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As we age, there are several changes that occur in our bodies. In the genitourinary system, the bladder capacity decreases, leading to more frequent urination and difficulty voiding. Men may develop a condition called benign prostatic hypertrophy (BPH), where the prostate swells and blocks the urethra. This can cause urinary retention and potential kidney damage. Incontinence is not a normal part of aging and can lead to skin irritation, UTIs, and yeast infections. Thyroid hormone levels may decrease, leading to symptoms such as slower heart rate, fatigue, dry hair and skin, cold intolerance, and weight gain. Endocrine changes can also result in increased fluid retention, hyperglycemia, and an increase in norepinephrine, which can affect the cardiovascular system. Hyperosmolar hyperglycemic non-ketotic syndrome (HHNS) is a complication in older people with type 2 diabetes, characterized by severe dehydration and high blood sugar levels in the genitourinary urinary system, decrease in bladder capacity. Your bladder is a fluid-filled sac, and it expands, it's like elastic. What happens to elastics over the years? They weaken, so therefore they don't expand that much. You have more frequency, more urgent need to urinate, and a lot of times patients aren't able to because they develop what they call, men develop a culture. I mean, they develop what they call BPH, benign prostatic hypertrophy. The prostate, which is the size of up-size of a walnut, and it's wrapped around the urethra, it actually, the urethra, it actually swells, and it doesn't swell out, it swells in, mostly, and it closes off the urethra. So patients have difficulty urinating, they have difficulty voiding, right? And so the guy will go pee, and they'll have just a short little quick stream, but he's gotta pee, and you can end up with what they call urinary retention. That urinary retention can retain all the way up into the kidneys, and damage the kidneys. So patients with BPH end up going through a procedure called a TURP procedure, T-U-R-P, Transurethral Resection Procedure. It's like a Roto-Rooter. They go inside the urethra, all the way up to the prostate, and they can't open it up, God bless you, and they might put in stent, so that the patient is able to urinate. So declined sphincter control, which can lead to that bladder leakage, decline in the sense of voiding, and that increasing nocturnal voiding, so which means that if I have BPH, I'm not able to pee a good stream. I have poor urinary release when I do pee, which means I pee more times during the day, which means I pee more at night. So instead of getting a good eight hours of sleep, every two hours, I'm up to pee. I don't sleep well at night, so that can lead to patients not sleeping well. And we talked about BPH. Incontinence is not a normal part of aging. It can lead to skin irritation, skin breakdown, and UTIs, as well as if you have bowel incontinence, or bowel leaks, that can lead to yeast infections in women. Stress incontinence occurs during activities such as coughing, laughing, sneezing, licking, or exercising. That's an issue in my mother's side of the family, my sister's, my mother, my aunt. You have a tendency to pee a little bit. First, incontinence is triggered by hot and cold, running water, or thinking about going to the bathroom. Did you ever jump in a really cold pool, and all of a sudden you gotta pee? That's called cold water diuresis. It can actually happen in very cold air. If you get that blast of very cold air, it can cause you to feel like you have the diuresis as well. The opposite of incontinence is urinary retention, or difficulty urinating. It's very bad, because it can lead to kidney failure, because it can damage the nephron by the hydrostatic pressure. In men, enlarged prostate, that benign prostatic hypertrophy, can place pressure on the urethra. Bladder and urinary tract infections can also cause inflammation. In severe causes, in severe urinary retention, patients will experience renal failure. This is one of the reasons why some people have to go, they end up having to catheterize themselves, and you've seen the ads for the pocket catheter, the slimline catheter, the micro catheter, the self-lubricating catheter, and the guy puts it in his pocket, he orders them. What you do is, every time you have to pee, you catheterize your urethra. This is usually the urethra. So, if the bladder doesn't pop, it's gonna cause something to happen? The bladder won't pop, it won't pop. What it'll do is, I mean, it eventually would, but I mean, it's gonna cause kidney failure before it'll pop. The bladder will actually can hold over a liter of fluid. I mean, it can get really big. Yeah, it's hard for people to block it when they do this. Eventually. What if it pops? And when it pops, it's no good. No good. Reduction in thyroid hormones. So, you have three thyroid hormones, basically. It's TSH, which is the thyroid-stimulating hormone, which stimulates T1 and T2. T1 causes increase in metabolism. T2 causes the control of uptake, organism, as to T2 and T3. T2 causes the decalcification of bones to increase their calcium levels, and T3 causes the parathyroids to, from the parathyroids cause the bones to recalcify, if you have too much calcium. Yeah, TSH is the thyroid-stimulating hormone. That comes from the hypothalamus, and it stimulates the thyroid to release T1, T2, T3. T1 causes, it affects metabolism. Then, T2 causes increased serum calcium levels, and T3 causes decreased serum calcium levels. TSH, thyroid-stimulating hormone, we can actually take a medication to affect this. If patients can have hypothyroidism, which is the decreased thyroid function, and so they take medications called Synthroid. Synthroid is the trade name. Levothyroxine, or thyroxine, is the generic name, and you take levothyroxine. You'll see that in many patients' medical histories. They have hypothyroidism. Is that what they take when they remove the thyroid? Yeah, you take thyroxine, yeah, or levothyroxine. So, you're gonna take things like, it's thyroxine or Synthroid, and both of those are levothyroxine, just different manufacturers. So, signs and symptoms would be a slower heart rate, because it slows your metabolism down. You don't have as much thyroxine. Fatigue, drier hair and skin, cold intolerances, and weight gain. So, these kind of patients are kind of slower, more tired all the time, weaker, don't sleep right, very dry skin. Other endocrine changes occur. An increase in the secretion of antidiuretic hormone causes gluten imbalance. The antidiuretic hormone keeps me from diuretic. It makes me retain fluid. So, my kidneys already are not producing as much urine. Now, my body's putting out more antidiuretic hormone, making me retain even more fluid. Again, the reason why hyper, one of the more common reasons for hypertension in the elderly, is just increased fluid. That's why patients take diuretics or ACE inhibitors. Hyperglycemia, which is in high glucose levels, and an increase in the level of norepinephrine, possibly having a harmful effect on cardiovascular systems. Norepinephrine is positive to alpha-1 and alpha-2. Of course, it causes basal constriction in the periphery and the GI system, which leads to poor, it leads to malabsorption. HHNS, hyperosmolar, hyperglycemic, and non-catillic syndrome is a type two diabetic complication in older people. This is people with insulin resistance. They're making insulin, they're burning sugar, but not enough, and so what happens is the sugar builds up and produces a severe dehydration because we diurese to get rid of the excess sugar. We pee out the sugar, and we pee out the water, too. Hyperosmolar, the blood has a high osmolarity because it's got a lot of sugar in it, a lot of solutes. Hyperglycemic, it's the sugar that causes the hyperosmolar. Non-catillic, I'm not producing ketones. My cells are not burning fat like in type one diabetes. They're burning sugar, just not enough. I'm not absorbing enough sugar. What happens? These patients will have warm, lush skin because of all the extra sugar in the blood will cause the blood vessels to dilate. Poor skin fervor, they'll be dehydrated. I pinch the skin, and it stays up, it stays pinched. Pale, dry mucosa with a furrowed tongue. You know what a furrowed tongue is? If you look at the tongue, it looks like the Grand Canyon. They have all these crevices in the tongue because it's so dry, we call it a furrowed tongue. And signs of shock. So patients with endocrine emergencies should have a full set of vital signs, listen to lung sounds, keep them warm, assess their blood sugar, and continue to treat airway, ventilatory, and circulatory emergencies, high priority transport. Not a lot we can do even in ALS. I mean, we can give them IV fluids, but there's not a lot we can do for these patients even in ALS. Changes in immune system infections are commonly seen in older people because of their increased risk. They're less able to fight infection, their immune system, like everything else, has degraded. I'm 70 years old, my immune system is running, you know, 40%, it's running 60% of what it was when I was 30. Anorexia, what is that? Wanna eat, why would you wanna eat? What's one of the main causes of that? Nope. Yeah, poor taste buds, exactly. Fatigue, which can come from anorexia, weight loss, fall, changes in mental status, may be the primary symptom. Pneumonias and UTIs are common in patients who are bedridden. Again, if they don't get up and move around, they're not increasing their breathing, so they develop anaphylactic system, and they cough like this. And they'll clear everything up. Signs and symptoms may decrease because of loss of sensation, lack of awareness, or fear of being conflicted. This is a big one. It's important to understand, especially when you go to somebody's home. Some people have lived in their home for 50 years. They built their home, this is their home. They're gonna die in it. I told my wife, I'm gonna die in my home. I prepare for it. I'm not leaving my house to go to a nursing home. So you have an elderly family, or maybe a single person who lives in their home, the home's paid for, this is their home. You go to pick them up, you go to see them, and they need to go to the hospital. And they're gonna give you every excuse in the book not to go to the hospital. And it's not that they know they're not sick. Why? They're afraid they're gonna lose their home. They're afraid that when they leave, they're gonna go to a nursing home and they'll never get back in their home. Or somebody will take their home, or somebody. At least if I'm home, I'm in my home, you can't take me from my home. So sometimes it takes a lot of convincing to get patients to realize that, hey, we're not trying to take your home. You'll come back, but we need to get you checked out now. And nobody really wants that. I mean, there are some patients who do end up. You know, that's a rarity. But there are some patients who do end up in a nursing home who do not make it back home. But they shouldn't be home anyway. All right. Decrease in bone mass, especially in post-menopausal women. Bones are more brittle and tend to break more easily. I have seen patients break their femur or have like an intercostal anterior hip fracture because they stood up and they turned. And when they turned, they caught their foot on a chair. And they went right to the ground and had hip fractures because the bones are so weakened due to osteoporosis. Joints lose their flexibility. A decrease in the amount of muscle mass often results in less strength, which means they're less likely to balance and keep themselves from falling. That's why elderly people are more prone to falls because they don't have the musculature, the development to maintain their body stature. I will tell you now, one of the main things you can do to save off getting old is exercising daily. Walking, you don't even have to be a gym rat, but walking, light weights, riding a bike, that daily exercise, that daily muscles, that daily strengthening and using those muscles builds bone. So the more you work those muscles, the more you work those bones, the bigger the bones get, the longer they stay. Changes in physical ability can affect older patients' confidence in mobility. Muscle fibers become smaller and fewer, so they have less of an ability to balance, or less of an ability to recover from the loss of balance. Motor neurons decrease in number, so they have less motor response, reflexes. Strength declines, ligaments and cartilage lose their elasticity, they become stiff. You see those 80-year-olds, and they kind of walk like this. The bones become, the joints become stiff. And cartilage goes through the degenerative changes just like everything else does. Osteoporosis is characterized by a decrease in bone mass, reduction in bone strength, and greater susceptibility to fractures. Extent of bone loss depends on genetics and body weight. You know, if your family's prone to osteoporosis, you're more likely to get it. Obesity has an effect on it as well. Smoking and alcohol consumption, especially later in life, as well as level of activity and diet. Osteoarthritis is that progressive disease of the joints. Wear and tear, especially those like people in the military, in the trades, you know, ship building, or road building, or construction. They tend to use the joints more, and they wear out. Our body wears out, it gets overused. And most commonly in the hands, knees, hips, and spine. Sometimes you get those fingers that go, I had an uncle who had osteoarthritis, and it caught his finger to turn this way. So his finger literally looked like that. So when he pointed at you, he was actually pointing over there. He used to do that all the time. He'd point at me, he's my uncle Michael Edwards. He used to call him Uncle Boo-Boo when I was a kid. I couldn't say Edward, Uncle Boo-Boo. So he'd always say, ah, it's your Uncle Boo-Boo. But he used to point at me, I'd be like, what the hell are you looking at? Of course I was. Proteins, skin changes. Proteins that make up the skin pliable decline with age. That sebum that's released from the sebaceous gland, it breaks down over time, and we have less sebum, which is more likely to cause thin skin. You know, we see that thin skin in individuals. Layer of fat under the skin becomes thinner, because they have less subcutaneous fat. So they have less energy stores when needed, but they also have less insulation. Their thermal regulatory system becomes weakened because of age, and then they have less insulation. They're more prone to hot and cold weather emergencies. Bruising becomes more common, and again, the skin becomes paper thin sometimes. Dialysis doesn't help. Sweat glands do not respond readily to heat, which means they're more prone to those hot and cold weather emergencies. Pressure ulcers become a problem. We call these decubitus ulcers. When I sit down, or when I lie down, wherever my bone is close to the skin and pushes on something, it blocks off blood flow. When I sit, if I'm sitting on this, my ischial tuberosity is pushing on the skin and it's blocking off blood flow. Well, I get up and move around, no big deal. But if I'm laying down for hours and hours a day, that tissue becomes ischemic, and then you develop these pressure sores. I've seen pressure sores on ears, cheeks, because patients lay on one side. I've seen it on the shoulders. I've seen pressure ulcers like on a sacrum to the point where you have what they call undermining. There'd be a wound here this big, and all you can see is the sacrum because all the tissue's gone. And they can take a q-tip, Michael, these long q-tips, and they can go underneath the skin, and they go three and four and five, six millimeters, and they measure it. That's called undermining. Really, really bad. And what's the problem? What's in this area? Sorry about the bathroom. Fecal matter. Now I have fecal matter introduced to my spinal column. Bad stuff. And this is very common in patients who end up bedridden, whether they be in nursing homes or hospitals, because, again, in order to avoid a pressure ulcer, you have to be turned every 30 minutes. There is no nursing home on the planet that I know of that turns patients every 30 minutes. So pressure sores develop over time. It happens. That's why they want to get you up and get you moving, sit you in a chair, et cetera. And these are the four stages. Stage one is non-blanching redness. So it's red, the spot is red, and when I push on it, it doesn't blanch out. It stays red. It's irritated, infected. A blister ulcer that can affect the dermis and epidermis. Sometimes that blister ruptures. When you get to stage three, it invades into the fat layer and down to the fascia. Usually it's open at that point. And then stage four is invasions of bone and muscle. And then you can get what they call unstageable. Stage five is called unstageable, and that's when you get that open sore with the undermining. Very, very bad. Matter of fact, that's what kills a lot of patients, is the infection. Christopher Reeve, Superman. Remember how I told you he was on a ventilator? Paralyzed? That's what he died from, the infection from the bed sore. Toxicology! Actually, we'll take a break here, and then we'll get into toxicology.