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Contents

For Teresa, David and Shona

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Author profiles

Alistair Farley

MSc in Nursing, BSc (Nursing), Dip Ed, Dip N (CT), RGN, RMN

Lecturer in Nursing, School of Nursing and Midwifery, University of Dundee, 11 Airlie

Place, Dundee DD1 4HJ, UK

Alistair Farley has a background in trauma and orthopaedic nursing. He became a clinical nurse teacher in 1986 before qualifying as a lecturer in nursing in 1992. As a staff nurse in orthopaedics and a charge nurse in trauma, his nursing interests were focused on the acute management of patients. However, as many of the patients in an orthopaedic/trauma setting are older adults, he gradually developed an interest in this field of nursing. His experience and knowledge of older adults was further developed through his studies for his BSc and MSc in Nursing.

Ella McLafferty

PhD, BSc (Hons), Dip Ed, Dip N (CT), RGN, RM

Senior Lecturer in Nursing, School of Nursing and Midwifery, University of Dundee, 11 Airlie Place, Dundee DD1 4HJ, UK

Dr Ella McLafferty’s main interest is older people nursing, although her background was originally in general nursing within surgical settings. Interest in older people’s issues came about through working as a clinical teacher in a hospital that specialised in older people nursing. Through her BSc and her PhD, she has developed her knowledge in this field. She has had the opportunity to develop older adult nursing within nurse education.

Charles Hendry

PhD, BA (Hons), Dip Ed, Dip N (CT), RGN, RMN

Senior Lecturer in Nursing, School of Nursing and Midwifery, University of Dundee, 11 Airlie Place, Dundee DD1 4HJ, UK

Dr Charles Hendry has a background in Acute and Critical Care Nursing. As a clinician, educator and researcher, he knows the value of having the right information to provide focused and meaningful patient care. He has always believed in the importance of evidence-informed nursing practice and despite its many challenges would still recommend nursing as a career. Every day is different and it is a career in which you can make a real difference to people and their families.

Preface

It is our intention that this book will serve as a comprehensive resource for student nurses and qualified nurses who in the course of their work come into contact with older people. This book will also be of use to allied health professionals who want to develop their knowledge and understanding of the ageing process.

The aim of the book is to encourage all practitioners who work with older people to apply their knowledge of the ageing process to their practice and in doing so, enhance care delivery.

This book emphasises the normal ageing changes before considering possible effects of ageing on body systems, using as its framework Roper, Logan and Tierney’s activities of living. Although problems associated with ageing are identified, nursing assessment and interventions are considered which can help reduce the impact these changes have on a person’s functional ability.

Alistair Farley
Ella McLafferty
Charles Hendry

Chapter 1

Growing Older

Introduction

It is expected that the global population of older people will reach 20% of the total population by the year 2050, but this figure will be reached by 2020 in the United Kingdom (The House of Lords Science & Technology Committee, 2005). The number of older people will continue to increase over the next 15 years and beyond. The number of people in England aged over 90 is set to double between 1995 and 2025 (Department of Health (DH), 2001). The projection for Scotland is that by the year 2030 there will be more people in Scotland who are of retirement age than there will be children. The biggest growth is expected to be among the oldest old; in other words, the number of people aged over 80 is expected to double by the year 2030.

People over the age of 65 constitute the largest patient population in and out of hospital. More than 66% of patients who occupy acute care beds are over 65 years of age (DH, 2001). In 1998/99, the National Health Service (NHS) spent approximately 40% of its budget on those aged over 65 whilst social services spent nearly 50% on the same group (DH, 2001). Older people are traditionally admitted to hospital more frequently and for longer periods of time than younger people (Standing Nursing and Midwifery Advisory Committee (SNMAC), 2001). The DH (2001, p. 6) states that ‘older people often require more intense, more skilled and more specialised nursing than younger adults’. Therefore, nursing older people requires well-prepared nurses to identify and manage their needs whether in hospital or at home.

The reality for most ageing people is that they have relatively good health, activity and independence (Feldman, 1999), with the ageing process being perceived not as something to be glorified but neither to be irrationally feared. That people are living longer is something to celebrate, reflecting the real achievements of organisations like the NHS, social services and the voluntary sector (DH, 2001). The DH goes on to state that older people should no longer be seen as a burden on society as they have vital resources of wisdom, experience and talent.

However, when older people are admitted to acute care settings they and their carers are the least satisfied with the care they receive when they are acutely ill (DH, 2001). Hospital admission itself can dramatically reduce the physical and psychological ability of an older person to self-care (Clark, 1998). A combination of actions such as infantilisation (treating older adults like children), fostered dependency, not listening or offering choices can all contribute to the objectification of an older person in care (Nay, 1998). Hancock et al. (2003) identified that hospitalisation for an older person is associated with a decline in health and increased dependency. This decline in health and associated loss of independence may prevent the older adult from being discharged home, making it more likely that they will have to be transferred into long-term care. In their study, Hancock et al. (2003) identified that nurses felt that they did not have enough time to provide all aspects of care to hospitalised older adults. This situation can easily be rectified by ensuring that more staff are available to care for the older population.

Nurse education specifically in the care of older people is vital if they are to receive the care they require. Older patients tend to present as more acutely unwell than younger patients and are more likely to be dependent on nurses because of co-morbidities. There is also huge pressure to discharge patients from hospital as early as possible in their pathway. However, this does not take into account the effects of the ageing process combined with the effects of stressors on the speed of recovery. Edwards et al. (2008) have identified that nursing students need to be prepared specifically to care for older people. It is imperative that nursing students have a thorough grounding in the care of older people as they will meet older people in most clinical settings in the hospital and in the community.

Drivers in the care of older adults

A number of drivers have been published to improve the care delivered to older people. One of the most influential drivers has been the National Service Framework for Older People published by the DH in 2001.This is a comprehensive strategy to enable the delivery of fair, high-quality, integrated health and social care services for older people.

The aim of this strategy is to support independence and promote good health for older people, and to try and ensure that older people and their carers are treated with respect, dignity and fairness.

The strategy rightly identifies that older people live for many years into retirement as fit and healthy individuals. Old age is described as beginning at 60 for women and 65 for men. Although entitlement to the state pension is in the process of being equalised so that by the year 2020 women will be entitled to the pension if they are 65 years old. However, the goals of health and social care policy are to promote and extend healthy and active life and to compress morbidity.

There are four main themes in the National Service Framework (NSF) (DH, 2001):

The Scottish Executive in 2005 produced the document Building a Health Service Fit for the Future, which puts forward a strategy to manage the shifting patterns of disease in an ageing population in order to take account of the number of older people with multiple conditions, especially long-term conditions and for those with complex needs.

They identify the need to move from a reactive to a proactive approach and reduce the risks of some health problems or to manage them appropriately and that is the purpose of this book, to give nursing students the knowledge and the tools to manage older people’s issues in order to reduce or minimise their problems.

Documents producing specific protocols and guidelines that are relevant to the care of older people have also been published. NICE Guidelines giving best practice for falls in older people were produced in 2004 (CG 21) while guidelines to promote older people’s mental well-being have been produced in 2008 (PH 16).

The National Health Service Quality Improvement Service (NHSQIS) produce standard statements on a variety of nursing issues. The role of the NHSQIS is to lead the use of knowledge to promote improvement in the quality of health care for people in Scotland. They have produced standard statements for Nutrition in Older People in 2002 and Oral Health in Older People in 2005 among many others.

Activities of living

The framework for this book is based on the model of nursing originally described by Roper et al., in the publication The Elements of Nursing in 1980. This model for nursing based on a model of living has been used widely in clinical practice areas to guide the management of nursing care and has been used in many Schools of Nursing and Midwifery to aid students in the linking of nursing theory to nursing practice (Roper et al., 2000). Curricula have also been based around this particular model. The aim of the model is to identify the management of a patient by identifying patients’ abilities to carry out the activities of living. The model is divided into two parts. Part 1 is the model of living and part 2 is the model of nursing. The model of living consists of five main components: activities of living, lifespan, dependence/ independence, factors influencing the activities of living and individuality in living. There are 12 activities of living, and these are the activities that we carry out in order to live from day to day. The activities, although considered separately, do overlap. The lifespan is a continuum from birth to death. The dependence–independence continuum acknowledges that a person, depending on where they are in their lifespan, may not be able to be fully independent through stages of life or through illness. This continuum is inextricably linked to the activities of living. There are five factors that influence the activities of living and they include:

This book is based around old age in the lifespan. We emphasise the importance of maintaining and promoting independence in older people, and we concentrate on the biological factors associated with the ageing process. Not all of the activities of living have been utilised. As has already been stated, this is a book about the physiological aspects of ageing and not all of the activities are relevant for this purpose. This book has been written around the following activities of living:

The activities that have not been included within the book are:

The rationale for excluding these three activities are that the physiological effects of ageing for personal cleansing and dressing are included in other chapters such as mobilising and changes associated with the skin as well as oral health which is included in the activity of eating and drinking. There are no physiological effects associated with working and playing, although physiological changes in other activities may influence the ability to carry out activities associated with living and working. The process of dying has been excluded as it is similar for many people no matter their age, and the issues associated with dying are also similar.

Overall aims

This book should support the theoretical component of the undergraduate nursing curriculum relating to nursing older people. Undergraduate programmes in the United Kingdom provide an academic and professional qualification through integrated study of theory and supervised nursing practice in NHS and independent clinical settings. The curriculum should conform in the main to recommendations by the Nursing and Midwifery Advisory Committee (2001) regarding the achievement of fundamental skills required by Registered Nurses to meet the needs of older people. Gerontological education plays an important role in countering ageism; therefore, greater attention is required in relation to gerontological nursing within curricula, as how information presented can influence learning (Happell and Brooker, 2001).

The aim of this book is to describe the normal physiological effects of ageing. Every organism ages, and humans are no different. This book emphasises that the ageing process is normal and is not directly responsible for disease. However, some diseases and problems become more prevalent as we grow older and some disorders can be minimised or prevented. These issues will be addressed in this book. We need to appreciate that the ageing body is efficient and effective in that there is spare capacity associated with most systems of the body that allow our body to cope with the loss of cells as we age and feel little effect from these losses. There are also efficient and effective compensatory mechanisms used by a number of the body systems ensuring that the functioning of the whole person continues often with no apparent (or perhaps minimal) reduction in ability.

Problems that are commonly found among older people are also considered including their assessment and management. It is not the purpose of this book to provide a comprehensive text on the disorders of ageing, but rather by selecting some common health problems of older adults, the reader will be able to make strong links between anatomy and physiology and the changes that occur in older adults.

This book is written with the intention of providing nurses and other health-care professionals with a comprehensive text relating to the ageing process. From the outset, we wish to make it clear that in this book we will focus primarily on the physiological impact of growing older; however, this is not to minimise the significance of the psychological, social and spiritual elements of human being. Lecturers too will find it useful as we believe that it is the only text of its kind that provides a comprehensive account of the physiological effects of ageing.

If there is one thing that we all have in common it is the fact that each and everyday we are all getting older. However, it is important to state at the outset that ageing is a normal process and does not necessarily lead to disease and disability. Ageing is inevitable and irreversible. However, it is acknowledged that with advancing age comes a decline in functional ability of each organ and system (Herbert, 1992). Nevertheless, individuals do not age at the same pace and within each individual, systems and organs age at different rates. Experience also tells us that the consequences of ageing vary greatly between individuals.

Lifestyle, environment and family history all play a part in how we age; however, how we each experience growing older is in part determined by our own philosophies and outlook on life. The following chapters will, we hope, prepare the health-care professionals of tomorrow to provide advice and care for older adults which will allow them to derive maximum benefit from their ‘golden years’.

References

Clark, J. 1998. Clinical Standards Advisory Group: Community Health Care for Elderly People. The Stationery Office, London. Department of Health. 2001. The National Service Framework for Older People. The Stationery Office, London.

Edwards, H., Nash, R., Sacre, S., Courtney, M. and Abbey, J. 2008. Development of a virtual learning environment to enhance undergraduate nursing students’ effectiveness and interest in working with older people. Nurse Education Today 28(6), 672–679.

Feldman, S. 1999. Please don’t call me ‘dear’: older women’s narratives of health care. Nursing Inquiry 6(4), 269–276.

Hancock, K., Chang, E., Chenoweth, L., Clarke, M., Carroll, A. and Jeon, Y.H. 2003. Nursing needs of acutely ill older people. Journal of Advanced Nursing 44(5), 507–516.

Happell, B. and Brooker, J. 2001. Who will look after my grandmother? Attitudes of student nurses toward the care of older adults. Journal of Gerontological Nursing 27(12), 12–17.

Herbert, R. 1992. The normal aging process reviewed. International Nursing Review 39(3), 93–96.

House of Lords’ Science & Technology Committee. 2005. Ageing: Scientific Aspects, Vol. 1: Report. The Stationery Office, London. National Health Service Quality Improvement Scotland. 2002. Nutrition in Older People. NHSQIS, Edinburgh.

National Health Service Quality Improvement Scotland. 2005. Oral Health in Older People. NHSQIS, Edinburgh.

Nay, R. 1998. Contradictions between perceptions and practices of caring in long-term care of the elderly. Journal of Clinical Nursing 7(5), 401–408.

NICE. 2004. Best Practice for Falls in Older People. CG21. NICE, London.

NICE. 2008. Guidelines to Promote Older People’s Mental Wellbeing. PH16. NICE, London.

Nursing and Midwifery Advisory Committee. 2001. Caring for Older People: A Nursing Priority.

Department of Health, London. Roper, N., Logan, W. and Tierney, A. 2000. The Roper, Logan and Tierney Model of Nursing. Churchill Livingstone, Edinburgh.

Scottish Executive. 2005. Building a Health Service Fit for the Future. Scottish Executive, Edinburgh.

Chapter 2

Theories of Ageing

Aims

After reading this chapter you will be able to discuss the current theories of biological ageing and consider how these may account for the physiological changes seen in the older adult.

Learning Outcomes

After completion of this chapter you will be able to:

Introduction

We will begin this chapter with an examination of a number of current theories that propose a mechanism for the phenomenon of ageing. We will then go on to discuss the effects of ageing on homeostasis and body function.

Ageing theories

Scientists agree that there would appear to be no single mechanism of ageing (Kirkwood, 2003). Rather, it is suggested that there are multiple mechanisms which over time result in a deterioration in general cellular function and a less vigorous response to internal and external stressors. Most theories agree that the cumulative cellular damage associated with ageing is a consequence of the body’s failure to adequately repair this damage. These mechanisms, as stated earlier, are considered to be metabolically harmful. They include mutations in DNA, defective mitochondria, oxidative damage over time by the presence of free radicals and a build-up of atypical proteins. It can be seen, therefore, that ageing is a result of a gradual amassing of faults in the cells and tissues within the body (Kirkwood, 2003), changes which contribute to an increased risk of chronic disease and death.

We will now go on to consider a number of different theories of ageing.

Error theory

Increases in somatic mutations associated with the ageing process can result in alterations in the genetic sequences within DNA (Montague et al., 2005). By somatic we mean the non-sex cells within the body. Error theory or error catastrophe theory suggests that these changes in DNA are passed onto the next generation of cells (Ricklefs and Finch, 1995). These new cells, containing altered DNA, will produce proteins which are different from the original ones, that is, deviant proteins. The next generation of cells will also contain this deviation, and this will continue until eventually the cells being produced are significantly different from the original parent cell. Error theory suggests that this leads to a diminished functional ability of the resulting cell line. Over time tissues, organs and systems demonstrate a reduction in reserve capacity. Initially, the individual may only notice this reduction in function with exertion or strenuous activity, but as more functionality is lost, this may become increasingly evident with less activity or even at rest.

Free radical theory

The free radical theory of ageing was first discussed by Harman in 1956. Free radicals are molecules with one or more unpaired electrons in their outer orbits. These atoms are therefore very unstable and try to initiate rapid chemical reactions in an attempt to form more stable molecules. During this process, free radicals attack and modify other molecules (Ricklefs and Finch, 1995). Free radicals are produced normally within the body as a by-product of cell metabolism. Although there are many different types of free radicals, it would appear that oxygen radicals are the most pathological to the human body (Woodrow, 2002). In a very real sense, whilst we need oxygen to live, oxygen is also a poison. Free radicals are therefore toxic compounds produced when oxygen is metabolised.

Free radicals are normally eliminated within the body by enzymes found in peroxisomes and cytosol (Tortora, 2005). However, an accumulation of free radicals can cause oxidative damage to cellular structures including cell proteins, cell membranes and nucleic acids. Over time this damage leads to cell mutation and senescence (Amella, 2004). Oxidative stress is strongly linked to the ageing process, and a major target for oxidative damage is DNA (House of Lords Science and Technology Committee, 2005).

Accumulation of damage by the recurrent effects of free radicals within the body has been linked to the development of several chronic diseases, including cardiovascular disease, respiratory disease, cancers and dementia (Khaw, 1997), which may not necessarily be associated with ageing. A very visible demonstration of damage caused by the presence of free radicals is ‘age spots’, or Lentigo, which are pigmented areas of skin caused by deposition of lipofuscin, a by-product of free radical activity. Lipofuscin causes deprivation of oxygen and nutrients to healthy tissue eventually leading to its death (Meiner and Lueckenotte, 2006).

It is known that exposure to a number of factors can increase the production of free radicals within the body and hence also increase the damage associated with their presence. These factors include:

The production of free radicals is also appreciably increased following exposure to ionising radiation such as prolonged and excessive exposure to the sun or accumulative exposure to X-rays (Nowak and Handford, 1996).

Seeley et al. (2003) and Meiner and Lueckenotte (2006) suggest that antioxidants (free radical foragers) such as vitamin C, beta-carotene, selenium and vitamin E may alleviate the damage caused by free radicals. Antioxidants prevent oxidation (and subsequent damage) of cell components by donating an electron to the outer orbit of the free radicals and in this way make them more stable (Seeley et al., 2003).

Activity

Identify foods that are good sources of vitamin C, beta-carotene, selenium and vitamin E.

Immune theory

There is a decline in immunocompetence in the older adult. The immune theory of ageing proposes that as the immune system deteriorates over time, the resulting decline in function contributes to the development of cancers, opportunistic infections and other immune associated diseases. Whilst T and B lymphocyte function declines, macrophage activity can actually increase contributing to sustained inflammation and swelling (Ricklefs and Finch, 1995). Matteson (1997) also suggests that autoantibodies accumulate in the body with advancing age, which then direct the immune system to attack ‘self’ cells, that is, the body’s own cells. It is suggested that this may be due to the effects of age-related changes in cells. Cells reach a point where they are no longer recognised as ‘self’ and are therefore viewed as foreign and targeted by the immune system.

Montague et al. (2005) suggest that, in addition, alterations in amino acids result in changes to protein synthesis. These altered proteins can then be viewed as ‘non-self’ triggering an immune response.

The overall efficiency and effectiveness of our immune system can be enhanced by taking zinc, selenium, vitamin A and riboflavin and by participating in exercise. However, experimental studies have shown that chronic nicotine exposure has an effect on the animal immune systems and may contribute to nicotine/cigarette smoke-induced immunosuppression (Geng et al., 1995, 1996). Arcavi and Benowitz (2004) suggest that smoking not only increases the risk of infections due to structural changes in the respiratory tract, but also results in a decrease in immune response, thereby putting smokers at greater risk of opportunistic infections.

Activity

Identify your local ‘stop smoking’ resources. These may be a health promotion professional, a drop-in clinic, self-help groups, health advice leaflets, etc. Using these local resources, explore the strategies that you may employ to assist an older person give up smoking.

Programmed theory of ageing: changes in cell replication

Each cell in the body has its origin in an original fertilised ovum. All subsequent generations of cells result from a parent cell dividing and producing daughter cells. Each daughter cell then divides in its turn and so on throughout life. During embryonic development cells must also differentiate into different cell types.

The programmed theory of ageing suggests that cells have a finite, or limited, number of times that they can divide, or replicate. When they reach this limit, they become unable to continue replication. The cell recognises this limit and triggers a cell death sequence known as apoptosis. As more and more cells reach this stage, functional ability declines and obvious signs of ageing appear.

Telomeres are sections of DNA that protect the ends of chromosomes from decay and from sticking to one another.

img Revision Point

If you are unsure of the structure of DNA and chromosomes, you might find it helpful to review this in your preferred textbook.

However, with each subsequent cell division the telomeres shorten. After many cycles of cell division, the telomeres are significantly reduced in size and no longer able to protect the chromosome. In the absence of this protective ‘cap’, the chromosomes themselves ‘fray’ and deteriorate over time, leading to a breakdown in the organism’s genetic material. This disruption in the chromosome prevents cells from replicating and can lead to cellular damage, cell death or cancer (Amella, 2004).

Telomerase is an enzyme found in abundance in cancerous cells but not in non-cancerous cells (Mauk, 2006; Meiner and Lueckenotte, 2006). This enzyme prevents the shortening of telomeres after cell division and therefore prevents the cell from dying after a finite number of divisions where the telomeres would have been used up (Lueckenotte, 2000). Cancerous cells are not governed by the same rules as non-cancerous cells (Siegel, 2008) and as such they maintain their telomeres and therefore can continue to divide indefinitely. This may account for the increasing incidence of cancers seen in older adults. It also opens up the possibility of treatments aimed at blocking the action of telomerase, thus preventing cancer cells from multiplying.

Theories of ageing (adapted from Farley et al. (2006), with permission from the RCN).

Theories Description
Error theory Alteration in the sequencing of genes in DNA. Error theory suggests that this leads to decreased functional ability of the cell.
Free radical theory Free radicals are toxic compounds leading to oxidative stress that damages DNA. Accumulation of damage by the recurrent effects of free radicals within the body has been linked to the development of several chronic diseases.
Immune theory Decline in immune system functioning where age-related changes in cells may result in them no longer being recognised as ‘self’ and therefore seen as foreign and targeted by the immune system. Or an increase in autoimmune responses where altered proteins are viewed as ‘non-self’ triggering an immune response.
Programmed theory of ageing: changes in cell replication Loss of telomeres disrupts cell replication. This disruption in the chromosome prevents cells from replicating and can lead to cellular damage, cellular death or cancer.
Neuroendocrine theory The secretion of a range of hormones from the neuroendocrine system begins to fail with age. These changes result in an increase in disease in a number of body systems and organs.

Neuroendocrine theory

We know that the nervous and endocrine systems play a key role in regulating normal growth, repair and development. It is postulated that as we age the regulatory pathways and the secretion of a range of hormones from the neuroendocrine system begin to fail. Notably, these include the hormones oestrogen, growth hormone and melatonin (Mauk, 2006). Plasma cortisol levels have also been shown to increase as a result of increased activation of the hypothalamus–pituitary–adrenal axis. The net effect of these changes is an increase in disease in a number of body systems and organs.

See for a brief description of these ageing theories.

Effects of ageing on homeostasis and body function

Homeostasis is the maintenance of a constant internal environment which is necessary for effective physiological activity. Homeostasis involves a complex series of physiological and biochemical changes and responses. Nearly all organs and systems are involved in this process (Redfern and Ross, 2001). Whilst homeostasis is maintained in older adults, functional ability will decline over time. This decline may not be obvious or uniform and may not necessarily interfere with a person’s social functioning. However, a combination of stressors (internal or external) and ageing changes can have a deleterious effect on homeostasis. Such stressors can include illness, trauma, exposure to extreme environmental temperatures and strenuous exercise. These stressors may impact negatively on homeostasis in the older adult as although they have reserve capacity in organ systems, this capacity is reduced to the point where it cannot match the demands made by these stressors. In other words, systems which may normally function well most of the time can be overwhelmed by illness, trauma, infection and other stressors. When this occurs, the individual is no longer in homeostasis and problems ensue. When such a state is reached, it takes longer for the older adult to recover and return to the pre-stressor condition.

Reserve capacity is the spare capacity that systems have which ordinarily are not used but will be available if needed. A person uses their reserve capacity when there are increased health demands made on the body. Reduction in reserve capacity is an important consideration in frailty. Borz (2002) states that all organ systems of the body show evidence of redundant structure and function, stating that most systems have as much as a 70% margin of loss before signs of failure become apparent. Consequently, 30% of normal functioning is adequate for most needs. However, the reserve capacity becomes significant during episodes of stress, injury or illness, and as stated earlier, in older adults this reserve capacity is diminished, making it more likely that they succumb to illness.

Summary

Contrary to the impression that we often have of ageing, growing older is not synonymous with disease and infirmity. Regardless of which theory or theories of ageing proves to be correct, older adults can, for the most part, continue to lead a full and active life and maintain their usual daily activities.

However, the loss of ‘spare capacity’ in organs and systems may be significant when the older adult becomes unwell. Recovery from illness is slower in older adults and healthcare professionals need to plan accordingly.

It is also important to acknowledge that there is a psychological, social and spiritual as well as physiological dimension to growing older. It is not our intention in this text to examine these elements of ageing; however, the reader is directed to further reading if they wish to pursue this further.

For health-care professionals, knowledge of current theories of ageing should help them to advise adults about particular risks or compounding factors such as obesity or smoking. In this way, they can assist the ageing adult to maintain an optimum level of health for as long as possible and help them to adapt their activities of living when and if required.

References and further reading

Amelia, E.J. 2004. Presentation of illness in older adults. American Journal of Nursing 104(10), 40–51.

Arcavi, L. and Benowitz, N.L. 2004. Cigarette smoking and infection. Archives of Internal Medicine 164(20), 2206–2216.

Borz, W.M., II. 2002. A conceptual framework of frailty: a review. The Journals of Gerontology Series A: Biological Sciences and Medical Sciences 57(5), 283–288.

Farley, A.H., McLafferty, E. and Hendry, C. 2006. The physiological effects of ageing on the activities of living. Nursing Standard 20(45), 46–52.

Geng, Y., Savage, S.M., Johnson, L.J., Seagrave, J. and Sopori, M.L. 1995. Effects of nicotine on the immune response. I. Chronic exposure to nicotine impairs antigen receptor-mediated signal transduction in lymphocytes. Toxicology and Applied Pharmacology 135(2), 268–278.

Geng, Y., Savage, S.M., Razani-Boroujerdi, S. and Sopori, M.L. 1996. Effects of nicotine on the immune response. II. Chronic nicotine treatment induces T cell anergy. Journal of Immunology 156(7), 2384–2390.

Harman, D. 1956. Aging: a theory based on the free radical and radiation chemistry. Journal of Gerontology 11(3), 298–300.

House of Lords Science and Technology Committee. 2005. Scientific Aspects of Ageing. The Stationary Office, London.

Khaw, K. 1997. Healthy aging. British Medical Journal 315(7115), 1090–1096.

Kirkwood, T.B. 2003. The most pressing problem of our age. British Medical Journal 326(7402), 1297–1299.

Lueckenotte, A.G. 2000. Gerontologic Nursing. 2nd ed. Mosby, St. Louis, MO.

Matteson, M.A. 1997. Biological theories of ageing. In Matteson, M.A., McConnell, E.S. and Linton, A.D. (Eds). Gerontological Nursing: Concepts and Practice. 2nd ed. Saunders, Philadelphia, PA, pp. 159–171.

Mauk, K.L. 2006. Gerontological Nursing: Competencies for Care. Jones and Bartlett Publishers, Sudbury, MA.

Meiner, S.E. and Lueckenotte, A.G. 2006. Gerontologic Nursing. 3rd ed. Mosby Elsevier, St. Louis, MO.

Montague, S., Watson, R. and Herbert, R. 2005. Physiology for Nursing Practice. 3rd ed. Elsevier, Edinburgh.

Nowak, T.J. and Handford, A.G. 1996. Essentials of Pathophysiology. WC Brown Publishers, Dubuque, IA.

Redfern, S.J. and Ross, F.M. 2001. Nursing Older People. 3rd ed. Churchill Livingstone, Edinburgh.

Ricklefs, R.E. and Finch, C.E. 1995. Aging: A Natural History. Scientific American Library, New York, NY.

Seeley, R.R., Stephens, T.D. and Tate, P. 2003. Anatomy and Physiology. 6th ed. McGraw Hill, London.

Siegel, L.J. 2008. Are telomeres the key to aging and cancer. . Last accessed 4th May 2009.

Tortora, G. 2005. Principals of Human Anatomy. 10th ed. Wiley, Hoboken, NJ.

Woodrow, P. 2002. Ageing: Issues for Physical, Psychological and Social Health. Whurr, London.