Chapter 2 Part 2: Biological (Physical)

Aspects of Aging

Osteoarthritis

Osteoarthritis is the most common type of arthritis---70% of those over seventy years old have x-ray evidence of this malady (Srikulmontree 2008). Osteoarthritis chiefly affects the tissue, known as cartilage, which pads the ends of bones within a joint. Osteoarthritis takes place when cartilage begins to wear or fray, sometimes completely wearing away, leaving a bone-on-bone joint (NIAMS n.d.a).

[QN.No.#11.The most common type of arthritis found in elderly persons:] Some predispositions to osteoarthritis are:

• Being overweight or obese
• Injury and/or stress to the joint(s)
• Family history of osteoarthritis

Symptoms of osteoarthritis can include the following joint problems (WD 2009):

• Joint pain or tenderness
• Joint stiffness, reduced motion
• Slow, often painful, movement
• Crunching sound
• Swollen joints
• Joints that lock
• A crunching or grinding sound

Other symptoms can include (WD 2009):

• Fever
• Weight loss
• Fatigue
• Trouble breathing
• Rash and/or itch

Osteoarthritis may also cause disability which usually happens when the spine, knees, or hips are affected.

Treatments for osteoarthritis are fourfold:

• Physical resources:
  • Exercise
  • Support devices
  • Thermal therapy
  • Alternative therapies, e.g., chiropractic, acupuncture, or massage
• Drug therapy:
  • Topical agents, e.g., capsaicin cream
  • Oral pain relievers, e.g., acetaminophen
  • Nonsteroidal anti-inflammatory drugs (NSAIDs) for swelling and inflammation
  • Narcotics for severe pain
  • Joint injections with corticosteroids or a form of lubricant called hyaluronic acid (HA) derivatives
• Surgery:
  • Arthroscopy
  • Joint replacement
  Nutritional supplements:
  • Chondroitin/glucosamine sulfate supplementation is recommended by the National Institutes of Health (NIH 2009), with the caution to consult a pharmacist or physician to avoid drug interactions.

Osteoporosis

Osteoporosis is a disease manifested by a decrease in bone strength; this leads to a greater risk of fractures, or broken bones (NIAMS n.d.b, 1). Osteoporosis is the primary underlying cause of fractures in postmenopausal women and the elderly. Bones of the hip, spine, and wrist more frequently sustain fractures, but any bone can be affected. Some fractures can be permanently crippling, especially if they are in the hip.

[QN.No.#12.The primary underlying cause of fractures in postmenopausal women and the elderly is:]



The first plan of attack is to aid your clients in preventing osteoporosis. The following are some of the ways an individual can help prevent and/or treat osteoporosis (NIAMS n.d.b, 17ff, 32ff):

• Adequate calcium consumption (the earlier in life this can be started, the better the result). Calcium needs vary from time to time in one's life; supplements may be beneficial. For adult men and women, the following amounts (in milligrams) are recommended:
  • 19–50 years 1,000
  • 51–70 years 1,200
  • Over 70 years 1,200
• Adequate Vitamin D consumption (like calcium, the earlier in life this begins, the better the result); supplements may be helpful. For adult men and women, the following amounts (in International Units) are recommended:
  • 19–50 years 200
  • 51–70 years 400
  • Over 70 years 600
• Overall nutrition---a balanced, nutritious diet with a large quantity and variety of fruits and vegetables, plus enough calories
• Exercising and keeping other facets of a balanced life, including sleep

Pseudogout

Deposits of crystals, calcium pyrophosphate dihydrate (CPPD), in and around joints, cause pseudogout---a type of arthritis (inflammation of joints). The symptoms of pseudogout are the same as those of gout; however, gout is cause by crystals called monosodium urate. These two types of crystals have very different appearances when joint fluid containing them is observed under a microscope, and the treatment is different (MedicineNet n.d.). Almost 50% of people age ninety and older have CPPD crystals in their joints. However, most of them do not experience indications or symptoms of pseudogout (Mayo 2008).

One of the risk factors of pseudogout is older age (Mayo 2008), whereas that is not as true of gout (Mayo 2007). Other risk factors of pseudogout are:

• Joint trauma
• Genetic disorder
• Excess iron stored in the body (hemochromatosis)

Polymyalgia Rheumatica

An inflammatory disorder, polymyalgia rheumatica (PMR) causes widespread muscle pain and stiffness, especially in one's neck, shoulders, upper arms, thighs, and hips. Symptoms may appear gradually or very suddenly. The exact cause of PMR is not known, but it is possibly a problem with the immune system; it may involve both genetic and environmental aspects. There may also be a link with particular viruses (Mayo 2008a):

• Adenovirus, which causes respiratory infections ranging from the common cold to pneumonia
• Human parvovirus B19, the source of an infection that primarily affects children
• Human parainfluenza virus

PMR is diagnosed through blood tests: sed rate, rheumatoid factor (RF), C-reactive protein, and other blood tests. Polymyalgia rheumatica will usually resolve itself in one to two years, but symptoms may be improved with medications and self-care strategies.

[QN.No.#13.An inflammatory disorder that is diagnosed through blood tests: sed rate, rheumatoid factor (RF), C-reactive protein is:]

Symptoms may include:

• Aching and stiffness in the neck, shoulders, upper arms, thighs, and hips
• Fatigue
• Unintentional weight loss
• General feeling of malaise or weakness
• A slight fever at times
• Anemia---low red blood cell count

Risk factors that may increase the likelihood of an individual getting PMR are (Mayo 2008a):

• Age---that average age of onset is seventy
• Sex---women are twice as likely to develop PMR as are men
• Race---anyone can get PMR, but most are white, and people of Northern European and Scandinavian origin are especially at risk
• Giant cell arteritis---approximately half of those having giant cell arteritis also have polymyalgia rheumatica

Doctors may treat the disease with nonsteroidal anti-inflammatory drugs (NSAIDs) or oral corticosteroid drugs such as prednisone, but they prefer not to use either of these medications over a long period of time because of potential side effects. Other things clients can do to help are:

• Exercise (surprise, surprise!)
• Eat a healthy diet (another surprise!)
• Pace themselves. Try to interchange demanding or repetitious tasks with easier ones to avoid straining painful muscles.

About seven out of one thousand of those over 50 have PMR (WD n.d.), and anywhere from 15-25% of those also have Giant Cell Arteritis (GCA) (Werner 2008), another rheumatic disease. Because of its relatively small percent of incidence, GCA will not be discussed in this course, but healthcare workers are urged to learn more about it "just in case."

Paget's Disease of Bone

Bones, as other parts of the body, continually rebuild themselves. When this happens at an accelerated rate, the bones can become misshapen and soft, a condition called Paget's disease of bone. If a bone has become soft through this condition, it can cause the involved pelvis, spine, hips, thighs, head, or arms to bend and be weak. If the bone is misshapen or enlarged, it is prone to arthritis and fractures and may cause hearing loss and discomfort (Altman 2006).

[QN.No.#14.When bones rebuild themselves at an accelerated rate, the bones can become misshapen and soft, this condition is called :]

This is a condition that is seldom diagnosed before age forty, and the frequency of diagnosis increases in each progressive age group to 10% by age 80 (WD n.d.a). For this reason, the symptoms are often assumed to be simply part of the aging process. Fortunately, the condition does not spread from bone to bone and is usually limited to one or a few bones of the pelvis, spine, hips, thighs, head, or arms (Altman 2006). Very rarely, in less than 1% of those with Paget's, it can lead to cancer---osteosarcoma---although this usually happens only after the individual has had Paget's for a long time. Osteoarthritis and congestive heart failure are more common complications of Paget's disease (Mayo 2008b).

The only known risk factors are age and heredity, although men are more likely to get Paget's than are women. It is diagnosed through an alkaline phosphatase blood test, an x-ray---usually taken for unrelated reasons, and/or a bone scan.

[QN.No.#15.The only known risk factor for Paget's disease of bone are:]

[QN.No.#16.'Men are more likely to get Paget's than are women' . true or false]

Symptoms, if any, will depend on the part of the skeletal system that is involved, and can include (Mayo 2008b):

• Pain in the affected bone(s)---the most common symptom. It may be a constant, deep ache, and it may be worse at night.
• Pain, swelling, and/or stiffness in the joints
• Pain from nerve compression---usually more intense pain than that in the bone
• Numbness, tingling, weakness, hearing loss, and double vision may occur from nerve compression.
• Warmth in the skin over the affected area
• Neurological problems such as headache, hearing loss, and occasionally vision loss
• Bone deformities (bowed legs, enlarged head)
• Fractures
• Loss of bladder or bowel control accompanied by weakness in the legs---this can indicate severe spinal damage

One of two kinds of bone-regulating medications, bisphosphonates and calcitonin, may be prescribed. Nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin may be prescribed for inflammation, and acetaminophen (e.g., Tylenol) may be used to reduce pain. In a very few cases, the patient may need surgery to aid in the healing of fractures, to replace damaged joints, to realign deformed bones, or to reduce pressure on nerves (Mayo 2008c).

[QN.No.#17. The prescribed bone-regulating medications are:]

In addition to the anticipated healthy diet and exercise, Paget's patients need to take extra care to avoid falls.

Aging and Depression

Depression in the aged is a significant problem. Changes in physical abilities, illnesses and diseases, the loss of loved ones, lack of a defining activity, and lack of work can all contribute to significant depressive feelings. Without a feeling of some purpose, many will not feel that getting out of bed in the morning is worth it, and depression can get worse as health declines.

Everyone, young or old, feels "down in the dumps" at times. But if they have little joy or pleasure from life, and the "down in the dumps" feeling lasts more than a week or two, they probably are depressed. Depression in the elderly needs to be diagnosed and treated. It could be a side-effect of a medication or a disease such as Parkinson's. But no matter the cause it can likely be treated.

The risk of depression in the elderly increases just as other illnesses do. When the inability to function is more limited than before, they are especially at risk. Estimates of major depression in older people who still live in the community range from less than 1% to about 5%, but it rises to 13.5% in those who require home health care and to 11.5% in elderly hospital patients (Hybels and Blazer 2003).

The percentages of people with clinically relevant depressive symptoms, along with age groups are displayed for 2004 in the following table:



Depression is one of the conditions most commonly associated with suicide in older adults (Conway and Brent 1995). It is widely under-recognized and undertreated. Studies show that up to 75% of older adults who committed suicide visited a physician within a month before death (Conwell 2001). The rate of suicide is highest among the elderly as compared to any other age group; highest of all is the suicide rate for those 85 years and older---twice the overall national rate (AAGP 2004). These statistics show the urgency of learning to recognize and treat depression among older adults.

[QN.No.#21.Up to 75% of older adults who committed suicide visited a physician within a month before death? true/false?]

Depressive symptoms can be different in older adults than younger, often being masked under the resemblance to changes that occur with age. For example, older adults often have a natural tendency for lower appetite and a change in sleep pattern. It is important to do a complete psychosocial assessment, which includes a history of depressive symptoms.

Common symptoms of depression are (Gallo and Katz n.d., MDConsult 2008):

• Depressed or irritable mood; temper, agitation
• Fatigue (tiredness or weariness)
• Loss of interest in self-care and/or following medical advice
• Little interest in social activities
• Feeling "empty" inside
• Trouble sleeping and/or anxiety
• Trouble concentrating or remembering things
• Unexplained aches and pains
• Change in appetite and weight
• Feeling hopeless about the future
• Feelings of helplessness
• Feeling worthless or sad
• Easily irritated and/or listless
• Feeling that one is a burden---excessive or inappropriate guilt
• Abnormal thoughts about death
• Irresponsible behavior
• Thoughts about suicide, plans to commit suicide or actual attempts

[QN.No.#22.Symptoms for Major Depression include:]

The cause(s) of clinical depression are not known. No biologic event or gene has been associated with depression; however, if there is a family history of depression, there seems to be an increased risk. Cerebrovascular disease, which is more common among the elderly, appears to play a role in late-onset depression---this has led to the "vascular depression hypothesis" (Conway and Steffens 1999).

Treatment for Depression

Depression may be a result of events (situational) or may have a more neurological or psychological cause. The elderly are at risk for situational depression because of the many losses they suffer (death of loved ones, loss of job, hearing impairment, memory impairment, independence, poor health, etc.). It is important to find out when the depressive symptoms started, how long they have lasted and how severe they are. You should also find out if there was a precipitating event. The presence of such an event can help direct treatment. The patient should also receive a complete medical examination to determine what illnesses may be contributing to the depression in addition to what medications may be contributing to the symptoms.

The doctor will perform a complete physical examination, obtain laboratory tests, and assess mental status (ability to think clearly, remember, and make plans). The purpose of this workup is to determine if a medical condition or medication may be causing or contributing to the depression.

Treatments for geriatric depression are much like those for the rest of the population:

• Antidepressants---often a trial and error period is needed to find the antidepressant that works best for the client (NIMH 2009); it may take four to eight weeks for a medication to work best
• Psychotherapy

Psychotherapy for depression can include (Alexopoulos et al 2001):

• Cognitive-behavioral therapy (changing pessimistic thoughts and beliefs)
• Supportive psychotherapy (providing emotional support to help the person cope with and resolve difficulties)
• Problem-solving therapy (helps the person learn more effective ways to manage problems)
• Interpersonal therapy (professional works with the person to improve problems in relationships)

Educating the person and their family about depression are also important interventions.

Cognitive therapy is one of the more common therapies used to help with depression. If not contraindicated by a client's mental capacity, it can be effective in alleviating or minimizing the depressive symptoms. In cognitive restructuring the professional helps the client replace faulty thinking or misconceptions with beliefs and thoughts that are more aligned with reality, leading to enhanced functioning. The therapist helps people improve their self-dialogue, educating them that it is this inner dialogue that is affecting their depressed mood. Sometimes, in working with the elderly, much of their dialogue may be pessimistic and negative about the elderly person's life situation, and thoughts that their life has been a failure.

The following steps are useful in cognitive restructuring (Cormier and Cormier 1979):

• Assisting clients to accept that their statements and beliefs affect their emotional reactions to life's events
• Assisting clients to identify dysfunctional beliefs and patterns of thoughts that underlie their problems
• Assisting clients to identify situations that engender dysfunctional cognitions
• Assisting clients to substitute functional self-statements in place of self defeating cognitions
• Assisting clients to reward themselves for successful coping efforts

For other guidelines in helping the elderly and their families with depression, go to the following link: http://www.psychguides.com/Geriatric%20Depression%20LP%20Guide.pdf

Memory Impairment

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

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



There are different studies that examine what causes memory impairment. According to Marsha K. Johnson (2003), Yale University, source monitoring has great impact in how someone remembers, and this function is processed by the frontal lobes. Being able to process information and then tie these experiences together so they make sense---such as the environment in which the memory occurred---is part of memory. For example, if somebody goes to the beach with friends, they will gather and process information: e.g., the friends there, the sights and sounds of the ocean and the wind, etc. Being able to tie all these details together helps people create accurate memories. Damage to the frontal lobes can cause a person to gather less specific information, resulting in a less accurate memory and even false memories. Johnson elaborates:

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

Dementia, Alzheimer's Disease

There are many similarities between dementia and Alzheimer's disease; it is necessary to know what the differences are. Alzheimer's is one kind of dementia---the most common one. In addition to Alzheimer's, dementias related somewhat to age include (Health-cares.net 2005):

• Vascular dementias (including multi-infarct dementia)---the second most frequent type of dementia, caused by poor circulation to the brain. In multi-infarct dementia multiple mini-strokes (infarcts) take place which cut off the blood supply to parts of the brain. Progress may be slowed by control of blood pressure and diabetes, as well as stopping smoking.
• Parkinson disease. Not everyone with Parkinson has dementia; it generally occurs when the disease is well-developed. Reasoning, memory, speech, and judgment are most likely to be affected.
• Lewy body dementia, caused by microscopic deposits of protein in the nerve cells called Lewy bodies. Over time the protein destroys the cells. It can cause symptoms much like Parkinson disease. This type of dementia cannot be reversed or cured.
• Alcohol-related dementia. Drinking too much alcohol can destroy brain cells, which leads to the dementia. The dementia may not show up until the person is elderly.

[QN.No.#23.Not everyone with Parkinson has dementia.true or False?]

Alzheimer's is a progressive and fatal brain disease that gradually destroys a person's memory, ability to learn and make judgments, etc. The disease kills brain cells that eventually will kill a person if they do not die first of something else. The progress of the disease can take from 3-20 years (ALZ 2008). Although a person may have recently been diagnosed with the disease, the progress of the disease may actually be advanced.

Early warning signs of the disease include (ALZ 1999):

• Memory loss---forgetting recently learned information, forgetting more often and not being able to recall the information later (normal is forgetting names or appointments occasionally)
• Difficulty performing familiar tasks---e.g., losing track of the steps of preparing a meal, making a phone call, or playing a game (normal is occasionally forgetting why you came into a room or what you planned to say)
• Problems with language---often forgetting simple words or substituting unusual words (normal is sometimes having trouble finding the right word)
• Disorientation to time and place---such as getting lost in their own neighborhood, forgetting where they are and how they got there, not knowing how to get back home (normal is forgetting the day of the week or where you were going)
• Poor or decreased judgment---e.g., dressing improperly for the weather, frequently falling for telemarketers spiels (normal is making a questionable decision occasionally)
• Problems with abstract thinking---e.g., forgetting what numbers are and how they should be used (normal is finding it challenging to balance a check book)
• Misplacing things---putting them in unusual places such as a book in the refrigerator or the salt shaker in the medicine cabinet (normal is misplacing keys or a wallet temporarily)
• Changes in mood or behavior---showing rapid mood swings for no apparent reason (normal is occasionally feeling moody)
• Personality changes---dramatic changes, becoming extremely confused, suspicious, fearful, mean, or dependant on a family member (normal is slight personality changes with age)
• Loss of initiative---becoming very passive, sitting in front of the TV for hours---not apparently really watching, sleeping a lot more than usual, not wanting to do usual activities (normal is sometimes feeling weary of work or social obligations)

[QN.No.#24.Early signs of Alzhemier's disease include:]

The changes that occur as a result of Alzheimer's can affect both the diagnosed individual and loved ones. Reactions to these changes can include depression, anxiety, fear, embarrassment, shame, isolation, loneliness, and feeling of loss. In response to these reactions the Alzheimer's Association suggests the following ways a healthcare professional can help (ALZ 1999):

• Acknowledge feelings and provide an opportunity to talk and ask questions
• Refer the individual and/or their family to an Alzheimer's support group
• Assess for depression and/or suicidal thoughts; short term counseling and medication may be helpful in some cases
• Refer families to a physician knowledgeable in dementia for evaluation and treatment
• Encourage the diagnosed individual and the caregiver to take care of their physical and mental health

Medication Management

Because of the difficulties mentioned above, individuals involved in medication management for the elderly, need to be aware of several things. You, as a social worker or therapist, may need to confront a physician regarding these things, as one therapist did---with negative results to herself. She was a licensed mental health therapist with an M.S. degree in Counseling and Human Resource Development. At one point she was given the assignment to go to a nursing home to do an annual evaluation for the payor of a patient's care. She was to interview the patient, study all of the patient's records at the necessary to accomplish this.

[QN.No.#26.You, as a health care professional, will never need to confront a physician regarding medication management.True/False]

On reviewing the records she noted the huge numbers of medications being given and that many were prescribed over the phone when nurses called with a new complaint of the patient. The physician had seldom seen the patient. The therapist called the doctor to ask about the medications, but he was curt and unwilling to give adequate answers.

Being a thorough person, the therapist looked every drug up in the Physicians' Desk Reference (PDR) and found that the concurrent use of two of them required a blood test being taken every six months. No blood tests had ever been taken in the more than eighteen months the two medications were used. This was noted in her report, with quotations from the PDR to substantiate it.

The therapist was remanded for practicing medicine without a license, and the center for which she worked changed the rules to only allow therapists whose degree was in psychology to perform these evaluations in the future. (But the patient's blood was checked!)

With this story in mind, be aware---unhesitatingly---of the following information.

First, there are several basic principles that pertain to drug use in the elderly (Diasio 2007):

• The drugs eliminated by the kidneys may be reduced by 50%
• Typically, the only drugs that are eliminated by the liver that need adjustment for age are those with high hepatic clearances
• Only the lowest effective dose should be used
• The patient's drug history should be reviewed frequently, including prescription medications, OTC medications, and vitamin or herbal preparations, keeping in mind potential adverse drug interactions and responses

[QN.No.#27.Which of the following is important for you about, in regards to what the client is taking?]

Some steps that can be taken to help prevent drug interactions are (Diasio 2007):

• All of the drugs the patient is taking, or has recently taken---prescription, OTC, herbal---should be documented.
• Frequently review the patient's drug list to be sure that each drug is still needed.
• Be very suspicious when medications used have a low therapeutic index with a high risk of drug interactions (anticoagulants, antiarrhythmics, anticonvulsants, Digoxin, Lithium carbonate, oral hypoglycemics, Theophylline)
• High-risk clinical settings, such as happen with critically ill patients, should get extra attention.
• Whenever there is a change in the patient's course, the differential diagnoses should consider adverse drug interactions.

[QN.No.#28.To help prevent drug interactions, as a health care worker, you need to:]

It is very important that you know, or know enough to realize you should find the interactions and side effects of the medications your clients are taking, especially those most commonly prescribed to older adults. Make a chart of the interactions and side effects of these 20 medications most often prescribed to older adults (Solomon 2000):

• Calcium channel blockers
• Digitalis preparations
• Antiarthritics, systemic
• Diuretics
• Angiotensin-converting enzyme inhibitors
• Nitrites and nitrates
• Beta-blockers
• Cephalosporins
• Antispasmodics
• Diabetes, insulin
• Diabetes, oral
• K-sparing diuretics
• Aspirin
• Codeine and combinations
• Antihypertensives
• Xanthines
• Potassium supplements
• Corticoids (oral)
• Benzodiazepines
• Diuretics, thiazides

Only a relatively small group of drugs causes most of the well-known adverse drug effects---every drug has side effects and can potentially cause an adverse drug response. Even if a particular drug has not had an adverse response reported, the physician needs to be aware that it could still take place. Diasio (2007) lists the following information about clinical presentations associated with adverse drug responses.

• Some presentations are obvious, such as a rash in someone who has been prescribed a single drug such as penicillin
• Some are difficult to distinguish from other disease states
• Sometimes the adverse effect mimics the illness being treated---e.g., depression from an antidepressant, development of an arrhythmia in a person being given an antiarrhythmic drug

Practitioners need to be aware of the drugs that are potentially contraindicated in elderly patients (Col et al 1990):

Prescriptive Medications That May Be Potentially Contraindicated in the Elderly
Analgesics	Propoxyphene, pentazocine, meperidine
Antiarrhythmics	Disopyramide
Anticholinergics and antispasmodics	Belladonna, propantheline, dicyclomine combos
Antidepressants	Amitriptyline or combos, doxepin
Antiemetic agents	Trimethobenzamide
Antihypertensive agents	Reserpine or combos
Antiplatelet agents	Dipyridamole, ticlopidine
Antipsychotics	Phenothiazine
Hypoglycemics (oral)	Chlorpropamide
Muscle relaxants and antispasmodics	Carisoprodol, cyclobenzaprine, methocarbamol, chlorzoxazone, orphenadrine, metaxalone, oxybutynin
NSAIDs	Indomethacin, aspirin
Sedative/hypnotic agents	Chlordiazepoxide, diazepam, flurazepam, meprobamate, barbiturates (except phenobarbital)

Note: This chart is from 1990, so it may need to be updated; updated chart not found.

Some drugs and combinations of OTC, prescription, and herbal drugs should be avoided because of potential drug interactions, for example (Col et al 1990):

• H2 blockers (e.g., Tagamet)
• Antihistamines (e.g., Benadryl)
• Gingko with Coumadin, NSAIDs, aspirin
• St. John's Wort with antidepressants
• Garlic with Coumadin, NSAIDs, aspirin
• Echinacea with Coumadin

[QN.No.#29. The client should not use garlic if he/she is taking which medications?]

For a more complete list, go to the University of Michigan Health System's Website at http://www.med.umich.edu/1libr/aha/umherb01.htm.

Compliance Issues

One definition of medication compliance is "the extent to which a person's behavior coincides with medical or health advice" (Coates n.d.).

Patient compliance to a medication procedure has become more of a problem over time. The reasons are multiple, but perhaps fixed income leads the pack.

However good the reason, noncompliance can lead to a number of problems (Coates n.d.):

• Possible decline in health
• Need for additional medical treatment
• Increased hospitalizations
• Even death

[QN.No.#30.Medication noncompliance can lead to:]

Herrick (2006) has an outstanding booklet with very specific ways and helps to reduce drug costs. He sums some of it up in the following chart:



Kane et al (2004) offers the following strategies to improve compliance in the geriatric population:

• Making drug regimens and instructions as simple as possible
  • Using the same dosage schedule whenever feasible (e.g., once or twice per day)
  • Timing the doses in conjunction with a daily routine
• Instructing relatives and caregivers on the drug regimen
• Enlisting others (e.g., home health aides, pharmacists) to help ensure compliance
• Making sure the older patient can get to a pharmacist (or vice versa), can afford the prescriptions, and can open the container
• Using aids (such as special pillboxes and drug calendars) whenever appropriate
• Keeping updated medication records
• Reviewing knowledge of and compliance with drug regimens regularly

To give a little different point of view as to how you can help your clients to improve their medication compliance and thus reduce the risk of adverse reactions, Solomon (2000) suggests:

• Establishing a rapport with these elderly folks
• Helping them understand that some medications must be continued whether they feel better or not, e.g., antibiotics, blood pressure medications, and cholesterol medications
• Having them bring in ("brown bag") all of their medications (prescription, OTC, herbal) for review
• Aiding them in using a medication calendar, medication organizer, or pillbox. There are even pillboxes that will ring an alarm when it is time to take medication
• Through this, being sure that they know what they are taking and why they are taking them
• Keeping the regimen simple, and use once-daily dosing when possible.

Alcohol and Substance Abuse Issues among Elderly

The phrase substance abuse brings to mind out-and-out alcoholics, "shoot 'em up" druggers, and other extremes. Although it is estimated that up to 17% of Americans 65 years or older have problems with alcohol (Task Force n.d.), that does not mean they are all alcoholics. Alcohol used in combination with certain medications can cause harmful effects--- including impaired coordination and cognition (Breslow et al 2003)---and elders that use these combinations can be defined as substance misusers and are generally classified as substance abusers. That is possibly why the statistics of alcohol and drug abuse are so high.

Besides potential interactions with medications, there are other reasons why seniors should not use alcohol, or use it very sparingly. Elderly men (and women of all ages) have a smaller volume of total body water than younger men, so they reach a higher blood alcohol concentration from the same amount of alcohol consumption (Kalant 1998). Body composition continues to change with age; therefore, the effects of alcohol may be greater for an 80-year-old than for a 70-year-old (Vestal et al 1977). This tends to result in more harm from the same amount of intake as compared to younger people. Other vulnerabilities of the elderly to the effects of alcohol may be raised by age-related changes in functional status, nutritional status, and psychological and cognitive status (Breslow et al 2003).

With these concerns in mind, it is important to note that heavier use (which is not as heavy for the elderly) of alcoholic beverages has been linked with a number of detrimental health consequences, including cirrhosis of the liver, motor vehicle crashes and other unintentional injuries (NIAAA 2000), as well as with hemorrhagic and ischemic stroke (Reynolds et al 2003). Other reports indicate that the consumption of three to five drinks per day over years has been associated with an increase in the death rate (Yee and Williams 2002, 265). On the other hand, light or moderate consumption (one drink per day at most) has been linked with some health benefits, including reduced rates of coronary heart disease (Mukamal et al 2003)---this may be due to the antioxidants and resveratrol content of red wine which can be obtained through safer means (Mayo 2009a).

Moving from alcohol misuse or abuse to drug abuse---again the biggest problem for seniors is drug misuse. A client who does not take medications as prescribed---forgetting to take them or taking extra because "if a little is good for me, a lot must be better"---is a drug misuser. That is why it is so important to oversee and regularly monitor their medication use.

As with other populations, there are situations that tend to motivate some elderly persons to drink. Four factors that may cause the elderly to be susceptible to drinking alcohol or abusing some drugs are (Brody 1980):

• Retirement and its boredom, role changes, and financial problems
• Increased concern with death and losses of relatives and friends
• Poor health and chronic discomfort
• Loneliness, particularly among older women

Perhaps the greatest situational motivator of all is depression (Whelan 2003), which has been discussed earlier in this course.

When an older person is amenable to treatment for substance use problems, they usually have better success in treatment than do younger people according to Frederic Blow, professor in the Department of Psychiatry at the University of Michigan and a Huss Research Chair on Older Adults and Alcohol/Drug Problems at Hazelden's Butler Center for Research (Hazelden 2006).

If clients or their relatives need help and intervention for substance use, Hazelden has an outstanding pamphlet with information and suggestions, How to Talk to an Older Person Who Has a Problem with Alcohol or Medications, available at
http://www.hazelden.org/web/public/document/ip_talkolderperson.pdf.

Weight Gain and Obesity vs. Weight Loss and Cachexia

Appropriate Weight

People, even the elderly, may approach the understanding of ideal body weight in several ways. Perhaps the most common is to stand on the scale and think of the size of some new clothing they want and decided if they are at their ideal weight or not. This is not likely to lead them to a healthy view of their weight.

Those more educated in view of the ideal weight may use the Body Mass Index (BMI), which is a demographic measure of the relationship between a person's height and weight. It may be calculated manually using one of the following formulas:



A person can also use a BMI Chart such as the one at http://www.nhlbi.nih.gov/guidelines/obesity/bmi_tbl.htm. Or a BMI calculator can be used, such as the one at http://www.revolutionhealth.com/calculators/body-mass-index-bmi. In a similar vein, to discover the range of one's "ideal weight" might be, use the calculator at http://www.calculatorslive.com/Ideal-Weight-Calculator.aspx.

A healthy BMI for adults is usually considered to be between 18.5 and 25; anything higher indicates a certain amount of overweight; if it is over 30 obesity is suggested, and anything over forty reportedly signifies extreme obesity. However, there are some exceptions, and being elderly is one. In this case it may be better to have a BMI in the range of 25—27 as a slightly high BMI after age 65 may help protect from osteoporosis (HLCG 2007).

Another way to assess whether an individual has a problematic weight is to notice where they have the most fat. For reasons still unknown, it is more problematic if the fat is around the middle (waist) than around other parts of the body such as hips or thighs. More fat around the waist is considered to be an "apple" shape; if it is in the hips it is called "pear" shape.

Picture courtesy of A.D.A.M.

A high waist-to-hip ratio is considered to put one more at risk for diseases linked with excess weight, especially diabetes and heart disease. To find the waist-to-hip ratio, first measure the hip circumference at the level of the two bony prominences found at the front of the hips; then measure around the middle at naval height. Divide waist circumference by hip circumference. The guidelines say that this ratio should be below 0.8 for a woman and 1.0 for a man (HLGC 2007).

The National Heart, Lung, and Blood Institute (NHLBI) offers a more accurate way to estimate the risk of disease. The steps for this are:

1. Measure the waist circumference as noted above.
2. Determine the BMI using one of the methods given above.

Using those two figures, look at this chart from the NHLBI to see the degree of risk (NHLBI n.d.c):

Classification of Overweight and Obesity by BMI, Waist Circumference, and Associated Disease Risks
			Disease Risk* Relative to Normal Weight and Waist Circumference
	BMI (kg/m2)	Obesity Class	Men 102 cm (40 in) or less Women 88 cm (35 in) or less	Men > 102 cm (40 in)Women > 88 cm (35 in)
Underweight	< 18.5		-	-
Normal	18.5 - 24.9		-	-
Overweight	25.0 - 29.9		Increased	High
Obesity	30.0 - 34.9	I	High	Very High
	35.0 - 39.9	II	Very High	Very High
Extreme Obesity	40.0 +	III	Extremely High	Extremely High

* Disease risk for type 2 diabetes, hypertension, and CVD.
+ Increased waist circumference can also be a marker for increased risk even in persons of normal weight.

Overweight and Obesity

Unless an elderly person is obese, he/she probably does not need to lose weight according to one meta-analysis study (Asefeh et al 2001). The conclusion of the study said, "Evidence does not support mild-to-moderate overweight, defined by the new guidelines, as a risk factor for all-cause and cardiovascular mortality among elderly persons. We agree that marked overweight (obesity) might be a risk factor for this population. However, adverse effects of energy (calorie) restriction in elderly persons and the potential harms of diet-induced weight reduction, as well as the paucity of information about effectiveness of weight loss programs, would not support weight reduction interventions among mildly to moderately overweight elderly individuals."

Harlan M. Krumholz, the study's senior author, stated, "We found that in general, higher weight is associated with a smaller excess risk in older people compared with younger people" (Yale 2001).

Additionally, repeated dieting with weight loss followed by weight gain is bad for one's health. The Medical University of South Carolina discovered that "weight fluctuation is associated with a higher risk of all-cause and cardiovascular disease mortality in the U.S. population, even after adjustment for pre-existing disease, initial BMI and the exclusion of those in poor health or incapacitated. Thus, health care providers should promote a commitment to maintaining weight loss to avoid weight fluctuation and consider patients' weight histories when assessing their risk status" (Diaz et al 2005).

The U.S. Department of Health and Human Services and the U.S. Department of Agriculture (HHS & USDA 2005) make the following recommendation to " sustain weight loss in adulthood: Participate in at least 60 to 90 minutes of daily moderate-intensity physical activity while not exceeding caloric intake requirements. Some people may need to consult with a healthcare provider before participating in this level of activity."

Sometimes, however, there is unplanned weight loss.

Weight Loss and Cachexia

Many people who are not elderly may wish they had unintentional weight loss, because intentional doesn't seem to work very well. Unfortunately, unintentional weight loss, particularly cachexia (which includes wasting loss of fat and muscle), at any age is usually associated with illness and/or other problems. The cause of cachexia in the elderly is associated with increased morbidity and mortality. But it is hard to identify the cause, especially if the individual has multiple medical problems and is taking numerous medications, and especially if there is cognitive debilitation (Huffman 2002).

In addition to unintentional weight loss, cachexia is associated with one or more of the following symptoms and/or consequences ((Wikipedia 2009; Lewko et al 2003):

• Muscle atrophy (always occurs in cachexia), and wasting of fat
• Fatigue
• Weakness
• Significant loss of appetite
• Anemia
• Decreased cognition
• Edema
• Falls
• Hip fractures
• Immune dysfunction
• Infections
• Muscle loss
• Osteoporosis
• Pressure sores

There are numerous potential causes for cachexia. A mnemonic for common treatable causes of unintentional weight loss in the elderly is MEALS ON WHEELS (Huffman 2002):

"Meals on Wheels": A Mnemonic for Common Treatable Causes of Unintentional Weight Loss in the Elderly
M	Medication effects
E	Emotional problems, especially depression
A	Anorexia nervosa, alcoholism
L	Late-life paranoia
S	Swallowing disorders
O	Oral factors (e.g., poorly fitting dentures, caries)
N	No money
W	Wandering and other dementia-related behaviors
H	Hyperthyroidism, hypothyroidism, hyperparathyroidism, hypoadrenalism
E	Enteric problems
E	Eating problems (e.g., inability to feed self)
L	Low-salt, low-cholesterol diet
S	Stones (cholecystitis), social problems (e.g., isolation, inability to obtain preferred foods)

In addition to the problems listed with the mnemonic, other studies have found that unintentional weight loss may be a preclinical indicator of Alzheimer's disease and that the weight loss often accelerates before diagnosis (Stewart et al 2005; Johnson et al 2006).

Protein-Energy Malnutrition

(Merck 2007)

Protein-energy malnutrition (PEM) refers to a form of malnutrition where there is inadequate protein intake, sometimes also called protein-calorie malnutrition. At times a person may ingest enough calories but not enough protein, which causes pure protein deficiency, but usually both deficiencies occur. Some individuals may get PEM not from inadequate ingestion but because they are unable to absorb protein (and probably other nutrients) or convert them into the energy needed to form healthy tissue or enable organs to function properly.

Primary PEM is the result of a diet lacking enough sources of protein and/or energy. Secondary PEM is the more common form that appears in the United States, and is usually a complication of AIDS, cancer, chronic kidney failure, inflammatory bowel disease, and other illnesses that hinder the body's ability to absorb or use nutrients or to compensate for nutrient losses.

In the U.S., PEM occurs most commonly in elderly people who live in nursing homes. It also occurs in 50% of surgical patients and 48% of all other hospital patients.

Secondary PEU is most commonly caused by:

• Disorders that affect GI function; these disorders can interfere with digestion (e.g., pancreatic insufficiency), absorption (e.g., enteritis, enteropathy), or lymphatic transport of nutrients (e.g., retroperitoneal fibrosis, Milroy's disease)
• Wasting disorders such as AIDS or cancer
• Conditions that increase metabolic demands, including infections, hyperthyroidism, pheochromocytoma, other endocrine disorders, burns, trauma, surgery, and other critical illnesses.

In a patient with a chronic illness or who has chronic semi-starvation, PEM can gradually evolve. In a patient with an acute illness it may appear abruptly.

Secondary PEM symptoms range from mild to severe; they can change the form or function of just about every organ in the body. The nature and severity of the symptoms are influenced by patient's prior nutritional status, the makeup of the underlying disease and how fast it is progressing.

Individuals who unintentionally lose 10-20% of their body weight, have a weakened grip, and are unable to perform high-energy tasks are said to have moderate secondary PEM. This also fits the description of cachexia.

A person with severe secondary PEM will have lost 20% or more of body weight, and are unable to eat normal-size meals. They also have low blood pressure and body temperature, and slow heart rates. They may also have:

• Baggy, wrinkled skin
• Constipation
• Dry, thin, brittle hair
• Lethargy
• Pressure sores and other skin lesions

Most people can unintentionally lose up to 10% of their body weight without side effects; the loss of more than 40% is almost always fatal. In these cases death usually results from heart failure, an electrolyte imbalance, or low body temperature. Patients with the poorest prognosis have particular symptoms, including:

• Semiconsciousness
• Persistent diarrhea
• Jaundice
• Low blood sodium levels

If you have clients that begin to have symptoms of malnourishment, notify their physicians as soon as possible. They are likely aware of the problem, but if not will design a treatment to give adequate nutrition, restore normal body composition, and cure the condition that caused the deficiency. For patient who can't or won't eat protein-rich foods, tube or intravenous feeding may be used to furnish needed nutrients (Gale Encyclopedia 2008).

Food Safety

In addition to adequate nutrient intake, food safety is also to be recognized. From January 24 through March 27, 2009---a period of sixty days, over 550 food products were recalled in the U.S. ("the most significant product actions"), some voluntary and some involuntary, many based on a recall of the manufacturer of an ingredient, such as the peanut factory recall during that time (FDA 2009).

With this quantity of recalls, it is impossible for the average American, let alone the elderly, to never risk eating contaminated food. Also, the elderly population is more at risk to food-borne illness, because (FDA 2001):

• The immune system no longer functions at optimal levels.
• The lining of the stomach often is somewhat inflamed, and there is a reduction in stomach acids.
• There is often a lack of good and/or sufficient nutrition.

While a wide variety of foods is best for optimal nutrition, the FDA warns that seniors should not eat (FDA 2001):

• Raw fin fish and shellfish, including oysters, clams, mussels, and scallops.
• Raw or unpasteurized milk or cheese.
• Soft cheeses such as feta, Brie, Camembert, blue-veined, and Mexican-style cheese. (Hard cheeses, processed cheeses, cream cheese, cottage cheese, or yogurt need not be avoided.)
• Raw or lightly cooked egg or egg products including salad dressings, cookie or cake batter, sauces, and beverages such as eggnog.
• Raw meat or poultry.
• Raw alfalfa sprouts which have only recently emerged as a recognized source of food-borne illness.
• Unpasteurized or untreated fruit or vegetable juice. When fruits and vegetables are made into fresh-squeezed juice, harmful bacteria that may be present can become part of the finished product. Most juice in the United States, 98%, is pasteurized or otherwise treated to kill harmful bacteria. To help consumers identify unpasteurized or untreated juices, the Food and Drug Administration is requiring a warning label on these products. The label says:
  
  [QN.No.#31.The FDA warns that seniors should not eat (FDA 2001):]
  
  
  WARNING:
  This product has not been pasteurized and therefore may contain harmful bacteria that can cause serious illness in children, the elderly, and persons with weakened immune systems.


• CLEAN: Wash hands and surfaces often. Bacteria can spread throughout the kitchen and get onto cutting boards, utensils, sponges and counter tops. Here's how to Fight BAC:
  • Wash your hands with hot soapy water before handling food and after using the bathroom, changing diapers and handling pets.
  • Wash your cutting boards, dishes, utensils and counter tops with hot soapy water after preparing each food item and before you go on to the next food.
  • Use plastic or other non-porous cutting boards. These boards should be run through the dishwasher -- or washed in hot soapy water -- after use.
  • Consider using paper towels to clean up kitchen surfaces. If you use cloth towels, wash them often in the hot cycle of your washing machine.
• SEPARATE: Don't cross contaminate Cross-contamination is the scientific word for how bacteria can be spread from one food product to another. This is especially true when handling raw meat, poultry and seafood, so keep these foods and their juices away from ready-to-eat foods. Here's how to Fight BAC:
  • Separate raw meat, poultry and seafood from other foods in your grocery shopping cart and in your refrigerator.
  • If possible, use a different cutting board for raw meat products.
  • Always wash hands, cutting boards, dishes and utensils with hot soapy water after they come in contact with raw meat, poultry and seafood.
  • Never place cooked food on a plate which previously held raw meat, poultry or seafood.


[QN.No.#32.scientific word for how bacteria can be spread from one food product to another.]


• COOK: Cook to proper temperatures Food safety experts agree that foods are properly cooked when they are heated for a long enough time and at a high enough temperature to kill the harmful bacteria that cause food-borne illness. The best way to Fight BAC is to:
  • Use a clean thermometer, which measures the internal temperature of cooked foods, to make sure meat, poultry, casseroles and other foods are cooked all the way through.
  • Cook roasts and steaks to at least 145°F. Whole poultry should be cooked to 180°F for doneness.
  • Cook ground beef, where bacteria can spread during processing, to at least 160°F. Information from the Centers for Disease Control and Prevention (CDC) link eating undercooked, pink ground beef with a higher risk of illness. If a thermometer is not available, do not eat ground beef that is still pink inside.
  • Cook eggs until the yolk and white are firm. Don't use recipes in which eggs remain raw or only partially cooked.
  • Fish should be opaque and flake easily with a fork.
  • When cooking in a microwave oven, make sure there are no cold spots in food where bacteria can survive. For best results, cover food, stir and rotate for even cooking. If there is no turntable, rotate the dish by hand once or twice during cooking.
  • Bring sauces, soups and gravy to a boil when reheating. Heat other leftovers thoroughly to 165°F.
• CHILL: Refrigerate promptly
  •  
    • Refrigerate or freeze perishables, prepared food and leftovers within two hours.
    • Never defrost food at room temperature. Thaw food in the refrigerator, under cold running water or in the microwave. Marinate foods in the refrigerator.
    • Divide large amounts of leftovers into small, shallow containers for quick cooling in the refrigerator.
    • Don't pack the refrigerator. Cool air must circulate to keep food safe.
  Refrigerate foods quickly because cold temperatures keep harmful bacteria from growing and multiplying. So, set your refrigerator no higher than 40°F and the freezer unit at 0°F. Check these temperatures occasionally with an appliance thermometer. Then, Fight BAC by following these steps:
  It is unlikely that you will get a senior to follow all of these, especially if they haven't done it for most of their lives already---you probably won't follow them all yourself. However, do your best to be sure they are aware of them, and if you become aware of them repeatedly doing one of the more risky procedures, do your best to help them change.

Finding an Eating Plan

In these days of the Internet, individuals can find an eating plan for any philosophy they choose. Many are healthy diets, many are not---and many of those are simply fads. The U.S. Department of Health and Human Services and the U.S. Department of Agriculture jointly recommend using either the USDA Food Guide or the DASH Eating Plan (HHS & USDA 2005).

The USDA food guide has been discussed earlier when their food pyramid was presented, so it will not be further considered here.

The DASH diet formed the basis for the USDA MyPyramid (DASH 2009), so it also many not be adapted for seniors, but guidelines given earlier should be used. The basic diet is:

Type of food	Number of servings for 1600 - 3100 Calorie diets	Servings on a 2000 Calorie diet
Grains and grain products (include at least3 whole grain foods each day)	6 - 12	7 - 8
Fruits	4 - 6	4 - 5
Vegetables	4 - 6	4 - 5
Low fat or non-fat dairy foods	2 - 4	2 - 3
Lean meats, fish, poultry	1.5 - 2.5	2 or less
Nuts, seeds, and legumes	3 - 6 per week	4 - 5 per week
Fats and sweets	2 - 4	limited

Another excellent plan is presented by Dr. Eric R. Braverman in Younger You: Unlock the Hidden Power of Your Brain to Look and Feel 15 Years Younger (2007) and Younger You: Unlock the Hidden Power of Your Brain to Look and Feel 15 Years Younger (2009). Dr. Braveman focuses on nutrient-dense foods that together restore hormonal balance of the brain and improve health and aid in weight loss if that is needed.

Nutritional Supplements

There are those who strongly advocate taking nutritional supplements; there are those who advocate just as strongly against them, stating that people can get all the nutrients they need from food. You can find experiences of people on both sides, but many who take supplements have astounding stories, whereas those who do not take them also seldom have astounding stories. A 2007 survey (Williams) found that, of 1,202 adults under 60 years of age and 528 who were 60+, there were significantly more people who regularly took vitamin and mineral supplements than those who took them only occasionally or never took them. Those who took them regularly also (Williams 2007):

• Relied heavily on the medical profession for general health information
• Obtained supplements and diet information from diet books and periodicals
• Believed that taking vitamins and minerals prevented serious illness; reduced stress; prevented colds, skin problems, heart attacks, cancer, and other health problems
• Believed their overall well-being was improved through the use of supplements, but apparently did not believe that the use of supplements ensured good health.
• Did not seem to believe that the current food supply filled nutritional needs.

Whether or not one can get proper nutrition from foods alone takes one to the argument regarding organic vs. non-organic foods. One meta-analysis of studies on this topic says in the abstract (Heaton 2002):

"Any attempt to answer the question ‘is organic food better for you?’ requires an assessment of the safety, nutritional content and biological value aspects of food quality. Previous reviews have been unable to reach definitive conclusions after failing to ensure only valid comparisons are considered. When methodologically flawed studies are screened out and a complete assessment of nutritional quality is made, collectively, the available evidence supports the hypothesis that organically produced food is superior in terms of safety, nutritional content and nutritional value to that produced non-organically."

Rather than get in the fray, the best procedure for you is to help them get the best they can from food; if they want food supplements, help them find the best there---there are huge differences in quality and effectiveness between different supplements.

Age and Sexual Response

In elderly men, increased physical stimulation is needed to achieve and maintain erections; orgasms are not as intense. In women, after menopause there are changes because of estrogen reduction or deficiency (Meston 1997).

The extent that aging affects sexual function is largely dependent on psychological, pharmacological, and illness-related causes.

Bretschneider and McCoy (1988) found that for both men and women ages 80--102, the most common activity was touching and caressing with no sexual intercourse. Next was masturbation, and then sexual intercourse. Only touching and caressing declined significantly from the 80s to the 90s for men, but not for women. With the exception of touching and caressing and past enjoyment of sexual intercourse, men had more activity and enjoyment. Being married, extramarital sex, and church attendance were significantly related with continuing to perform and enjoy some sexual behaviors. Current physical and social factors were of more importance than past and present frequency of sexual behavior except for sexual intercourse.

General effects of aging include (Laflin 2002, 281-2):

• Men:
  • Circulating testosterone is decreased but rarely contributes to erectile disorders in healthy aging men.
  • Penile erection takes more time, and the erection may not be as hard as before; direct, continuous penile stimulation is usually required. The advent of drugs has aided in this area.
  • Testicles do not increase in size; they elevate later and to a lesser degree.
  • Nipple erection becomes less discernible.
  • Ejaculatory control increases.
  • Sex flush is rare in the elderly.
  • Sense of ejaculatory inevitability is diminished or absent.
  • Ejaculation is less powerful and orgasm is often less intense, consisting of one or two expulsive contractions vs. four major contractions followed by minor contractions over several seconds of younger men.
  • Ejaculate is expelled with less force and contains less seminal plasma. Men do not become sterile because of age.
  • Loss of erection after ejaculation and testicular descent occur rapidly.
  • Refractory period between ejaculations is longer, generally 12 to 48 hours.
  • Climax still provides extreme sensate pleasure.
• Women:
  • Vaginal lubrication takes longer.
  • The expansion of the vaginal barrel is reduced in length and width.
  • The lining of the vagina begins to thin and becomes easily irritated.
  • The bladder and urethra may become irritated during intercourse.
  • Vaginal secretion becomes less acidic, increasing the possibility of vaginal infection.
  • The uterus does not elevate as high.
  • The labia majora loses fullness, the clitoral size decreases, and the clitoral hood and fat pad over the mons veneris atrophy.
  • Orgasmic phase is shorter.
  • Resolution phase occurs more rapidly.
  • Capability for multiple orgasm remains.

Sexuality, Estrogen Replacement and Other Hormone Therapy

In some cases, decreased sexual desire in women may have a hormonal element; post-menopause, hypopituitarism, adrenal inefficiency, or surgical menopause may play a role, but the major factors are likely to reside in psychological and situational conditions.

How the decline in levels of estrogen and progesterone and the role of testosterone relate to female sexual functioning as aging advances is not wholly clear. It is known that estrogen replacement therapy will restore vaginal epithelial function, increase vaginal flow, and increase the sense of well-being, but whether or not it improves sexual function is uncertain (Kuzmarov et al 2008).

Estrogen replacement therapy (ERT) has been reported to improve sexual desire in a significant percent of women, but there are many who experience no response. There is apparently a significant subgroup of women, particularly those whose problem has been a loss of libido, whose sexual issues initially respond to ERT, but who later regress to their original problems (Sarrel 2000).

ERT may have other benefits. Some studies suggest that hormone replacement therapy may have a selective beneficial effect on verbal memory in older non-demented women (Maki et al 2001).

There has been a general belief that since testosterone has libido-enhancing properties, it might intensify currently declining sexual interest among women---at least among women who have a low testosterone-producing capability due to physiological or pathological reasons (Kuzmarov and Bain 2008).

Erectile Dysfunction

(Merck n.d.a)
When the soft spongy tissue in the shaft of a male penis fills with blood, causing the penis to enlarge, stiffen and become erect, you have what is called penile erection. Erectile dysfunction has been a commonly used phrase ever since the first advertisements of Viagra.

There are several kinds of causes of erectile dysfunction:

• Vascular disorders, the most frequent cause in the elderly.
• Neurologic disorders---penile sensitivity may diminish with age and contribute to erectile dysfunction.
• Endocrine disorders, of which the most common in elderly men is the ADAM (Androgen Deficiency in the Aging Male) syndrome.
• Structural abnormalities
• Drugs
• Psychologic disorders. Among the elderly, most erectile dysfunction is organic rather than psychologic.

Treatment of erectile dysfunction has had radical changes in the last number of years. The patient's goals and desires and the risks of various options guide the choice of treatment.

• Drugs
  • Sildenafil---a common trade name is Viagra. However, it can cause problems with cardiac function and vision, as well as headaches, flushing, and dyspepsia.
  • Alprostadil---common adverse effects are a penile burning sensation and aching; less common in priaprism.
  • Testosterone therapy may help if the problem is libido or the erectile dysfunction is due to hypogonadism.
• Other means
  • Constriction rings may be useful for men who can obtain erections but can't sustain them.
  • Vacuum tumescent devises that increase penile engorgement by creating a vacuum or negative pressure, drawing blood into the penis.
  • Permanent penile prostheses or implants, used when other treatments don't seem to work.
  • Penile revascularization surgery, so far not found to have a high success rate.

Sex in Nursing Homes

Everyone has heard of "strange bedfellows." Is "senior care and sex" one of them? Well, perhaps not. Aging does not stop one from being a sexual being---nor does living in a nursing home. Sexuality doesn't always mean intercourse; many residents are lonely or depressed and looking for ways to relieve them---simple touching may be enough.

Nursing homes are beginning to come to grips with the fact of senior sexuality. Following the guidelines of a study by Kansas State aging experts, they are looking at the following goals:

• Through education and open discussion, make staff comfortable with talking about seniors' sexuality (Hamilton 2008).
  • Explain what sexuality means for older adults.
  • Identify barriers to fulfilling the sexual needs.
  • Find strategies to help residents.
  • Learn how to discern appropriate from inappropriate sexual behaviors.
• Clear up staff misconceptions; add a dose of humor.
• Once staff appreciate the seniors' needs to be sexual and to be touched, look at several issues:
  • Residents' right to privacy
  • Finding ways to give residents this privacy
  • When is sex for a person with dementia consensual and when is it rape?
  • Making sure the sex is safe---educate the residents about sexually transmitted diseases.
  • Be prepared to answer resident's requests for
    • Lubrication products
    • Pornography
    • Double beds
    • Access to drugs like Viagra

If social workers have a nursing home client with an unmet sexual need, they must find a way to address that need (KSU 2008, Edwards 2003). They also recommend some steps for preparing food safely at home.