II. Biological Aspects of Aging

One of the most notable changes that occur as we age is our bodies change.  There is the common refrain, "Youth is wasted on the young."  This is probably understood only by those who no longer qualify as young, and there is probably nothing the aged miss more than a young and healthy body.  Even those in the best of shape find themselves running a little slower, jumping a little lower, and recovering slower still.  Aches no longer come and go, they come and linger.  For some, the aches include severe pain that is a constant companion, or a lack of physical control.  As Bette Davis said, "Old age is no place for sissies."  The following are common physical and biological concerns that face the aging.

A. Physical Challenges and Diseases

Difficulty with Hearing Vision and the Loss of Teeth

As we age hearing, sight and dental health often decline.  Trouble hearing can be especially frustrating to the elderly and to those around them.  The ability to hear impacts speaking and equilibrium, so a person who has trouble hearing may also have difficulty speaking, and feeling off balance or dizzy.  In a national survey of people 65 and over 47 percent of men and 30 percent of women reported having trouble hearing. (CDC 2002)

This can have very difficult social effects.  Some say that as you lose hearing you lose people.  In social gatherings it is difficult to stay engaged in conversations when not all the comments are heard.  Frustration over not being able to hear comments can produce anger displaced on those who are speaking.  Communication becomes more laborious and, after time, avoidance of communication can occur. 

Basic learned hand gestures used between the hearing impaired and loved ones can help increase communication.   This may vary in levels of sign language or just basic gestures that are shared and understood for communication. Since a great majority of communication is non-verbal, there is still much that can be communicated, especially with those with whom the hearing impaired is familiar.    Some who have lost hearing find comfort in the ability to communicate and interact with people through the Internet—emailing and message boards.  This provides the opportunity to exchange ideas and communicate without the usual frustrations.  Because of the more recent access to computers, many of the elderly have avoided its use.  The healthcare professional can help the person overcome their fear or indifference by showing them basic steps of communication over a computer.  Of course, this does not supplant the personal interactions emotionally important to most, but it can provide a feeling of competence and satisfaction lost in face-to-face interactions.

The advanced technology of hearing aids has also helped the elderly suffering from hearing loss maintain good social interaction.  Early hearing aids could only amplify all sounds without distinguishing volume or wave levels between things such as the human voice or cars on the road.  They also did not allow the hearer to distinguish the direction from which the sound was coming.  Newer hearing aids are able to do these things and have greatly improved the quality of social interactions and quality of life for those having difficulty hearing.

Vision can also decline for the elderly.  In a national survey  16 percent of men and 19 percent of women 65 and older reported having trouble with vision even with glasses and contacts on.  (CDC 2002)

This can affect many previously enjoyed activities, such as reading, watching television, and attending the theater or sporting events.  Depending on the severity of the vision trouble, it can also impede facial recognition, transportation issues (reading street signs or various public transportation signs), and also communication, especially non-verbal cues.

The same survey that inquired as to older persons' sight and hearing also surveyed to find the number who are affected by the loss of teeth.  The respondents were asked if they had lost all of their upper and lower teeth.  Twenty-six percent of men and 29 percent of women reported to having no natural teeth. (CDC 2002)  Technological advances in the area of dentures and dentistry has benefited the elderly a great deal.  However, having dentures still requires care for oral cleanliness and can affect the benefits some have in eating.

This survey illustrates some of the physical difficulties that disproportionately affect the elderly.  Each of these problems are important to assess and determine the affect it has on the client's quality of life and emotional well being.  Having these problems, along with others to follow, remind the elderly that they are getting older, manifested very often, in undesirable ways.

With all of these impairments there are community resources that can help the patient manage their symptoms.  The healthcare professional should look to fill each loss with a skill that improves day-to-day functioning.  This can become more difficult when the problems are as a result of disease.

Chronic Diseases and Causes of Death

In addition to problems with vision, hearing and teeth are common chronic diseases that affect the elderly.  The CDC also did a survey on a number of Chronic diseases that affect the elderly.  These statistics are illustrated in the table below. (CDC, 2002)

Each of these diseases has an impact on the quality of life for each patient.  Some of these diseases can start to define their lives and overcome the patient with both the fear of dying and the loss of health and activities.  The healthcare professional can assist in this area by assessing the following: 1) How the disease is impacting the patient. 2) What changes in lifestyle has it caused.  3) What pain is felt, how severe it is, how constant it is.  4) Is the pain all encompassing?  5) What feelings do they have about dying?  6) What are their greatest fears?  7) Do they still feel like they have purpose and enjoy meaningful activities?  8) Is there depression accompanying the other symptoms?  9) What is the content of their depressive thoughts (fear of pain or death, not seeing grandchildren grow, loss of functioning, the unknown of the disease's progress and how it will affect them in the future.   

In addition assessing for these problem areas, the healthcare practitionaer can assist the patient in finding appropriate activities to.  These can help increase physical health, create and expand advantageous social interactions and relationships and improve mental and emotional health.  The patient should have access to a physician to receive care and find out information about the disease(s).  Defining a disease and its potential progress can help the patient feel more in control of what is happening.  It will also help eliminate a many of the fears that the imagination can dream up.  

Causes of Death

Knowing the leading causes of death can encourage older people to change their lifestyles in order to live longer.  For instance, heart disease is still the number one cause of death among the elderly; however, heart disease as a cause of death among people 65 and older has declined during the last 20 years.  In 1981, over 2500 per 100,000 deaths were due to heart disease, while in 2001 this number had shrunk to approximately 1500 per 100,000.  This may be attributed to the emphasis on physical exercise, nutrition, and medical and pharmacological advances.  Malignant neoplasms, the second highest cause of death, held steady between 1981 and 2001 at just over 1000 per 100,000, while Cerebrovascular diseases dropped from about 650 to 400 per 100,000.  Chronic lower respiratory diseases and influenza/pneumonia stayed about the same through the twenty years, as did Diabetes mellitus, the 6^th leading cause of death of about 100 out of 100,000 older people (CDC 2002).

B.  Health and Nutrition

Health and nutrition are important for a person's health at any age.  For those getting older, it becomes increasingly important to be aware of diet and nutrition.  The following are guidelines provided by the U.S. Department of Health and Human Services (HHS) and the U.S. Department of Agriculture (USDA).  Each recommendation of guidelines provides further guidelines for special populations, such as the aged.  

ADEQUATE NUTRIENTS WITHIN CALORIE NEEDS

Key Recommendations

• Consume a variety of nutrient-dense foods and beverages within and among the basic food groups while choosing foods that limit the intake of saturated and trans fats, cholesterol, added sugars, salt, and alcohol.
• Meet recommended intakes within energy needs by adopting a balanced eating pattern, such as the USDA Food Guide or the DASH Eating Plan.

Key Recommendations for Specific Population Groups

• People over age 50. Consume vitamin B₁₂ in its crystalline form (i.e., fortified foods or supplements).
• Women of childbearing age who may become pregnant. Eat foods high in heme-iron and/or consume iron-rich plant foods or iron-fortified foods with an enhancer of iron absorption, such as vitamin C-rich foods.
• Women of childbearing age who may become pregnant and those in the first trimester of pregnancy. Consume adequate synthetic folic acid daily (from fortified foods or supplements) in addition to food forms of folate from a varied diet.
• Older adults, people with dark skin, and people exposed to insufficient ultraviolet band radiation (i.e., sunlight). Consume extra vitamin D from vitamin D-fortified foods and/or supplements.

WEIGHT MANAGEMENT

Key Recommendations

• To maintain body weight in a healthy range, balance calories from foods and beverages with calories expended.
• To prevent gradual weight gain over time, make small decreases in food and beverage calories and increase physical activity.

Key Recommendations for Specific Population Groups

• Those who need to lose weight. Aim for a slow, steady weight loss by decreasing calorie intake while maintaining an adequate nutrient intake and increasing physical activity.
• Overweight children. Reduce the rate of body weight gain while allowing growth and development. Consult a healthcare provider before placing a child on a weight-reduction diet.
• Pregnant women. Ensure appropriate weight gain as specified by a healthcare provider.
• Breastfeeding women. Moderate weight reduction is safe and does not compromise weight gain of the nursing infant.
• Overweight adults and overweight children with chronic diseases and/or on medication. Consult a healthcare provider about weight loss strategies prior to starting a weight-reduction program to ensure appropriate management of other health conditions.

PHYSICAL ACTIVITY

Key Recommendations

• Engage in regular physical activity and reduce sedentary activities to promote health, psychological well-being, and a healthy body weight.
• To reduce the risk of chronic disease in adulthood: Engage in at least 30 minutes of moderate-intensity physical activity, above usual activity, at work or home on most days of the week.
• For most people, greater health benefits can be obtained by engaging in physical activity of more vigorous intensity or longer duration.
• To help manage body weight and prevent gradual, unhealthy body weight gain in adulthood: Engage in approximately 60 minutes of moderate- to vigorous-intensity activity on most days of the week while not exceeding caloric intake requirements.
• To sustain weight loss in adulthood: Participate in at least 60 to 90 minutes of daily moderate-intensity physical activity while not exceeding caloric intake requirements. Some people may need to consult with a healthcare provider before participating in this level of activity.
• Achieve physical fitness by including cardiovascular conditioning, stretching exercises for flexibility, and resistance exercises or calisthenics for muscle strength and endurance.

Key Recommendations for Specific Population Groups

• Children and adolescents. Engage in at least 60 minutes of physical activity on most, preferably all, days of the week.
• Pregnant women. In the absence of medical or obstetric complications, incorporate 30 minutes or more of moderate-intensity physical activity on most, if not all, days of the week. Avoid activities with a high risk of falling or abdominal trauma.
• Breastfeeding women. Be aware that neither acute nor regular exercise adversely affects the mother's ability to successfully breastfeed.
• Older adults. Participate in regular physical activity to reduce functional declines associated with aging and to achieve the other benefits of physical activity identified for all adults.

FOOD GROUPS TO ENCOURAGE

Key Recommendations

• Consume a sufficient amount of fruits and vegetables while staying within energy needs. Two cups of fruit and 21/2 cups of vegetables per day are recommended for a reference 2,000-calorie intake, with higher or lower amounts depending on the calorie level.
• Choose a variety of fruits and vegetables each day. In particular, select from all five vegetable subgroups (dark green, orange, legumes, starchy vegetables, and other vegetables) several times a week.
• Consume 3 or more ounce-equivalents of whole-grain products per day, with the rest of the recommended grains coming from enriched or whole-grain products. In general, at least half the grains should come from whole grains.
• Consume 3 cups per day of fat-free or low-fat milk or equivalent milk products.

Key Recommendations for Specific Population Groups

• Children and adolescents. Consume whole-grain products often; at least half the grains should be whole grains. Children 2 to 8 years should consume 2 cups per day of fat-free or low-fat milk or equivalent milk products. Children 9 years of age and older should consume 3 cups per day of fat-free or low-fat milk or equivalent milk products.

FATS

Key Recommendations

• Consume less than 10 percent of calories from saturated fatty acids and less than 300 mg/day of cholesterol, and keep trans fatty acid consumption as low as possible.
• Keep total fat intake between 20 to 35 percent of calories, with most fats coming from sources of polyunsaturated and monounsaturated fatty acids, such as fish, nuts, and vegetable oils.
• When selecting and preparing meat, poultry, dry beans, and milk or milk products, make choices that are lean, low-fat, or fat-free.
• Limit intake of fats and oils high in saturated and/or trans fatty acids, and choose products low in such fats and oils.

Key Recommendations for Specific Population Groups

• Children and adolescents. Keep total fat intake between 30 to 35 percent of calories for children 2 to 3 years of age and between 25 to 35 percent of calories for children and adolescents 4 to 18 years of age, with most fats coming from sources of polyunsaturated and monounsaturated fatty acids, such as fish, nuts, and vegetable oils.

CARBOHYDRATES

Key Recommendations

• Choose fiber-rich fruits, vegetables, and whole grains often.
• Choose and prepare foods and beverages with little added sugars or caloric sweeteners, such as amounts suggested by the USDA Food Guide and the DASH Eating Plan.
• Reduce the incidence of dental caries by practicing good oral hygiene and consuming sugar- and starch-containing foods and beverages less frequently.

SODIUM AND POTASSIUM

Key Recommendations

• Consume less than 2,300 mg (approximately 1 tsp of salt) of sodium per day.
• Choose and prepare foods with little salt. At the same time, consume potassium-rich foods, such as fruits and vegetables.

Key Recommendations for Specific Population Groups

• Individuals with hypertension, blacks, and middle-aged and older adults. Aim to consume no more than 1,500 mg of sodium per day, and meet the potassium recommendation (4,700 mg/day) with food.

ALCOHOLIC BEVERAGES

Key Recommendations

• Those who choose to drink alcoholic beverages should do so sensibly and in moderation—defined as the consumption of up to one drink per day for women and up to two drinks per day for men.
• Alcoholic beverages should not be consumed by some individuals, including those who cannot restrict their alcohol intake, women of childbearing age who may become pregnant, pregnant and lactating women, children and adolescents, individuals taking medications that can interact with alcohol, and those with specific medical conditions.
• Alcoholic beverages should be avoided by individuals engaging in activities that require attention, skill, or coordination, such as driving or operating machinery.

FOOD SAFETY

Key Recommendations

• To avoid microbial foodborne illness:
• Clean hands, food contact surfaces, and fruits and vegetables. Meat and poultry should not be washed or rinsed.
• Separate raw, cooked, and ready-to-eat foods while shopping, preparing, or storing foods.
• Cook foods to a safe temperature to kill microorganisms.
• Chill (refrigerate) perishable food promptly and defrost foods properly.
• Avoid raw (unpasteurized) milk or any products made from unpasteurized milk, raw or partially cooked eggs or foods containing raw eggs, raw or undercooked meat and poultry, unpasteurized juices, and raw sprouts.

Key Recommendations for Specific Population Groups

• Infants and young children, pregnant women, older adults, and those who are immunocompromised. Do not eat or drink raw (unpasteurized) milk or any products made from unpasteurized milk, raw or partially cooked eggs or foods containing raw eggs, raw or undercooked meat and poultry, raw or undercooked fish or shellfish, unpasteurized juices, and raw sprouts.
• Pregnant women, older adults, and those who are immunocompromised: Only eat certain deli meats and frankfurters that have been reheated to steaming hot.

C. General Health Trends and Costs

Good to Excellent Health

Older people reporting good to excellent health differed according to ethnicity.  Those 65 and over reporting good to excellent health were 76% of whites, 59% of blacks and 63% of Hispanics.  As would be expected, the percentage of those enjoying good health declined as age increased.  Those between the ages of 65 and 74 who reported enjoying good health included 80% of whites, 62% of blacks and 65% of Hispanics, as compared to 67% of whites, 52% of blacks and 53% of Hispanics 85 and older.  Although health does decline with age, some might see it as impressive that the majority report good to excellent health after the age of 85.  (CDC 2002)

Obesity

The percentage of men and women between the ages of 65 and 74 reported to be obese has risen over the last four decades,  as has the percentage of those between the ages of 75 and over.  However, those 75 and over have nearly a 10% lower rate in obesity, than the younger group.  This may be a result of death causing the obese to pass away before reach the years after 74.  It is also interesting to note that even though obesity has gone up an estimated 15-20% since the early 1980's, death from heart disease has declined.  (CDC, 2002)

Medicare, Medication and Healthcare Costs

Hospital stays for those covered by Medicare showed a proportional increase from 300/1000 hospital stays by Medicare enrollees in 1992 to about 350/1000 in 2001. A higher percent age increase was found in those staying in skilled nursing facilities (nursing homes) which increase from about 30/1000 to 70/1000 of Medicare enrollees. (CMM 2002)

The average annual health care costs for Medicare enrollees went up from 1992 to 2001.  Measuring in 2001 dollars, a medicare current beneficiary survey found that costs went up the following:

(CMM 2002)

These benefit costs were broken down in the following specific categories of health care costs:

The average annual prescription drug costs and sources of payment among noninstitutionalized Medicare enrollees from 1992-2000 are as follows:

This illustrates a large percentage increase for prescription drug costs.  Beginning January 1, 2006 the funding from public programs (Medicare) will increase greatly as the Medicare Prescription Drug Program goes into effect.  The following "Quick Facts" for seniors regarding the plan are available at the Health and Human Services Website, Centers for Medicare & Medicaid Services at the following link: http://www.cms.hhs.gov/medicarereform/newcovprescdrug.pdf

If you join, your costs will vary depending on which plan you choose. In general, you pay a monthly premium (generally around $37 in 2006) and a yearly deductible (up to the first $250 in 2006). You will also pay a share of your prescription drug costs, and your plan pays a share. Medicare helps pay for drugs up to a limit ($2,250 in total) and once your total out-of-pocket costs for drugs reach $3,600, you pay 5% of the costs and Medicare pays 95% of the costs for the rest of the year.

• Many people with limited income and resources will get extra help paying for their prescription drug coverage. People with the lowest incomes and resources will get the most help. Those in this group should have received  information in the mail in the summer of 2005 from the Social Security Administration (SSA) or from Medicare telling them what to do. [After 2006 seniors should receive this information as they approach the age to qualify for coverage].

What if I already have prescription drug coverage?

If you already have prescription drug coverage through your Medicare private health plan or other insurance, check with your current plan to see if this coverage is changing. Unless you have other drug coverage that is, on average, at least as good as standard Medicare prescription drug coverage, it's important for you to join a Medicare prescription drug plan when you are first eligible. For most people, joining when you are first eligible means you will pay a lower monthly premium than if you wait to join until later. (USHHS 2005)

D. Memory Impairment

Often as we age our memory suffers.  For the majority, this impairment is mild and does not cause problems beyond being a nuisance.  For others, the impairment is more severe and is troublesome both to family and to the patient.  Sometimes the memory impairment creates an issue of safety when stoves are left on or the person wanders and gets lost.  In even more severe cases the senior may not remember significant life experiences and/or lose the ability to identify loved ones, including children and spouse.  Memory impairment that creates issues of safety often leads to the discussion of the need for alternative long term care.  

The following table provides an illustration of the frequency of memory problems among older Americans.  Specifically it reports the percentage of people age 65 and older with moderate or severe memory impairment, by age group

                                                        (HRS 2005)

There are different studies that examine what causes memory impairment.  According to Marsha K. Johnson, Yale University, source monitoring has great impact in how someone remembers, and this function is processed by the frontal lobes.  Being able to process information and then tie these experiences together so they make sense-such as the environment in which the memory occurred.  For example, if somebody goes to the beach with friends they will gather and process information i.e.:  the friends there, the sites and sounds of the ocean and the wind, etc.  Being able to tie all these details together helps people create accurate memories.  Damage to the frontal lobes can cause a person to gather less specific information, resulting in a less accurate memory and even false memories. Johnson elaborates:

"Neuro-imaging experiments along with the patient data suggest that the frontal lobes are important in monitoring the source of memory. So, we also know that children do less well under certain circumstances in source monitoring tasks. We also know that older adults do less well under certain circumstances in source monitoring tasks than do healthy, young adults. They are poorer on source recognition than on old-new recognition. Investigators have suggested that this occurs because the frontal lobes are among the slower to mature regions, and they are also more likely to show increasing neuropathology with age." (Johnson 2003)

Alzheimers

Alzheimers is a progressive brain disease that gradually destroys a person's memory, ability to learn and make judgments, etc.  The disease kills brain cells that eventually will kill a person if they do not die first of something else.  The progress of the disease can take between 3 and 20 years. (ALZ 2005) Although a person may have recently been diagnosed with the disease, the progress of the disease may actually be advanced. Early signs of the disease include a decreased ability to: recall recent events, make decisions and judgments, manage routine chores, express thoughts and feelings, process what was said by others and handle complex tasks. (ALZ 1999)

The changes that occur as a result of Alzheimers can affect the diagnosed individual and loved ones.  Reactions to these changes can include depression, anxiety, fear, embarrassment, shame, isolation, loneliness, and feeling of loss.  In response to these reactions the Alzheimers Association suggests the following ways a healthcare professional can help:

• Acknowledge feelings and provide an opportunity to talk and ask questions. 

·        Refer the individual and their family to an Alzheimers support group.

·        Assess for depression and /or suicidal thoughts.  Short term counseling and medication may be helpful in some cases.

·        Refer families to a physician knowledgeable in dementia for evaluation and treatment.

·        Encourage the diagnosed individual and the caregiver to take care of his or her physical and mental health.

                                                                  (ALZ 1999)