Geriatric nursing16 hours A.

The Aging Population Although individuals age at an inevitable and steady pace from birth to death, the aging of society is neither inevitable nor uniform. Populations age when the proportion of older people relative to that of younger people increases. Aging of population (also known as demographic aging, and population aging) is a summary term for shifts in the age distribution (i.e., age structure) of a population toward older ages. A direct consequence of the ongoing global fertility transition (decline) and of mortality decline at older ages, population aging is expected to be among the most prominent global demographic trends of the 21st century. Population aging is progressing rapidly in many industrialized countries, but those developing countries whose fertility declines began relatively early also are experiencing rapid increases in their proportion of elderly people. This pattern is expected to continue over the next few decades, eventually affecting the entire world. Population aging has many important socio-economic and health consequences, including the increase in the old-age dependency ratio. It presents challenges for public health (concerns over possible bankruptcy of Medicare and related programs) as well as for economic development (shrinking and aging of labor force, possible bankruptcy of social security systems). The Nurses Role in Health Promotion for Older Adults The aging of our society is the dominant demographic phenomenon of our time. Three of the four most common causes of death among older adultsheart diseases, cancer, and strokeare the result of an unhealthy lifestyle. However, the gloomy image of an aging nation of sedentary, chronically ill older adults is gradually being replaced by new concepts such as successful aging, and compression of morbidity. Within the context of these new concepts, health protection and health promotion have emerged as appropriate frameworks for a care of older adults. Professionals caring for older adults are recognizing that prevention for a 65-year-old person, who can be expected to live another 17.5 years, is a necessary component of health care. Who are the older adults? Development of this approach required consideration of who older adults are and what constitutes successful aging, as well as health promotion and prevention for this segment of the population. We know that older adults are a heterogeneous group. Each older adult represents a unique set of goals, experiences, values and attitudes. What is successful aging? Successful aging is defined as the ability to maintain three key behaviors or characteristics: a low risk of disease and disease-related disability; high mental and physical function; and active engagement in life. These three aspects are not unrelated. Rather, the combination of all three represents the concept of successful aging most clearly. Avoiding disease and disability places an emphasis on the role of lifestyle factors in the development of chronic diseases such as diabetes, hypertension, osteoporosis, and heart disease. Maintaining mental and physical function is critical to remaining independent in all activities of daily living. Continuing to be engaged in life captures the essence of the needs of the human spiritto be connected to others in a meaningful and satisfying manner. Nursing practice in this segment of the population must incorporate these parameters. B. Theories of Aging There are many theories of aging, but few are widely accepted. Aging proceeds at different rates in different species. Even within a species, aging proceeds at different rates among individuals. A reasonable

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conclusion is that aging must be genetically controlled, at least to some extent. Both within and between species, lifestyle and exposures may alter the aging process. Some theories of aging focus on what controls the degenerative and entropic processes that occur with aging and why the controls exist as they do. Other theories focus on the evolutionary origins of senescence. All of these theories generally agree that senescence does not offer a genetic advantage and developed mainly because it is not selected against. Biological Theories Biological theories attempt to explain the physical process of aging, including alterations in structure and function, development, longetivity and death. It also attempts to explain why people age differently over time and what factors affect longetivity, resistance to organisms, and cellular alterations or death. An understanding of the biological perspective can provide the nurse with knowledge about specific risk factors associated with aging and about how people can be helped minimize or avoid risk and maximize health. *Genetic Theory Some scientists regard this as a Planned Obsolescence Theory because it focuses upon the encoded programming within our DNA. Our DNA is the blue-print of individual life obtained from our parents. It means we are born with a unique code and a predetermined tendency to certain types of physical and mental functioning that regulate the rate at which we age. But this type of genetic clock can be greatly influenced with regard to its rate of timing. For example, DNA is easily oxidized and this damage can be accumulated from diet, lifestyle, toxins, pollution, radiation and other outside influences. Thus, we each have the ability to accelerate DNA damage or slow it down. One of the most recent theories regarding gene damage has been the Telomerase Theory of Aging. First discovered by scientists at the Geron Corporation, it is now understood that telomeres (the sequences of nucleic acids extending from the ends of chromosomes), shorten every time a cell divides. This shortening of telomeres is believed to lead to cellular damage due to the inability of the cell to duplicate itself correctly. Each time a cell divides it duplicates itself a little worse than the time before, thus this eventually leads to cellular dysfunction, aging and indeed death. *Wear and Tear Theory The Wear and Tear Theory proposes that the cumulative damage to vital irreplaceable body parts leads to the death of cells, tissues, organs, and finally the whole body. Thus, cumulative damage to DNA leads to a decline in cell function. The problem with this theory is that there are no research models that give credible support at this time. *Environmental Theory According to this theory, factors in the environment (e.g., industrial carcinogens, sunlight, trauma, and infection) bring about changes in the aging process. Although these factors are known to accelerate aging, the impact of the environment is a secondary rather than a primary factor in aging. Nurses can have a profound impact on this aspect of aging by educating all age groups about the relationship between environmental factors and accelerated aging. Science is only beginning to uncover the many environmental factors that affect aging. *Immunity Theory As the body ages, the immune system is less able to deal with foreign organisms & increasingly make mistakes by identifying ones own tissues as foreign (thus attacking them). These altered abilities result in increased susceptibility to disease & to abnormalities that result form autoimmune responses.

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*Neuroendocrine Theory First proposed by Professor Vladimir Dilman and Ward Dean MD, this theory elaborates on wear and tear by focusing on the neuroendocrine system. This system is a complicated network of biochemicals that govern the release of hormones which are altered by the walnut sized gland called the hypothalamus located in the brain. The hypothalamus controls various chain-reactions to instruct other organs and glands to release their hormones etc. The hypothalamus also responds to the body hormone levels as a guide to the overall hormonal activity. But as we grow older the hypothalamus loses it precision regulatory ability and the receptors which uptake individual hormones become less sensitive to them. Accordingly, as we age the secretion of many hormones declines and their effectiveness (compared unit to unit) is also reduced due to the receptors down-grading. Psychological Theories These theories focus on behavior and attitude changes that accompany advancing age, as opposed to the biological implications of anatomic deterioration. *Disengagement Theory Refers to an inevitable process in which many of the relationships between a person and other members of society are severed & those remaining are altered in quality. Withdrawal may be initiated by the aging person or by society, and may be partial or total. It was observed that older people are less involved with life than they were as younger adults. As people age they experience greater distance from society & they develop new types of relationships with society. In America there is evidence that society forces withdrawal on older people whether or not they want it. Some suggest that this theory does not consider the large number of older people who do not withdraw from society. This theory is recognized as the 1 st formal theory that attempted to explain the process of growing older. *Activity Theory This is another theory that describes the psychosocial aging process. Activity theory emphasizes the importance of ongoing social activity. This theory suggests that a person's self-concept is related to the roles held by that person i.e. retiring may not be so harmful if the person actively maintains other roles, such as familial roles, recreational roles, volunteer & community roles. To maintain a positive sense of self the person must substitute new roles for those that are lost because of age. And studies show that the type of activity does matter, just as it does with younger people. *Continuity Theory This theory states that older adults try to preserve & maintain internal & external structures by using strategies that maintain continuity. It means that older people may seek to use familiar strategies in familiar areas of life. In later life, adults tend to use continuity as an adaptive strategy to deal with changes that occur during normal aging. Continuity theory has excellent potential for explaining how people adapt to their own aging. Changes come about as a result of the aging person's reflecting upon past experience & setting goals for the future. C. Geriatric Assessment Introduction A multidimensional process designed to assess an elderly person's functional ability, physical health, cognitive and mental health, and socioenvironmental situation.

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Comprehensive geriatric assessment differs from a standard medical evaluation by including nonmedical domains, by emphasizing functional ability and quality of life, and, often, by relying on interdisciplinary teams. This assessment aids in the diagnosis of health-related problems, development of plans for treatment and follow-up, coordination of care, determination of the need for and the site of longterm care, and optimal use of health care resources. Geriatric assessment programs vary widely in purpose, comprehensiveness, staffing, organization, and structural and functional components. Most attempt to target their services to high-risk elderly persons and to couple their assessment results with sustained individually tailored interventions (eg, rehabilitation, education, counseling, supportive services). Comprehensive geriatric assessment of frail or chronically ill patients can improve their care and clinical outcomes. The possible benefits include greater diagnostic accuracy, improved functional and mental status, reduced mortality, decreased use of nursing homes and acute care hospitals, and greater satisfaction with care. However, the cost of comprehensive geriatric assessment programs has limited their use. Although some cost-effectiveness evaluations suggest that these programs can save money, few programs operate in integrated care systems that can track these savings. Wide use of comprehensive geriatric assessment programs has thus been slow to develop. An alternative approach is to conduct less extensive assessments in primary care offices or emergency departments. To identify elderly persons who might benefit from assessment (in a special comprehensive geriatric assessment unit or in a primary care setting), some health care organizations mail multidimensional self-administered health questionnaires to elderly populations. Responses are scored according to defined algorithms, and reports of high-risk conditions and behaviors are sent to the patients and their primary care physicians to stimulate more detailed follow-up evaluation and treatment. Other organizations identify candidates for assessment by interviewing elderly persons in their homes or meeting places (eg, meal sites, senior centers, places of worship). Family members who are concerned about an elderly relative's health or functional abilities may also arrange referrals for geriatric assessment. History and Physical Assessment The approach to the history and physical examination sometimes needs to be modified for elderly patients, especially those who are very old or frail. History-taking and physical examination may have to be done at different times, and physical examination may require 2 sessions because a patient is fatigued. If possible, a physician should interview the caregiver as well as the patient; usually, each should be interviewed separately for at least part of the session. History Geriatric Essentials

Unless corrected, sensory deficits, especially hearing deficits, may interfere with history-taking. Many disorders in the elderly manifest solely as functional decline. As part of the drug history, the patient or a family member should be asked to bring in the patient's Health care practitioners must often interview caregivers to obtain the history of functionally Frail elderly patients with complex conditions (eg, multiple disorders, use of several drugs) often

prescription and OTC drugs at the initial visit and periodically thereafter. dependent elderly patients.

require assessment by an interdisciplinary team. Physicians often need to spend more time interviewing and evaluating elderly patients than younger patients. When elderly patients present with many nonspecific symptoms, structuring and focusing the interview may be difficult and require more time. Sensory deficits (eg, hearing or vision deficits), which are common among elderly people, can interfere with the interview. Elderly patients may underreport

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symptoms that they consider a part of normal aging (eg, dyspnea, hearing or vision deficits, problems with memory, incontinence, gait disturbance, constipation, dizziness, falls). However, no symptom should be attributed to normal aging unless a thorough evaluation is done and other causes have been eliminated. In elderly patients, clinical features of disorders may differ from those in younger patients. Disorders may manifest solely as functional decline. In such cases, standard questions may not apply. For example, when asked about joint symptoms, patients with severe arthritis may not report pain, swelling, or stiffness, but if asked about changes in activities, they may report that they no longer take walks or no longer volunteer at the hospital. Questions about duration of functional decline (eg, "How long have you been unable to do your own shopping?") can elicit useful information. Identifying people when they have just started to have difficulty doing basic activities of daily living (ADLs) or instrumental ADLs may provide more opportunities for interventions to restore function or to prevent further decline and thus maintain independence. Elderly patients with cognitive dysfunction may have difficulty recalling past illnesses, hospitalizations, operations, and drug use; a physician may have to obtain these data from an alternative source (eg, family members, home health aide, medical records). The main problem reported by the patient may differ from that reported by family members. Frail elderly patients with complex conditions, especially patients who have multiple disorders or who take several drugs, often require assessment by an interdisciplinary team. Such a team typically consists of some combination of physician, nurse, pharmacist, nutritionist, physical therapist, occupational therapist, and social worker. Team members evaluate from their own perspectives, then meet to discuss their findings and develop a single treatment plan that considers the patient's functional status, resources, and the many potential interactions between different disorders and drugs. *Medical History When asking patients about their past medical history, a physician should ask about disorders that used to be more common (eg, rheumatic fever, poliomyelitis) and about outdated treatments (eg, pneumothorax therapy for TB, mercury for syphilis). A history of immunizations (eg, tetanus, influenza, pneumococcus), adverse reactions to immunizations, and skin test results for TB is needed. If the patient recalls having surgery but does not remember the procedure or its purpose, surgical records should be obtained if possible. Questions designed to systematically review each body area or system are asked to check for other disorders and common problems that patients may have forgotten to mention. *Drug History The drug history should be recorded; a flow sheet is often useful. A copy should be given to the patient or caregiver. The drug history includes the drugs used, dose, dosing schedule, prescriber, and reason for prescribing the drugs. Topical drugs must be included, partly because they may be absorbed systemically; eg, -blocker eyedrops for treating glaucoma can have cardiovascular and pulmonary effects that may be comparable to those of -blockers taken po or given IV. OTC drugs must be included. Their overuse can have serious consequences (eg, diarrhea due to laxative use, salicylism due to aspirin use, GI or renal toxicity due to NSAID use), and their use may affect drug prescriptions (eg, when OTC acetaminophen is taken, the amount of prescribed analgesics that contain acetaminophen must be limited). Dietary supplements and medicinal herb preparations must also be included because many can interact adversely with prescription and OTC drugs; for example, ginkgo biloba extract taken with NSAIDs or warfarin increases risk of spontaneous bleeding. Also, the precise nature of any drug allergies should be determined.

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The patient or a family member should be asked to bring in all of the patient's prescription and OTC drugs, dietary supplements, and medicinal herb preparations at the initial visit and periodically thereafter. However, the patient's possession of current prescription drugs does not guarantee the patient's adherence to the treatment regimen. Counting the number of tablets in each vial during the first and subsequent visits may be necessary. If someone other than the patient administers the drugs, that person is interviewed. Patients should demonstrate their ability to read labels (often printed in small type) and open containers (especially the child-resistant type). Patients should also demonstrate their ability to recognize drugs, which may be difficult to differentiate if patients put the drugs into one container. *Alcohol, tobacco and recreational drug use History Tobacco and alcohol use are recorded. Patients who smoke should be counseled to stop. They should also be warned against smoking in bed because elderly people are more likely to fall asleep while doing so. Patients should be checked for signs of alcohol use disorders, which are underdiagnosed in elderly people. Such signs include confusion, anger, hostility, alcohol odor on the breath, impaired balance and gait, tremors, peripheral neuropathy, and nutritional deficiencies. Screening questionnaires (eg, CAGE questionnaire) and questions about quantity and frequency of alcohol consumption are effective means for identifying patients with an alcohol use disorder. Questions about use of other recreational drugs or substances of abuse are appropriate. *Nutrition History The type, quantity, and frequency of food eaten are determined. People who eat <= 2 meals a day are at risk of undernutrition. Any special diets (eg, low-salt, low-carbohydrate) or self-prescribed fad diets are noted. Intake of dietary fiber and prescribed or OTC vitamins is recorded. Asking about weight loss and change of fit in clothing is also important. The amount of money a patient has to spend on food, accessibility of food stores, and access to suitable kitchen facilities should be determined. The variety and freshness of foods is also important; many elderly people are limited to bread products and canned foods. The patient's ability to eat (eg, to chew and swallow) is evaluated. It may be impaired by xerostomia, which is common among elderly people. Decreased taste or smell may reduce the pleasure of eating, so patients may eat less. Patients with decreased vision, arthritis, immobility, or tremors may have difficulty preparing meals and may injure or burn themselves when cooking. Patients who are worried about urinary incontinence may reduce their fluid intake; as a result, they may eat less food. *Mental Health History Mental health problems may not be detected as easily in elderly patients as in younger patients. Insomnia, changes in sleep patterns, constipation, cognitive dysfunction, anorexia, weight loss, fatigue, preoccupation with bodily functions, and increased alcohol consumption are common symptoms. The patient should be asked about delusions and hallucinations, past mental health care (including psychotherapy, institutionalization, and electroconvulsive therapy), use of psychoactive drugs, and recent changes in circumstances. Sadness, hopelessness, and crying episodes may indicate depression. Many circumstances (eg, recent loss of a loved one, including a pet; hearing loss; a change in residence or living situation; loss of independence) may contribute to depression. Irritability may be the primary affective symptom of depression, or patients may present with cognitive dysfunction. Patients' spiritual and religious preferences, including their personal interpretation of aging, declining health, and death, are clarified. *Functional Status Evaluating the patient's functional status is part of comprehensive geriatric assessment. The evaluation is done to find out whether patients can function independently, need some help with basic or

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instrumental ADLs, or need total assistance. Patients may be asked open-ended questions about their ability to do activities or be asked to fill out a standardized assessment instrument with questions about specific basic and instrumental ADLs (eg, Katz ADL Scale, Lawton IADL Scale). *Social History Social history includes evaluation of the patient's living arrangements, possibly best done by visiting the home. The number of rooms, number and type of phones, presence of smoke and carbon monoxide detectors, and condition of plumbing and heating system are determined, as is the availability of elevators, stairs, and air conditioning. Home safety evaluations can identify home features that can lead to falls (eg, poor lighting, slippery bathtubs, unanchored rugs), and solutions can be suggested. Having the patient describe a typical day, including activities such as reading, television viewing, work, exercise, hobbies, and interactions with others, provides valuable information. The patient is asked about the frequency and nature of social contacts (eg, friends, senior citizens' groups), family visits, and religious or spiritual participation. The patient should also be asked about driving and availability of other forms of transportation. Caregivers and support systems (eg, church, senior citizens' groups, friends, neighbors) that are available to the patient are identified. The ability of family members to help the patient (eg, their employment status, their health, traveling time to the patient''s home) is determined. The patient's attitude toward family members and their attitude toward the patient (including their level of interest in helping and willingness to help) are explored. Drug abuse and patient abuse by the caregiver should be considered when appropriate. The patient's marital status is noted. Questions about sexual practices and satisfaction must be sensitive and tactful but thorough. The number and sex of sex partners are determined, and risk of sexually transmitted diseases is evaluated. Many sexually active elderly people do not know about safe sex practices. The patient should be asked about educational level, jobs held, known exposures to radioactivity or asbestos, and current and past hobbies. Economic difficulties due to retirement, a fixed income, or death of a spouse or partner are discussed. Financial or health problems may result in loss of a home, social status, or independence. The patient should be asked about past relationships with physicians; a longtime relationship with a physician may have been lost because the physician retired or died or because the patient relocated. The patient's wishes regarding measures for prolonging life must be documented. The patient is asked what provisions for surrogate decision making have been made in case the patient becomes incapacitated, and if none have been made, the patient is encouraged make them. Physical Examination Geriatric Essentials Valuable information about a patient's function can be gained by observing the patient and the patient's movements. Physical examination should include all systems, particularly mental status, and may require 2 sessions. Observing the patient and the patient's movements (eg, walking into the examination room, sitting in or rising from a chair, getting on and off an examination table, taking off or putting on socks and shoes) can provide valuable information about a patient's function. The patient's personal hygiene (eg, state of dress, cleanliness, smell) should be noted; it may provide information about mental status and the ability to care for self.

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Two sessions may be needed for the physical examination because patients may become fatigued. Elderly patients may require additional time to undress and transfer to the examining table; they should not be rushed. The examining table is adjusted to a height that the patient can easily access; a footstool facilitates mounting. Frail patients must not be left alone on the table. Portions of the examination may be more comfortable if the patient sits in a chair. The patient's general appearance is described (eg, comfortable, restless, malnourished, inattentive, pale, dyspneic, cyanotic). If the patient is examined at bedside, use of protective padding or a protective mattress, bedside rails (partial or full), restraints, a urinary catheter, or an adult diaper is noted. *Vital Signs Weight should be recorded at each visit. During measurement of height and weight, patients with balance problems may need to grasp grab bars placed near or on the scale. Temperature is recorded. Hypothermia can be missed if the thermometer cannot measure temperatures more than a few degrees lower than normal. Absence of fever does not exclude infection. Pulses and BP are checked in both arms. The pulse is taken for 30 sec, and any irregularity is noted. Because many factors can alter BP, BP is measured several times after the patient has rested > 5 min. BP may be overestimated in elderly patients because their arteries are stiff. This condition, called pseudo hypertension, should be suspected if patients develop symptoms of dizziness when antihypertensive drug therapy is increased to treat elevated systolic BP. All elderly patients are checked for orthostatic hypotension because it is common. BP is measured with the patient in the supine position, then after the patient has been standing for 3 to 5 min. If systolic BP falls >= 20 mm Hg, orthostatic hypotension is diagnosed. Caution is required when testing hypovolemic patients. A normal respiratory rate in elderly patients may be as high as 25breaths/min. A rate of > 25 breaths/min may be the first sign of a lower respiratory tract infection, heart failure, or another disorder. *Skin Initial observation includes color (normal rubor, pale, cyanotic). Examination includes a search for premalignant and malignant lesions, tissue ischemia, and pressure ulcers. Unexplained bruises may indicate abuse. Because the dermis thins with age, ecchymoses may occur readily when skin is traumatized, often on the forearm. Uneven tanning may be normal because melanocytes are progressively lost with aging. Longitudinal ridges on the nails and absence of the crescent-shaped lunula are normal age-related findings. With aging, the nail plate thins and becomes prone to fracture. Black splinter hemorrhages in the middle or distal 1/3 of the fingernail are more likely to be due to trauma than to bacteremia. A thickened, yellow toenail indicates onychomycosis, a fungal infection. Toenail borders that curve in and down indicate ingrown toenail (onychocryptosis). Whitish nails that scale easily, sometimes with a pitted surface, indicate psoriasis. Page *Head and Neck

Face: Normal age-related findings may include the following: eyebrows that drop below the superior orbital rim, descent of the chin, loss of the angle between the submandibular line and neck, wrinkles, and dry skin. Thick terminal hairs develop on the ears, nose, upper lip, and chin. The temporal arteries should be palpated for tenderness and thickening, which may indicate giant cell arteritis. Nose: Progressive descent of the nasal tip is a normal age-related finding. It may cause the upper and lower lateral cartilage to separate, enlarging and lengthening the nose. Eyes: Loss of orbital fat is a normal age-related finding. It may cause gradual sinking of the eye backward into the orbit (enophthalmos). Thus, enophthalmos is not necessarily a sign of dehydration in the elderly. Enophthalmos is accompanied by deepening of the upper eyelid fold and slight obstruction of peripheral vision. Other normal findings include pseudoptosis (decreased size of the palpebral aperture), entropion (inversion of lower eyelid margins), ectropion (eversion of lower eyelid margins), and arcus senilis (a white ring at the limbus). With aging, presbyopia develops; the lens becomes less elastic and less able to change shape when focusing on close objects. The eye examination should focus on testing visual acuity (eg, using a Snellen chart). Visual fields can be tested at the bedside by confrontation. The patient is asked to stare at the examiner so that the examiner can determine differences between the examiner's and the patient's visual field. However, such testing has low sensitivity for most visual disorders. Tonometry is occasionally done in primary care; however, it is usually done by ophthalmologists or optometrists as part of routine eye examinations or by ophthalmologists when a patient is referred to them because glaucoma is clinically suspected. Ophthalmoscopy is done to check for cataracts, optic nerve or macular degeneration, and evidence of glaucoma, hypertension, or diabetes. Findings may be unremarkable unless a disorder is present because the retina's appearance may not change much with aging. In elderly patients, mildly to moderately elevated intracranial pressure may not result in papilledema because cortical atrophy occurs with aging; papilledema is more likely when pressure is markedly increased. Areas of black pigment or hemorrhages in and around the macula indicate macular degeneration. For all elderly patients, an eye examination by an ophthalmologist or optometrist is recommended every 1 to 2 yr because such an examination may be much more sensitive for certain common eye disorders (eg, glaucoma, cataracts, retinal disorders). Ears: Tophi, a normal age-related finding, may be noted during inspection of the pinna. The external auditory canal is examined for cerumen, especially if a hearing problem is noted during the interview. If the patient wears a hearing aid, it is removed and examined. The ear mold and plastic tubing can become plugged with wax, or the battery may be dead, indicated by absence of a whistle (feedback) when the volume of the hearing aid is turned up. To evaluate hearing, the examiner, with face out of the patient's view, whispers 3 to 6 random words or letters into each of the patient's ears. The hearing of a patient who correctly repeats at least half of these words for each ear is considered functional for one-on-one conversations. Patients with presbycusis (age-related, gradual, bilateral, symmetric, and predominantly highfrequency hearing deficits) are more likely to report difficulty in understanding speech than in hearing sounds. Evaluation with a portable audioscope, if available, is also recommended. Page Mouth: The mouth is examined for bleeding or swollen gums, loose or broken teeth, fungal infections, and signs of cancer (eg, leukoplakia, erythroplakia, ulceration, mass). In patients with xerostomia, the

mouth and tongue may be fissured, and the tongue blade may stick to the buccal mucosa. With aging, the teeth may darken because of extrinsic stains and less translucent enamel. Erythematous, edematous gingiva that bleeds easily usually indicates a gingival or periodontal disorder. Bad breath may indicate caries, periodontitis, another oral disorder, or sometimes a pulmonary disorder. The dorsal and ventral surfaces of the tongue are examined. Common age-related changes include varicose veins on the ventral surface, erythema migrans (geographic tongue), and atrophied papillae on the sides of the tongue. In an edentulous patient, the tongue may enlarge to facilitate chewing; however, enlargement may also indicate amyloidosis or hypothyroidism. A smooth, painful tongue may indicate vitamin B12 deficiency. Dentures should be removed before the mouth is examined. Dentures increase risk of oral candidiasis and resorption of the alveolar ridges. Inflammation of the palatal mucosa and ulcers of the alveolar ridges may result from poorly fitting dentures. The interior of the mouth is palpated. A swollen, firm, and tender parotid gland may indicate parotitis, particularly in dehydrated patients; pus may be expressed from Stensen's duct. Painful, inflamed, fissured lesions at the lip commissures (angular cheilitis) may be noted in edentulous patients who do not wear dentures; these lesions are usually accompanied by a fungal infection. Temporomandibular joint: The temporomandibular joint should be evaluated for degeneration (osteoarthrosis), a common age-related change. The joint can degenerate as teeth are lost and compressive forces in the joint become excessive. Degeneration may be indicated by joint crepitus felt at the head of the condyle as the patient opens and closes the jaw, by painful jaw movements, or by both. Neck: The thyroid gland, which is located low in the neck of elderly people, often beneath the sternum, is examined for enlargement and nodules. Carotid bruits due to transmitted heart murmurs can be differentiated from those due to carotid artery stenosis by moving the stethoscope up the neck: A transmitted heart murmur becomes softer; the bruit of carotid artery stenosis becomes louder. Bruits due to carotid artery stenosis suggest systemic atherosclerosis. Whether asymptomatic patients with carotid bruits require evaluation or treatment for cerebrovascular disease is unclear. The neck is checked for flexibility. Resistance to passive flexion, extension, and lateral rotation of the neck may indicate a cervical spine disorder. Resistance to flexion and extension can also occur in patients with meningitis, but in patients with meningitis and without a cervical spine disorder, the neck can be rotated passively from side to side without resistance. *Chest and Back All areas of the lungs are examined by percussion and auscultation. Basilar rales may be heard in the lungs of healthy patients but should disappear after patients take a few deep breaths. The extent of respiratory excursions (movement of the diaphragm and ability to expand the chest) should be noted. The back is examined for scoliosis and tenderness. Severe low back, hip, and leg pain with marked sacral tenderness may indicate spontaneous osteoporotic fractures of the sacrum, which can occur in elderly patients.

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Breasts: In men and women, the breasts should be examined annually for irregularities or nodules. For women, monthly self-examinations are also recommended, as is annual screening mammography, especially for women with a family history of breast cancer. If nipples are retracted, pressure should be applied around the nipples; pressure everts the nipples when retraction is due to aging but not when it is due to an underlying lesion. Heart: Heart size can usually be assessed by palpating the apex. However, displacement caused by kyphoscoliosis may make assessment difficult. Auscultation should be done systematically. In elderly patients, a systolic murmur most commonly indicates aortic valve sclerosis, which typically is not hemodynamically significant. This murmur peaks early during systole and is rarely heard in the carotid arteries. In contrast, the murmur of aortic valve stenosis typically peaks later during systole, is transmitted to the carotid arteries, and is loud (> grade 2); the 2nd heart sound is dampened, pulse pressure is narrow, and the carotid upstroke is slowed. However, in elderly patients, the murmur of aortic valve stenosis may be difficult to identify because it may be softer, a 2nd heart sound is rarely audible, and narrow pulse pressures are uncommon. Also, in many elderly patients with aortic valve stenosis, the carotid upstroke does not slow because vascular compliance is diminished. Systolic murmurs may be due to other disorders, which should be identified. The murmur of mitral regurgitation is usually loudest at the apex and radiates to the axilla. The murmur of hypertrophic obstructive cardiomyopathy intensifies when the patient performs a Valsalva maneuver. Fourth heart sounds are common among elderly people without evidence of a cardiovascular disorder and are commonly absent among elderly people with evidence of a cardiovascular disorder. Diastolic murmurs are abnormal in people of any age. Unexplained and asymptomatic sinus bradycardia in apparently healthy elderly people may not be clinically important. If new neurologic or cardiovascular symptoms develop in patients with a pacemaker, evaluation for variable heart sounds, murmurs, and pulses and for hypotension and heart failure is required. These symptoms and signs may be due to loss of atrioventricular synchrony. *GI System The abdomen is palpated to check for weak abdominal muscles, which are common among elderly people and which may result in hernias. Most abdominal aortic aneurysms are palpable; however, only their lateral width can be assessed during physical examination. A pulsatile mass located in front of the aorta does not expand laterally. The liver and spleen are palpated for enlargement. Frequency and quality of bowel sounds are checked, and the suprapubic area is percussed for tenderness, discomfort, and evidence of urinary retention. The anorectal area is examined externally for fissures, hemorrhoids, and other lesions. Sensation and the anal wink reflex are tested. A digital rectal examination (DRE) to detect a mass, stricture, tenderness, or fecal impaction is done in men and women. *Male GU System The prostate gland is palpated for nodules and consistency. Estimating prostate size by DRE is inaccurate, and size does not correlate with urethral obstruction; however, DRE provides a qualitative evaluation *Female Reproductive System

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Regular pelvic examinations are recommended, with a Papanicolaou (Pap) test every 2 to 3 yr until age 70. At age 70, testing can be stopped if results of the previous 2 consecutive tests were normal. If women >= 70 have not had regular Pap tests, they should have at least 2 negative tests, 1 yr apart, before testing is stopped. Once Pap testing has been stopped, it is restarted only if new symptoms or signs of a possible disorder develop. If women have had a hysterectomy, Pap tests are required only if cervical tissue remains. For pelvic examination, a patient who lacks hip mobility may lie on her left side. Postmenopausal reduction of estrogen leads to atrophy of the vaginal and urethral mucosa; the vaginal mucosa appears dry and lacks rugal folds. The ovaries should not be palpable; palpable ovaries suggest cancer. The patient should be examined for evidence of prolapse of the urethra, vagina, cervix, and uterus. The patient is asked to cough to check for urine leakage and intermittent prolapse. *Musculoskeletal System Joints are examined for tenderness, swelling, subluxation, crepitus, warmth, and redness. Heberden's nodes (bony overgrowths at the distal interphalangeal joints) or Bouchard's nodes (bony overgrowths at the proximal interphalangeal joints) can occur in patients with osteoarthritis. Subluxation of the metacarpophalangeal joints with ulnar deviation of the fingers may indicate chronic RA. Hyperextension of the proximal interphalangeal joint and flexion of the distal interphalangeal joint (swan-neck deformity) and hyperextension of the distal interphalangeal joint and flexion of the proximal interphalangeal joint (boutonnire deformity) suggest RA. These deformities may interfere with functioning or usual activities. Active and passive range of joint motion should be determined. The presence of contractures should be noted. Variable resistance to passive manipulation of the extremities (gegenhalten) sometimes occurs with aging. Feet: Diagnosis and treatment of foot problems, which are common with aging, help elderly people maintain their independence. Common age-related findings include hallux valgus, medial prominence of the 1st metatarsal head with lateral deviation and rotation of the big toe, and lateral deviation of the 5th metatarsal head. Hyperflexion of the proximal interphalangeal joint (hammer toe), which may occur in RA, and hyperflexion of the proximal and distal interphalangeal toe joints (claw toe) may interfere with functioning and daily activities. Patients with foot problems should be referred to a podiatrist for regular evaluation and treatment. *Neurologic System Neurologic examination for elderly patients, similar to that for any adult, includes evaluation of cranial nerves, motor function, sensory function, and mental status. However, nonneurologic disorders that are common among elderly people may complicate this examination. For example, visual and hearing deficits may impede evaluation of cranial nerves, and periarthritis (inflammation of tissues around a joint) affecting certain joints, especially shoulders and hips, may interfere with evaluation of motor function. Signs detected during the examination must be considered in light of the patient's age, history, and other findings. Symmetric findings unaccompanied by functional loss and other neurologic symptoms and signs may be noted in elderly patients. The physician must decide whether these findings justify a detailed evaluation for a neurologic lesion. Patients should be reevaluated periodically for functional changes, asymmetry, and new symptoms. Cranial nerves: Evaluation may be complex. Elderly people often have small pupils; their pupillary light reflex may be sluggish, and their pupillary mitotic response to near vision may be diminished. Upward gaze and, to a lesser extent, downward gaze are slightly limited. Eye movements, when

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tracking a physician's finger during evaluation of visual fields, may appear jerky and irregular. Bell's phenomenon (reflex upward movement of the eyes during closure) is sometimes absent. In many elderly people, sense of smell is diminished because they have fewer olfactory neurons, have had numerous upper respiratory infections, or have chronic rhinitis. However, asymmetric loss (loss of smell in one nostril) is abnormal. Taste may be altered because the sense of smell is diminished or because patients take drugs that decrease salivation. Visual and hearing deficits may result from abnormalities in the eyes and ears rather than in nerve pathways. Motor function: Strength, coordination, gait, and reflexes are evaluated. Elderly people, particularly those who do not do resistance training regularly, may appear weak during routine testing. For example, during the physical examination, the physician may easily straighten a patient's elbow despite the patient's effort to sustain a contraction. If weakness is symmetric, does not bother the patient, and has not changed the patient's function or activity level, it is likely to be clinically insignificant. Increased muscle tone, measured by flexing and extending the elbow or knee, is a normal finding in elderly people; however, jerky movements during examination and cogwheel rigidity are abnormal. Patients can be evaluated for tremor during handshaking and other simple activities. If tremor is detected, amplitude, rhythm, distribution, frequency, and time of occurrence (at rest, with action, or with intention) are noted. A decrease in muscle mass (sarcopenia) is a common age-related finding. It is insignificant unless accompanied by a decline or change in function (eg, a patient is no longer able to rise from a chair without using chair arms). Sarcopenia affects the hand muscles (eg, interosseous and thenar muscles) in particular. Weak extensor muscles of the wrist, fingers, and thumb are common among patients who use wheelchairs because compression of the upper arm against the armrest injures the radial nerve. Arm function can be tested by having the patient pick up an eating utensil or touch the back of the head with both hands. Motor reaction time and motor coordination are tested. Reaction time often increases with aging, partly because conduction of signals along peripheral nerves slows. Coordination decreases because of changes in central mechanisms, but this decrease is usually subtle and does not impair function. The deep tendon reflexes are checked. Aging usually has little effect on them. However, eliciting the Achilles tendon reflex may require special techniques (eg, testing while the patient kneels with the feet over the edge of a bed and with the hands clasped). A diminished or absent reflex, present in nearly of elderly patients, may be normal. It occurs because tendon elasticity decreases and nerve conduction in the tendon's long reflex arc slows. Asymmetric Achilles tendon reflexes may indicate sciatica. Overall postural control is evaluated using the Romberg test (patients stand with feet together and eyes closed). With aging, postural control is often impaired, and postural sway (movement in the anteroposterior plane when the patient remains stationary and upright) may increase. Cortical release reflexes (known as pathologic reflexes), which include snout, sucking, and palmomental reflexes, occasionally occur in elderly patients who have no detectable brain disorders (eg, dementia). Babinski's reflex (extensor plantar response) in elderly patients is abnormal; it indicates an upper motor neuron lesion, which is often cervical spondylosis with partial cord compression.

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Sensation: Evaluation of sensation includes touch (using a skin prick test), cortical sensory function, temperature sense, proprioception (joint position sense), and vibration sense testing. Aging has limited effects on sensation. Many elderly patients report numbness, especially in the feet. It may result from a decrease in size of fibers in the peripheral nerves, particularly the large fibers. Nonetheless, patients with numbness should be checked for peripheral neuropathies. In many patients, no cause of numbness can be identified. Many elderly people lose vibratory sensation below the knees. This loss occurs because small vessels in the posterior column of the spinal cord change. However, proprioception, which is thought to use a similar pathway, is unaffected. Mental status: A mental status examination is a key component of evaluation. A patient who is disturbed by such a test should be reassured that it is routine. The examiner must make sure that the patient can hear; hearing deficits that prevent a patient from hearing and understanding questions may be mistaken for cognitive dysfunction. Evaluating the mental status of a patient who has a speech or language disorder (eg, mutism, dysarthria, speech apraxia, aphasia) can be difficult. Orientation may be normal in many patients with dementia or other cognitive disorders. Thus, evaluation may require questions that identify abnormalities in consciousness, judgment, calculations, speech, language, praxis, executive function, or memory, as well as orientation. Abnormalities in these areas cannot be attributed solely to age, and if abnormalities are noted, further evaluation, including a formal test of mental status, is needed. With aging, information processing and memory retrieval slow but are essentially unimpaired. With extra time and encouragement, patients perform such tasks satisfactorily. *Nutritional Status Aging changes the interpretation of many measurements that reflect nutritional status in younger people. For example, aging can alter height. Weight changes can reflect alterations in nutrition, fluid balance, or both. The proportion of lean body mass and body fat content changes. Despite these agerelated changes, body mass index is still useful in elderly patients. Thorough nutritional evaluation, including laboratory measurements, is indicated if patients have an abnormal nutrition history (eg, weight loss, suspected deficiencies in essential nutrients) or body mass index. *Unusual Presentation of Illness Certain disorders manifest differently in elderly patients than in younger patients. Hyperthyroidism may not produce the classic signs (eg, eye signs, enlarged thyroid gland). Symptoms and signs may be subtle and may include tachycardia, weight loss, fatigue, weakness, palpitations, tremor, atrial fibrillation, and heart failure. Patients may appear apathetic rather than hyperkinetic. Hypothyroidism may be subtle in elderly patients. The most common symptoms are nonspecific (eg, fatigue, weakness, falling). Anorexia, weight loss, and arthralgias may occur. Cold intolerance, weight gain, depression, paresthesias, hair loss, and muscle cramps are less common than among younger adults; cognitive dysfunction is more common. The most specific sign, prolonged relaxation time after muscular contraction, may not be detectable in elderly patients because of decreased amplitude or absent reflexes. Hyperparathyroidism may produce nonspecific symptoms: fatigue, cognitive dysfunction, emotional instability, anorexia, constipation, and hypertension. The characteristic symptoms are often absent. Sarcoidosis in the elderly most commonly causes nonspecific symptoms (eg, weight loss, anorexia, weakness, fatigue) but may also cause shortness of breath, blurred vision, myopathy, and adenopathy.

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Bacteremia may not cause fever; however, most elderly patients have at least a low-grade fever. Nonspecific manifestations (eg, general malaise, anorexia, night sweats, unexplained change in mental status) may also occur. UTIs may be present in afebrile elderly patients. These patients may not report dysuria, frequency, or urgency but may experience dizziness, confusion, anorexia, fatigue, or weakness. Meningitis may cause fever and a change in mental status without symptoms of meningeal irritation (eg, headache, nuchal rigidity). Pneumonia may be indicated by malaise, anorexia, or confusion. Tachycardia and tachypnea are common, but fever may be absent. Coughing may be mild and without copious, purulent sputum, especially in dehydrated patients. TB may manifest differently in elderly patients with coexisting disorders. Symptoms may be nonspecific (eg, fever, weakness, confusion, anorexia). Pulmonary TB may manifest with fewer respiratory symptoms (eg, cough, excessive sputum production, hemoptysis) than in younger patients. Appendicitis pain tends to begin in the right lower quadrant rather than periumbilically, as it does in younger adults. Also, the eventual location of pain may be diffuse in the abdomen rather than localized to the right lower quadrant. However, tenderness in this quadrant is a significant early sign. Biliary disorders may result in nonspecific mental and physical deterioration (eg, malaise, confusion, loss of mobility) without jaundice, fever, or abdominal pain. Abnormal liver function test results may be the only indication of a biliary disorder. Acute bowel infarction may be indicated by acute confusion. Abdominal pain and tenderness may be absent. Peptic ulcer disease may not produce classic ulcer symptoms; pain may be absent, nonspecific, or masked by NSAIDs. Dyspepsia (usually epigastric discomfort with bloating, nausea, or early satiety) is more common among elderly than among younger patients. GI bleeding may be painless. Slow, unrecognized blood loss may occur, resulting in severe anemia. MI may manifest as diaphoresis, dyspnea, epigastric distress, syncope, weakness, vomiting, or confusion rather than as chest pain. Elderly patients with acute MI tend to delay longer than younger patients in seeking medical assistance after the onset of chest pain or other presenting symptoms of MI. Heart failure may cause confusion, agitation, anorexia, weakness, insomnia, fatigue, weight loss, or lethargy; patients may not report dyspnea. Orthopnea may cause nocturnal agitation in patients with dementia and heart failure. Peripheral edema is less specific as a sign of heart failure in elderly than in younger patients. In bedridden patients, edema may occur in the sacral area rather than in the lower extremities. D. Common Aging Changes Introduction One can catalog changes that typically occur with age.

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For people of developed countries age changes include: A loss of hearing ability, particularly for higher frequencies. There is a decline in the ability to taste salt&bitter (sweet&sour are much less affected). There is a reduction of the thymus gland to 510% of its original mass by age 50. Levels of antibodies

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increase with aging. One third of men and half of women over 65 report some form of arthritis. About half of those aged 65 have lost all teeth. The elderly require twice as much insulin to achieve the glucose uptake of the young. There is reduced sensitivity to growth factors & hormones due to fewer receptors and dysfunctional post-receptor pathways. The temperature needed to separate DNA strands increases with age. Weight declines after age 55 due to loss of lean tissue, water and bone (cell mass at age 70 is 36% of what it is at age 25). Body fat increases to age 60. Muscle strength for men declines 3040% from age 30 to age 80. Reaction time declines 20% from age 20 to 60. Elderly people tend to sleep more lightly, more frequently and for shorter periods with a reduction in rapid eye-movement (REM) sleep. Neurogenesis in the hippocampus declines with age. Degree of saturation of fats drops by 26% in the brains of old animals. Presbyopia (reduced ability to focus on close-up objects) occurs in 42% of people aged 5264, 73% of those 6574 and 92% of those over age 75. Most people over age 75 have cataracts. About half of those over 85 are disabled (defined as the inability to use public transportation). Over 75% of people over 85 have 39 pathological conditions, and the cause of death for these people is frequently unknown. Aging changes are frequently associated with an increase in likelihood of mortality, but this is not necessarily the case. For example, graying of hair is a symptom of aging, but graying does not increase likelihood of mortality. Aging changes which are not associated with a specific disease, but which are associated with a generalized increase in mortality would qualify as biomarkers of aging and would distinguish biological age from chronological age. Biomarkers would be better predictors of the increased likelihood of mortality (independent of specific disease) than the passage of time (chronological age). Crosslinking of collagen, insulin resistance and lung expiration capacity have been proposed as candidates but, as yet, no biomarkers of aging have been validated and universally accepted. Nervous System *Changes in the Brain In persons who do not have neurologic disease, intellectual performance tends to be maintained until at least age 80. However, tasks may take longer to perform because of some slowing in central processing. Verbal skills are well maintained until age 70, after which, some healthy elderly persons gradually develop a reduction in vocabulary, a tendency to make semantic errors, and abnormal prosody. Other age-related changes in mentation are subtle but can be detected as difficulty learning, especially languages, and forgetfulness in noncritical areas. However, this mild forgetfulness is unlike dementia in that it does not impair recall of important memories or affect function. The elderly, particularly those with some degree of neurologic disease, are especially susceptible to the actions of drugs. Hypnotics, which may be effective and safe for most persons, may cause confusion or delirium in the elderly. Stress due to medical or psychologic disorders can worsen even minimal brain disease. Depression often produces a dementia-like syndrome (pseudodementia) in elderly persons. New onset of seizures is uncommon in the elderly. *Loss of Nerve Cells With normal aging, the number of nerve cells in the brain decreases. Cell loss is minimal in some areas (eg, brain stem nuclei, supraoptic and paraventricular nuclei) but is as great as 10 to 60% in others (eg, hippocampus). Loss also varies within the cortex (eg, loss is 55% in the superior temporal gyrus but 10 to 35% in the tip of the temporal lobe). From age 20 or 30 to age 90, brain weight declines about 10%, and the area of the cerebral ventricles relative to the entire brain (as seen on cross section in the coronal view) may increase three to four times. The clinical effects of these changes are difficult to determine because brain weight and

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ventricular size may not correlate with intelligence; indeed, severe dementia may occur in persons who have normal ventricular size for their age. *Histologic Changes With normal aging, the pigment lipofuscin is deposited in nerve cells, and amyloid in blood vessels. Also, senile plaques and, less frequently, neurofibrillary tangles occur in elderly persons even without clinical evidence of dementia (in Alzheimer's disease, plaques and tangles occur in much greater numbers). *Accumulation of free radicals Free radicals (atoms or molecules with one unpaired electron), which are produced normally during metabolism, accumulate with age and may have a toxic effect on certain nerve cells. *Changes in neurotransmitter systems With normal aging, changes in neurotransmitter systems (enzymes, receptors, and neurotransmitters) occur. For example, choline O-acetyltransferase levels tend to decrease; the number of cholinergic receptors tends to decrease; and g-aminobutyric acid, serotonin, and catecholamine levels usually decrease. Choline O-acetyltransferase levels and dopamine levels may further decrease in Alzheimer's disease and in Parkinson's disease, respectively. Another age-related change is an increase in monoamine oxidase levels. When this increase is inhibited by monoamine oxidase inhibitors, onset of disability in patients with Parkinson's disease may be forestalled. Decreased cerebral blood flow With normal aging, cerebral blood flow decreases by about 20% on average; decreases are even greater in persons with small-vessel cerebrovascular disease due to diabetes and hypertension. Although blood flow in women is usually greater than in men until age 60, the subsequent rate of decrease is slightly more rapid. Decreases are greater in certain areas of the brain (eg, the prefrontal region) and are greater in gray matter than in white matter. *Compensatory mechanisms Certain properties of the brain may reduce the clinical effects of age-related changes. Redundancy is a property whereby more nerve cells exist than are needed. For example, diabetes insipidus (due to a lack of antidiuretic hormone) does not appear until > 85% of the nerve cells in the supraoptic and paraventricular nuclei have been destroyed. Furthermore, hydrocephalic patients, who have only a thin cerebral cortical mantle, may have normal intelligence. The number of cells required for certain functions is unknown, so the extent of redundancy is difficult to estimate. However, redundancy probably reduces the effects of age-related neuron loss. Plasticity at the nerve cell level involves compensatory lengthening and production of dendrites in remaining nerve cells to offset the age-related gradual deterioration and loss of nerve cells. New connections in the dendritic tree may compensate for the fewer nerve cells. Plasticity in the dendritic tree may also occur in Alzheimer's disease, perhaps as a biologic attempt to preserve function. Other compensatory mechanisms may occur when the brain is damaged. For example, the nondominant hemisphere may compensate when speech centers in the dominant hemisphere are damaged, leading to gradual improvement in speech function. Other motor systems may compensate when large areas of the cerebellum are destroyed by injury, vascular disease, or tumor, often leading to functional recovery. Compensatory mechanisms are more effective in the higher centers. For example, the brain has a greater ability to compensate after injury than does the spinal cord, but the ability to compensate declines with age. The spinal cord does not have the redundancy of the brain to compensate for cell damage.

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*Changes in the Spinal Cord The number of cells in the spinal cord decreases with age, but actual counts have not been well investigated; the decrease does not appear to affect the functional capacity of the spinal cord. Decreases in nerve conduction are mostly due to changes in the peripheral nerves. A decrease in muscle strength is likely due to a loss of muscle fibers (sarcopenia) rather than to denervation. The principal effect of aging on spinal cord function is due to indirect changes, such as degenerative disease of the spine and intervertebral disks with compression of the spinal cord and entrapment of the nerve roots. *Changes in Peripheral Nerves Nerve conduction time slows with age, although generally a change in function is not perceptible. In any injury to the peripheral nerves, reparative growth of the axons occurs if the cell body is intact; this reinnervation continues throughout life but is not as effective in elderly persons as in younger persons. Musculoskeletal System *Introduction Geriatric Essentials Between ages 40 and 50, bone density begins to decrease in both sexes, most rapidly in women. Because bone mass is lost, fractures occur commonly at the proximal ends of long bones and the spine, often with minimal trauma. Articular cartilage shows a reduced response to growth factors, becomes brittler, and tends to accumulate calcium pyrophosphate with aging. Connective tissue in ligaments and tendons loses tensile strength, elasticity, and regenerative capacity with aging. A decrease in muscle mass (sarcopenia) occurs with aging. Although sarcopenia tends to decrease maximal muscle strength, elderly people can normally perform most locomotor functions as well as younger people. Immobilized elderly people undergo rapid acceleration of muscle loss. * Changes in Bones The increase in bone mass during growth results from an increase in bone size, not bone density (bone mass per unit volume). After growth stops, the bones continue to increase slowly in girth (except the mandible, which gets smaller). However, between ages 40 and 50, bone density begins to progressively decrease. This decrease occurs because bone is lost from within. Bone cortices become thinner from the inside; also, whole structural elements of cancellous bone are removed, a process that differs in detail between the central and peripheral skeletons. Interestingly, decreased bone density does not tend to result from decreased bone production; bone remodeling can actually increase with aging. Bone loss that occurs as part of normal aging can be divided into 2 mechanisms: a rapid one that affects women after menopause (menopausal bone loss) and a slow one that affects both women and men after age 40 to 50 (senescent bone loss). These 2 mechanisms have distinct histologic and clinical features; however, in women, the 2 mechanisms eventually overlap and become difficult to differentiate. Senescent bone loss may also overlap with secondary hyperparathyroidism, which may result from the aging intestine's impaired ability to absorb calcium, and with relative hypercortisolism. Sarcopenia, inactivity, and reduced mechanical loading also contribute. Clinical bone loss is usually multifactorial. The extent to which the 2 mechanisms contribute can vary significantly among aging individuals. This variability is one reason why therapies that target only 1 of the mechanisms produce results that vary among elderly individuals. Menopausal bone loss: Before menopause, sex hormones protect the bone, at least in part, by regulating the production, development, and death (by apoptosis) of osteoclasts and osteoblasts. Sex

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hormones may also protect the bone by regulating production of cytokines and responsiveness of bone marrow cell progenitors to cytokines. For example, sex hormones inhibit production of cytokines IL-1, IL-6, and tumor necrosis factor. Overproduction of these cytokines increases osteoclast production and thereby increases bone resorption, which is largely responsible for menopausal bone loss. The same cytokines are involved in pathologic bone resorption that occurs in several disorders, including multiple myeloma, Paget's disease, rheumatoid arthritis, Gorham-Stout or disappearing bone disease, hyperthyroidism, primary and secondary hyperparathyroidism, and McCune-Albright syndrome. Sudden loss of sex hormones causes bone loss to increase up to 10-fold. In women, estrogen declines precipitously at menopause, causing rapid bone loss during the next 5 to 10 yr (menopausal bone loss). In men, testosterone production normally declines gradually, so bone loss is linear and slow. However, in men who undergo castration, the abrupt cessation of testosterone production results in rapid bone loss. Sex hormone deficiency seems to delay osteoclast apoptosis but promotes osteoblast apoptosis, increasing bone resorption relative to bone formation. Delayed osteoclast apoptosis may also deepen resorption cavities, resulting in trabecular perforation characteristic of estrogen deficiency. Senescent bone loss: The amount of bone formed during remodeling decreases with aging in both sexes, causing a consistent decrease in wall thickness, especially in trabecular bone. Aging decreases osteoblast and new bone formation, decreases bone mineral density, and increases adipocyte formation in the bone marrow. Vitamin D likely plays a role in inhibiting osteoblast apoptosis; therefore, vitamin D deficiency may result in a decrease in the number of osteoblasts and thus contribute to the age-related decrease in bone formation. Pathologic factors: Loss of bone mass in either sex may accelerate because of high circulating levels of endogenous or exogenous glucocorticoids and thyroxine, alcoholism, prolonged immobilization, gastrectomy, malabsorption, hypercalciuria, some types of cancer, and cigarette smoking. Consequences: Bone mass decreases in the axial (primarily cancellous) and appendicular (primarily cortical) skeletons. In cancellous bone, trabeculae thin or are destroyed. Cortical bones thin and become more porous. Increased bone loss causes loss of height (stooping) and dorsal kyphosis (dowager's hump). Decreased bone density and microarchitectural bone deterioration increase the susceptibility of bone to fractures, a condition known as osteoporosis . Conventionally, osteoporosis is diagnosed when bone density is at least 2.5 standard deviations below the young adult mean; when bone density is between 1 standard deviation and 2.5 standard deviations below the young adult mean, the condition is termed osteopenia. Because women accumulate less skeletal mass than men during their growing years (particularly during puberty), resulting in smaller, narrower, more fragile bones with thinner cortices, and because women undergo menopausal bone loss, women are at higher risk for osteoporosis and osteopenia. Purely menopausal bone loss increases risk of vertebral and Colles' fractures disproportionately. Purely senescent bone loss increases risk of vertebral and hip fractures disproportionately. However, in clinical practice, determining the relative contributions of the type of bone loss to the development of a fracture is difficult and usually not helpful. In general, the elderly typically develop fractures in the spine or proximal long bones (eg, hip fractures) secondary to minimal forces; this contrasts with younger adults, who often develop fractures in the middle of bones secondary to maximal forces. *Changes in Cartilage Nonarticular cartilage grows throughout life (eg, the ears and nose tend to grow larger relative to the face as a person ages). Age-related crystal formation and calcification occur in nonarticular cartilage, but the effect of these changes on cartilage function is unclear.

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In articular cartilage, most age-related biochemical changes correlate poorly with the presence of joint disease. However, calcium pyrophosphate crystals tend to deposit around chondrocytes in the elderly, who have an increased incidence of chondrocalcinosis. Articular cartilage decreases in thickness, possibly because cartilage hydration decreases. The number of chondrocytes (which control the composition and organization of the extracellular matrix that surrounds linking proteins and collagen fibrils in cartilage) decreases slightly. The amount of collagen in cartilage does not change much; however, collagen becomes stiffer because advanced glycation end products accumulate and produce increased cross-linking. These changes in cartilage, which occur at highly variable rates, make cartilage less able to handle mechanical stress. *Changes in Connective Tissue Fibroblasts are responsible for growth and regeneration of the connective tissue that makes up most of ligaments and tendons. With aging, the in vitro proliferative capacity and synthetic activity of fibroblasts decrease. These changes may at least partially explain why, with aging, tensile strength, elasticity, and regenerative capacity of ligaments and tendons decrease. As a result, ligaments and tendons are predisposed to rupture and prolonged healing time. *Changes in Muscle After about age 30, the number and size of muscle fibers progressively decrease, resulting in a decrease in skeletal muscle mass and thus lean body mass. This process is termed sarcopenia. Age-related factors contributing to sarcopenia may include reduced levels of exercise and physical activity; a loss of motor units, possibly beginning during middle age; and reduced skeletal muscle protein synthesis. Other factors that may contribute in some cases include a relative deficiency of anabolic hormones, such as growth hormone (GH), insulin-like growth factor I (IGF-I), testosterone, and perhaps dehydroepiandrosterone (DHEA). GH stimulates production of IGF-1, which may mediate the anabolic effect of GH. GH levels decrease with aging. In young adults, resistance exercises increase GH and IGF-1 levels. In the elderly, the increase in GH and IGF-1 is attenuated. In the elderly, exogenous GH, when combined with exercise, increases muscle mass more than exercise alone but does not seem to meaningfully increase muscle strength. In healthy young people, 30% of body weight is muscle, 20% is adipose tissue, and 10% is bone. Muscle accounts for 50% of lean body mass and about 50% of the total amount of body nitrogen. By age 75, about the muscle mass has disappeared; 15% of body weight is muscle, 40% is adipose tissue, and 8% is bone. The faster-contracting type II muscle fibers participate in sudden powerful muscle contractions, whereas the slower-contracting type I fibers function to maintain posture and to perform rhythmic, endurance-type exercises. Type II fibers decrease to a greater extent than do type I fibers. Maximum isometric contraction force decreases about 20% by age 50 and about 50% by age 70. Despite this, healthy elderly people can usually easily climb stairs, rise from a squatting position, walk along a straight line, hop on either foot, and perform typical activities of daily living. Elderly people whose mobility is restricted, particularly those with acute illness or who are bedridden, lose muscle mass and strength (deconditioning). The rate of loss is greatest in the antigravity muscles--those used to sit up, stand up, and pull up--which are essential for performing activities of daily living. Up to 1.5%/day of muscle mass can be lost; for 1 day of absolute bed rest, up to 2 wk of reconditioning may be necessary to return to baseline function.

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Patients with sarcopenia and insufficient dietary protein require nutritional support; those with sarcopenia and hormonal deficiencies may require hormonal supplementation. Hospitalized elderly people, especially those who are bedridden, require early physical therapy and individualized exercise regimens. In the elderly, the beneficial effects of exercise are usually specific to the training activity. For example, if the goal is to improve throwing a ball, then strengthening the muscles involved in throwing is necessary; however, to develop maximum function, the exercise should involve actually throwing a ball. In addition to the debilitated, exercise is helpful in all elderly people. More studies are needed to determine the optimal frequency, intensity, duration, and types of exercise. Respiratory System *Introduction Geriatric Essentials Lung function gradually declines after age 20. In the absence of respiratory insults (eg, smoking, exposure to environmental toxins, prior respiratory infections), most elderly people have sufficient respiratory reserve to avoid symptoms. Aging's reduction of respiratory reserve, which tends to cause only minimal symptoms in healthy people, often increases the risk and severity of pulmonary disorders. The effects of aging on the lungs are physiologically and anatomically similar to those that occur during the development of mild emphysema. After about age 20, the number of alveoli and the number of lung capillaries gradually begin to decrease. Although aging affects compliance, lung volumes, airflow, diffusing capacity, and other parameters of lung function, purely age-related changes do not lead to clinically significant symptoms or changes in nonsmokers. However, in smokers, former smokers, and those exposed to environmental toxins, injury due to inflammation is superimposed on and accelerates the effects of aging, resulting in dyspnea. Other serious risk factors for pulmonary symptoms in the elderly include deconditioning, obesity, and heart disease. * Compliance and Lung Volumes Pulmonary compliance is the change in lung volume per unit change in elastic recoil pressure. Chest wall compliance is the change in thoracic volume per unit change in intrathoracic pressure. Changes in lung and chest wall compliance are primarily responsible for age-related decreases in ventilation and the corresponding decreases in gas distribution that result from collapse of small airways. Beginning at about age 30, there is a decrease in the number and elasticity of parenchymal elastic fibers, which causes gradual loss of elastic recoil of the lungs (increasing compliance). Airway size also decreases. At about age 55, respiratory muscles begin to weaken, and the chest wall gradually becomes stiffer (decreasing compliance). These changes likely result from age-associated kyphoscoliosis, calcification of intercostal cartilage, and arthritis of the costovertebral joints. The increased outward pull of the stiffer chest wall combined with the reduced ability of the lung to pull inward result in a small increase in functional residual capacity (FRC--ie, lung volume at the end of a quiet expiration) and residual volume (RV--ie, lung volume after a maximal expiration). Total lung capacity (TLC--ie, lung volume after maximal inspiration) remains fairly constant. *Airflow Airway collapse is prevented by intra-alveolar pressure generated by the elastic recoil of the lung. Age-related loss of this elastic recoil results in easy collapse of poorly supported peripheral airways, which in turn may result in decreased flow at low lung volumes.

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The forced expiratory volume in 1 sec (FEV1) begins to decrease after age 20. The annual decline is small at first but accelerates with aging. The forced vital capacity (FVC) decreases as well, by about 14 to 30 mL/yr in men and 15 to 24 mL/yr in women. Until age 40, decreases in FEV1 and FVC are thought to result from changes in body weight and strength rather than from loss of tissue. After age 40, decreases in FEV1 and FVC are due to aging itself and superimposed cumulative effects of inflammatory injury from respiratory illness, smoking, and exposure to environmental toxins. For example, cigarette smoking repeatedly induces inflammatory mediators, humoral protection (elastase and antielastase, oxidant and antioxidant), neutrophil recruitment, and tissue repair, culminating in inflammatory lung destruction and airway obstruction. Accumulated environmental oxidant injuries produce similar damage. *Diffusing Capacity Diffusing capacity peaks in people in their early 20s and then declines; from middle age onward, it declines at a rate of about 17% (2.03 mL/min/mm Hg) per decade in men and at a rate of about 15% (1.47 mL/min/mm Hg) per decade in women. This decline results from decreased alveolar-capillary surface area caused by inflammation-induced destruction of alveoli and by thickening and inflammation-induced destruction of capillary-containing alveolar walls. The loss of alveolar-capillary surface area decreases venous blood oxygenation, particularly under conditions of high pulmonary blood flow (eg, exercise). The rate of decline in diffusing capacity among women may be lower because endogenous estrogen may slow the destruction of alveolar-capillary tissue in women between ages 25 and 46; destruction slows presumably because of preserved vascular integrity. *Partial Pressure of Arterial Oxygen Partial pressure of arterial oxygen (PaO2) declines linearly with aging (about 0.3%/yr) until age 75, at which time it stabilizes at about 80 mm Hg in healthy nonsmokers. This gradual decline is mostly attributable to ventilation/perfusion (V/Q) mismatch caused by age-related collapse of peripheral airways, leading to shunting of blood through nonventilated alveoli. PaO2 at any age can be roughly estimated by the equation PaO2 = 109 - (0.43 x age). *Autonomic Response Heart rate and ventilatory responses to hypoxia and hypercapnia diminish with aging because peripheral and central chemoreceptor responses diminish, as do their integration of CNS pathways. Aging also decreases neural output to respiratory muscles and lowers chest wall and lung mechanical efficiency. As a result, the ventilatory response to hypoxia is reduced by 51% in healthy men aged 64 to 73 compared with healthy men aged 22 to 30; the ventilatory response to hypercapnia is reduced by 41%. These reductions increase the risks of developing hypoxia and hypercapnia if elderly people acquire disorders that produce low O2 levels (eg, pneumonia, COPD, obstructive sleep apnea). Effects are greater in people who are deconditioned. With aging, the diaphragm weakens by up to 25%. This weakening is not usually clinically relevant in healthy people, but in the presence of a disorder that requires sustained increases in ventilation (eg, pneumonia), it predisposes the elderly to hypoxemia and hypercapnia, and thus possibly the need for mechanically assisted ventilation. *Oxygen Consumption Maximal O2 consumption (VO2max) is the body's ability to maximally deliver O2 to the tissues. It is the standard measurement of physical work (exercise) capacity. VO2max increases during childhood (from growth of muscle, heart, and lungs), peaks in the late teens, plateaus until the mid-20s, then gradually declines each decade by 7.6% (32 mL/min/yr) in men and 5.3% (14 mL/min/yr) in women due to age-related reductions in maximal heart rate, muscle mass, and cardiovascular deconditioning associated with lower levels of physical activity or from changes in cardiovascular function. VO 2max and exercise capacity tend to

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be higher in people who undergo regular aerobic training than in people of similar age and health who do not; however, exercise does not seem to slow the age-related decline in VO2max and exercise capacity. *Immunity The rate of mucociliary transport declines with aging, although effects on clinical infection are unproven. More than 70% of elderly patients with community-acquired pneumonia develop a blunted cough reflex (compared with only 10% of age-matched controls), probably due to accompanying hypoxia, druginduced sedation, and neurologic disorders. Dysphagia and other swallowing difficulties and impaired esophageal motility occur more often in the elderly and increase risk of aspiration. Antibody responses to some vaccines that can decrease risk of pneumonia (eg, pneumococcal, influenza) decline with aging, but precise implications for challenges with natural antigens are unknown. Cellular immunity also declines with aging. Elderly people produce fewer helper T cells and the ones they do have are often less effective than they were earlier in life. Among the elderly who have been exposed to TB, T cells may have surrounded TB organisms in a granuloma for many years, inactivating the organisms; cellular immune senescence may result in reactivation of TB. Cardiovascular System Differences between cardiovascular function in older and younger persons have been extensively quantified. However, interactions between age, disease, and lifestyle are often overlooked. Whether the high prevalence of cardiovascular disorders such as hypertension, coronary artery disease, and heart failure is due to an aging process, or these disorders merely occur more frequently in elderly persons because of a longer exposure to risk is not yet established *Cardiovascular Structure The Heart With age, the heart can atrophy, remain unchanged, or develop moderate or marked hypertrophy. Atrophy usually coincides with various wasting diseases and is not observed during aging in healthy persons. A modest increase in left ventricular wall thickness is normal with age; an exaggerated increase occurs in persons with hypertension. Other normal age-associated changes may include enlargement of the left atrium and slight enlargement of the left ventricular cavity and of the cardiac silhouette, seen on chest xray. The amount of fibrous tissue within the myocardium increases with age but does not contribute appreciably to cardiac mass. Rather, myocardial wall thickening occurs largely because cardiac myocytes increase in size. Some myocytes are replaced by fibrous tissue, so that the number of myocytes probably decreases with age. However, cardiac myocytes are probably able to reenter the cell cycle and proliferate, thereby partly offsetting cell loss due to necrosis or apoptosis. In nearly half of persons > 70 years, amyloid can be detected in the heart, and the incidence increases sharply with age. About half of these persons have only small amounts of amyloid confined to the atria. Whether cardiac amyloidosis is part of normal aging is debatable; it is not present in all elderly persons, not even in centenarians. The Vasculature With age, the walls of large distributing arteries (eg, the aorta) thicken, and the arteries become dilated and elongated. The thickening results mainly from an increase in intimal thickness due to cellular accumulation and to matrix deposition; fragmentation of the internal elastic membrane also occurs. These changes may partly explain the elderly's increased likelihood of developing atherosclerosis. With age, increases in collagen and changes in the cross-linking of collagen within the vascular media may make the

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media less elastic. Glycoprotein eventually disappears from elastin fibrils, and elastin becomes frayed. An age-associated increase in elastase activity and in Ca++ and cholesterol deposition on elastin may contribute to elastin fragmentation or to a reduction in elastin content. The total mucopolysaccharide content (ground substance) of the interstitial matrix is unaltered with age, but the amount of dermatan and heparan sulfate contained in the matrix increases and that of hyaluronate and chondroitin sulfate decreases. *Cardiovascular Function Cardiovascular function is determined by the interaction of several variables, which may be affected by age. However, aging does not alter overall systolic cardiac pump function at rest in normotensive elderly persons. *Compliance, Cardiac Filling, and *Preload An age-associated reduction in ventricular compliance remains unproved, because proof would require the simultaneous measurement of pressure and volume; such invasive measurements are not usually attempted in healthy persons. The early diastolic left ventricular filling rate progressively slows after age 20, so that by age 80, the rate is reduced by up to 50%. This reduction is attributed to structural (fibrous) changes in the left ventricular myocardium or to residual myofilament Ca++ activation from the preceding systole, resulting in prolonged isovolumic relaxation. Although left ventricular filling in early diastole is less in older than in younger persons, filling in later diastole is greater, because the atrial contraction is augmented. Thus, end-diastolic volume in the supine or seated position is not usually decreased in healthy older women and increases slightly with age in men as long as the atrial contraction is normal. The augmented atrial contraction is accompanied by atrial enlargement and is manifested on auscultation as a fourth heart sound (atrial gallop). Lack of an augmented atrial contraction in elderly patients with acute atrial fibrillation or with a pacemaker that does not stimulate atrial contraction can be clinically significant if ventricular function is compromised for other reasons. The result may be heart failure, particularly if the ventricular rate is rapid. *Afterload The extent to which aging affects afterload (which depends on peripheral vascular resistance, aortic impedance, and aortic pulse wave velocity) varies dramatically from person to person. Some studies have reported that peripheral vascular resistance at rest increases with age. An age-associated increase has been measured in aortic impedance, which is usually < 10% of total vascular impedance. Aortic pulse wave velocity increases with age. As a result, pressure waves from peripheral sites are returned to the heart more quickly in elderly persons. In healthy elderly men and women, pressure in the aortic root continues to rise and peaks later in systole, thereby altering the pressure pulse contour and causing a late augmentation of systolic blood pressure. Arterial stiffening, the resulting increase in pulse wave velocity, and late augmentation of systolic blood pressure may explain the overall increase in systolic blood pressure with age. The increase in systolic blood pressure may reflect a resetting of the baroreceptor reflex to a higher level in the elderly. The same structural changes that make the aorta stiffer and cause pulse wave velocity to increase may explain the decreased baroreceptor stimulation required for a given change in aortic pressure. Alternatively, the baroreceptor response may be blunted because of ageassociated changes in afferent nerve impulses from the baroreceptors or in efferent nerve impulses to the arterial system. The increase in resting systolic blood pressure affects resting left ventricular afterload. However, if the increase in systolic pressure remains within normal limits, left ventricular wall thickness may increase sufficiently to normalize wall stress and thus maintain a nearly normal cavity size and ejection fraction. Page

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*Myocardial Contractility Myocardial contractility involves Ca++ activation of myofilaments (excitation-contraction coupling). The effects of age on the mechanisms that govern excitation-contraction coupling in cardiac muscle have been studied in animal models. Some of the age-associated changes are partly related to alterations in gene expression. In rats, contractile force production, at least at low stimulation rates, is preserved in old age. Although passive stiffness in isolated cardiac muscle has not been shown to increase with age, stiffness during contraction increases. The increase in myoplasmic Ca++ after excitation at low rates and the affinity of myofibrils for Ca++ do not change with age. At higher rates of excitation, the amplitude of the Ca++ transient (a brief increase in the cytosolic concentration of calcium) is not well characterized with respect to aging. Relaxation is prolonged in senescent cardiac muscle, probably because Ca++ is removed more slowly from the myoplasm during diastole. This slow removal probably occurs because the sarcoplasmic reticulum sequesters less calcium. The action potential lasts longer in senescent cardiac muscle, but the role of this change in prolonging contraction is unclear. Action-potential changes may reflect age-associated changes in sarcolemmal ionic conductances or may result from the prolonged myoplasmic Ca ++ transient elicited by excitation. In isolated senescent cardiac muscle, myosin isoenzymes shift to slower forms, and adenosine triphosphatase activity decreases. These changes may explain why shortening velocity decreases during isotonic contraction. A reduction in the myocardial relaxation rate results in less complete myocardial relaxation when the mitral valve opens and in a reduction in the early diastolic left ventricular filling rate. *Ejection Fraction and Stroke *Volume The resting ejection fraction is not reduced in healthy older men and women. Resting stroke volume increases slightly in older men (commensurately with the slightly larger end-diastolic volume) and remains constant in older women. Heart Rate With age, the supine resting heart rate does not change in healthy men; the heart rate while seated decreases slightly in men and women. Spontaneous variations in heart rate during a 24-hour period decrease in men without coronary artery disease, as do variations in the sinus rate with respiration. The intrinsic sinus rate (ie, measured after sympathetic and parasympathetic blockade) decreases significantly with age. For example, the average intrinsic sinus rate is 104 beats/minute at age 20 compared with 92 beats/minute at age 45 to 55. Data from persons > 55 are lacking. Cardiac Output The resting cardiac index (cardiac output per unit of time [L/minute], measured while seated and divided by body surface area [m2]) is not reduced in healthy older men who have been rigorously screened to exclude occult heart disease and who live independently in the community. However, in older women, resting cardiac output decreases slightly because neither end-diastolic volume nor stroke volume increases to compensate for the modest reduction in heart rate. These sex-related differences appear to be due in part to differences in fitness, even between sedentary men and women. *Aerobic Capacity and *Cardiovascular Function During *Exercise Aging affects aerobic capacity and cardiovascular performance during exercise. Peak exercise capacity and peak oxygen (O2) consumption decrease with age, but interindividual variation is substantial.

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Aerobic capacity decreases by 50% between ages 20 and 80, because maximum cardiac output decreases by 25% and peripheral O2 utilization decreases (ie, the arteriovenous O2 difference decreases by 25%) as a result of age-associated reductions in muscle mass and strength. Other possible mechanisms include inefficient redistribution of blood flow to working muscles and reduced O2 extraction and utilization per unit of muscle. With age, heart rate during exhaustive exercise decreases, but heart volume at end-diastole and throughout the cardiac cycle (including end-systole) is larger during exercise in older than in younger persons. Thus, in older persons, the early diastolic left ventricular filling volume increases during exercise. As a result, the end-diastolic volume, even at peak exercise, is not compromised because of a "stiff heart," and stroke volume during exercise is maintained in older persons. The 25% reduction in maximum cardiac index that occurs between ages 25 and 85 is completely due to the age-associated reduction in maximum heart rate. During all levels of exercise, the older heart, on average, pumps blood from a larger filling volume. However, stroke volume in older persons does not exceed that in younger persons, because the endsystolic volume in older persons remains larger than it does in younger persons. Consequently, the ejection fraction does not increase as much in response to an increase in end-diastolic volume. Thus, although the stroke volume during exercise is maintained at the same level in older persons as in younger persons, the Frank-Starling mechanism is blunted with age. These changes result from a combination of age-associated factors, including augmented vascular and cardiac components of afterload, reduced maximal intrinsic myocardial contractility, and reduced augmentation of contractility by -adrenergic stimulation. * -Adrenergic Modulation The activity of the sympathetic nervous system seems to increase with age, as suggested by higher blood levels of norepinephrine and epinephrine in older than in younger persons during any effort. Because levels of norepinephrine and epinephrine are higher, more -adrenergic receptors on cardiac and vascular cell surfaces are occupied. The result is a desensitization of -adrenergic receptors, thereby causing a down-regulation of associated intracellular signaling pathways. Such desensitization may account for all or a substantial portion of the age-associated postsynaptic reduction in responsiveness to adrenergic stimulation. -Adrenergic stimulation of pacemaker cells partially accounts for an increased heart rate during exercise. When a rapid intra-arterial infusion of a -adrenergic agonist (eg, isoproterenol) is used to mimic exercise, the increase in heart rate and in ejection fraction is smaller and forearm vascular dilation and venorelaxation are less in older than in younger men. (In isolated human cardiac muscle and in myocytes, response to -adrenergic stimulation is also reduced with age.) However, -adrenergic-mediated venoconstriction during exercise is not impaired with age and is a major factor in facilitating the return of blood to the heart. -Adrenergic blockade during exercise abolishes age-associated differences in heart rate, in early diastolic left ventricular filling rate, and in end-diastolic volume. Thus, the cardiovascular response to exercise is similar in younger persons during acute -blockade and in older persons. Animal studies confirm the age-associated reduction in contractile response of cardiac myocytes to -adrenergic stimulation. The contractile response is reduced because with age, -adrenergic stimulation is less able to increase L-type sarcolemmal Ca++ channel availability and thus to augment the brief increase in cytosolic calcium concentration (Ca++ transient). The age-associated reduction in the postsynaptic response of myocytes to -adrenergic stimulation appears to be due to multiple changes in coupling of 1and 2-adrenergic receptors to postreceptor intracellular machinery. The major age-associated change that limits this signaling pathway appears to involve the coupling of the -adrenergic receptor to adenylyl cyclase via the stimulatory G (Gs) protein. Because of this change, not enough intracellular cyclic adenosine

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monophosphate (cAMP) is produced to adequately activate protein kinase A, which phosphorylates key proteins, leading to altered protein function and augmented cardiac function. The reduced response to adrenergic stimulation in healthy older persons resembles that in patients with chronic heart failure. However, unlike the case in chronic heart failure, neither -adrenergic kinase activity nor inhibitory G (Gi) protein activity (Gi inhibits intracellular adenylyl cyclase) appears to be involved in the age-associated blunting of -adrenergic effects. *Cardiovascular Function in *Hypertension The same vascular and cardiac (hemodynamic) changes that are observed in normotensive persons as they age also occur in hypertensive persons but at a younger age, and in some, the changes are exaggerated. However, with age, hypertensive persons undergo some changes that do not occur in normotensive persons. In hypertensive persons, peripheral vascular resistance increases substantially with age. The increase in peripheral vascular resistance elevates diastolic and mean arterial pressures and plays a greater role in the vascular afterload of the heart than it does in normotensive persons. Also, resting stroke volume and cardiac output are lower in hypertensive persons than in normotensive persons. *Effects of Lifestyle Diet, exercise habits, and smoking may affect the heart and blood vessels of older persons, as suggested by cross-cultural studies. For instance, a difference in dietary sodium may account for some of the differences in age-associated blood pressure changes that occur among persons of different countries. However, some changes occur because the sodium sensitivity of arterial pressure regulation increases with age. Physical conditioning appears to lessen the vascular stiffening associated with aging. Late augmentation of resting systolic blood pressure, which is an index of arterial stiffness, is increased by only about half as much in endurance-trained elderly persons as it is in sedentary ones. Physical conditioning can also improve the aerobic capacity of older persons by increasing cardiac output and O2 utilization. Older persons in good physical condition can match or exceed the aerobic capacity of unconditioned younger persons. Effects of exercise in older animals are consistent with those in older persons: Some of the ageassociated changes in cardiac function (eg, prolonged myocardial relaxation, reduced sarcoplasmic reticulum function) are reversed. However, conditioning does not affect the prolonged action potential or the myosin isoenzyme shift to slower forms. Urinary System *Introduction Although renal function declines substantially with age, it is usually sufficient for removing bodily wastes and regulating the volume and composition of extracellular fluid. Nevertheless, reduced renal function decreases the elderly person's ability to respond to various physiologic and pathologic stresses. Doses of many drugs excreted primarily by the kidneys (eg, digoxin, aminoglycosides) require adjustment to compensate for decreases in renal function. *Renal Anatomy and Function Renal blood flow progressively decreases from 1200 mL/minute at age 30 to 40 years to 600 mL/minute at age 80. The primary underlying factor is the decreased renovascular bed. However, the reduction in flow does not simply reflect decreased renal mass because flow per gram of tissue decreases progressively after age 30 to 40. This decrease is due to fixed anatomic changes rather than to reversible vasospasm, as shown by studies with vasoactive agents. Of significance is that cortical blood flow decreases and medullary flow is preserved, a finding consistent with histologic studies that show selective

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loss of cortical vasculature with age. These vascular changes probably account for the patchy cortical defects commonly seen on renal scans of healthy elderly persons. A decrease in glomerular filtration rate is the most important functional defect caused by aging. The decrease is measured by creatinine clearance, which is stable until age 30 to 40 and then declines linearly at an average rate of about 8 mL/minute/1.73 m2/decade in about two thirds of elderly persons without renal disease or not undergoing treatment for hypertension. One third of elderly persons show no decrease in glomerular filtration rate. This variability suggests that factors other than aging may be responsible for the apparent reduction in renal function. For example, increases in blood pressure still within the normotensive range are associated with an accelerated, age-related loss of renal function. Unless hypertension or marked vascular disease is present, the kidney maintains its relatively smooth contour. With age, however, renal mass progressively declines and renal weight decreases from 250 to 270 grams at about age 30 to 180 to 200 grams at about age 70. The loss of renal mass is primarily cortical, with relative sparing of the medulla. The number of identifiable glomeruli decreases, roughly in accordance with the decrease in renal weight. The proportion of sclerotic glomeruli increases from 1 to 2% between ages 30 and 40 to > 12% after age 70 and is proportionate to the amount of atherosclerosis occurring elsewhere in the body. The glomerular tufts become less lobulated, the number of mesangial cells increases, and the number of epithelial cells decreases, thus reducing the surface area available for filtration. However, glomerular permeability does not change with age. Several minor microscopic changes occur in the renal tubule with age. Diverticula appear in the distal nephron, reaching a high of about three per tubule by age 90. These diverticula may become retention cysts, which are common in the elderly. Their clinical significance is unknown. The walls of the large renal blood vessels undergo sclerotic changes with age. The sclerosis does not encroach on the lumen but is augmented when hypertension is present. Smaller vessels appear to be spared--only 15% of elderly normotensive persons have sclerotic changes in the renal arterioles. X-rays show that normotensive persons > 70 have an increasing prevalence of abnormalities (eg, abnormal tapering of interlobar arteries, abnormal arcuate arteries, increased tortuosity of intralobular arteries) similar to that of younger hypertensive persons. Two age-related patterns of change occur in arteriolar-glomerular units. The first pattern, occurring primarily in the cortical area, is characterized by hyalinization and collapse of the glomerular tuft. The lumen of the preglomerular arteriole becomes obliterated, with a resultant loss in blood flow. The second pattern, occurring primarily in the juxtamedullary area, is characterized by glomerular sclerosis and the development of anatomic continuity between the afferent and efferent arterioles. The end point is shunting of blood flow from afferent to efferent arterioles and loss of glomeruli. Blood flow is maintained to the vasa recta, the medulla's primary vascular supply; these arterioles do not decrease in number with age. Several proximal tubular functions--maximal excretion of p-aminohippurate and iodopyracet and maximal absorption of glucose--parallel the decline in glomerular filtration rate, suggesting that tubular function disappears in entire nephrons with age. The renal threshold for glycosuria, which relates inversely to the degree of splay in reabsorptive capacity of individual nephrons, increases with age. Thus, glucose generally spills into the urine at a higher blood glucose level in an older diabetic patient than in a younger one. Unless a specific tubular defect exists, the ability to concentrate and dilute urine and to excrete acid also parallels changes in glomerular filtration rate in most persons. Although the renal tubular system responds normally to graded dosages of vasopressin, the maximum ability to concentrate urine decreases.

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This decrease seems to be due to a relative inability to maintain the solute (osmotic) gradient in the medullary portion of the kidney. The reason for this inability is unclear. *Renin-Angiotensin-Aldosterone System Whether estimated by the plasma renin level or renin activity, the basal renin level decreases by 30 to 50% in the elderly despite normal levels of renin substrate. Certain therapies and measures (eg, salt restriction, diuretic administration, upright posture), all designed to augment renin secretion, produce increases in plasma renin concentrations that remain 30 to 50% lower than those observed in younger persons under the same conditions. The lower renin levels in elderly persons result in 30 to 50% reductions in plasma aldosterone levels; the secretion and clearance rates of aldosterone are comparably reduced. Plasma aldosterone and cortisol responses after corticotropin stimulation are not impaired with age. Therefore, aldosterone deficiency in the elderly is usually a function of the coexisting renin deficiency and is not secondary to intrinsic adrenal changes. Age-related decreases in renin and aldosterone levels contribute to the development of various fluid and electrolyte abnormalities. For example, elderly persons on salt-restricted diets have a decreased ability to conserve sodium. Decreased angiotensin II production, which also can result from a lack of renin stimulation, has been reported to seriously impair tubular concentrating ability. Together, these conditions contribute to the increased tendency of elderly persons to develop volume depletion and dehydration. Still, the most important cause of dehydration, especially the hypernatremic dehydration that occurs when water loss is greater than sodium loss, is the loss of thirst, which is characteristic in the elderly in response to increased serum osmolality or volume contraction. Loss of thirst is especially important when elderly persons are confronted with an illness that increases demands for or limits the intake of salt and water (eg, an infection). Age-related decreases in renin and aldosterone also contribute to the elderly's increased risk of hyperkalemia in various clinical settings. Through its action on the distal renal tubule, aldosterone increases sodium reabsorption and facilitates potassium excretion. Aldosterone provides one of the major protective mechanisms in preventing hyperkalemia during periods of potassium challenge. Because glomerular filtration rate (another major determinant of potassium excretion) is impaired in the elderly, plasma potassium levels are likely to become seriously elevated, especially if gastrointestinal bleeding (a major abnormal source of potassium) occurs or if potassium salts are given orally or IV. The tendency toward hyperkalemia is enhanced by acidosis because the aging kidney is slow to correct an increase in acid load, resulting in prolonged depression of serum pH and a shift of potassium out of cells. Potent antagonists of renal potassium excretion (eg, spironolactone, triamterene, most nonsteroidal anti-inflammatory drugs, -blockers, angiotensin-converting enzyme inhibitors) should be administered cautiously to the elderly. The concomitant administration of these drugs with potassium supplements should be avoided. Gastrointestinal System * Introduction Geriatric Essentials Clinically significant abnormalities in gastrointestinal function should be evaluated and not attributed to aging. Taste sensation and saliva production decrease to some degree with aging. Aging diminishes the capacity of the gastric mucosa to resist damage. Aging modestly slows gastric emptying. Calcium absorption diminishes with aging; therefore, the dietary calcium requirement is higher.

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 The incidence of diverticulosis increases with aging. Hepatic blood flow decreases with aging, accounting for some of the decrease in hepatic drug

elimination that occurs in the elderly.

Aging has relatively little effect on gastrointestinal (GI) function because of the large functional reserve capacity of most of the GI tract. However, aging is associated with an increased prevalence of several GI disorders, including those induced by drugs (eg, esophagitis caused by NSAIDs or bisphosphonates). Therefore, clinically significant abnormalities in GI function, including reduction in food intake, should be evaluated and not attributed to aging. The presentation of some GI disorders may be atypical in the elderly, possibly reflecting a reduction in visceral perception. Gut immune function declines with aging; the clinical significance of this is uncertain. *Oral Cavity Taste sensation decreases with aging. Elderly people demonstrate an impaired ability to identify food by taste. A number of drugs and diseases can also affect taste, and reversible causes of taste impairment must always be considered. Although dentition may be well preserved in the absence of caries and periodontal disease, poor dentition is common and a major contributor to impaired chewing and reduced caloric intake. Tooth loss in the elderly has declined dramatically, although in some populations > 60% of the elderly are edentulous. A modest decrease in saliva production occurs with aging and may contribute to the severity of acid reflux in the elderly. *Esophagus In healthy people, aging has only minor effects on esophageal motility. Upper esophageal sphincter pressure decreases with aging (with a delay in swallow-induced relaxation), but lower esophageal sphincter pressure does not seem to change. Secondary peristalsis is elicited less consistently by esophageal distention, which may impair the clearance of refluxed acid and bile. Furthermore, the perception of distention or acid perfusion decreases, while cerebral evoked potentials elicited by esophageal balloon distention have a prolonged latency and reduced amplitude in healthy elderly people compared with younger people, which indicates a deficit in afferent sensory pathways from the esophagus. Previous reports of presbyesophagus (a condition associated with marked abnormalities in esophageal peristalsis) are almost certainly attributable to neurologic or vascular disorders that affect esophageal function and not to age-related changes. Gastroesophageal reflux appears to be as prevalent in elderly people as in the young, and though it causes milder symptoms, it tends to be associated with more severe disease, possibly because of impaired acid clearance. The elderly also have a reduction in the intra-abdominal length of the lower esophageal sphincter and an increased incidence of hiatus hernia. Many drugs, including NSAIDs, potassium chloride, tetracycline antibiotics, quinidine, alendronate, ferrous sulfate, and theophylline, can cause esophageal injury. The elderly are at higher risk of drug-induced esophagitis and its complications because they are prescribed a greater number of drugs and are more likely to have delayed esophageal transit and to suffer from immobility. Therefore, patients should swallow these drugs while in an upright position and should follow them with a glass of water. *Stomach Although aging has no significant effect on secretion of acid and pepsin by the stomach, conditions that reduce acid production are common. Reductions in basal and stimulated gastric acid secretion that occur with aging (hypochlorhydria) are attributable to atrophic gastritis, the prevalence of which is increased

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by Helicobacter pylori infection. In the absence of atrophic changes in the gastric mucosa, the number of acid-secreting (parietal) cells probably increases with aging. Evidence indicates that aging diminishes the capacity of the gastric mucosa to resist damage. A number of factors that may be important in cytoprotection, including gastric mucosal blood flow and secretion of prostaglandin, glutathione, bicarbonate, and mucus, diminish with aging. These changes may account for the impaired barrier function of the gastric mucosa and the increased risk of gastric and duodenal ulcers in the elderly, particularly those caused by NSAIDs. These changes may also contribute to an increased incidence of H. pylori-induced gastroduodenal ulcers in the elderly. Aging is associated with a modest slowing of gastric emptying, which may prolong gastric distention, increase meal-induced fullness and satiety, and predispose to decreased food intake and some degree of weight loss. *Small Intestine Aging has only minor effects on the small intestine, with some alteration in villus architecture and a reduction in the neuronal content of the myenteric plexus. Aging does not result in major changes in small intestinal motility, transit, permeability, or absorption. Although changes in small intestinal immune function occur, there is no evidence that these changes are clinically important. Bacterial overgrowth in the small intestine, while unusual in healthy elderly people, is common among those with co-existing illness. Predisposing conditions include hypochlorhydria, small intestinal diverticula, and diabetes mellitus. Bacterial overgrowth may be asymptomatic or cause relatively nonspecific symptoms (eg, anorexia, weight loss) and may cause micronutrient malabsorption (eg, folate, Fe, Ca, vitamins K and B6). Bacterial overgrowth is also a cause of diarrhea. With aging, Ca absorption diminishes even in vitamin D-replete elders because of intestinal resistance to the action of 1,25-dihydroxyvitamin D. Vitamin D deficiency also contributes. Ca malabsorption is almost certainly a major factor in age-related bone loss in men and women; accordingly, the dietary Ca requirement is higher in the elderly. *Large Intestine Aging does not appear to cause major changes in colonic or anorectal motility. Rectal compliance and tone are normal, but the perception of anorectal distention is reduced in the elderly. This reduction in rectal wall sensitivity, together with a modest delay in colonic transit, may play a role in constipation. Fecal incontinence occurs in up to 50% of nursing home residents. Common causes are constipation with fecal impaction, laxative use, neurologic disorders (eg, autonomic neuropathy), anorectal surgery or previous obstetric injury, and colorectal disorders (eg, rectal prolapse or radiation injury). Fecal incontinence is often a feature of diarrheal illness but the two may occur separately. The incidence of diverticulosis increases with aging because of declining tensile strength in the smooth muscle of the colonic wall. Ischemic colitis occurs almost exclusively in the elderly as a result of mesenteric atherosclerosis. Inflammatory bowel disease, often regarded as a disease of young adults, has a smaller incidence peak in adults in their 50s through their 80s (mainly ulcerative colitis) and is more likely to be limited to more distal colonic segments. However, the initial presentation may be severe and associated with complications (eg, toxic megacolon). *Pancreas The pancreas undergoes substantial structural changes with aging, including a decrease in overall weight, duct hyperplasia, and lobular fibrosis. Surprisingly, these changes do not affect pancreatic exocrine

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function significantly; pancreatic enzyme and bicarbonate levels decrease only modestly, so that fat and carbohydrate absorption are unaffected by age. Insulin secretion decreases (as a result of decreased responsiveness of the pancreatic cell to glucose) and insulin resistance increases with aging; both contribute to the higher risk of glucose intolerance and type 2 diabetes mellitus in the elderly. *Liver Age-related changes occurring in the liver may be gross, histologic, biochemical, or related to blood flow or stress. With the exception of changes that affect drug metabolism, most probably have no clinical relevance. Grossly, the liver becomes more brown and decreases in volume and weight. The color change is attributable to accumulation of lipofuscin (a brown pigment) in hepatocytes as a by-product of lipid and protein metabolism. Capsular and parenchymal fibrosis also increases but does not affect function and does not indicate cirrhosis. Hepatic volume decreases by about 17 to 28% between the ages of 40 and 65; weight decreases by about 25% between the ages of 20 and 70. Histologically, hepatocytes probably enlarge with aging, and some evidence suggests an increase in nuclear polyploidy and size. The number of mitochondria per hepatic volume decreases with an increase in the number of swollen, vacuolated mitochondria. The numbers of lysosomes and dense bodies also increase. Biochemically, serum bilirubin levels decrease with aging, although < 0.2% of test results in elderly patients are below the normal range. Protein synthesis also appears to decrease with aging, although the degree varies widely by protein; serum total protein and albumin levels decrease slightly but remain within the normal range. Phase 1 enzymatic reactions (oxidation, reduction, hydrolysis), which take place in hepatocyte smooth endoplasmic reticulum and which metabolize drugs, decrease linearly with aging. Phase 2 reactions (conjugation) remain essentially unchanged. Phase 1 enzyme activity per gram of liver tissue may actually be preserved, and decreased phase 1 activity may result primarily from an age-related decline in hepatic mass. Why phase 2 reactions are preserved despite the decline in hepatic mass is unclear, but it may be because of compensatory extrahepatic conjugation. The older liver may also be less responsive to enzyme induction by some agents. Hepatic blood flow decreases by 35% between the ages of 40 and 65 largely because of a decrease in splanchnic blood flow. The decreased hepatic blood flow, together with decreased hepatic weight, accounts for decreases in hepatic drug elimination of some compounds in the elderly. Response to physiologic stress may also decrease with aging. Many hepatotoxic drugs cause more severe injury in older people, possibly due to altered drug metabolism, impaired cellular protective mechanisms, and diminished reserve in other organs. Hepatic regeneration is delayed but not greatly impaired. The regulation of regeneration, however, is poorly understood. Some effects are clearly extrahepatic, including decreased serum levels of epidermal growth factor (EGF) and transforming growth factor- . In the elderly, hepatocytes seem less able to respond to hepatotropic growth factors (eg, EGF). Studies have demonstrated a decrease in EGF receptors and their binding capacity for EGF. Therefore, delayed hepatic regeneration is clinically important for elderly patients undergoing liver resections--mortality rates resulting from liver resection are higher in patients > 60 than in those < 60. Postoperative morbidity and mortality, however, are usually not due to liver failure but rather to extrahepatic complications of the surgery. The overall survival of transplanted livers is not dramatically different in older and younger patients,

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and older patients are increasingly undergoing liver transplantation. Evidence suggests that livers from donors 65 may be viable for transplantation. *Gallbladder Bile acid synthesis declines, reflecting a significant reduction in the hydroxylation of cholesterol (cholesterol 7 -hydroxylase). This change may contribute to the increased incidence of cholelithiasis (gallstones) in the elderly. A similar age-related decrease in hepatic extraction of low-density lipoprotein cholesterol from the blood occurs, elevating serum cholesterol levels and possibly promoting coronary artery disease in the elderly. Both stimulated and fasting concentrations of cholecystokinin (a peptide hormone released from duodenal mucosa that contracts the gallbladder and relaxes the biliary sphincter) are higher in elderly people. However, gallbladder emptying rates and fasting and nonfasting gallbladder volumes do not change with aging, suggesting diminished sensitivity to the effects of cholecystokinin. Sexuality * Aging and Sexual Function With normal aging, persons require more time to become sexually aroused. Although some persons perceive this gradual slowing as a decline in function, others do not consider it an impairment because it merely results in men and women taking more time to achieve orgasm. -Changes in Men In addition to slowing of arousal, elderly men may notice less preejaculatory fluid and less forcefulness at ejaculation. The erection is less firm and shorter-lasting. After orgasm, elderly men take longer than younger men to achieve another erection. Unlike women, who undergo a physiologic climacteric, men often remain fertile throughout life. Erectile dysfunction is a common concern for many men. Although the incidence of erectile dysfunction increases with age, aging per se is not the cause. Drug treatment helps some men with erectile dysfunction. -Changes in Women Women usually can maintain sexual functioning throughout life unless a medical disorder intervenes. Women tend to be less concerned than men about sexual performance but are more worried about loss of youthful appearance or sexual attractiveness. The frequency of sexual activity for women often relates to the age, health, and sexual functioning of their partner (or the availability of a partner) rather than to their own sexual capacity or desire. For women, most sexual changes occur during menopause, when estrogen production slows. These changes may include atrophic vaginitis, with dryness of the vaginal mucosa leading to irritation or pain during intercourse. The ability to engage in pleasurable intercourse may be further compromised by age-related shortening and narrowing of the vagina. Less acidic vaginal secretions increase the likelihood of vaginal infections. Cystitis is more common in elderly women than in younger women because of the changes from atrophic urethritis. Decreased estrogen levels can lead to a reduction in clitoral size, stress incontinence, and an increase in facial hair. However, estrogen replacement therapy prevents or reduces many of these problems, and some women enjoy sexual activity more after menopause because pregnancy is not an issue. Many women are skeptical about the benefits of estrogen, are concerned about its risks, and may experience "estrogen anxiety." The decision whether to use estrogen should be made by a woman and her physician through careful weighing of the risks and benefits. Nonestrogen measures (eg, water-based vaginal lubricants such as K-Y Jelly) can help prevent or control vaginal dryness and irritation during intercourse.

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Dermatologic Changes in Aging *Age-Related Changes in Skin Structure and Function The overall result of structural changes is an increase in skin dryness, roughness, wrinkling, and laxity, and a decrease in skin elasticity. The overall result of functional changes is a decline in skin barrier function, mechanical protection, sensory perception, wound healing, immunologic responsiveness, thermoregulation, and vitamin D production. Aging may also affect the absorption of some topical drugs, although clinically important differences have not been identified. Epidermis: The epidermis gives rise to the outer barrier layer of dead cells, the stratum corneum, through terminal differentiation of keratinocytes, the predominant cell type. The epidermis recognizes invading pathogens and other foreign substances and generates abundant cytokines. Melanocytes reside in the epidermal basal layer, producing and distributing photoprotective melanin to the keratinocytes. With aging, the dermal-epidermal junction flattens--the number of interdigitations dramatically decreases--resulting in a smaller contact surface area between the dermis and epidermis. As a result, dermal-epidermal separation occurs more readily in elderly skin, and elderly skin is more likely to tear or blister. The change probably also compromises communication and nutrient transfer between epidermis and dermis, affecting the mechanical, barrier, and immunologic functions of the epidermis. Elderly skin often appears dry and flaky, especially over the lower extremities, at least partly due to a dramatic age-associated decrease in epidermal filaggrin, a protein required for the binding of keratin filaments into macrofibrils. Epidermal turnover rates decrease by about 30 to 50% between a person's 20s and 70s. This decrease slows the replacement rate of the stratum corneum, likely resulting in a rougher skin surface and a less adequate barrier. Slow replacement of the surface layer is also thought to be responsible for the prolonged healing times for epidermal wounds as well as the decreased barrier function that results from slow replacement of neutral lipids. The number of active melanocytes decreases by about 10 to 20% per decade, probably explaining in part the increased vulnerability to ultraviolet (UV) radiation in old age. An accompanying age-associated decline in DNA repair capacity compounds the loss of melanin protection and increases the risk for developing skin cancers. The prevalence of melanocytic nevi also declines, from a peak between ages 20 and 40 to near zero after age 70. Vitamin D production, which depends on sun exposure, declines with aging, possibly because of a 75% decrease between early and late adulthood in the amount of epidermal 7-dehydrocholesterol, the immediate biosynthetic precursor of vitamin D. Decreased vitamin D production is often compounded by reduced outdoor activity, leading to insufficient sun exposure. Dermis: The dermis contains the blood vessels, lymphatics, nerves, and deeper portions of the hair follicles and glands that arise from the epidermis. It is composed largely of extracellular matrix and gives skin its strength and elasticity. Dermal thickness decreases by about 20% in the elderly and often even more in photodamaged areas. UV damage produces hyperplastic changes initially, followed by atrophic changes, particularly in fairskinned people. These opposing changes probably explain observed variations in the effects of photodamage. Even when elderly skin has been consistently protected against the sun, within the dermis there is about a 50% decrease in mast cells and a 30% decrease in venular cross-sectional area. Basal and peak levels of cutaneous blood flow are reduced by about 60%. As a result of these decreases, there is a decrease in release of histamine (a mast cell product) and other measures of inflammatory response after

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exposure to UV radiation or immune challenge. Vascular responsiveness during injury or infection is also compromised. The striking involution of vertical capillary loops in dermal papillae is thought to account for the pallor, decreased temperature, and impaired thermoregulation found in elderly skin. As well, the decline in vascular supply to hair bulbs and to the eccrine, apocrine, and sebaceous glands may contribute to their senescence. Reduced synthesis and increased degradation of collagen, the major component of the dermal matrix, probably contribute to impaired wound healing in the elderly. Elastic fibers decrease in number and diameter with aging, accounting for decreased elasticity in elderly skin. Fragmentation, progressive crosslinkage, and calcification of elastic fibers also occur. Alterations of mucopolysaccharides that normally bind water in the dermal matrix may affect skin turgor. Subcutaneous fat: Subcutaneous fat acts as a shock absorber, protecting the body from trauma, and plays a role in thermoregulation by limiting conductive heat loss. The overall volume of subcutaneous fat usually diminishes with aging. Distribution changes as well; eg, there is a relative decrease in subcutaneous fat on the face and hands but a relative increase on the thighs and abdomen. These changes can alter the appearance of the face and hands and reduce the pressure diffusion over bony areas that prevents some pressure ulcers and fractures. Hair: Hair substantially grays in about 50% of people by age 50, apparently due to loss of melanocytes. Although the degree of hair graying often runs in families, the responsible genes are unknown. Linear growth rate decreases with aging because the follicular keratinocytes that normally differentiate to form the hair shaft proliferate more slowly. Hair loss (more correctly, conversion from terminal to vellus hairs) in the vertex and frontotemporal regions (androgenetic alopecia) in men begins between the late teens and the late 20s; by the time they reach their 60s, 80% of men are substantially bald. In women, the same pattern of hair loss may occur after menopause, although it is rarely pronounced. Hair thinning, or diffuse hair loss, sometimes termed female alopecia, is more correctly termed miniaturization of hairs. The cause is a shortened anagen (growth) phase and decreased proliferation of follicular keratinocytes. Diffuse hair loss normally occurs in both sexes with aging and should be distinguished from diffuse hair loss caused by iron deficiency, hypothyroidism, chronic renal failure, undernutrition, and use of certain drugs (especially anabolic steroids and antimetabolites). Excessive or unwanted hair growth becomes common after menopause in women as a result of altered estrogen-androgen balance in hormonally sensitive hair follicles. The most distressing symptom may be the appearance of scattered terminal hairs in the beard area. Men may notice excessive hair growth in the eyebrows, nares, or ears. Nails: Linear growth rate and thickness ("strength") of nails decreases with aging because of a decrease in the proliferative rate of nail matrix keratinocytes, which differentiate to form the nail plate. Nails become dry and brittle and flat or concave instead of convex, often with longitudinal ridging. Longitudinal pigment banding, common among blacks, often becomes more pronounced with aging. Nail color may vary from yellow to gray, reflecting changes in the nail bed. The lunulae can become poorly defined. Occasionally, the nails become grossly thickened and distorted (onychogryphosis) Lamellar dystrophy manifests as brittle nails with split ends or layering and commonly occurs in elderly people, though it may also occur in middle-aged women. Nerves and glands: The density of cutaneous sensory end organs decreases progressively between the ages of 10 and 90 by about 1/3. The result is an age-related reduction in sensations of light

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touch, vibration, corneal sensitivity, 2-point discrimination, and spatial acuity. The cutaneous pain threshold increases by about 20%. Eccrine glands decline in number by an average of 15% during adulthood. Decreased gland secretion results in marked decreases in spontaneous sweating in response to dry heat. These changes, compounded by decreased cutaneous vascularity, make the elderly more vulnerable to heat. Apocrine glands also decrease in size and function with aging, but these changes do not appear to have any clinically significant effect (except possibly a decline in body odor). The size and number of sebaceous glands do not appear to decrease with aging. However, sebum production decreases by about 23% per decade, beginning in early adulthood, probably due to the concomitant decrease in production of gonadal or adrenal androgens, to which sebaceous glands are exquisitely sensitive. Immunologic function: The number of epidermal Langerhans' cells (immune cells in skin responsible for antigen presentation) decreases by 20 to 50% during adulthood. Alterations in the production of ILs and cytokines by other cells such as keratinocytes may also contribute to overall immunologic decline observed in the elderly. The result is presumed to be increased susceptibility to infections and increased incidence of neoplasms. E. The Specialty of Gerontological Nursing Clinical specialists in gerontologic nursing (often referred to as gerontologic or geriatric clinical nurse specialists) are registered nurses who have a master's or higher degree in nursing and who specialize in care of the elderly. Gerontologic clinical nurse specialists have substantial clinical experience with patients and their family members; they have expertise in formulating health and social policies and in planning, implementing, and evaluating health problems. They can also take histories, perform physical examinations, and manage medical and nursing problems. Unlike nurse practitioners, clinical nurse specialists usually cannot diagnose and cannot prescribe drugs. Most gerontologic clinical nurse specialists work in hospitals as consultants to interdisciplinary teams. They consult for and advise staff nurses about problems common among the elderly and provide continuing education about new research findings. Gerontologic clinical nurse specialists also help staff nurses by serving as liaisons between the hospital and nursing homes or community health agencies. They may make home visits after a patient is discharged from the hospital and manage and coordinate care as a patient moves between several care settings. Gerontologic clinical nurse specialists sometimes teach and train staff nurses more formally, as in the geriatric resource nurse program, which includes participation in interdisciplinary geriatric care rounds. After completing this training program, staff nurses are recognized as geriatric resource nurses, although no certification occurs. In addition to providing expert care for elderly patients, geriatric resource nurses provide information and support for other staff members caring for elderly patients and for patients and their family members. Geriatric resource nurses also act as advocates for elderly patients. F. Gerontological Nursing Practice Gerontologic (geriatric) nurse practitioners are registered nurses with a master's degree from a nurse practitioner program that focuses on care of the elderly. In 2004, only about 4,000 of > 100,000 certified nurse practitioners were certified gerontologic nurse practitioners. However, many certified family nurse practitioners and adult nurse practitioners also provide care for the elderly. The curriculum for gerontologic nurse practitioners focuses on normal aging, common problems of old age and their management, and detection of complex problems that typically require referral.

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Gerontologic nurse practitioners perform many functions previously performed only by physicians. They perform physical examinations, diagnose disorders, order laboratory and other diagnostic tests, develop and implement treatment plans for patients with certain acute or chronic disorders, prescribe certain drugs, teach and counsel patients, provide long-term monitoring, consult with other health care practitioners, and refer patients to specialists. Nurse practitioners may practice in collaboration with physicians or other health care practitioners. Many gerontologic nurse practitioners work in nursing homes or for physicians with practices in nursing homes. Others work in acute care settings or in primary care offices. Community health services (eg, home care agencies, hospices, clinics) may be managed primarily by gerontologic nurse practitioners. Nursing roles have expanded because basic health care services are lacking in certain areas, especially rural areas and inner cities, and because few physicians make home visits. Many gerontologic nurse practitioners provide primary care in the community. G. Ethics of Caring and Legal Aspects of Gerontological Nursing

The most common legal and ethical issues in geriatric care involve assessment of decisional capacity and competence, identification of decision makers, resolution of conflicts about care, disclosure of information, termination of treatment at the end of life, and decisions about long-term care. Although the approach to resolution of these issues is similar for all age groups, the physiologic, psychologic, and social reserves of the elderly place them at greater risk of adverse outcomes. The fact that the elderly often lack the support of family and friends makes them especially vulnerable to the automatic and sometimes unthoughtful process of the health care system. Although aging may pose some special challenges, it is unfair to make assumptions about a person's abilities or needs based on age alone. Rather, physicians should assess each elderly patient individually and delineate treatment options accordingly. Physicians must also advocate for their patients' ethical interests and legal rights, especially in the medical context, about which patients are often illinformed or misled. Elderly patients are often targets of unscrupulous schemes to defraud them of property or money. Health care practitioners may be the first to recognize such schemes and should offer help and referral for legal assistance. Attorneys knowledgeable about elder law can defeat these schemes with timely and effective legal intervention through services provided by the local agency on aging. Capacity A clinical determination of a patient's ability to make decisions about treatment interventions or other health-related matters. Competence A legal designation that recognizes that persons beyond a certain age generally have the cognitive ability to negotiate certain legal tasks, such as entering into a contract or making a will. Informed Consent A decisionally capable patient's legally binding treatment decision reached voluntarily and based on information about risks, benefits, and alternative treatments gained from discussion with a health care practitioner. Confidentiality and Disclosure Ethical oaths and specific statutes protect the confidentiality of physician-patient communication, an ethical and legal bedrock of the therapeutic relationship. Even well-meaning family involvement without the patient's consent violates the patient's right of confidentiality. Protection of private patient information is

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essential to encouraging patient candor in revealing symptoms and behaviors relevant to diagnosis and treatment. Protection of a patient's secrets, private thoughts, and feelings is also required by decency. Patient utterances are also protected by the doctrine of privilege, which grants patients the right to exclude otherwise relevant and admissible testimony in a court of law. This privilege can be invoked only by the patient. Additionally, most states have professional licensing statutes that incorporate the ethical and legal confidentiality mandates and make them a clear part of professional practice. All patients are entitled to confidentiality unless they give permission for disclosure or they clearly can no longer express a preference (eg, a severely confused, comatose, or decisionally incapacitated patient). Even in these cases, secrets should be guarded, although decisions about care may require discussion with appropriate surrogates. When a patient can no longer make health care decisions, prior expressed preferences should be respected whenever possible. Advance Directives Legal statements that allow persons to articulate values and establish treatment preferences to be honored in the future when capacity has lapsed. Living Wills A living will lists the interventions the patient would request, accept, or reject in the future, usually at the end of life. Physicians often have difficulty accepting a patient's choice to abandon aggressive care and permit death. Most patients use living wills to refuse life-sustaining care when the prognosis for improvement or recovery is hopeless and the ability to relate to others is severely diminished or destroyed. However, as managed care becomes more pervasive and as patients become concerned about being denied care, living wills that request care are becoming more common. The living will specifies a set of circumstances followed by a set of consequences (eg, "If I am hopelessly ill and my physicians say that I will not recover, then..." or "If I am not able to recognize and relate to family and friends and my physicians say that I will not recover, then..."). The consequences specify the interventions the patient would or would not want (eg, intubation, resuscitation, dialysis, surgery, antibiotic therapy). The document usually states that, despite these specific refusals, all measures necessary for comfort should be provided. The goal of the most usual type of living will--prospective refusal-is to ensure that invasive, aggressive, and life-sustaining treatments will not be used if they would merely prolong the dying process or support a vegetative state. Some living wills limit their applicability to terminal illness; thus a patient desiring to refuse care if in a vegetative state or deep coma should not use this restricted type of living will. Durable Power of Attorney for Health Care A durable power of attorney for health care differs from a regular power of attorney, which addresses decision making concerning financial matters or property rights (eg, the right to sell a car or manage stocks). A durable power of attorney for health care, or health care proxy, is a legal document that allows the patient to appoint a person, called a health care agent or proxy, to make health care decisions should the patient become temporarily or permanently incapacitated or be declared legally incompetent. This legal appointment places a loving, concerned, trusted person in a dialogue with the physician to reach an appropriate decision. The agent's decisions are guided by specific instructions from the patient, by notions of substituted judgment (what the patient would likely want under the circumstances), and by the concept of best interest. The agent can discuss the patient's diagnosis, prognosis, treatment alternatives, and likely

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outcomes with the physician, respond to the patient's changing condition, and base a decision on current circumstances in light of known patient preferences and values. Prior discussions between patient and agent provide the agent with a richer understanding of the patient's values and preferences, allowing more nuanced decisions to be made later. This opportunity for dialogue generally results in a better decision than could have been reached by following the static directives in a living will. Surrogate Decision Making A surrogate is a statutorily designated health care decider or an informally identified person, such as a close family member or friend. The more informal the appointment, the less likely the surrogate will be able to refuse life-sustaining treatment, especially in states with very restrictive laws. If the patient is incapacitated and no advance directive exists, some other person or persons must provide the direction (either a loved one or the medical staff). Most hospitals and physicians accept consent to provide care from a spouse, an adult child, a close friend, a clergy member, or even a distant and uninvolved relative, although in most states, none of these persons is legally empowered to consent on a patient's behalf without being appointed by a court. However, accepting the judgment of a close relative or friend over that of a distant relative or total stranger makes practical and ethical sense. Thus, a decision agreed on by hospital, physician, and family almost always constitutes the basis for providing care, although it may not be legally adequate if challenged. Elderly patients without family or close friends may receive a court-appointed guardian, who is often disinterested and serves a perfunctory role. Some institutions and jurisdictions are experimenting with the appointment of public guardians and patient advocates, which may prove appropriate and cost-effective. When surrogates attempt to refuse treatment by deciding to withhold or withdraw interventions (an often articulated distinction without any substantial legal or ethical difference), legal concerns increase because of the possibility of death. The initial questions in these circumstances are (1) Who decides? (2) On what basis is the decision made? and (3) What possibilities exist for appeal and review? Answers vary widely among the states. In New Jersey hospitals, for example, if an ethics or prognosis committee determines that the prognosis is hopeless (and, in the case of elderly residents in long-term care, the state Office of the Ombudsman determines that the decision does not constitute abuse), a specially appointed guardian may opt to withhold treatment. Conversely, in New York, surrogates who have not been appointed by the patient have very limited ability to withhold care unless the patient has addressed a similar circumstance when capacitated and has left explicit instructions to be followed. The problem is that these practices assume that continued existence is the desired state. Under certain circumstances, however, permitting death is not incompatible with a patient's best interest nor with the state's usual interest in preserving life. Unless there is a durable power of attorney for health care, the choice of a surrogate may be unclear. Once identified, the surrogate bases a decision on one of three standards, in the following hierarchy:
Explicit directive, ie, the instructions expressed by the patient when capacitated Substituted judgment, ie, inferences about what the patient would likely want in this situation based

on what is known about his prior behavior and decision making

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Explicit directive, the first standard, is usually determined by a written document (eg, a living will) but can also be fulfilled by discussions with the patient as reported by the surrogate or others, particularly by

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Best interest, ie, what the surrogate and health care team believe is best for the patient

close family members. Statements to health care practitioners, especially when documented in the medical chart, can also be important in determining the patient's preferences. Do-Not-Resuscitate Orders A statement in the medical record that cardiopulmonary resuscitation will not be performed. The do-not-resuscitate (DNR) order, which averts CPR in cases of cardiopulmonary arrest, has been particularly useful in preventing unnecessary and unwanted invasive intervention at the end of life. Currently, resuscitation is attempted except in cases in which it would not be effective or that are not in accordance with the desires or best interests of the patient. This default position evolved slowly over recent decades. There is a question of whether the decision to issue the order not to resuscitate belongs to the physician or patient. The New York statute, for example, permits the patient or surrogate to choose resuscitation even if health care practitioners believe it will result in extremely poor subsequent quality of life. Conversely, interpretation by the New York State Department of Health provides for physicians to write a DNR order over patient or family objections in the rare cases of "DNR futility," referring to the very specific circumstances in which resuscitation would be physiologically ineffective. However, even if the physician claims futility as a basis for overriding the patient's or surrogate's decision, the issue must be raised first with the patient or his guardian. In most other jurisdictions, the policies and procedures related to DNR orders are somewhat less demanding. Most hospitals, nursing homes, and home health care agencies have policies for situations in which the likely benefit of CPR is so slim and the burden on the patient so great that a DNR order is appropriate. Most institutions require that resuscitation be discussed with the patient or family, although not that it be raised as a question open for their decision. Physicians should discuss the possibility of cardiopulmonary arrest with patients, describe CPR procedures, and elicit patients' preferences about interventions. Ideally, discussion takes place in an outpatient setting or early in hospitalization as part of a discussion of general treatment preferences. Under these circumstances, patients are more likely to be mentally alert and relaxed, which helps ensure understanding and thoughtful participation in the decision-making process. Subsequent periodic discussions can determine if the patient has changed his mind due to changes in his condition or in treatment alternatives. If a patient is incapable of making a decision about CPR, the surrogate may make the decision based on the patient's previously expressed preferences or, if such preferences are unknown, in accordance with the patient's best interests. No matter who decides, some system should exist for communicating, recording, and reviewing the decision. There is no widely recognized case in which a physician or institution was found liable for respecting a DNR order that was authorized after being discussed with the patient and family and being recorded in the patient's medical record. It is essential to clarify that DNR does not mean do not treat. Only CPR will not be performed. Other treatments (eg, antibiotics, transfusions, dialysis, ventilatory support) may and should still be provided if indicated. More specific orders are required to indicate whether the person should be hospitalized, treated in an intensive care unit, or subjected to other interventions. Many hospitals and long-term care facilities have policies to guide decisions about resuscitation. These policies vary widely; some reserve the decision for the physician, whereas others allow patients or designated surrogates to decide. Hospital medical staffs should periodically review their experience with DNR orders, revise their DNR policies as appropriate, and inform physicians about their role in the decisionmaking process.

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Euthanasia, Assisted Suicide, and Palliation Euthanasia, an action taken by a health care practitioner intended to result in a patient's death, is illegal in the USA. Some patients whose life expectancy is reduced and who are suffering severely request euthanasia. Traditionally, euthanasia has been forbidden in medical practice, and purposeful intervention to end life disturbs most physicians and patients. However, in certain clinical situations involving hopelessness and suffering, death is the end of pain, not of meaningful life. Assisted suicide, an action taken by a patient intended to cause his own death with drugs supplied by a physician, is illegal in all states except Oregon. Physicians can provide treatment intended to minimize physical and emotional suffering, even if a secondary result is the shortening of life, but they cannot specifically intend to hasten death. H. Spirituality Introduction With the high prevalence of physical and mental health conditions that beg for the attention of nurses who work with older adults, spiritual needs are often overlooked in geriatric care. Yet more than any other time in life, the relationship between spirituality and the general state of health and well-being is greatest in advanced years. When the body no longer functions as it did when it was younger, when taking medications and addressing other care needs becomes a pervasive daily routine, and when the feeling prevails that one is viewed as a Model T in a NASCAR society, the essence of being---the spirit---can provide a safe haven. Even for the senior who is blessed with fine health and has been afforded and taken advantage of opportunities to be fully engaged in society, reflection on the purpose and value of life becomes significantly more common and acute than was often apparent during the younger years when ones doing often masked the importance of ones being. Developmental Tasks For some time, it has been recognized that psychological growth continues into old age. Erik Erikson (1950) was among the earliest psychologists to consider generational cycles and the mapping of a sequence of stages through which individuals progress over the life cycle. The eighth and final stage of the model he offered was Integrity vs. Despair. Erikson described ego integrity as the acceptance of ones life as something that had to be, inclusive of joys and sufferings, accomplishments and failures. Robert Peck refined Eriksons description of the last stage of life by discussing the specific challenges older people faced that influenced their ability to achieve ego integrity. He offered these as (Peck, 1968): Ego differentiation vs. role preoccupation: to develop satisfaction from the essence of who one is rather than through parental or occupational roles Body transcendence vs. body preoccupation: to find psychological pleasures rather than become defined and limited by physical limitations imposed by aging or illness Ego transcendence vs. ego preoccupation: to achieve satisfaction by reflecting on ones past life rather than to be absorbed and discouraged with the limited numbers of years remaining Robert Butler and Myrna Lewis (1982), among their contributions to gerontology, built on previous theorists descriptions as they summarized major late life tasks as: Adjusting to ones infirmities Developing a sense of satisfaction with the life that has been lived Preparing for death

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Most of these developmental tasks considered an integration process that required reflection on ones circumstances within the world as it has been. Consideration of looking forward, redefining reality, and seeing a self separate from the physical body was introduced with the theory of gerotranscendence. Gerotranscendence suggests that there is a shift from a materialistic and pragmatic view of the world to a more cosmic and transcendent vision (Tornstam, 1994). Engaging in affairs of more significance and establishing meaningful connections with others become more significant than accumulating material possessions and wealth, engaging in superficial relationships, and being absorbed with self-interests. Faith and Health There was a time when many health professionals believed the benefits of supporting a patients faith rested in the comfort it brought the patient and the respect it showed for the individuals religious preferences. However, increasing evidence supports that the beneficial impact of religious commitment and practices on health and healing goes beyond the placebo effect. Religious commitment and prayer have shown to improve health care outcomes, reduce complications, decrease the risk of psychopathology, and enhance the elderlys functional ability Spiritual Needs Regardless of age, people have basic spiritual needs that include love, meaning and purpose, hope, dignity, forgiveness, gratitude, transcendence, and the expression of faith (Eliopoulos, 2005). In fact, some of these needs may take on greater significance for older adults in light of the growing risk and prevalence of chronic conditions and the heightened awareness of the finiteness of life. Love Of all spiritual needs, the exchange of love is perhaps the most significant. This is hardly surprising when we consider that humans are relational beings. People normally value being cared about and valued by others, and having others for whom they can care. Love, from a spiritual perspective, is unconditional, reliable, and genuine. It does not depend on what one looks like or can offer. Instead, it is a deep feeling that rests on appreciation of the person within a heart to heart to connection. In the changing world of the elder individual, multiple losses are faced: loved ones, personal health and function, financial security, home, roles. The exchange of love fills in the void left by losses and gives reason to face another day. Love is healing at many levels; conversely, the lack of love can interfere with optimal health and well being, as is profoundly witnessed in the Failure to Thrive Syndrome. Meaning and Purpose To accept that everything served a purpose helps the elderly realize that their lives were not lived in vain. Although they may not have achieved the fame and fortune that they once dreamed of, they can appreciate that their lives made a difference, be it through supporting and raising a family or making something a little better than it was before their involvement. Hope Hope is the expectation that something will happen in the future. It is not merely the desire for something to happen, but rather, the belief that it actually will. That something can range from having ample provisions to keeping a roof over ones head to finding a treatment that will control a disease to having eternal life. Hope is derived from a relationship with Spirit that is not limited by the constraints of this world, but for whom all things are possible.

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The elder with hope sees life as an unfolding of new experiences. Life is dynamic, not static. Lost roles and relationships can be replaced by new ones. In the presence of pain and suffering, hope for relief and a better tomorrow can motivate a person to face a new day and continue engaging in life. Dignity It is natural for people to want to be valued and respected, and although this need is not diminished with age, it can become more of a challenge. In our society, older adults have a risk of having stereotypes applied to them on the basis of their age. This is apparent in statements such as most old people are in nursing homes, people lose interest in sex as they grow old, and older workers arent as productive as younger workers. These views can result in prejudicial treatment of elderly individuals, a process that a few decades ago was given the label ageism (Butler, Lewis, and Sutherland, 1991). Ageism erodes the selfworth of older adults. A relationship with Spirit offers a means to preserve dignity in light of societal ageism. God and many other higher powers value the intrinsic worth of every human being regardless of age or other characteristic. Forgiveness Humans are imperfect beings and will err. With the volume of interactions that people typically experience by the time they reach old age, being the perpetrator and recipient of wrongs is hardly uncommon. Carrying resentment and grudges for these wrongs is a significant burden that can deplete emotional resources. Forgiveness is crucial to peace of mind and healing. This implies not only forgiveness of others, but also, forgiveness of self. Gratitude It tends to be common for people to take the blessings in their lives for granted. Many people forget to appreciate the profound gifts of good health, shelter, independence, freedom, and opportunities. Instead, there is the temptation to be resentful for what one doesnt have. Good health is ignored as people complain of having wrinkles and fat thighs. A comfortable home is minimized by resentment that there isnt a pool in the backyard. The good fortunate at having a child who is healthy and happy is overlooked by criticisms that the child didnt make straight As. An attitude of thankfulness nourishes the spirit and, in turn, heightens spiritual awareness so that gratitude can be felt for the ordinary. Transcendence Some of the mystery of life can be accepted when people feel there is a reality beyond their own physical beings. The connection to Spirit offers a source of strength that is unable to be realized independently. Difficult and confusing circumstances can be understood as serving a purpose in a larger plan, guided by the hands of a higher, wiser power. Expression of Faith It is important for people of faith to express that faith in the manner they desire. For many people, this encompasses prayer, which can take many forms (Display 2). Prayer can be individual or communal, silent or spoken, at specific times or whenever the mood strikes, conversational with Spirit or a recitation of scripture verse. Some people may quietly kneel or sit with head bowed, while others may walk or sing. In addition to prayer, faith is expressed through worship, scripture reading, celebration of specific holy days, and the practice of rituals (e.g., lighting candles, fasting). Assessing Spiritual Needs

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The complexity, diversity, and individual meaning of spirituality limit the usefulness of objective assessment tools in identifying spiritual needs. Open-ended questions, life review, and intentionality are beneficial approaches for exploring spiritual needs. Spiritual needs can be revealed with the use of questions that open the door for sharing and discussion. With a keen ear for what is implied and omitted, the nurse needs to use responses to these questions as guides for additional inquiry. In gerontological nursing, the value of life review has been recognized and discussed for some time (Butler and Lewis, 1982; Webster and Haight, 2002). This therapeutic reflection on ones life aids the elder in interpreting and refining past experiences as they relate to self-concept and life purpose. Life review can be facilitated through a variety of strategies, including: Discussions: introduce a specific topic such as World War II, immigration to America, differences in raising children when they were parents vs. now, career (old magazines, music, and films can be used also) Oral history: ask the elder to share the story of his or her life from earliest memories to the present Book of life: suggest that the older person imagine that he or she is writing an autobiography and to create chapter titles that indicate highlights of life Time line: draw a time line that begins with the decade of birth and ask the person to share significant events and memories from each decade of life. The nurse may be able to identify certain themes or feelings that arise during the life review. For example, the elder may share the multiple burdens he faced throughout life and his ability to carry them. This could open a discussion of what the person believes helped him get through those times. Current challenges, losses, and impending death can be better tolerated when put in perspective of ones total life. Intentionality is clear, focused thinking that exceeds merely feeling kindly toward another person. The nurse makes a planned effort to connect with the person in a healing relationship. The difference between a nurse assessing with intentionality versus collecting data for an assessment tool is similar to a friend listening to your story verses a bank manager asking you the questions on a loan application. It entails attentive listening and encouraging sharing of stories. Often, it requires the nurse to silently be with the person--perhaps massaging shoulders, holding a hand, or sitting alongside---as those individual journeys through the labyrinth of feelings and memories. The important work of unfolding ones soul cannot be rushed. Questions Useful in Spiritual Assessment Is there a faith or religion that you believe in? If so, describe how you practice this. Do you believe in God or a higher power? Describe what this means to you. Do you pray? What is the nature of your prayers? How are your prayers answered? What gives your life meaning and purpose? Could you describe what or who is your source of strength or support? What brings you joy? Do you have peace? How is this reflected in your life? In looking back on your life, what has been most meaningful? What is your source of love? Who are the recipients of your love? Ho do you feel connected to other people? Is there anyone, including yourself, who you have not been able to forgive? If so, please describe this. Do you have any regrets? If so, please tell me about them. How has aging affected your outlook on life? What do you desire for the future?

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Care of the Spirit Preparing self Perhaps it is possible to effectively administer a medication or change a dressing without connecting to all facets of the person---body, mind, and spirit---however, spiritual care demands heart to heart connections that rest on the nurse entering the dance of the persons life. And just as the graceful dancer prepares before taking a partners hand, the nurse prepares prior to engaging with the person. The nurses own spiritual practices contribute to a wholeness that enables him or her to engage with intentionality and connect with others. These spiritual practices, like those of clients, can vary and include prayer, meditation, scripture reading, and planned periods of solitude, drumming, chanting, and worship. It is tempting for some nurses to omit such practices from their regular schedules due to the demands of more concrete needs; however, this eventually will impact optimal whole-person health and well-being. The ability to center, focus, cope, and be fully available is significantly affected by spiritual selfcare. The availability to connect with another persons heart and spirit begins before physical contact is made by the nurse shifting focus to the individual. Before entering the persons room, the nurse can take a deep breath and think about the individual. Affirmations such as I am here to serve this person and this person will have my undivided attention can be useful. Associating deep breathing and focusing shifts to the act of hand washing between clients can help to make physical, mental, and spiritual preparation for the next care encounter a routine. Supporting faith practices The assessment should provide an understanding of the way faith is expressed in the persons life. The individuals beliefs and practices are more significant than mere knowledge of religious orientation as people of similar faith may engage in vastly different activities. Nurses should assure that a persons desire for a special diet, prayer times, dress style, and restrictions to activities are incorporated into the care plan and respected. The persons desire for visits from clergy or other members of his or her faith community should be facilitated. Noise, interruptions, clutter, and odors are among the features in many hospital and long-term care facility rooms that can affect a persons ability to engage in spiritual practices. Nurses can assist a person in creating a sacred space within these settings by establishing a personal private time for the person and assuring that during that period the room is fresh, Bibles or other desired materials are available, and privacy is afforded. Appropriate music and aromatherapy with relaxing scents can assist in creating the right atmosphere. Seeking hope and meaning in difficult situations Changes in appearance and function retirement reductions in income losses of loved ones threatened independence ageism. There are many circumstances in late life that threaten the well being of the body, mind, and spirit. Superimposed on this is the reality that in most circumstances when nurses encounter older adults, it is in situations in which they are receiving services due to a health condition. Some older adults may be discouraged that on top of all other challenges, they have to deal with a disease, or they may question why they are suffering when they have tried to be a good person. They may be angry with God or feel that God has abandoned them. Nurses need to encourage the expression of feelings and maintain an open, nonjudgmental attitude. Statements such as it isnt all that bad, youre better off than many people, and God wouldnt send you more than you can handle serve little purpose and can heighten the distress that is felt. Instead, nurses can

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listen and allow feelings to be vented. Realistic hope can be offered. For instance, telling someone with terminal cancer that they shouldnt think about their illness of limited benefit, whereas it would be helpful to assure them that their pain will be managed so that they can enjoy their final days. Listening is important as individuals process the reality of their life circumstances. Attentive listening is fostered by the nurse allocating time and space when the person can talk. Interruptions and distractions must be controlled as much as possible. Even if it is only for five minutes, the person should have the nurses undivided attention during that time. It is important for the nurse to establish a comfortable psychological space in which any feeling can be communicated and to be sensitive to verbal and nonverbal cues. The nurse neednt feel pressured to structure or control the conversation but rather, to allow it to flow. There is no need to fill silent periods; considerable communication can occur without a word being spoken. Offering the gift of unconditional listening demonstrates appreciation of the person as a spiritual being. Addressing spiritual distress When there is a disruption in the relationship individuals have with Spirit or their spiritual needs are not satisfied, they are in a state of spiritual distress. Factors that contribute to this state include new or worsened illness, losses, inability to engage in religious or spiritual practices, caregiver stress, and feelings that their current problems are the result of sin or inadequate faith. Signs of spiritual distress could include: crying depression, withdrawal expression of hopelessness, powerlessness sarcasm, cynicism noncompliance with care suicidal thoughts or plans physical symptoms: poor appetite, sleep disturbances, fatigue, sighing Effective communication skills can assist in assessing factors that contribute to spiritual distress. Once these factors are identified, specific interventions can be planned; these interventions could include referral to clergy/spiritual leader, assisting with participation in religious or spiritual practices (e.g., reading the Bible, affording periods of solitude), arranging for prayer. A persons desire not to engage in religious practices or to reject visits from clergy should be respected, even if this is out of character for the individual. Praying with and for As discussed earlier, prayer can be comforting and therapeutic. It can be quite powerful for a person who is frightened or suffering to have a caregiver hold his or her hand and offer a prayer, or to know that someone is offering prayers on his or her behalf. Nurses who are comfortable doing so should feel free to pray with and for the people they serve. Conversely, if there are nurses who are not comfortable offering prayer, they should not feel compelled to do so, but rather, find a coworker or volunteer who can provide prayers. Awareness that a spiritual self exists separate from the physical body enables elders to find meaning, purpose, and satisfaction in the presence of the illness, losses, and declining function. Helping older individuals to achieve that awareness and fulfill spiritual needs are essential components of holistic geriatric nursing care. Caring for the spirit causes nurses to walk on new paths. They learn to accept the mystery of life that not everything can be explained by science and reason, and trust that their presence and intention can be as healing as any prescribed procedure they may perform.

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I.

Safe Medication Use Pharmacotherapy in the elderly is complicated by multifactorial issues, including age-related physiologic changes, the presence of multiple chronic disease states, functional changes in neuropsychiatric and physical abilities, and the patient's desire versus ability to comply with recommended therapy. Adverse drug reactions and interactions are more common than in the general population. Geriatric clinical syndromes such as falls, fecal impaction, incontinence, etc., can be induced or exacerbated by prescribed and OTC pharmaceuticals as well as "natural" or herbal supplements. Withdrawal of pharmaceuticals may also result in significant illness. 1. Start low, go slow. Start psychotropics at to of the "recommended" starting dose. 2. Avoid drugs with a prolonged half-life when possible. Oxazepam is the preferred benzodiazepine in older patients. 3. Review both prescribed and OTC medications/ vitamins/ herbs with the patient on each visit. 4. Give the patient and/or the family a written list of medications, the purpose of the drug, dosing intervals and potential side effects. Strive for once or twice a day dosing. 5. Make sure that for every medication taken (prescribed or OTC) there is an indication. 6. Encourage the patient (or family) to report problems with compliance, (e.g. medication expense, personal fears of taking drugs, symptoms that may be side effects of the medications). 7. Consider the use of anticonvulsants (e.g., valproate sodium) instead of antipsychotics in dementia patients with overtly aggressive behavior. 8. Try to tailor a drug's known side effects to a patient's needs; for instance, trazodone may be the ideal selection for a patient with hypertension, insomnia/anxiety, depression and chronic pain or neuropathy. When a patient has new complaints, remember that drugs can cause illness. J. Care for Depression A disorder characterized by feelings of sadness and despair and ranging in severity from mild to life threatening. Depression is one of the most common psychiatric disorders among the elderly. The prevalence of clinically significant depressive symptoms ranges from 8 to 15% among community-dwelling elderly persons and is about 30% among the institutionalized elderly. Major depression occurs less often in later life than at younger ages and affects about 3% of elderly persons in the community, 11% in hospitals, and 12% in longterm care settings. The current cohort between ages 70 and 90 years has had fewer severe depressive episodes in adult life than earlier cohorts. The number of cases is expected to increase substantially over the next 20 to 30 years as younger cohorts, who have a higher prevalence of depression than the current elderly cohort, age. Depression is one of the most common risk factors for Suicide. The highest rates of suicide in the USA occur in persons >= 70. For white men, suicide is 45% more common among those aged 65 to 69 years, > 85% more common among those aged 70 to 74, and more than three and a half times more common among those >= 85 than among white men aged 15 to 19 years. Suicide rates do not increase with age among women. The elderly are less likely than younger patients to seek or respond to offers of help designed to prevent suicide. The elderly make fewer suicide gestures but more often succeed at suicide attempts. As many as 70% of elderly persons who completed suicide visited their primary care physician within the previous 4 weeks. Etiology The etiology of depression in the elderly, as in younger persons, is biopsychosocial.

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Medical disorders may cause depression in the elderly as may abuse of alcohol, some prescription drugs (especially some antihypertensives), cocaine, or other illicit drugs. Psychologic risk factors are similar across age groups and include guilt and negative thought patterns. Cognitive dysfunction is another major risk factor. Social risk factors (eg, loss of a spouse or partner, decreased social support) appear to cause depression more often in men than in women. Persons with lower incomes are at greater risk for depression. Heredity plays less of a role in depression with first onset in late life than in that with first onset in midlife. However, persons who first experience depression in early or midlife and have a recurrence in late life are just as likely to report a family history as are persons who experience depression in midlife. Structural brain changes, seen on MRI and thought to be secondary to vascular insufficiency, are associated with depression in late life. Such cases are referred to as vascular depression. Symptoms and Signs Chronic and persistent dysphoria (restlessness, malaise) with a mildly depressed mood, common among the elderly, is not severe enough to warrant a diagnosis of depression. Episodes of brief depression, which are also common among the elderly, include moderately severe depressive symptoms that are consistent with the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria except for their duration (2 weeks). The symptoms may have no clear cause and may resolve spontaneously, and episodes may occur in increasingly rapid cycles. Some elderly persons experience a brief period (usually lasting a few days) of severe depressive symptoms that usually can be explained by obvious difficulties in adjustment or by bereavement. Adjusting to a severe or ultimately fatal chronic illness and losing a spouse or partner are common causes of such symptoms. Affected persons recover with time or when the stressor resolves. Dysthymic disorder, which may be chronic, persistent, and moderately severe, is defined by DSM-IV as a depressed mood with two or more additional symptoms (eg, sleep problems, decreased appetite, feelings of hopelessness, lethargy). Symptoms must persist for at least 2 years but are not severe enough to constitute a major depressive episode. Major depression, with or without melancholia, includes a core symptom of dysphoric mood or loss of interest plus at least four of the following symptoms: sleep disturbance (usually decreased sleep), appetite disturbance, weight loss, psychomotor retardation, suicidal ideation, poor concentration, feelings of guilt, and loss of interest in usual activities (if not the core symptom). Melancholia is present if these symptoms are predominated by a lack of interest in the social environment, diurnal variation (ie, feeling significantly worse during one part of the day, usually the morning, compared with the remainder of the day), and psychomotor agitation or retardation. Sometimes major depression is characterized predominantly by psychotic features, especially delusions of illness or guilt about past actions, thoughts, or events. Psychotic depression is more prevalent in late life than in midlife. Generally, psychotic symptoms are similar among elderly and younger patients, although elderly patients usually have more of them and are less likely to experience self-deprecation and guilt. Bipolar I disorder is characterized by one or more manic episodes, with or without episodes of depression. A manic episode is a distinct period (lasting >= 1 week) during which there is an abnormally and persistently elevated, expansive, or irritable mood. Manic episodes may occur for the first time in late life but most often recur from an earlier age. During a manic episode, a person may experience an inflated self

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esteem, decreased need for sleep, increased talkativeness, a subjective sense that thoughts are racing, distractibility, psychomotor agitation, and involvement in activities that are perceived to be pleasurable but that can lead to adverse outcomes, such as unrestrained buying. Elderly persons are less likely to experience inflated self-esteem or grandiosity during an episode and are more likely to experience irritability and psychomotor agitation, thus making it somewhat difficult to distinguish a manic episode from agitated depression. A thorough history, including information from the patient and family, can assist in making this distinction. For example, if the elderly person has had previous episodes of depression associated with psychomotor retardation and, over a short period of time, enters an episode of acute agitation, decreased sleep, and increased talkativeness, a manic episode is likely even if the mood is dysphoric. Some elderly persons may never experience an acute episode of mania but do have clear episodes of major depression. Between the episodes of depression, however, these persons are more elated or more irritable than usual. Such persons are diagnosed as having bipolar II disorder. The periods between episodes of depression may last for days, weeks, or even months. The symptoms, although uncharacteristic of the usual behavior of the elderly person, usually do not significantly interfere with function. Relatives and friends, however, may notice a problem with function. Diagnosis A thorough history and physical examination, including complete neurologic and mental status assessment, are necessary. A complete review of drug use (including illicit drugs) and alcohol use is also critical. Interaction with family members is helpful, and if the patient is demented or uncommunicative, obtaining a history from family members or other informants is essential. When the diagnosis is complicated by comorbid conditions or by poor communication with the patient, the physician should focus on the symptoms reported by family members and on change in symptoms over time. The Geriatric Depression Scale are useful assessment instruments. However, they are screening devices and should not replace a thorough evaluation and interaction with the patient and family members. Depressed patients should be asked directly about suicidal thoughts and intentions (eg, "Do you ever feel that life is not worth living? Have you thought of harming yourself?"). Asking about suicide does not increase the risk of suicide. Patients with suicidal thoughts should be asked about plans (eg, "Have you planned how you would do it?"). Those with suicidal plans should be hospitalized immediately. Sometimes a definitive diagnosis cannot be made on the basis of history and examination alone. Such situations are common when demented patients stop eating or deteriorate in another way that suggests depression. A trial of treatment, usually with an antidepressant, is the best course for these patients. Laboratory tests have an adjunctive role in the evaluation of depressed patients. However, thyroid function should be assessed for all new cases. A slightly low thyroxine level and an elevated thyroidstimulating hormone level are common during a depressive episode. Most other tests should be ordered only when clinical findings suggest a concurrent disorder. An ECG can provide a baseline if concerns arise about the effect of tricyclic antidepressants on cardiac function. Although not diagnostic, the dexamethasone suppression test may help predict prognosis. A positive test result (ie, a postdexamethasone cortisol level of > 5 g/dL [140 nmol/L]) suggests that a relapse is likely if the level remains high, even when symptoms improve. Polysomnography, when available, can help identify melancholia; decreased sleep time with shortened rapid eye movement latency supports the diagnosis.

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The differential diagnosis of major depression includes many medical and psychiatric disorders that may manifest as depression in later life. Prognosis and Treatment Patients with dysphoria rarely benefit from traditional modes of therapy. The outcome of major depression in late life, if uncomplicated, follows the "rule of thirds." One third of elderly patients get better and stay better, one third get better but relapse, and one third do not improve or improve only marginally. With time, however, most elderly patients who experience major depression in late life recover. Recovery, however, may take months. The prognosis is worse when depression is complicated by an underlying dysthymic disorder, by a medical disorder, or by cognitive impairment. The key to the management of depression, especially major depression, in the elderly is early identification and intervention. All caregivers must be alert to the possibility of depression, especially when illness or loss of a loved one occurs. Family members, in particular, must be alert for subtle changes in personality, especially lack of enthusiasm and spontaneity, loss of sense of humor, and new forgetfulness. Loss of interest in sex may be apparent only to a spouse or other sexual partner. Nurses must be alert to loss of appetite, new sleep disturbances, and other signs and symptoms of depression. During treatment, family members and professional caregivers must be trained to monitor for adverse effects of drugs. They must also be alert to warning signs that the depression is worsening or that the patient is considering suicide. Psychotherapy: Elderly patients with mild, recently established depression may respond to psychotherapy alone and may not need pharmacotherapy. Psychotherapy is often effective in treating depression without significant melancholic symptoms. When combined with antidepressants, it may benefit patients with severe depression. Behavioral and cognitive therapies are considered more effective than nondirected or analytically oriented therapies. Behavioral and cognitive therapies may help reintegrate the patient into a social environment after severe depression and may help prevent relapses, especially for episodic depression. Psychotherapy may be conducted by a psychiatrist, clinical psychologist, or mental health social worker, or it may require an interdisciplinary team. Pharmacotherapy: Treatment of severe depression with melancholic features is primarily pharmacologic. Choosing a drug depends primarily on which one produces the fewest adverse effects. Although tricyclic antidepressants (eg, nortriptyline, desipramine, amitriptyline) are used often, elderly patients have difficulty tolerating the anticholinergic effects (especially those of amitriptyline) and the postural hypotension these drugs are likely to induce. Monoamine oxidase inhibitors are used less often because they have significant adverse effects and because they are not more effective than other drugs. Therefore, the drugs of choice are the selective serotonin reuptake inhibitors (SSRIs [eg, fluoxetine, nefazodone, sertraline, paroxetine]), which have relatively few adverse cardiovascular and anticholinergic effects. However, agitation, a common adverse effect with some of these drugs (eg, fluoxetine), can be especially troublesome for elderly depressed patients. Sexual dysfunction is a problem for some persons who take SSRIs. Also, SSRIs can cause akinesthesia and other movement disorders. Usual starting doses in otherwise healthy elderly patients are typically one half the usual adult doses: eg, fluoxetine 10 mg po daily, nefazodone 100 mg po bid, sertraline 25 mg po daily, or paroxetine 10 mg po daily. A typical starting dose for the tricyclic antidepressant nortriptyline is 10 to 25 mg po at night with gradual increases. Doses should be titrated upward slowly (eg, weekly) and not every 3 to 5 days as for younger adults. Adjuncts may augment the response to antidepressants. For example, low-dose lithium may augment the effect of tricyclic antidepressants and SSRIs, and carbamazepine may reduce a patient's

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tendency to cycle in and out of depressive episodes. Methylphenidate has been used independently and as an adjunct to antidepressants, especially for patients in long-term care facilities. Its use may be advantageous for patients who have stopped eating because, if the drug works, it works quickly and also independently stimulates appetite. Methylphenidate may activate the depressed patient, is relatively safe, and rarely leads to dependence. An acute manic episode may be treated with a mood stabilizer coupled with hospitalization to reduce the likelihood of behavior that can harm the patient or others; lithium carbonate, usually 300 to 600 mg/day, is the treatment of choice. Serum levels for effective therapy in the elderly are usually 0.4 to 0.8 mEq/L; higher levels are often associated with agitation and confusion. Given the toxicity of lithium, many clinicians elect to treat with valproic acid, at an initial dose of 10 to 15 mg/kg/day in 1 to 3 divided doses. Acute symptoms may require that the mood stabilizer be augmented with an antipsychotic drug (eg, olanzapine 2.5 mg daily, haloperidol 0.25 to 0.5 mg daily to bid). In such elderly patients, the doses of both the mood stabilizer and the antipsychotic drug must be increased significantly. Electroconvulsive therapy (ECT): ECT is used for severely depressed patients, especially those who have previously responded to ECT, those who demonstrate significant psychotic symptoms or selfdestructive behavior, and those who do not tolerate or respond to antidepressants. ECT is safest with multiple-channel monitoring (electroencephalography [EEG], ECG, blood pressure, pulse, and respiratory function); it should be administered by a psychiatrist under the supervision of an anesthetist or anesthesiologist. After rehydration, ECT is the treatment of choice for patients with malnutrition and dehydration due to severe depression. ECT induces improvement in 80% of elderly patients who did not respond to antidepressants--the same rate as for younger patients. Maintenance ECT on an outpatient basis significantly reduces the likelihood of relapse for patients who responded to ECT. If maintenance ECT is impossible, then the risk of relapse can be reduced by the use of antidepressants, even if the patient did not respond to them initially. Patients who undergo ECT experience acute amnesia, which is often distressing. Some memory loss can persist after ECT, but the nature and extent of this problem have not been determined. Treatment of Medically Ill and Hospitalized Patients Some patients respond to an acute or chronic medical disorder by developing a psychiatric disorder (eg, adjustment disorder with depressed mood). Support and psychotherapy (eg, formal intervention with the patient and family members) are often helpful. Small doses of SSRIs (eg, trazodone, 25 mg at night) can help, especially when sleep problems are present. For patients who are dying, similar measures can be used; however, not every dying patient needs psychotherapy or antidepressants. Pharmacotherapy for major depression in patients with other medical disorders requires special attention. Tricyclic antidepressants and SSRIs (although SSRIs are of less concern) can cause adverse cardiovascular effects in patients with heart disease or unstable blood pressure (eg, a tendency toward orthostatic hypotension). Both classes of drugs are reasonably safe when used properly in patients without serious heart disease. With longer hospitalization, the inability to respond to rehabilitative efforts and a patient's and family members' fears of chronic invalidism become proportionately greater. Hospitalized patients with depression often view themselves as hopeless; their hopelessness spreads to the staff members, who may pay less attention to them. Modifying the patient's environment may help (eg, involving the patient in group activities), but the depression itself also needs to be treated, usually with pharmacotherapy. K. Family Caregiving Introduction

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In the past two decades, the role of informal caregivers in providing care to older persons and the relationship of informal caregivers to nurses and other health care providers have undergone changes as a result of sociopolitical trends. Shifting demographic patterns have resulted in a growing number of elders who require acute and long-term care. The change in the Medicare system from a retrospective costreimbursed system to a prospective fixed payment system has shifted the responsibility for care during recuperation, rehabilitation, and long-term disability from institutions to individuals and families in the community. Because of these changes, the long-term care system would not be able to meet the needs of older persons without the services provided by family and other lay caregivers. Consequently, informal caregivers have come to be viewed legitimately as nurse-extenders. Informal caregivers provide most of the nursing care to elderly in long-term care; improving the quality of that care requires an empirically-based understanding of the structures, processes, and outcomes of family and informal caregiving as well as the ways in which nurses can work with informal caregivers and effect change within the caregiving relationship. Quality of Family Caregiving Although most long-term home care is provided by informal care providers, no external regulatory mechanisms exist to monitor the quality of this care. Substantial evidence suggests that the quality of informal home care is adequate to meet the needs of some care recipients; the quality of informal home care, however, varies widely. Research indicates that: 1) the quality of care is less than optimal for many care recipients, resulting in unmet physical, emotional, and social needs; and 2) some care recipients are at high risk for abuse, neglect, and other forms of maltreatment by their informal care providers (Giordano & Giordano, 1983). The study of quality of care is complicated by several factors. Researchers and clinicians have failed to define operationally both extremes of the quality of care continuum for informal care providers. By default, adequate to excellent care has been defined by the absence of abuse or neglect. Operational definitions for abuse and neglect, however, are neither definitive nor clear and, clinically, these definitions are known to be confounded by legal issues such as degree of intent, amount of harm, and assignment of blame (Johnson, 1986; Phillips, 1989a). Some clinicians have tried to circumvent these problems by defining quality of informal home care by the degree to which the recipient's needs for physical and/or emotional support are met by the informal care providers (O'Malley et al., 1983; Phillips, 1989a). There is, however, no appropriate measurement standard against which the care provided by informal care providers can be judged. Without a measurement standard, judgments about the adequacy of home care will continue to be confounded by variables such as socioeconomic status, ethnicity, and the care recipient's personal characteristics. Unlike care provided in hospitals, care outcomes in the home rely primarily on the skills and expertise of family members and secondarily on the counseling and educational roles of the nurse (Baines, 1984). This presents a special dilemma for the evaluation of quality indicators. Although quality of home care has recently been discussed in the literature, articles focus primarily on evaluating the care provided by professionals or nonprofessional staff (Daniels, 1986; Mumma, 1987). Other factors also contribute to the problems of studying the quality of informal home care. For example, there are currently no acceptable alternatives for the service provided by the informal care system. Therefore, substandard care generally is tolerated and, to some degree, supported if identifying that care as less than adequate could jeopardize the living arrangements and autonomy or independence of the care recipient. In addition, prevailing social attitudes dictate against questioning the "good intentions" of family members or violating the sanctity of the home setting. Monitoring the quality of home care generally is viewed as the responsibility of the care recipient and/or the care recipient's family regardless of whether they are physically or emotionally capable of assuming that responsibility. These factors have made it difficult to estimate the scope of the problem of poor quality informal home care. Some research has focused on identifying the incidence of frank elder abuse with estimates ranging from 4 percent (Pillemer &

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Finkelhor, 1988) to 23 percent (Steinmetz, 1983). From clinical observations and from discussions with home health nurses and adult protective service workers, it is clear that although these figures provide some information about the incidence of frank abuse, they seriously underestimate the incidence of poor quality informal home care. Despite the complications involved in studying the quality of informal home care, some efforts have been made to study both process and outcome. There are several reasons why study of the processes of informal caregiving is particularly appropriate for nurse-researchers. First, nursing is process and the ability of nurses to effect positive caregiving outcomes is related to how care is provided as much as to what is actually done. Second, most in-home care is done by lay caregivers who must be taught both what to do and how to do it. Thus, effecting positive outcomes for homebound elders is possible only if care processes can be clearly identified and effectively taught to lay caregivers. L. Care of the Dying Patient Introduction Geriatric Essentials Health care practitioners should provide dying patients and their family members with clear, realistic information about their illness and its course. Patient preferences should be accommodated as much as possible when care is planned. For this reason, elderly people, even those who are healthy, should be encouraged to document their wishes for end-of-life care and to discuss these instructions with their physicians. Control of symptoms, based on their cause when possible, is essential. Concern about drug dependence should not interfere with symptom control. Helping patients and their family members and friends find comfort in the experience of dying is often more important than adhering to medical routines or correcting symptomless physiologic abnormalities. However, distressing symptoms should be prevented or relieved as effectively as possible. Preventing suffering is also important. Suffering is a global perception of distress caused by factors that, together, undermine quality of life; these factors include pain, dyspnea, delirium, asthenia, physical impairment, psychologic disturbances, and financial, social, family, and spiritual concerns. Anorexia may be distressing to the patient but is more likely to distress family members and health care practitioners. People differ in what they consider important, especially when facing death. Some people search for closure. They reach out to friends and family members to share time and express love, complete projects important to their lives, and tie up loose ends. Often, with appropriate support, people die at a time and in a way that allows them to experience satisfying closure. To experience such closure, people need to be given realistic information about their illness and prognosis. Even people who choose not to accept their illness can benefit from information provided in a tactful way. Some people cannot accept their imminent mortality and avoid such closure. For some, life is to be prolonged, even at the cost of pain, marked confusion, or severe respiratory distress. For others, quality of life is the overarching concern; they prefer comfort measures rather than a prolonged period of disability. Accommodating patient preferences as much as possible is essential when planning care. For example, some patients may prefer relief from pain, even when doing so may increase sedation; others may prefer to avoid sedation, even when doing so involves tolerating pain. Truth telling is important. Practical information needs to be provided so that patients and family members can understand realistic options. For instance, CPR is of little benefit to patients with metastatic cancer or end-stage dementia; if aware of this information, most patients would choose to forgo CPR, as would their family members. Respecting autonomy is important, but patients and their family members cannot have true autonomy unless they are

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given adequate guidance. Some patients choose to receive treatments that are ineffective. However, health care practitioners should not provide treatment that is harmful or not helpful. Health care practitioners should know local laws and institutional policies governing living wills, durable power of attorney, and procedures for forgoing resuscitation and hospitalization. Such knowledge helps ensure that patients' wishes are followed when patients are no longer able to direct their own care. Patients, while they are still able, should be encouraged to document their wishes for end-of-life care and to discuss these instructions with their physicians. Supportive care may be the only realistic goal for a dying patient. Medical management of troubling symptoms can enable patients, family members, and friends to avoid needless suffering and to share valuable time. However, to say that a patient's care has changed from curative to supportive or from treatment to palliation is an oversimplification of a complex decision process. When death is imminent, patients and their family members may wish to begin focusing on planning end-of-life care, relieving symptoms, maximizing function, and attending to spiritual issues. Thus, many patients ask whether the time until death can be predicted. Prediction can be difficult; many people live for months or years in a very fragile state of health. Predicting time until death is particularly difficult for disorders in which death tends to come suddenly and without reliable warning signs (eg, heart failure, emphysema). For other disorders (eg, commonly cancer), recognizable changes may presage death by several weeks or months. Still, most health care practitioners overestimate the time until death by a wide margin, possibly depriving patients and their family members of the opportunity to plan for death. Health care practitioners should estimate time until death for patients and their family members using 1 of 4 categories: hours to days, days to weeks, weeks to months, or months to years. Estimates of a specific time unit (eg, 6 mo) are usually inaccurate. Effective care for dying patients usually involves a team of caregivers because no one caregiver is available 24 h/day and because the skills and perspectives of several disciplines are needed. Palliative care or hospice teams anticipate potential problems and make appropriate arrangements (eg, obtaining supplies or opioids in anticipation of a potential emergency). When death is imminent, an experienced team member can comfort and support family members and friends and may prevent an inappropriate call to the emergency medical system. Dying patients often have spiritual needs that should be recognized, acknowledged, and addressed. Symptom Control Physical and mental distress is common during terminal disorders. Patients commonly fear that their suffering will be protracted and that no one will control it. Relief of discomfort enables patients to focus on living as fully as possible and on confronting the issues presented by the approach of death. Symptom control should be based on etiology when possible. For example, vomiting due to hypercalcemia is treated differently from vomiting due to elevated intracranial pressure. However, diagnosing the cause of a symptom may be inappropriate if testing is burdensome or if a specific treatment (eg, major surgery) has already been ruled out. For dying patients, comfort measures, including nonspecific treatments or short sequential trials of empiric treatments, are often better than an exhaustive diagnostic evaluation. Because one symptom can have many causes and may respond differently to treatment as the patient's condition deteriorates, treatments must be closely monitored and repeatedly reevaluated. Drug overdosage or underdosage must be avoided, especially as worsening physiology causes changes in drug disposition.

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When survival is expected to be brief, symptom severity frequently dictates initial, empiric treatment. Sometimes the fear that a symptom will worsen can be more crippling than the symptom itself, and reassurance that effective treatment is available may be all a patient needs. Other times, a symptom is so severe and the diagnostic alternatives are so nonspecific that immediate symptom suppression is indicated. * Pain About of patients dying of cancer have severe pain. Yet, only of these patients receive reliable pain relief. Many patients dying of organ system failure or dementia also have severe pain. Sometimes pain could be controlled but persists because patients, their family members and friends, and health care practitioners have misconceptions about pain and the drugs (especially opioids) that can control it, resulting in significant underdosing. Patients perceive pain differently, depending on whether other factors (eg, fatigue, insomnia, anxiety, depression, nausea) are present. Analgesic choice depends largely on pain intensity and cause, which can be determined only by talking with and observing patients. Most pain can be relieved by an appropriately potent drug at sufficient dosage. Palliative sedation may be the most appropriate treatment for patients whose pain or other troubling symptoms cannot be adequately controlled. Commonly used drugs are acetaminophen or NSAIDs for mild pain; codeine or hydrocodone for moderate pain; and hydromorphone, oxycodone, morphine, or fentanyl for severe pain or palliative sedation. As long as patients can swallow drugs, oral opioid therapy is convenient and cost-effective. Long-acting opioids are best for long-lasting pain. When opioids are indicated, the health care practitioner should prescribe them in adequate dosages and on a continuous basis to prevent pain. Tragically, unreasonable concerns of the public and of health care practitioners about addiction are often barriers to appropriate opioid use. Drug dependence may result from regular use but causes no problems in dying patients except the need to avoid inadvertent withdrawal. Addictive behaviors are rare and usually easy to control. When death is imminent, oral analgesic therapy may not be feasible. Giving morphine or oxycodone solutions 20 mg/mL sublingually can often control pain even when patients cannot swallow other tablets or liquids. The usual recommendation when death is imminent is to switch from a long-acting opioid to an immediate-release form because absorption and clearance changes rapidly during the dying process and patients may need the opioid dose adjusted often. Rectal administration provides slower absorption but with very little first-pass effect; morphine suppositories or pills may be given rectally at the same dose used for oral forms and then adjusted as needed. IV or sc opioid therapy is preferred to IM injections, which are painful and result in variable absorption. Adverse effects of opioids include nausea, sedation, confusion, constipation, and respiratory depression. Constipation should be treated prophylactically with a large-bowel stimulant such as senna or bisacodyl. Patients usually develop substantial tolerance to the respiratory depressant and sedative effects of morphine but do not develop as much tolerance to the analgesic and constipating effects. Rarely, opioids may also cause myoclonus, agitated delirium, hyperalgesia, and seizures. These effects may result from accumulation of toxic metabolites and may be associated with reduced clearance in patients who are near death; the effects usually resolve when another opioid is substituted (opioid rotation). When patients on a stable opioid dose experience increased pain, the dose should be increased. If pain is mild to moderate, the daily dose should be increased by 25 to 50%; if pain is moderate to severe, the dose may need to be increased by 50 to 100%. Continuous infusions of opioids using IV or sc patientcontrolled analgesia (PCA) can be effective when opioid doses are very high. With the support of home hospice, sc opioid PCA pumps with both continuous and bolus functions can be used easily at home.

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Usually, serious respiratory depression does not occur unless the dose is increased to more than twice the previously tolerated dose. Using adjunctive drugs for pain control often increases comfort and allows the opioid dosage and consequent adverse effects to be reduced. Corticosteroids are widely used in the terminally ill to reduce pain caused by inflammation and swelling. Gabapentin 300 to 1200 mg po tid or pregabalin 100 to 200 mg po tid (or 300 mg bid) helps relieve neuropathic pain. Tricyclic antidepressants (eg, nortriptyline, doxepin) help manage neuropathic pain; doxepin provides sedation as well. Methadone is effective for refractory or neuropathic pain; however, its metabolism and half-life can vary, and patients must be closely monitored. Benzodiazepines are useful for patients whose pain is worsened by anxiety. For severe localized pain, regional nerve blocks, done by an anesthesiologist experienced in pain management, may provide relief with few adverse effects. Various nerve-blocking techniques may be used. Indwelling epidural or intrathecal catheters may be inserted to provide continuous infusion of analgesics, often mixed with anesthetic drugs. Nondrug pain-modification techniques (eg, guided mental imagery, hypnosis, acupuncture, relaxation) help some patients. Counseling for stress and anxiety may be very helpful, as may spiritual support from a chaplain. *Dyspnea Dyspnea is one of the most feared symptoms and probably the most distressing to dying patients. Its causes may be treatable. For example, antibiotics for pneumonia or thoracentesis for a pleural effusion may be appropriate. However, if death is imminent, such measures are more burdensome than beneficial; patients can be made comfortable without invasive or aggressive measures, regardless of the cause of dyspnea. Initially, O2 helps correct hypoxemia. Even when its benefit is no longer certain, O 2 may continue to be psychologically comforting to patients, family members, and friends. It is usually most comfortable when given by nasal cannula because masks may be uncomfortable and may make patients feel smothered. Morphine 2 to 10 mg sublingually or 2 to 4 mg sc q 2 to 4 h prn helps reduce breathlessness without significantly affecting ventilation. The drug must be given continuously so that blood levels remain steady. If levels increase, respiratory drive and ventilation may decrease. If patients are already taking typical doses of opioids for pain, doses for respiratory symptoms may need to be much higher. Airway congestion is best managed with drugs that dry secretions (eg, scopolamine transdermal patch 1.5 mg applied q 72 h, hyoscyamine 0.125 mg sublingually q 8 h, atropine eye drops 2 drops po q 4 h prn). Nebulized saline may be used to treat patients with viscous secretions. Bronchospasm and bronchial inflammation may be treated with nebulized albuterol and oral or injectable corticosteroids. Benzodiazepines often help relieve anxiety associated with dyspnea. Useful nondrug measures include providing a cool draft from a fan or open window and maintaining a calming presence. *Anorexia Anorexia and marked weight loss are common among dying patients. For family members and friends, accepting the patient's poor oral intake is often difficult because it means accepting that the patient is dying. Sometimes even health care practitioners have trouble accepting a patient's poor oral intake. Patients should be offered their favorite foods whenever possible. Conditions that may cause poor intake

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and can be easily treated (eg, gastritis, constipation, oral candidiasis, pain, nausea) should be treated. Some patients benefit from appetite stimulants such as oral corticosteroids (eg, dexamethasone 2 to 8 mg bid or prednisone 10 to 30 mg once/day). Dronabinol does not help most patients but may help a subset of patients (eg, those who have used marijuana earlier in life). Megestrol, although commonly used as an appetite stimulant in patients with cancer, is not recommended. It causes only temporary weight gain by increasing fluid retention and body fat; it does not increase lean body mass, prolong survival, or improve quality of life. IV fluids, TPN, and tube feedings are often begun because family members or health care practitioners cannot tolerate the patient's poor oral intake. These measures do not prolong the life of dying patients, seem to increase discomfort, and may even hasten death. In dying patients who are fed artificially, incidence of pulmonary congestion and pneumonia is increased. Artificial hydration may worsen edema and pain associated with inflammation. Conversely, dehydration and ketosis due to caloric restriction are associated with analgesic effects and absence of discomfort. The only reported discomfort caused by dehydration near death is xerostomia, which is easily relieved with oral swabs or ice chips. If a patient is close to death, family members and friends should be gently told that the patient is dying and that food does not help the patient's strength nor substantially delay death; they should be reassured that the patient does not suffer from having little or no intake. Suggesting concrete measures (eg, providing favorite foods, small portions, or foods that are easy to swallow) and other ways to show caring and love can help family members and friends. Even debilitated and cachectic patients may live for several days to weeks after all food and hydration are stopped. Family members and friends should be told that stopping fluids will not result in the patient's immediate death and ordinarily does not hasten death. Supportive care, including good oral hygiene (eg, brushing the teeth, swabbing the oral cavity, applying lip salve, providing ice chips for xerostomia), is imperative for the comfort of the dying patient and can be provided by family members and friends. *Nausea and vomiting Many seriously ill patients experience nausea, frequently without vomiting. Nausea may be exacerbated by GI problems (eg, constipation, gastritis), metabolic abnormalities (eg, hypercalcemia, uremia), drug adverse effects, increased intracranial pressure secondary to cerebral cancer, and psychosocial stress. Treatment should be guided by the likely cause; for example, NSAIDs are stopped, gastritis is treated with H2 blockers or proton pump inhibitors, and patients with known or suspected brain metastases are treated with a trial of corticosteroids. If nausea is due to gastric distention and reflux, metoclopramide (orally or subcutaneously) is useful because it increases gastric tone and contractions while relaxing the pyloric sphincter. If no cause for mild nausea is identified, patients may benefit from nonspecific treatment with a phenothiazine (eg, promethazine 12.5 to 25 mg po qid; prochlorperazine 5 to 10 mg po before meals or, for patients who cannot take oral drugs, 25 mg rectally bid). Anticholinergic drugs such as scopolamine and the antihistamines meclizine and diphenhydramine prevent recurrent nausea in many patients but increase risk of delirium. Because nausea has multiple simultaneous causes in many patients, combining drugs that work via different mechanisms often improves efficacy. Second-line drugs for intractable nausea include haloperidol, started at 0.5 to 1 mg po or sc q 8 to 12 h, then increased to as much as 15 mg/day. The serotonin (5-HT3) receptor antagonists ondansetron and granisetron and the neurokinin antagonist aprepitant often dramatically relieve chemotherapy-induced nausea but frequently do not work as well in patients with chronic nausea.

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Nausea and pain due to intestinal obstruction are common among patients with widespread abdominal cancer. Surgery, which can relieve symptoms and prolong survival, may be appropriate, even for certain patients whose prognosis is poor otherwise and, rarely, even for hospice patients. If surgery is not appropriate for a hospice patient (eg, because health is poor, an obstruction is inaccessible, or there are multiple obstructions), IV fluids and nasogastric suction are usually not useful. Symptoms of nausea, pain, and intestinal spasm may be controlled with hyoscyamine 0.125 to 0.25 mg sublingually or sc q 4 h, scopolamine 1.5 mg topically q 72 h, morphine (sc, sublingually, or rectally), or any antiemetic (eg, diphenhydramine, granisetron, haloperidol, meclizine, ondansetron, prochlorperazine, promethazine, scopolamine). Octreotide 150 g sc or IV q 8 to 12 h inhibits GI secretions and peristalsis, effectively calming the bowel and dramatically reducing nausea and painful distention. Given with antiemetics, octreotide usually eliminates the need for nasogastric suctioning. Corticosteroids (eg, dexamethasone 40 mg/day for 4 days and then 4 to 6 mg IV, sc, or rectally tid) may decrease obstructive inflammation at the tumor site and temporarily relieve the obstruction. IV fluids may exacerbate obstructive edema. *Constipation Constipation is common among dying patients because of inactivity, opioid and anticholinergic drug use, and decreased fluid and dietary fiber intake. Laxatives help prevent fecal impaction, especially in patients receiving opioids. All patients should be asked about bowel function. Most patients do well on a twice/day regimen of stool softener (eg, docusate) plus a mild stimulant laxative (eg, casanthranol, senna, bisacodyl). If stimulant laxatives cause cramping discomfort, patients may respond to increased doses of docusate alone or an osmotic laxative such as lactulose or sorbitol (which is much cheaper and equally effective) started at 15 to 30 mL po bid and increased as needed. Soft fecal impaction may be treated with a bisacodyl suppository or saline enema. For a hard fecal impaction, a mineral oil enema may be given, possibly with an oral benzodiazepine (eg, lorazepam) or an analgesic, followed by digital disimpaction. After disimpaction, patients should be placed on a rigorous bowel regimen to avoid recurrence. Regular bowel movements are essential for a dying patient's comfort, at least until the last day or two. *Diarrhea If diarrhea occurs, an examination is done to rule out impaction. All laxatives, including stool softeners, are stopped. If diarrhea is severe, the patient should be given clear liquids and bland carbohydrates. Other foods can be added as symptoms permit. For severely dehydrated patients, electrolytes may be given po, IV, or sc to make the patient comfortable more quickly. Sports drinks, which contain electrolytes and carbohydrates, are similar to IV fluids and can be used in oral rehydration plans. Often, diarrhea must be suppressed with nonspecific treatment (eg, opioids; loperamide 4 mg po initially, then 2 mg after each diarrheal stool [up to 16 mg/day]; diphenoxylate-atropine 5 mg [2 tablets of 2.5 mg diphenoxylate] po after each diarrheal stool, up to qid). However, more specific treatment may be needed: for carcinoid tumors or dumping syndrome after gastrectomy, octreotide 150 to 300 g sc bid or 300 g continuous IV infusion given over 24 h; for Clostridium difficile colitis due to recent antibiotic treatment, metronidazole 250 to 500 mg po tid for 10 days; for fungal infection due to immunosuppression, clotrimazole 10 to 20 mg po tid or fluconazole (first dose is 200 mg po, then 100 mg po once/day for 14 days); and for pancreatic insufficiency, pancreatic enzymes such as pancreatin 1 to 2 tablets with meals and the dose with any snack. Zinc oxide helps relieve irritation around the anus, and corticosteroid cream (for as few as 1 to 2 days) helps relieve maceration or inflammation. *Pressure ulcers

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Many dying patients are immobile, poorly nourished, incontinent, and cachectic and thus are at risk of developing pressure ulcers. Prevention requires relieving pressure by rotating patients every 2 h; a specialized mattress or continuously inflated air-suspension bed may be used. Incontinent patients should be kept as dry as possible. Generally, using an indwelling catheter, with its inconvenience and risk of infection, is justified only when bedding changes cause pain or when patients, family members, or caregivers strongly prefer it. *Delirium Mental changes that can accompany the terminal stage of a disorder may distress patients, family members, and friends. Patients may appear distressed, often becoming agitated and crying out; however, if delirium resolves, patients forget what happened during the delirium. Confusion is common; causes include drugs, hypoxia, metabolic disturbances, and intrinsic CNS disorders. Confusion in debilitated patients is worsened by sleep deprivation. Agitation and restlessness often result from urinary retention, which resolves promptly with urinary catheterization. If the cause can be determined, simple treatment may be worthwhile provided it enables patients to communicate more meaningfully with family members and friends. Patients who are comfortable and less aware of their surroundings may do better with no treatment. When possible, the health care practitioner should ascertain the preferences of patients, family members, and friends and use them to guide treatment. In dying patients, the goal is to control agitation and relieve confusion while maintaining alertness and consciousness as much as possible (for some patients, alertness is not a goal). Thus, if drugs are needed, those with relatively mild sedative effects are preferred. Agitated patients may benefit from low doses of antipsychotics such as haloperidol 0.5 to 2 mg po or sc titrated as needed to control delirium. Atypical antipsychotics such as risperidone and quetiapine have been recommended for the elderly, but they must be given orally. If patients are unable or unwilling to take the drugs orally, having an sc or IV option (eg, haloperidol) is helpful. Benzodiazepines are sometimes given for agitation associated with delirium and for exacerbated delirium. In terminal delirium not adequately controlled with haloperidol, adding a benzodiazepine to increase sedation may be the most appropriate next step. Patients with severe terminal agitation resistant to other measures may respond best to continuous sedation with midazolam, a short-acting benzodiazepine. Family members and visitors may help lessen confusion by frequently holding the patient's hand, saying where the patient is, and letting the patient know what is happening. Supportive therapy, including listening and talking to the patient, should precede and supplement drug therapy. Sometimes symptoms of anxiety and agitation can be managed with gentle reassurance. Meditation, guided imagery, prayer, music therapy, and massage are often helpful. *Depression Most dying patients experience some depressive symptoms. Providing psychologic support and allowing patients to express concerns and feelings are usually the best approaches. A skilled social worker, physician, nurse, other health care practitioner, or chaplain can help with these concerns. A trial of antidepressants is often appropriate for patients who have persistent, clinically significant depression. SSRIs are useful for patients likely to live beyond the 4-wk period usually needed for onset of the antidepressant effect. A possible alternative for patients with depression and significant insomnia is trazodone 25 to 50 mg po daily at bedtime, increased in 25- to 50-mg/day increments every 3 days as tolerated, to a maximum of 300 mg/day. For patients who are withdrawn or who have vegetative signs, methylphenidate may be started at 2.5 mg po once/day and increased to 2.5 to 5 mg bid (given at breakfast and lunch) as necessary. Methylphenidate (same dose) is sometimes used to provide a few days or weeks

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of increased energy for patients who are fatigued or somnolent because of disease progression or analgesics. Methylphenidate has a rapid effect but occasionally precipitates agitation. Because its duration of action is short, adverse effects are also short-lived. *Stress A few people approach death peacefully, but most patients, family members, and friends experience stress. Death is particularly stressful when interpersonal conflicts keep patients, family members, and friends from sharing their last moments together in peace. Such conflicts can lead to excessive guilt or pathologic or dysfunctional grieving in survivors and to anguish in patients. A family member or friend who is caring for a dying patient at home may experience physical and emotional stress. Usually, stress in patients and in family members and friends is best treated with compassion, information, counseling, and sometimes brief psychotherapy. Social services may be needed to help increase home support and relieve caregiver burden. Sedatives should be used sparingly and briefly. When a loved one dies, the survivor may be overwhelmed by having to make decisions about legal or financial matters or having to manage the household; these responsibilities can compound grief. For an elderly couple, the death of one may reveal the survivor's cognitive impairment, for which the deceased partner had compensated. Health care practitioners should identify such high-risk situations, usually with the help of social workers, so that they can mobilize the resources needed to prevent undue suffering and dysfunction. *Grieving Grieving is a normal process that usually begins before an anticipated death. For patients, grief often starts with denial caused by fears about loss of control, separation, suffering, an uncertain future, and loss of self. Staff members can help patients accept their prognosis by listening to their concerns, helping them understand that they can still control important elements of their life, explaining how the disorder will progress and how death will come, and assuring them that their physical symptoms will be controlled. Printed educational materials that provide information about the illness, dying process, grief, or other important topics are helpful and can be reviewed later. Family members and friends may need support in expressing grief. Any health care team member who has come to know the patient, family members, and friends can help them through this process and direct them to professional services if needed. Team members need to develop regular procedures that ensure follow-up of grieving family members and friends. Financial Concerns Financial coverage for care of dying patients is problematic. Medicare regulations restrict payment for many aspects of supportive care. Not all patients qualify for hospice care, and health care practitioners are often reluctant to certify the 6-mo prognosis required for coverage. Health care practitioners should ask themselves whether they would be surprised if their patient died in the next 6 mo. If they would not be surprised, discussion with the patient and family members about palliative care concerns and needs is indicated. Prognostication is difficult, and hospice programs can help by assessing eligibility. If patients referred to hospice live > 6 mo, there is no penalty; they can be discharged if their health improves and readmitted later if they decline clinically, again without penalty. Health care practitioners should know financing options and the financial effects of choices and discuss these issues with patients or with family members and friends. Legal and Ethical Concerns Many health care practitioners worry that medical treatments intended to relieve pain or other suffering can hasten death, but such treatments rarely do; relieving dyspnea or pain may even prolong life. When treatment of symptoms, even at the risk of hastening death, is best for a dying patient, health care

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practitioners are ethically bound to do so. Thus, opioids should be used to relieve suffering (eg, dyspnea) even though they could cause respiratory depression. Assisting with suicide remains a criminal act in most states, but laws vary substantially and are rarely invoked, particularly if opioids are used appropriately to relieve suffering. Directly providing a dying patient with lethal drugs and instructions for using them is grounds for prosecution in all states except Oregon. In Oregon, the Death with Dignity Act provides for physician-assisted suicide under strict regulations. Patient requests for assisted suicide should be seen as an opportunity to explore causes of the patient's suffering, which in almost all cases can be managed with education, specific treatment for symptoms, and support for the patient's and family members' social and existential distress. Health care practitioners who manage symptoms vigorously and forgo life-sustaining treatment need to document decision making carefully, provide care in a reputable setting, and be willing to discuss these issues honestly and sensitively with patients, other practitioners, and the public. Spiritual Concerns Patients who are dying often ask what their life means, who they really are, why illness has affected them, and what will happen to them when they die. Patients may question God's existence and love or may feel abandoned by God. Some feel guilty or worry that their behavior is what caused their illness. Thus, dying can precipitate a spiritual crisis. Unresolved spiritual distress can lead to despair and hopelessness, which in turn can lead to anxiety, depression, and, for some, a desire to die or to commit suicide. Patients need help working through this distress so that despair can be transformed into hope and serenity. Dying patients do not always need to hope for a cure; instead, they can hope for having time to reconcile with loved ones, sharing time with family and friends, finishing a personally important project, or making peace with God or a higher power. When spiritual distress is relieved, patients can die more peacefully. Dying patients may review their life; this process may elicit positive and negative emotions as they try to resolve past hurts, reexamine relationships, and recount accomplished goals. Belief in an afterlife and possible reunion with loved ones can comfort patients and their family members and friends. Physicians, nurses, other health care practitioners, social workers, chaplains, family members, and friends can listen and offer support; doing so may help them deal with their own feelings of loss. Patients who are religious need opportunities for prayer, devotional reading, and religious ritual, such as receiving a chaplain's blessing. Other spiritual resources may include meditation, guided imagery, music, and art. Patients may need physical space and privacy for these practices. Hospice provides an excellent environment for spiritual practices. Each hospice team includes chaplains and others who are skilled at helping patients, family members, and friends with their spiritual needs. The serious matter of a patient's medical condition should be discussed openly so that religious and cultural traditions are respected and can be accommodated if possible. The discussion may include particular rites before and at the time of death and cleaning and preparing the body after death. Health care practitioners should enquire sensitively about these traditions because such traditions vary greatly in modern society and members of the care team cannot be familiar with all of them. Concerns at the Time of Death *Managing Death The health care practitioner should prepare family members and friends for the death of their loved one far in advance. Preparation includes discussion of the likely course of events and a reasonable range of complications that could occur during the time until death. Patients should be told that their disorder is likely to cause death (even if the time frame is unclear) and when death becomes imminent. A health care practitioner must not assume that patients or their family members and friends understand the fatal nature of certain disorders (even metastatic cancer) or that they recognize when the patient is nearing death. Initial

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discussions should be honest and sensitive to the language and culture of patients and their family members and friends. The health care practitioner should not delay full disclosure because such a delay can give patients, family members, and friends false hope and reduce the opportunity for attending to spiritual and family concerns. Patients and their family members and friends benefit from making plans based on their priorities and preferences for the different possibilities provided by various end-of-life treatments. At some point, almost every dying patient should have a do-not-resuscitate (DNR) order written in their medical record, and all health care practitioners in every setting should abide by this decision. Other important decisions about medical care (eg, whether patients are to be hospitalized or use a ventilator) should also be made and recorded. Often, specific actions are required to implement these decisions (eg, to have the needed drugs at home). Family members and friends should be told about the changes that may occur in the patient's body directly before and after death. They should not be surprised by irregular breathing, cool extremities, confusion, a purplish skin color, or somnolence in the last hours. Some patients close to death develop noisy bronchial congestion or palatal relaxation, commonly known as the death rattle. If this symptom distresses family members or friends, scopolamine, atropine, or hyoscyamine, used in doses that dry the patient's secretions, can reduce the noise. Agitation and restlessness may also develop; they can be relieved with a sedative. If a patient is expected to die at home, family members and friends should be told whom to call (eg, physician, hospice nurse) and whom not to call (eg, ambulance service). They should also be told how to obtain legal advice and how to arrange burial or cremation services. Religious practices may affect how the body is cared for and usually should be discussed before death with the patient and their family members and friends. The last moments of a patient's life can have a lasting effect on family members, friends, and caregivers. The patient should be in an area that is peaceful, quiet, and physically comfortable. Any stains or tubes on the bed should be covered, and odors should be masked. Family members and friends should be given the opportunity to be with their loved ones and to maintain physical contact with the patient as desired (eg, holding hands). If desired by the patient and family members, the presence of friends and clergy should be encouraged. Accommodations should be made for spiritual, cultural, ethnic, or personal rites of passage desired by the patient and family members. *After Death A physician, nurse, or other authorized person should make the official determination of death as quickly as possible to reduce the anxiety and uncertainty of family members and friends. Family members or funeral directors should be provided with a completed death certificate as quickly as possible. Even when death was expected, a health care practitioner may need to report the death to the coroner or police. Health care practitioners should respond to the psychologic needs of family members and friends and provide appropriate counseling, a comfortable environment where family members can grieve together, and adequate time for them to be with the body. Friends, neighbors, and clergy may be able to help provide support. Health care practitioners should be sensitive to cultural differences in behavior at the time of death. Organ donation, if appropriate, should be discussed before death or immediately after death; such discussions are sometimes mandated by law. The attending physician should know how to arrange for organ donation and autopsy, even for patients who die at home or in a nursing home. Autopsy should be readily available regardless of where the death occurred. The decision about having an autopsy can be discussed before or just after death. Usually, a health care practitioner who has had previous contact with

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family members should discuss autopsy with family members. This discussion should not be left to a covering health care practitioner or house officer.

References
HANDBOOK OF THE BIOLOGY OF AGING E.Schneider/J.Rowe (Editors) 1996 ANNUAL REVIEW OF GERONTOLOGY AND GERIATRICS (V.21) V.Cristofalo 2001 Hamilton, Sandy "Detecting dehydration & malnutrition in the elderly". Nursing. FindArticles.com. 10 Jul, 2009. Harrison TR, Fauci AS. Harrison's Principles of Internal Medicine. 14th Edition. New York: McGraw-Hill, Health Professions Division; 1998. Stephen CR, Assaf RAE. Geriatric Anesthesia: Principles and Practice. Boston: Butterworths; 1986. Anderson, JR. Cognitive Psychology & Its Implications. 4th Edition. W.H. Freeman; 1995. Dempster FN, Brainerd CJ. Interference and Inhibition in Cognition. San Diego: Academic Press; 1994. Ricklefs RE, Finch CE. Aging: A Natural History. New York: Scientific American Library: W.H. Freeman; 1995. Snyder DL, Roberts J, Friedman E. Handbook of Pharmacology of Aging. 2nd Edition. Boca Raton, Fla.: CRC Press, Inc; 1996. Mahoney DJ, Restak RM. The Longevity Strategy: How to Live to 100 Using the Brain-Body Connection. New York: Dana Press: J.Wiley; 1998. Matthews & Larson, 1995; Koenig, George, Meador, Blaazer, & Dyck, 1994; Idler & Kasl, 1992. Baillie, V., Norbeck, J., & Barnes, L. (1988). Stress, social support, and psychological distress of family caregivers of older persons. Nursing Research, 37, 217-222.

Internet Sources: http://longevity.about.com/od/longevity101/a/why_we_age.htm http://findarticles.com/p/articles/mi_qa3689/is_200112/ai_n9016339/pg_2/?tag=content;col1 http://www.ninr.nih.gov/NR/rdonlyres/87C83B44-6FC6-4183-96FE-67E00623ACE0/4776/FamCare.pdf http://findarticles.com/p/articles/mi_qa3689/is_200112/ai_n9016339/

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