Normal Aging

Vaishali Singhal DMD, PhD, MS

Rutgers, The State University of New Jersey

 Objectives-Normal
• Aging
Review aspects of normal aging physiology for older
adults to be able to make necessary modifications
to care
• Understanding normal aging to have an
appreciation of what is not normal and may
require further investigation.
• Slides courtesy of Dr. Kevin Overbeck, New
Jersey Institute for Successful Aging, Rowan
University School of Osteopathic Medicine
 Phases of
Aging

https://www.researchgate.net/figure/Figure-1-Model-of-Successful-Aging_fig2_321
981055
 Homeostenosi
s
• As people age and experience disease
processes such as dementia there is a
narrowing (stenosis) of capacity to bear
stress. Something that used to be a nuisance
becomes a major problem. This results in a
decreased ability to maintain homeostenosis.
• Gradual loss of reserve function & ability
to maintain homeostasis under stress
 Aging Physiology:
Homeostenosis
• Progressive &
predictable loss of
coordinated cell
function such that the
organism becomes
less fit to survive /
reproduce
• Late stages of aging
may include altered
function at rest
Heomoestenosi
s
 Loss of
•
Resiliency
Health and The New Normal - For those over 65, The New Normal is that
you will be dealing with one or more chronic conditions such as
diabetes, cardiovascular disease, arthritis, or orthopedic problems and
will be taking an increasing number of prescriptions.
• An AARP study in 2005 reported that those over 45 took an average of
four prescription medications per day. As one moves into their 60s, 70s,
or 80s, that number will increase.
• How one copes with these health concerns is partially dependent upon
attitude and action, i.e. Resilience.

• https://www.psychologytoday.com/us/blog/refire-don-t-retire/201704/aging-resilience-and-
the-new-normal
 Aging
Body Composition
Physiology:
• Application: Implications for
Drug Prescribing
• Lipid Compartment Expands (lipophilic drugs
such as TCA and antipsychotics have
increased half-life)
• Total Body Water (mainly extracellular fluid
or ECF) declines (diuretics)
• Lean Muscle Mass Declines (ex-digoxin)
 Aging Physiology
Pharmacology

Pharmacokinetics: drug absorption,

distribution, transformation, elimination

Pharmacodynamics: intensity of the

drug response at its receptor
 Additional pharmacologic
concepts relevant to older
adults
• Polypharmacy
• Prescribing cascade
• The mantra when prescribing for older
adults:
– “START LOW, GO SLOW”
Applied Aging Physiology

DERMATOLOGY
Aging Physiology:
Hair
 Aging Physiology:
Skin
Which of the following statements is true …
as a result of normal aging …

1. There is an increased amount of collagen deposited in the

dermis contributing to wrinkle formation
2. There is a decrease is apocrine (sweat) and sebaceous
gland function resulting in a decreased need for
antiperspirants / deodorants.
3. The epidermis (stratum corneum) thins predisposing older
adults to have enhanced cutaneous manifestations of contact
dermatitis.
4. Due to thinning skin, there is increased efficacy of topical
medications manifested by shortened treatment durations.
 Aging Physiology:
Skin
• There is an increased amount of
collagen deposited in the dermis
contributing to wrinkle formation (F)
 Aging Physiology:
Skin
• There is a decrease is apocrine (sweat)
and sebaceous gland function resulting in
a decreased need for antiperspirants /
deodorants(T)
 Aging Physiology:
Skin
• The epidermis (stratum corneum) thins
predisposing older adults to have
enhanced cutaneous manifestations of
contact dermatitis (F)
 Aging Physiology:
Skin
• Due to thinning skin, there is increased
efficacy of topical medications manifested by
shortened treatment durations (F)
 Aging Physiology:
Skin
79 year old female presents with burning sensation and
red plaques at the corner of her mouth. What is the
diagnosis?
(1) Candida infection
(2) Herpes Zoster
(Shingles)
(3) MRSA Cellulitis
(4) Bullous Pemphigoid
(5) Psoriasis
 Aging Physiology:
Skin
Rete pegs projecting more into Smaller/flatter rete
dermis pegs
Aging Physiology:
Exocrine Glands

• Eccrine Sweat
Gland (decreased #
& function)

• Apocrine Gland
(decreased
secretion)

• Sebaceous Gland
(increased size,
yet decreased
sebum output)
Applied Aging Physiology

CARDIOLOG
Y
 Aging Physiology:
Cardiology
• Resting HR
Unchanged
With Aging
• https://
www.justrunlah.com/2017/08/08/underst
a
nding-your-heart-rate-zones /
 Aging
Physiology:
Vascular
Changes

• Increased Tunica Media

Thickness
• Decreased Elastin
• Increased Vessel Stiffness

“Stiff
Pipes”
 Aging Physiology:
Blood Pressure

SBP threshold for drug treatment raised

from
Aging Physiology:
Postural Change

In response to an
orthostatic stress (i.e.
assumption of the
sitting from the supine
position) the heart rate
response is blunted in
older compared with
younger individuals1.
 Aging Physiology:
Marathon, Greece to Athens

• Dimitrion Yordanidis
• October 10, 1976
• 7 hours 33 minutes
• 98 years old
 Aging
Physiology The
‘Iron Nun’
2005 Hawaii Ironman – at age 75 – the Iron Nun
became the oldest woman ever to complete the race,
finishing 1 hour before the 17-hour midnight cut-off
time.
2006 Hawaii Ironman – at age 76 – she again became
the oldest woman ever to complete the race, finishing
with a time of 16:59:03.
2008 British Columbia Ironman – at age 78 – Sister
Madonna Buder participated in the Ironman race held
in British Columbia Canada. She was unable to finish
the race by a factor of seconds as she was unable to
reach the finish line within the 17 hours cut-off limit.
Spectators cheered and encouraged her as time ran
out.
• Sister Madonna Buder When she was unable to finish many broke down in
tears and applauded her efforts nonetheless.
• Age 79 2009 British Columbia Ironman (371 days later) – at
age
record79of
– Sister
being Madonna
the oldestcompleted Ironman Canada in
female to complete
• Ironman British a
thetime of 16:54:30. This accomplishment broke her
own
Columbia Ironman distance at 79 years old.
• Time 16:54:30 On October 5, 2010 Sister Madonna released her
autobiography, The Grace to Race: The Wisdom and
Inspiration of the 80-Year-Old World Champion
Triathlete Known as the Iron Nun.
• Autobiography “The Grace to
 Pulmonary Changes
Total lung capacity is felt to decrease

Impact of smoking, pollution,

infection over time

Decreased elasticity of chest

wall and weakening of
respiratory muscles
(diaphragm) mean more
work for someone 70 to
breathe than a 20 year old.

Impact is likely in
decreased athletic capacity
decreased
and in resiliency to handle
https://
www.researchgate.net/figure/Schematization-of-the-main- infection such as pneumonia
alterations-in-the-respiratory-system-of-the-elderly-that-
may_fig1_330205818
Applied Aging Physiology

ORAL
HEALTH
 Oral Changes in
Aging
• Most significant oral changes in aging occur due
to disease or treatment for disease rather than
physiologic aging
• Taste
• Teeth and periodontal tissues
• Saliva
• Masticatory and orofacial musculature
• Oral Stereognosis (ability to use tactile sense to
recognize
an object without other senses)
 Oral
Stereognosis
A healthy natural dentition offers a very good oral stereognostic ability.
E dentulous subjects usually show a decreased oral stereognostic ability,
d epending on the rehabilitation form.
 Tast
• Taste discrimination
e
decreases with age
for sour and salt
• Implications for
diet modification

This affect is increased with

medications

https://www.slideshare.net/narasimhabc/health-care-of-elderly
 Teeth and Periodontal
•
Tissues
Secondary dentin deposition
results in greater distance to
pulp (neurovascular complex)
• Gingival recession typically due
to aggressive toothbrushing and
periodontal breakdown
• Age changes in the teeth are
Goldstein, R. Esthetics in Dentistry, 2002
therefore loosely defined as
‘frequently occurring changes
found in functional, intact
teeth from older individuals’.

Hargreaves & Cohen, Pathways of the Pulp, 2010

 Saliv
• Roles
a
– Movement of food bolus
– Lubricate oral mucosa
– Preservation of microbial
ecologic balance
– Mechanical cleansing
– Antibacterial and
antifungal
activities
– Maintenance of oral pH https://
www.slideshare.net/shravyashivanand/age-changes- in-
– Remineralization of oral-tissues-58306712
the dentition
– Maintenance of taste
acuity
1. From MacEntee MI, Oral Healthcare
and the Frail Elder, 2011, Wiley-
Blackwell
 Saliv
• What causes reduction in saliva flow
(Xerostomia) a
– Many medications
– Radiation therapy
– Some diseases
– NOT aging alone
• Problems with xerostomia
• Management of xerostomia

https://www.pharmacytimes.com/publicatio
ns/issue/2011/november2011/drug-induced-
dry-mouth

https://www.pharmacytimes.com/publica
tions/issue/2007/2007-11/2007-11-8229
 Oral
mucosa in older personsmucosa
• A systematic review of literature to identify major lesions of the oral
with data received from thirteen countries-
showed that some of the more relevant diagnosis in elderly persons
are:
denture-related stomatitis
– epulis fissuratum
– traumatic ulcers
– irritation fibroma
– recurring aphthous stomatitis
– fissured tongue
– Hemangioma
– melanin pigmentations
– oral lichen planus.
• The changes in the oral mucosa which occur frequently during the
ageing process are related to the subtle changes in the lining of the
buccal structures.
• Rivera, César, & Arenas-Márquez, María Jesús. (2017). Gerodontology: effects of ageing on the oral mucosa. Revista
clínica de periodoncia, implantología y rehabilitación oral, 10(1), 9. https://dx.doi.org/10.4067/S0719-
01072017000100009
Common Oral Lesions in Older
Adults
Atrophic glossitis-with depapillation and erythema in
a patient with iron deficiency anemia

From Oral Manifestations of Systemic Disease by Bruch, Jean M.; Treister, Nathaniel S.
Lip
s • More fissured
• Dry and cracked
• Pale
• Angular cheilitis
– Skin folds
– Loss of vertical
dimension
• Loss of elasticity
Masticatory and oropharyngeal
musculature
• Chewing efficiency does not seem reduced
• Bite force reduction not a natural part of aging
• Denture use, tooth loss, periodontally
involved teeth, carious teeth can lead to
chewing difficulties
• There is a decrease in swallowing function due
to xerostomia and loss of muscle strength in
the muscles involved in swallowing.

1. Ikebe K et al., Association of bite force with ageing and occlusal

support in older adults. J. Dent. 2005. 33:131.
2. Gleason DL, Oropharyngeal swallowing in aging: A review.. J.
COMMUN. DISORD. 32 (1999), 373–396
 Dysphagia
Some observable signs
indicating potential problems
include the following:
• coughing while eating or
drinking;
• choking on food, fluid, or
medication;
• a gurgly sounding voice,
especially after eating
or drinking;
• difficulty swallowing
food or
fluid; and
• the pocketing of food on one •had been previously?
side of the mouth.
http://www.todaysgeriatricmedicine.com/archive/winter2011_p8.sht
Questions healthcare providers can ask
that offer clues related to potential
dysphagia problems among elder
patients include the following:
•Do you often cough or choke after eating
or drinking?
•Does it sometimes feel as though food is
going down the “wrong way”?
•Do you often feel that food is stuck in
your
throat?
•How long does it take you to eat a meal?
•Is eating sometimes less enjoyable than
it
Have you recently experienced weight
loss without trying to lose weight?
 Aging Physiology:
Esophagus & Stomach

• Maximum upper
esophageal sphincter (UES)
resting pressure declines
with age- movement of
food not affected by this
change
• Gastric acid secretion does
not decline with age
• Gastric Emptying Time
• Reduced gastric
secretion of
– Pepsin
– Mucosal Prostaglandin
– Mucus
– Bicarbonate
 Aging Physiology:
Esophagus & Stomach

• 83 year old male with

chronic left knee pain
secondary to
osteoarthritis takes
glucosamine daily &
400mg of ADVIL every
8 to 12 hours for
relief.
He presents to your
clinic with mid-
epigastric pain relieved
with food & belching
 GI-
Function
Age-associated change Possible disease
outcomes
↓ stomach acid production Atrophic gastritis

Impaired acid clearance GERD

Slowing of gastric emptying Prolong gastric distention

↑ meal-induced satiety
↓ Ca absorption Bone loss
Delay in colonic transit Constipation
↓ rectal wall sensitivity
↓ tensile strength in smooth muscle Diverticulosis
of colonic wall
↓ Insulin secretion ↑ Insulin resistance
 Aging Physiology:
Liver
• Decreased hepatic
blood flow by 35% or
more
• Decreased
hepatic
biotransformation
(type 1)
oxidation
• But, acetylation &
conjugation (type 2)
is unchanged
 Kidney
s
• Decreased Renal Blood flow
• Renal mass by 25% (mainly cortical)
• Renal weight
• Problems with fluid and electrolyte
balance
• Renal function declines with age
 Infection and
•
Immunity
Immune system:
– Less effective with aging
– Reduced number of T cells and Elderly patients often fail to exhibit
B the classic signs of infection. Pyrexia
and an elevated white cell count
cells may be conspicuous by their
– Reduced effectiveness of T cells absence. The signs may be subtle
and deterioration rapid. Fatigue,
and B cells malaise, and altered mental status
– Fewer macrophages may be early indicators of infection,
electrolyte abnormality or MI. The
– Skin and oral mucosa are ability to make the appropriate
thinner diagnosis relies on a strong index of
suspicion.
– Role of diet, role of teeth in
diet
 Aging Physiology:
Neurology
• On average: brain decreases 5-
10% of weight between ages 20
and 90yrs
• Cognitive challenge can create
new
neurons in the brain
• Performance on
neuropsychological testing
shows decrease in the speed of
processing but not in quality
• Decrease in cerebral blood flow
by
as much as 27%
• Decreased
Blood brainnumber of neurons inhttps://medlineplus.gov/ency/article/004023.htm
barrier (BBB)
the brain
weakens
 Aging Physiology:
Neurology (Senses)
• Olfactory: Decreased by as much as 50%
• Hearing: Age related decrease (aka Presbycusis)
• Vision: Reduced color vision, visual acuity, upgaze,
convergence, speed of visual pursuit, and there is
a decrease in pupil size; increased opacity of the
lens, decrease light sensitivity, decrease in
lacrimation
• Taste: [seeORAL HEALTH]
• Touch: Reduced Vibration in the lower
extremities (impaired position sense a factor in
falls)
 Aging Physiology
Peripheral Nervous System
• Nerve conduction slows
• ↓ vibratory sensation
– especially feet
• ↓ thermal sensation
• ↓ size of large
myelinated fibers
Applied Aging Physiology

MUSCULOSKELETA
L
 Aging Physiology:
The Skeleton

https://courses.lumenlearning.com/ap1/chapter/exercise-nutrition-hormones-and-
bone-tissue/
 Is this waiting area good for older
patients?

From “The Senior-Friendly Office”, Goldblatt and Yellowitz, Ch. 5 in Geriatric Dentistry, PK Friedman, Ed., 2014, Wiley
Blackwell
 Bad waiting area design for older patients
1. Deep chairs that are low to the ground
2. Good ambient lighting but no task lighting for reading
3. Floors are highly reflective and will be slippery if they get wet
4. No place to put down papers-the only small table has a plant on
it.
From “The Senior-Friendly Office”, Goldblatt and Yellowitz, Ch. 5 in Geriatric Dentistry, PK Friedman, Ed., 2014, Wiley
Blackwell
 Is this waiting
area good for
older
patients?

6
2
From “The Senior-Friendly Office”, Goldblatt and Yellowitz, Ch. 5 in Geriatric Dentistry, PK Friedman, Ed., 2014, Wiley
Good waiting area for
older patients
1.Overhead lighting
AND task lighting
2.Chairs have arms, but
are not overstuffed and
difficult to get up from
3.Floor is textured

• But-avoid sharp edges

on tables
From “The Senior-Friendly Office”, Goldblatt and Yellowitz, Ch. 5 in Geriatric Dentistry, PK Friedman, Ed., 2014, Wiley
6
3
Applied Aging Physiology

PSYCHIATR
Y
 THE AGING BRAIN

DATA: Schaie, K.W.: Developmental Influences on Adult Intelligence: The Seattle Longitudinal Study. NY:
Oxford University Press, 2005. FIGURE: Agronin, M.E.: Therapy with Older Clients, NY: W.W. Norton, 2010
What Is
Wisdom?
Age brings increased ability to:
• See both sides of the coin
• Think more relatively, less
black- and-white
• Think more pragmatically
• See one’s own role and
perspective amidst
others
• ALSO: Faster pattern
recognition
“I have needed all that time to reach
the stage where I can say what I want
to say.”

Henri Matisse; Sorrow of the King (1952)

1869-1954