Geriatric ppt

Question 1

Tips for examination of elderly patients

Answer 1

1. Perform as much of the exam as possible with the patient seated.
2. Avoid excessive up and down
3. Consider waiting room time- may need bathroom first
4. Evaluate gait while patient is walking to exam room

Question 2

Vital Signs (Geriatric considerations)

Answer 2

1. Consider orthostatic hypotension with position change (baroreceptors)
2. Meds can exacerbate this (i.e. HTN meds)
3. SA node declines- impacts HR response to exercise- more ectopy
4. Fever less likely when infected
5. Utilize home blood pressure monitoring with HTN

Question 3

Like children, geriatrics present differently

Answer 3

1. Less likely to have a fever
2. More likely to get confused from minor infection or constipation
3. Bowel issues are frequent

Question 4

Skin/Hair Nails Geriatric Considerations:

Answer 4

1. Basal cell carcinoma on face common
2. Hair loss normal-Men and women
3. Consider thyroid evaluation (Hashimoto’s - go low and SLOW can cause MI w/ thyroid medication)
4. Slowly replace thyroid due to cardiovascular risk
5. Actinic keratosis and seborrheic keratosis common- benign

Question 5

Eyes/Vision- Hearing (Geriatric Considerations)

Answer 5

1. Presbyopia- Rosenbaum better option
2. Most require some visual assistance
3. Look for cataracts- (Red Light Reflex)
4. Encourage sunglass use
5. Annual eye exam to include glaucoma evaluation
6. Discuss home safety (rugs, clear walk paths?)
7. Lighting- Night light for bathroom
8. May be embarrassed about hearing loss (presbycusis) Hearing loss Creates isolation
9. Offer referral for hearing aids
10. Discuss cost- not covered by all insurance agencies

Question 6

HEENT (Geriatric considerations)

Answer 6

1. Dry mouth- (xerostomia)
2. Taste buds change- Require more salty food
3. Angular cheilitis
4. Periodontal disease- loss of bone/hygiene/dentures
5. Pain may impact eating- watch weight
6. Facial bone loss
7. Ill fitting dentures
8. Sunken eyes/cheeks
9. Hearing loss - Drop tone not volume - Easier for patients to hear male/lower voice

Question 7

Thorax- CV/Lung

Answer 7

1. Medicare: can’t get ECG over 65 beyond the initial ECG without a reason
2. Kyphosis common- Barrel chest from COPD
3. Osteoporosis T score- DEXA scan
4. Men- Lupron for Prostate cancer - Compression fractures more likely
5. Cardiac calcification - Bruits-aneurysm
6. AAA screening if smoker, especially men over 65
7. S4 normal variant of aging but S3=CHF
8. Reduced exercise response

Question 8

T-score

Answer 8

is a number that compares the density of your bones to the average bone density of a healthy young adult.

Question 9

WOMEN:

Answer 9

1. Hot flashes- menopause- average 52 years old
2. Atrophic vaginitis- estrogen levels drop- HRT discussion
3. Urge incontinence- pelvic floor therapy

Question 10

MEN:

Answer 10

1. Testosterone drops- Controversial to replace (accelerates heart disease)
2. BPH common- ask about number of trips to bathroom in middle of night
3. Incontinence- flow
4. ED common- Early sign of CV disease (May be embarrassed to discuss) - Normalize this as common- Meds prn- CV risk eval first

Question 11

Stop mammogram screening and prostate cancer screening when < ____ years to live;
Pap smears stop at ___ in women

Answer 11

Stop mammogram screening and prostate cancer screening when <10 years to live;
Pap smears stop at 65 in women

Question 12

MS/Nervous

Answer 12

• Resting tremor- Parkinson’s’ disease onset
• Depression
• Use screening tools
• Isolation- death of spouse/friends
• MMSE- memory loss
• Alzheimer’s support groups for family
• Have end of life care discussion early in disease
• Muscle loss-
• Aging and inactivity

Question 13

GI

Answer 13

• Slowed Peristalsis
• Constipation!
• Laxative abuse
• Colonoscopy stops at 75
• Encourage diet to manage bowels
• Water intake
• Drive of thirst diminishes

Question 14

Colonoscopy stops at ___ age

Answer 14

Colonoscopy stops at 75

Question 15

Other special considerations (EOL)

Answer 15

1. End of life care
2. AD/ACP
3. Family spokes person
4. Quality over Quantity of life

Question 16

Access to healthcare

Answer 16

1. Dialysis
2. van
3. Stairs- less frailty
4. Neighbor-Friends
5. Home equipment monitoring

Question 17

Polypharmacy

Answer 17

1. Med reconciliation (BEERS criteria)
2. Limit unnecessary meds
3. Consider stopping statins after 75-80; especially if primary prevention
4. Watch for anticholinergic/synergistic meds
   (side effects)
5. Pharmacist can assist- Pharm consult!
6. Encourage patient keep one pharmacy only
7. LABEL MEDS “BLOOD PRESSURE” etc..

Question 18

Nutrition

Answer 18

1. Access to food- meals on wheels
2. Appetite reduced - watch weight
3. Less calories needed
4. Iron deficiency/B12 deficiency
5. Multivitamin

Question 19

Fall prevention

Answer 19

1. Avoid Frailty
2. Home safety eval- Home PT/OT
3. Rugs/lights
4. Same environment

Question 20

BLUE ZONE (More people over 100)

Answer 20

1. Physical activity
2. Walk- manual labor
3. Purpose/Connection
4. Life satisfaction
5. Reason to get up in the morning
6. Strong family ties
7. Sense of community- Social connections
8. Sleep - Prioritize sleep and rest- naps
9. Diet - Eat until 80% full
10. Mostly plant-based diet
11. Moderate alcohol use

Question 21

Medicare Annual Wellness Exam

Answer 21

• Not a physical exam
• Extensive Questionnaire
• Educate your patient
• Chronic Care Management- Advance Care Planning
• Medicare does not cover a routine physical exam-
• Initial Preventive Physical Exam (IPPE) exam within 12 months of getting Part B coverage
• AWV- Annual Wellness Visit
• Health risk Assessment
• Personalized Prevention Plan

Question 22

Advanced Care Planning

Answer 22

• Have the discussion early and often
• Matter of fact
• We are all going to die
• Give the patient some control
• Explain pros and cons
• Five Wishes
• State Advance Directive
• Power of Attorney for healthcare decisions

Question 23

Signs of Elder Abuse

Answer 23

• Look for signs of
• Withdrawn
• Poor hygiene
• Unkept
• Not making appointments
• Unexplained bruising

Question 24

Lupron

Answer 24

Gonadotropin-releasing hormone injection suppresses estrogen and causes artificial and rapid development of menopause. increased risk for osteoporosis.

Question 25

“older adult” is used for

Answer 25

for persons 65 years and older

Question 26

The aorta and large arteries stiffen and become _______. As the aorta becomes less distensible, a given stroke volume causes a greater rise in _____. Diastolic blood pressure (DBP) stops rising at approximately the ______ decade.

Answer 26

The aorta and large arteries stiffen and become atherosclerotic. As the aorta becomes less distensible, a given stroke volume causes a greater rise in SBP. Diastolic blood pressure (DBP) stops rising at approximately the sixth decade.

Question 27

With the greater rise in SBP, systolic hypertension with a ______ pulse pressure (PP) often ensues.

Answer 27

With the greater rise in SBP, systolic hypertension with a widened pulse pressure (PP) often ensues.

Question 28

Declines in the _________ cells of the ____ node and the maximal heart rate, which affect the response to exercise and physiologic stress.

Answer 28

Declines in the pacemaker cells of the sinoatrial node and the maximal heart rate, which affect the response to exercise and physiologic stress.

Question 29

Older adults are more likely to have abnormal heart rhythms such as ______ or ________ _______.

Answer 29

Older adults are more likely to have abnormal heart rhythms such as atrial or ventricular ectopy.

Question 30

In terms of temperature older adults are susceptible to _________.

Answer 30

hypothermia

Question 31

actinic purpura

Answer 31

spots and patches come from blood that has leaked through poorly supported capillaries and spread within the dermis

Question 32

Pupils become smaller, making it more difficult to examine the ocular fundi. The pupils may also become slightly _______ but should continue to ______ to _____ and show the near reaction

Answer 32

The pupils may also become slightly irregular but should continue to respond to light and show the near reaction

Question 33

presbyopia usually becomes noticeable during the ___ decade

Answer 33

presbyopia usually becomes noticeable during the fifth decade

Question 34

Vision

Answer 34

It diminishes gradually until approximately 70 years and then more rapidly. Nevertheless, most older adults retain good to adequate vision (20/20 to 20/70 as measured by standard charts). Near vision, however, begins to blur noticeably for virtually everyone. From childhood on, the lens gradually loses its elasticity, with progressive loss of accommodation and the ability to focus on nearby objects.

Question 35

Vision (Risks w/ aging)

Answer 35

Aging increases the risk of developing 1. cataracts 2. glaucoma 3. macular degeneration.

Question 36

Presbyopia (in Aging)

Answer 36

With age, the lens stiffens and can no longer cause rays from near objects to converge on the retina.

Question 37

Hearing loss associated with aging, known as presbycusis, becomes increasingly evident, usually after age ____ years.

Answer 37

Hearing loss associated with aging, known as presbycusis, becomes increasingly evident, usually after age 50 years.

Question 38

Angular cheilitis

Answer 38

Overclosure of the mouth may lead to maceration of the skin at the corners

Question 39

Respiratory changes

Answer 39

1. increase in closing volumes of small airways 2. predisposes to atelectasis and risk of pneumonia 3. Diaphragmatic strength declines

Question 40

Kyphosis

Answer 40

1. Osteoporotic vertebral collapse produces kyphosis, 2. Increases the AP diameter of the chest. 3. Resulting “barrel chest” has little effect on function.

Question 41

Extra Heart Sounds S4

Answer 41

As a person ages, decreased ventricular compliance and impaired ventricular filling result in a fourth heart sound, often auscultated in older healthy adults.

Question 42

Extra Heart Sounds S3

Answer 42

S3 - HF from volume overload of the LV in conditions like heart failure and valvular heart disease

Question 43

T/F atherosclerosis is a normal change of aging

Answer 43

False

Question 44

CONCERN FOR AAA

Answer 44

1. Abdominal or back pain in older adults raises the important concern of possible AAA 2. especially in MALE SMOKERS over age 65 years.

Question 45

Abdominal pain in older adults

Answer 45

1. Aging can blunt the manifestations of acute abdominal disease. 2. Pain may be less severe 3. fever is often less pronounced 4. signs of peritoneal inflammation, such as guarding and rebound tenderness, may be diminished or even absent.

Question 46

Erectile dysfunction (ED), or the inability to maintain an erection, affects approximately____% of older men. ______ causes are the most common, from both atherosclerotic arterial occlusive disease and corpora cavernosa venous leak.

Answer 46

50%; Vascular

Question 47

Increase prevalence of ED

Answer 47

1. Chronic diseases such as diabetes, hypertension, dyslipidemia 2. smoking 3. medication side effects

Question 48

ovarian function usually starts to decline during the ____ decade; on average, menstrual periods cease between age ____ and ___ years.

Answer 48

ovarian function usually starts to decline during the FIFTH decade; on average, menstrual periods cease between age 45 and 52 years.

Question 49

As _______ stimulation falls, many women experience hot flashes, sometimes for up to 5 years.

Answer 49

Estrogen

Question 50

Menopause symptoms

Answer 50

1. flushing, sweating, and palpitations to chills and anxiety. 2. Sleep disruption and mood changes are common 3. vaginal dryness, urge incontinence, or dyspareunia. 4. vulvovaginal changes occur: Pubic hair becomes sparse as well as gray, and the labia and clitoris become smaller, vagina narrows and shortens, and the vaginal mucosa becomes thin, pale, and dry, with loss of lubrication.

Question 51

Within 10 years after menopause, the ovaries are usually no longer _______.

Answer 51

The uterus and ovaries diminish in size. Within 10 years after menopause, the ovaries are usually no longer PALPABLE.

Question 52

Androgen-dependent proliferation of prostate epithelial and stromal tissue, termed benign prostatic hyperplasia (BPH), that begins in the ______ decade, continues to the ________ decade, then appears to plateau.

Answer 52

Androgen-dependent proliferation of prostate epithelial and stromal tissue, termed benign prostatic hyperplasia (BPH), that begins in the third decade, continues to the seventh decade, then appears to plateau.

Question 53

Sarcopenia

Answer 53

loss of lean body mass and strength with aging.

Question 54

Delirium

Answer 54

TEMPORARY state of confusion and inattention that may be the first clue to infection, problems with medications, or an underlying cognitive impairment

Question 55

Parkinsonian tremors

Answer 55

are slightly slower and persist at rest, and with associated muscle rigidity.

Question 56

Hyperthyroidism increases the risk of _________

Answer 56

Hyperthyroidism increases the risk of osteoporosis, and, in affected women, the risk of hip and vertebral fractures increases threefold.

Question 57

activities of daily living (ADLs),

Answer 57

six basic self-care abilities—bathing, dressing, toileting, transferring, continence, and feeding

Question 58

instrumental activities of daily living (IADLs)

Answer 58

using the telephone, shopping, preparing food, housekeeping, laundry, transportation, taking medicine, and managing money.

Question 59

________ are the single most common modifiable risk factor associated with falls.

Answer 59

Medications are the single most common modifiable risk factor associated with falls.

Question 60

Clues to alcohol-use disorders in older adults

Answer 60

Memory loss, cognitive impairment Depression, anxiety Neglect of hygiene, appearance Poor appetite, nutritional deficits Sleep disruption Hypertension refractory to therapy Blood sugar control problems Seizures refractory to therapy Impaired balance and gait including falls

Question 61

Recommended drinking limits for older adults

Answer 61

Older adults should have no more than 2 drinks on any one day or 7 drinks a week

Question 62

Palliative care

Answer 62

encompasses the alleviation of pain and suffering and the promotion of optimal quality of life across all phases of treatment, including curative interventions and rehabilitation (Fig. 27-7). Its goals are “to consider the physical, mental, spiritual, and social well-being of patients and their families in order to maintain hope while ensuring patient dignity and respecting autonomy”

Question 63

Assessment of functional status

Answer 63

10-Minute Geriatric Screener

Question 64

For identifying causes of transient incontinence, the DIAPPERS mnemonic may be helpful:

Answer 64

■ Delirium, ■ Infection (e.g., urinary tract infection), ■ Atrophic urethritis or vaginitis, ■ Pharmaceuticals (e.g., diuretics, anticholinergics, calcium channel blockers, opioids, sedatives, alcohol), ■ Psychological disorders (e.g., depression), ■ Excessive urine output (e.g., heart failure, uncontrolled diabetes), ■ Restricted mobility (e.g., hip fracture, environmental barriers, restraints), ■ Stool impaction

Question 65

Systolic HTN

Answer 65

Isolated systolic hypertension (SBP ≥140 mm Hg with DBP <90 mm Hg) after age 50 years and pulse pressure ≥60 increase risk of stroke, renal failure, and heart disease

Question 66

For adults aged ≥60 years, the eighth Joint National Committee (JNC8) recommends blood pressure targets of ≤150/90 but notes that if treatment results in SBP <140 and is “well tolerated and without adverse effects to health or quality of live, treatment does not need to be adjusted.”57 However, in the “oldest old,” those aged 80 years and older, other experts cite studies showing that blood pressure targets of 140 to <150/70 to 80 appear optimal for notable reductions in stroke, cardiovascular events, and all-cause mortality.

Question 67

orthostatic or postural hypotension, defined as a drop in SBP of ≥20 mm Hg or DBP of ≥10 mm Hg within 3 minutes of standing. Measure blood pressure and heart rate in two positions: supine after the patient rests for up to 10 minutes; then within 3 minutes after standing up.

Question 68

basal cell carcinoma, a translucent nodule that spreads and leaves a depressed center with a firm elevated border, and squamous cell carcinoma, a firm reddish-appearing lesion often emerging in a sun-exposed area. A dark raised asymmetric lesion with irregular borders may be a melanoma.

Question 69

Inspect for the benign lesions of aging, namely comedones, or blackheads, on the cheeks or around the eyes; cherry angiomas, which often appear early in adulthood; and seborrheic keratoses, raised yellowish lesions that feel greasy and velvety or warty.

Question 70

Vesicular lesions occurring in a dermatomal distribution are suspicious for herpes zoster from reactivation of latent varicella- zoster virus in the dorsal root ganglia. Risk increases with age and impaired cell-mediated immunity

Question 71

Pressure ulcers arise from obliteration of arteriolar and capillary blood flow to the skin or from shear forces during movement across sheets or when lifted upright incorrectly.

Question 72

Check the eyelashes in the lower lids to see whether they are directed toward the eye (entropion).

Question 73

describe any sagging and outward turning of the lower eyelid and eyelashes (ectropion) which can lead to excessive tearing, crusting of the eyelid, mucous discharge, and irritation of the eye

Question 74

If the pupil dilates as the light swings over, a relative afferent pupillary defect is present, which is suspicious for optic nerve disease. Refer to an ophthalmologist.

Question 75

prevalence of cataracts, glaucoma, and macular degeneration all increases with aging.

Question 76

An increased cup-to-disc ratio suggests primary open angle glaucoma (POAG), caused by irreversible optic neuropathy and leading to loss of peripheral and central vision and blindness (Fig. 27-10). Prevalence of POAG is four to five times higher in adults with African and Latino ancestry. People of Asian descent are more prone to develop angle-closure glaucoma and normal- tension glaucoma.

Question 77

Macular degeneration causes poor central vision and blindness (Fig. 27-11).76 Types include dry atrophic (more common but less severe) and wet exudative, or neovascular.

Question 78

common causes of hyperthyroidism are Graves disease and toxic multinodular goiter. Causes of hypothyroidism include autoimmune thyroiditis, followed by drugs, neck radiotherapy, thyroidectomy, or radioiodine ablation.

Question 79

Malodor points to poor oral hygiene, periodontitis, and caries. Gingivitis accompanies periodontal disease. Dental plaque and cavitation may cause caries. For increased tooth mobility from abscesses or advanced caries, consider removal to prevent aspiration. Decreased salivation results from medication effects, radiation, Sjögren syndrome, or dehydration. Oral tumors can cause lesions, usually on the lateral margins of the tongue and floor of the mouth.

Question 80

Increased anteroposterior diameter, purse-lipped breathing, and dyspnea with talking or minimal exertion suggest chronic obstructive pulmonary disease

Question 81

A sustained PMI is present in LVH; a diffuse PMI and an S3 signal left ventricular dilatation from heart failure or cardiomyopathy (see pp. 1127–1128).80 An S4 often accompanies hypertension.

Question 82

Isolated systolic hypertension and a widened PP are cardiac risk factors, prompting a search for left ventricular hypertrophy (LVH).

Question 83

A systolic crescendo–decrescendo murmur in the second right interspace suggests aortic sclerosis or aortic stenosis, seen, respectively, in up to 40% and 2% to 3% of community-dwelling older adults. Both are associated with an increased risk of cardiovascular disease and death.81,82 A harsh holosystolic murmur at the apex radiating to the axilla suggests mitral regurgitation, the most common murmur in older adults.

Question 84

Diminished or absent pulses are present in peripheral arterial disease (PAD) with an ABI <0.9. The ABI has a sensitivity of 70% and specificity of 90%. In patients with PAD, 30% to 60% report no leg symptoms.

Question 85

Abdominal bruits are suspicious for atherosclerotic vascular disease. A widened aorta of ≥3 cm and pulsatile mass occur in abdominal aortic aneurysm, especially in older male smokers.

Question 86

Timed Get up and Go

Answer 86

1. Get up from the armless chair 2. Walk 3 m (in a line) 3. Turn around 4. Walk back to the chair 5. Sit back down Time the second effort. Observe patient for postural stability, steppage, stride length, and sway. Scoring: Normal: completes task in <10 seconds Abnormal: completes task in >20 seconds

Question 87

Tremor, Rigidity, Akinesia, and Postural instability, or TRAP. These are several of the most common features of Parkinson disease.92 The tremor in Parkinson disease is slow frequency, occurs at rest, has a “pill-rolling” quality, and is aggravated by stress and inhibited during sleep or movement. Also look for bradykinesia, the most characteristic clinical sign, and micrographia, shuffling “freezing” gait, and difficulty rising from a chair.

Question 88

Household Safety Tips for Older Adults108 Install bright lighting and lightweight curtains or shades. Install handrails and lights on all staircases. Pathways and walkways should be well-lit. Remove items that cause tripping like papers, books, clothes, and shoes from stairs and walkways. Remove or secure small throw rugs and other rugs with double-sided tape. Wear shoes both inside and outside the house. Avoid bare feet and wearing slippers. Store medications safely. Keep commonly used items in cabinets that are easy to reach without using a step stool. Install grab bars and nonslip mats or safety strips in baths and showers. Repair faulty plugs and electrical cords. Install smoke alarms and have a plan for escaping fire. Secure all firearms. Have a clinical alert device/system for calling a universal emergency number such as 911 or emergency contacts.

Question 89

Older Adult Immunizations, 2018111 Influenza vaccination: One high-dose vaccine annually Tetanus, diphtheria, and acellular pertussis (Tdap) vaccination: Administer 1 dose to older adults who previously did not receive a dose of tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine (Tdap) as an adult or child Tetanus and diphtheria toxoids (Td): One dose Td booster every 10 years Varicella vaccination: Administer 2 doses to older adults without evidence of immunity to varicella 4 to 8 weeks apart Zoster vaccination: Administer 2 doses of recombinant zoster vaccine (RZV) 2 to 6 months apart to adults ≥50 years regardless of past episodes of herpes zoster or receipt of zoster vaccine live (ZVL) Pneumococcal vaccination: Administer to immunocompetent older adults 1 dose of 13- valent pneumococcal conjugate vaccine (PCV13, Prevnar13) at age 65 years or older then followed by 1 dose of 23-valent pneumococcal polysaccharide vaccine (PPSV23, Pneumovax23) at least 1 year after PCV13. Once a dose of PPSV23 is given at age 65 years or older, no additional doses of PPSV23 should be administered.

Question 90

Low-Value Screening for Five Types of Cancer in Adults >65 Years120 Cancer Screening Low Value (not recommended) Type Strategy Breast Any Older adult women ≥75 years or older adult women ≥65 years not screening in good health and with life expectancy <10 years Cervical Any Older adult women >65 years with previous recent negative screening screening results Colorectal Any Olderadults>75yearsorolderadults≥65yearsnotingood screening health and with life expectancy <10 years Colonoscopy Olderadults65–74yearswithnormalcolonicexaminationresults (i.e. without adenomatous polyps) within the last 10 years or normal flexible sigmoidoscopy results within the last 5 years Prostate PSA testing Older adult men 65–69 years who have not had an informed discussion and have not expressed a clear preference for testing after the discussion Older adult men >69 years or older adult men 65–69 years and not in good health and with a life expectancy <10 years

Question 91

Delirium is an acute confusional state characterized by sudden onset, fluctuating course, inattention, and at times alteration of consciousness. Confusion Assessment Method (CAM) is recommended for screening at-risk patients.

Question 92

DSM-5, delirium and dementia fall under the new category of neurocognitive disorders

Question 93

dementia. The most common types are Alzheimer disease (affecting 5 million Americans over age 65 years), Lewy body dementia, and frontotemporal dementia.

Question 94

Screening for Dementia: The Montreal Cognitive Assessment (MoCA), p. 277.

Question 95

Screening for Dementia: The Mini-Cog

Question 96

Patient Health Questionnaire (PHQ) and the Geriatric Depression Scale in older adults.

Question 97

Normal Changes in Anatomy Clinical Manifestations and Disease Outcomes and Physiology Cardiovascular Increase in thickness of left ventricular wall, involving both myocyte hypertrophy and increase in collagen deposition secondary to decreased turnover of these cells1,2 Myocardial thickening combined with lipofuscin deposits, fatty infiltration, and fibrosis2 Dilation of left atrium3 Loss of about 10% of pacemaker cells every decade4 Increased fibrosis, myocyte hypertrophy, and calcium deposition5 Increase in dilation, elasticity and rigidity of arterial walls, with decrease in sensitivity to receptor-mediated agents6–8 Increase in peripheral resistance and decrease in central arterial compliance6–8 Respiratory Decrease in number and elasticity of parenchymal 1. Decrease in early diastolic cardiac filling, increase in cardiac filling pressure and lower threshold for dyspnea 2. Left ventricular stiffness and thus a fourth heart sound 3. Lone atrial fibrillation 4. Sinus arrest or tachy–brady syndrome 5. Prolonged PR and QRS intervals and right bundle branch block 6. Atherosclerosis 7. Systolic hypertension 8. Stroke 1. Gradual loss of elastic recoil of lungs elastic fibers, the latter in part because of decrease in collagen levels1,2,4 Less effective ciliary action3 Less compliant and stiffer chest wall3 2. Smaller airway size, with airway collapse in lower lung zone 3. Increase in susceptibility to respiratory infections 4. Decrease in both quiet breathing (effort- independent) Weaker respiratory muscles and diaphragm, the latter by about 25%3,5,7 2 Decrease in forced expiratory volume and forced vital capacity (30% by age 80)6,7 Increase in residual volume by about 20 mL/year6,7 Gastrointestinal Increase in tongue varicosities1 Decrease in saliva production1 Increase in nonperistaltic spontaneous contractions of esophagus2 Decrease in stomach acid production3,4 Decreased gastric acid clearance5 Slowed gastric emptying after fatty meal, prolonging gastric distention6 Decrease in gut-associated lymphoid tissue7 Atrophy of large intestine mucosa8 Decrease in tensile strength of colonic smooth muscle8 Decrease in effectiveness of colonic contractions and sensitivity of rectal wall9 Decrease in calcium absorption10 Atheromata in large intestine vessels11 Decrease in liver size and blood flow12 Decrease in pancreatic mass and enzyme reserves13 mismatching (acceptable PaO2 = 100 – [0.32 × age]) 7. Decrease in pulmonary reserve and exercise tolerance 1. Increase in oral infections and gum disease 2. Dysphagia 3. Atrophic gastritis (in those >70 years, the incidence of atrophic gastritis is 16%) 4. Decrease in vitamin B12 and iron absorption 5. Gastroesophageal reflux disease 6. Increasing meal-induced satiety 7. Impaired response to gastric mucosal injury, thus increasing risk of both gastric and duodenal ulcers 8. Increase in diverticulosis 9. Frequent constipation 10. Bone loss 11. Chronic intestinal ischemia 12. Impaired clearance of drugs requiring phase I metabolism 13. Decrease in insulin secretion and increase in insulin resistance 5. Decrease in forced breathing (effort-dependent) 6. Decrease in PaO due to ventilation–perfusion Hyperplasia of pancreatic duct13 Increase in pancreatic cyst formation, fatty deposition and deposition of lipofuscin granules in acinar cells13 Urinary Decrease in number and length of functional renal tubules1 Increase in tubular diverticula and basement membrane thickness1 Altered vascular pattern, atherosclerotic changes, altered arteriole-glomerular flow and focal ischemic lesions2 Decrease in creatinine clearance and glomerular filtration rate, the latter by about 10 mL/decade3 Decrease in concentrating and diluting capacity of kidneys4 Decrease in serum renin and aldosterone by about 30– 50%4 Decrease in vitamin D activation5 Immunologic/Hematologic Average decline in function, including more stimulus and time required for activation1 Decrease in T-cell function1 Decrease in naive T cells and increase in memory T cells2 Gradual decrease in B-cell function3 Decrease in response of naive B cells to new antigens2 Atrophy of thymus4–6 Loss of ability of hematopoietic stem cells to self-renew7 1. Impairs permeability and decreased ability to resorb glucose 2. Decreased renal blood flow with a selective loss of cortical vasculature 3. Decrease in elimination of drugs and toxins (Given a decrease in renal drug elimination among older adult patients, clinicians must dose drugs for these patients with care. When hepatic clearance of drugs requiring phase I metabolism is also impaired, these drugs must be dosed with particular care) 4. Fluid and electrolyte abnormalities causing increased volume depletion and dehydration, hyperkalemia and decrease in sodium and potassium excretion and conservation 5. Vitamin D deficiency 1. Less primary and secondary responses to infection 2. Reduced body’s ability to mount immune response to new pathogens 3. Production of abnormal antibodies 4. Decrease in production and functioning of T lymphocytes 5. Decrease in proliferation of natural killer cells 6. Decrease in production of cytokines needed for maturation of B cells 7. Dysfunctional immune system 8. Slight decrease in average values of both hemoglobin and hematocrit Decrease in rate of erythropoiesis and incorporation of iron into red blood cells8 Sensory Organs Vision Loss of periorbital fat1–3 Laxity of eyelids1–3 Thickening and yellowing of lens combined with lipid infiltrate accumulations (arcus senilus)4 Increase in fibrosis of iris5 Increase in lens size and rigidity due to constant formation of central epithelial cells at front of lens6 Progressive increase in annular layers of lens7 Compression of central components that become hard and opaque7 Decrease in lacrimation Hearing Thickening of tympanic membrane and loss in its elasticity as well as in efficiency of its ossicular articulation9 Decrease in the elasticity and efficiency of ossicular articulation10 Increasing deficit in central processing11,12 Smell and Thirst Decrease in smell detection by about 50%13 Decrease in thirst drive14 Impaired control of thirst by endorphins14 Dermatologic Decrease in skin elasticity1 Decrease in barrier function2 Slower cell replacement3 1. Sunken eyes 2. Senile entropion and ectropion 3. Increase in vulnerability to conjunctivitis 4. Decrease in transparency of cornea 5. Decreases accommodation and slows dark adaptation (as dark adaptation decreases with age, a person’s continuing recognition of objects in subdued light requires double the illumination every 13 years) 6. Presbyopia 7. Increase in rate of cataract formation 8. Dry eye syndrome 9. Conductive deafness affecting low-frequency sounds 10. Sensorineural hearing loss of high-frequency sounds 11. Difficulty discriminating source of sound 12. Impaired discrimination of target from noise 13. Diminished ability to enjoy food and decrease in appetite 14. Dehydration 1. Lax skin 2. Dry skin 3. Rough skin with delayed healing Ineffective DNA repair4 Altered mechanical protection and decrease in sensory perception5 Decrease in immunologic and inflammatory responses6 Decrease in sweating and effectiveness of thermoregulation7 Decrease in vitamin D production8 Loss of melanocytes at base of hair follicles9 Slowing of linear nail growth10 Nervous System Central Nervous System1–3 Decrease in weight of brain and cerebral blood flow by about 20%1–3 Decrease in number and functioning of nerve cells1–3 Less fluid and stiffer cell membranes in brain neurons1–3 Irregularity in structure of internal membranes1–3 Accumulation of lipofuscin and tangled neurofibrils1–3 Decrease in ability of neuron to grow branches of both axons and dendrites4 Peripheral Nervous System Age-related changes in somatic motor function5 Slower action potentials and spreading of muscle cell contraction6,7 Lower peak strength of muscle contractions, with slower relaxation7 Musculoskeletal Muscle Decrease in muscle fibers (mainly type II—fast switch)1 4. Increase in rate of photocarcinogenesis 5. Greater susceptibility to injury 6. Chronic low-grade infections and impaired wound healing, with persistent wounds and weak scars 7. Tendency toward hyperthermia and greater vulnerability to both heat and cold 8. Osteomalacia 9. Gray hair 10. Nails thicker, duller and more brittle, opaque and yellow, with development of longitudinal ridges 1. After age 70, gradual decrease in vocabulary, with increase in semantic errors and abnormal prosody 2. Increased forgetfulness in noncritical areas, which does not affect function or impair recall of important memories 3. After age 80, slower central processing, which prolongs time to complete tasks 4. Decrease in fine motor control 5. Decrease in cells that can be stimulated and decrease in maximum strength of muscular contractions 6. Prolonged time required for impulses to arrive, muscle cells to contract and movements to be initiated 7. Decrease in maximal muscle strength when performing quick movements 1. Decrease in muscle mass (sarcopenia), leading to lean body mass 2. Thin, bony appearance to hands Replacement of lost muscle tissue with tough fibrous tissue2 Bone Decrease in vitamin D absorption, which decreases osteoblasts3 Decrease in bone formation and modeling by osteoblasts and osteoclasts, impairing bone microarchitecture3–6 Joints Decrease in thickness of articular cartilage, though not in nonarticular cartilage8 Stiffer collagen, resulting in disordered cartilage matrix7 Endocrine Pituitary gland Minimal changes but on average, decrease in pulsatile secretion pattern, including nocturnal pulsatile secretion of prolactin1,2 Pineal gland Decrease in diurnal melatonin rhythm3,4 Thyroid gland Atrophy, with increased fibrosis and nodule formation5 Decrease in T4 production in the very old (if aging is normal, blood thyroxine concentration continues unchanged even though T4 production decreases)5 Parathyroid glands In women over 40 years of age, increase in parathyroid hormone and decrease in metabolism, with associated decrease in 1,25 (OH) vitamin D levels and changes in bone mineral homeostasis6 3. Brittle bone 4. Greater susceptibility to fracture, with slower healing 5. Osteoporosis 6. Dorsal kyphosis 7. Less ability to handle mechanical stresses 8. Joint breakdown, including inflammation, pain, stiffness, and deformity 9. Overall decrease and limitation in movement 10. Decrease in arm swing and steadiness of walking 1. Decrease in size of various structures 2. Decrease in lean body mass to fat ratio 3. Insomnia 4. Deficit in free-radical defenses 5. Increase in rate of hypo-and hyperthyroidism 6. Vitamin D deficiency 7. Orthostatic hypotension 8. Masculinization of postmenopausal women 9. Decrease in immune function increasing the risk of infection and cancer 10. Changes in skin, hair, muscle and bone and decrease in body fat, despite increase in leptin 11. Skin changes, increase in LDL and decrease in bone minerals 12. Decrease in body fat Adrenal gland Moderate decrease in aldosterone secretion7 In postmenopausal women, increase in androgen secretion8 Thymus Decrease in immune function9 Male gonads Large decrease in estrogen and progesterone11 After age 70, decrease in leptin12