------------------------------------------------------------------------------- TITLE: Geriatric Otolaryngology SOURCE: Dept. of Otolaryngology, UTMB, Grand Rounds DATE: 7 February 1990 RESIDENT PHYSICIAN: Lane F. Smith, M.D. FACULTY: Byron J. Bailey, M.D. DATABASE ADMINISTRATOR: Melinda McCracken, M.S. -------------------------------------------------------------------------------- "This material was prepared by resident physicians in partial fulfillment of educational requirements established for the Postgraduate Training Program of the UTMB Department of Otolaryngology/Head and Neck Surgery and was not intended for clinical use in its present form. It was prepared for the purpose of stimulating group discussion in a conference setting. No warranties, either express or implied, are made with respect to its accuracy, completeness, or timeliness. The material does not necessarily reflect the current or past opinions of members of the UTMB faculty and should not be used for purposes of diagnosis or treatment without consulting appropriate literature sources and informed professional opinion." I. THE GERIATRIC POPULATION A. Epidemiology 1. 12% of the population is over age 65 (28 million people) 2. The number of those over 65 will increase to 18% of the population in the next 10 years. 3. Since 1900 the population of those over 65 has increased 9 fold and those over eighty 21 fold. 4. For the first time in the history of America there are more people over the age of 65 then under the age of 18. 5. The fastest growing segment of our population is the over 85 age group (2.7 million). Their number is expected to double by the year 2000 and by the year 2050 there will be 15 million people over age 85. 6. There are 35,000 Americans over 100 years old and that number is expected to triple by the year 2000. B. The costs of an aging population 1. In the 1960's less then 15% of all federal dollars went to those over 65, by 1985 28% of all federal dollars went to those over 65. 2. Increased need to support people for longer periods after retirement. 3. Skyrocketing medical costs a. 1984 costs from medicare were 59 billion dollars, of this only 196 million went to otolaryngologists. These costs cover only about 2/3 of the medical costs of the elderly. b. About 55% of hospitals loose money under the current medicare payment system for the elderly. c. Those over 65 while consisting of only 12% of the patient population account for 30% of hospital admissions and more then 47% of hospital days. C. Health problems in our aging population 1. Most older people have at least one chronic condition and many have more then one. 2. The most common health problems: a. Arthritis (47%) b. Hypertension (39%) c. Hearing impairments (29%) d. Heart disease (30%) e. Orthopedic impairments (29%) f. Sinusitus (17%) g. Cataracts (17%) h. Diabetes (10%) I. Visual impairments (10%) 3. 50,000 people get head and neck cancer most are over the age of 50 (more then 50% are older then 60). 15,000 people die each year from this. D. Goals and lifestyles of the elderly in the 1990's 1. Not only longer life, but better quality of life. 2. Examples of healthy elderly: Ada Thomas 72 y.o. b.f. who began jogging at age 65 and completed a marathon at age 68. Helen Zechmeister age 81 powerlifter who lifts 245 lbs and squats 148 lbs. Walter Stack who is the oldest man to finish the Iron Man Triathalon at age 74. 3. There has been a great increase in the demand for plastic and cosmetic surgery (up 61% from 1981 to 1984). 4. They want cheaper health care. 5. They want more political clout. II. NORMAL AGING A. Changes in stature and posture 1. Kyphosis 2. Postural changes a. flexion at the knees b. flexion of the hips c. Head droops forward 3. Height decreased progressively after age 40 in females and age 50 in males. 4. Total decrement 1.5 to 3.0 cm, and is mostly due to shortening of the vertebral column (arm span remains unchanged) a. disc's narrow b. vertebrae shorten c. osteophytes form on the spine 5. Shortening of the neck a. Thyroid may descend to clavicles b. Submandibular glands may become ptotic and be confused for a neck mass c. Lengthening of the aorta may cause elevation of the aortic arch causing the right innominate artery to come up into the neck resulting in a kinking of the artery, producing a pulsating palpable mass behind the the clavicular portion of the sternocliedomastoid. This is more common in hypertensives and women. B. Bone and joint changes 1. Osteoarthritis (DJD) almost universal in the knee and spine. 2. See other spinal changes above. 3. Osteoporosis in women. C. Skin changes 1. Loss of subcutaneous fat 2. Loss of elastin fibers and skin elasticity 3. Wrinkling of skin 4. Thinning of skin 5. alteration in ground substance; the amount of glycosaminoglycans decrease and keratin sulfate increases 6. Soluble collagen decreases and insoluble collagen increases D. Contour changes 1. The loss of subcutaneous fat leads to increasing sharpness of body contours 2. Bony landmarks become increasingly prominent. This gives the elderly a bony appearance and is not significantly reversible by increased caloric intake. a. Tip of vertbrae become more prominent b. Also angles of scapula c. ribs d. sternum e. crests of the ilium f. patella 3. Tendinous attachments become more visible 4. Subcutaneous loss in the orbits give the eyes a hollow sunken appearance. E. Skeletal muscle decreases; at age thirty we have 452g muscle per kilogram body weight, at age seventy only 270g/kg. F. Body Hair 1. Hair becomes thinner 2. Hair becomes depigmented (may become yellow or green) 3. Gradual loss of axillary and pubic hair proceeding from the periphery to center (the opposite of changes seen in puberty) 4. Loss of hair from the outer third of the eyebrows 5. Females may have increased facial hair G. Facial changes 1. See skin changes above 2. Dieting in middle age may accentuate wrinkles 3. Among the earliest wrinkles are on the forehead 4. Generalized ptosis (eyelids, nose, ears, jowls etc.) 5. Cartilaginous supports droop a. elongation of the ear, which averages 12mm mostly secondary to lobe becoming pendulous b. Drooping of nose due partly to loss of cartilagenous supports and cartilage resilience 6. Neck changes may be greater then face changes 7. Face appears pale and anemic secondary to loss of capillaries and loss of functioning melanocytes 8. Fluid retention leads to edema of the eyes with venous congestion (baggy eyelids) H. The aging brain 1. Decrease in memory; most marked in short term memory. 2. A loss of 100g to 150g of brain tissue during a life span. 3. Increase in ventricle and cistern size. 4. Loss of neurons begins around age 20 for a total loss of 30% of neurons by age 90. 5. Generalized slowed cerebration and slight decrease in intelligence. G. Generalized decline in function of nearly every organ system: immune system, pulmonary, cardiovascular, hepatic, kidney, endocrine etc. III. PRESBYCUSIS (literally elderly hearing) A. The basic etiologic factors are unknown, probably multifactorial etiology. Wear and tear of the auditory system (lifetime of noise trauma and environmental toxins) and a genetically programmed biologic degeneration of the auditory system as a sequel to aging. B. Presbycusis is commonly separated into 3 or 4 categories which may occur singly or in combination. C. Characterized by progressive symmetrical sensorineural hearing loss, more often in the high frequencies. D. The four types of presbycusis 1. Sensory Presbycusis a. Bilateral symmetrical high-tone hearing loss with an abrupt slope. b. Involves mostly the basel turn of the cochlea c. Characterized by the loss of hair cells and sustentacular cells. d. Acoustic trauma felt to be most important factor in development of this type of hearing loss. 2. Neural Presbycusis a. may begin at any age, but hearing loss only noted late in life when population of neural units falls below that required for effective processing of acoustic information. b. progressive loss of about 2000 neurons per decade. c. effects all areas of the cochlea d. effects all frequencies 3. Strial or Metabolic Presbycusis a. characterized by atrophy of the stria vascularis b. often runs in families c. effects mainly middle and apical ends of the cochlea d. effects all frequencies 4. Cochlear or Conductive Presbycusis (an optional classification) a. characterized by a gradual sloping hearing loss b. word discrimination correlates with slope of loss c. possibly due to a thickening of the basilar membrane d. hearing loss greatest in the high frequencies IV. Dysequilibrium of aging (PRESBYSTASIS) A. Dysequilibrium the first or second most common ENT diagnosis in patients older then 65. B. Balance requires a large amount of integration from many systems. C. Cerebellum 1. Degenerative changes in the cerebellum probably the most important cause of balance disturbances in the elderly. 2. The cerebellar ocular system and cerebellar vestibular spinal system are greatly effected by aging. 3. There is a greater loss with aging of Purkinje cells in the cerebellum, than in the rest of the brain, which occurs most markedly around the fifth decade. 4. Compensation for unilateral vestibular and bilateral vestibular defects is therefore decreased in the elderly. D. The vestibular ocular reflex shows little change with aging E. The vestibulospinal reflex 1. Is greatly effected by aging, with decrease in function. 2. Measured by posturography 3. Leads to increased postural sway and increased risk of falling. F. The vestibular system 1. Input from the vestibular system is decreased by up to 30% in the elderly. 2. There is an increased prevalence of vestibular disorders in the elderly. 3. Several degenerative changes occur in the otoconia with aging a. first pitting, then cavitation, then fragmentation of of then otoconia b. this leads to cupulolithiasis 4. Other degenerative changes include: a. loss of vestibular neurons b. changes in hair cells (ie. increased vacuolization, lipofuscin etc.) c. loss of sensory epithelium in maculae and ampullae d. microfractures of the otic capsule e. occ. rupture of the saccular membrane 5. A 30% loss of sensitivity in the horizontal canals is found on caloric testing. G. Other neurological disorders (of increased prevalence in the elderly) which effect balance. 1. Parkinsons disease 2. Huntingtons chorea 3. Vit. B12 deficiency 4. Dementia 5. Diabetic neuropathy 6. Loss of integrity of the autonomic nervous system 7. Brain and spinal cord tumors H. Other conditions effecting balance 1. Postural hypotension (autonomic nervous system, medications, etc.) 2. Cerebrovascular disease 3. Atherosclerosis (leading to cerebral hypoperfusion) 4. Musculoskeletal disorders 5. Metabolic disorders (thyroid disease, Addisons disease etc.) 6. Cardiovascular disease (arrythmias, HTN etc.) 7. Medications 8. Visual impairment (cataracts) V. THE AGING VOICE A. Pitch is increased with old age in men 1. Felt to be due to muscle atrophy and fibrosis of the vocal ligament. 2. Vocal cords thickest (and voice deepest) at age 40's to 50's, then they begin a progressive thinning. 3. The pitch change is more noticeable in males then females. B. In Females the pitch gets lower with age 1. Felt to be due to frequent finding of vocal cord edema (Reinkes space edema). 2. Most often occurs in female smokers. 3. At extreme age pitch increases again (70's to 80's) C. Resonance changes with age 1. Ossification of laryngeal cartilages felt to play a role, begins in the 20's and usually complete by age 65. 2. Range of arytenoid excursion may be decreased secondary to cartilage ossification. D. A glottic gap (poor glottic closure) may be a normal change in a elderly person and may cause a breathy voice E. Acoustic instability or tremulousness, increases with age but in more related to general physical condition then age F. Patients may attempt to compensate for voice changes leading to vocal nodules etc. (common in males) G. Older speakers tend to speak slightly louder, speak slower, take longer pauses and have more imprecise articulation then younger speakers H. Common causes of dysphonia in elderly 1. Gastroesophageal reflux 2. Essential tremor 3. Parkinsons disease (a flat monotone voice may be the first symptom of this disease) 4. Stroke 5. Amyotropic lateral sclerosis 6. Iatrogenic 7. Causes of vocal cord paralysis (ie. Cancer etc.) VI. OLFACTION AND TASTE IN AGING A. Aging changes cause a decrease in our sense of smell 1. The olfactory neuroepithelium is gradually replaced with respiratory epithelium (this is felt to be due to repeated insults to the epithelium such as URI's and exposure to environmental toxins) 2. Radiation therapy damages olfactory neuroepithelium 3. Downward displacement of the nasal tip, alar cartilages, and nasal sill that occur with aging lead to a narrowed nasal valve and precludes the nose to easier obstruction 4. Decreased immune function leads to an increase in viral and bacterial infections (ie. increased incidence of sinusitus etc.) 5. There is a generalized atrophy of the nasal mucous membrane which leads to increased mucous crusting 6. The worsening of olfaction begins earlier in women then men and becomes most marked around age 65. Peak performance in odor identification occurs around age 30 to 40. 7. The worsening in olfaction leads to a decrease in flavor sensation. B. Taste (gustation) seems to be less effected by aging then olfaction. 1. The suprathreshold taste sensation is not usually impaired to any great extent. Older patients are slightly less sensitive to NaCl then younger patients. 2. Elderly loose taste perception is patchy area on the tongue and palate 3. Xerostomia is more common is the elderly, but only minimally effects taste thresholds. C. Disturbances in olfaction and gustation can herald the onset of a number of diseases in the elderly including; Korsakoffs psychosis, Parkinsons disease, alzheimers disease, intracranial neoplasms (meningiomas), viral infections, autoimmune diseases, and neurotoxicity. 1. Some researchers suggest that alzheimers disease has it's origins in the olfactory system and loss of olfaction is an early sign of alzheimers disease. 2. Olfactory disturbances occur in people with parkinsons, but the degree of olfactory disturbance does not correlate with the severity of the parkinsons disease. VII. PRESBYPHAGIA Primary presbyphagia: deglutition modified by physiologic changes that accompany aging. Secondary presbyphagia: dysphagia in elderly attributable to specific disorders such has neurologic, iatrogenic, or other comorbidites. A. Presbyesophagus; refers to alteration in esophageal motility thought to be due to degenerative aging changes of the esophagus 1. Resting esophageal pressures are higher 2. Esophageal peristaltic contractions are weaker and less coordinated B. Diaphragmatic hernias 1. Incidence increases progressively each decade (10% of those under age forty have this, to over 70% of those who are age seventy have a diaphragmatic hernia). 2. Complications such as volvulus and paraesophageal hernias are more likely in aged. C. Dysphagia Aortica 1. Refers to impingement on the mobile upper esophagus by a thoracic aortic aneurysm or rigid atherosclerotic aorta. 2. Conservative measures usually work as therapy (ie. avoid solid bulky foods.) D. Barrets esophagus (replacement of the stratified squamous epithelium of the esophagus with columnar epithelium) and esophageal carcinoma occur most frequently between the ages of 50 to 70 and need be considered in the elderly patient with dysphagia. E. Other disorders causing dysphagia found chiefly in senescence include: 1. Atrophic gastritis 2. Esophageal diverticuli (mid esophageal and epiphrenic) 3. Plummer Vinson syndrome (1/2 the pts. over age 50) 4. Esophageal candidiasis F. Neurological diseases leading to dysphagia and/or aspiration found chiefly in the elderly: 1. CNS neoplasms 2. Drugs 3. Myoclonus 4. Tardive dyskinesias 5. Amyotrophic lateral sclerosis 6. Progressive bulbar palsy VIII. ASPIRATION (more common in the elderly for all of aforementioned esophageal and neurological reasons) A. Most often due to difficulty with phase one (the oral phase of swallowing). B. Often improved dental prostheses can be of benefit in patients with this problem. C. Vocal cord paralysis or an open glottic chink are frequently causes of aspiration 1. RLN damage, cancer, s/p CA or thyroid surgery, CVA's leading to vagus n. lesions, neuromuscular disorders. 2. Incomplete glottic closure is a common often normal finding in the aged (as was previously stated). 3. Posterior glottic closure most important for prevention of aspiration. An anterior opening in the vocal cords rarely leads to significant aspiration. D. Treatment aimed at correction of the underlying disorder. Many surgical procedures exist for alleviation of the problem of aspiration. (total laryngectomy, Glottic prosthesis, vocal cord augmentation etc.) IX. HEAD AND NECK CANCER AND THE AGING IMMUNE SYSTEM A. As mentioned the majority of head and neck cancer occurs in those over age 50. (More detailed discussion on head and neck cancer to be covered in other grand rounds topics.) B. Impaired immunity in the elderly 1. Felt to be one reason why cancer is more common in this age group. 2. All areas of the immune system function more poorly in the aged. a. There is decreased production of immune mediators (lymphokines, etc.) b. Cellular immunity (T-cell mediated immunity), is is effected to a much greater extent by aging then humoral immunity (B-cell mediated, immunoglobulins). c. Cellular immunity is thought to play a primary role in prevention of cancer. 3. The incidence of autoimmune diseases is increased in the elderly. 4. Radiation therapy (used in cancer patients) further impairs the immune system. C. Immunotherapy may play a role in the treatment of cancer in the aged. (ie. administration of immune mediators etc.) X. PLASTIC AND RECONSTRUCTIVE SURGERY A. Skin (see previously mentioned comments) 1. Many, if not the majority, of age related changes in the skin are related to solar damage. 2. Wrinkles, solar elastosis, seborrheic keratosis, basal and squamous cell carcinoma and melanomas more common. B. Plastic, reconstructive and cosmetic surgery 1. Less is better; surgery must be done conservatively. These patients usually wish to be restored not remade. Minimal excision and contour changes are desirable. 2. Skin is less elastic, cartilage less resilent, and bone is more brittle in these patients. 3. Wound healing is impaired in the elderly and tension must be avoided. There is reduced collagenous healing which can be used to the surgeons advantage to create delicate and better camouflaged scars. 4. Remember, the face in the aged has a poorer blood supply. 5. Because of the increased number and complexity of some busy facial plastic surgeons recommend a complete medical workup by an internist prior to surgery. 6. One author felt that the Shaw hemostatic scalpel was a significant advance in this area of surgery and indispensable for use in the elderly because of less post-op swelling, ecchymosis, and patient discomfort. XI. GOALS OF THE GERIATRIC OTOLARYNGOLOGIST (as taken from Dr. Byron Bailey's summary in Perspectives on Health Care for the Elderly, chapter 27, Geriatric Otolaryngology pp. 189 - 192.) A. Prevention of premature death by the early detection of head and neck cancer, improved management of trauma, and programs directed at smoking and ethanol cessation. B. Prevention of disability, particularly through programs of hearing conservation and the improved treatment of hearing loss. C. Control and management of annoying to disabling symptoms such as nasal congestion, chronic sinusitis, tinnitus and vertigo. D. Treatment of common and usually benign diseases such as upper respiratory infections, acute sinusitis, otitis media and pharyngitis. E. Management of conditions that limit mobility and promote isolation among the elderly, such as hearing loss, dysequilibrium and voice changes. F. Improvment of quality of life, for example with facial and reconstructive surgical techniques. G. Treatment of sometimes fatal conditions such as head and neck cancer. H. Providing informed participation in the societal deliberations concerning the social and economic aspects of the disproportionate growth of the elder segment of our population. BIBLIOGRAPHY 1. Rowe J., Besdine R.: Geriatric Medicine; second edition. Little, Brown and Company, 1988. 2. Goldstein, et al.: Geriatric Otolaryngology; 1989. 3. Johns M., et al.: Goals and mechanisms for training for training otolaryngologists in the area of geriatric medicine. Otolaryngology Head Neck Surgery: vol 100:4 April 1989 pp. 262 - 265. 4. Gates G., et al.: Presbycusis. Otolaryngology Head and Neck Surgery: vol 100:4 April 1989 pp. 266 - 271. 5. Jenkins H. A., et. al.: Dysequilibrium of aging. Otolaryngology Head and Neck Surgery: vol 100:4 April 1989 pp. 272 - 281. 6. Leopold D. A., et. al.: Aging of the upper airway and the senses of taste and smell. Otolaryngology Head and Neck Surgery: vol 100:4 April 1989 pp. 287 - 289. 7. Ward P. H., et. al.: Aging of the voice and swallowing. Otolaryngology Head and Neck Surgery: vol 100: April 1989 pp. 283 - 286. 8. Endicott J. N., et al.: Head and neck surgery and cancer in aging patients. Otolaryngology Head and Neck Surgery: vol 100:4 April 1989 pp. 290 - 291. 9. Eufemio M. A.: Problems in the therapy of thyroid disease in the elderly. Geriatric Medicine vol 8:67 June 1989 pp. 67 - 73. 10. Brandstetter R. D.: Chronic Aspiration. Geriatric Medicine December 1988; pp. 60. 11. Babin R. W., Harker L. A.: The vestibular system in the elderly. Otolaryngology Clinics of North America: vol 15, number 2; May 1982 pp. 387 -393. 12. Boone. D. R., et. al.: Communicative aspects of aging. Otolaryngology Clinics of North America: vol 15, number 2; May 1982 pp. 313 326. 13. Anderson R. G., Myerhoff W. L.: Otologic manifestations of aging. Otolaryngology CLinics of North America: vol 15, number 2; May 1982 pp. 353 -368. 14. Chvapil M., Koopmann C. F.: Age and other factors regulating wound healing. Otolaryngology Clinics of North America: vol 15, number 2; May 1982 pp. 259 -268. 15. Saunders R. J.: Anesthesia and the geriatric patient. Otolaryngology Clinics of North America: vol 15, number 2; May 1982 pp. 395 - 402. 16. Stuart W. H.: Geriatric neurology for the otolaryngologist. Otolaryngology Clinics of North America: vol 15, number 2; May 1982 pp. 329 - 350. 17. Norre M. E., et. al.: Vestibular dysfunction causing instability in aged patients. Acta Otolaryngologica (Stockh): 1987 vol 104; pp. 50 - 55. 18. Cohen H. J., Lyles K. W.: Geriatrics. JAMA: 1989 May 19;261 pp. 2847-2848. 19. Bressler R.: Adverse drug effects in the elderly patient. Otolaryngology Clinics of North America: vol 15, number 2; May 1982 pp. 451 - 461. --------------------------------END--------------------------------------------