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fourth grade education and 27 for those with a college education (out of maximum score of 30) The foregoing effects of age on mental abilities are extremely variable Some 70-year-olds perform better on psychologic testing than some normal 20-year-olds And a few individuals retain exceptional mental power and perform creative work until late life Verdi, for example, composed Otello at the age of 73 and Falstaff at 79 Humboldt wrote the ve volumes of his Kosmos between the ages of 76 and 89 years; Goethe produced the second part of Faust when he was more than 70 years old; Galileo, Laplace, and Sherrington continued to make scienti c contributions in their eighth decades; and Picasso continued to paint in his nineties It must be pointed out, however, that these accomplishments were essentially continuations of lines of endeavor that had been initiated in early adult life Indeed, little that is new and original is started after the 40th year High intelligence, well-organized work habits, and sound judgment compensate for many of the progressive shortcomings of old age Personality Changes in the Aged These are less easily measured than cognitive functions, but certain trends are nevertheless observable and may seriously disturb the lives of aged persons and those around them Many old people become more opinionated, repetitive, self-centered, and rigid and conservative in their thinking; the opposite qualities undue pliancy, vacillation, and the uncritical acceptance of ideas are observed in others Often these changes can be recognized as exaggerations of lifelong personality traits Elderly persons tend to become increasingly cautious; many of them seem to lack self-con dence and require a strong probability of success before undertaking certain tasks These changes may impair their performance on psychologic testing Kallman s studies of senescent monozygotic twins suggest that genetic factors are more important than environmental ones in molding these traits One of the weaknesses of studies of the aged has been the bias in selection of patients Many of the reported observations have been made in cohorts of individuals residing in nursing homes Studies of functionally intact old people of comparable age and living independently, such as those of Kokmen and of Benassi and their colleagues, reveal fewer de cits, consisting mainly of forgetfulness of names, smallness of pupils, restriction of convergence and upward conjugate gaze, diminished Achilles re exes and vibratory sense in the feet, stooped posture, and impairments of balance, agility, and gait (as mentioned earlier and below)
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and more cautious in walking and habitually touches the handrail in descending stairs, to prevent a misstep To be distinguished from the ubiquitous and subtle changes in gait of the normal aged population is a more rapidly evolving and inordinate deterioration of gait that af icts a small proportion of the aging population while they remain relatively competent in other ways In all likelihood, this latter disorder represents an agelinked degenerative disease of the brain, since most instances of it are sooner or later accompanied by mental changes The basis of this gait disorder is probably a combined frontal lobe-basal ganglionic degeneration, the anatomy of which has never been fully clari ed, as discussed on page 106 However, in many of such patients we have observed, there is no disproportionate atrophy or reduction of blood ow in the frontal lobes, making the cause of the gait disorder obscure It has also been postulated that age-related changes in the substantia nigra are the cause of the parkinsonian appearance of the gait of the aged, but it does not respond to L-dopa or to any other therapeutic measure The main differential diagnostic consideration is normal-pressure hydrocephalus, correctable by a ventriculoperitoneal shunt, which accounts for the gait disorder of a sizable group of these elderly patients, as discussed in Chaps 7 and 30 (Fisher) Parkinson disease is yet another potentially treatable cause of walking dif culty Progressive supranuclear palsy is a degenerative process in which gait and stability are affected early and profoundly Urinary incontinence, de ned as a state in which involuntary loss of urine is a social or hygienic problem and is objectively demonstrated, is a surprisingly common occurrence in the elderly (Wells and Diokno) Doubtless this complex of motor impairments is based on the aforementioned neuronal losses in the spinal cord, cerebellum, and cerebrum Falls in the Elderly Among elderly persons without apparent neurologic disease, falls constitute a major health problem About 30 percent suffer one or more falls each year; this gure rises to 40 percent among those over the age of 80 and to more than 50 percent among elderly persons living in nursing homes According to Tinetti and colleagues, 10 to 15 percent of falls in the elderly result in fractures and other serious injuries; they are reportedly an underlying cause of about 9500 deaths annually in the United States Several factors, some mentioned above in regard to deterioration of gait, are responsible for the inordinately high rate of falling among older persons Impairment of visual function and particularly of vestibular function with normal aging are important contributors In a group of 34 elderly patients who were free of neurologic disease, postural hypotension, and leg deformities, Weiner and colleagues found a moderate or severe degree of postural re ex impairment in two-thirds The failure to make rapid postural adjustments, which is a product of aging alone, accounts for the occurrence of falls in the course of usual activities such as walking, changing position, or descending stairs Postural hypotension, often due to antihypertensive agents and the use of sedative drugs, is another important cause of falling in the elderly (page 464) Of course, falling is an even more prominent feature of certain age-related neurologic diseases: stroke, Parkinson disease, normalpressure hydrocephalus, and progressive supranuclear palsy, among others Other Restricted Motor Abnormalities in the Aged These are too numerous to be more than catalogued They re ect the many
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Effects of Aging on Stance and Gait and Related Motor Impairments (See also Chap 7)
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These are among the most conspicuous manifestations of the aging process Motor agility actually begins to decline in early adult life, even by the 30th year; it seems related to a gradual decrease in neuromuscular control as well as to changes in joints and other structures The reality of this motor decrement is best appreciated by professional athletes who retire at age 35 or thereabout because their legs give out and cannot be restored to their maximal condition by training They cannot run as well as younger athletes, even though the strength and coordination of their arms is relatively preserved More subtle and imperceptibly evolving changes in stance and gait are ubiquitous features of aging (Chap 7) Gradually the steps shorten, walking becomes slower, and there is a tendency to stoop The old soldier must repeatedly remind himself to maintain an erect bearing The older person becomes less con dent
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