Strategies for Successful Aging

1. Strategies for Successful Aging Steve Swedlund, MD Program Director,Geriatric Fellowship WSUBSOM

2. ‘Strategies for Successful Aging’Learning objectives The learner shall: • Describe trends in aging in US, and World. • Recite 3 age-related physiologic changes for these organ systems: brain, eye, ear, cardiac, pulmonary, gastrointestinal, renal, genital, musculoskeletal, endocrine, immune. • Describe interventions to slow disease-related changes in organ functions. • Discuss ‘successful aging,’ and interventions for success.

3. GLOBAL AGING TRENDS The number of older adults is increasing faster in developing countries than in more developed countries Between 2006 and 2030, projected to increase by 140% vs. 50%, respectively Individuals ≥80 yr are the fastest-growing age group in the world Increasing at a rate of 3.8% per year Slide 3

4. DEMOGRAPHY OF AGINGIN THE US Slide 4

5. AGING OF THE US POPULATION (1 of 2) 2000 2030 Slide 5

6. AGING OF THE US POPULATION (2 of 2) Number of people 65 yr, in millions Slide 6

7. LIFE EXPECTANCY IN 2007 Slide 7

8. Life expectancy If the pace of increase in life expectancy in developed countries over the past two centuries continues, most babies born since 2000 will celebrate their 100th birthdays. The Lancet, 3 October 2009

9. fewer workers for each retiree

10. Physiology of Aging--Caveat • It is sometimes difficult to discern physiologic changes in the body from pathophysiology.

11. Brain • Can you describe changes in brain structure and function with aging?

12. Age-related Structural and Physiologic Changes in Brain • Brain mass decreases after age 30 years. • Tends to involve mild decline in memory. • More time needed to recall new information. • Learning tends to be slower.

13. Primary interventions to protect from cognitive decline? • Physical activity/exercise/leisure activities. • Avoid metabolic syndrome. • Do not smoke. • No clear role for nutrition, vitamins, food supplements, statins, antihypertensive or anti-inflammatory medications, avoiding alcohol. • Not a clear role for cognitive exercises. NIH State-of-the-Science Conference Statement on Preventing Alzheimer’s Disease and Cognitive Decline—April 26-28, 2010.

14. Sleep changes with aging • What happens?

15. Sleep changes with aging • Total sleep time increases. • Latency stays same or increases. • Frequency of waking after sleep onset increases. • Less REM sleep. • Sleep efficiency decreases. • More daytime napping.

16. Interventions to enhance sleep in older patient? • Establish bedroom for only sex or sleep (no TV, or other functions) • Physical activity/Exercise during the day. • Limit daytime napping to 30 minutes, or less. • Separate alcohol intake and sleep by at least 6 hours. • Limit caffeine to early in day, and limited amounts. • Limit fluid intake, after supper.

17. Vision and aging • What changes occur in the aging eye?

18. Physiologic Changes in Vision • Dynamic vision peaks at about age 18 years and then decreases. • Dark adaptation decreases with age, in a linear fashion. • Lens becomes less compliant, and leads to ‘presbyopia.’ • Lens becomes denatured and causes halos and glare around lights during acitivities at night (such as with driving at night).

19. Primary interventions to protect vision? • Use lenses to protect eyes from ultraviolet light.

20. Hearing and aging • What happens to the ear and hearing function with aging?

21. Ear/Hearing function with aging (1 of 2) • Cerumen becomes thicker and more tenacious. • Skin of auditory canal becomes thin. • TM gets thicker and appears duller. • Loss of Cochlear sensory hair cells. • Calcification of auditory structures. • Cochlear neuronal loss.

22. Hearing and Aging (2 of 2) • Hearing thresholds go up at higher frequencies (4000 to 6000 Hz), and this leads to ‘presbycusis.’ • Speech discrimination decreases, due to changes in central auditory processing.

23. The aging heart • What would you say happens to the heart with aging?

24. The aging heart • The heart and great vessels become less compliant. • Maximum Heart Rate decreases (220 bpm minus age=MHR). • Decrease in myocardial relaxation. • Beta adrenergic receptors in heart are less responsive to agonists (natural beta blockade). • Baroreceptors become less responsive.

25. Primary interventions for heart health? • Regular physical activity, strive for 150 minutes of moderate level activity per week. • Diet for keeping lipids low. • Avoid tobacco.

26. The lungs and aging • What happens to function of lungs?

27. Lungs and aging • Chest wall becomes less compliant. • Forced Vital Capacity decreases. • Forced Expiratory Volume at 1 second decreases. (25-30 ml/yr) • Residual Volume increases. • Pa02 decreases. (Pa02=110-(0.4 x age)) • A-a gradient increases. (A-a gradient= (age/4) plus 4)

28. Interventions to protect lungs? • Inhale clean air, do not smoke.

29. Kidneys and aging • How do you describe changes in renal function with aging?

30. The Aging Kidney • More loss of cortical nephrons, in relation to loss of medullary nephrons = less diluting and concentrating ability. • GFR decreases with aging; Cockroft-Gault formula: (140-age )(weight in Kg)(0.85 if female)/(72) (Serum Creatinine) = GFR • More free water is excreted in the later half of the day, as opposed to the first half of the day, as we age.

31. Bladder and aging • What happens with the bladder?

32. Bladder and aging (1 of 2) • Total bladder capacity tends to go down. • Detrusor contractility decreases. • Slower rate of expressing urine. • More random contractions. • Detrusor becomes overactive. • Lowering of estrogen in females associated with change in urethral mucosa, less ability to withstand increased intra-abdominal pressure.

33. Bladder and aging (2 of 2) • Males with 5-dihydro-testosterone reductase are developing prostatic hyperplasia, and then bladder outlet resistance. • Females have more UTIs than males from birth to age 80, and then males = females in rate of UTIs.

34. Sexual function • What are the 5 phases of sexual function? • How do the 5 phases change with aging?

35. Sexual function and aging • With respect to phases of sex (excitement, plateau, orgasm, resolution, and refractory period), • Excitement phase is prolonged. Vaginal lubrication is lessened. • Plateau phase is prolonged. • Orgasm is less intense, shorter, and may not occur. • Resolution is shorter. • Refractory period is prolonged.

36. Vagina and aging • How would you describe changes here?

37. Vagina and aging • Vaginal pH increases, and less likely to withstand infections. • Vaginal rugae become smaller. • Vaginal mucosa thins, with waning estrogen.

38. Aging Skin • Can you list things that occur with aging skin?

39. Aging Skin • Skin becomes thinner, and we reach more ‘definition’– that is we can see our tendons, muscles, and veins. • Subcutaneous layer thins. • Less capillaries per unit volume of skin. • Rete pegs flatten out. • Less sebaceous oil secreted onto skin. • Number of melanocytes decrease.

40. Interventions to protect skin? • Limit exposure to sunlight. • Apply moisturizers to skin daily, particularly within a few minutes after bathing.

41. Aging Musculoskeletal system • What happens with bones and muscles?

42. Aging musculoskeletal system • Bone mass peaks in 4th decade, and then decreases (more rapidly right after menopause in females). • Most of the bone loss is cancellous bone. • Number of muscle cells decreases (‘sarcopenia’ describes loss of muscle mass). • Strength tends to decrease, but this is may be affected by amount of exercise.

43. Primary interventions for bone and muscle? • Build bone at young age with calcium and vitamin D intake and exercise, and stay active with weight bearing activity; minimize alcohol intake. • Maintain muscle mass with exercise.

44. Endocrine changes with aging • What can you describe?

45. Endocrine system and aging • Nocturnal ADH secretion in younger patients becomes blunted in aging patient. (more free water excreted later in day) • Higher resting levels of catecholamines in blood circulation (but less responsive beta adrenergic receptors). • FSH and LH increase at menopause in females, as estrogen decreases. • Testosterone tends to decrease in males.

46. Endocrine and aging • TSH is unchanged. • T4 is unchanged. • Insulin resistance tends to increase.

47. Immune Function changes with aging • What would you say about immune function as we age?

48. Immune function and aging • Number of neutrophils does not change, nor does the adherence or chemotaxis functions, but the intracellular killing function decreases. • Marked decrease in T cells (shift from naïve to memory subtypes). • Moderate decrease in function of the natural killer cells.

49. Immune function with aging • IL-2 is markedly decreased, after stimulation. • Moderate decrease in delayed-type hypersensitivity.

50. Psychology of Aging • How we humans deal with stress is a BIG factor in health outcomes.