the elderly age well!
 Most of our images are based on the frail sub-set
who frequently use medical services
 Generally normal aging is associated with a
reduction in functional reserve capacity in tissues
and organs
Age related change in function
reserves
 Normal Aging
 Despite stereotype most of the elderly age well!
 Most of our images are based on the frail sub-set
who frequently use medical services
 Generally normal aging in associated with a
reduction in functional reserve capacity in tissues
and organs
 At advanced age more common to see evidence of
impaired homeostasis and response to external
insults (e.g. illness)
Traditional medical approaches do not
cater for the heterogeneity of disease in
the elderly!
 Skin and Aging
In general, the skin tends to become drier, thinner,
and more wrinkled with age. Other age-related
changes include:
– Loss of the inter-digitations between the epidermis and
dermis, leading to ease of tearing or breakdown (see
picture opposite).
– Decline in the vascular supply which influences
thermoregulation as well as drug absorption and the
response to toxic substances.
– Decline in the immune cells of the integument.
– Decline in the activation of Vitamin D.
Skin and Aging
 Consequences of Aging Skin
 Older skin tends to be more vulnerable to
tearing, bruising, and breakdown.
 Pressure ulcers (decubiti), are seen more
commonly within the hospitalized elderly.
 There may be delayed response to topically-
administered toxic agents.
 Exposure to sunlight exacerbates age-
related changes in the skin.
Cardiac Output and Age
Heart Rate and Age
Cardiovascular

 Higher Syst. BP
more common
 Reduced ability to
increase HR
 Increased postural
hypotension
 Prone to diastolic
dysfunction
Respiratory

 Increased energy of breathing

 Increased airways resistance
 Increased in dead-space
 Reduced V/Q ratio
 Sensory (1)
 Vision
– The lens tends to opacify, which
influences color perception.
– There is a decrease in light and dark
adaptation.
– The lens tends to lose elasticity,
which increases the distance of
focusing.
– There is a decline in contrast
sensitivity and an increase in
sensitivity to glare.
 Sensory (2)
 Hearing
– Hair cells tend to be lost in the organ
of Corti.
– Cochlear neurons tend to be lost.
– Stiffening, thickening, and
calcification occur in multiple
components of the auditory
apparatus.
 Taste
– Older persons may have decreased
sensitivity to taste.
 Neuromuscular
 Reduced sensory input including propio-ceptive
information
 Delayed nerve conduction
 Reduced numbers of motor neurones
 Reduced fast twitch fibres
 Reduced muscle mass

Therefore vulnerability to falls!

 Osteoporosis and Fractures
 Low dietary intake of Calcium
 Loss of endocrine protection
 Reduced endogenous production
of Vitamin D
 Disuse
 Disease – Chronic Renal Disease,
Rheumatoid Arthritis, Thyroid
Disease
 Medications – Steroids, Thyroxine
Sobering Facts re Falls in Elderly
 4,821 per 100,000 pop. over 65 attend A&E with
falls and almost 25% resulted in hospitalization
 90% of “faller”s sent home from A&E have no
change in fall-risk factors
 40% of Fallers presenting to A&E will # within
one year
 Life time risk for hip # in males 11% and females
27%
 Estimated in 2001 one year cost of hip # was
$26,527 ($21,365 in those -> community and
$44,156 -> LTC)
 Sobering Facts (2)
 Less than 40% of # hip patients will regain
previous level of ambulation!
 7% short-term mortality rising to 20-35%
after one year!
 Restraints increase incidence of serious falls
 40% of admissions to LTC are “frequent
fallers”
 Fall rate increases in first six weeks in LTC!
The Digestive System

• Stomach
motility
pH
• Sm. Intestine
absorption
• Large Intestine
motility
• Liver
•blood flow
 Renal
 General decline in glomerular filtration rate by
about 8-10ml/min per 1.73m2 per decade after age
30-35.
 Progressive decline in ability to excrete a
concentrated or a dilute urine
 Delayed or slowed response to sodium deprivation
or a sodium load
 Delayed or sluggish response to an acid load
 Pharmacokinetics and Aging
 Absorption - gastric pH higher, decreased motility
and absorption
 Distribution - reduced total body water, proteins and
lean body mass, and increased total body fat
 Metabolism - hepatic oxidative pathways impaired
(benzodiazepines) and P-450 (B-blockers, TCA’s,
verapamil)
 Excretion - reduced GFR and change in tubular
function (aminoglycosides, lithium, digoxin)
 Low Body Water -> reduced vol. of dist. for polar drugs eg.
Aminoglycocides, Digoxin
 High Fat Stores -> increased vol. of dist. for lipid soluble
drugs eg. Phenytoin, Diazepam, Flurazepam
 Pharmacokinetics and Aging
 Absorption - gastric pH higher, decreased motility
and absorption
 Distribution - reduced total body water, proteins and
lean body mass, and increased total body fat
 Metabolism - hepatic oxidative pathways
(benzodiazepines and P-450 (B-blockers, TCA’s,
verapamil)
 Excretion - reduced GFR and change in tubular
function (aminoglycosides, lithium, digoxin)
 Pharmacodynamics
(effect of drugs at target site)
 No generalization regarding receptor
numbers or affinity or hormone levels
 Examples of changes are insulin receptors,
Beta receptors and heart, Ach receptors and
colon
 Genitourinary (men)
 Decreased blood flow may lead to a
decrease in erectile function.
 Spermatogenesis continues, although sperm
count tends to decline and chromosomal
abnormalities tend to increase.
 The prostate tends to increase in size, and
prostatic fluid tends to decrease in amount.
 Genitourinary (women)
 Reproductive capacity is lost at the time of
menopause.
 Ovary, uterus, and vagina tend to atrophy
following menopause
 The urethra is more likely to be colonized
by gram negative organisms.
 Alterations in mucosa lead to increased
bacterial adherence.
 Newer results...
 The Starr-Weiner report:
– 97% liked sex
– 91% approved of unmarried/widowed aged
having sex
– quality more important than frequency!
– Women in survey had intercourse 1.4/week
 Newer results...
 Large proportion of seniors sexually active:
– 54% of married men & women
– 65% of women over age 70

 Netherlands:34 % of women surveyed

enjoy sexual activity most of time
– Vs. 70% of premenopausal women
 What problems may women
report
 43% of older Swedes reported vaginal
dryness
 10% vaginal burning
 urinary incontinence may occur
 dyspareunia
 decreased orgasm (30%)
 What changes for men?
 Changed libido
 erectile function
– increased need for stimulation
– inadequate rigidity associated with risk factors
 decreased ejaculatory demand
 decreased ejaculatory power
 prolonged refractory stage (up to one week)
 Impact of Physiological and
Epidemiological Factors in the
Elderly and the Health Care
System

John Puxty, Queen’s University

Atypical presentations of disease
are frequently seen
 Classical
 Silent
 Pseudosilent
 Atypical Presentations
Weakness/Fatigue
Dwindles
Falls/Immobility
Incontinence
Cognition/Mood Change
Social Crisis
 High users have overlap of
physical and social vulnerabilities
 Predictors of Frailty
 Extreme age
 Visual loss
 Impaired cognition/mood
 Limb weakness
 Abnormalities of gait and balance
 Sedative use
 Multiple chronic diseases
 Acute illness superimposed
on Frailty
 Multiple organ stress
 Failure of homeostasis
 potential exacerbation of chronic diseases
 Increased potential for drug interactions and
adverse effect
 Increased vulnerability to delirium, falls and
incontinence with caregiver stress
 Significance of the
“Atypical Presentation”
 Presence associated with delay in diagnosis
and increased mortality (Puxty et al 1984)
 Predictive of future functional declines in
community elderly (Choo-Cho et al 1998)
 Functional decline (dwindles) increases
likelihood of further decline and increased
mortality (Hebert et al1997)
 Clinician’s general approach
to the “Atypical Presentation”
 Consider recent change in function a result
of disease or drugs until proven otherwise
 Longitudinal multiple assessments often
necessary
 Additional informants often invaluable
 Appropriate screening investigations have a
role
 Multiple pathologies are the rule
Small changes can result in major functional
gains!

Medications
Foot wear
Walking aides
Surface heights
Chairs/bed
Wall bars
Lighting
Flooring/mats
 Conclusions
 Aging of the population will result in 25% of the
population being over 65 by 2030
 The majority of the elderly are well and enjoy a
reasonable socio-economic status
 A small but significant subset of frail, vulnerable
elderly account for an excess of adverse socio-
economic and health care outcomes
 A typical profile is the very old, female, living
alone, with multiple chronic diseases and taking
multiple medications
 The presence of acute illness should be suspected
with recent unexpected functional decline