EPA/630/R-01/003
Final Report
EXPLORATION OF AGING & TOXIC RESPONSE ISSUES
Contract No. 68-C-99-238
Task Order 15
Prepared for:
Risk Assessment Forum
U.S. Environmental Protection Agency
1200 Pennsylvania Ave., NW (8623D)
Washington, DC 20460
Prepared By:
Versar, Inc.
6850 Versar Center
Springfield, VA 22151
February 15,2001
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NOTICE
Although the development of this report has been funded by the U.S. Environmental Protection
Agency (EPA) under Contract Number 68-C-99-238 to the National Center for Environmental
Assessment, it does not necessarily reflect the views or policies of the EPA, and no official
endorsement should be inferred. Mention of trade names or commercial products does not
constitute endorsement or recommendation for use.
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TABLE OF CONTENTS
1.0 DEFINITION OF "AGED," "ELDERLY," OR "GERIATRIC" POPULATION 1
2.0 ANATOMICAL, PHYSIOLOGICAL, BIOCHEMICAL, AND
PATHOPHYSIOLOGICAL AGE CHANGES 2
2.1 Heterogeneity Among Individuals in the Extent of Age-related Changes 2
2.2 Nervous System 2
2.2.1 Central Nervous System 3
2.2.2 Peripheral Nervous System 3
2.2.3 Blood Brain-Barrier 3
2.2.4 Cognition-Alzheimer's Disease and Other Dementias 3
2.2.5 Motor System-Parkinson's Disease 5
2.2.6 Sensory System 7
2.2.7 Strokes 9
2.3 Cardiovascular System 9
2.3.1 Heart 9
2.3.2 Blood Vessels 11
2.4 Gastrointestinal System 12
2.4.1 Motility 12
2.4.2 Secretion 13
2.4.3 Digestion and Absorption 13
2.5 Respiratory System 14
2.5.1 Thoracic Air Pump 14
2.5.2 Gas Transport-Anemia 14
2.6 Liver 14
2.7 Kidneys 15
2.8 Urinary Tract - Incontinence 16
2.9 Immune System 16
2.10 Endocrine System 17
2.10.1 Pituitary-Thyroid Axis 17
2.10.2 Pituitary-Adrenal Axis 17
2.10.3 Growth Hormone 18
2.11 Reproductive System 18
2.11.1 Menopause 18
2.11.2 Andropause 19
2.12 Skin 19
2.13 Body Mass and Structure 20
2.14 Skeletal System 21
2.14.1 Bone-Osteoporosis 21
2.14.2 Osteoarthritis 22
2.14.3 Gout 22
2.15 Metabolism 22
2.15.1 Mitochondria-Oxidative Stress 23
2.15.2 Carbohydrate, Fat, and Protein Metabolism 23
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2.16 Thermoregulation 23
2.17 Genomic Structure and Function 24
2.18 General Cellular Functions 24
2.19 Neoplasia 24
3.0 AGE-RELATED CHANGES IN PHARMACOKINETICS AND
PHARMACODYNAMICS 25
3.1 Pharmacokinetic Changes in the Gastrointestinal System 26
3.1.1 Secretion 26
3.1.2 Motility 26
3.2 Pharmacokinetic Changes in the Liver 26
3.2.1 Splanchnic Blood Flow 26
3.2.2 Mixed Function Oxidase-P450 System 27
3.3 Age-related Changes in Drug Distribution 27
3.3.1 Body Composition 27
3.3.2 Plasma Protein Binding 28
3.3.3 BloodFlow 28
3.4 Pharmacokinetic Changes in the Kidney 28
3.4.1 GFR 28
3.4.2 Excretion 29
3.5 Ciprofloxacin and Nonsteroidal Anti-Inflammatory Drugs: Examples of Age-
related Pharmacokinetic Changes 29
3.5.1 Ciprofloxacin 29
3.5.2 Nonsteroidal Anti-inflammatory Drugs (NSAIDs) 29
3.6 Drug Responses in the Cardiovascular System 30
3.7 Drug Responses in the Pulmonary System 30
3.8 Drug Responses in the Nervous System 31
3.8.1 Central Nervous System 31
3.8.2 Peripheral Nervous System 32
3.8.3 Blood-Brain Barrier 32
3.9 Nutrition and Drug Responses 32
3.10 Comment 33
4.0 AGE-ASSOCIATED FUNCTIONAL CHANGES AND RESPONSE TO
ENVIRONMENTAL EXPOSURES 33
4.1 Example: Response to Lead 33
4.1.1 Absorption, Distribution, and Clearance 33
4.1.2 Toxicity and Potential Effects 33
4.2 Example: Response to Trichloroethylene 34
4.2.1 Absorption and Distribution 34
4.2.2 Toxicity and Potential Effects 34
4.3 Nutrition, Cancer, and Aging 35
4.4 Comment 36
5.0 ANIMAL MODELS FOR THE STUDY OF AGING 36
5.1 Cell Culture and In Vitro Models 36
5.1.1 Fibroblasts 37
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5.2 Non-mammalian Species 37
5.2.1 Fruit Flies 37
5.2.2 Nematodes 38
5.3 Mammalian Species 38
5.3.1 Rats 39
5.3.2 Mice 40
5.3.3 Hamsters 40
5.3.4 Cats and Dogs 40
5.3.5 Non-human Primates 40
5.4 Comment 40
6.0 AGE-ASSOCIATED FUNCTIONAL CHANGES AND RESPONSE TO
ENVIRONMENTAL EXPOSURES 41
7.0 REFERENCES 43
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AUTHORS
Edward J. Masoro, Ph.D.
University of Texas Health Center
Austin, Texas
Janet B. Schwartz, M.D.
Northwestern University
Chicago, Illinois
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EXPLORATION OF AGING AND TOXIC RESPONSE ISSUES
1.0 DEFINITION OF "AGED," "ELDERLY," OR "GERIATRIC" POPULATION
When referring to humans, gerontologists use the nouns "aged," "elderly," or the
adjective "geriatric" as synonyms. This seems appropriate since the dictionary definition of
elderly is "past middle age and approaching old age" and the definitions of "aged" and
"geriatric" are similar to that of "elderly." Gerontologists and geriatricians tend to use these
terms for everyone older than a given age but a general agreement does not exist on what that
age should be. Some published papers refer to those over age 55 years as elderly. The United
Nations defines people of age 60 years and older as elderly (1). In the United States and many
other countries, elderly refers to those age 65 years older, which appears to be based on what has
been traditionally viewed as the age of retirement from the work force. For example, in the
United States, age 65 years is the minimum age for the receipt of Medicare and of full benefits
from Social Security. Many gerontologists are concerned about grouping all elderly in this one
broad category because the characteristics of people change markedly with increasing age past
the age of 65 years. For example, the percentage of persons requiring help from others for basic
life activities is about 9 percent in the 65-74 years age range and increases to 20 percent in the
75-84 years age range and to 50 percent in those 85 years and older (2). This issue has been
addressed by the sub-classification of the elderly such as the one proposed by Waneen Spirduso
(3): 65-74 years, young-old; 75-84 years, old; 85-99 years, old-old; over 100 years, oldest-old.
Most gerontologists refer to the last group as centenarians and this group has recently been the
subject of much research in an attempt to discover the basis of their extreme longevity.
A concern about grouping people in calendar age classes is the fact that within an age
range, the extent of age-associated deterioration varies greatly among individuals, with some
showing little or no deterioration and others marked deterioration. To address this issue,
gerontologists have developed the concept of biological age as distinct from calendar age. Thus,
the person with marked deterioration is considered much older in regard to biological age than
the one with little or no deterioration even though both are of the same calendar age. Most
gerontologists subscribe to this concept and much effort has gone into developing biomarkers
that would enable biological age to be measured (4). Unfortunately, no biomarker or panel of
biomarkers is believed to be a reliable measure of biological age. Thus, at this point in time the
concept of biological age is not a useful one for research gerontologists, practicing geriatricians,
or the EPA. Nevertheless, each of these professional groups must keep in mind the heterogeneity
in extent of deterioration among members of a geriatric population.
The terms "elderly," "aged," and "geriatrics" are not usually used in aging studies
employing animal models. Rather, investigators use life table characteristics such as the median
length of life of the population and the age of tenth percentile survivors as a guide to what might
be called an old animal. Many investigators call an animal "old" if its age is greater than the
median length of life of the population and "oldest old" if older than the age of the tenth
percentile survivors. However, no generally agreed upon criterion is available on when to call an
animal "old."
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EXPLORATION OF AGING AND TOXIC RESPONSE ISSUES
2.0 ANATOMICAL, PHYSIOLOGICAL, BIOCHEMICAL, AND
PATHOPHYSIOLOGICAL AGE CHANGES
2.1 Heterogeneity Among Individuals in the Extent of Age-related Changes
Most studies of morphological and functional changes with age have been of a cross-
sectional design in which measurements are made on subjects of different ages at a given point
in time (e.g., the calendar year 1990). Such studies do not provide information on age changes in
individuals and thus, marked individual differences m such changes tend to be obscured. More
importantly, there are two major confounders that cloud the interpretation of age changes based
on cross-sectional studies: cohort (generational) effects and selective mortality. Different cohorts
(generations) have different experiences (e.g. diet, education, etc.) and thus the differences found
between the young and the old could be the result of these experiences rather than aging. Also,
with increasing age, the fraction of a cohort that is still alive decreases which means that those of
old ages may in many regards be different than those who died; thus, mean differences between
the old and young in a population may be the result of this selective mortality rather than aging.
Longitudinal studies of individuals circumvent some of these problems but they are costly and
also have other drawbacks. The bottom line is that research on human aging has used and will
continue to use primarily the cross-sectional design; such studies provide information on age
differences in functional and morphological characteristics within a population at a point in time.
However, these age differences may or may not be due to aging.
Before considering the age-related changes in organ systems that have been found, the
subject of individual differences should be discussed. Rowe and Kahn (5) have proposed the
concepts of "Usual Aging" and "Successful Aging." Usual Aging refers to elderly who are
functioning well but are at substantial risk of disease and/or disability. Many in this group of
elderly exhibit modest deterioration of the physiological systems. Successful Aging refers to
those elderly having the following three key characteristics: low risk of disease and disease-
related disability; high mental and physical function; and active engagement in life. Rowe and
Kahn downplayed the role of genetics in Successful Aging. Rather, their focus has been on
extrinsic factors such as exercise, diet, personal habits, and psychosocial influences as the major
determinants of Successful Aging.
2.2 Nervous System
Over the years, many claims have been made about generalized age changes in the
nervous system. When carefully studied with improving technology, the most dramatic of these
claims have proven to be exaggerated (6). Brain weight was reported to decline markedly with
advancing age; recent research has shown that much of this decline was due to a cohort effect
and that only a modest decrease in brain weight with increasing age actually occurs. However,
the volume of the cerebrospinal fluid does increase with age with a concomitant decrease in
brain volume (7). In the 1950s, the generally held belief was that large numbers of neurons were
lost with increasing adult age. This belief has not been supported by modern studies. Now most
experts agree that generalized age-associated loss of neurons is small, although some localized
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brain regions do suffer substantial loss (6). The number of synapses does decline with advancing
age (8).
2.2.1 Central Nervous System
The neurotransmitter systems of the central nervous system change with age (9).
Glutamate receptors change with age. Binding to NMDA (N-methyl-D-aspartate) receptors
decreases with age and KA (kainic acid)-binding levels decrease in the hippocampus. These
changes may be compensated for by an increase in glutamate levels. The level of GABA in the
cerebrospinal fluid increases at advanced ages. Whether these changes in the neurotransmitter
systems are balanced to maintain function and whether they become unbalanced at a given stage
of aging remain to be defined.
2.2.2 Peripheral Nervous System
Aging also alters the neurotransmitter systems of the peripheral nervous system.
Although somatic motoneurons supplying skeletal muscle are lost, no evidence is available that
function at the myoneural junction of the remaining somatic motoneurons changes during aging.
However, neurotransmitter function of the autonomic nervous system is affected by aging (10).
The elderly have higher blood levels of the sympathetic neurotransmitter norepinephrine than
younger people. The higher levels are believed to be due to an increased rate of release of
norepinephrine by sympathetic nerve fibers. However, a decreased clearance of norepinephrine
from the circulating blood may also be involved. The response to the sympathetic
neurotransmitter is impaired at advanced ages in a number of important target sites. For example,
beta-adrenergic stimulation of the heart is impaired at advanced ages and this impairment is not
due to a decrease in the number of beta-adrenergic receptors but to an alteration in the cellular
signal transduction response to beta-adrenergic receptor stimulation. Beta-adrenergic dilatation
of blood vessels is also impaired and alpha-adrenergic constriction of veins is decreased at
advanced ages.
2.2.3 Blood Brain-Barrier
The blood-brain barrier was thought to be compromised in the elderly. However, most
evidence indicates that it remains intact in the normal elderly (11). No evidence exists for an
age-associated increase in the permeability of the blood brain barrier to water-soluble substances
including proteins. However, carrier based transport may be somewhat compromised; e.g., the
transport of choline and glucose across the blood brain barrier is decreased.
2.2.4 Cognition-Alzheimer's Disease and Other Dementias
Cognition refers to processes of the mind such as perceiving, remembering, thinking,
learning, and creating. This report will consider the influence of aging on the following aspects
of cognition: attention, memory, and intellectual functions.
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EXPLORATION OF AGING AND TOXIC RESPONSE ISSUES
Attention refers to the ability to focus on and perform a simple task without losing track
of the task objective. This function does not undergo an appreciable age-associated change and
since this involves the circuitry of the brain stem and the thalamus, these brain regions appear to
remain functionally intact in the elderly (12). However, in the presence of distractions, the
elderly are less able to focus on a task than are the young.
As people grow older, most of them complain of memory loss. However, memory is a
complex phenomenon, and not all aspects of memory deteriorate with advancing age (13).
Changes in the initial processing of sensory information do not appear to be a major reason for
age-associated memory deterioration. Primary memory refers to how many things a person can
keep in mind at one time such as the longest string of numbers a person can repeat without an
error; this kind of memory is not appreciably compromised in the normal elderly. However, the
elderly have a more difficult time keeping this string of numbers in mind if asked to do another
task than do young people. Some aspects of long-term memory deteriorate at advanced ages. The
elderly have a more difficult time recollecting prior personal experiences such as where
automobile keys have been left. However, the normal elderly have little difficulty with semantic
memory such as defining words or naming the authors of books, although they may take longer
than young people to retrieve such information. Procedural memory, that which requires the use
of learned motor and cognitive skills such as typing or riding a bicycle, does not deteriorate in
the normal elderly.
In the absence of disease, intellectual functions are rather well maintained in the elderly
(14). With respect to semantic knowledge (verbal ability in vocabulary, information, and
comprehension), intellectual performance changes little during adult life, at least until the middle
of the ninth decade. Indeed, some aspects of intellectual function (e.g., vocabulary, information,
practical judgment) may improve in healthy individuals between the third and eighth decades of
life. However, timed tasks (e.g., the speed of addition and subtraction) are markedly deteriorated
at advanced ages. Old people can learn but the speed of learning decreases with advancing age.
Some kinds of learning become increasingly difficult with increasing age, such as learning tasks
requiring great perceptual speed and a high level of physical coordination. However, the elderly
can master most new tasks, if they are allowed to learn at their own pace. Some elderly
individuals maintain a high level of creativity into the tenth decade of life (e.g., Pablo Picasso,
Pablo Casals and Frank Lloyd Wright), and some even develop creativity at that age (e.g.,
Grandma Moses). However, because of the difficulty of defining creativity, how common this
phenomenon is cannot be determined.
Dementia, a decline in intellectual functions and deterioration in personality and
emotions, is a major age-associated syndrome (15). The prevalence of dementia increases with
age, as does its incidence. The prevalence is in the order of 1 percent in the age range of 65 to 70
years, about 10 percent in the age range of 80 to 85 years, and about 40 percent in the age range
of 90 to 95 years. While more than 70 disorders may produce dementia, the most common causes
are Alzheimer's disease and cerebrovascular disease.
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EXPLORATION OF AGING AND TOXIC RESPONSE ISSUES
Alzheimer's disease begins in an insidious manner, for it can be difficult to distinguish
from mere forgetfulness, but the symptoms progress in severity, with the individual remaining
alert and aware until the terminal stages (16). Memory disturbance is the most prominent initial
symptom. With further progression, deficits occur in the ability to express oneself in speech and
writing, in the ability to understand written or spoken language, in the ability to recognize
familiar objects by sight, and in the ability to copy simple drawings. Alzheimer's disease
involves degeneration of neurons in the cerebral cortex and, in particular, the hippocampus. The
morphologic hallmarks of the disease are senile plaques and neurofibrillary tangles. The senile
plaques contain a core protein, known as beta-amyloid, surrounded by swollen degenerating
nerve terminals and glia cells. The neurofibrillary tangles are found inside the axons and
dendrites of brain neurons. Strong, but not unequivocal, evidence indicates that the beta-amyloid
protein deposited in the plaques is toxic and plays a causal role in the genesis of Alzheimer's
disease. A genetic predisposition for the development of Alzheimer's disease appears to exist.
The epsilon-4 allele of the apolipoprotein E gene has been found to increase the risk of the
disease at advanced ages (17).
The other major class of dementia, vascular dementia, is due to problems with blood
flow to the brain (18). Of the vascular dementias, the best known is multi-infarct dementia,
which is caused by obstructions to blood vessels, many too small to have produced a major
clinical problem. A history of either strokes or transient ischemic attacks (TIAs) may be present.
Typically, a sudden appearance of dementia with a stepwise deterioration occurs, though often
with a fluctuating course. However, in some cases, the onset of the dementia may be gradual
with a progressive increase in severity. Major risk factors are high blood pressure, diabetes
mellitus, and smoking. Effective treatment of high blood pressure reduces the risk of this form of
dementia.
2.2.5 Motor System-Parkinson's Disease
The elderly have many problems with motor function, some due to age-associated
deterioration of the nervous system and some to changes in the skeletal muscles. A decrease in
skeletal muscle mass (referred to as sarcopenia) occurs with increasing adult age (19). A
decrease in the number of muscle fibers is generally agreed to occur with increasing age in many
but not all skeletal muscles. Associated with this decline in muscle mass is a decrease in muscle
strength, i.e., the maximum force that can be produced by the contraction of the muscle (20).
Between 30 and 80 years of age, muscle strength declines by about 30 percent for the arm
muscles and about 40 percent for the back and leg muscles. With the decrease in muscle force, a
decrease in muscle power occurs (the product of muscle force X speed of movement); as a result,
the ability to perform everyday tasks, such as rising from a chair or climbing stairs, can be
impaired.
With increasing adult age, most people adopt a more sedentary lifestyle (5). Skeletal
muscle is very plastic (modifiable), and disuse will lead to a decrease in muscle fiber size as well
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as a change in functional characteristics. An unresolved question is the extent to which disuse is
responsible for the age-associated loss of skeletal muscle fibers.
Elderly who have been physically active or have undergone strength training can develop
muscle force as great as sedentary young adults (21). This stems from developing increased
muscle fiber size to compensate for the reduced number of fibers. Thus, some of the age changes
in skeletal muscle function with advancing age are clearly due to lack of usage. The
effectiveness of exercise programs to increase muscle mass and strength in the elderly are such
that they are being put to therapeutic use.
Reaction time, i.e., the time from stimulus to initiation of a motor response such as the
contraction of a skeletal muscle, slows with advancing age (3). Although this is due, in small
part to the slowing of both muscle contraction and peripheral nerve impulse conduction velocity,
the slowing of central processing is the primary defect. Reaction time in the elderly is slowed
even more when the individual is confronted with a choice of alternative responses. Indeed, the
elderly execute all movements more slowly than do the young and the extent of this slowing
increases as the movement complexity increases. The good news is that this reduced speed
appears to enable the elderly to maintain accuracy of movement. Nevertheless, the elderly do
ultimately have some loss in ability to precisely control skeletal muscle activity. Thus, the
elderly have many deficits in motor performance ability. These deficits are not only due to
changes in central processing but also to changes in sensory and muscle function.
Balance and posture are compromised to varying extents in the elderly (22). Postural
sway when standing on two feet is somewhat greater in the old than in the young. However, the
sway difference between old and young becomes much more pronounced when the individual
stands on only one foot. In addition, tests, such as maintaining balance when reaching for an
object or opening a door, show that dynamic balance is compromised to varying extents in most
of the elderly. The deterioration of posture and balance is a contributing factor, but one of many,
making the elderly more prone to falls (23).
Walking changes only moderately in the elderly who are free of discernible diseases, such
as Parkinson's disease, strokes, cerebellar degeneration, and osteoarthritis (24). The most
striking characteristic of walking in the healthy elderly is that it is slower than that of the young.
This slowness is often not because they are not able to walk faster, but rather that they prefer to
walk slower. Walking speed decreases more rapidly with increasing age in women than in men.
During slow walking, the healthy elderly exhibit characteristics similar to those of the young, but
during fast walking, the elderly take shorter, more frequent steps than the young. The preference
for shorter steps has advantages for the elderly. Endurance of limb muscles is enhanced by
shorter strides, and the energy cost of walking is reduced. A shorter stride length is also less
taxing when ankle and knee joints are less flexible. In addition, in taking more steps to cover the
same distance, both feet are on the ground for a greater fraction of the time; and this may be
important for the elderly because of their more fragile balance. In addition, a slow gait enhances
the ability of the elderly to monitor the environment thus enabling them to avoid hazards.
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Parkinson's disease is an age-associated motor disorder; it rarely has an onset earlier
than age 40 years and its incidence increases with increasing age, with 68 years the average age
of onset (25). The syndrome includes tremors at near rest, rigidity (resistance to passive
movement of limbs), slowness in initiating movements, deterioration of postural reflexes, lack of
facial expression, and rapid, small steps with decreased associated movements such as arm
swinging. In this disease, neurons in the substantia nigra that send axons to the striatum are lost,
resulting in a decrease in the release of the neurotransmitter dopamine in this brain region. The
relative lack of dopamine in the striatum causes the syndrome of Parkinson's disease. This is a
progressive disease leading to severe disability and ending in death. The rate of progression
varies among individuals, with death occurring within 5 years in 25 percent and within 10 years
in 60 percent of the cases.
2.2.6 Sensory System
Impairment of the sensory system is a complaint of almost all elderly people. Indeed,
studies show that virtually all sensory modalities decline in acuity with age (26).
Changes occur in the visual system with age (27). Resting pupil size decreases, thus
reducing the illumination of the retina. The ability of the lens to become more spherical when the
person is looking at near objects (called the power of accommodation) progressively decreases
with increasing age, and is essentially completely lost in most people by age 60 years. This loss
in the power of accommodation, a condition referred to as presbyopia, is the reason that most
elderly individuals cannot read a newspaper without corrective lenses. It is due to a change in the
physical properties of the lens and in the function of the ciliary muscles. Visual acuity (the
ability to see objects in fine detail) decreases with increasing age, even if corrective lenses
rectify the optical system deficits. The loss in acuity does not appear to be due to the small loss
of cones, but more likely results from a decrease in the number of neurons making up the optic
nerve. The slight loss in rods that occurs with increasing age appears to be compensated for by
hypertrophy of the remaining rods. Nevertheless, rod vision is impaired and the elderly have a
reduced ability to adapt to low-intensity light. The reduced ability of the elderly to discriminate
colors in the green-blue-violet region of the visible light spectrum does not appear to be due to a
defect in the cones, but rather relates to a yellowing of the lens with increasing age. Indeed, an
alteration in the optical properties of the lens probably underlies the increased susceptibility to
glare. Those over age 50 years have some loss in depth perception, for reasons that remain to be
identified.
In addition to the changes just discussed, which occur almost universally with advancing
age, several other visual disorders occur much more commonly in the elderly than in the young
(28). Indeed, about two-thirds of those with severe visual impairment are older than age 65
years.
Cataracts are the most common of these disorders (29). The incidence of age-related
cataract begins to rise after age 50 years. Over 45 percent of persons between the ages of 75 and
85 years have cataracts, and nearly 70 percent beyond the age of 85 years suffer from this
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EXPLORATION OF AGING AND TOXIC RESPONSE ISSUES
disorder. A cataract is an opacity in the optical system of the eye, usually the lens; possible
causes include oxidative damage and glycation or glycoxidation. Cataracts diminish visual
acuity and increase light scatter, resulting in an increase in image blur.
Glaucoma is a frequent problem for the elderly (30). It is due to elevated intraocular
pressure. Although both the production and drainage of the aqueous humor decrease with
increasing age, drainage appears to be more affected than production, thus causing the
intraocular pressure to rise. If untreated, glaucoma causes atrophic changes in both the optic
nerve and retinal components that mediate peripheral vision, and this can result in tunnel vision.
Macular degeneration is another eye disorder that plagues the elderly (28). Atrophy of
the cones and nerve cells within the central retina or macula characterizes this condition, which
markedly reduces visual acuity. The condition is poorly understood.
Hearing loss associated with old age is called presbycusis, and almost 40 percent of those
65 years and older are affected (31). With aging, many changes occur in the structures of the
inner ear. Hair cells (which encode high frequency sound) atrophy and are lost. This process
leads to hearing loss. A loss of nerve cells in the auditory nerve with advancing age also
contributes to hearing loss. In addition, hearing loss results from a reduced blood supply to the
cochlea, as well as alteration in the structure of the basilar membrane. In the elderly, hearing loss
due to changes in the external and middle ear appears to be of minor importance. Although
accumulation of wax in the external ear does cause hearing loss in many, removing the wax can
easily rectify this problem. Long-term exposures to intense sounds, such as those from power
tools or loud music, are contributors to presbycusis. Indeed, some researchers believe that
lifetime noise exposure, rather than intrinsic aging, is the cause of presbycusis.
Because of presbycusis, many elderly have difficulty in distinguishing spoken words, a
problem magnified by background noise (32). In addition, this problem is likely to contribute to
an age-associated decline in cognitive ability in some individuals.
Because of methodological difficulties, the effects of age on taste and smell are not well
understood (33). Thus, conclusions about age-related changes in these senses must be viewed as
tentative. Age does not appear to affect the sweet and salty taste sensations, but some reduction
in the bitter and sour taste sensations may occur. Smell sensations dim at advanced ages.
Aging alters the cutaneous sensory system (34). The number of Pacinian corpuscles and
Meissner corpuscles decreases throughout life, so that by late life far fewer of these structures
are present than in the young adult. Little change with age occurs in the number of Merkel discs
and free nerve endings. Sensitivity to touch decreases (particularly in the hand region) as well as
the ability to distinguish between two spatially distinct points of contact. High-frequency
vibration is sensed less well with increasing age by the Pacinian corpuscles, particularly in the
feet and legs. Although the ability to detect the onset of pain is not affected by age, whether the
elderly are more or less tolerant of pain is debatable.
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EXPLORATION OF AGING AND TOXIC RESPONSE ISSUES
Aging altersproprioception (35); however, the subject is understudied. The ability to
sense limb movement and to reproduce changes in limb position appears to deteriorate with
advanced age. In addition, a decrease in the number of receptors in the vestibular apparatus
seems to occur with advancing adult age, but initially this loss may be compensated for by
changes in the response of the central nervous system to vestibular apparatus stimulation.
Indeed, as people age, they first appear to become more responsive, and then with a further
increase in age they become less responsive to vestibular apparatus stimulation. The elderly
often experience light-headedness and vertigo (the sensation that the person or the surroundings
are spinning), and, at least in some individuals, altered functioning of the vestibular apparatus
may be involved.
2.2.7 Strokes
Stroke refers to a sudden or relatively rapid occurrence of inadequate blood flow to the
brain, resulting in disturbed brain function (36). Strokes are caused by the blockage or rupture of
a brain blood vessel. Although stroke may occur at any age, it is most common in the elderly.
From middle age onward, the frequency of stroke doubles in each successive decade. In the
United States, the incidence of stroke is about 500,000 to 700,000 per year, and more than
150,000 deaths are annually attributed to strokes. More than half the survivors have functional
impairments, ranging from the inability to function in the work force to loss of ability to carry
out activities of daily living. Stroke can lead to dementia, and an estimated 10 to 20 percent of all
dementia cases are thought to be due to stroke.
2.3 Cardiovascular System
2.3.1 Heart
In healthy people, the heart increases modestly in size from age 20 to 80 years (37). This
increase is due primarily to an increase in thickness of the wall of the left ventricle of the heart,
resulting from hypertrophy of the wall's cardiac muscle cells. The age-associated increase in
heart mass is far greater in people who suffer from hypertension.
The conductile system of the heart also undergoes age-associated changes (38). After age
60 years, the number of cells in the SA node progressively declines. Some decrease in the resting
heart rate with increasing adult age also occurs, and this appears to be due, in part, to a change in
the SA node's pacemaker function. Some change with age also takes place in the AV node and
its connection to the conductile system of the ventricles, causing a minor delay in the progression
of action potentials from the atria to the ventricles. Increasingly common with increasing age are
abnormal rhythms (arrhythmias) of the heart, such as a too rapid (tachycardia) or a too slow
(bradycardia) heart rate, or the occurrence of pacemaker cells at sites other than the SA node.
Sudden death due to an arrhythmia may be relatively common in the very old.
The pump function of the heart also changes with increasing age (39). With aging, the
blood flow into the left ventricle during diastole becomes slower, but this is compensated for by
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the increased amount of blood pumped by the left atrial contraction in late left ventricular
diastole. Thus, at rest, the total amount of blood entering the left ventricle during diastole is
similar for old and young people of the same size and gender. The stroke volume in resting
healthy people is similar for young and old of the same size and gender, as is the cardiac output.
However, in the healthy young and old, there is one difference in the pump function of the left
ventricle. The contraction of the left ventricle is prolonged with increasing age, and this
prolongation helps the healthy elderly maintain a stroke volume similar to that of the young.
Although only small age changes in the functioning of the heart as a pump occur in healthy
people at rest, substantial differences emerge when a person is challenged.
The sympathetic nervous system plays an important role in the response of the
cardiovascular system to challenges and its influence is blunted with increasing age (40).
Exercise is a good example of how this age-associated blunting alters pump function of the heart
in response to a challenge. In young people, the need to increase the cardiac output during
exercise is met by an increase in the activity of the sympathetic nerve fibers to the heart, which
increases the heart rate and stroke volume, the latter because of the increased contractility of the
ventricular cardiac muscle cells. In healthy old people, heart rate and ventricular contractility
increase much less in response to exercise because of decreased effectiveness of the sympathetic
nervous system. This is compensated for by an increase in the blood volume in the chamber of
the left ventricle at the end of diastole, causing an increase in the length of the left ventricular
muscle cells. Within limits, an increase in the length of the cardiac muscle cells increases the
force of contraction. Therefore, in the elderly, an increase in stroke volume during exercise is
secondary to the increase in diastolic volume of the left ventricle. Thus, the healthy elderly can
increase cardiac output in response to exercise, but by a different mechanism than that of the
young. However, this compensatory ability is compromised in the elderly who suffer from age-
associated cardiovascular disorders.
A major age-associated medical problem is cardiac ischemia, an inadequate supply of
oxygen to the heart muscle (41). The coronary arterial system can be subject to atherosclerosis, a
progressive process involving plaques that narrow the lumen of the coronary arteries. If this
narrowing is sufficiently great, the heart muscle suffers from ischemia leading to death of heart
cells, referred to as myocardial infarction. An infarction can be sudden when, in addition to an
atherosclerotic plaque, it involves a thrombus or an embolus. Both the incidence and the
prevalence of coronary heart disease increase with increasing age. The prevalence is 50 percent
in the age range from 65 to 75 years and 60 percent in those over 75 years of age. The major risk
factors include: elevated systolic blood pressure, high levels of low density lipoproteins, left
ventricular hypertrophy, diabetes mellitus, elevated plasma glucose levels, and smoking.
Although in healthy people, only modest changes in heart pump function occur with increasing
age, coronary heart disease can cause serious deficits that range from difficulty in exercising to
decreased function at rest. Coronary heart disease is a major contributor to death of the elderly.
Heart failure involves a decline in the pump function of the heart, which can result in
several systemic problems. A person with heart failure may have inadequate oxygen delivery to
the tissues, pulmonary congestion, systemic venous congestion, or all three life-threatening
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conditions (42). It is an age-associated syndrome in that 75 percent of the patients suffering
from heart failure are over age 60 years. The two major causes of this syndrome are coronary
heart disease and hypertension. Lesions in the heart valves, not an uncommon problem in the
elderly, are also a potential cause.
2.3.2 Blood Vessels
Arterial blood vessel structure changes with age (43). With increasing age, the diameter
of the lumen of the large arteries increases. The walls of these arteries increase in thickness, and
become stiffer. While the lumen diameter of the smaller peripheral arteries shows less of an
increase, wall thickness shows a greater increase. These age changes in arterial structure are due
to several factors: a decrease in elastin relative to collagen in the arterial walls, an increased
mineralization of the elastin with calcium and phosphorus, and an increase in sustained
contractile activity of smooth muscle in the walls of the arteries. One of the hallmarks of aging
of the cardiovascular system is the increased velocity of the pulse wave, which stems from the
increased stiffness of the arterial walls. Arterial impedance does not increase through middle
age because the increase in arterial wall stiffness is compensated for by the increase in the
arterial lumen. However, at advanced ages, impedance increases because the effect of the
increased stiffness prevails.
With increasing age, atherosclerosis progressively alters the structure of arteries in many,
but not all, people (44). Atherosclerotic plaques can impede blood flow in the arteries in which
they occur, particularly by serving as sites of clot formation. The consequences of
atherosclerosis have already been discussed in regard to the coronary circulation. In addition,
atherosclerotic plaques commonly occur in the internal carotid arteries near their origin in the
neck, the middle cerebral arteries, the vertebral arteries, and the basilar arteries; as these plaques
grow in size with increasing age, they often become sites for formation of blood clots that cut off
the blood supply to regions of the brain.
Several population studies have shown that systolic, diastolic, and mean blood pressure
increase between the ages of 20 and 70 years (45). The increase in mean and diastolic pressure is
primarily due to increased resistance of the arterioles. The increase in systolic pressure stems
from the increased stiffness of the walls of the arteries as well as to increased resistance of the
arterioles. However, not everyone has an age-associated increase in blood pressure. For example,
a study of 144 Italian nuns showed no significant increase in blood pressure with increasing age
(46). Body weight, physical exercise, and smoking have been shown to modify the age-
associated increase in blood pressure.
Hypertension, persistently elevated blood pressure, occurs in over 60 percent of the
elderly (47). There are two basic forms. One involves elevation of both the systolic and diastolic
blood pressures, defined numerically as a systolic pressure of 140 mm Hg and above and a
diastolic pressure of 90 mm Hg and above. The other form, termed isolated systolic
hypertension, is defined as a systolic pressure greater than 160 mm Hg and a diastolic pressure
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of 90 mm Hg or less. Both forms of hypertension are dangerous in that they increase the risk of
stroke and heart attacks, but fortunately, both are treatable by changing the diet, increased
exercise, taking medication or a combination thereof.
About 60 percent of the population over age 65 years show postural hypotension; i.e.,
upon standing their systolic pressure drops by 20 mm Hg and remains at that reduced level for at
least 1 minute (48). By decreasing blood flow to the head, postural hypotension is a contributor
to falls by the elderly. This hypotension is caused by altered reflex responses to a falling blood
pressure, the most important being the blunting of the arterial baroreceptor reflex, which
readjusts the blood pressure by modifying both heart rate and resistance of the arterioles. The
elderly are also prone to postprandial hypotension (i.e., a fall in blood pressure an hour or so
after eating); this is due to an inability to compensate for a decrease in the resistance of the
arterioles of the gastrointestinal tract by increasing the resistance of the arterioles of other
regions (49).
The influence of aging on capillaries is an under-studied subject (37). The limited
information available indicates no change with age in their structure and function. However, in
some tissues, the number of capillaries decreases at advanced ages.
With increasing age, vein distensibility, and the strength and speed of smooth muscle
function are reduced (37). Some loss in the efficiency of sympathetic nervous system control of
venous smooth muscle may also occur. In addition, an age-associated widening of the veins
occurs; this interferes with the proper functioning of the valves and, as a result, fluid tends to
collect in the legs.
2.4 Gastrointestinal System
2.4.1 Motittty
The processing of food by the gastrointestinal system involves the following activities:
motor activity of the gastrointestinal tract; glandular secretion; digestion; and absorption of
substances from the lumen of the gastrointestinal tract into the blood or lymph. Although the
healthy elderly carry out these functions rather well, some age-associated changes in each of the
functions do occur (50).
In the absence of dental interventions, mastication is often greatly compromised with
increasing age. In addition, the skeletal muscles involved in mastication become weaker with
increasing age, and consequently some decrease in the efficiency of mastication occurs. In the
healthy elderly, changes in swallowing are minor and do not cause significant functional
difficulties. However, swallowing difficulties can arise with age-associated diseases that
adversely affect motor nerve control of the swallowing process; these include: stroke,
Parkinson's disease, amyotrophic lateral sclerosis, and myasthenia gravis. In addition, reduced
compliance of the upper esophageal sphincter is more common in the elderly, which interferes
with the passage of the food bolus from the throat down into the esophagus. Another swallowing
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disorder, called achalasia, relates to a reduced esophageal peristaltic wave production when
swallowing and a failure of the lower esophageal sphincter to open; as a result, the food bolus
tends to remain lodged in the esophagus. The prevalence of this disorder increases with
increasing age. Heartburn is the result of reflux of stomach contents through the lower
esophageal sphincter up into the esophagus. It increases with age, causing elderly people
considerable distress. Serious complications may sometimes arise. Gastric emptying was long
believed to slow with advancing age. However, using advanced technologies, recent studies
indicate that significant age-associated change in gastric emptying occur only when a meal is
very large. The elderly frequently complain of constipation, but studies utilizing objective
measures of constipation indicate that it does not occur more frequently in the elderly than in the
young. The elderly also frequently complain of diarrhea, but the healthy elderly do not suffer
from diarrhea. When diarrhea poses a serious problem for the elderly, it is related to some
disease. The elderly are more prone to fecal incontinence than the young because of both higher
rectal pressures, when the rectum is distended by a fecal mass, and reduced force of the anal
sphincters.
2.4.2 Secretion
Experts disagree as to whether secretion of saliva decreases with age in healthy people,
but all agree that medications used to treat age-associated diseases often cause alterations in
salivary secretion. Although gastric secretion of hydrochloric acid was long believed to decline
with increasing age, recent research has shown that this is not true for healthy elderly. The long-
held, erroneous belief relates to atrophic gastritis, which does increase in prevalence and severity
with increasing age. This inflammatory disease, probably caused by an autoimmune mechanism,
leads to destruction of the parietal cells, which secrete hydrochloric acid; thus, those suffering
this disease secrete little or no hydrochloric acid. The parietal cells also secrete intrinsic factor;
thus, those who have lost most of the parietal cells will also suffer from pernicious anemia unless
they are treated. The elderly have no other significant problem regarding gastrointestinal
secretions although bile may be prevented from reaching the lumen of the gastrointestinal tract
because of gallstones that are more prevalent at advanced ages.
2.4.3 Digestion and Absorption
The ability to digest starch and sucrose is not compromised at advanced ages, but in those
genetically susceptible to lactase deficiency, the ability to digest lactose decreases with
increasing age. The healthy elderly have no problem digesting protein or fat unless massive
amounts of these substances are ingested.
The capacity to absorb the products of carbohydrate, protein and fat digestion decreases
with age but this poses no problem for the elderly because the capacity to absorb each is well in
excess of what is needed. The ability to absorb calcium deteriorates at advanced ages, which
causes little problem when dietary calcium intake is abundant, but presents a substantial one
when intake is low. This may relate to: (1) a decreased availability of vitamin D, (2) a reduced
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ability of the kidney to generate the vitamin D hormone, (3) the blunting of the effect of the
vitamin D hormone on the small intestine, or to all three.
2.5 Respiratory System
2.5.1 Thoracic Air Pump
The thorax-lung air pump undergoes age-related changes (51). The vital capacity, the
maximum amount of air that can be expired after a maximum inspiration, decreases with
increasing age, because of the changes in the physical properties of the thorax-lung system and
the diminished force-generating ability of the respiratory muscles. The residual air (the amount
of air remaining in the lungs after a maximal forced expiration) increases with increasing age for
similar reasons. A widely used and informative test is the measurement of the volume of air
exhaled during the first second of a forced expiration. Beyond 25 years of age, the volume of air
exhaled progressively decreases, because of the increased resistance to airflow in the
bronchioles, the change in elastic properties of the lungs, and the decrease in the force generated
by the respiratory muscles. The decrease is greater in smokers than in nonsmokers. In spite of
age-related changes in the thorax-lung air pump, alveolar ventilation in the healthy elderly is not
sufficiently altered to limit their ability to carry out vigorous exercise. Such is not the case with
those suffering from chronic obstructive pulmonary disease (COPD). COPD refers to the
combined occurrence of chronic bronchitis and emphysema (52). The bronchial lining undergoes
progressive changes including gradual loss of cilia and thickening of the epithelium by
proliferation of mucosal cells. The emphysema component involves dilation and disruption of
alveolar walls. Thus unlike most elderly, the deterioration of pulmonary function in those
suffering from COPD markedly limits their functional abilities.
Although deterioration of the respiratory system does not appreciably limit the activities
of normal elderly, they do suffer from a reduction in its functional reserve. As a result, the
elderly are less able to meet challenges to the system such as pneumonia secondary to bacterial
and viral infections (53). Also sleep apnea becomes increasingly common with increasing age, a
rare occurrence in nonsmokers but a problem for a sizable fraction of smokers.
2.5.2 Gas Transport-Anemia
The transport of oxygen from the lungs to the tissues and of carbon dioxide from the
tissues to the lungs is not affected by aging in the absence of anemia. Anemia is not found in the
healthy elderly but is frequently found in those suffering from age-associated diseases (54).
2.6 Liver
The liver decreases in size with increasing age becoming quite small in nonagenarians.
Total hepatic blood flow and portal venous blood flow both decrease with age (50). Hepatic
clearance of some drugs declines with age and hepatic regeneration after injury is delayed in the
elderly (53). The altered drug clearance is due to age-related reductions in phase I reactions (e.g.,
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oxidation, hydrolysis, reduction), first-pass hepatic metabolism, and serum albumin binding
capacity (54). Phase II reactions (e.g., glucuronidation, sulfation) are not affected by aging. In
rodents, monooxygenase enzyme activities and P450 isozyme concentrations show an age-
associated decline.
Little more is known regarding the effects of aging on the liver of humans. The current
state of knowledge is well summarized in the first and last sentences in the abstract of a recent
paper by Douglas Schmucker (57) entitled Aging and the Liver: An Update. "The issue of
whether or not liver function is compromised in the elderly population remains unresolved. "
"Although the livers of elderly subjects are characterized by a decline in adaptive
responsiveness and reduced reserve capacity, clinical tests suggest that liver function is well-
maintained in this age group. "
2.7 Kidneys
Several structural and functional changes occur in the kidneys with increasing age during
adult life (58). Starting in young adulthood, the mass of the kidneys decreases progressively with
increasing age. This loss in mass occurs primarily in the cortex of the kidney, with little loss
occurring in the medulla. Kidney blood flow decreases with increasing age, with a decrease of
more than 50 percent between the fourth and ninth decades of life. Much of the decrease stems
from the constriction of the kidney arterioles, which increases the resistance to blood flow
through the kidneys. In cross-sectional studies, the glomerular filtration rate has been found to
decrease with increasing age, with those in the age range of 75-84 years having about 70 percent
the rate of those in the age range of 25-34 years. However, longitudinal research has shown that
a decrease in glomerular filtration rate does not occur in all people; in the Baltimore
Longitudinal study of aging a significant number of participants did not exhibit an age-
associated decrease in glomerular filtration rate (59). Most of the renal transport systems
involved in tubular reabsorption and tubular secretion continue to function effectively with
advancing age unless the individual is challenged. For example, the ability of the kidneys to
conserve sodium when the individual is challenged by a very low sodium diet declines with age.
Although this decreased ability to conserve sodium may be due, in part, to intrinsic changes in
the kidney transport systems, much of the decrease appears to be the result of an age-related
change in the endocrine system. Conserving sodium involves the hormone renin which promotes
the generation of angiotensin II which in turn causes the adrenal cortex to secrete aldosterone, a
hormone that increases the rate of sodium reabsorption by the kidneys; the response of this
renin-angiotensin-aldosterone system to low sodium levels decreases with increasing age. The
kidneys of the elderly are also less effective in excreting sodium under conditions of high
sodium intake; in this case, the decreased renal blood flow and glomerular filtration rate with
increasing age appear to the reasons for this age-related change. The elderly are also less able to
cope with water deprivation than the young; this is primarily due to a decrease in the ability of
the kidney to generate urine that is highly concentrated (i.e., high osmolality) because of
blunting of the response of the kidneys to vasopressin.
Hydrogen ions are highly reactive and their concentration in the body fluids must be
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tightly controlled to prevent serious functional disorders. The kidneys play a key role in the
regulation of hydrogen ion concentration and alterations in the regulation of the ion with
increasing age, at least in part, relates to altered kidney function. The hydrogen ion concentration
in the blood of healthy, unchallenged people increases progressively with age, being 6 to 7
percent higher in 80-year olds than in 20 year olds, and an altered kidney function is responsible
for this increase (60). In addition, the kidneys of the young excrete a large acid load much more
rapidly than do those of the old (61).
Although the age changes in kidney function just discussed are of little consequence for the
elderly under every day living conditions, they become clinically relevant when an elderly
individual is challenged by the superimposition of an acute illness (62). For example, the
alterations in kidney function relative to water and electrolyte metabolism result in elderly
patients frequently experiencing hyponatraemia or hypernatraemia with central nervous system
dysfunction due to the impact of an acute disease and/or the medications used to treat the disease
(63).
2.8 Urinary Tract - Incontinence
The involuntary passage of urine is referred to as urinary incontinence, and it is a
common medical problem in the elderly (64). An estimated 15 to 30 percent of the community
dwelling-elderly suffer from incontinence, and, of course, the prevalence is much higher in
nursing home residents. Common causes are urinary infections, drugs used for the treatment of
other disorders, restricted mobility, confusional states, psychological disorders, endocrine
disorders, and stool impaction; the incontinence disappears when the causative problem is
corrected. In addition, prostatic enlargement in men and diabetic neuropathy in both genders are
common causes of long-term urinary incontinence.
Benign prostatic hyperplasia often also causes obstruction of urinary flow; the
enlargement of the prostate begins at about age 45 years and progresses in severity from that age
on (65). As a result of this obstruction, a man can suffer from hesitancy in initiating urinary flow,
a weakened urinary stream, the inability to terminate urination abruptly without dribbling,
incomplete emptying of the bladder, urinary frequency and/or urgency, and, as just mentioned,
urinary incontinence. Ultimately, the ability to void may be lost, which can be fatally destructive
to the kidneys unless appropriate medical intervention is employed immediately.
2.9 Immune System
Immune system function diminishes with increasing age in many, if not most, people (66,
67). Following puberty, the thymus continuously decreases in size and the cellular elements of
this gland are gradually replaced by adipose tissue. The production of thymic hormones ceases
by about age 40 years. The ability to increase the number of T-lymphocytes that can respond to a
particular antigen is impaired. The amount of antibody secreted by a given number of B-
lymphocytes decreases with increasing age. The deterioration of the immune system
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undoubtedly contributes to illness in the elderly. This decline in function is a factor in the
increased susceptibility of the elderly to infectious diseases such as pneumonias, urinary tract
infections, and tuberculosis. In addition to this underlying role in the higher incidence of these
infectious diseases, the deterioration of the immune system also results in an increased morbidity
and mortality from such diseases. The deterioration of the immune system could be a factor in
the increasing incidence of cancer with increasing age. Specifically, the deterioration of immune
surveillance may fail to effectively eliminate mutant cells, thereby increasing the risk of cancer;
however, the validity of this scenario has yet to be established. The age-associated increase in
autoimmune diseases, such as rheumatoid arthritis, systemic lupus erythematosus, and
glomerulonephritis, certainly results from deterioration of the immune system; specifically, the
ability to distinguish between self and non-self is altered.
2.10 Endocrine System
Aspects of the endocrine system have already been discussed, such as the consideration
of aldosterone and vasopressin in relation to age changes in kidney function. In addition, other
aspects will be presented in relation to other topics such as metabolism and bone. The focus here
is on age-related changes in the pituitary-thyroid axis, pituitary-adrenal axis, and growth
hormone.
2.10.1 Pituitary-Thyroid Axis
In the healthy elderly, the functioning of the pituitary-thyroid axis is not markedly
different from that of the young (68). The concentration of serum thyroxine is not affected by
aging and that of triiodotyrosine is either not affected or somewhat decreased. The concentration
of thyroid stimulating hormone is either not affected or modestly decreased by aging. The rate of
production of the thyroid hormones is either not affected or modestly decreased by aging and a
similar statement can be made regarding their rate of degradation. The secretion of thyroid
stimulating hormone by the pituitary in response to the hypothalamic thyrotropin releasing
hormone is modestly decreased or unchanged by aging and that is also the case for the response
of the thyroid gland to thyroid stimulating hormone. The ability of thyroid hormone to suppress
the pituitary secretion of thyroid stimulating hormone is decreased at advanced ages. The
response of the basal metabolic rate to thyroid hormone is decreased with advancing age. The
consequences to the healthy elderly, if any, of these modest age-related changes in the pituitary-
thyroid axis have not been defined.
2.10.2 Pituitary-Adrenal Axis
The pituitary-adrenal axis refers to the influence of pituitary adrenocorticotrophic
hormone on the secretion of cortisol and dehydroepiandrosterone by the adrenal cortex. Little or
no increase occurs in the level of plasma cortisol with advancing age in non-stressed healthy
people, but under conditions of stress, plasma cortisol levels increase more in the elderly than in
the young, and the increase is more prolonged (69). Whether the increased cortisol response is
beneficial or detrimental remains to be determined. The blood level of dehydroepiandrosterone
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peaks at ages 25 to 30 years and decreases thereafter, so by age 80 years the level is 10 percent
of that at age 25 to 30 years (70). Low levels of blood dehydroepiandrosterone have been
associated with age-associated disorders such as some forms of cancer and cardiovascular
disease, dementia, Type II diabetes, obesity, and osteoporosis.
2.10.3 Growth Hormone
The secretion of growth hormone by the pituitary decreases with increasing age and this
results in a progressive decrease with age in the plasma levels of growth hormone and in insulin-
like growth factor I, the secretion of which is controlled by growth hormone (71). Growth
hormone promotes the use of fat as fuel, thereby sparing the use of protein as fuel. Thus the
decreasing level of growth hormone with increasing age may play a role in the age-associated
increase in body fat and decrease in muscle mass.
2.11 Reproductive System
2.11.1 Menopause
Marked age-related changes occur in the reproductive function of women (72). At ages
greater than 35 years the fertility of women decreases, with infertility occurring at age 50 years
or so. Also starting at about age 35 years of the mother, newborns increasingly have
chromosomal abnormalities resulting in diseases such as Down Syndrome. Menopause is the
natural permanent cessation of menstruation and occurs at about age 50 years. In the 2 to 8 years
preceding menopause, the length of the menstrual cycle becomes variable, ranging from less than
28 days to more than 60 days. During this time, plasma estradiol levels are lower than at younger
adult ages and follicle stimulating hormone levels are elevated. Menopause is believed to result
primarily from the decreased ability of the ovaries to secrete estradiol. Following menopause,
plasma estradiol levels are very low and follicle stimulating hormone and luteinizing hormone
levels are markedly increased. Also following menopause, pubic hair decreases and the vagina
shortens, loses elasticity and is at increased risk of bacterial infections and mechanical damage.
The oviducts shorten, and their diameter decreases. The breasts undergo atrophy of the glandular
structure, with replacement by adipose tissue. The uterus reduces in size and the cervix
atrophies. The most common symptom of menopause is the "hot flush" or "hot flash," which is
characterized by blushing and a sensation of heat (due to dilation of skin blood vessels), as well
as inappropriate sweating. The intensity of this symptom varies among women, from an
occasional transient sensation of warmth to periodic episodes of a sensation of heat, drenching
sweats, and tachycardia. In some women, these episodes result in disturbed sleep, fatigue, and
irritability. The intensity of these problems peaks during the first two years after the cessation of
menstruation, but in some women the problem continues for as long as ten years. A number of
psychological symptoms are associated with the menopause, such as apprehension, apathy,
depression, excitability, fear, loss of libido, rage, and bouts of uncontrollable crying. Usually
these symptoms gradually disappear during the postmenopausal years.
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2.11.2 Andropause
Men do not undergo an andropause comparable to menopause but the male reproductive
system does undergo age-related changes (73). Atrophy of the seminiferous tubules occurs with
advancing age. Nevertheless, some sperm are found in the ejaculate of about half the men in the
age range of 80 to 90 years. Plasma free testosterone declines after the age 40 years, but some
older men have levels well within the range found in young men. Impotence increases with
increasing age. The arterial filling of the penis is slowed and venous drainage from the penis
increases, thus yielding a less firm erection. This ultimately can result in an erectile response that
is inadequate for entrance into the vagina, hence impotence. By a conservative estimate, 5 to 10
percent of men in the sixth decade of life suffer from impotence; the figure rises to 20 percent in
the seventh decade, 30 to 40 percent in the eighth decade, and 50 percent in the ninth decade.
2.12 Skin
In nonsmokers, age-related changes occur in the skin areas protected from exposure to
the sun, and these changes are referred to as intrinsic aging of the skin (74). To some extent, this
is probably a misnomer. Although sun exposure and smoking are the major extrinsic factors
influencing skin aging, they are not likely to be the only ones. The thickness of the flat
keratinocytes at the surface of the skin does not change with age, but the rate of shedding of
these cells decreases, as does their rate of replacement. Thus, in the elderly, these cells remain
longer at the surface of the skin, which increases the likelihood that they will accumulate
damage. The number of melanocytes decreases with increasing adult age, a 10 to 20 percent
reduction occurring each decade; thus the skin of the elderly, if exposed to sunlight, is less
protected from the damaging action of ultraviolet light. At advanced ages, the epidermis contains
20 to 50 percent fewer Langerhans cells than at young ages. With increasing age, the structure of
the basement membrane alters, decreasing the extent of interaction between the dermis and
epidermis, and increasing the likelihood of injuries causing the two layers to separate. The
thickness of the dermis is about 20 percent less in the elderly, and the dermis is stiffer and less
malleable, making it more vulnerable to injury. Many of the changes in the dermis are due to
alterations in the fibrous proteins (collagen and elastin) of the dermis' extracellular matrix; fine
wrinkles are probably related to these alterations. The small blood vessels of the dermis change
and the number of hair follicles declines. In addition, an age-associated reduction (about 15
percent) in both the number and functional capacity of the sweat glands occurs. In addition, the
ability of the sebaceous glands to secrete sebum is decreased. A decline in sebaceous gland
secretion of about 23 percent per decade in men and 32 percent per decade in women has been
measured. Subcutaneous fat increases with advancing age in some regions of the body (the waist
in men and thighs of women) and decreases in other regions (face, hands, shins, and feet).
Areas of the skin exposed to sunlight show much more deterioration with advancing age
than do those that are protected, a phenomenon called photoaging (75). Chronic photodamage is
estimated to cause more than 90 percent of the skin cosmetic problems. It leads to coarseness of
the skin, dilation of groups of small cutaneous blood vessels, irregular pigmentation, and deep
wrinkles. It also causes a decrease in the number of epidermal Langerhans cells. Damage to the
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elastin and collagen in the dermal extracellular matrix probably underlies many of the cosmetic
problems.
Physiological functions of the skin are also altered during aging (74). The barrier
function is changed and body water loss through the epidermis is decreased with increasing age.
The ability of substances to enter the body through the skin appears to decrease; the extent of
this decrease relates to the molecular structure of the entering substance. The inflammatory
response of skin to harsh chemicals, such as kerosene, is less intense in the elderly. Because
inflammation alerts the individual to noxious substances, the attenuation of this response makes
older people more susceptible to harm from such substances.
Pressure sores (i.e., decubitus ulcers or bedsores) are a major concern of geriatricians
(76). Pressure sores can occur in people of all ages, but their prevalence increases so markedly
with increasing age that people over 70 years account for 70 percent of those with this lesion.
The mildest form has a redness of the skin area that, if the lesion becomes more severe,
progresses to a loss of epidermal and dermal structures. Ultimately full-thickness skin loss and
tissue necrosis can occur resulting in a severe lesion. The main causal factor is prolonged
pressure on a particular area because of reduced mobility. Additional factors are friction and
moisture, particularly moisture due to fecal or urinary incontinence. The elderly have a greater
incidence because they are more likely to have medical problems requiring prolonged periods in
bed as well as urinary and/or fecal incontinence. In addition, the elderly are predisposed to
pressure sores because of the age changes in the skin discussed above.
2.13 Body Mass and Structure
By age 70 years, the height of men and women is some 2.5 percent to 5 percent below its
peak level (3). The decrease begins at about age 25 years in men and age 20 years in women.
The loss in height is due primarily to the compression of the cartilaginous discs between the
vertebrae and to a loss in vertebral bone. Body mass, commonly referred to as body weight,
increases in most American men from age 20 years until middle age, followed by a decline at
advanced ages. For most American women, weight increases from age 20 to 45 years, after
which it remains stable until about age 70 years and then declines with increasing age.
Age-related changes in weight can be assessed by a two-compartment model consisting
of the lean body mass and the fat mass (77). During adult life, the lean body mass, which is
greater in men than in women, declines by about 0.3 percent per year in men and 0.2 percent per
year in women. Much of this decrease is due to the loss of muscle mass, but a loss of bone and
other structures is also involved. Part of this loss may be secondary to the more sedentary
lifestyle with increasing age. Indeed, those who continue to engage in athletics have a greater
lean body mass at any age than those of similar size who are sedentary. However, even in
athletes, lean body mass is progressively lost with advancing adult age. The percentage fat
content of the body increases with increasing adult age, and the extent of increase varies among
individuals within a population and among different populations. In the United States, the
percent fat content of men is about 18 percent at age 30 years and 26 percent at age 70 years,
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while in women, the percent fat content is about 24 percent at age 24 years and about 36 percent
at age 70 years. With increasing age, the distribution of body fat changes with a preferential
accumulation of fat in the abdominal region, primarily around the viscera in both sexes, though it
is greater for men than for women. The age-associated abdominal visceral accumulation of fat
occurs to a lesser extent in athletes. The preferential distribution of fat to the abdominal region
has been implicated as a risk factor for age-associated cardiovascular disease.
The body fluids are not markedly affected by aging (78). Little or no change occurs in the
composition and volume of the extracellular fluid with age in the healthy, unchallenged
individual; however, the amount of intracellular water does decrease with age.
2.14 Skeletal System
2.14.1 Bone-Osteoporosis
Bone loss and joint deterioration commonly occur with increasing age. In some
individuals, the extent of bone loss and/or joint deterioration is so great that it reduces the quality
of life.
In the young adult remodeling of bone occurs by the process of bone resorption being
balanced by bone reformation, so that remodeling causes no change in the amount of bone. With
advancing adult age, the balance during remodeling shifts in favor of bone resorption (79). In the
case of every population that has been studied, an age-associated loss in bone mass has been
found to occur. Nearly all bones in the skeleton are so affected, though to varying degrees. Bone
loss is greater in women than in men, and the rate of loss accelerates after menopause; such
acceleration has been found to be due to the low postmenopausal levels of estrogen. The rate of
bone loss is most rapid during the first 10 years following cessation of menses and slows after
that. In women, bone loss in the vertebrae begins as early as the third decade of life, but bone
loss in the legs and arms does not occur until the sixth decade. Men start to lose bone at later
ages than women do, and, in some men, the amount of loss is trivial.
Osteoporosis is a medical condition characterized by low bone mass and increased
susceptibility to bone fractures from minor trauma (80). Its prevalence increases with advancing
age. There are two major types of age-associated osteoporosis, the postmenopausal Type I, and
the senile Type II. Type I occurs six times more frequently in women than in men, and is
frequently associated with fractures of the vertebrae and wrists. An increase in the rate of
remodeling of bone with bone resorption outpacing bone formation leads to Type I. The lower
incidence in men is due to three factors: a greater bone density upon reaching maturity, the
shorter life expectancy of men, and the fact that men do not have a rapid endocrine change
equivalent to menopause. Type II osteoporosis occurs at an older age, primarily in those over age
70 years and affects about twice as many women as men. A decreased rate of bone formation is
responsible for Type II and results mostly in vertebral wedge fractures and hip fractures.
Lifetime exercise and an adequate dietary intake of calcium minimize the occurrence of
osteoporosis. Alcoholic beverages, smoking, and caffeine are risk factors for osteoporosis.
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2.14.2 Osteoarthritis
In the healthy elderly, the synovial joints show deteriorative changes (3). Functionally,
joint flexibility is lost, thus reducing the range of motion and increasing the possibility of
damage to the joints and the muscles crossing the joints. In addition, many elderly suffer from
age-associated joint disease.
The most common of these diseases is osteoarthritis, a degenerative disease of the joints
(81, 82). It affects, to some degree, about 80 percent of people over age 65 years; women are
more seriously affected than men are. In this disease, the cartilage of the joint changes in
consistency, cracks, and wears away, ultimately exposing the bone surface to another bone. With
time, further changes in bone may occur, such as the development of bone spurs, abnormal
thickness, and fluid-filled pockets. Periodic or chronic inflammation can occur, which is
accompanied by pain. While osteoarthritis can occur in any joint, most commonly it affects the
joints of the fingers, knees, and hips.
2.14.3 Gout
Gout involves the formation of uric acid crystals in the synovial fluid that causes
inflammation of the involved joint (83). The joint is hot, red, swollen, and extremely painful.
Although the joint in the big toe is the one most commonly involved, any joint may be affected.
Gout is more common in men than in women, whose age of onset is older than men. Peak age in
men is the fifth decade of life. Exacerbations and remissions characterize the course of the
disease. The major causal factor of gout is an increase in plasma uric acid concentration. The
elevation of plasma uric acid concentration with increasing age probably accounts for the age-
associated characteristic of this disease.
2.15 Metabolism
Total daily energy expenditure (i.e., daily metabolic rate) decreases with increasing adult
age (78). The major components of the daily metabolic rate in those who are not exposed to low
environmental temperature are the basal metabolic rate (usually accounting for 60 to 75 percent
of the daily energy expenditure), fuel use due to physical activity, and diet-induced
thermogenesis. The basal metabolic rate decreases with increasing age. However, if the basal
metabolic rate is expressed per kilogram of lean body mass, little age-related decline can be
seen. Thus, the major reason for the decreased basal metabolic rate is likely due to the change in
body composition with age, namely the decreasing skeletal muscle mass and the increasing fat
mass. The effect of age on the use of fuel for physical activity has not been directly measured;
however, fuel use may decrease significantly, based on extensive evidence that physical activity
decreases with age. While aging does not appear to cause a major change in diet-induced
thermogenesis, this subject remains to be carefully studied.
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2.15.1 Mitochondria-Oxidative Stress
The oxidative metabolism involved in fuel utilization has been hypothesized to cause
much of the deterioration that characterizes aging. Indeed, the use of fuel leads to the generation
of reactive oxygen molecules such as superoxide, hydrogen peroxide, and hydroxyl radicals
which cause damage to biological macromolecules including mitochondrial DNA (84). Although
such damage does accumulate with increasing age, evidence is lacking that damage from
reactive oxygen molecules is of sufficient magnitude to play a major role in aging.
2.15.2 Carbohydrate, Fat, and Protein Metabolism
Based on the glucose tolerance test, the elderly have a decreased ability to use
carbohydrate as fuel; i.e., many elderly exhibit impaired glucose tolerance (85). The cause of this
impaired glucose tolerance is an increased insulin resistance. However, agingper se is not the
major reason for the increase in insulin resistance. The major causal factors appear to be the
decrease in physical activity and the increase in body fat associated with aging. Indeed, little
insulin resistance is present in the elderly who are physically fit and relatively lean.
Fat oxidation is decreased in the elderly at rest and during exercise (86). This decrease is
related in part to loss of fat-free mass and is amenable to partial correction by exercise training.
Type II diabetes (non-insulin-dependent diabetes mellitus) increases in prevalence with
increasing age (85). In addition to a marked insulin resistance, the ability of the pancreas to
secrete insulin in those with Type II diabetes is also impaired.
With advancing age, the rate of protein synthesis and protein degradation decreases; i.e.,
the rate of protein turnover decreases (87). This poses a problem because the length of time a
protein molecule spends in the body increases. As they reside in the body, protein molecules are
gradually damaged by oxidation, glycation, heat, and other factors. Thus by increasing the
average length of time a protein spends in the body, the age-associated decrease in the rate of
protein turnover acts to increase the amount of damaged protein molecules. The age-associated
decrease in muscle mass probably relates, at least in part, to the decrease in protein synthesis.
2.16 Thermoregulation
With increasing age, the ability to regulate body temperature deteriorates and, thus, to
meet the challenge of different thermal environments (88). The extent of this deterioration varies
among individuals, depending on health, physical fitness, and lifestyle factors. In a hot
environment, the elderly have a reduced ability to redistribute blood flow from the core of the
body to the skin, due to structural changes in the skin blood vessels and to a decreased capacity
to constrict the vessels supplying the viscera. In addition, the sweating response is decreased
with increasing age. In a cold environment, the elderly show a decrease in constriction of the
skin blood vessels and a reduced shivering ability.
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Elderly people have a much greater risk of developing hyperthermia and hypothermia
than do young people. One reason for this is the physiological deterioration just discussed.
However, the main reason the elderly are more vulnerable to extremes in environmental
temperature is the blunting of perception of ambient temperature. This loss is critical, because
humans utilize behavioral responses rather than physiological responses as their major mode of
coping with temperature extremes. The blunting of temperature perception means that the elderly
are less likely to make effective behavioral responses, such as seeking appropriate clothing or
shelter.
2.17 Genomic Structure and Function
Aging is associated with genomic instability in that the frequency of point mutations in
DNA, microsatellite expansions and contractions, amplifications and contractions of DNA
sequences, gene rearrangements, and chromosomal aberrations increase with increasing age (89).
However, the functional consequences of this genomic instability are not clear.
Gene expression changes with age (87). The transcription of some genes increases with
age while that of others decreases and many are not affected by aging. In contrast to
transcription, translation appears to decrease with increasing age for all species of proteins.
2.18 General Cellular Functions
Cellular signal transduction plays a key role in the regulation of function in multicellular
animals (90). In several aging studies using animal models, a variety of cellular signal
transduction pathways are altered during aging, but such information has yet to become available
for humans.
Since aging in humans involves hyperplasia and neoplasia as well as cell loss, alterations
in apoptosis (i.e., programmed cell death) have been suggested to play a major role in aging (50,
91). The effects of aging on apoptosis in humans remain to be studied. The other side of the coin
from apoptosis is mitosis and in many rodent tissues, the rate of mitosis declines with increasing
age but in some tissues it increases (e.g., the colon and small intestine) (92), but comparable
information is not available for humans.
2.19 Neoplasia
Cancer is predominantly a disease of the aged (93). Deaths from colon cancer increase
slowly with age until middle age and rapidly after middle age (94). Prostate cancer is rare before
age 50 years, but it is a common form of cancer with further increasing age (65). Although in
many men it progresses slowly (particularly at advanced ages), prostate cancer is the third most
common cause of death in men over age 55 years. The incidence of breast cancer in women
increases with advancing age (95). Uterine and cervical cancers peak at age 45 to 55 years and
cancer of the uterine endometrium at age 60 to 64 years (96). Lung cancer is most common in
old people (97). Approximately 80 percent of the cases of pancreatic cancer occur between the
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age of 60 and 80 years (98). After age 30 years, the incidence of skin cancer increases
exponentially with increasing age (74). About 90 percent of these cancers occur in the
approximately 10 percent of the skin habitually exposed to the sun, which indicates that aging
alone does not appreciably predispose skin to cancer in the absence of an extrinsic factor such as
sunlight.
3.0 AGE-RELATED CHANGES IN PHARMACOKINETICS AND
PHARMACODYNAMICS
Pharmacokinetics refers to the physiological processes that determine drug
concentrations in the blood and at the drug's site of action. Pharmacokinetic processes also
determine the length of time drugs remain at peak concentration and how long they stay in the
body. These processes involve absorption, distribution, metabolism, and clearance.
Pharmacodynamics refers to the specific drug action within the body. Drug action usually
involves a complex interaction between drug receptors located on cell membranes or within the
cell cytoplasm. The response to drug action can be immediate or take several days.
Age-related changes in pharmacokinetic processes are well documented and to a lesser
extent so are age-related pharmacodynamic changes (99). Pharmacokinetic drug properties have
been studied more extensively than pharmacodynamic processes in the elderly because drug
concentrations are easier to measure. Changes in gastrointestinal, kidney, and liver function may
raise or lower drug concentrations in the plasma and site of drug action resulting in greatly
altered drug responses in the elderly. Given the individual variation in age-related physiological
changes summarized in the previous section, the degree to which any elderly individual will
exhibit pharmacokinetic and pharmacodynamic changes cannot be predicted based on
chronological age.
In addition to what may be considered the effects of normal aging, the elderly also suffer
from numerous degenerative diseases (e.g., arthritis, diabetes, cardiovascular and kidney disease)
that require the chronic consumption of drugs intended to maintain organ function. The elderly,
therefore, are prone to adverse drug reactions linked to the greater probability of harmful drug
interactions (100-102). Multiple drug use in the elderly may range from more than four in an
ambulatory care setting to eight or more in nursing homes. The occurrence of adverse drug
interactions is known to increase with the number of drugs prescribed. Adverse effects increase
from 4 percent of patients receiving five drugs to 28 percent in those receiving 11 to 15 drugs.
Given these facts, the three to seven time higher risks of adverse drug reactions seen in the
elderly is not surprising.
This section of the report will examine the specific age-related physiological changes that
are responsible for the pharmacokinetic and pharmacodynamic changes seen in the elderly.
Pharmacokinetic changes are primarily due to altered gastrointestinal, liver, and kidney function
that change drug clearance, and due to changes in body composition that alter drug distribution.
These areas will be discussed first. Pharmacodynamic changes in the elderly are less well
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documented but do occur. Specific examples, if available, will be presented for each organ
system in which a pharmacodynamic change occurs.
3.1 Pharmacokinetic Changes in the Gastrointestinal System
Age-related changes in gastrointestinal function may influence oral drug absorption by altering
gastrointestinal acid and enzyme production and gastrointestinal motility (133).
3.1.1 Secretion
Drug absorption is dependent on the pH of the various segments of the gastrointestinal
tract. The low pH of the stomach provides a favorable environment for the absorption of weak
acids which will tend to remain in an un-ionized form. Weak bases will tend to remain
un-ionized at the higher pHs prevailing in the upper sections of the small intestine. Therefore,
weak acids will not be as readily absorbed in the stomachs of elderly individuals with
achlorhydria due to atrophic gastritis.
3.1.2 Motility
Gastric residence time increases in the elderly (103, 104). The slower transit time
through the stomach and lower gastrointestinal tract will increase the time available for drug
absorption and potentially increase the maximal plasma concentration and the length of time of
maximal plasma concentration. The absorption process may also be extended due to reduced gut
motility.
Significant modification in drug action due to age-related changes in gastrointestinal
function have not been documented. The extent to which drug absorption is affected by age will
depend on the nature of the drug and the degree to which any elderly individual has
compromised gastrointestinal function.
3.2 Pharmacokinetic Changes in the Liver
The liver is the main site of drug metabolism. Hepatic drug metabolism is divided into a
preparative Phase I and a synthetic Phase II. Phase I includes oxidation, reduction, and
hydrolysis reactions. Hepatic microsomal enzymes containing cytochrome P-450 are responsible
for Phase I reactions. Phase II reactions involve conjugation reactions that involve the
attachment of glucuronide, sulfate, glutathione or acetate to the drug to make it more polar and
eliminate pharmacological activity.
3.2.1 Splanchnic Blood Flow
After absorption, most drugs must pass through the liver before entering the systemic
circulation and reaching a site of action. Drugs that undergo a high degree of pre-systemic or
first-pass metabolism are referred to as high-clearance or high-extraction drugs. For these drugs,
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hepatic blood flow will determine the rate at which they reach the liver and the extent of
metabolism. Decreases in hepatic blood flow will increase bioavailability and decrease
clearance. As a function of age, splanchnic (i.e., visceral) and portal blood flow decreases (105,
106). Splanchnic blood flow may decrease by as much as 40 percent by age 70 years. The high
extraction drug nifedipine, a calcium channel blocker, was found to have a 30 percent higher
bioavailability and decreased clearance in the elderly as compared to young adults (107).
3.2.2 Mixed Function Oxidase-P450 System
Little evidence is available to suggest that reduced drug clearance in the elderly is due to
deficiencies in cytochrome P-450 dependent metabolism of xenobiotics (105). The consensus is
that no decline occurs in protein content, immunohistochemical content, or in vivo enzyme
activity in the elderly compared to the young. The decline in liver weight and the number of
hepatic cells are major contributors to the overall reduction in hepatic drug clearing capacity
(105, 117).
A study in 226 patients (ages 20 to >70) with equal histopathologic conditions were
examined for P450 content in a liver biopsy sample and for their ability to metabolize antipyrine
(108). P450 content decline after 40 years, remained constant till 70 years, and then declined
further resulting in an overall reduction of 30%. Antipyrine clearance also declined by 30%
between age 40 and 70. The reduction in antipyrine clearance could be due to the losses in liver
mass and hepatic blood flow and not to an intrinsic alterations in the constituents of the
microsomal monooxygenase system (105).
Although changes in liver size and blood flow may be the primary reasons for reduced
drug clearance, the activity of some subfamilies of the cytochrome P450 may decline with age in
humans (117). Reduced lidocaine and comarin clearance in the elderly, reflecting CYP3A4 and
CYP2A6 activities, may indicate that an age-related reduction in the microsomal
monooxygenase system exists in humans (109). The age-related decrease in the calcium channel
blocking drug nifedipine may be due to a reduction in metabolism by the CYP3A isoform (110).
Clearance of propranolol, a substrate for CYP2D6, indicates no change with age (111) and
clearance of hexobarbital, a substrate for CYP2C, indicates a reduction of activity with age
(112). Subfamilies of cytochrome P450 are also found in the intestines, kidney, lungs, and brain,
but no information is available on possible age-related changes in their function (117).
3.3 Age-related Changes in Drug Distribution
There are three major determinants of drug distribution, all of which are impacted by the
aging process: (1) body composition, (2) plasma protein binding, and (3) blood perfusion.
3.3.1 Body Composition
The distribution of lipophilic drugs depends on the adipose tissue content of the body.
The relative body fat content in males increases from 7-19 percent in their 20's to 35 percent at
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age 70 years (113). For females in their 20's, the body fat content ranges from 27-33 percent and
can increase to as much as 50 percent by 60 years. These changes mean that lipid-soluble drugs
are better distributed and retained longer in the elderly. As an example, benzodiazepines are
very lipophilic and have an increased volume of distribution in the elderly (114).
Lean body mass shows a corresponding decline in the elderly. The loss is more
pronounced in females with a possible decrease of 25 to 30 percent by age 70 years. Drugs with
hydrophilic properties would be expected to have a decrease in volume of distribution in the
elderly. Body water content also decreases with age, causing polar drugs to be less well
distributed but to be present at a higher concentration in the remaining body water (115).
3.3.2 Plasma Protein Binding
The plasma albumin fraction is responsible for most drug binding in the plasma. Age-
related changes in protein binding may be due to decreased liver production of serum proteins
and/or changes in drug affinity for the proteins (116). Inadequate protein intake in the elderly
may also contribute to decreased plasma protein synthesis. Serum albumin may decrease by
about 10 to 20 percent between 30 and 70 years of age. With the reduction in serum albumin,
the amount of unbound free drug in the plasma increases. Increased free drug levels can enhance
target organ responses and lead to adverse drug reactions. At the same time, more drug is
available for metabolism and excretion, which will increase drug clearance.
3.3.3 Blood Flow
As peripheral vascular resistance increases with age and other changes occur in the
cardiovascular system, organ perfusion decreases (117). As mentioned earlier, the decrease in
blood flow to the liver has a detrimental effect on drug clearance.
3.4 Pharmacokinetic Changes in the Kidney
Renal blood flow is reduced by 40 to 50 percent by age 60 and results in a greatly
reduced glomerular filtration rate (GFR). Kidney mass and the number of functioning nephrons
also decline with age (118, 119). Superimposing chronic diseases of the elderly, such as heart
failure, may accelerate these changes in kidney function (124).
3.4.1 GFR
Because of these changes in kidney mass and blood flow, GFR can decline by as much as
45 percent between 50 and 85 years.
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3.4.2 Excretion
Tubular secretion and reabsorption are also affected by aging. The reabsorption capacity
decreases by approximately 0.5 percent per year. Elderly individuals tend to excrete many drugs
and their metabolites at a reduced rate.
3.5 Ciprofloxacin and Nonsteroidal Anti-Inflammatory Drugs: Examples of Age-related
Pharmacokinetic Changes
Numerous examples of pharmacokinetic changes in the elderly could be discussed, but a
full treatment of all of them is beyond the limits of the Scope of Work. Age-related changes in
ciprofloxacin, a drug used to treat bacterial infections, and NSAID pharmacokinetics have been
documented (121) and will serve as examples of the potential changes in drug absorption,
distribution, and excretion in the elderly.
3.5.1 Ciprofloxacin
Studies comparing young and old subjects indicate comparable dissolution rates and
transport through the gastrointestinal membranes. No differences were observed between age
groups in the time required to reach maximum serum concentrations. Higher peak serum
concentrations and areas under the concentration-times curves (AUC) were seen in elderly
individuals compared to young individuals. Explanations for the higher peak concentrations and
AUC were increased bioavailability, reduced volume of distribution, reduced clearance, or a
combination of these factors. Reduced total body water seems to be responsible for a decrease
in the apparent volume of distribution. Only 20 to 40 percent of ciprofloxacin is serum protein
bound so a reduction in serum binding proteins has little effect on ciprofloxacin
pharmacokinetics.
Non-renal clearance of ciprofloxacin, produced primarily through hepatic, pulmonary,
and intestinal actions, is reduced by 50 percent in the elderly. This suggests that some decline in
the function of hepatic microsomal enzymes responsible for Phase I oxidation has occurred in
the elderly. Renal clearance of ciprofloxacin is also significantly smaller in the elderly. Both a
reduction in GFR and a reduction in tubular secretion are responsible for the reduced clearance
rate.
3.5.2 Nonsteroidal Anti-inflammatory Drugs (NSAIDs)
NSAIDs are frequently used by the elderly to control the pain associated with
musculoskeletal disorders (K). These drugs are also responsible for a large number of adverse
drug reactions in the elderly. The major drug-drug interactions of NSAIDs involve competition
for drug binding sites on serum proteins and for renal secretion of organic acids. The
development of gastric ulcers in the elderly seems to be related to the use of NSAIDs. NSAIDs
inhibit the protective effects of gastrointestinal prostaglandins that normally enhance mucus and
bicarbonate secretion in the stomach. As many as 20 percent of long-term NSAIDs users will
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develop peptic ulcer disease. Patients over 65 years have a 4 times greater chance of developing
ulcers compared to non-users. Alterations in serum albumin levels due to aging or poor nutrition
may result in higher free NSAID levels in the blood and an increase in gastric ulcer incidence in
the elderly.
3.6 Drug Responses in the Cardiovascular System
Release of norepinephrine from adrenergic nerve terminals within the cardiovascular
system is the primary mechanism for increasing heart rate and blood pressure in order to increase
organ perfusion. One consequence of normal aging of the cardiovascular system is a decline in
beta-adrenergic receptor function associated with alterations in responsiveness to beta-adrenergic
therapy. The intrinsic ability for muscle contraction or relaxation does not change, but
alterations in the processes linking the receptor with the contractile or relaxation mechanisms do
occur with age. These age-related changes in the beta-adrenergic receptor are among the best
documented of the pharmacodynamic changes that can occur during aging (122, 123). These
changes contribute to altered baroreflex responses that often impair the ability of elderly
individuals to adapt to cardiovascular stressors. Because of the age-related decline in beta-
adrenergic function, the maximal heart rate in response to exercise decreases with age.
Pharmacological responses to beta-agonists (drugs that stimulate beta-adrenergic responses) and
beta-antagonists (drugs that inhibit beta-adrenergic responses) are less pronounced in elderly
individuals compared to younger individuals. The predominant effect of age is to decrease the
contractility and chronotropic responses in the heart to beta-adrenergic stimulus while having
less of an impact on peripheral vasodilation. Although not as well studied, heart rate suppression
induced by calcium channel blockers is greater in the elderly (123).
The pharmacokinetics of numerous cardiovascular drugs are affected by changes related
to the aging process (123). All three chemical classes of calcium channel blockers are cleared
primarily via hepatic metabolism and their elimination decreases with age. Digoxin, a drug
commonly used to treat heart failure in the elderly, has a decreased volume of distribution
because of the loss of lean body mass with aging. In addition, the decline in kidney function also
reduces digoxin clearance. Any additional drugs or toxins that reduce kidney function may
result in elevating digoxin levels past their narrow therapeutic range and into the toxic range.
While normal aging has a predictable effect on cardiovascular drug actions, heart failure may
impose additional changes on drug actions (124). Heart failure patients are given ACE inhibitors
to decrease peripheral vascular resistance and reduce the work load on the heart. In patients with
heart failure, the absorption of ACE inhibitors is unchanged but the half-life is much longer and
the clearance is much slower due to reductions in tubular secretion in the kidneys. Therefore,
these patients are at greater risk for severe chronic renal insufficiency and renal failure due to
decreased renal blood flow, an adverse effect that is common to all ACE inhibitors.
3.7 Drug Responses in the Pulmonary System
Pulmonary function declines in the elderly due to loss of elastic recoil and weakness in
diaphragmatic, chest wall, and abdominal muscles that results in decreased gas exchange (122).
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The great reserve function of the lung permits reasonable physical capacity in healthy
individuals despite these age-related changes, and training can improve the aerobic capacity and
endurance in the elderly. Diffusion of oxygen may decline due to disruption of alveolar walls
that may be the result of inflammatory insults or environmental pollutants. However, these
changes are relatively minor and sufficient lung surface area is available to allow gas exchange
and the exposure to environmental agents.
The development of asthma in the elderly is not uncommon. Data from the National
Center for Health Statistics indicates that the prevalence of active asthma in the 65- to 74-year-
old group is 10.4 percent compared to 5.7 percent in young teenagers and 6.9 percent in 18- to
44-year-olds (126). The treatment of asthma in young individuals relies on the use of • *2
agonists as bronchodilators. With the decrease in • *2 receptors in the smooth muscles lining the
airways of older individuals, these drugs may be expected to become less effective (127).
However, cholinergic receptors may become the dominant smooth muscle receptors as aging
progresses and anticholinergic drugs such as ipratropium should be effective at inducing smooth
muscle relaxation.
Theophylline was a standard treatment for asthma, but it has now largely been replaced
by the • 2-agonists. The elderly are at increased risk of theophylline toxicity due to reductions in
drug clearance from age-related diminished hepatic clearance, concurrent illness such as heart
failure, and medication such as cimetidine and macrolide and quinolone antibiotics. An age-
related reduction in the basal capacity to oxidize theophylline in the liver has been reported
(128). The reduced capacity is presumably due to changes in at least two isozymes of
cytochrome P-450 (CYP^, CYP2E1,and possibly CYP3A). The ability of cimetidine (an H2
histamine receptor blocker commercially know as Tagament) to inhibit P-450 enzymes and
theophylline metabolism is preserved in the elderly. The combination of theophylline and
cimetidine in the elderly can easily lead to theophylline toxicity in the heart and brain that would
not have occurred in younger individuals
The elderly are markedly more sensitive to the respiratory effects of opioid analgesics
because of age-related changes in respiratory function.
3.8 Drug Responses in the Nervous System
3.8.1 Central Nervous System
The elderly are more likely to suffer from ataxia and motor impairment in response to
sedative-hypnotics, such as benzodiazepines and barbiturates, due to decreased clearance and
greater sensitivity (123). The half-lives of these drugs may increase between 50 and 150 percent
by age 70 years. Antipsychotic and antidepressant drugs can be effectively used in the elderly
with some dosage adjustment to compensate for longer half-lives. The elderly are more sensitive
to their toxic effects (124). In particular antipsychotic drugs in the elderly are likely to produce
acute movement disorders related to the extrapyramidal syndromes of dystonia, akathisia,
parkinsonism, and tardive dyskinesia. Antidepressants are more likely to produce sedation and
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drowsiness, acute confusion, disorientation, memory loss, and movement disorders in the
elderly.
Increasing age is an established risk factor for the development of Parkinson's disease
(PD). However, several environmental factors have been proposed as additional risk factors.
International differences in the prevalence of PD may be related to toxicant exposure (129, 130).
An association may exist between rural residence, farming, well water drinking, and
herbicide/pesticide exposure and an increased risk of developing PD. However, the studies
showing these relationships are limited by their small sample size. These observations may also
be confounded by studies that suggest that eating foods high in vitamin E or some other dietary
factor may protect against the development of PD. Therefore, areas of low PD prevalence may
not be the result of reduced exposure to environmental toxins but the result of increased dietary
intake of protective foods. The percentage of all PD cases that might be related to occupational
pesticide use is only 10 percent but may vary between 2 percent and 25 percent (131).
3.8.2 Peripheral Nervous System
The age-related changes in beta-receptor function in the periphery has been discussed
with regard to control of the cardiovascular system.
3.8.3 Blood-Brain Barrier
Most of the studies examining blood-brain barrier function and aging have failed to show
any significant age-related alterations in permeability to water-soluble substances and high
molecular weight solutes in the absence of neurological disease (132). However, the blood-brain
barrier may be more vulnerable to damage in elderly individuals. Conditions such as
hypertension, diabetes, and cerebral ischemia may damage the integrity of the barrier. The
impairment seems to be even greater in patients with Alzheimer's disease. Thus, both drugs and
environmental toxins may be freer to penetrate the blood-brain barrier in the elderly, especially
when exposure is concurrent with one of the chronic diseases common to the elderly.
3.9 Nutrition and Drug Responses
The status of all vitamins is compromised by reduced food intake and absorption of
nutrients in the elderly (134, 136). Decreased active intestinal transport and the increased
propensity for atrophic gastritis may reduce the absorption of vitamins A, Bl, folate, and B12.
Decreased exposure to sunlight and reduced cutaneous synthesis may impair vitamin D status.
Various drugs may also impair nutrient intake by reducing appetite and slowing gastric emptying
and gut motility. Both vitamin and protein malnutrition in the elderly can have a severe impact
on hepatic drug metabolism and clearance (133, 135). Over-the-counter medications, such as
laxatives and antacids, consumed by many elderly can affect both nutrient absorption and drug
actions.
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3.10 Comment
This discussion of the effect normal aging can have on drug action provides only a brief
glimpse of what is a large and complex problem. A key point to emphasize in any discussion of
the elderly is their greater vulnerability to any type of stressor. Aging reduces the reserve
capacity that is available to adapt to environmental changes. The reduced ability to increase
cardiac output and the loss of reserve glomerular filtration rate (GFR) capacity are two important
examples. Elderly individuals will function well until challenged by a stressor for which normal
adaptive processes are no longer available. Superimposed on these normal physiological
changes are the effects of chronic diseases, the potential toxic effects of various drugs used to
treat these chronic diseases, the increased probability for adverse drug interactions, and changes
in nutritional status among the elderly. Any estimation of the potential effects of environmental
toxins on the elderly must take each of these circumstances into consideration.
4.0 AGE-ASSOCIATED FUNCTIONAL CHANGES AND RESPONSE TO
ENVIRONMENTAL EXPOSURES
The literature search conducted as a part of this report contained few if any clinical
studies that examined the absorption, distribution, and potential effects of environmental toxins
in the elderly. However, the well-documented pharmacokinetic changes that occur during aging
can be used to predict the extent to which the elderly may be at greater or lesser risk of toxic
effects compared to younger individuals.
4.1 Example: Response to Lead
4.1.1 Absorption, Distribution, and Clearance
Inorganic lead is absorbed through the respiratory (industrial exposure) and
gastrointestinal (non-industrial exposure) tracts while organic lead is well absorbed through the
skin (137). Lead first distributes to the soft tissue and then redistributes to the bone. The half-
life in soft tissues is 1 to 2 months but in bone the half-life can be years to decades. Absorbed
lead is excreted predominantly through the urine. Therefore, clearance in the elderly may be
greatly reduced due to increased GFR, depending on the exposed individual.
4.1.2 Toxicity and Potential Effects
Lead may cause anemia by interfering with heme synthesis. Poor nutritional intake in the
elderly has the potential to exacerbate this condition. The signs and symptoms of lead toxicity in
the central nervous system may be confused with effects of normal aging. Irritability, fatigue,
decreased libido, anorexia, sleep disturbance, impaired visual-motor coordination, and slowed
reaction time are conditions that occur with lead poisoning but also with advanced age. Chronic
high-dose lead exposure may result in renal interstitial fibrosis and nephrosclerosis. In an
elderly individual, lead exposure has the potential to accelerate the age-related decline in kidney
function. Lead exposure could therefore reduce drug clearance to the point of causing adverse
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drug effects in elderly individuals taking digoxin or diuretics. Lead exposure can also precipitate
congestive heart failure (138).
The skeleton accumulates inorganic lead and holds 90 percent of the body's lead burden.
Rapid release of this stored lead by skeletal disease could produce a considerable health risk
(139). The potential effect of osteoporosis on the lead status of women before and after
menopause has been examined by Silbergeld et al. 1988 (140). Using the NHANES II dataset
compiled between 1976 and 1980, the authors found a highly significant increase in both whole
blood and calculated plasma lead concentration after menopause. Lead may also aggravate
osteoporosis by inhibiting activation of vitamin D, uptake of dietary calcium, and aspects of
bone cell function. Modeling of bone loss with aging also suggests that loss of bone in women
after menopause could create a hazard related to release of lead into the blood (141).
4.2 Example: Response to Trichloroethylene
4.2.1 Absorption and Distribution
Trichloroethylene (TCE) has a wide variety of uses, especially as a degreaser for both
metal fabrication and dry cleaning of clothes (144). TCE is released into the air and water
primarily from industrial sites, but humans may also be exposed by using TCE-containing paint
removers, strippers, adhesives, spot removers, and rug-cleaning fluids. The percentage of
inhaled TCE absorbed by the pulmonary vasculature ranges from 50 percent to 76 percent. TCE
is highly lipid soluble and distributes to lipophilic organs such as the brain and liver. In the
elderly, the volume of distribution may be expected to increase compared with younger
individuals due to age-related increases in fat mass and decreases in lean body mass. The
principal site of TCE metabolism is the liver, but the lungs, kidney, spleen, and small intestine
are also involved. Cytochrome P-450-mediated metabolism is responsible for biotransformation
of TCE into dichloroacetic acid, trichloroacetic acid, trichloroethanol, and oxalic acid.
Depending on the subform of cytochrome P-450 involved in TCE metabolism, this phase of TCE
biotransformation may not be affected by aging.
Unmetabolized TCE is exhaled and the metabolites are excreted primarily in the urine.
The major urinary metabolite is trichloroethanol, accounting for 90 percent of the metabolites in
urine. Excretion of TCE metabolites in the bile can account for up to 30 percent of TCE
metabolite elimination. The half-life of TCE is 30 to 38 hours, but the half-life for renal
elimination of trichloroethanol is about 10 hours. The larger volume of distribution in the
elderly may increase the half-life of TCE. Decreases in renal function with age are likely to
increase the half-life of TCE metabolites.
4.2.2 Toxicity and Potential Effects
Liver: TCE does have hepatotoxic effects that seem to be mediated by the production of
toxic metabolites, reactive free radicals, or both (144). Use of ethanol can potentiate TCE
toxicity in the liver. The elderly are at risk for enhanced TCE induced liver toxicity because of
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their reduced renal capacity to excrete TCE metabolites and the decreased capacity of the aging
liver to counter the effects of free radical production. Decreased nutrient intake and increased
ethanol consumption among the elderly may also add to the deterioration of liver function when
exposed to TCE.
CNS: Mental deterioration is a serious complication of TCE exposure (144) . Chronic
signs and symptoms of TCE exposure that mimic the effects of aging include fatigue, dizziness,
weakness, nausea, blurred vision, poor concentration, poor short-term memory, confusion,
hearing loss, and difficulty solving sequential problems. TCE neurotoxicity has been connected
to TCE metabolites and the production of free radicals from TCE metabolites. A consistent
connection between exposure to organic solvents and decreased concentration ability and
memory difficulties has been found for both workers and retirees following occupational
exposures to mixed solvents (145). Therefore, mental difficulties experienced by the elderly
after TCE exposure may be confused with behavior believed to be common among the elderly.
Neurological disorders resembling dementia, with loss of cognitive and verbal ability, have been
described as an effect of more chronic and severe stages of TCE exposure. TCE exposure may
also exacerbate mental difficulties already affecting elderly individuals. Age has been
considered a problematic confounder in efforts to determine the effect of TCE exposure on
mental functions because age is strongly correlated with cumulative exposure. Age adjustments
can only be based on data from a small population of older workers who have limited
accumulative exposure.
4.3 Nutrition, Cancer, and Aging
Balducci et al. (136) examined the interrelationship of diet and carcinogenesis in the
elderly. Their review makes several important points with regard to environmental toxin
exposure in the elderly. The elderly may be more vulnerable to chemical carcinogenesis because
of a decreased capacity to repair DNA damage caused by mutagens. Also, the elderly have a
decreased ability to dispose of free radicals and may be vulnerable to the capacity of free radicals
to promote indefinite proliferation in cells that have gone through the initiation phase of
chemical carcinogenesis. Decreased immunologic defenses may also increase the vulnerability
of the elderly to chemical carcinogens. On the other hand, other physiological changes in the
elderly which may reduce their vulnerability to chemical carcinogens include: decreased ability
to metabolically activate the carcinogen, increased ability to deactivate carcinogens, decreased
enteric absorption of carcinogens, and decreased capacity for cellular proliferation. The authors
point out that the vulnerability to dietary carcinogens results from a combination of
individualized factors that cannot be predicted based solely on an individual's age. This
emphasizes the heterogeneity of responses in the elderly.
Exposure to environmental toxins and a lack of vitamin E and selenium may contribute to
increased risk for neurodegenerative disease (142). The capacity of vitamin E and selenium to
reduce free radical accumulation may influence the development of Alzheimer's disease.
Deficiencies in calcium intake could also have profound effects on the development of
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neurodegenerative diseases. A deficiency of calcium in the diet could increase the intestinal
absorption of toxic metals, such as lead, that follow the same absorption pathway as calcium.
4.4 Comment
Although few clinical studies are available, one researcher has speculated that exposure
to environmental toxins may accelerate the aging process (143). Weiss (143) cautions that when
determining the neurobehavioral effects of endocrine disrupters, a variety of possible outcomes
ranging from acute impairment to accelerated aging must be considered. [Weiss' opinion was not
based on actual clinical studies of toxic exposure, and the purpose of his publication was focused
on a discussion of risk assessment for neurobehavioral toxicity of endocrine disrupters.] Current
approaches to neurobehavioral risk assessment are deficient in several respects. In particular,
they rarely include longitudinal designs capable of assessing the influence of aging on central
nervous system damage.
5.0 ANIMAL MODELS FOR THE STUDY OF AGING
Biological models used to study the aging process are available and vary greatly in
complexity. Cell culture and non-mammalian models are used to explore specific genetic and
cellular changes that occur during aging. These models may not be generalizable to aging in
humans, but they allow basic theories of the molecular basis for aging to be tested. Numerous
mammalian species have been used to evaluate potential connections between dietary,
environmental, genetic, and disease factors with what might be considered the normal aging
process. Each of these various models may be useful in assessing the risk of environmental toxin
exposure in the elderly.
5.1 Cell Culture and In Vitro Models
In vitro techniques have been used to identify toxic hazards and investigate the
mechanisms of toxicity (146). Primary cell cultures are cells which are harvested directly from
the organism's tissues, dissociated into single cells before seeding into the culture vessel, and
maintained in vitro for periods beyond 24 hours. Cell lines are cultures that have been serially
transplanted or subcultured through a number of generations and can be propagated for a
extended period of time. In vitro systems often provide only partial answers to more complex
problems. These systems can supplement but rarely replace experiments with whole animals. In
vitro systems are important when studying the mechanism of action of toxic agents, but their use
in hazard identification in human health risk assessment has not been widely accepted. Toxicity
in neurons in vivo may be due to responses mediated by non-neuronal cells or systemic
biological processes that produce toxic metabolites. Dose-response relationships obtained in
vitro may not match in vivo results because of pharmacokinetic properties that determine drug
concentration at the site of action. Individual differences in drug metabolism and excretion are
important contributors to the large population variation seen in both dose responses and types of
toxic responses following drug or chemical exposure. Responses in cell cultures will not be
affected by these types of individual variations in the amount of drug or chemical reaching the
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site of action. The age of the animal providing the cells to be cultured will affect the success of
the culture. Primary cultures of central nervous system tissues are best derived from fetal or
neonatal material. Cultured cells from peripheral nervous system tissue can be derived from
adult or even older donors.
5.1.1 Fibroblasts
Human diploid fibroblast cell models are used to study the mechanisms that underlie
cellular senescence (146). Fibroblasts in culture go through several stages. The first stage
involves outgrowth and establishment in the culture. This stage is followed by a period of
vigorous proliferation that has a variable length depending on the age of the tissue donor. The
next stage is a period of declining proliferative vigor that includes cell death. The final stage
involves the emergence of an apparently long-lived population that is unable to proliferate in
response to mitogens. A variety of other cell types in culture go through the same stages. These
stages in the life cycle of a cell culture have been examined for a possible mechanism underlying
cell senescence. These include: studies of DNA repair, errors of protein synthesis, chromatin
structure and function, and mechanisms modulating replicative life span. Many of the alterations
which accompany senescence in vitro have also been demonstrated to occur in vivo. Studies can
be performed in cell cultures derived from animals of various ages in order to determine the
vulnerability of these cells to free radical production initiated by toxin exposure. Other potential
mechanisms of toxicity can also be examined in cells showing various stages of proliferation and
senescence.
5.2 Non-mammalian Species
5.2.1 Fruit Flies
Fruit flies (Drosophild) have several advantages and disadvantages when used in
experimental aging research. Advantages include: (1) a relatively short life-span that allows
multigenerational studies, (2) they are inexpensive to raise and assay, and (3) most of the cells in
adult flies are post-mitotic which allows the examination of senescent processes uncomplicated
by the effects of cell division and replacement. The disadvantages include: (1) the fact that
Drosophila are small animals and obtaining enough tissue per fruit fly to be able to examine
inter-individual differences is difficult; and (2) as an invertebrate, the experimental results may
be difficult to generalize to mammals. However, at the cellular level, many of the phenomena
related to fundamental aging processes are similar between fruit flies and mammals. Their
primary advantage is in the study of genetic mechanisms involved in the aging process. Specific
gerontology genes, if identified, may be manipulated in fruit flies to extend or shorten life span.
Genes involved in the antioxidant defense systems can be tested to determine their effect on
longevity and their vulnerability to toxic exposure. The fruit fly may provide a suitable model
for examining the interaction between specific genes, environmental toxins, and aging (147).
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5.2.2 Nematodes
The nematode is similar to the fruit fly in that its advantages for aging research include:
(1) a short life cycle, (2) short mean and maximum life spans (i.e., about 2-5 weeks), (3) a simple
multicellular structure composed essentially of post-mitotic cells, and (4) being relatively easy to
raise under well-defined and easily controlled nutritional conditions (148). Caenorhabditis
elegans (C. elegans), a self-fertilizing hermaphrodite, is the nematode most often used in aging
research. C. elegans's very small genome (about 100 megabases) allows for extensive research
related to molecular genetics and development.
Nematodes have been used extensively to investigate the connection between altered
enzyme molecules and aging. In particular, nematodes have been used to study protein
synthesis, damage, and degradation at various ages. Nematodes have also been used to study the
effects of antioxidants on oxidative damage and the potential for these agents to extend life span.
In the same manner, differences in toxin-induced free radical production and damage between
young and old nematodes can be determined.
5.3 Mammalian Species
Rats and mice are the most frequently used experimental models of aging. In order to
provide an environment free of infectious diseases (which may greatly compromise the health of
senescent animals), rats and mice are raised from birth in specific pathogen-free (SPF) barrier
conditions. The Food and Drug Administration's National Center for Toxicological Research
and the National Institute on Aging maintain barrier facilities which raise rats and mice for use
by experimental gerontologists examining the aging process. Once in the hands of the
researcher, the same barrier housing must be maintained until the animal is used. The specific
requirements involved in raising SPF animals, such as sterilization of bedding material and diet,
have been published (149). The use of SPF animals will be especially critical when examining
effects of toxin exposure on old animals. Raising test animals under SPF conditions will
eliminate confounding environmental factors which might distort the effects of toxic chemicals
in old animals.
The latency between carcinogen exposure and cancer development presents several
problems when considering its effect in the elderly. The striking increase of cancer incidence
with age may be related to decreased immune function, a longer duration of carcinogenic
exposure, increased susceptibility of cells to carcinogens, and several other biological factors
(150). However, actual exposure time may be very limited when carcinogen exposure is
initiated late in life. The latency period may be longer than the expected remaining life span.
Fundamental aspects of cancer development in the elderly, including latency, are not well
understood (151). Molecular epidemiology of environmental carcinogens seems to indicate that
young age at exposure is a key risk factor (152, 153). This suggests that environmental
carcinogen exposure in the elderly may not provide sufficient time for cancer development to
take place.
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Rats and mice are the major animal models used in aging research, primarily because of
their size and relatively short life spans (e.g., less than 5 years). These characteristics make them
less costly than most other mammalian species in the resources needed for lifelong maintenance
and in the amount of an investigator's scientific lifetime required to complete a study. Moreover,
rats and mice appear to be good models of human aging. It is not possible to prepare a table in
which biological age is related to chronological age in these species because valid biomarkers of
biological age have yet to be identified. However, there are many phenotypic aging
characteristics that are similar among the three species. Some examples are listed in Table 1.
Table 1
Similarities Among Rats, Mice, and Humans in Aging Phenotypic Characteristics
1. Low mortality between puberty and mid-life and high mortality thereafter.
2. Prevalence of neoplasia markedly increases after mid-life.
3. Total infertility of female by about mid-life.
4. Decreasing fertility of male with advancing age.
5. Increasing body fat mass through mid-life.
6. Loss of body weight at advanced ages.
7. Impaired response to cold environment at advanced ages.
This is not meant to imply that rats and mice are perfect models. Atherosclerosis, a
major problem in humans, does not occur in rats and mice in the absence of extreme
experimental measures nor do Alzheimer type brain lesions.
Restricting the caloric intake of rats and mice by 30 to 50 percent for much of the life
span markedly increases their length of life, delays physiological deterioration and delays the
onset and/or slows the progression of most age-associated disease processes (154). It also has
been found to increase the resistance of animals of any age to the damaging action of acute
stressors such as surgery, high environmental temperature, inflammatory agents and the toxic
effects of drugs (155).
5.3.1 Rats
Depending on the organ or system being examined for age-related changes, a number of
rat strains are available (156). Rats and mice have been extensively used in all fields of
biomedical and behavioral research. Therefore, researchers are very familiar with their care and
maintenance and with their biology and behavior. An extensive collection of gerontologic
characteristics is available for comparison to data derived from new experiments. This data base
will be particularly useful when exploring the vulnerability of old animals to toxic chemicals.
Many inbred and outbred strains of rats are used in aging research. The most widely
used rat strains are the inbred F344 strain, outbred Wistar stock, outbred Sprague-Dawley stock,
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outbred Long-Evans stock, inbred Brown-Norway (BN), inbred WAG/Rij strain, the F344 x BN
Fl hybrid, and the WAG x BN Fl hybrid. The NIA maintained colony provides the F344, BN,
andF344xBNFl hybrid.
Typical experiments involve the use of 6-month-old and 24-month-old rats. Six-month-
old rats are considered young adult animals and 24-month-old rats are considered old, but are not
yet particularly over-burdened with kidney or liver disease. Knowledge of the pathology
common to old rats in each strain is essential in interpreting the results of gerontological studies
using these strains. What might be interpreted as representing normal aging can actually be the
effect of age-associated diseases. A middle age of 12 or 18 months may also be examined.
Middle-aged groups are helpful in determining when in the life span of a species biochemical
and physiological changes actually occur.
5.3.2 Mice
The C57BL/6, DBA/2, CBA/Ca, and BALB/c inbred strains of mice and the Swiss
Webster outbred stock are frequently used in aging research. Mice are often used in studies
examining the effect of aging on the immune system.
5.3.3 Hamsters
Three species of hamsters have been used in aging research: the Syrian hamster, the
Chinese hamster, and the Turkish hamster.
5.3.4 Cats and Dogs
Cats and dogs are used in a variety of toxicological studies, but do not appear to be used
to any great extent in aging research (157).
5.3.5 Non-human Primates
Because of the cost and limited availability of old nonhuman primates of known age and
health status, few aging studies using these animals have been performed (157). The NIA and
the University of Wisconsin are currently examining rhesus and squirrel monkeys with the goal
of determining if the life extending properties of dietary restriction extend to primates.
The rhesus monkey is the most widely used animal model for studying recognition
memory tasks and has been used to examine the effects of aging on cognition (158).
5.4 Comment
Numerous animal models are available to study the vulnerability of elderly individuals to
the effects of environmental toxins. In vitro cell culture methods offer defined cells and
environments in which to study the mechanisms of toxicity. The interaction between genetics,
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aging, and toxins may best be studied in fruit flies or nematodes. Rats and mice offer models to
study complex changes in physiology and behavior and the indirect influences that organ
systems have on each other during the aging process. Nonhuman primate models can be used to
examine the effect of toxin exposure on cognitive function in elderly animals.
A speculative model for designing an animal study to examine the effect of aging on
toxic responses can be proposed. Animal housing and diet will be important confounding factors
in any design. The F344 rat strain is probably the best animal model for both short-term and
long-term exposure because of the large background information available for this strain.
However, an outbred Wistar strain may also be used for comparison to the inbred strain. SPF
conditions must be maintained with particular attention to the composition of the bedding and
water. Potential toxins must be eliminated from the bedding and water. Some thought must be
given to the recycling and conversion of administered toxins in the GI tract since rats are know
to consume their own feces. Wire flooring can be used, but only in short-term studies because
lesions will develop on the rat's feet. Short-term studies may provide information on the
absorption, distribution, and metabolism of toxins in young and old animals. Long-term studies
may provide information on the effects of life-time exposure, but in this design the confounding
effects of dietary restriction must be considered. The toxin has the potential to reduce food
intake, reduce body weight, and through the action of dietary restriction improve toxin clearance,
reduce the pathology associated with the toxin, and even increase life span compared to control
animals that do not receive the toxin. In both short-term and long-term study designs,
pathological, physiological, biochemical, and cellular changes in all major organ systems will
need to be determined. Several preliminary test runs of study designs may be necessary to
discover the proper approach to evaluating the relationship and consequences of aging and toxic
exposures. An equally important consideration is the personnel running the study. The National
Center for Toxicological Research has the facilities, both animal and laboratory, and the
experienced personnel to conduct these studies.
6.0 AGE-ASSOCIATED FUNCTIONAL CHANGES AND RESPONSE TO
ENVIRONMENTAL EXPOSURES
Clearly, most physiological functions undergo deterioration with increasing adult age and
this deterioration undoubtedly increases vulnerability to harmful environmental agents.
However, two important caveats need to be emphasized. First, the extent of this deterioration
varies greatly between and within individuals and, second, most investigators have attempted to
quantify the extent of deterioration and variation using cross-sectional study designs. Thus,
although strong qualitative evidence regarding age-associated physiological deterioration is
available, data on the extent of deterioration are soft.
The influence of age on glomerular filtration rate (GFR) is a good example of the first
issue. In a large cross-sectional study, the GFR within the sample group decreased in a linear
manner from 140 ml/min/m2body surface in men in the age range of 25-34 years to 97
ml/min/m2body surface in the age range of 75-84 years (159). However, a longitudinal study
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(56) of the participants of the Baltimore Longitudinal Study of Aging revealed that one-third of
the participants did not exhibit an age-associated decrease in GFR even though the average
change in GFR was similar to that observed in the cross-sectional study cited above. This
suggests that within any aging cohort one-third experience no age-related change, one-third
experience some age-related change, and the remaining one-third experience a large age-related
change in any one physiological function. Finally, a documented age-related change in one
function does not mean that other physiological functions have changed to the same extent.
The interpretation of cross-sectional design studies of aging is often confounded factors
in addition to aging that may influence the findings (160). A major type of confounder is
referred to as "cohort effects" or "generational effects." For example, in the developed countries,
the number of years of schooling steadily increased during the twentieth century. Thus when
comparing cognitive function between 30 year olds and 80 year olds, determining how much of
the difference between age groups is due to education rather than aging is difficult. The other
major type of confounder is referred to as "selective mortality." The older the age group under
study, the smaller is the fraction of its birth cohort still alive. Members of the cohort with risk
factors for fatal diseases are preferentially removed from the birth cohort. Thus, finding higher
levels of FtDL-cholesterol in those in the age range of 80 to 90 years compared to those 50 to 60
years of age is more likely due to selective mortality than to aging.
Any attempt to quantify the risk associated with toxic exposures in the elderly must take
these two caveats into consideration. Risk will be dependent upon the extent of age-related
deterioration in physiological function in a number of organ systems and the extent of
deterioration will vary among organs and individuals. Cross-sectional studies can provide
important information on the risks associated with toxic exposure in the elderly, but the
interpretation of results will be complicated by the confounding factors of "cohort effects" and
"selective mortality."
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7.0 REFERENCES
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of Evaluating Chemical Effects on the Aged Population. Geneva: World Health
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2. Jette, A. M. Disability trends and transitions. In: Binstock, R. H., George, L. K., eds.
Handbook of Aging and the Social Sciences, 4th ed. San Diego, CA: Academic Press;
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3. Spirduso, W. W. Physical Dimensions of Aging. Champaign, IL: Human Kinetics: 1995.
4. McClearn, G. E. Biomarkers of age and aging. Exper. Gerontol. 1997; 32: 87-94.
5. Rowe, J. W., Kahn, R. L. Successful Aging .New York: Pantheon: 1998.
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11, Aging. New York: Oxford University Press: 1995: 325-344.
7. Stafford, J. L., Albert, M. S., Naesser, M. A., Sandor, T., Garvey, A. J. Age-related
differences in computed tomographic scan measurements. Arch. Neurol. 1988; 45:
409-415.
8. Masliah, E., Mallory, M., Hansen, L., DeTeresa, R., Terry, R. D. Quantitative synaptic
alterations in the human neocortex during normal aging. Neurology 1993; 43: 192-197.
9. Cotman, C. W., Kahle, J. S., Korotzer, A. R. Maintenance and regulation in brain of
neurotransmission, trophic factors, and immune responses. In: Masoro, E. J., ed.
Handbook of Physiology, Section 11, Aging. New York: Oxford University Press: 1995:
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10. Collins, K. J., Cowen, T. Disorders of the autonomic nervous system. In: Tallis, R., Fillit,
H., Brocklehurst, J. C., eds. Brocklehurst's Textbook of Geriatric Medicine and
Gerontology, 5th ed. London: Churchill Livingstone: 1998:539-563.
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Schneider, E. L., Rowe, J. W., eds. Handbook of the Biology of Aging, 4th ed. San Diego:
Academic Press: 1995: 300-327.
12. Albert, M. S., Moss, M. B. Neuropsychology of aging: Findings in humans and monkeys. In:
Schneider, E. L., Rowe, J. W. eds. Handbook of the Biology of Aging, 4th ed. San Diego:
Academic Press: 1995: 217-233.
13. Smith, A. D., Earles, J. L. K. Memory changes in normal aging. In: Hess, T., Blanchard-
Fields, F., eds. Cognitive Changes in Adulthood and Aging. New York: McGraw-Hill:
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14. Kausler, D. H. Learning and Memory in Normal Aging. San Diego: Academic Press: 1994.
15. Jorm, A. F., Korten, A. E., Henderson, A. S. The prevalence of dementia: a quantitative
integration of the literature. ActaPsychiatr. Scand. 1987; 76: 464-479.
16. Terry, R. D., Katzman, R. Alzheimer's disease and cognitive loss. In Katzman, R., Rowe, J.
W., eds. Principles of Geriatric Neurology. Philadelphia: Davis: 1992: 51-84.
17. Strittmatter, W. J., Saunders, A. M., Schmechel, D., Pericak-Vance, M., Enghild. J.,
Salvesen, G. S., Roses, A. D. Apolipoprotein E: high-avidity binding to beta-amyloid and
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