BBS I: BLOCK 6 , MODULE 3 , CASE 1

THE PHYSIOLOGY OF AGING

● The elderly made up 6.8% of the 92 million household
THE PHYSIOLOGY OF AGING
population, higher than the 6% that was recorded in 2000.
Definition ● Among the senior citizens, females (55.8%) outnumbered
Apoptosis the males (44.2%)
● A programmed sequence of events that leads to the
elimination of cells (programmed cell death) without Life Expectancy
releasing harmful substances into the surrounding area. It ● The overall life expectancy among Filipinos according to the
plays a crucial role in developing and maintaining the health life expectancy at birth (years) by the UN World Population
of the body by eliminating old cells, unnecessary cells, and Prospects 201.0 was 67.8 years.
unhealthy cells. ● It was 64.54 years for males; 71.29 for females
● The world average, as recorded is at 67.88 years.
Aging
● Aging describes the temporal process that converts healthy Theories of Aging
adults into frail ones with diminished reserves in most ● Aging clearly occurs at different rates of different species
physiologic systems and an exponentially increasing and varies within species, and aging occurs at different
vulnerability to most diseases and death. rates among different individuals. The mechanism that
controls the rate of aging is still unknown. The search for the
Senescence most likely cause of biological aging has resulted in the
● A degenerative process caused by the accumulation formulation of the theories of aging. This falls into two major
irreversible damage. There is gradual loss of power of cell groups: random change theories and programmed change
division and growth and function that is ultimately theories.
incompatible with and primarily evident at the end of life.
Table 1. The Two General Theories of Aging and their examples
Successful Aging
RANDOM CHANGE PROGRAMMED CHANGE
● Describes an individual who demonstrates minimal THEORIES THEORIES
physiologic decline from being alone. Strategies such as
exercise, modification of diet, social and intellectual Errors and mutation Genetic
stimulation, and cessation of smoking promote unsuccessful Chance Developmental
aging. It is also known as optimal aging. Environmental Toxins Metabolic
Chemical Autoimmune
Usual Aging Radiation
● Refers to the more common mode of aging. It is associated Bacteria
Free Radicals
with the observed decline in renal, immune, visual, and
Wear and Tear
hearing function as well as the occurrence of disease.

Life Span A. Random Change Theories

● The length of life of an individual or the average length of life A. Error and Somatic Mutation Theory
in a population or species. ● Somatic mutations and errors in DNA and/or RNA synthesis
result in abnormal protein synthesis and impaired cellular
Life Expectancy function. As people age, environmental exposure to
● The number of years, based on statistical averages, that a radiation and toxins results in a progressive increase in
given person of a specific age, class, or other demographic abnormal protein synthesis.
variable may be expected to continue living.
B. Free Radial Theory
Gerontology ● Free radicals damage cellular protein, DNA and enzymes
● Gerontology is the study of aging itself, as well as of any resulting in altered cellular metabolism and accumulation of
processes or phenomena that develop around aging lipofuscin and other substances. Senescence is caused by
change. It is a research discipline that employs methods the accumulation of irreversible damage. The use of
and paradigms from biology, sociology, epidemiology, antioxidants (Vitamin E and C) may be effective in limiting
political science and economics, to name only a few fields. damage from free radicals and extending life.

Geriatric Medicine C. Wear and Tear Theory

● The branch of medicine deals with the physiologic ● Inability to continuously repair damage to crucial cell
characteristics of aging and the diagnosis and treatment of components (e.g. DNA) results in declining cellular function
diseases affecting the aged. It is essentially concerned with and subsequent tissue destruction.
senescence: to promote aging with as little senescence as
possible.
B. Programmed Change Theories
A. Genetic Theories
Who are considered as Senior Citizens in the Philippines?
● Assumes that life span is inherited; longevity encoded in the
● In the PH, people who are regarded as senior citizen are
genome.
those aged 60 years old or over.
B. Neuroendocrine Theory (Developmental Theory
PH Census of 2010
● Decline in the neuroendocrine system produces profound
● According to the National Statistics Office, PH population in
impairment in homeostatic systems, including loss of
2010 was 92 million.
reproductive function and metabolic regulation which occur
with age.
C. Glucosylation Theory (Metabolic Theory) Eyes
● Glucose is thought to promote senescence through
non-enzymatic attachment to proteins and nucleic acids. Variable Structural Change Clinical
Since dietary restriction increases maximum life span and Significance
also reduces blood sugar and rate of glycation, role of
glyaction in aging become interesting. Conjunctiva ● ↓ number of mucous ● Contributes to dry
cells eye condition
D. Immune Theory (Autoimmune Theory)
● Immune system is particularly vulnerable during senescence Vitreous ● Discrete opacities of ● Generalized
humor structural changes haziness
which is expected to produce an increased susceptibility to
infection and decreased ability to reject tumor cells
Cornea ● Arcus senilis ● No clinical
● ↓ sensitivity to touch significance
Physiologic (Functional) Reserve in Older Adults
● Physiologic reserve is the difference between max and basal Iris ● Muscles that ● Decline in dark
organ function (figure 1). Its gradual decline with aging regulate pupillary adaptation
mirrors the progressive decline in homeostatic control and size weaken; pupils
increases vulnerability to stressors which is the hallmark of become smaller
frailty. ● More rigid ® less ● Loss of color
light enters the eye discrimination

Lens ● Loses flexibility ● Inability to focus

on close targets
(presbyopia)
● Decline in dark
adaptation

Retina ● Receives less light ● ↑ sensitivity to

because of - light glare
absorption by the ● Reduction in visual
lens, cornea, and acuity, contrast
vitreous. sensitivity,
Figure 1. Schematic Diagram of Physiologic Reserve ● Rods and cones are dark-light
lost, as well as adaptation , and
Anatomic, Physiologic and Biochemical changes of the retinal and ganglion functional
cells peripheral vision.
organ system and their clinical implications
Skin Lacrimal ● ↓ tear production ● Dry eye surface
gland
Variable Structural Change Clinical
Significance
Ears
Epidermis ● Thinning of the ● ↑ Risk of cellulitis
epidermis and pressure ulcer Variable Structural Change Clinical
Significance
Wound healing ● Flattening of ● Impaired wound
dermal-epidermal healing External ear
junction ● ↓ Photoprotection
● ↓ Proliferative ● ↓ Vitamin D External ● Walls become thin, ● Itching
potential of production auditory and skin drier
keratinocytes canal
● ↓ Number of ● ↓ number of ● Cerumen
melanocytes cerumen glands production
and apocrine sweat slightly ↓ ; drier &
Dermis ● ↓ Vascularity ● ↑ Risk of cellulitis glands activity accumulates→
● Degeneration of and pressure ● Narrows impairs hearing
elastin fibers sores
● ↓ Fibroblasts and ● ↓ Skin turgor Middle Ear
mast cell content
● ↓ Number and ● Altered sensory Ossicles ● Sclerotic changes of ● Presbycusis
distorted structure perception ossicles (impairment of
of specialized ● Atrophic changes auditory acuity)
nerve endings Tympanic ● No effect on
Membrane hearing
Subcutaneous ● Degenerates ● Lax, inelastic feel
fat of aged skin Inner ear

Appendages ● ↓ Sweat and ● Drying of skin Cochlea ● Atrophy of cochlear ● Presbycusis

sebaceous glands hair
and production Auditory ● Degenerative ● Presbycusis
● ↓ Number of hair ● Impaired neurons changes of auditory
follicles thermoregulation neurons
● ↓ Number of hair ● Hair
bulb melanocytes depigmentation
● Conversion of ● Loss of Hair
terminal to vellus
hairs
● Abnormal nail
plates
 Respiratory System Cardiovascular System

Variable Structural Change Clinical Variable Structural Change Clinical

Significance Significance

Chest wall ● Stiffening from ● Less compliant Heart

changes in ribs, ● ↑work of General ● Loss of myocytes ● ↑ incidence of
sternum and breathing ● Fibrosis and fatty sinus, AV, and
articular cartilages infiltration ventricular
● Loss of thoracic ● ↓ muscle strength defects
skeletal muscle and endurance Atrium ● ↑ in L atrial size

Lungs ● ↓ lung mass ● Loss of elastic Ventricle ● ↑ in L ventricular ● Limitation of

● Becomes stiffer recoil → ↓ PO2, wall thickness (to heart’s ability to
● ↓ in parenchymal FEV1 compensate for adjust SV and
elastic fibers myocyte loss) impair ventricular
filling
Valves
Trachea and ● ↑ in diameter ● - in anatomic and
● Sclerosis of heart ● Valvular stiffness
Larger Airways physiologic dead
valves
space
Innervation
● ↑ calcification of
● ↓ parasympathetic
the cartilage of
& sympathetic
bronchi
nerve conduction
● ↑ in thickness of
pathways
the mucous gland
layer
● ↑ airway reactivity Heart (function)
● ↑ elastin content
Sinus node ● Loss of function ● Intrinsic sinus
cells rate ↓
Small Airways ● ↓ in diameter ● No significant
effect on airway
Heart rate, ● ↓ at rest ● Impairs the
resistance
stroke volume, ● ↓ in response to heart’s ability to
● Distal order of
ejection stress buffer changes in
respiratory
fraction circulatory
bronchiole and
volume
alveolar ducts
dilate
Response to ● ↓ response ● Impairs the
catecholamine heart’s ability to
Alveoli ● Alveolar septal ● ↓ in alveolar buffer changes in
membrane surface→ ↓ in circulatory
markedly stretched alveolar gas volume
and weakened → exchange
fusion and ● ↓ maximal Early diastolic ● Diminished ● Diastolic
enlargement of oxygen uptake filling of LV dysfunction
alveoli
● Loss of
Arteries
parenchymal tissue
● Kohn’s pore
Gross ● Elongation and ● Decreased
become more
tortuosity output during
numerous
exercise
Lung volume ● ↓ ability to Intimal layer ● ↑ intimal ● May represent
and capacity effectively meet thickening the early stages
the challenges of of
hypoxia and atherosclerosis
hypercarbia
Medial layer ● Calcification and ● ↑ thickness and
Vital capacity ↓ fibrosis rigidity→systolic
hypertension and
Total Lung ● Stable (may not higher pulse
Capacity change pressure →
significantly) cardiac
hypertrophy
Residual ↑ Adventitial ● Fragmentation of
Volume layer elastin fibers
● ↑ in collagen
content
FRC ↑
Veins
Maximal ↓
breathing
General ● Progressive ● Reduced
capacity
thickening buffering ability
with changes in
Defense ● ↓ mucociliary ● ↑ risk of intravascular
mechanisms function pulmonary volume→
infection exaggerate
● ↓ cough reflex hypotension
Capillaries ● ↓ number and position sense, ↑ risk of falling
density smell, and
● ↑ basement peripheral pain
membrane and temperature.
thickening
● ↑ collagen Reflex ● Less brisk deep
deposition tendon reflexes

Baroreceptor ● Less sensitive ● Higher incidence Cerebellar ● Balance and ● ↑ risk of falling
of orthostatic or coordination can
postural be impaired
hypotension

Urinary System
Nervous System
Variable Physiologic Clinical Significance
Variable Physiologic Clinical Change
Change Significance
Kidneys ● Decline in number ● ↓ concentrating
Brain of nephrons ability → solute load
(mainly cortical) (sodium and protein)
Volume ● ↓ not excreted
efficiently.
Blood Supply ● ↓
● ↓ Functional ● Diluting declines →
Neuro ● ↓ levels of ● Limits the ability of glomeruli → ↑ prevalence of
transmitter acetylcholine, the older brain to sclerosis of hyponatremia ↓
epinephrine, and integrate neural remaining ability to conserve
dopamine and inputs nephrons. water.
their respective
receptors ● ↓ Blood supply ● Impairment of
Synaptic ● ↓ ● Reduction in the (with maintenance PTH-mediated renal
Density complexity of of medullary synthesis of
neuronal perfusion) 1,25-dihydroxycho-le
connections calceferol

Spinal Cord ● ↓ glomerular ● ↑ sensitivity to

capillary surface nephrotoxic injury
Neuron ● Neuronal loss ● Changes in spinal area and GFR → and susceptibility to
and cord reflex and renal failure
demyelination reductions in ● Interstitial fibrosis
proprioception
ADH ● Normal or
Peripheral ● Changes in the ● Decreases in Increased basal
Nerves peripheral nerve conduction secretion.
nerves ● ↑ ADH release
with osmotic
Autonomic stimulation.
Nervous ● ↓ ADH response
System to upright position.
● Decreased
Neuronal ● Loss and fibrosis ● Impairment of nocturnal
Density of peripheral cardiovascular secretion.
sympathetic reflexes
neurons ● Lack of the normal ● Nocturnal polyuria
Receptor ● ↓ in ● ↑ adrenomedullary diurnal rhythm and predisposal to
Sensitivity adrenoceptor output and plasma secretion nighttime
responsiveness catecholamine incontinence
levels
● ↓responsiveness ● ↓ heart rate and ● ↑ secretion of ● ↑ risk of
of peripheral and ventilatory ADH despite ↓ hyponatremia
central responses to blood tonicity
chemoreceptor hypoxia (SIADH)
function
Atrial ● Increased basal
Motor ● Reduction in the ● Chronic skeletal natriuretic secretion
number and size muscle hormone ● Increased
of spinal cord denervation →↓ response to
motor neurons. contributes to stimulation.
● Alteration in muscle strength
axonal flow. and endurance. Renin ● Decreased Activity
● Neuromuscular
junction
alteration Aldosterone ● Decreased
production
Sensory ● ↑ threshold for ● Visual, auditory,
Urinary, ● Bladder capacity
all forms of joint position and bladder,
perception, vibration senses declines
urethra & ● Residual urine
including vision, may be pelvic muscle
hearing, joint compromised → increase
 Immune System
● Unstable bladder ● Frequently noted in
contractions most incontinent
patients. Variable Physiologic Change Clinical
Significance
● ↓ bladder outlet ● Predisposes to the
and urethral development of T cell ● ↓ T-Cell proliferative ● ↑ susceptibility
resistance stress incontinence response, cytotoxic to infections,
pressure in activity, cytokine and anergy and
women mononuclear malignancy.
phagocyte production.
● Decreased ● Symptoms of
estrogen → dysuria and urgency B cell ● ↓ humoral antibody ● ↑ susceptibility
atrophic vaginitis and ↑ risk of UTI response to infection,
and urethritis and urge ● Antibodies produced anergy and
incontinence. have less affinity for malignancy.
antigen.
Prostate ● Hyperplasia of ● Obstruction and
Gland stromal fibrous irritation of ● ↑ production of ● ↑ risk for
elements and intraprostatic urethra autoimmune antibody. autoimmune
glandular tissue → causing symptoms. disease
hyperplastic
nodules enlarge ● Normal Ig response ● Reduced
and ↑ in number. but there is blunting of antibody
IgG and IgM response responses
after primary antigenic following
Hematopoietic System stimulation or infection or
rrechallenge. vaccination.
Variable Physiologic Clinical
Change Significance
Endocrine System
Bone Marrow ● ↓ number of stem ● Little impact on
Variable Physiologic Change Clinical
cells as marrow fat peripheral blood
Significance
increases ● ↓ capacity to
make new blood
cells quickly with Pituitary ● Little change in
disease weight and size
(diminished ● ↑ LH, FSH, and
marrow reserve). prolactin levels
● ↓ rate of iron ● ↑ or unchanged TSH
uptake with levels
erythropoietin ● ACTH and
stimulation somatotropic
(slowed hormone (STH) are
erythropoiesis) unchanged.

Peripheral Blood Adrenals ● Atrophy of Zona

glomerulosa (main
Red Blood ● Hemoglobin and ● Anemia is not source of
Cell hematocrit ↓ part of a normal aldosterone).
slightly but remain aging. ● Response to ACTH
within normal adult is unchanged.
range. ● ↓ secretion of ● The small amount
● Lifespan and cortisol of estrogen in
morphology do not women comes
change mainly from
significantly. adrenal
androstenedion-e
→ estrone.
White blood ● Total lymphocyte
Cell and granulocyte HPA axis ● Higher cortisol levels
counts reported as and remain elevated
normal or slightly ↓ longer than younger
persons after
Platelet ● Platelet counts stressful stimulus.
reported as
normal or slightly ↑ Thyroid ● Atrophy with
● Platelet function histopathologic
reported as changes: fibrosis, ↑
normal,↑ and ↓ in colloid nodules
● Morphology do not and lymphocytic
change with age. infiltration
● Total T4 production ↓
Coagulation ● ↑ levels of ● T4 concentration
fibrinogen and unchanged
coagulation ● T4 degradation ↓
factors V, VII and ● T3 degradation ↓
IX. ● Serum TBG
concentration
unchanged.
Parathyroid ● ↑ parathormone and ● May partly explain Esophagus ● ↓ contractile
↓ calcitonin levels ↓ density of amplitude
bones. ● ↓ upper esophageal ● Delay in relaxation
sphincter after deglutition.
Renin-Angiot ● ↓ basal renin level ● Development of ● Lower esophageal
ensin- → ↓ aldosterone fluid and sphincter
Aldosterone levels electrolyte unchanged
System
abnormalities (e.g.
↓ ability to Stomach ● ↓ parietal cell mass ● ↓ gastric acid
conserve sodium) secretion.

● End-organ ● ↓ renal free water ● ↓ intrinsic factor ● Impaired vitamin

resistance to effects retention and production B12, calcium, and
of vasopressin impairment of iron absorption.
thirst mechanism.
● Motility and ● May predispose to
emptying minimally anorexia and
Pancreas ● ↑ insulin reduced weight loss.
● ↓ responsiveness to ● Risk factor for ● Ability to relax and
the pancreatic B cell glucose dilate to accept
to glucose intolerance, type 2 food bolus is
DM and insulin impaired.
resistance.
● ↓ mucosal blood ● ↓ cytoprotection
flow and mucosal lead to increased
Testis ● ↓ Testicular weight ● ↓ in testosterone
prostaglandin, susceptibility to
and volume production rate,
glutathione, mucosal injury
● Leydig cells ↓ in testosterone, free
bicarbonate and from NSAID use
number and testosterone and
mucus secretion.
testosterone bioavailable
production ↓ testosterone
● Less vigorous levels Small ● Villous atrophy and ● ↓ absorption of
spermatogenesis; ● Only some men Intestine loss of lymphoid iron, calcium,
sperm quality become tissue. vitamin D and
deteriorates. hypogonadal ● Duodenal lactose.
● Sex-hormone bicarbonate
binding globulin secretion may ↓.
increases with age.
● Loss of diurnal ● Poorer T-cell ● Impairement of
rhythm city occurs function and ↓ gut associated
for LH, testosterone intraepithelial immunity and
and bioavailable lymphocytes. relative
testosterone. susceptibility to
● Decreased infections that
feed-forward enter GIT.
stimulation by LH ● ↓ neuronal content
and delayed of myenteric
feedback inhibition plexus.
by testosterone. ● Less vigorous
intestinal motility.
Ovary ● Ovaries become ● Menopause
● ↓ Lactase level in ● Lesser capacity to
more fibrotic, follicles
the intestinal tolerate milk.
↓ in number become
mucosa.
less responsive to
gonadotropic
● ↓ tone of external
hormones and
and internal
produce ↓ estrogen
sphincter
→ no estrogen
production
Large ● Atrophy of mucosa
Intestines ● Rectal compliance
Gastrointestinal System and tone are
unchanged.
Variable Physiologic Change Clinical
Significance ● ↓ perception of ● May play a role in
anorectal the pathogenesis
distension. of constipation.
Oral Region ● Fewer taste buds ● Impaired ability to
● Taste sensation ↓ identify food by
● ↓ tensile strength of ● Predisposes to
taste
muscle wall. diverticular
disease.
● Loss of denture ● Well-fitting
and ↓ volume oral denture may
● Slowing of colonic ● ↑ water resorption
soft tissues become ill-fitting
transit time and hard feces
with time

● Reduced salivary ● ↑ mastication to Liver ● ↑ capsular and

gland secretion. prepare food parenchymal
fibrosis (but does
● Impaired ● Increased not represent
neuromuscular dysphagia, cirrhosis)
coordination aspiration
 Functional Assessment
● Hepatic volume
and weight ↓ ● Functional assessment in the measurement of a patient’s
performance of the skills needed to in everyday life.
● ↓ blood flow ● ↓ hepatic drug ● The patient is assessed on his ability to conduct each of a
elimination; series of basic activities relate to basic physical and
increased risk of cognitive functions.
drug interaction
● Phase I enzyme
Katz Basic Activities of Daily Living
activity- ↓ linearly
● Phase II enzyme ● The ability to carry out basic self-care activities is reflected in
activity- remain the Activities of Daily Living (ADL).
unchanged. ● The index of independence in ADLs is based on an
● ↓ number of evaluation of the functional independence or dependence of
mitochondria per patients in:
hepatic volume.
○ Bathing
● Liver function test
preserved. ○ Dressing
● Synthesis of ○ Going to the toilet
clotting factors ○ Transferring
unchanged. ○ Feeding
● Hepatic
regeneration is
Lawton Instrumental Activities of Daily Living
delayed.
● This refers to the tasks required to maintain an independent
● ↓ in hepatic household. It includes tasks such as:
extraction of LDL ● May contribute to ○ Using the telephone
from blood can lead the ↑ artery ○ Managing money
to further ↑ serum disease. ○ Shopping
cholesterol levels
○ Preparing meals
○ Doing light housework
Gallbladder ● Increased ● May contribute to
precipitation of ↑ incidence of ○ Getting around the community
supersaturated bile cholelithiasis in
and concomitant the elderly.
crystallization of
cholesterol or
calcium
bicarbonate
● Stimulated and
fasting levels of
cholecystokinin are
higher.
● Emptying rates and
fasting and
nonfasting GB
volumes do not
change with age.

Pancreas ● Structural changes: ● No significant

↓ in overall weight, effect on
duct hyperplasia pancreatic
and lobular fibrosis exocrine function.

● Pancreatic enzyme ● Carbohydrate and

and bicarbonate fat absorption
levels ↓ modestly unaffected.

Musculoskeletal System

Variable Physiologic Change Clinical

Significance

Muscle ● Loss of skeletal ● ↓ strength and

muscle mass endurance

Bone ● Bone density ↓ ● ↑ risk of fracture

(osteopenia) and (osteoporosis)
bones become more
fragile especially
women

Joint ● Joint cartilage erodes ● ↓ joint mobility

from wear and tear
● Elastic synovial tissue
replaced by more rigid
collagen fibers.
● Synovial fluid
becomes more
viscous.