THEORIES OF AGING Aging is a complex process of biologic, psychosocial, cultural, and experiential changes.

No one theory on aging completely embraces and explains all the many facets of change. Following is a discussion of several biologic and psychosocial theories on aging that provide a frame of reference for providing nursing care to elderly clients. Biological Theories There are several biological theories which address the physical changes of aging. The stress theory suggests that irreversible structural and chemical changes occur in the body as a result of stress throughout the life span and that individuals must learn to adapt to these changes. The cross-linkage theory describes the deterioration of tissues and organs as the cause of loss of flexibility and functional mobility that occurs with aging. The somatic mutation theory takes a similar cellular level approach in stating that changes in DNA that are not repaired lead to replication of mutated cells, which brings about decreased cellular functioning and loss of organ efficiency. The programmed aging theory states that life span is determined by heredity and that an internal genetic clock is responsible for the rate at which an individual develops, ages, and eventually dies. Psychosocial Theories Psychosocial theories on aging present the position that many factors in addition to genetics contribute to the aging process. The disengagement theory posits that as individuals age, they inevitably withdraw from society and society withdraws from them in a mutually agreed on dance of separation. The continuity theory suggests that an individuals values and personality develop over a lifetime and that goal and individual characteristics will remain constant throughout life; an individual thus learns to adapt to changes and will tend to repeat those reactions and behaviors that brought success in the past. The activity theory proposes that an individuals satisfaction with life depends on involvement in new interests, hobbies, roles, and relationships. Volunteering is one way that many retirees stay connected to the community. In addition to providing social connection, volunteer activities provide a daily routine, a way to make a contribution, and a sense of being needed. MYTHS AND STEREOTYPES OF AGING In our youth-driven society, old age has a negative connotation. In many cultures, elderly people are accorded a position of respect, and young people feel a moral and familial responsibility to care for parents and older relatives. In American culture, misconceptions about the elderly abound. Older adults are often stereotyped as being ill, bald, hard of hearing, forgetful, rigid, grumpy, or boring, simply on the basis of their age and regardless of their competencies and individual characteristics. Many younger Americans also believe that all older people live in nursing homes and fail to consider the independence of the older generation and their contributions to society. These types of attitudes are known as ageism (the process of stereotyping of and discriminating against people because they are old). To many aging is synonymous with death; these individuals have a negative view of the aging process, which usually results from fear, lack of exposure to older individuals, and a lack of understanding of how varied experiences can enhance the overall quality of life. Surprisingly, many older adults have negative attitudes toward other older adults; these often result from fear of

stereotypes and social stigmas, or a sense of anxiety over guilt by association. Caregivers need to be aware of these myths and stereotypes and to separate them from the realities of the aging process in order to provide sensitive and appropriate care to older clients. CHANGES ASSOCIATED WITH AGING Change is an ongoing part of life. Anyone who has a difficult time accepting change and therefore adapts poorly to it, will experience problems and pain, even if he or she lives to be 100. Changes of aging can be viewed as developmental, physiological, or psychosocial in nature. Developmental Changes At every stage of life, including old age, new developmental challenges constantly arise. Like developmental challenges faced earlier in life, these occasions are opportunities for success or failure. Older people may experience feelings of satisfaction or success over completing certain developmental tasks associated with aging, such as: Gaining insight or wisdom, even if physical powers are in decline Developing better social skills, with more same-sex friendships Becoming more open-minded and tolerant Finding an unexpectedly active and pleasurable sexual dimension Seeing children transform into responsible, successful adults Becoming a grandparent Holding civic and community positions of responsibility Achieving mastery of ones occupation or skills Developing new skills, hobbies, and avocations Renewing and deepening ones relationship with ones spouse Gaining new knowledge and experiences Accepting and adjusting to physical changes associated with aging Coping with aging parents, spouses, and friends On the other hand, any older person would be challenged to find successful ways to cope with other developmental tasks of aging, such as: Adjusting to the death of a spouse Adapting to major declines in health or physical ability Adjusting to the loss of social role, prestige, occupation, income, or sense of usefulness Getting accustomed to loss of independent living Adjusting to any kind of loneliness or loss without boredom or depression Research shows that loneliness is the greatest problem among homebound elders. It is important for the health workers to assess the nature of any developmental challenges a client may be experiencing because a clients adaptation to changes can have a profound effect on health status. Physiological Changes From the moment of birth, the human body begins the aging process. As a unique individual, each person ages differently; the rate of age-related changes varies from one individual to the next. However, some generalized physiological changes occur with the aging process, including: A decrease in the rate of cell mitosis A deterioration of specialized non-dividing cells (such as neurons) Decreased elasticity and increased rigidity of connective tissue Decreased functional capacity Some of the physical changes of aging, such as graying of the hair and decreased visual acuity, are readily apparent. Other changes are more subtle and may go undetected until a problem occurs. The rate of aging is influenced by: genetic composition lifestyle (dietary and exercise patterns) previous experience (e.g., adaptive responses to stressors) presence of chronic illnesses

Neurological Changes Aging brings about several changes in the nervous system that alter sensory and perceptual responses. As a result of these changes, reaction time is usually slowed. The generalized slower response to environmental changes leads to increased risk for falls, burns, and other injuries. It is important that we allow older clients time to respond to questions and instructions. Teaching safety measures is a preventive aspect of caring that must not be overlooked when dealing with older clients. Sensory and Perceptual Changes Sensory changes are progressive and usually cause some limitations in later years. The resultant changes may impair the individuals ability to enjoy life to the fullest, as well as present related health problems. Vision The aging process causes some visual changes. For example, pupils decrease in size and are less responsive to light. Usually a loss of visual acuity occurs because of degenerative changes related to aging. By the age of approximately 42, the lens cortex becomes thicker, impairing its ability to change shape and focus. This condition causes farsightedness and is corrected by the use of bifocals. Cataracts, glaucoma, and age-related macular degeneration are the most common pathological visual problems experienced by the elderly. Cataracts (or opacity of the lens) can be surgically corrected. If untreated, glaucoma can result in blindness; thus, annual screening is recommended for all individuals over age 40. Age-related macular degeneration is the loss of central vision; magnification must be used to compensate for the changes. Diabetes, hypertension, and other systemic diseases will exacerbate macular degeneration. Fewer tears are produced by the lacrimal glands so the cornea is likely to become irritated. Most elderly people experience a decreased ability to see colors; pastels fade, and monotones, blacks, and whites are difficult to see. These changes normally occur with aging. The caregiver caring for older clients must be aware of the clients increased sensitivity to glare and allow time for the eyes to accommodate changes in lighting. The use of eyedrops or artificial tears may also be beneficial. Brighter colors compensate for the decline in color discrimination. Hearing Generally, hearing is diminished with age. There is a drying and wrinkling of the auricle with a noticeable increase of hair in the auditory canal. Cerumen becomes drier and can cause impaction, which blocks transmission of sounds. The hearing loss associated with old age is called presbycusis. In the middle ear, bony joints show some degeneration. However, the major changes occur in the inner ear, where degeneration of the vestibular system and simultaneous atrophy of the cochlea and the organ of Corti produce deficits in equilibrium and hearing. Caregivers need to be very patient in their approach to the older client. With anticipated changes in sensory perception, it is important that we face our clients, speak slowly and clearly, and protect them from injury. It is important when teaching clients that we ask for feedback and evaluate comprehension. Taste and Smell With aging, taste perception declines and salivation is diminished. Many older clients prefer more highly seasoned foods, with more salt and sugar to compensate for a decreased sensation of taste. Increased loss of appetite often occurs and may be medication-related in some individuals. It may be helpful for older adults to eat small portions frequently throughout the day. The caregiver seeks to make food visually appealing and know the clients food preferences. It is important to teach clients about healthy eating patterns. Olfactory nerve cells decrease in number. We should instruct family members and other caregivers to be alert for safety hazards associated with decreased sense of smell, such as the inability to detect smoke, leaking gas, or spoiled food.

 Cardiovascular Changes As a result of aging, functioning of the cardiovascular system becomes less efficient. Reduced elasticity of the heart muscle and arteries causes a subsequent increase in systolic blood pressure. Increased fat deposits in the blood vessels lead to a reduced supply of oxygen. The arterial diameter decreases as a result of arteriosclerosis. Thickening of venous walls leads to decreased elasticity. Thickening of aortic and mitral valves leads to incomplete closure; murmurs may occur in some older people. The development of varicose veins is common. As a result of decreased cardiac output, many elderly experience a decreased capacity for physical activity. A diminished cardiac output is problematic when the older person becomes physically, mentally, or emotionally impaired. We should instruct the client about the importance of remaining physically active and the need to balance activity with adequate rest and sleep. Older clients also need information on lifestyle modifications that promote cardiovascular health. Such instruction would include the following: Avoid smoking and use of other forms of tobacco. Avoid secondary tobacco smoke. Eat a proper diet (low fat, low cholesterol). Avoid a sedentary lifestyle, which can result in impaired cardiac output and fatigue. Respiratory Changes Most older adults experience a decreased functional respiratory reserve capacity, with a generalized decreased elasticity and tone of muscles, including the muscles necessary for respiration. Physical changes in the lungs include fewer functioning alveoli and a decreased number of cilia. Therefore, ineffective clearing of the respiratory system occurs. Calcification of the chest wall and rib cage causes the lungs to remain hyperinflated on exhalation, thereby decreasing vital capacity. FACTORS CONTRIBUTING TO RESPIRATORY DISEASES Smokingthe major contributing factor to respiratory problems; workload of the lungs is increased due to decreased oxygenation level. Impaired functioning of immune systemincreases the risk of respiratory infections. Impaired mobilitylung expansion is decreased; secretions pool in lungs and provide a medium for growth of microorganisms; increased risk of pneumonia. Obesityleads to decreased lung expansion and volume. Surgerymost anesthetic agents cause decreased respiratory rate and decreased tidal volume and lead to hypoventilation. To deal with respiratory changes, the caregiver teaches the client how to breathe deeply and cough effectively. The client needs to establish a balance between exercise and activity to conserve respiratory effort while at the same time improving vital capacity. Because physical exercise increases lung capacity, we should encourage clients to walk. Gastrointestinal Changes Aging brings about several alterations in gastrointestinal functioning. The major changes are described in the following section. Mouth Many elderly people lose their teeth for a variety of reasons, including years of inadequate dental hygiene and extended use of medication. Other physiological changes include atrophy of oral mucosa, loss of elasticity in connective tissue, and a decreased number of nerve cells that control chewing, swallowing, and taste. Saliva production is decreased, and saliva becomes more alkaline. The elderly persons ability to chew food is often impaired by loss of teeth, gum recession, and degeneration of the mandible. The caregiver should instruct the client to have foods that are easily chewed and swallowed. Gastrointestinal Tract There is a decrease in peristaltic action with a relaxation of the lower esophageal sphincter. This causes a decreased emptying of the esophagus and stomach. Intestinal motility is slowed. Shrinkage of gastric mucosa leads to changes in the levels of hydrochloric acid, the reason for many older peoples complaint of heartburn. Older adults have an inability to tolerate large amounts of foods containing fat. Elimination is often impaired in elderly clients. As a result, there is decreased absorption of nutrients. Some loss of sphincter control may be noted. We should instruct older clients about the importance of

adequate nutrition, especially fluids and bulky foods. Keep clients well hydrated by instructing them to drink at least 8 glasses of fluid daily. Other methods to prevent constipation are physical activity and a regular time for toileting. Genitourinary Changes Major changes in the structure and function of the urinary system are associated with aging. The kidneys, bladder, and ureters are all affected by the aging process. The loss of some muscle tone in the bladder and urethra can result in incomplete emptying of the bladder. Residual urine can lead to bladder infection. Decreased bladder capacity may cause subsequent nocturia and polyuria. Renal function is the major determinant of an individuals fluid and electrolyte balance. In the elderly, renal function is often affected by diminished blood flow to the kidneys as a result of arteriosclerosis, hypertension, and other cardiovascular disorders. The glomerular filtration rate slows and there are fewer functioning nephrons. The risk of renal failure increases with age, as does fluid retention. Dehydration is a very real threat for many older adults. The aging body loses some of its functional ability to adapt to changes in total body water, which is essential for metabolism. If clients are dehydrated, they should be instructed to drink 2000 ml (10 glasses) of liquid a day. Note that the fluid intake should be limited 2 hours before bedtime to decrease the likelihood of nocturia. Endocrine Changes During the aging process, the following changes occur in the endocrine system: Slowing of metabolism Alteration in pancreatic activity Decreased blood levels of growth hormone, estrogen, and testosterone As a person ages, the number of hormonal receptors in the adrenal and thyroid glands decreases. Thus, the persons ability to respond effectively to stress is diminished. Aging is associated with altered functioning of the pancreas; there is an increased level of insulin and circulating glucose. The major changes affecting men are enlargement of prostate gland (benign hypertrophy) and decreased reserves of testosterone. The age-related changes for women include a loss of elasticity in breast tissue with resultant sagging of the breasts, decreased size of uterus and fallopian tubes, and decreased motility of fallopian tubes. The nurse must provide information about the normal changes associated with aging and listen in a nonjudgmental manner when clients discuss their concerns about the physical changes. Reproductive/Sexual Changes To promote discussion of sexuality, it is important for us to adopt an understanding and accepting attitude. Sensitivity to verbal and nonverbal cues will also promote the clients expression of concerns. We must not assume that the elderly client is heterosexual, sexually inactive, or uninterested in sex. Sexual function is not normally lost with age, yet attitudes and expectations seem to imply that older adults are not interested in or capable of sex. It is important to recognize the elderly as sexual beings and to provide privacy to promote intimacy. Older adults who are sexually active may need education about sexually transmitted diseases (STDs), including AIDS. This is one health education topic that is frequently overlooked in health promotion for the elderly. When caring for clients of either gender, the caregiver should teach about the effects of aging on reproduction and sexuality and should use a nonjudgmental approach when clients discuss sexual issues. Changes in Men As men age, the testes become softer and smaller as a result of decreased concentration of testosterone in the bloodstream. The production of sperm is inhibited or decreased, and ejaculations are less forceful. Sexual dysfunction increases in prevalence with aging; however, it is not an inevitable result of the aging process. According to Sheehy (1999), 40% of normal healthy males remain completely potent at age 70. Several factors contribute to the possible development of erectile dysfunction (ED), also referred to as impotence;

RISK FACTORS FOR ERECTILE DYSFUNCTION (ED) Anemia Anxiety Cigarette smoking Concern about sexual performance Depression Diabetes Hormonal imbalances Hyperlipidemia Hypertension Medications Multiple sclerosis Previous traumatic sexual experience Prostate surgery Renal failure Spinal cord injury Substance abuse Thyroid abnormalities Vascular bypass surgery Changes in Women The older woman experiences a decline in the serum levels of estrogen. As a result, the vaginal walls thin and vaginal secretions decrease. The vulva and external genitalia shrink because of loss of subcutaneous body fat. Postmenopausal changes, such as vaginal dryness, may cause the woman to experience pain during intercourse. We need to inform the older woman about using water-soluble lubricants to relieve the pain and discomfort that may occur during intercourse. AGE-RELATED CHANGES IN SEXUAL RESPONSES Women Nipple erections during sexual excitement may last several hours postorgasm. Orgasms are usually unchanged, except that vaginal contractions may be of shorter duration. Vaginal lubrication is decreased. Urinary frequency and urgency occur after intercourse. Clitoral response to stimulation is the same as in youth. Skin is less flushed due to superficial vasocongestive skin response. Men

It takes longer to achieve an erection. More direct physical stimulation is required for erection. Erection is more readily lost after interruption. There is an increased ability to prolong time before ejaculation. Ejaculation may be less forceful or may not occur. Orgasm is similar to that experienced in youth. Less flushing of skin occurs.

Musculoskeletal Changes Many people experience a decrease in height as they age. Long bones take on a disproportionate size, and many aged people assume a stooped posture. These postural changes occur primarily as a result of calcium loss from bone, creating osteoporosis and kyphosis. These conditions are more common in women than in men and are implicated in estrogen loss that occurs with aging. Ligaments, tendons, and joints are also affected by age. They show results of collagen loss and become hardened, more rigid, less flexible, and predisposed to tears. Cartilage wears down around the joints, making flexion painful. Walking and a consistent exercise pattern can promote function and prevent the disabling effects of many of these changes. The caregiver should instruct women about the importance of calcium consumption. Foods with high calcium content include dairy products and green leafy vegetables.

Encourage exercise, especially walking, to promote flexibility and perform passive range of motion exercises for those who need it. It is essential that the nurse teach safety measures, including fall prevention measures, to clients and caregivers. Integumentary Changes Older adults frequently experience dry, wrinkled, flaccid skin. This is an expected condition that occurs with aging because the skin loses many of the properties that help make it appear youthful. It takes approximately 20 days for epidermal cells to be replaced in a young person, whereas in the older adult, this process takes about 30 days. Therefore, it takes longer for an elderly clients wounds to heal. Because of collagen loss, the skin of an older person loses its ability to stretch, and thus tears more easily. Loss of subcutaneous fat, moisture content of the skin, and elastic fibers causes the older persons skin to wrinkle, dry, and sag, leading to the development of elongated ears, jowls, and double chin. If the client has had years of sun exposure, skin drying is accelerated. For the aging smoker, dehydration of the skin is exacerbated even more. The development of lentigo senilis (brown pigmented areas on the face, hands, and arms of older people) can cause the person concern over his appearance. Sometimes called liver spots or age spots, these colorations are benign. Some cosmetic agents may lighten or almost eliminate these spots. Skin appendages (hair and nails) also undergo changes associated with aging. Hair loses its original color as the production of melanin decreases, turning it gray, and eventually, white. Hair also tends to thin, both on the head and elsewhere on the body. Nails thicken and become more brittle. Care of the toenails often becomes a problem for many older people because they may not have the flexibility to reach their feet easily. The caregiver must take special care to assess the skin and its appendages. Referrals to a podiatrist may be necessary for an older person to receive adequate care of the toenails. As a person ages, the number of sweat glands decreases; this decrease can result in heat exhaustion. The decreased amount of subcutaneous fat may also lead to increased susceptibility to cold. Some elderly clients will have body image changes as a result of these visible signs of aging. The caregiver must assess for body image alterations. If the client has an altered body image, it may be appropriate to: Assist with grooming as necessary. Use photographs of client to help adjust to changing appearance. Use touch to help clarify body boundaries. Alterations in Mental Status Alterations in mental status that occur with aging can be mild and have little impact on a clients functioning, or they can be severe and require the older adult to have assistance in managing psychosocial and physical needs. We must understand the types of cognitive deficits experienced by the elderly and what each one means to the clients health status. Acute confusion is a state of diminished awareness and attention of typically short duration (hours to weeks). The level of confusion often varies according to the time of day, worsening at night; this may cause sleep pattern disturbances. The individual is usually unaware of the setting, time of day, or day of the week and needs frequent reorientation to reality. An individual with dementia experiences chronic confusion, usually of a long duration (months to years), that impedes functioning. Individuals with dementia will exhibit personality changes, difficulty with sequential speech and thoughts, and possibly a lack of orientation to reality. Alzheimers disease is a type of dementia that causes numerous deficits, including diminished intellectual abilities, confusion, and impaired judgment. Depression is an altered state of mood that lasts at least 6 weeks. Individuals suffering from depression typically are alert and oriented to their environment but are characterized by exaggerated sadness, apathy, and preoccupation with negative thoughts. Many people believe that it is normal for older adults to become sad and withdrawn; this is a false assumption, which leads to lack of diagnosis and treatment of a serious health problem. Late life depression can be successfully treated if it is not dismissed as an inevitable part of the aging process.

Distinguishing Acute Confusion, Delirium, Dementia, and Depression Parameter Acute Confusion Delirium Dementia Depression Definition Inability to think Perceptual Deterioration of all Altered emotional with usual clarity, disorder cognitive functions state speed, and characterized by with little or no characterized by coherence, heightened disturbance of feelings of intense awareness, consciousness or sadness, hallucinations, perception helplessness, and vivid dreams, and hopelessness intense emotional outbursts Onset Variable Sudden Gradual Variable Duration Reversible Reversible Irreversible Reversible Pathophysiology Metabolic Drug intoxications Alzheimers Neurochemical disorders Toxic Withdrawal from disease abnormalities substances alcohol and other Metabolic Significant loss Cerebrovascular drugs disorders Parkinsons accident (CVA) Encephalitis CVA disease Trauma Trauma Head injury Alzheimers Febrile states Febrile states disease CVA Hypoxia Medications Fluid and electrolyte imbalance Attention Impaired: dulled Impaired: Impaired Intact heightened or dull Memory Short term: Short term: Short term: Variable because impaired Long impaired Long impaired first Long of concentration term: may be term: intact term: intact until ability impaired disease progresses to later stages Judgment Impaired Grossly impaired Impaired Impaired Impulsive Volatile Insight Impaired Impaired Impaired Impaired if in bipolar (manic) phase Spatial perception May be impaired Intact Impaired Intact Thought process Impaired, Impaired, Impaired Intact but may and incoherent hallucinations demonstrate flight content of ideas (jumping rapidly from one unrelated topic to another)