Universal Challenges

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January/February 2004

By Susan M. Nochajski, PhD, OTR/L

The phrase “graying of America” is often used to describe recent demographic trends in the United States and includes persons with developmental disabilities. Currently, there are an estimated 526,000 people with developmental disabilities over the age of 60 in the United States, and by the year 2030, it is anticipated that this number will double.¹

Concurrent with a growth in the number of persons with developmental disabilities over the age of 60, the life expectancy of these individuals is also increasing.² The need for rehabilitation services by this group of individuals will be increasing over the next several years. Therefore, rehabilitation professionals need to have knowledge of the physical changes associated with aging, how to assess these changes and their impact on functional activities, develop appropriate interventions, and share this information with the person who has a developmental disability and his or her care providers. This article will provide a summary of age-related physical changes and how these changes impact a person’s function, an overview of aging with a developmental disability, and a discussion of the implications of aging with a developmental disability for rehabilitation professionals, with a focus on assistive technology and environmental modifications.

Changes Associated with Aging
Aging produces changes that affect all body organs and systems. However, age-related changes in the nervous, sensory, and musculoskeletal systems may be viewed from a therapy perspective as having the most significant impact on an individual’s functional abilities. An overview of some of the physiological changes that occur with aging in these systems and their impact on a person’s functional capabilities will be briefly discussed here.

Nervous System: As a person ages, changes occur within the central nervous system, including a gradual loss of neurons and a decreased number of cells. Within the brain, there are decreases in blood flow, synaptic interconnections, and neurotransmitter activity; increased synaptic delay; and decreases in neurotransmitter activity. As a result of these changes in the central nervous system, along with changes in the peripheral nervous system, older persons may experience problems with their ability to receive, process, and respond to various stimuli. Decreased activity in the nervous system leads to problems for older adults in many areas of functioning that are important for their safety, well-being, and quality of life. For example, age-related changes in the nervous system that result in a decline in the speed of information processing may de-crease the individual’s ability to adapt to and use new information for reasoning or problem solving. However, it is important to remember that major memory loss and decline in intelligence are not typical age-related nervous system changes.³

Sensory System: Visual changes are a phenomenon associated with aging. With increasing age, structural changes in the eye affect vision and impact on the individual’s functional abilities. Presbyopia is one of the earliest conditions resulting from structural changes in the eye. As the lens ages, old cells are not shed, but “build up” leading to a yellowing of the lens. This yellowing of the lens decreases clarity, increases glare, and makes it more difficult for an individual to distinguish between blue-green and yellow-white colors.4 A decrease in pupil size results in an increased sensitivity to glare and difficulty with adaptation to the dark. Other structural changes within the eye result in altered depth perception, a narrowing of the visual field, changes in color vision, and a slower processing of visual information.³ Disease processes, such as the development of cataracts and glaucoma, also have an effect on an individual’s visual abilities. However, these are not “normal” age-related changes.4 Visual changes may affect a person’s ability to drive a vehicle, go up and down stairs, or read for information or pleasure.³

Hearing impairments also increase with age. Between 25% and 40% of persons over the age of 65 experience a significant hearing loss. Degenerative changes in the auditory system result in a condition known as presbycusis, a sensorineural hearing loss that interferes with the person’s ability to hear high-pitched sounds. When high-pitched sounds are filtered out, words become distorted and sentences incoherent, making conversations difficult.4 Acute or chronic ear diseases and excess wax buildup can also lead to hearing difficulties. The problems experienced by older adults due to hearing loss are often incorrectly associated with senility. Additionally, hearing deficits may lead to social isolation.³

Musculoskeletal System: Osteoarthritis, a chronic condition that is one of the most universally acknowledged indicators of aging, occurs in virtually all older individuals. General symptoms of osteoarthritis include stiffness, pain and discomfort, and limited range of motion. More severe forms of arthritis may be characterized by contractures, joint deformity, posture changes, and fine and gross motor impairments.4

Osteoporosis, the increased porosity or “softening” of the bone structure, is another chronic condition that occurs in older adults. It is generally characterized by low bone mass density and deterioration of bone tissue that make a person susceptible to fractures.4,5
As a person ages, muscular changes occur including a decreased number of motor neurons, a loss of muscle mass, and a deterioration of and decrease in the number of muscle fibers.4 These changes result in a gradual diminishing of muscle strength and endurance, a slower speed of muscle contraction, and problems with both fine and gross motor coordination.^4,6 One of the most significant consequences of age-related changes in the musculoskeletal system is the impact of the combination of skeletal, muscular, and neurological changes on gait and balance. When an individual is inactive and remains in one position, particularly sitting, for extended periods of time, there is a tendency for the flexor muscles in the body to shorten, resulting in a “stooped” posture.⁷ This posture changes the center of gravity and impedes a person’s ability to maintain balance.4 Poor balance often leads to falls that have very serious consequences for persons with osteoporosis.

Aging with a Developmental Disability
Persons with developmental disabilities experience the same age-related changes and medical problems that occur in individuals without disabilities.⁸ The majority of the physical age-related changes described here typically occur similarly in the general population and among persons with developmental disabilities. However, the aging process may start earlier in persons with developmental disabilities, perhaps as early as age 35. It has been found that sensory changes, especially those related to vision and hearing, occur earlier in persons with developmental disabilities and have a greater impact on function than in the general population.

However, for adults aging with developmental disabilities, vision and hearing changes may be unidentified due to an individual’s inability to communicate the problem and may often be assumed to be cognitive, learning, mobility, or behavioral problems.⁹

Similarly, although it is typically not found in individuals younger than 40, osteoarthritis reportedly occurs at younger ages in persons with developmental disabilities.⁷ Likewise, persons with cerebral palsy or Down syndrome were found to be more likely to develop osteoporosis at an earlier age than persons in the general population.5

It has been suggested that age-related changes are likely to occur, not only at an earlier age, but also at a faster rate among persons with developmental disabilities, particularly those with Down syndrome, than in the general population.¹⁰ Therefore, chronological age may not be an appropriate measure to consider when looking at aging issues that affect persons with developmental disabilities. Age-related changes must be taken into consideration long before we consider a person with a developmental disability to be “old.”

It is important to remember that individuals with developmental disabilities experience age-related changes that may have an impact on their functional abilities and interpersonal interactions. It cannot be assumed that functional changes occur merely as a result of chronic conditions associated with the developmental disability.

Implications for Rehab Professionals
Recently, aging in persons with developmental disabilities has become an important issue for service providers.¹¹ Although the life expectancy for persons with developmental disabilities is increasing, longevity without quality of life is problematic. Assistive technology (AT) and environmental interventions (EI) can have a positive impact on impairment, functional activity, community living, and quality of life of people aging with developmental disabilities.

Table 1. Examples of assistive technology useful for older adults with developmental disabilities.

Rehabilitation professionals need to provide AT-EI assessment, intervention, and training within the everyday context and environments of older persons with developmental disabilities. AT-EI interventions should focus on activities that are meaningful to the individual and frequently involve not only the individual, but his or her care providers as well.⁹ Table 1 lists a variety of AT-EI devices and interventions that may be useful for older persons with developmental disabilities. For AT-EI interventions to be successful, training for both older adults and care providers is imperative. Hammel9 offers several suggestions for rehabilitation professionals to facilitate the process:

select AT-EI with the most intuitive, user-friendly interface that can be adjusted for complexity;
arrange frequent, short training sessions, with opportunities for follow-up practice, to build AT-EI problem-solving skills over time;
provide the individual and care provider with setup and troubleshooting strategies and the opportunity for them to demonstrate the strategies in order to ensure competence;
provide checklists, in verbal, print, or picture formats, on the AT-EI setup, maintenance procedures, and troubleshooting;
connect AT-EI users and care providers to information and support resources, such as other local users, vendors, information and advocacy programs, and product and information Web sites.

Rehabilitation professionals, who have the use of AT-EI, can provide older adults with developmental disabilities with the strategies needed for an enhanced quality of life.

References

Heller T, Factor A. Research Advances and Research Directions on Aging with Mental Retardation. Chicago: Rehabilitation Research and Training Center on Aging with Mental Retardation, Univeristy of Illinois at Chicago; 1998.
Herr SS, Weber G. Aging and developmental disabilities. In: Herr SS, Weber G, eds. Aging, Rights, and Quality of Life. Baltimore: Paul H. Brookes; 1999:1-16.
Nochajski SM. Impact of aging on persons with developmental disabilities. Physical and Occupational Therapy in Geriatrics. 2000;18(1):5-21.
Miller CA. Biophysical development during late adulthood. In: Schuster CS, Ashburn SS, eds. The Process of Human Development: A Holistic Life-span Approach. Philadelphia: JP Lippincott Company; 1992:804-830.
Center J, Beange H, McElduff A. People with mental retardation have an increased prevalence of osteoporosis: a population study. Am J Ment Retard. 1998;103(1):19-28.
Machemer RH, Overeynder JC, eds. Aging and Developmental Disabilities: An In-service Curriculum. Rochester, NY: University of Rochester; 1993.
Connolly BH. General effects of aging on persons with developmental disabilities. Topics in Geriatric Rehabilitation. 1998;13(3):1-18.
Hotaling G. Rehabilitation of adults with developmental disabilities: an occupational therapy perspective. Topics in Geriatric Rehabilitation. 1998;13(3):73-83.
Hammel J. Assistive technology and environmental intervention (AT-EI) impact on the activity and life roles of aging adults with developmental disabilities: findings and implications for practice. Physical and Occupational Therapy in Geriatrics. 2000;18(1):37-58.
Lubin RA, Kiley M. Epidemiology of aging in developmental disabilities. In: Janicki MP, Wisniewski HM, eds. Aging and Developmental Disabilities: Issues and Approaches. Baltimore: Paul H. Brookes; 1985:95-113.
Hogg J. Intellectual disability and aging: ecological perspectives from recent research. J Intellect Disabil Res. 1997;41(2):136-143.

Susan M. Nochajski, PhD, OTR/L, is director of professional and graduate studies for the Occupational Therapy Program of the Department of Rehabilitation Science at the University at Buffalo in Buffalo, NY.

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January/February 2004