TOPIC 1: INTRODUCTION TO AGEING

WHAT IS AGEING?

Aging is an ongoing process that leads to the loss of functional reserve of

multiple organ systems, increased susceptibility to stress, it is associated with
increased prevalence of chronic disease, and functional dependence.
Determined by a combination of genetic and environmental factors, this
process is highly individualized and poorly reflected in chronologic age. 1

Here are two ideas that most people in Western cultures would agree on:
ageing is something that affects everybody,
ageing results in functional decline and is at best a challenge, at worst a
burden.
However, in cultures which venerate (=revere) age, the changes that occur
may be viewed as welcome and desirable.
This shows us one important idea about ageing:

we interpret ageing in terms of our cultural beliefs.

The way that we interpret ageing is important because the way that the ageing
population view themselves, and the way that they are viewed by other sectors
of society, has a significant impact on the provision of aged care services.

This means that your perceptions impact on the way that you provide care and
on the way that your clients receive care.

To provide the best quality care for the aged, you must have a positive outlook
on ageing and the aged care process.
For the aged to receive the maximum benefit from care, they must be receptive
(= willing to listen to or to accept new ideas or suggestions) to it, and actively
participate in it.

Once we accept that the way in which we interpret ageing matters, we need to
think about how we define ageing - in other words what shapes our
perceptions. There is no one right answer; people will think about ageing
variety of ways.

1Colloca G; Corsonello A; Marzetti E; Balducci L; Landi F; Extermann M; Scambia G; Cesari M; Carreca I;

Monfardini S; Bernabei R.Treating cancer in older and oldest old patients. Current Pharmaceutical Design.
21(13):1699-705, 2015.
 There are many definitions of ageing.
The definition you use will depend to some extent on your particular interest in
ageing.

The following definitions provide a general concept of ageing.

"...a process of intrinsic (part of the real nature of something), progressive

(happening or developing steadily), and generalized physical deterioration that
occurs over time".
2

a progressive, generalized impairment of function, resulting in an

increasing vulnerability to environmental challenge and a growing risk of
disease and death.

The common concept in these definitions is the loss of function. This leads us
into the core aim of aged care:

The aims of aged care should be:

to minimise loss of function,
to restore function wherever possible,
to facilitate adaptation to the functional changes that are
occurring.

Function is the key concept in aged care.

Function determines
1. a person's ability to live independently;
2. a person's ability to move through the world; and
3. a person's quality of life.

Function is also an important determinant of a persons need to utilise health

care services.

Preventing or curing disease does not necessarily mean that people will retain
functional capacity, but functional capacity can be maintained in the presence
of disease.

2 Masoro EJ and Austad SN (2001), Handbook of the Biology of Ageing, 5th edn, San Diego:
Academic Press.
This is a critical idea and you need to think carefully about its implications. Is it
more important to be free of disease or to maintain function?

Often health professionals, especially doctors, focus on curing disease as their

primary goal.
But for older people themselves, maintaining function is more important.
Maintaining function is also important for society because it will help to
decrease the load for health care system asked to carry as the population ages.

Everybody will think about ageing in a way that reflects their own interests.
Ageing occurs at many levels:
social,
psychological,
physiological,
morphological,
cellular, and
molecular.

To a cell biologist, ageing is primarily a change that occurs at the molecular

level in cells.
To a sociologist, it may be principally a change in a persons engagement with
society.
However, the changes are not unrelated.
Even complex sociological changes are the result of changes that are occurring
at the level of molecules and cells.

There are many theories of thinking about ageing, but no one way provides a
complete explanation for why ageing occurs.

Thinking about ageing - the evolutionary approach

The evolutionary approach says that ageing is part of our genetic make-up.
The term evolution implies that ageing is something that is selected for
because it enhances the survival of the species.
But why would ageing, which results in our functional decline, enhance
survival?

One explanation is that the genes which are associated with ageing have a
positive effect on survival early in life.
Those early benefits result in the genes being selected for and therefore
passed on to future generations.
The fact that they also cause adverse effects later in life is irrelevant.
Evolution occurs together with sexual reproduction.
Once reproduction has ceased, the direct effects of evolution also cease.
In purely evolutionary terms, we could die as soon as our reproductive life is
complete, and some species, such as salmon and spiders do this.

Le Bourg provides more background to this theory.

Evolutionary theories take into account the fact that, in the wild, mean
lifespan of many species is usually shorter than it could be in protected
environments.
In such conditions, because most of animals die before reaching old age, there
is no selection in favour or against alleles with effects at old age.
Alleles with negative effects at this age can thus accumulate in successive
generations, particularly if they also have positive effects at young age and are
thus retained by selection.3

Although they are different things, thinking about the relationship between
ageing and longevity helps us to understand the evolutionary theory.

Can you explain the relationship between ageing and longevity? Would the
elimination of ageing lead to immortality?
Ageing and longevity are different, although they are related to each other.
An increased rate of ageing will decrease longevity.
However longevity can be shortened by diseases which have no relationship to
the ageing process.
In order to achieve immortality it would be necessary to prevent both ageing
and disease.

Longevity is also influenced by genetic inheritance - one of the best predictors

of the age at which you can expect to die is the age at which your parents die.
Longevity may be influenced by genes which have beneficial survival effects
earlier in life, and are more likely to be passed on to future generations.
The same genes may have beneficial effects on disease prevention and the
maintenance of function after the age of reproduction is passed.
In other words, the genes have two effects:
1. they increase survival after the age at which reproduction ceases (and
are therefore selected for by evolution); and
2. they prolong life after reproduction has ceased (if that is the case, the
fact that longevity is heritable can be considered coincidental).

3Le Bourg E. Evolutionary theories of aging can explain why we age. Interdisciplinary Topics in Gerontology.
39:8-23, 2014.
Another alternative is that longevity may have a role in the survival of the
family group, and therefore the long term endurance of the genes.
It is easiest to understand this concept by going back to prehistoric
(=connected with the time in history before information was written down)
times-if your family carried genes promoting longevity there would be more
older family members who would be available to care for children while
younger family members were hunting or collecting food.
The fact that your family was long-lived supported better food collection and
childcare and therefore better survival.

The evolutionary approach does not really help us to understand ageing in a

way that improves our ability to provide health care for the aged.

Thinking about ageing - the organistic approach

The organistic approach describes the most obvious changes associated with
ageing - the effects on the gross function of the individual.
These are the easiest changes to observe, and in practical terms, are of the
greatest significance.
The organistic approach is more concerned with effect than cause, but may
indicate the areas where research can be focused to identify the cause of age-
related changes.

Thinking about ageing the cellular approach

The cellular approach focuses on ageing at the level where the basic changes
occur - the level of the cell.
This approach highlights the inevitability of cell death, and the fact that ageing
creates a progressive decrease in cell functioning.
It is clear that changes in function at the cellular level are an integral part of
the ageing process.4

How can the theories be combined to produce an integrated theory of ageing?

Changes at the molecular level affect normal cell function and therefore
ultimately the overall function of the organism.

4Lopez-Otin C. Blasco MA. Partridge L. Serrano M. Kroemer G. (2013) The hallmarks of aging. Cell.
153(6):1194-217.
 The molecular changes are frequently the result of mutation or a genetic
damage which are the result of years of environmental insults to which the
body is exposed.

Changes at the cellular level occur because cell function depends on the
molecules within the cell.
It may be that the deterioration is genetically programmed (causing
apoptosis, or programmed cell death).
These changes are known as direct deteriorations.

Changes at the organ level are the result of changes in the function of
individual cells.
Changes occurring in one organ can alter cellular function in other organs.
Renal disease can cause hypertension, which damages the blood vessels and
decreases oxygen delivery to other tissues.
The cells respond to the fall in oxygen delivery by adapting their metabolic
processes to the changed conditions.
These changes may have an effect at the organistic level - changes in one
tissue have resulted in changes in others.

This holistic approach is very important to remember when we come to discuss

the effects of ageing on individual organ systems. These can be described as
compensatory changes.

2. WHY DO WE AGE?

Now that we have seen that there are different ways to think about ageing, we
can go back to the molecular approach that underpins (=support or form the
basis of an argument, a claim, etc.) all age-related changes and ask why those
changes occur.
The answer to that question focuses on gene regulation, mutations, and on
damage to cellular macromolecules.

Ageing is generally multifactorial in nature - there are several factors that

contribute to the ageing process.
Usually more than one process will be contributing to ageing at any given
time and different combinations of processes may occur in different
individuals.

Why is an understanding of the mechanism of ageing important?

One good reason is to help us to assess the claims of the various (usually
expensive) anti-ageing strategies that are now available.
More importantly, it helps us understand why people lose function and
become more susceptible to diseases as they age.

A good scientific explanation is provided by Nikoletopoulou et al:

Human lifespan has been increasing steadily during modern times, mainly due
to medical advancements that combat infant mortality and various life-
threatening diseases.
However, this gratifying (=pleasing and giving satisfaction) longevity rise is
accompanied by growing incidences of devastating age-related pathologies.
Understanding the cellular and molecular mechanisms that underlie (=to be the
basis or cause of something) aging and regulate longevity is of utmost
relevance towards offsetting the impact of age-associated disorders and
increasing the quality of life for the elderly.
Several evolutionarily conserved (=protect something and prevent it from being
changed or destroyed) pathways that modulate (=affect something so that it
becomes more regular, slower, etc.) lifespan have been identified in organisms
ranging from yeast to primates (=any animal that belongs to the group
of mammals that includes humans, apes and monkeys).5

As we think about individual theories, there is one key concept that you will
need to keep in mind.

No single theory provides a rational, unified explanation for ageing.

Here is an excellent summary of the concept and its implications.

Aging is commonly defined as the accumulation of diverse deleterious

(=harmful and damaging) changes occurring in cells and tissues with advancing
age that are responsible for the increased risk of disease and death.
The major theories of aging are all specific of a particular cause of aging,
providing useful and important insights for the understanding of age-related
physiological changes.
However, a global view of them is needed when debating of a process which is
still obscure (=not well known) in some of its aspects.
In this context, the search for a single cause of aging has recently been
replaced by the view of aging as an extremely complex, multifactorial process.

5Nikoletopoulou V; Kyriakakis E; Tavernarakis N. Cellular and molecular longevity pathways: the old and the
new. Trends in Endocrinology & Metabolism. 25(4):212-23, 2014
Therefore, the different theories of aging should not be considered as mutually
exclusive, but complementary of others in the explanation of some or all the
features of the normal aging process.
To date, no convincing evidence showing the administration of existing anti-
aging remedies can slow aging or increase longevity in humans is available.
Nevertheless, several studies on animal models have shown that aging rates
and life expectancy can be modified.6

Genetic theories of ageing

Throughout the 19th and 20th centuries, the life expectancy of the population
increased dramatically.
This was largely because of a decrease infant mortality that meant that more
people reached adult hood and old age.
Better medical care for adults also played a part.
It has been estimated that if atherosclerosis and cancer could be eliminated
from the population as a cause of death, about 10 years would be added to the
average human lifespan.
Improved medical care affects longevity but it does not increase the
maximum lifespan.7

The human life span is finite, with an absolute upper limit of about 120 years.
This fact is used to support the view that the lifespan is genetically
programmed.
The program limits the number of times cells can divide and reproduce
themselves.
Another way to look at the idea is to think that cell death is programmed.
The evidence in support of the concept of programmed cell death comes from
experiments which show that cells grown in culture (in vitro = outside a living
body, in scientific apparatus) have the potential for only a limited number of
divisions.
Cells age with each division, and it is the number of divisions rather than the
amount of time passed that determines the rate at which ageing occurs.
Cells that have been held in a quiescent (=not active) state (during which no
division occurred) will, when removed from that state, undergo approximately
the same number of divisions as cells that continued to divide without
interruption.

6 Tosato, M., Zamboni, V., Ferrini, A., & Cesari, M. (2007). The aging process and potential
interventions to extend life expectancy. Clinical interventions in aging, 2(3), 401.
7Mackenbach, JP; Kunst, AE; Lautenbach, H; et al. (1999) Gains in life expectancy after elimination of major
causes of death: revised estimates taking into account the effect of competing causes. Journal of Epidemiology
and Community Health 53: 32-37
One reason for this appears to be that the telomeres shorten each times a cell
divides.
They cap each chromosome and are often likened to (=compare one thing
or person to another and say they are similar) the hard ends of shoe laces that
stop the lace from fraying (=if cloth frays , the threads in it start to come
apart).
Telomeres perform a similar function in the chromosome.
They also adjust the cellular response to stress and growth stimulants.
The telomeres shorten each time a cell divides, and when they become too
short, the chromosomes are unprotected.
Apoptosis, or cellular senescence/death, is triggered when too many
uncapped telomeres accumulate. 8
Cells contain the enzyme telomerase which can repair shortening telomeres,
but its activity is limited in most cells.

In long-lived mammals, cells can only divide about 40 times before the
telomeres become too short to function and the cell becomes senescent (=old
and showing the effects of being old).
Senescent cells secrete proinflammatory factors and reactive oxygen species
that accentuate (=emphasize something or make it more noticeable) the
ageing process and create the perfect conditions for cancer development.9

Telomeres become shorter as cells divide, and when they become too short
the cell becomes senescent.

A variety of sustained psychosocial stresses in adulthood appear to be

associated with shorter telomeres.
More recent work has shown a robust (=strong and not likely to fail or become
weak), and perhaps dose-dependent, relationship between early-life stress and
shortened telomeres.10

Stress can shorten telomeres and accelerate ageing.

There appear to be other genetic factors that influence ageing, including the
regulation of gene expression.

8 Aubert G, Lansdorp PM. Telomeres and Aging. Physiol Rev 88: 557579, 2008;
9 Pereira B. Ferreira MG. (2013) Sowing the seeds of cancer: telomeres and age-associated tumorigenesis.
Current Opinion in Oncology. 25(1):93-8.
10 Price LH. Kao HT. Burgers DE. Carpenter LL. Tyrka AR. (2013) Telomeres and early-life stress: an overview.

Biological Psychiatry. 73(1):15-23.

Although mice and bats have only a 0.25% difference in their DNA sequences,
the maximum lifespan of mice is about 2.5 years, compared with 25 years for
bats.
(Remember that longevity is not the same as ageing, but the ageing process
certainly has a significant impact on longevity).
Although the genomes are very similar, the expressions of genes, and the
proteins that are produced, differ greatly.
It is the difference in gene expression that accounts for the difference in
longevity.
Silencing specific genes has been shown to increase the lifespan of yeasts.
Although yeasts are very different to mammals, the control of cell division is
similar in both groups.

Expression of specific genes alters the speed of ageing.

Progeria syndromes cause rapidly accelerated ageing.

People in their mid teens can appear similar to people in their 80s with grey
hair, wrinkled skin etc.
Several of the syndromes are caused by mutations in single genes.

Single alleles can determine the rate of ageing.

(Note the difference with mice and bats we are talking about whether or not
a single gene is being expressed, which means used to produce proteins.
Just because genes are present doesnt mean they are expressed.
In progeria the issue is a mutation that results in an abnormal copy of a gene.)

The expression of genes is influenced by environmental factors.

Therefore, we can't simply look at an individual's genotype (genetic makeup)
and predict their lifespan.
There is increasing interest in the relationship between environmental effects
on gene expression (the epigenetic relationship) and ageing.

To summarise a persons genes, and the way in which those genes are
expressed plays a role in determining the rate of ageing.

Environmental theories of aging the wear and tear theories

Damage to genes can also cause cell dysfunctional or death that contribute to
the ageing phenotype (=the set of characteristics of a living thing, resulting
from its combination of genes and the effect of its environment).
Damage to the DNA may have a major part to play in the ageing process, and
free radicals (or reactive oxygen species - ROS) are an important cause of DNA
damage.
ROS are by-products of aerobic metabolism, the energy producing process
which occurs in the mitochondria of cells.
Because aerobic metabolism occurs continuously, ROS are always being
produced.
Although ROS are essential for various biological functions, including cell
survival, cell growth, proliferation and differentiation, and immune responses,
they also damage DNA and proteins in cells.
ROS generation in animals is inversely related to longevity, and free radical
inhibiting enzymes are found in higher concentrations in animals with longer
life spans.

Here is one view on the role of ROS in ageing.

Aging is a stage of life of all living organisms.
According to the free-radical theory, aging cells gradually become unable to
maintain cellular homeostasis due to the adverse effects of ROS.
ROS can cause irreversible DNA mutations and protein and lipid damage which
accumulate over time if cells cannot overcome their effects by the antioxidant
defence system.
Accrued (=increase over a period of time) damaged molecules in cells may
either induce cellular death or contribute to develop various pathologies.11

The production of ROS can be reduced by a diet in which calorie intake is

severely restricted.
This has been shown to increase longevity in a variety of laboratory animals,
but is not practical in humans.

Because ROS are produced by the basic functions of life, their impact on ageing
is considered to be part of normal wear and tear.

ROS are produced by metabolic pathways essential for life, but they can
damage DNA and accelerate ageing.

The reaction of glucose with intracellular proteins, resulting in the formation of

glycation-cross linkages is another wear and tear theory of ageing.
Glycation cross linkages damage makes proteins dysfunctional.

11Tezil T; Basaga H. Modulation of cell death in age-related diseases. Current Pharmaceutical Design.
20(18):3052-67, 2014.
The changes in protein function going to have an adverse effect on cell
function. Glycation will occur more readily when blood glucose levels are
elevated.

Glucose, which is essential for life, can damage proteins and accelerate
ageing.

Other wear and tear related causes of DNA damage include the intrinsic
mutagenesis theory, which states that spontaneous mutations occur at
different rates in different species, which accounts for lifespan variability.
Radiation causes spontaneous mutations that can accelerate ageing.
We are constantly exposed to radiation in the environment, and its effects are
often obvious think how exposure to the sun increases skin ageing.
Cells have systems to repair damaged DNA, but these systems can fail.
Damage to DNA repair systems within cells has been proposed as a cause of
ageing.

Spontaneous mutations and damage to DNA repair systems can accelerate

ageing.

Inflammation contributes to ageing.

Blood concentrations of autoantibodies (antibodies against proteins that are
normally present in the body) and various inflammatory markers (=a sign that
something exists or that shows what it is like) often correlate with age, even in
the absence of autoimmune or infectious diseases.
Low grade chronic inflammation contributes to the development of many age-
related human diseases.
For example, the low grade inflammation associated with periodontal disease
is believed to contribute to cardiovascular disease.

As we age, changes in essentially all physiological functions, including

immunity, are apparent.
Immune responses decrease with aging, contributing to the increased incidence
of different chronic diseases with an inflammatory component (sometimes
referred to as 'inflamm-aging').
Many data in humans support the notion that age-associated immune
dysfunction may at least in part explain the aging process.
Explanatory power may be enhanced by combination with other theories such
as the free radical theory.12

12Fulop T; Witkowski JM; Pawelec G; Alan C; Larbi A. On the immunological theory of aging. Interdisciplinary
Topics in Gerontology. 39:163-76, 2014.
 Inflammation may accelerate ageing.

Mitochondrial dysfunction is another emerging explanation to ageing.

Mitochondrial dysfunction may contribute to ageing.

It has recently been shown that the bacterial population of the gut changes
with ageing.
There is considerable interest in the interactions between gut microbes and
function in various body systems.
It is likely that in the future considerable research will be conducted looking at
the influence of gut microbes on the ageing process.

Changes in the gut microbiome may contribute to ageing.

The causes of ageing

Listing all the potential contributors to ageing shows just how complex the
process is, and how difficult it will be to stop it from occurring.

Genetic Factors Telomere shortening

Expression of specific genes.
Single alleles.
Wear and Tear ROS.
Factors Glucose.
Spontaneous mutations and damage to DNA repair
systems.
Inflammation.
Mitochondrial dysfunction.
Changes in the gut microbiome.

Can you describe the two main processes that are believed to drive the
process of ageing?
The two main theories are the genetic theory and the environmental theory.
Each has several components.
For example in the genetic theory telomere shortening and apoptosis
(programmed cell death) are important.
In the environmental theory, DNA damage and other biochemical changes are
important.
Can you explain why it is unlikely that there will ever be a single drug that
will prevent ageing?
Ageing is a multi-factorial process.
It has both genetic and environmental components.
Any drug that was to prevent ageing would need to prevent all these changes
from occurring.
It is likely that many of the factors contributing to ageing are also essential for
life.

An integrated model of ageing

Changes in cell and organ function cause the body to lose the ability to control
its internal environment.
In other words, ageing is due to failure of homeostasis.
Once the body is unable to control its internal environment, it loses the
capacity to function normally.

Human longevity is a complex trait and increasingly we understand that

both genes and lifestyle interact in the longevity phenotype.
Non-genetic factors, including diet, physical activity, health habits, and
psychosocial factors contribute approximately 50% of the variability in
human lifespan with another 25% explained by genetic differences. 13

3. DIFFERENTIATING AGEING AND DISEASE

As people get older, they experience more diseases.

The presence of disease can accelerate the process of ageing, resulting in

functional changes that are often attributed to ageing.
With increasing age, it becomes more and more difficult to differentiate
between functional losses due to illnesses and those due to ageing.

However, appreciating the difference between ageing and disease can be vital
it can influence how the person manages their own health, and how health
professionals provide care.

Because ageing and disease often coexist, we can extend our key concepts to
include these ideas.

13Rea IM; Dellet M; Mills KI; ACUME2 Project. Living long and ageing well: is epigenomics the missing link
between nature and nurture? Biogerontology. 17(1):33-54, 2016
 It may be difficult to describe normal ageing

Many of the functional changes which are attributed to ageing may in fact
be due to disease, and be reversible.

It is essential to remember that although ageing and disease are related,

ageing is not a disease, and diseases are not solely due to ageing (although
age related changes may contribute to them).

Why is it important to differentiate ageing from disease?

Ageing affects everybody.
Disease only affects some people.
Ageing and disease are related-the incidence of disease increases as people
age. The most important idea to arise from this concept is that people should
not simply write off symptoms as being a result of ageing.
Many of the decreases in function that are attributed to ageing may be due to
disease, and therefore be treatable.

This is fundamental to health care because:

we do not want older people to write off symptoms as being due to
getting old and therefore not seek treatment for reversible conditions;
we want older people to retain function for as long as possible; and
we do not want ageism to enter health care.

4. THE RESERVE CAPACITY CONCEPT

In order to survive, we need to be able to cope with stresses that exceed those
normally placed on the body.
To do this, organ systems have a maximum capacity that exceeds the
requirements for normal functioning.
This reserve is called upon when the body system is damaged or stressed.
A good example is the cardiovascular system - during exercise our heart rate
increases to pump extra blood around the body to meet our metabolic needs.

One of the effects of ageing is to decrease the maximum functional capacity

of body systems.
As a result, the gap between the capacity used during normal activities and
maximum performance decreases - the reserve capacity falls.
It has been estimated that reserve capacity in a healthy young adult is 7 to 11
times greater than the average demand, but, by age 85, organ reserve is only 3
5 times average demand.14

Compared to younger people, older people are always functioning closer to

their physiological limits.

Explain the reserve capacity concept, and why it is important.

The reserve capacity concept states that body systems are mostly working at
less than the maximum capacity.
Body systems can increase the amount of work they are doing in order to cope
with stress.
The difference between the usual capacity being utilised, and the maximum
possible capacity is known as the reserve capacity.
Younger people have a larger reserve capacity than older people because the
maximum capacity in any body system is larger.
As people age the maximum capacity falls, and therefore the difference
between the capacity required for normal function and the maximum capacity
decreases. People may be able to function perfectly well when only normal
capacity is required, but the loss of reserve capacity may diminish the ability to
cope with stress.

Beyond age 30, physiological function declines at a rather consistent linear rate
of 0.5% to 1.3% annually. 15 This affects all body systems, as the following
extract shows.

The following diagrams illustrate the concept of reserve capacity.

1. Normal ageing

14 Manhapra A. Why is chronic kidney disease the spoiler for cardiovascular outcomes:
an alternate take from a generalist. J Am Coll Cardiol. 2004;43(5):924.
15 Strehler BL, Mildvan AS. General theory of mortality and aging. Science. Jul 1

1960;132:14-21.
 Functional capacity

Age in years

This diagram illustrates the normal change in functional capacity that occurs
with ageing.
Functional capacity increases until the third decade of life and subsequently
progressively decreases with age.
In this diagram assume that a functional capacity of 10 units is necessary in
order to avoid disability.
You can see that this level of function is not reached until the person is at an
extremely old age.
A very young child has not achieved this level of function, and consequently
cant look after themselves.
The reserve capacity is the distance between the curve and the 10 unit line.
Reserve capacity falls with age even though functional capacity may be
sufficient to enable a person to live a normal life.

2. Higher peak capacity

Functional capacity

Age in years

In this diagram, peak capacity is higher than it was in the preceding diagram.
Although function is lost progressively with age, because the loss began from a
higher starting point functional capacity is always greater than it was in the
first diagram.
Bone mass follows this relationship.
Better nutrition and more weight bearing exercise will result in a greater peak
bone mass and minimise the risk of subsequently developing osteoporosis.
In fact, it now appears that factors such as maternal nutrition during
pregnancy can also impact on peak bone mass.

3. Effects of disease
Functional capacity

Age in years

In this diagram, the person was affected by disease at about the age of 70, and
as a result there was an increase in the rate at which reserve capacity was lost.
As result, this person experienced disability in later life.

4. Interventions to decrease the rate at which functional capacity is lost

Functional capacity

Age in years

At about the age of 70 the person in this example implemented a strategy to

decrease the rate at which the functional decline occurs.
One of the best examples would be commencing an exercise program.
5 The effects of temporary stress on functional capacity

Functional capacity

Age in years

In this example, the person suffered to severe stressors (probably disease);

one the age of 40, the other at the age of 80.
Both resulted in a temporary decrease in functional capacity.
At the age of 40, the large reserve capacity meant that the person did not
suffer any disability.
However the age of 80, functional capacity fell below the 10 unit threshold
that signifies (=to be a sign of something) disability.
In this case the person would experience a period of disability.
A good example of this is delirium that develops in people suffering from
severe infections.
It is important to note that functional capacity may return to the previous level
quickly when the stress is removed, or that recovery may be prolonged.
In other words, the disability may last far longer than the disease itself.
In some cases, functional capacity will never return to its previous level.

Here is an example of how functional capacity changes. It comes from

Neustadt and Pieczenik.16
By age 70, voluntary muscle contractile strength decreases by 20% to 40% in
both men and women.
Starting in the fourth decade of life, knee extension strength tends to decline by
8% to 10% per decade in both men and women.
By the time men and women are in their 7th or 8th decade of life, on average
they have lost 20% to 40% of the contractile strength of voluntary muscles, and
50% by the 9th decade.

16 Neustadt J and Pieczenik S. Organ Reserve and Healthy Aging. Integrative Medicine. 7(3): 50-53. 2008
The brain shows a decrease of viable (= capable of developing and surviving
independently) cells with age, amounting in some areas to a 25% to 30%
decrease, and a decrease in brain tissue of 9% to 17%.
Similarly, renal mass tends to decrease with advancing age.
From birth to young adulthood, renal mass increases from about 50 g to 400 g,
then decreases to 300 g in the 9th decade.

But it is also important to recognise that people age at their own rate this is
another application of the key concept that it is difficult to describe normal
ageing.

The level of maximal organ reserve does not necessarily correlate with
chronological age because both the onset and the progression of decline show
profound individual variations.
A study:
They measured cardiac output in 67 male volunteers aged 19 to 86 years
(average 52.5 years) with no diagnosed circulatory disorders.
In regression (=the process of going back to an earlier or less advanced form or
state) analysis, cardiac output showed a significant average decline of
approximately 1% per year after the third decade of life (P<.001), but the
standard deviation was 21.8%.
This large standard deviation means that many participants had much lower or
higher rates of decline.14

Physiological function decreases with age, but the rate of the decrease varies
from person to person.
The main effect of this physiological decrease is a reduction in the reserve
capacity.

Under normal circumstances, the decrease in reserve capacity has little effect
and organ systems are able to cope with the activities of daily living
throughout life.
However, when a system with reduced reserve capacity is stressed it may be
unable to cope, and a loss of homeostasis may occur.
A common cause of stress in a body system is disease.
Factors such as environmental insults and disease may further reduce reserve
capacity (or increase the rate at which it is lost).
The picture of age related decreases in function can be confused by other
processes which are occurring simultaneously.

These are the key concepts which we will return to throughout this subject:
 ageing reduces reserve capacity;
disease and environmental insults may further reduce functional
capacity and affect the capacity to perform normal activities;
the loss of reserve capacity decreases the ability to maintain
homoeostasis, especially during times of stress.

The key issues in gerontology (=the scientific study of old age and the process
of growing old)

Although they are not the focus of this unit of study, it is important to
recognise the key goals in the practice of gerontological care. The focus should
always be on maintenance, particularly the maintenance of
physical and cognitive function,
quality of life, and
independence.
Addressing these needs provides the best outcomes for older people.