Transcribed by Joseph Schwimmer

Organ Systems Lecture #60 Normal Aging of Organ Systems I & II 5/19/14

Slide 1 - Introduction
Dr. Rima Sehl OK guys good morning. Im gonna start with general statements about the aging process, then
Im gonna break down by the major organ systems and giving you as much clinical applications. Alright, lets
get going.

Slide 2 - Why
Why are we studying aging? I already spent an hour or so in HP1 talking about the health promotion of the
aging population, we talked about the increase of the aging population. Lets see if you still remember. What
percentage of the American population is 65 and over? 40? 13, remember I said the number 13, at the present
time about 13%, in the year 2030 were gonna have 30% of the population of 65 and over, and thats when
youre gonna practice and thats why you really need to know this information. The reason we study it is
because we need to be able to differentiate between whats normal aging and whats actually caused by
disease, by medication, by abuse, by disuse, by not using it you lose it kind of thing, we need to be able to
differentiate among those things. And thats why we need to study what normal is, and then go into different
conditions and be able to differentiate. For each one we have a have a specific way of dealing with. To
recognize changes in the body that represent the beginning of abnormal conditions, so if we get it early
enough we can probably do something about it and reverse it or maybe prevent it from progressing, or
prevent it from actually moving up to the next stage from affecting other organs. The sooner we get to it, the
better it is. And because of that, it allows up to appropriately select preventive and therapeutic measures. So
thats the reason to study it. Our society is aging, the entire world is getting older and hopefully were gonna
be a little healthier.

Slide 3- Process
Ok, if we look at aging, it's very hard for me to give you a definition of aging, because depends on who's
lecturing, they may give you a different definition of aging. Im gonna go with the most common one that you
can relate to clinically, but if I ask you what are some of the earliest signs of aging, things that you will see, you
can tell, this is an older person, this is a middle age person, this is a younger person what would you say, what
do you notice when you go in the streets or you see your elderly relatives? (student: wrinkles) Wrinkles! What
else? Oh yeah, youll see change in posture, and if they get really more frail you get the shuffling, and I find
myself shuffling more and more these days, even with healthy age group. Stamina is gonna decline. Those of
you who are now pulling all nighters, theres no way if I go back to school Im gonna be able to do that and
pass an exam. Ill probably stop studying at 9 oclock, fall asleep at 10, and hope for the next day Im fine to
take an exam. So thats the kind of stuff that youre not gonna be able to do as you get older.

Slide 4 Aging
So thats on the outside. Were just gonna zero in and talk about, what does it really mean as an operative
definition to say the word aging. Now as gerontologists and geriatric specialists look at the aging process, they
look at it as a cumulative process, its just gonna accumulate, one thing on top of the other is gonna happen to
the individual, its not like you get one age at one thing and then you go back and give something up. Its
universal. All humans will age eventually. But theyll be aging at a different rate, and well talk about that. Its
progressive, it keeps on going. Its intrinsic, it comes from within the individual. And its harmful, its not
something that people just walk through it and say ok Im gonna get better, its gonna get worse. Every
change, every loss you have is really harmful to the existence of the body and it manifests itself usually after
the reproductive maturity. A lot of people, if you prescribe to the school that defines aging from conception,
thats a different story. I tend to describe it a lot of other people describe the aging process from the time
the person reaches the mature/reproductive stage, and thats development and then you start aging. And
well talk a little bit about that difference later on. And eventually it culminates in death.
Slide 5 Caution
Now you may see people like that, there are healthy aging people out there doing these kinds of things b ut I
dont want you to think of your patient an 85yr old patient, a 90yr old patient that theres really no harm
that can be done for that patient. Because what happens is there are changes in that body, normal changes
that puts that person at risk. So aging is really a risk factor for a lot of things, especially diseases. So I dont
want you to consider old people as sick, but I also dont want you to consider them as completely healthy or
free of risk factors
Slide 6 - Aging
So what aging is really if you wanna give like a general definition for it, its really a decrease in the ability of the
person to maintain homeostasis. And thats gonna be in the face of environmental stressors. Because we are
born with a lot of reserve usually, and if were going on in our daily activities without any stressors were
usually doing ok as we get older. But if there is a crisis or a disease or a mental crisis like a loss of somebody,
then thats a stressor thats put on the person, and a healthy older person will not be able to really maintain
that health or bounce back from the incident as readily as a young person.
Slide 7 development
And thats how it differs from development. Development is really an early process that enhances the function
of he individual. Aging, just the opposite, it decreases the function of the individual. So thats why I tend to
think of it, it starts at the time when the person reaches a peak at reproductive maturity, and then they
decline after that. Again, I just want you to listen, Im not gonna ask you to really repeat definitions. When
theres something important I want you to know and be tested on and in the clinic I will let you know
Slide 8 Characteristics
Ok, this is important, because this is really the essence of how we treat older patients and why we do certain
things or why we dont do certain things and the strategy that we take. Aging, when you talk about the
functional definition now, is really a progressive decline in each organ system, so musculoskeletal system, the
respiratory system, there is a decline in the reserve. We are born with a lot of reserve, we are born with more
than we need. Even with teeth, we have 32 or 28, its more than you actually need, you can chew with just 14,
15, 20 teeth. You can do it. so we are born with a little bit more reserve that we dont always use, but as we
get older that reserve declines, and that decline in reserve is called homeostenosis, a constricting of the
reserve. And the decline is usually gradual, its not all of a sudden. Its linear, its not geometrically it goes up.
Variable among individuals, every person ages at a different rate, every organ system in the body ages at a
different rate. So you may fine somebody who is healthy as far as the cardiovascular system, but the
musculoskeletal system is not, they can just, they have hips, joint problems. Influences, and its usually
influenced by genetics, diet and personal habit. Now the genetic part, we use dot think its more gene than
environment. But now the more we look at it, the more we think its less genes and more environment. So its
50% the genetic makeup of the individual and the rest is really can be manipulated by environment and
personal habits. So thats why we say health promotion and prevention is very important at any age, because
even though you may be born with a specific gene, like a gene for hypertension, if you have a stress free, or at
least a low stress life you have good diet, you exercise, that gene may not express itself. So in that sense it can
be affected by the environment. So this term homeostenosis is very important. And that decline in reserve of
every organ system is very important. Because when you look at the 85yr old person thats water skiing he
may look healthy to you but his organ system have already lost some of their reserves, so if youre gonna put
too much stress on some of them, symptoms may start showing.
Slide 9 reserves
Under normal circumstances at age 19, we have ten times the reserves that we need in every organ system,
and we lose about 1% reserve every decade, so give or take abot by the age of 119-120 we really dont have
any reserve. So people can die of old age. They ran out of reserve and thats it. so that is important to
recognize. So the older the person is, the less reserve they have, and the more careful you have to be about
stressing them, and expecting them to bounce back, that's basically the essence of this slide. And if you
remember when I talked about the lifespan of humans, we talked about we haven't really changed it beyond
hundred and 20 and that's because the reserve runs out, so if were going to increase the lifespan, not life
expectancy, lifespan, we have to make sure that people have more reserve by the end of their life.
Slide 10 Principles
So important principles, these are the things I need you to really understand what you are seeing patients. So
individual, as they get older, they become less alike. Younger people are usually more alike, folder people are
less alike, so if you have an 85-year-old patients one after the other in your practice, each one of them to be
different, each one is going to come with a different variation in their aging system, their background is going
to be different, their medications might be different, their life experiences are going to be different, and that
means you have to treat every individual by customizing the treatments for him or her, then making sure you
take that history, or the intake as carefully as possible.
The other principle of that, any time you see an abrupt decline in any organ system, teasing and today he
doesn't even know where he is, thats abrupt, aging doesn't just happen like that, that means there is a
disease. Look for a disease, look for medications, look for a crisis that happened in that persons life to account
for that.
Normal aging, normal in quotation marks, for healthy aging, can be attenuated by modification of risk factors,
that means from the environment and from the personal habits of the individual. So we can control it a little
bit. So that's why prevention is important, education is important, and that's why people really have to take
control of their own health.
Healthy old age is not an oxymoron, it does exist. It may not be as healthy as you would like it to be, but a
person could be at a very advanced age free of diseases. That's possible. I'll also grant you that with aging
comes the increase of susceptibility to diseases.
Now, with absence of disease, the decline in homeostatic reserve, that the reserve we talked about , the
homeostenosis, shows no symptoms, patients could be going on in their daily activities getting up in the
morning, have their coffee, doing their house chores a little bit, going to the market, come back, that's fine.
The minute here is a crisis, and that crisis can be in the form of a disease, it can be a death in the family, a
death of a significant other, a death of a pet, a retirement sometimes if the person is not ready for retirement,
that can induce some symptoms, and that is when you see the aging process exhibiting itself. So again,
remember that reserve thing when you're treating the elderly.
Slide 11 - Age Changes
Now, this is just, I don't really expect you to remember the numbers or percentages or fractions. About one
third of functional decline is the result of a disease as we get older, because chances are we might get a
disease. One third is due to inactivity, activity is extremely important for successful aging, whether it's physical
as well as mental. About one third results from the aging itself. So keep that in mind, it's not all about the
passage of time.
Slide 12 Aging v Disease
This is just to show you that the difference between the normative age changes, which are what we said, you
know progressive, irreversible, intrinsic, and what we call age-prevalent changes, age-related changes. And
these are usually what is common with old age, what is associated with old age, like the disease, retirement,
slowing down, and things like that.
Slide 13 Pathologic
This is, again this picture really tells the story of pathologic aging versus normal healthy aging. This is a 70-
year-old person, pathologically aging, she's got many medical conditions, she's taking many medications, she is
confined to a wheelchair, she needs help with her activities of daily living. This is a 92-year-old person, three of
diseases, not taking any medication, maybe a vitamin, but not even probably an aspirin. She does have some
assistance as far as the cane is concerned, but she might need it, or she might just have it for some kind of
security. Given the exact mouth, if I had two identical oral cavities here, they would require two different
treatment plans probably. They will tolerate two different treatment plans. I don't expect this person to
tolerate the same treatment as this person. This is where the functional status comes to play. This is why it's
very important for you to recognize what is really due to aging, what's due to disease, be able to tell that this
difference, and base your treatment plan based on the functional status of the individual. And we'll teach you
how to really assess that in a second here.
Slide 14 As clinicians
So ask clinicians, again I said that in last week's lecture, you do not want to dismiss some pathology as part of
the aging process. You don't want to say to somebody, your knee is bothering you because you're 85, what do
you expect, you are going to lose your teeth at that age, you don't want to do that, because that will be under
treating the patient, because thats disease. Arthritis is a disease, they may benefit from some kind of
treatment. Losing teeth is a disease, it's caused by some kind of decay or a periodontal disease, it's not caused
by aging. The passage of time may increase the chances, but it's not really, patients who keep their mouth
healthy, they can maintain their teeth as well. And you want to avoid treating the natural aging process as a
disease, because you don't want to overt treat patients, so it's very important to recognize those two.
Slide 15 Different
The organ systems age in different ways. In general, I just want to give you an idea of how they age in the
body. And organ system can age by the loss of function completely. And the best example of that the female
reproductive system, by the age of 40, 45, 50, the reproductive system just stops working. And it reaches what
we call senescence. Sometimes, and organ system can age by losing units of function, like muscle mass, and
muscle fibers, you could lose them, even though the person is still functioning normally, so you lose just unit
of that organ system. Agent could be defined as reduced efficiency without anatomic loss. Some organ
systems they just lose efficiency, or they become deficient, like the eyes, the vision, or the hearing, even
though there is no anatomic loss in there. So that's another example of aging.
Slide 16 Different
It could be due to interruption in the central function. For instance, if you have a decrease in ovarian
hormones, that may lead to secondary increase in the pituitary hormones. That sounds good, because usually
any kind of increase in that direction is a good thing, but it actually, it's not really a positive thing to have, you
do not want an increase in pituitary hormones, when you don't have enough of the ovarian hormones,
because it may trigger a cycle that may not be wanted. So in that sense, an increase is not really a positive
thing.
Slide 16 Clinical case
Now, clinically, you're going to see an older person. This is an 87-year-old lady, a clinic patient, she is
ambulatory, she comes to the clinic, she is one of the 85% of those ambulatory patients that you're going to
be seeing here, you're going to be seeing in your private practice, and you're going to be able to tell the
difference between what is happening in the normal aging process with her, and what's happening as a
disease. And no patient is going to come to you most likely, except for the very few like that 92-year-old
patient, who is free of diseases. So she's going to come with a profile, she may have atherosclerotic heart
disease, angina, mitral valve prolapse, glaucoma, and a pacemaker. And you learn about those diseases next
year. And then you're going to have to figure out what is happening in her body, because of these diseases
and medications that are associated with it, but is happening as part of the normal age process, and how are
you going to consolidate the two and treat her safely. So that her to be your job.
Slide 17 Vision
Having said that, now let me go through them again, the most important organ systems thats going to impact
the treatment in the clinic. Vision and hearing are the two things that you really need to ascertain from your
patients before you start, because if they cant see as well, and they don't hear you as well, that treatment is
not to go too well. So let's see what happens in normal aging in the pupil and the lens. The pupil become
smaller, as we age, that means light going through that pupil is going to be restricted. The reaction from going
from dark to light is going to be sluggish, so that means when your patient is coming from a bright outside to
your office, it has a hallway that is not nicely lit, it's also be a problem for them to adjust. The lens is going to
increase in thickness and stiffness, it's not going to accommodate as well. It's going to become more opaque
due to some of the proteins being oxidized in there. And it's gonna have some pigments in there that is going
to make it like an amber tint, because the protein turns it into yellow or orange color in there.
Slide 18 Vision changes
Now having all of this, the accommodation of the lens from far vision to near vision is going to decrease the
cause of the lack of elasticity. All of the changes we talk about the pupil and the lens is going to increase the
susceptibility to glare, that's why you don't see older patients really driving at night to much, because when
the headlights come they can't see a thing. It's important that when they are in the clinic, or in your practice,
that you don't have the light in their faces, because it's going to be very annoying. But a lot of dentists now
use those dark glasses, so patients can wear them and be comfortable when sitting or lying back in the chair.
The tendency to see white objects yellow, because that amber tint in the lens, older patients are going to
insist, especially when you're doing matching up shades for teeth, they're going to insist oh Doc can you make
them a little bit more whiter, because they keep seeing white objects yellow. So that's very important,
because you need to educate the patient, and sometimes them to bring somebody with them, and another
85-year-old, because that's going to be, if they like one of your office staff, or they bring somebody who is
younger, to at least give them a realistic view of whats going to look good on them because their complexion
and the white teeth are not going to go together. But it's hard for them, and you don't want to be the only one
responsible for the decision. And because of that deposition of those pigments, but because of the loss of
elasticity, you're going to have cataract formation on the lens, that's part of the aging process, personal lives
long enough, they're going to have cataract, no two ways about it.
So this Presbyopia Island even though this term, and what it means. Because its very important because thats
when patients, especially when you want them to accommodate when they get into your office, and you want
them to read something, it's very important for you to understand.
Slide 19 Hearing
The other word I want you to know, the progressive hearing change in older individual is called Presbycusis. So
these two words are very important, because when you're communicating with physicians, when you're
communicating with other health care providers, these are the words that are going to keep on hearing, and I
want you to be very versed in them. The change in hearing usually in high-frequency sound, that's why yelling
at somebody doesn't really make sense, when you talk to somebody thats deficient in hearing. The loss
happens to be more in men than in women, and more after the age of 70. So it's very important to recognize,
that in elderly patients, they're going to really have a problem telling you sometimes, but older people, just as
vain as the rest of us, especially when you have a female dentist and a male patient, they may not want to
admit to you that they can't hear. You don't see too many people walking around with hearing aid as much as
glasses, glasses they have no stigma, they have glasses sometimes for fashion, but hearing aid, they have just a
different kind of stigma. So it's very important for you to ascertain that patients really does not hear, or does
not hear well, because they're going to go like this to you, they're going to smile, and they developed a lot of
strategies that they answer the question as if they heard you, they know how to answer that question, but
they really never heard the question. And there is difficulty usually in discriminating words, especially when
there is background noise, and that is very important because we work in an environment where the drill is
working, in the clinic everybody is doing their thing, different procedures, producing different kind of noise,
and the same thing in your office, you have background music, so you need to be aware of things. So the
strategy is to stand in front of the patient, make sure the mask is off, make sure the background noise is down,
and talk to them at an eye level where they can see your lips, read your lips if that's necessary, if they wear
hearing aids make sure they are on when you're talking to them, make sure they are off when you're drilling,
because that's very annoying and it it's not really a pleasant sensation. It's very important and of course to
give them instructions and any kind of educational material in writing as well.
Slide 20 Changes
Some of the changes that happened in the body composition that have really important consequences, that
we have less water, as we get older our organs do not retain as much water as we would like. So that's why
dehydration is a problem. There is more fat, and there is less solid, meaning muscle mass, and less bone
density. All of these changes, the major impact is usually on medication, and the metabolism of medication.
Because medications, when you learn in pharmacology next year, fall into two categories, fat-soluble and
water soluble, so if you're administering the medication and it's fat-soluble, like Valium, that's gonna stay in
the system for a long long time, that means the older patient is gonna suffer the consequences and the side
effects of that, that's why we say don't administer anything that has a long life, or half-life. So again, you may
want to choose something with a shorter half-life because of that reason. So all of the changes become very
apparent to you when you start prescribing medication.
Slide 21 Musculoskeletal
The musculoskeletal system, it's a decrease in lean body mass, thats the muscle, and a decrease in bone
density. Again, the decrease is not to the point of disease, this is very important for you, the decrease in
muscle mass we call it sarcopenia, a decrease in bone density is osteopenia. That is not a disease yet, that is a
precursor for a disease. What is a disease that you have after osteopenia? Osteoporosis usually, osteoporosis
is a disease process, and the climate in bone density is really a normal aging, so if you get a question like that
on the exam, be able to recognize what is disease and what is normal aging.
Slide 22 Muscle
muscle tissue, again, the atrophy of the muscle fibers is a decrease in muscle mass. We already talked about a
decrease in energy metabolism because of the degeneration of the mitochondria, and all of that is going to
lead to decreased in muscle strength, so an older patient is going to have less muscle strength, that's why we
say don't keep appointments too long, don't make them get up a few flights of stairs, you don't see these
people doing construction jobs. The same thing goes for the mastication muscle, mastication muscle lose
some of the fibers, the force of the bite is going to decrease. So that means you select teeth, and when you're
trying to replace teeth, you have to really pay attention to the degree of the cups, you don't want very sharp
cusps for somebody who cannot really bite as forcefully as a younger individual, so you may go for flat teeth.
And you'll hear all of these when you start doing prosthetics. Flat teeth, or 20 teeth, as opposed to 30. Okay,
so all of those things I'd like you to just remember when you start doing clinical work.
Slide 23 Bone
Bones also, the calcium in the bone decline, and you know that female lose it at an earlier age, around
menopause and afterward. Males don't start losing it until the age of 60, but that does not mean that men do
not get osteoporosis. That's a myth that people think osteoporosis is just for women but there are lot of
elderly men who can get it as well. Like we said, decline in bone density is osteopenia, and that happens to be
normal in old age, and of course is an increase in organic material that makes the bone more fragile.
Slide 24 Cartilage
Cartilage go through some of the changes I dont want to read them you can read them on the slide. But what
I'd like you to know, this is just interesting because you hear a lot of people taking the cosamines and the
chondroitin sulfate supplements. And the reason they taken because the proteoglycans changes as we age,
and a molecule that bind to the water become smaller, and it doesn't bind it much water, so that's why you
get the hydration and the joints, it's not lubricated as much, because there is not enough water. So when you
introduce the supplements, the cosamines and the chondroitin sulfate, you tend to bind more water and
that's supposed to help the joints get a little bit more lubricated.
Slide 25 Musculoskeletal
We talked about that. To just continue, and we talk about this? No. I just want to talk about the clinical
implications of all those changes. You get slower ambulation, and stiff ambulation. That's why your patient is
going to walk slower, and that is very, very funny how nobody really pay attention to these things, but I see it
a lot in the clinic. Sometimes in that clinic, when a student comes in, and there is a Mrs. Jones sitting there
who is 85 years of age, they say, Mrs. Jones, come one I'm ready for you, and he starts walking, or she starts
walking, and Mrs. Jones is still trying to get up, trying to keep up with that student, who is way down there
already, maybe even made a left or a right turn, and Mrs. Jones can't see him anymore, she doesn't know
which chair she is at, so really if you can just remember, when you have any patience really, but try to keep
pace with that patient because, just stay with them, give them a hand, maybe they need somebody to carry
their coat, maybe they need somebody to lift them off the chair, those chairs if they don't have armrest,
forget it, you can't get off them. So these are things I really want you to be aware of when you start to see
older patients. Because of all of these changes, things they can help, sitting in that chair in one position
becomes very difficult for them, so make sure you don't leave them there for a couple of hours, or if you need
to, make sure you give them the opportunity at least to move around, get up and move around a little bit.
There is an increased risk of disability, falls, unstable gait, and were going to talk about the unstable gait.
Increased risk of osteoporosis and osteoarthritis. Okay so again, all of these changes put the patient at slower,
more sluggish way of moving, and eventually it may lead to some disease in some people.
Slide 26 Journal
Now, even though very fit elderly patients, they did study with athletes who maintain their athletic activities
into old age, even with that, even when they maintained their shape, when they maintain the sports that they
are good at, there is still a decline. And when you reach age 75, there is a decline in the matter how much to
maintain your body. So yes, you can delay the aging process a little bit, but there is a point when a decline in
going to happen. It may not be as fast, but still, it's there. It's just an example.
Slide 27 Height
All right, height changes as we get older, we do shrink, remember that. And the shrinkage, it starts from the
age of 40, and it's about an inch per decade. So you could lose up to 4-5 inches if you reach the age of 90 or
100. And my grandmother, she did lose, she really started shrinking little by little, and even my own mother
the other day she was telling me, I just fixed those pants, and now they're long again. So it can be the pants, so
we do shrink. And the reason being, there is usually flattening of the foot arch. So that's why sometimes even
our shoe size gets bigger, half the size, or even maybe a whole size, we may go from a medium to a wide, and
there is an increase in the spinal curvature as we get older, that makes us a little bit shorter, and the collapse
of the vertebral column, and that's because of the lack of water, the desiccation in between those vertebrae.
So that collapses the column and that causes the shrinkage as well. And that's usually, you hear a lot of
physicians asking, especially the small elderly women, how many inches have you lost, since you are 40 or
since you are 30, because that's usually the beginning of the disease of osteoporosis, so you can ascertain that
from those questions.
Slide 28 Nervous
The nervous system, again there are some individual loss in neurons, but none of these losses should be to the
point where a person becomes demented, or becomes completely impaired. There is such a thing as benign
forgetfulness, which is fine, but a lot of people get really upset, thinking they're getting Alzheimer's, because
they forgot where they left their keys. I don't know how many times I forgot where I put my keys or I come to
a room and I don't know what I came here for, and that's fine, it's not Alzheimer's, believe me.
Slide 29 - Nervous
But that's what we call benign senescence, because things do slow down, the transmitter, the
neurotransmitters are declining, so we are going to see that sluggishness in the memory, and all the
neurotransmitters are declining as I said, whether it's the acetylcholine, the dopamine system, the
norepinephrine, and all of these cause the stiff gait, that's why older people have a stiff gait when they walk,
and you can tell from walking behind somebody their age, or at least the approximate age that they are.
Slide 30 Reflexes
Our reflexes decline, off course, that's why a lot of older people cannot really drive anymore, because they
need very fast reflexes. And when that, because of the increase of, or the delay in between the synapses, you
get increased reaction time. This is important, very important to remember. It is an increase in reaction time,
you don't react to the demands or react to situations as fast as you used to. As dentists, that important to you,
because you may want them to respond to some kind of instruction, like open or close your mouth, or put
your tongue to the side, or to take an impression, you want them to raise their tongue, it's very important to
recognize that the response is not going to be immediate. So that increase in reaction time is very important.
And you don't want to appear insensitive by becoming flustered because they don't respond as well or as fast.
Slide 31 point
A point to remember is that all of these cognitive impairments that we talked about, a decline in cognition,
really they are not have that stereotypes make them seem. It's not that caricature you see of a demented
older person, or a person just because they are over 60 they are not going to remember where they left their
car. That's all a stereotype, and usually when you see a severe cognitive decline, it's because of disease.
Slide 32 Cognitive decling
You have atherosclerosis, or infarcts in the brain, you have diabetes that are called dementia, or cognitive
impairment, and people would Alzheimer's gene also can exhibit that kind of decline. But in general the
decline should be benign. Benign forgetfulness, you may even have it now, and it's probably called by
overloads. Your circuits are overloaded.
Slide 31 Cardiovascular
the cardiovascular system, you're going to get stiffening of the arteries, you're going to get diminished in the
beta-adrenergic sensitivity, and that's important for medications also, and that's going to lead to cardiac
reserve decline, and cardiac contractility, the heart is just not going to pump as forcefully as it used to.
Slide 32 CVS
And again with all of these changes, especially with the baroreceptor sensitivity, that again, is also going to be
affected by medications. Also, you have to be very aware that older people are going to suffer from
orthostatic hypotension. That means that when they are sitting down, or that when they are reclining in the
chair, and they get up, and they don't get up slowly, because they don't sit and let their feet down, and just
take a minute or so to collect themselves, they are going to faint. And that as a dentist you really need to
know. Individuals who are free of diseases will exhibit this to some extent, individual who are on hypertensive
medications will exhibit this even more. So either way you have to be careful when your patients get off her
chair, always remind them, Mrs. Jones, I want you to get up, sit down in the chair for a minute before you get
up. I'll let you know when you need to get up.
Slide 33 - Resp
Respiratory system, again, the elasticity is going to decline, the stiffness of the wall is going to increase. Any
kind of respiratory function is going to decline, whether the amount of air that it's taken in, is going to be less,
the amount of air that stayed inside the lungs, the residual volume, is going to be less. The patient at age 85 is
working with 50% of the reserve. But they're working, they are functioning, that means they are going to be
doing well, but if they are in a race they are not going to be doing as well, because you are putting too much
demand now on the system.
Slide 34 GI
The gastrointestinal system, again the hepatic function, and going to decline, and that is going to be major for
the metabolism of the medication, but gastric acidity is going to decline, that's going to affect the calcium and
iron absorption. And that's why we see most older people are iron deficient, calcium deficient, because they
cannot absorb it as well. And that's why they need the supplement. And the colonic motility declines, and
that's why they suffer from constipation. And you're going to see a lot of your patients on some kind of stool
loosening medications. And that's going to contribute to the dehydration. So don't underestimate somebody
who is taking dedications, because if they had dry mouth to start with because of other medications, it's going
to be also exacerbated because of these medications. So ask about these medications, these are going to be
over-the-counter medications. And you're not going to know about them until you specifically ask.
Slide 35 Liver
We said there is changes in the liver, in the enzyme, now you will learn next year, when you take
pharmacology, about how these drugs are metabolized in the system. There are two different systems,
wanted the cytochrome P450, that's the one that's usually affected by aging the most. So that means any
medication or drug the patient take that have to go through that system will also be affected. That means it's
not going to be metabolized as well. So you may want to, if you're going to be prescribing any med, you may
want to stay away from those. You will be learning about them next year, I will not be asking those kinds of
questions on the exam. Bloodflow declines, liver mass declines, and again, don't worry about the percentages,
just think about the direction.
Slide 36 Endocrine
the endocrine system, like we talked about the neurotransmitters, hormone, or the growth hormone, insulin,
thyroxine, sexual steroids, they're all going to decline, and there is going to be decline in the communication
as well, and that's why there is going to be increase in diabetes in older patients.
Slide 37 Immune
The immune system definitely declines with old age, especially when it comes to the thymus.
Slide 38 Thymus
Now I'm going to show you just size of the thymus of the newborn, as opposed to the size of the thymus of a
60-year-old. And that really explains why certain diseases are more common in older people. When you start
at infancy here, as you get older, there is an increase in diseases, all kinds of cancer, the autoimmune diseases,
and infectious disease. And that's why we screen for cancer in older people, and that's why we look for, we
make sure they take their vaccine for infectious diseases like the flu, pneumonia, shingles, we want to make
sure they don't, because they are more susceptible, because of the evolution of the thymus.
Slide 39 Immune
So this is just to reiterate the infection, cancer, autoimmune disease, are categories of diseases that you're
going to encounter in old age, more so than in younger individuals.
Slide 40 Renal
Kidney, this is important, because this is one of the organ beside the liver where medications are going to be
metabolized, and go to be excreted. Should be excreted, not metabolized. There is a definite changes in the
glomeruli, and that is they become sclerotic, there is increased in fibrotic tissues as well.
Slide 41 Renal
Now, and you're going to see a decline in renal mass, remember the reserve. A patient is still going to function
well even with the client in the mass. There is going to be a reduction in the filtration rate, and there is going
to be, really an ineffective system, that maintain the homeostasis of water and electrolytes. So older individual
are not going to be controlling their electrolytes and water as well as younger patients. And that's why they
become either too hypothermic very quickly.
Slide 42 Points
Now, with aging, the serum creatinine concentration doesn't change. This is important to remember, that the
serum concentration doesn't change, and that's because the creatinine production falls. Remember there is a
decline in muscle mass, and that come from the destruction of the muscle, so if this goes down, so does the
clearance. the creatinine clearance, the two of them are going down together. The concentration in the serum
does not change, of the creatinine. It that clear? Because that is important. I want you to remember this.
Because when you look at lab results, and you see an increase in the creatinine in the serum, that's related to
disease. Because it should be the same as we get older, because both of these decline, so the outcome should
not really change, the average should not change here. From this graph just shows you, the serum creatinine
decrease, the creatinine clearance decreases, but overall at different ages, the serum creatinine concentration
does not change.
Slide 43 Renal
So clinical implications, you have impaired excretion of drugs, and that's why we don't want to give too much
medication, or high doses of medication, and there is a saying that when youre prescribing for the elderly:
start low and go slow. So you got to start very low, and go very slowly. And you can always increase it. And
that is the same for anesthesia. Delayed response to fluid restriction or overload. So they can't really balance,
that system and not very efficient anymore, and that's why older people go to the bathroom often at night.
Because they eliminate the water, because the urine is no longer have concentrated. They lose that ability to
concentrate the urine.
Slide 44 Water
And in addition to all of that, you also have a decrease in the thirst response. You remember from the health
promotion lecture I gave you in HP1, they don't feel that they are thirsty, so they have to be reminded,
Slide 45 = Pyramids
if you remember I showed you these two pyramids, and there are glasses of water here and how they have to
be reminded to drink the water so they don't get dehydrated. So like you and I can know I feel thirsty, I should
really drink something, that's response is not as efficient as we get older. And remember that flag where there
is usually a deficiency in calcium, vitamin D, and in the B. vitamins.
Slide 46 Genitourinary
The genitourinary, again, the mucosal atrophies a little bit, and there is usually dryness. This is important for
men, their prostate enlarges, it's benign hypertrophy of the prostate. If they live long enough, they are going
to have an enlarged prostate, and that will contribute to the frequent urination. That means that patients
sitting in the chair for a couple of hours may not be able to handle it. And again, he may not feel comfortable
saying I need to go to the bathroom. Remember, an 85-year-old person, you are about in your 20s, there is a
little bit of discomfort there, it's important that you at least build it into your practice, if you're going to be
away from the chair for a couple of minutes, tell the patient I'm going to be away for a while, this is a good
opportunity to take a break. Don't say you can go to the bathroom now. Just take a break.
Slide 47 Skin
The skin, it's really common sense, I am not going to read it for you, you can read it on your own, and because
of all the changes, the skin becomes more vulnerable to a lot of things including skin cancer. And all of these
decreases and the collagen and elastin, the density of the blood supply, the nerves, the gradual loss of sensory
receptor, all of the things have clinical implications.
Slide 48 Skin
The skin of the older person becomes more susceptible to wear and tear, decline in resilience over time. They
really don't feel the inflammatory reaction as well, they don't feel pain as well, so a patient can come to you
with an abscess or toothache, inflamed area, and they may not feel it, because of the blunting of the
inflammatory process and because of the increase in the threshold for pain.
Slide 49 Skin
This is important, again, the thinning or the atrophy of the skin when it comes to the feet, that's why a lot of
people really have foot problems, because if the pad on the sole becomes very thin, then they feel everything
that they are stepping on, and it can be very painful, and that can slow them down a little bit. So be aware, not
that you are going to be a physician and ask about everything, or a podiatrist, but be where and take note of
the things, that if you see somebody that's really having a hard time walking, if it's really the joints that
bothering them, is it the feet, is it something else that causing that problem?
Slide 50 Skin
And of course this is a diagram of young skin vs old skin. And you can see the difference, this is just visual for
you. And this is what it's going to look like to you on the outside.
Slide 51 Face
and the face, the face area is where you are going to be in close contact with, it's an opportunity for you to see
any kind of irregular spots or things. Not everything is going to be benign, but not everything is going to be
malignant. So it's important to ask your patience, when was the last time you had a dermatological exam. It's
recommended that individual should have one at that age every year, really just check out for skin cancer. Not
to alarm them, just to make them aware of what would be normal and what isn't.
Slide 53 Sun
And again not to forget that habits or environmental factors could affect aging process and well. In general it
speeds it up.
Slide 54 Variable
Certain variable, when you look especially at last result, certain variable should not change with age. So when
you see any change, its disease. So if you see a decline in hematocrit level, what is that an indication of? If
hematocrit levels are at 20, what is it an indication of? Anemia, that's right. Older people should not have low
hematocrit unless they are anemic. People have high white blood cells, what is it an indication of? Infection.
Again, none of these things should really change as we get older, and if there is a change we should look for a
disease or for a condition.
Slide 55 Functional decline
Functional decline, and again just to recap here, the decline in velocity at nerve conduction, thats why you
have an increase in reaction time, a decline in the filtration rate in the kidney, that's why you have to worry
about medication, and excretion of the medication, cardiac contractility decline, as well as vital capacity of the
lung, that means that older people are going to feel tired more often, that's why they don't have the stamina,
the blood is not pumping as strong as it used to. The lungs are not functioning at their 100%, even at 70%,
sometimes. This becomes very important when? When do we sometimes compromise that area, the
respiration? How do we do that? When you're doing dentistry, when might you compromise the patient's
breathing? Rubber dam, yes, that doesn't mean I don't want you using a rubber dam, it's important you have
to use a rubber dam, but be careful, the rubber dam is not sitting on top of the nose up to the eyeballs.
Sometimes I see people going to the bathroom with their rubber dam hanging. Please be careful, if you're
going to do a procedure with rubber dam, make sure you get your patience ready for the length of that
procedure, and make sure they are comfortable, and they had gone to the bathroom before. Because the last
thing you want to see, or another patient wants to see another patient going to the bathroom with a rubber
dam hanging, and they are drooling usually, cant swallow, it's a sight, I've seen it so many times. I am talking
out of experience here. So that with the rubber dam. But another situation that you might compromise
somebodys respiration? In positioning. If you put somebody all the way back, multiple people will not be
comfortable in that supine position. So you may have to just recline them a little bit, you may have to change
the way you sit in the chair, so ergonomically you may suffer a little bit because the patient needs to be more
comfortable. So all of these little things really matter.
Slide 56 Examples
So this again is just an example of the reduction of some of the organ systems, and remember, I just want you
to remember that with the baroreceptor sensitivity declining, you have that postural hypertension. With the
thirst you get the dehydration, a dark adaptation decline, so you get the hazardous night driving, and things of
that nature. This has a direct impact, because you don't want patients leaving your office in the dark, if they
are driving to your office. So make sure that you schedule them at a time, because they are not going to give
up their driving that easily. Older people will not give up that car, because independence depends on it. And
it's very important, it's never usually, you can't really get a family member to stop them, you have to get the
physician to do an evaluation, to get them diagnosed, to say Mr. Jones I examines your eyes, I examined you, I
examined your reflections, and I really believe that you should at least cut back on your driving. To not drive at
night, do not drive in rush hour, do not drive long distance anymore, don't go driving in areas you are not
familiar with, because they are not going to do it on their own. And the way you can help is not subjecting
them to times that they have to leave your office or come to your office, especially in the winter, at a time
when the driving is hazardous.
Slide 57 Stress
Again, this goes back now to the same thing that we said before. Usually a diminished reserve or function does
not show itself unless there is a stress in healthy older people. Not in compromised people, but in healthy
older people.
Slide 58 Homeostenosis
And this is just to show you an example of what homeostenosis is, especially when it comes to the kidney. The
excretion of drugs. When we are born, we are born with this much reserve, look at that area under that curve,
huge amount of reserve. As we get older that reserve gets smaller and smaller, that area gets smaller. We
reach a point where there is what we call the critical threshold. So if you give anesthesia to somebody, and
you start with two carpules here, no problem, patient can tolerate it. And if you start from here, and you use
those same two carpules, you may put the patient into the danger zone. So that's why you have to be really
careful about assessing the functional ability of your patients. And that's going to come from looking at the
medical history, the medications that they are taking, talking to the physicians, talking to the other healthcare
providers, and making sure knowing what the reserve of that patient is. Because by looking at the patient it
may not tell you something sometimes. And that's why we say, every older person is going to be different
Slide 59 Hallmark
The hallmark of aging. Aging does not impart disability under benign circumstances, but does limit the older
persons resiliency under circumstances of stress. Older person is not going to bounce back as readily as a
younger person when given the same amount of stress. That's the simplest way of putting it really.
Slide 60 Sick
And on the other hand, old people are sick not because they are old, because they are sick. Old age is not
synonymous with sickness, so an older person, when you see changes in the lab test, sudden changes and
things, it's usually an illness. So all people are sick because they are sick, not because they are old. And that's
very important to recognize, because we just sometimes dismiss it as what do you expect, at 85, what you
expect that 90? And there are a lot of things that can be done at 85 or 90 that would increase the quality of
life of that patient.
Questions? No? Alright guys good luck.