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CHAPTER
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2
PHYSICAL CHANGES AND THE AGING PROCESS
LEARNING OBJECTIVES
• Compare normal physical changes that accompany aging and diseases and conditions that become more common with
age.
• Identify the usual, normal physical changes that accompany aging.
• Outline adaptations that older people can make to accommodate normal physical changes.
• Explain how attention to normal physical changes can prevent serious consequences for older people.
• Summarize the two basic paradigms of biological theories of aging.
PUTTING PHYSICAL AGING CHANGES IN PERSPECTIVE
I am now, probably for the first time in my life, the person I have always wanted to be. Oh, not my body! I
sometimes despair over my body, the wrinkles, the baggy eyes, the skinny arms. And, often, I am taken aback by that
old person who lives in my mirror, but I don’t agonize over those things for long.
I would never trade my amazing friends, my wonderful life, for less gray hair. As I’ve aged, I’ve become kinder to
myself and less critical of myself. I’ve become my own friend.
....
I am blessed to have lived long enough to have my hair turn white, and to have my youthful laugh be forever etched
into the deep grooves of my face. So many have never laughed, and so many have died before their hair could turn
silver.
As we get older, it is easier to be positive. We care less about what other people think. I don’t question myself
anymore. I’ve earned the right to be wrong.
I like being old. It has set me free. I am not going to live forever, but while I am still here, I will try not to waste
time lamenting too much or too long about what could have been, or worrying too long about what will be. I shall
eat dessert and a piece of bread every single day, if I feel like it.
May you have a rainbow of smiles on your face and in your heart forever and ever.
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—Margaret Berry, age 100 (2015)
NORMAL PHYSICAL CHANGES THAT ACCOMPANY AGING AND
ADAPTATIONS TO THEM
Aging is accompanied by physical changes to the body—no surprise there! But, the physical changes that normally occur as
we grow older, such as our feet getting larger, can and should be differentiated from medical conditions that are more likely
as we age, such as heart disease. Some physical changes are part of the normal aging process and occur for a majority of
people, and sometimes for all people, as they age. For these changes there are mostly simple adaptations—in the case of
larger feet, buying shoes in a bigger size. On the other hand, some medical conditions become more common with age, which
means that the chances of acquiring them increase with age, but not every older person acquires them. Medical conditions are
presented and discussed in Chapter 11, Medical Conditions, Assisted Living, and Long-Term Care for Older Adults . In this
chapter, we focus on the physical changes that accompany the normal aging process.
There is no specified common timetable for human aging; instead, there are enormous individual differences in the aging
process, and all older people do not experience all possible changes. Nevertheless, as people grow older, changes that may be
hardly noticeable at first tend to occur throughout the physical systems of the body. Among the physical changes that can be
expected to occur as we age, some, such as gray hair and wrinkling skin, are more visible, while others, such as hearing loss
and hypothermia, may be less visible.
Hair
One of the most noticeable physical changes that occur with aging is hair color turning gray, silver, or white. Although this
change is usually a phenomenon of aging, young people’s hair can turn gray too, sometimes as a result of severe physical or
emotional stress. No one knows why specific hairs turn gray or white and others do not. Within each hair follicle (tubelike
organs in the skin) are cells that add color to the hair shaft. Each specific hair grows for about 3 years, then rests for several
months before it starts growing again. As one ages, the color-producing cells cease functioning, and the hair grows out gray or
white. At the present time, there is no known process to help those cells continue producing their original color. It is known
that there is a genetic component to the action of those cells, and as a result, those whose ancestors’ hair turned gray early in
life have a higher probability of their hair turning gray early in life ( Saxon, Etten, & Perkins, 2010). One way people adapt to
this change is by coloring or dyeing their hair. Others wear their new hair color with pride.
Another noticeable aging change with respect to hair is thinning or hair loss, which, like most normal aging changes, occurs
gradually over time. Hair thinning can lead to baldness, especially in men. Being bald is distressing for some people, so
various ways to manage hair loss have been developed, from hair pieces and home remedies to drugs and transplants. Existing
drugs have only marginal effects and must be taken continuously to work at all. Hair transplantation is a surgical procedure
that moves hair from one part of the head to the balding areas; it can be painful and there are risks of scarring and infection.
Low-level laser therapy is another treatment and seems to stimulate hair growth but the most effective way to use it and its
long-term effectiveness and safety have yet to be determined (Avci, Gupta, Clark, wikonkal, & Hamblin, 2014). Lots of
research is in the works, so new solutions for those who want to remedy their hair loss may be on the horizon. An entirely
different approach is to embrace baldness, and more and more men are doing that.
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Skin
As people grow older, their skin begins to change. It becomes thinner, loses fat, and wrinkles, losing some of its plumpness
and smoothness. For most people these changes begin in their 20s, and are accelerated by smoking and frequent, extended
exposure to the sun and very dry air. Thinner skin means that veins and bones can be seen more easily, and scratches, cuts, or
bumps can take longer to heal. The wrinkling process varies depending on a person’s genetic heritage. The skin of blonde,
pale-skinned people tends to wrinkle sooner than it does for those with darker skin.
Adaptations for age-related changes to our skin abound (National Institute on Aging, 2017b). Not smoking, or quitting
smoking, is an obvious one. Another is to minimize the effects of the sun by avoiding prolonged direct exposure and using a
sunscreen lotion or protective clothing that offer good protection from ultraviolet A and B solar radiation. Tanning parlors are
also something to be avoided. Indoors, rooms should be kept moist so that dry skin will not crack. If a humidifier is
unaffordable, pans of water placed on a heat register can be used to put moisture into the air. In addition, daily use of
moisturizers, such as lotions, creams, and ointments, softens dry skin. Massages and facials are excellent choices for
hydrating the skin. Manicures and pedicures can also be helpful because they involve massaging hands and feet with
moisturizers.
Thermoregulation
Older people do not adjust to temperature changes as well as young people do, and they are more likely to take prescription
medications or have a chronic medical condition that further changes their body’s ability to regulate its temperature. For these
reasons, older people are more prone to the negative effects of cold temperatures, which can result in hypothermia, and also to
hot temperatures, which can result in hyperthermia. The loss of subcutaneous fat and a diminished flow of blood to the skin
and extremities, both of which occur with aging, are important contributors to older people’s reduced thermoregulatory
abilities. Both hypothermia and hyperthermia can be fatal, so steps should be taken to avoid them. If they occur, they require
immediate medical attention.
Hypothermia
Hypothermia is a reduction in core body temperature, with a danger that the body’s temperature will get so low that a person’s
life may become endangered. Research seems to indicate that the danger of hypothermia among older persons is much greater
than previously believed. Hypothermia can even result in death, although it is often overlooked as a cause of death. Thus, it is
important to know the symptoms of hypothermia. One should be alert for the umbles—stumbles, mumbles, fumbles, and
grumbles. Check for slowed or slurred speech; sleepiness or confusion; shivering or stiffness in the arms and legs; poor
control over body movements; slow reactions; or a weak pulse. Whenever an older person has any of these symptoms and his
or her temperature drops to 95°F or lower, immediate medical attention should be sought (National Institute on Aging, 2017a).
Prevention of hypothermia among older adults can be quite simple: Indoors, room temperatures should be maintained at no
less than 68°F, and additional clothing such as long underwear, socks, slippers, and a hat can be helpful. When it is cold
outdoors, wearing layers of loose clothing and a hat, scarf, and gloves or mittens can reduce loss of body heat.
Hyperthermia
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Hyperthermia is an abnormally high body temperature due to hot conditions in the environment in conjunction with imperfect
heat-regulating mechanisms in the body, and, like hypothermia, it can be life-threatening. Symptoms of hyperthermia to
watch out for include: a strong, rapid pulse or a slow, weak pulse; lack of sweating; dry, flushed skin; change in behavior—
agitation, combativeness, or confusion; staggering; and faintness. Whenever an older person has any of these symptoms and
his or her temperature reaches above 104°F, immediate medical attention should be sought (National Institute on Aging, 2016a
).
Some ways to prevent hyperthermia are to stay indoors on hot days in cooled or air-conditioned rooms; drink plenty of
fluids, but avoid caffeine and alcoholic beverages; apply cold, wet cloths to the wrists, neck, armpits, and/or groin; and bathe
or sponge off with cool water. People without air-conditioning can go to places in the community that can offer a cooler
setting, such as senior centers, shopping malls, and libraries.
The Low-Income Home Energy Assistance Program (LIHEAP), a federally funded program that operates through state
governments, the District of Columbia, tribes and tribal organizations, and U.S. territories, can help families stay warm in the
winter and cool in the summer, reducing the risk of health and safety problems that can arise from unsafe heating and cooling
practices. This program provides assistance in managing costs associated with:
■ Home energy bills
■ Energy crises, for example, as a result of a natural disaster
■ Weatherization and energy-related minor home repairs
During the hot summer months, New York State used a portion of its LIHEAP funding to help low-income residents
with documented medical needs keep their homes at a healthy temperature. Prolonged exposure to very high indoor
temperatures is a health risk that disproportionately affects those already suffering from medical ailments. New York
State Homes and Community Renewal installed more than 3,200 window air conditioner units, helping to keep some of
New York’s most vulnerable people healthy and safe during summer heat waves. (Office of Community Services, n.d.)
More information about the LIHEAP program is available at www.acf.hhs.gov/ocs/programs/liheap (U.S. Department of
Health and Human Services, Administration for Children and Families).
Vision
Only 15% of older adults report any trouble seeing (National Center for Health Statistics [NCHS], 2017). Even so, several
changes occur in our eyes as we age, including presbyopia (farsightedness), dry eyes, and cataracts, all of which can be dealt
with relatively simply nowadays. These changes usually occur after the age of 40, but younger people can also experience
them. There are numerous ways to adapt to aging eyes so that a good quality of life can be maintained throughout the life
span. More serious eye conditions, including glaucoma and macular degeneration, are discussed as medical conditions in
Chapter 11, Medical Conditions, Assisted Living, and Long-Term Care for Older Adults.
Presbyopia/Farsightedness
Presbyopia, or farsightedness, is a normal condition, not a disease, and should not disrupt the daily lives of most people. It
usually begins to develop when a person is about 40 years of age. As we age, our eyes begin to lose the ability to adjust for
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different distances, and eventually most people will need bifocals or trifocals to maintain good vision. Presbyopia also means
that as a person grows older, it is more difficult to adjust to darkness and to glare, and it takes more time to adapt to changes
in light and darkness. These changes in vision make nighttime driving more hazardous for older people.
Cataracts
Cataracts are very common in older adults, though they can occur in children too. Research has shown that the risk of
cataracts is related to frequent sun exposure, which has its greatest effects on younger people (Neale, Purdie, Hirst, & Green,
2003). Protecting our eyes from intense sunlight throughout our life span will decrease susceptibility to cataracts. Eventually,
though, most people will develop cataracts if they live long enough. Cataracts result in increasingly blurred or misty vision as
the eye’s lens becomes milky. Some cataracts grow larger or denser over time, causing severe vision changes. These cataracts
can cause loss of independence for older adults because decreased vision may affect driving, working, reading, and hobbies.
Cataract growth can be slowed by protecting our eyes from the sun and from sunlamps, eating healthy foods, limiting
alcoholic drinks, and avoiding smoking (Kline & wenchen, 2005). In the United States, cataract surgery, which replaces the
clouded lens with a synthetic one, is the most commonly performed surgery in adults over age 65. Its success rate is very high.
Dry Eyes
Some people develop dry eyes as they grow older. This dryness can also cause redness in the eye. Mild cases can usually be
treated with over-the-counter artificial tear solutions. Optometrists can diagnose and recommend other treatments for more
serious cases of dry eye (American Optometric Association, n.d.).
In general, a complete eye examination is recommended for those older than age 45, with follow-up examinations every 2
to 4 years thereafter. As noted, some age-related changes in vision can be dealt with fairly easily—by wearing bifocals or
trifocals for presbyopia, by having surgery for cataracts, and by using artificial tears for dry eyes. Most other changes are best
dealt with by changes to our environment. Our built environment has been constructed using parameters that work best for
young people. Thus, the amount of light, the existence of stairs and escalators, and the typical size of print, for example, have
all been determined for the society we used to be—a society of mostly young people. With our changing demographics, and
our desire to make our environment more accessible to people with disabilities, it is time for us to make changes to our
existing environment, and rethink parameters for future built environments, to accommodate people of all ages and ability
levels.
As we age, we require more light to see as well as we did when we were younger (as much as three times more light).
Thus, simply increasing the amount of light assists older eyes to see better. Depth perception is also affected, so constructing
environments that clearly differentiate changes in levels, for example on stairways, is a good way to increase visibility of
those changes, and thus help decrease falls in older people. Varying textures, materials, and colors are helpful ways to signal
changes in levels. Also, ramps are preferable, especially to escalators, for moving from one level to another because they are
much safer for everyone.
Hearing
As we age, limitations in our hearing become much more common than limitations in our vision. In 2015, 30% of people age
65 to 74 years reported trouble hearing, and that percentage rises to 47% for people age 75 and over. Older men are more
likely to have hearing problems than are older women—41% of men and 21% of women age 65 to 74, and 55% of men and
41% of women age 75 and over (NCHS, 2017). Most people lose the ability to hear high-pitched sounds first, which leads to
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poor hearing when there is background noise. They also experience difficulty in hearing higher pitched sounds which are
common in women’s and children’s voices, and difficulty in distinguishing between some words because consonants, such as
Bs and Ps, and Cs and Ks, tend to be higher pitched than vowels are. Presbycusis, the most common type of sensorineural
hearing loss, can occur because of changes in the inner ear, auditory nerve, middle ear, or outer ear. Some of its causes are
aging, repeated exposure to loud noise, heredity, head injury, infection, illness, and certain prescription drugs. A recent
analysis of national data shows that hearing impairment is declining among adults between ages 20 and 69, a positive sign for
the future (Hoffman, Dobie, Losonczy, Themann, & Flamme, 2017). Reasons for this decline may be reduced exposure to
loud noise in the workplace, lower rates of smoking, and better management of chronic conditions, such as hypertension, that
can impact hearing.
Hearing is an essential component of well-being, especially for people who have enjoyed normal hearing for most of their
lives. Losing the ability to hear adequately in the routine activities of daily life can be very detrimental. Older adults with
moderate to severe hearing loss report more difficulty with tasks such as preparing meals, shopping, and using the telephone
than do those with no hearing loss (Gopinath et al., 2012). Once daily activities such as these become compromised,
independence and quality of life can be reduced. Thus, an important factor in hearing loss is the increasing isolation of the
person with impaired hearing. For most people, hearing loss is gradual. At the beginning of the loss of hearing, it is not
unusual for people to be irritable, to seem to be distracted from conversation, and to be unsociable. Often a person may be
unaware of the hearing loss and frequently give inappropriate answers to questions that were not heard well enough. As a
result, relationships may become strained as others believe the person to be a bit confused. As this process continues, the
person may begin to feel rejection conveyed in the nonverbal communication of others, and there is a real danger that
depression may set in (Gopinath et al., 2009), leading to a cyclical process of increasing isolation and depression.
Adaptations to age-related changes in hearing involve those communicating with older people as well as the older people
themselves. In communicating with people who have hearing problems, it is helpful to speak more slowly and enunciate
clearly. Shouting should be avoided. It is beneficial to speak face to face, so the person can see lip movements. Because much
communication is nonverbal, one can attempt to communicate emotions, moods, and acceptance by body language and facial
expressions. It is always helpful to eliminate background noise, including noise created by fans, air conditioners, and other
appliances. It is important that the acoustics as well as the sound equipment in an auditorium be very good for presentations to
older persons.
Older persons who believe they are suffering hearing loss can benefit from having a hearing checkup with an audiologist or
with an ear, nose, and throat specialist. If there is significant organic reason for hearing loss, many aids are available today
that can help. It is important for a person to be diagnosed by a certified specialist, such as an audiologist, and not by a person
who only sells hearing aids. Unfortunately, most people who could benefit from some type of hearing aid do not have one. In
the first national study that included audiometric testing of a large, representative sample, Chien and Lin (2012) analyzed data
from the National Health and Nutritional Examination Surveys (NHANES) on hearing loss and hearing aid use. Of the 27
million Americans 50 years of age or older with a hearing loss, they found that fewer than 4 million (14%) used hearing aids.
Hearing aid use does seem to be higher for those age 70 and older, with researchers in one study reporting that of those who
could benefit from using a hearing aid, one third were wearing one for at least 5 hours per week (Bainbridge &
Ramachandran, 2014), though that still leaves a lot of people without the improvements that hearing aids would afford them.
A variety of reasons have been suggested for the relatively low-level use of hearing aids. Some people think their hearing loss
is relatively minor, and they would rather not bother with hearing aids, which do not restore the entire range of lost
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frequencies and still do not fully eliminate distracting background sounds in a noisy environment. Others are concerned about
the stigma associated with wearing a hearing aid. There are also those who cannot afford them—good hearing aids are
expensive and are not covered by Medicare.
At first, a hearing aid may seem unnatural and strange because it amplifies sounds other than speech. It usually takes some
time to adjust to a hearing aid, and families and friends, as well as the user of the aid, need patience during the adjustment
process. Modern hearing aids are marvels of technological advancement. Many types are available, including ones that fit in
the ear canal (completely or partially), in the ear, or behind the ear. Most have been miniaturized so that they are comfortable
to wear and are cosmetically acceptable. Hearing aids can be indistinguishable in their appearance from earpieces for
electronic devices, so the stigma of wearing a hearing aid may disappear in the near future!
Chemical Senses: Smell and Taste
Our senses of smell and taste are intimately connected and interact with one another. For example, what we experience as the
flavor of a food is actually a consequence of both the smell and the taste of the food. Just think about how our food does not
seem to taste the same when our sense of smell is disrupted by a head cold. Nevertheless, smell and taste are separate senses
and each has its own receptors and physiological underpinnings.
Our sense of smell (olfaction) begins to decrease beginning around age 50, with women having a lower risk of their ability
being diminished over time compared to men (Liu, Zong, Doty, & Sun, 2016). Although olfactory cells regenerate throughout
the life span, it seems that the ability for them to do so decreases over time. In addition, age-related changes in the brain
where information about smell is processed—in the orbitofrontal cortex, hippocampus, and amygdala—may contribute to an
age-related decrease in sensitivity to smells (Gunzer, 2017). Estimates of the prevalence of olfactory impairments range from
17% for men in their 60s to 37% for men age 70 and over. Estimates range from 11% for women in their 60s to 25% for
women age 70 and over. In addition to gender, prevalence is also affected by race and ethnicity, socioeconomic status, a
history of asthma and hypertension, medication use, smoking, and alcohol consumption (Liu et al., 2016).
Our sense of taste is important for the pleasures we derive from consuming good food as well as for helping us to avoid
consuming harmful substances. In comparison to smell, our ability to taste seems to be less affected by age (Seiberling &
Conley, 2004), though much less is known about age-related changes that may take place, or their causes. Taste perception
may be affected if saliva production goes down, which happens in some older adults. Illnesses, medications, and smoking can
also negatively affect the ability to taste food. Older adults may need a much higher concentration of salt to detect its presence
in food (Stevens, Cain, Demarque, & Ruthruff, 1991), which could, for example, negatively affect the likelihood that
hypertensive patients will maintain a low-salt diet.
Potentially serious problems can arise as a result of changes in our sense of smell and taste. A reduction in these
chemosensory abilities can result in decreases in appetite, food consumption, and overall quality of life, and can even
endanger an older person’s health and safety. Some older people may lose the pleasure of smelling flowers, perfumes, and
well-cooked and seasoned food. At the same time, they may have difficulty smelling gas leaks, smoke, and spoiled food (
Seiberling & Conley, 2004). Given these negative effects, it is encouraging that there has been some research into possible
ways to ameliorate older adults’ sense of smell. It turns out that exercise seems to be one way. In a study of more than 1,600
older adults over a 10-year period, Schubert et al. (2013) found that those who worked up a sweat exercising at least once per
week had a reduced risk of olfactory impairment, and exercising more frequently reduced the risk even more. Thus, these
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researchers concluded that regular exercise may prevent some decrements in olfaction that otherwise would accompany aging.
Another way of reducing aging effects on olfaction seems to be by eating more fish and nuts (Gopinath, Sue, Flood,
Burlutsky, & Mitchell, 2015).
Adaptations for older adults with a decreased sense of smell include ensuring that smoke detectors are in place and working
well, and paying attention to food safety guidelines as well as expiration dates on food products. Friends, neighbors, and
family members can be helpful in detecting problematic smells or tastes, too. In addition, when taste seems to be affected, the
enjoyment of food can be enhanced by adding spices and incorporating a diversity of food flavors, textures, and temperatures
during meal preparation. “Eye appeal” can also positively affect enjoyment, so garnishes, variety in food colors, and
placement of food on a plate should not be overlooked.
Touch
When it comes to aging, touch is often an overlooked sense, and yet, our skin, through which we experience touch, is the
largest of our sense organs. The frequency of touch and responses to it are affected by the context in which it occurs, the
relationship between people who are engaged in touching, and culture, with some societies, like the American society,
actively discouraging touch (Field, 2010). The positive effects of touching are many. It decreases blood pressure, heart rate,
and cortisol (stress hormone) levels; increases oxytocin (“love hormone”) levels; improves immune function; increases
attentiveness, leading to improved performance on cognitive tasks; decreases depression; reduces pain; and may extend time
in deep sleep, the most restful stage of sleep ( Field, 2010). What older person could not benefit from these effects?
Regrettably, however, little research into touch has been conducted with older people.
Two studies give us a glimpse into the value of investing in more research in this arena: a study of older adults giving
massages to infants, and another investigating the affective responses to touch of older adults. In the first of these studies,
having already learned that massage has positive effects on those receiving it, the researchers wanted to know whether
massage also has positive effects on those giving it (Field, Hernandez-Reif, Quintino, Schanberg, & Kuhn, 1998). They
recruited older retired volunteers who were taught Swedish massage techniques and then each massaged a 1- to 3-month-old
infant for 15 minutes three times a week for 3 weeks. Giving those massages affected the older volunteers immediately,
improving their emotional well-being and decreasing anxiety and stress levels. In the second, more recent study, the
researchers asked people aged between 13 and 82 years, to rate from unpleasant to pleasant on a 20-point scale, their
experience of being gently stroked on their forearm (Sehlstedt et al., 2016). They found that older people gave significantly
higher ratings, indicating that the subjective appreciation of touch increases with age. This finding may not be that surprising
given that it has previously been noted that older people may be deprived of touch, especially after a partner or other loved
ones die.
Feet
Feet get bigger as we age. If you are in your 20s and wear a size 7 shoe now, you may wear a size 8 or even a size 9 by the
time you are in your 60s! Over our lifetime, feet tend to flatten out, and may get wider, due to some loss of elasticity in the
tendons and ligaments that support them. Other factors that can increase the size of feet are pregnancy and weight gain. Aging
also tends to diminish the fat tissue on the bottoms of our feet, leading to soreness when walking for a while on hard surfaces
wearing shoes that have thin soles. Sometimes, foot problems are the first sign of more serious medical conditions such as
arthritis, diabetes, and nerve or circulatory disorders. In addition, foot pain contributes to falls in older adults (Mickle, Munro,
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Lord, Menz, & Steele, 2010). If there seems to be a problem, a podiatrist, who specializes in diagnosing and treating foot
problems, can be consulted.
Foot pain and discomfort, though, need not be a normal part of aging. By the time we reach old age, our feet have had years
of wear and tear, so good foot care becomes especially important. Checking regularly for cuts, blisters, and ingrown toenails
is a good practice. Some adaptations work well for people of all ages, especially wearing comfortable shoes that fit properly,
which can prevent many foot problems. Add insoles, if necessary, to help cushion feet. Podiatrists can prescribe orthotics that
are custom-made for a patient based on a complete assessment of his or her feet, ankles, and legs. Research supports the value
of these custom orthotics in reducing foot pain and improving function and so some health insurance plans will help pay for
them. Raising feet when sitting helps keep blood moving to the feet. Stretching, walking, and gentle foot massages can serve a
similar function. Warm footbaths are helpful, too.
The Urinary Tract
Although some age-related changes occur in our kidneys, in the absence of disease, they usually continue to function quite
well throughout the later years of life. “Exercise; proper diet, including adequate fluid intake; limited use of medications; and
quitting smoking help the urinary system maintain adequate functioning” (Saxon et al., 2010, p. 218). Bladder capacity does
decline by 30% to 40%, but this is not a symptom of disease; it is simply a result of the aging process ( Saxon et al., 2010).
Most elderly persons need to get up in the night to empty their bladder. Older persons should know that having to arise in the
night to go to the bathroom is not in itself an indication of any serious disease. If they have to arise more frequently than twice
a night, however, they ought to see a healthcare professional.
The micturition reflex changes as one ages. Micturition is the signal a person receives when he or she has to urinate. For a
young person, the signal is usually sent when the bladder is about half full. As a result, young people have some time left
before they must absolutely get to a bathroom. Not so for the elderly. The signal to urinate is given when the bladder is nearly
full. Obviously that means when they receive the signal, there is not much time for delay. The reduced capacity of the
bladder, coupled with a delayed signal to urinate, can lead to problems of frequent urination and the need to urinate
immediately (Saxon et al., 2010).
Dribbling urine or urinary incontinence (UI) can be a problem for some older people. This can be viewed as both
physiologically and psychologically damaging. Women have a higher probability than men of having incontinence, likely the
result of childbirth and the associated weakening of the bladder outlet and pelvic musculofascial attachments. Although UI is
more common in older adults, people of any age can experience it. The most common type is stress incontinence, which is
brought about by a laugh, a cough, a sneeze, or lifting. In addition to stress incontinence, some older persons suffer from urge
incontinence, the sudden urge to go to the bathroom without time to get there. Others suffer from overflow incontinence, a
condition in which the bladder becomes too full and urine leaks out (Saxon et al., 2010).
There is an increased chance of urinary tract infections as a person grows older. Symptoms of a bladder infection include
cloudy or bloody urine, a low-grade fever, pain, or a burning sensation during urination, and a strong need to urinate often,
even right after the bladder has been emptied. If the infection spreads to the kidneys, symptoms may include chills and
shaking or night sweats; fatigue; fever above 100°F; mental changes or confusion; nausea and vomiting; and side, back, or
groin pain. In either case, a healthcare professional should be consulted for diagnosis and treatment. A course of antibiotics
usually clears up infections fairly quickly.
Older people, especially older men, are at higher risk than younger people of developing kidney stones. Kidney stones are
hard masses that form in the kidney out of substances in the urine. They may be as small as a grain of sand or as large as a
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pearl. Some stones are even as big as golf balls! Most kidney stones pass out of the body with urine. But sometimes a stone
will not pass by itself and then medical attention is necessary. The larger the stone, the more likely it is to cause severe pain,
in the back or side, that will not go away. Other symptoms include fever and chills, vomiting, urine that smells bad or looks
cloudy, a burning sensation during urination, or blood in the urine. The most common treatment is extracorporeal shockwave
lithotripsy (ESWL), in which a machine sends shock waves to the stone and breaks it into smaller pieces, which can then be
passed out of the body in urine. The best way to prevent kidney stones is to drink lots of water, which helps to flush away the
substances that form kidney stones (National Kidney & Urologic Diseases Information Clearinghouse, 2011). Producing at
least a liter (slightly more than a quart) of urine per day is indicative of drinking adequate fluids.
Awareness of age-related changes in the urinary tract, including its reduced capacity, can also be helpful because then older
people can plan to regularly visit lavatory facilities, and avoid foods and drinks that may cause them to urinate more often,
thereby avoiding the incontinence that might ensue. Another adaptation older people can make to changes in their urinary
tracts is to learn to do Kegel exercises to strengthen pelvic muscles, which can even prevent UI. Kegel exercises also
strengthen the uterus and large intestine. More information and instructions on how to do the exercises can be found online at
medlineplus.gov/ency/patientinstructions/000141.htm
The Musculoskeletal System: Bones and Muscles
Bones play many roles in the body. They provide structure, protect internal organs, anchor muscles, and store calcium.
Beginning early in life, engaging in regular weight-bearing physical activity and eating foods that are rich in calcium and
vitamin D (which helps the body to absorb calcium) build strong bones, optimize bone mass, and may reduce the risk of
osteoporosis later in life. Bone thinning, or loss of bone mineral density, begins at about age 35 when the body begins to
reabsorb bone cells faster than it makes new bone. Bone thinning, though, does not have to result in osteoporosis, a disease
that weakens bones, making them more likely to break. A person with high bone mass as a young adult will be more likely to
have a higher bone mass later in life. Thus, it is important for young people, and especially young women who are more
susceptible to osteoporosis than are young men, to reach their peak bone mass (genetic potential for bone density) in order to
maintain bone health throughout life. Strong bones are important to us for their positive effects on our bodies, which also
enable us to participate in all kinds of social and sports activities. Chapter 3, Health and wellness for Older Adults has more
information on maintaining strong bones and preventing osteoporosis.
Skeletal muscles help our body to move, keep our body upright and standing tall, and contribute to the health of bones, lung
and cardiovascular function, and regulation of our metabolism. Typically, beginning in middle adulthood, we gradually lose
muscle mass and muscle function, with both gender and physical activity affecting the extent of the loss. Such losses in
muscle mass are associated with a number of negative health outcomes, osteoporosis and hip fractures among them. Strong
quadriceps muscles and biceps muscles are especially important because they make it possible to get up out of a chair and to
lift things, ultimately affecting a person’s ability to remain independent as he or she ages. Between the ages of 40 and 90
years, quadriceps muscle mass can decrease by as much as 50% in men and 30% in women, and biceps muscle mass can
decrease by as much as 30% in men and 20% in women (Arts, Pillen, Overeem, Schelhaas, & Zwarts, 2007). However, losses
in muscle mass, and the decreases in function that accompany them, are not inevitable. “Reduce the demand on skeletal
muscle and it will adapt to the new lower requirement; increase the demand and the decline due to aging can be minimized, if
not eliminated” (Kirkendall & Garrett, 1998, p. 601). Thus, much of the age-related effects on muscles can be prevented by
engaging in physical activity throughout the life span.
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Progressive resistance training, using free weights, resistance machines, or isometrics, has been the exercise method of
choice for maintaining and improving muscle mass and strength. Although older adults seem to require more training than do
younger adults, with the right exercise program, they are nevertheless able to maintain muscle and even increase it, as well as,
or better than, their younger counterparts who do not train (Bickel, Cross, & Bamman, 2011). Research is also showing that
power training may be even more effective in improving functional independence because it enhances older adults’ ability to
carry out daily activities (Hazell, Kenno, & Jakobi, 2007). Of course, older people should consult their healthcare provider
prior to beginning a new exercise program. Finally, mounting evidence suggests that a moderate increase in dietary protein to
1.0 to 1.2 g/kg/day for older adults (0.8 g/kg/day is currently recommended for adults aged 19 and older), distributed across
the day’s meals or in a high protein meal at midday, has beneficial effects on both bone and muscle health (J. Bauer et al.,
2013). Protein needs are even higher for older adults to achieve these beneficial effects if they have acute or chronic disease,
severe illness or injury, or significant malnutrition, while daily protein intake should be limited for those with severe kidney
disease who are not on dialysis (M. Bauer et al., 2013).
Menopause
Menopause, the cessation of menstruation, is a normal part of every woman’s life. It is not a disease or disorder. After
menopause, many women feel relieved that they no longer have to worry about menstruation, cramps, or getting pregnant.
The average age for menopause is 51, but for some women it happens in their 40s, while for others it happens in their late 50s.
Postmenopausal women are more vulnerable to heart disease and osteoporosis, so it is important for them to eat a healthy diet
and to make sure they get lots of calcium and weight-bearing exercise to keep their bones strong.
The majority of women experience some menopausal symptoms, though not all women find them bothersome. Symptoms
can begin several years prior to when the last period occurs. They include changes in menstruation (e.g., increasing variation
in length of the cycle, lighter or heavier bleeding), hot flashes (sudden feelings of heat, usually in the upper part of the body,
lasting between 30 seconds and 20 minutes), vaginal dryness, trouble sleeping, and mood changes. Some symptoms of
menopause can last for months or years after. Changing levels of estrogen and progesterone are related to these symptoms.
Hot flashes and night sweats can be alleviated by sleeping in a cool room, drinking cold water or juice when a hot flash is
coming on, dressing in layers, and using sheets and clothing that let the skin “breathe.” Exercise and slow, deep breathing
may also help reduce hot flashes. Low-dose birth control pills will make menstrual cycles and flow more regular and also help
with hot flashes. A water-based lubricant or vaginal moisturizers may relieve vaginal discomfort, but not petroleum jelly
which can cause irritation. Sleep problems may be relieved by adopting good sleep hygiene practices, such as adhering to a
bedtime routine and creating a comfortable sleeping environment (see more suggestions in Chapter 3, Health and wellness for
Older Adults).
Some women require medication. The U.S. Food and Drug Administration has approved the use of paroxetine, a low-dose
antidepressant, to treat hot flashes. Women who use an antidepressant to help manage hot flashes generally take a lower dose
than those who use the medication to treat depression. Menopausal hormone therapy (MHT; or estrogen replacement therapy,
ERT; or hormone replacement therapy, HRT), which steadies the levels of estrogen and progesterone in the body, is very
effective at reducing the number and severity of hot flashes and in reducing vaginal dryness and bone loss. MHT was a widely
recommended treatment for menopausal symptoms until it was learned that side effects may include an increased risk of
breast cancer, stroke, and heart attacks. Newer versions of treatments developed since these findings may reduce the risk of
using hormones for women experiencing the menopausal transition, but research is needed to evaluate the long-term safety of
these newer treatments. The recommendation for those women who can benefit most from hormonal therapy is to consult
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with their healthcare provider about taking the lowest dose of a combined estrogen–progesterone formula for the shortest time
that is consistent with the reason for the therapy (National Institute on Aging, 2016b). As is the case for all prescription
medications, hormone therapy should be reevaluated regularly. Synthetic or “bioidentical” hormones are assumed to have the
same risks as any hormone therapy, and it is unknown whether herbs or other so-called natural products are helpful or safe
because the benefits and risks are still being studied.
Sleep
Older adults need about the same amount of sleep as do young adults—7 to 9 hours each night. On the other hand, sleep
patterns change with age. We often need more time to fall asleep as we grow older. The amount of time spent in rapid eye
movement (REM) sleep and non-REM sleep (the deepest and most restful sleep) shifts as we get older, with a decrease of
time in deep sleep. Compared to younger people, older people tend to sleep more lightly and awaken more quickly in
response to noises. Once awake, they can find it harder to get back to sleep (Ohayon, Carskadon, Guilleminault, & Vitiello,
2004).
It is not clear how many of these changes in sleep result from the normal aging process or from factors such as medications,
lack of exercise, napping during the daytime, or disease. Older adults tend to take more medications than do younger people,
and medications and their side effects can impair sleep or even stimulate wakefulness. A sedentary lifestyle can lead to
sleepiness all the time, or a lack of sleepiness. Sleep may be disturbed more frequently by an older person’s increased
probability of needing to urinate during the night, by rhythmic leg movements, or by sleep-disordered breathing such as
snoring or sleep apnea. Older persons may suffer from pain due to arthritic or other medical problems that may disrupt sleep.
In addition, psychological stress brought about by significant life changes, such as the death of a loved one or moving, can
inhibit sleep. A variety of psychological and behavioral treatments have proven to be effective in relieving sleep problems and
reducing or eliminating the use of sleep medications, even among individuals whose sleep problems may be related to a
chronic condition or pain (Morin et al., 2006). For example, cognitive behavioral therapy has been shown to significantly
reduce sleep latency (time to get to sleep), increase total sleep time, and eliminate the use of sleeping pills (Espie, Inglis,
Tessier, & Harvey, 2001).
In the National Health and Nutrition Survey, 2013 to 2014, 19.2% of 20- to 39-year-olds said that they had told a doctor or
other health professional that they had trouble sleeping, 32.8% of 40- to 59-year-olds said they had, and 33.2% of those 60
years of age and up said they had. Thus, while there is a relationship between age and trouble sleeping, poor sleep is not
inevitable as we age. Among the ways to adapt to sleep changes is to maintain daytime activities with some exposure to fresh
air, if possible. For people of all ages, good sleep hygiene, which is discussed in Chapter 3, Health and wellness for Older
Adults, can go a long way toward regularly obtaining a good night’s sleep.
BIOLOGICAL THEORIES OF AGING
Now that you know some important facts about the most common physical changes that accompany aging, you may be
asking, “How do these changes come about?” and “Why do these changes come about?” Biologists will tell you that aging is
a part of the circle of life. All organisms begin aging from the day they are born. Although biologists agree that genetic
programming determines the biological course of development from conception to reproductive maturity, there is much
debate among them about what happens after that. Ideas about the causes of aging have been around for at least 2,000 years,
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and as many as 300 have been put forward (Medvedev, 1990). Many of these ideas have been dismissed because they have
not stood up to the evidence. Two different paradigms for the causes of aging have emerged over time, each with their related
theories (see Table 2.1). According to one paradigm, aging is a result of the accumulation of damage or errors that occur over
the lifetime of an organism, gradually diminishing its ability to survive. According to the second paradigm, aging is driven by
a genetic program, that is, it is encoded in the genome.
TABLE 2.1 Paradigms of Biological Aging and Examples of Their Theories
DAMAGE ACCUMULATION PARADIGM
PROGRAMMED PARADIGM
Mutation accumulation theory
Programmed cell death/Telomere theory
Disposable soma theory
Neuroendocrine theory
Mitochondrial theory
Antagonistic pleiotropy theory
Damage Accumulation Theories of Aging
The mutation accumulation theory proposes that genes with negative effects on survival in late life tend to accumulate in an
organism’s genome, causing the decline and damage that we associate with aging ( Medawar, 1952). Genes whose negative
effects on survival appear only later in life would be passed from generation to generation because they do not affect an
organism’s offspring production. A good example of this principle can be found in Huntington’s disease, an almost entirely
inherited disease, the symptoms for which begin to appear only around age 40. Unless a person has been genetically tested
earlier in life, by the time he or she is diagnosed most people who are carriers of Huntington’s may have already had children,
and hence passed on the disease to the next generation. Though Huntington’s is a rare disease, its prevalence could be even
further reduced if early genetic testing became widely used.
According to the disposable soma theory, physiological and/or biochemical resources are limited and must be allocated
between maintenance and growth of an organism on the one hand, and reproduction on the other ( Kirkwood, 1977, 1990). A
higher investment in maintenance could prevent aging, but that would reduce reproduction, ultimately diminishing
evolutionary fitness. Thus, natural selection pressure favors reproduction at the expense of maintenance. Failure of
maintenance leads to aging because it makes organisms more susceptible to disease and environmental stresses.
The mitochondrial theory of aging, originally developed as the free radical theory of aging and subsequently revised (
Harman, 2009), proposes that mitochondria produce reactive oxygen species (ROS), which cause oxidative damage to DNA,
lipids, and proteins. The damage accumulates over the lifetime of an organism, ultimately leading to a loss of functionality
and death. Recent research (Ziegler, wiley, & Velarde, 2015) has revealed several different mechanisms through which
mitochondria could produce these effects.
Programmed Theories of Aging
The programmed cell death, or telomere, theory focuses on the protective structures at the ends of DNA chromosomes
(telomeres; Aubert & Lansdorp, 2008). Cells divide a limited number of times over the course of life, and the number depends
on an organism’s species. Named after the scientist who discovered the limit, the Hayflick number is between about 40 and 50
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for human cells (Hayflick, 1961). With each cell division, telomeres are shortened until the cell stops functioning properly (
Harley, Futcher, & Greider, 1990). Cells that are not protected by telomeres deteriorate and die. However, not all cells divide,
and for some cells that do, such as stem cells, the telomerase enzyme can rebuild the ends of DNA chromosomes.
The neuroendocrine system is composed of a complicated network of hormones that are regulated by the hypothalamus, a
structure at the base of the brain, and the pituitary gland. This system regulates virtually every function in the body.
According to the neuroendocrine theory of aging (Dilman, 1971, 1986), functional changes are programmed in neurons and
hormones, with the hypothalamic-pituitary-adrenal (HPA) axis as the timekeeper for these aging changes.
The basic idea of the antagonistic pleiotropy theory is that some genes that confer positive benefits early in life, and are
therefore selected, also confer negative effects later in life (Williams, 1957). Pleiotropy means that a single gene influences
more than one observable characteristic of an organism. In antagonistic pleiotropy, one of these effects is beneficial and
another is detrimental. One example comes from considering the possibility that one allele could have a positive effect on
bone growth during an individual’s early stages of development, but a negative effect of depositing excess calcium within
arterial walls later in life, leading to high blood pressure and blood clots, and increasing the risk of strokes and heart attacks.
Aging is a complex, multifactorial process. Despite a plethora of aging theories, there is not yet a single comprehensive
theory that explains why we age. It seems likely that neither the paradigms nor all the theories of aging are mutually exclusive
and that aspects of many of them will eventually be brought together to explain the aging process. A giant step in that
direction has been taken by a group of researchers who have created the Digital Ageing Atlas (see Suggested Resources),
which is compiling data on age-related changes in humans across different biological levels, and making them freely available
online (Craig et al., 2015).
Rate of Aging: Caloric and Dietary Restriction, Growth Hormone, and Exercise
Regardless of the cause of aging, there is much interest in discovering ways to decrease the rate at which aging takes place.
There are very great differences among individuals in the aging process. Among the possible ways of changing the rate of
aging, caloric and dietary restriction, the use of growth hormone, and physical activity have all been suggested.
Caloric and dietary restriction are both associated with the idea that limiting food intake without malnutrition can slow the
aging process. In fact, caloric restriction has been demonstrated to delay the aging process, prevent the onset of aging-related
diseases, and increase the life span of a variety of organisms (Xiang & He, 2011). Researchers are beginning to understand
the reasons for these effects, although there is much more to be learned (López-Lluch & Navas, 2016). Only one study to date
has conducted a randomized trial of the effects of caloric restriction on a large group of humans (age range: 21–50 years), the
Comprehensive Assessment of Long-term Effects of Reducing Intake of Energy (CALERIE; Ravussin et al., 2015). The
participants in the caloric restriction group experienced reduced risk factors for several age-related diseases including those
related to cardiovascular disease and diabetes, namely lower blood pressure, lower cholesterol, and decreased insulin
resistance. On average, participants in this study achieved only a 12% reduction in calories, though the goal was 25%. Thus,
the researchers were careful to point out that, “Our study, which involved a highly motivated population and very intensive
behavioral intervention, provides limited evidence regarding the feasibility of [caloric restriction] in broader nonobese
populations or with less intensive interventions” (Ravussin et al., 2015, p. 1102). Dietary restriction is an alternative to caloric
restriction. There is a variety of different forms of dietary restriction including: time-restricted feeding, an example of which
is eating only within a period of 12 hours or fewer per day; intermittent feeding (IF), an example of which is to adopt a
reduced calorie diet for only 2 days a week (referred to as a 5:2 diet); and fast-mimicking diets (FMDs), in which on those
days when calories are restricted the diet is augmented with micronutrients. Research into dietary restriction regimes in
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humans, still in its infancy, has begun to show its positive effects on risk factors for age-related diseases (Longo & Panda,
2016). Compared to caloric restriction, some of these forms of dietary restriction are also more likely to be adopted by
humans.
In the case of growth hormone, there are major concerns about its potentially serious side effects, which do not bode well
for it having a role in slowing individuals’ aging processes. Physical activity, however, has much promise in keeping people
healthy throughout their life spans. The importance of physical activity is discussed in Chapter 3, Health and wellness for
Older Adults.
PRACTICAL APPLICATION
INTRODUCTION
Chapter 2 outlines the normal physical changes that accompany aging and differentiates them from the diseases and
conditions that become more common with age. It also provides a discussion of the adaptations that older people can make to
accommodate such changes in their health. The chapter concludes with a summary of the two basic paradigms of the
biological theories of aging. Your ability to apply evidence-based theory to the scenarios you will encounter in the workplace
will play an important role in your professional success. Therefore, the theories presented in Chapter 2 are the focus of this
Practical Application.
THE BIOLOGICAL THEORIES OF AGING
Chapter 2 offers a summary of the two basic paradigms of the biological theories of aging. Your ability to apply evidencebased theories such as these to the scenarios you will encounter in the workplace will play an important role in your
professional success.
The damage accumulation and programmed theories of aging provide us with possible frameworks for understanding how and
why the physical changes of aging occur. Why is this information important to us? One reason, perhaps driven by a cultural
idolization of youth, would be to delay or even prevent aging as a way to stay forever young. However, for those of us who
work in the field of gerontology, we can employ our understanding of the aging process to better address the needs and issues
of the aging community we serve.
Take a few moments to reflect on the many physical changes described in Chapter 2 and the challenges associated with them.
For example, some older adults experience both physical and emotional distress as a result of urinary incontinence. How
could the biological theories of aging be applied to this challenge in order to alleviate the discomfort associated with it?
The best answer may not yet be known. Certainly there is more research to be done on the mechanisms of aging. In the
meantime, these theories provide valuable insights that may someday result in preventative, diagnostic, and treatment
measures aimed at helping older adults. Regardless of your role within the gerontology field, it will be important to stay
informed about current theoretical frameworks and the ongoing research behind them in order to make the most informed and
ethical decisions on a day-to-day basis.
STUDENT ACTIVITIES
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1. Differentiate between the normal physical changes that occur as part of the aging process and the medical conditions
commonly seen in the aging population. Provide three examples of each.
2. Abe and Maureen are both in their 60s and experiencing many of the physical changes associated with aging. Describe
some of the transformations that may be taking place and explain how their experiences might differ given their
genders.
3. Think of one or two older adults in your life. List at least three of the normal changes they have experienced as a result
of aging, describe the accommodations they made as a result of those changes, and explain how those accommodations
helped them maintain their quality of life.
4. On the basis of information provided by the Hearing Loss Association of America (www.hearingloss.org), outline four
ways to determine when sound is too loud. Then offer four examples of sounds that, with overexposure, could result in
hearing loss.
5. Conduct a search on Google Scholar (scholar.google.com) for journal articles related to the effects of oxidative stress
on the aging process. List the titles of five journal articles that look interesting to you and that were published no earlier
than 2015.
SUGGESTED RESOURCES
Digital Ageing Atlas. Retrieved from http://ageing-map.org
The DAA is a collection of human age-related data from various biological levels—molecular, cellular, physiological, psychological, and pathological. The
website includes anatomical models and tools to select and graph the data. Some data are also included from aging studies of mice. The Atlas is available for use
at no cost.
Hearing Loss Association of America. Retrieved from http://www.yourhearingloss.org
HLAA provides assistance and resources for people with hearing loss, and their families, to learn how to adjust to living with hearing loss. HLAA is working to
eradicate the stigma associated with hearing loss and to raise public awareness about the need for prevention, treatment, and regular hearing screenings
throughout life.
National Association for Continence. Retrieved from https://www.nafc.org
This nonprofit association’s goal is to destigmatize, promote prevention, and educate the community about incontinence. It provides a national database for
individuals seeking support and diagnosis of incontinence and incontinence-related disorders.
National Eye Institute. Retrieved from https://www.nei.nih.gov
Established by Congress in 1968 to protect and prolong the vision of the American people, NEI’s research leads to sight-saving treatments, reduces visual
impairment and blindness, and improves the quality of life for people of all ages.
North American Menopause Society. Retrieved from http://www.menopause.org
This nonprofit organization is dedicated to promoting the health and quality of life of all women during midlife and beyond through an understanding of
menopause and healthy aging. On the website are resources for clinicians, researchers, and the public. Visitors to the site can search for a menopause
practitioner in the United States and Canada, find answers to frequently asked questions, get information on menopause topics, and access a variety of other
resources.
REFERENCES
American Optometric Association. (n.d.). Dry eye. Retrieved from http://www.aoa.org/dry-eye.xml
Arts, I. M. P., Pillen, S., Overeem, S., Schelhaas, H. J., & Zwarts, M. J. (2007). Rise and fall of skeletal muscle size over the entire life span. Journal of the
American Geriatrics Society, 55(7), 1150–1152. doi: 10.1111/j.1532-5415.2007.01228.x
Aubert, G., & Lansdorp, P. M. (2008). Telomeres and aging. Physiological Reviews, 88(2), 557–579. doi:10.1111/j.1532-5415.2007.01228.x
Avci, P., Gupta, G. K., Clark, J., Wikonkal, N., & Hamblin, M. R. (2014). Low-level laser (light) therapy (LLLT) for treatment of hair loss. Lasers in Surgery and
Medicine, 46(2), 144–151. doi:10.1002/lsm.22170
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Bainbridge, K. E., & Ramachandran, V. (2014). Hearing aid use among older US adults: The National Health and Nutrition Examination survey, 2005-2006 and
2009-2010. Ear and Hearing, 35(3), 289–294. doi:10.1097/01.aud.0000441036.40169.29
Bauer, J., Biolo, G., Cederholm, T., Cesari, M., Cruz-Jentoft, A. J., Morley, J. E., . . . Boirie, Y. (2013). Evidence-based recommendations for optimal dietary
protein intake in older people: A position paper from the PROT-AGE study group. Journal of the American Medical Directors Association, 14, 542–559. doi:
10.1016/j.jamda.2013.05.021
Bauer, M., McAuliffe, L., Nay, R., & Chenco, C. (2013). Sexuality in older adults: Effect of an education intervention on attitudes and beliefs of residential aged
care staff. Educational Gerontology, 39, 82–91. doi:10.1080/03601277.2012.682953
Berry, M. (2015). Old age is a gift. Alcalde. Retrieved from http://alcalde.texasexes.org/2015/07/old-age-is-a-gift
Bickel, C. S., Cross, J. M., & Bamman, M. M. (2011). Exercise dosing to retain resistance training adaptations in young and older adults. Medicine and Science in
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Sugar, Judith A.. Introduction to Aging : A Positive, Interdisciplinary Approach, Springer Publishing Company, Incorporated, 2019. ProQuest Ebook Central,
http://ebookcentral.proquest.com/lib/uml/detail.action?docID=5841422.
Created from uml on 2025-09-03 16:28:42.