AGE RELATED PHYSIOLOGICAL CHANGES IN INTERGUMENTARY SYSTEM.

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INTRODUCTION 

The integumentary system is made up of  the skin and its appendages, (the hair and nails). Skin related disorders account for up to 10% of all ambulatory patients including the elderly.

Even psychological stress of illness or various personal and family problems can commonly exhibit outwardly as dermatological problems.

OVERVIEW OF THE INTEGUMENTARY SYSTEM

The largest organ system of the body. The skin is essential for human life. It forms anf barrier between the internal organ and the external environmental and participate in many vital body functions. This system is made up of the skin (which forms the largest put of the system, hair, nails and even the mucous membrane).

Skin

The skin has 3 main layers:

Epidermis: The outermost layer of stratified epithelial cells composed predominantly of Keratinocytes and other cells like Melanocytes Merkel cells, Langerhan cells etc. its thickness ranges from about 0.1mm on eyelid to about 1mm on the palms and sole. There are four distinct layers in the epidermis (stratum germinativum, stratum granulosa, stratum lucidum and stratum corneum).

Dermis: Makes up the largest portion of the skin, providing strength and structure. It is composed of two layers: Papillary and Reticular. It is the layer rich in blood vessels and nutrients.

Subcutaneous layer: Or hypodermis, is the innermost layer of the skin. It is primarily adipose tissue which provides a cushion between the skin layers and the muscles and bones, it insulates the body.

Hair

This is an outgrowth of the skin. It is present over the entire body expect for the palm, sole and mucous membrane. A strand of hair has a root formed in the dermis and a shaft that projects beyond the skin.

Nails

On the dorsal surface of the finger and toes, is a hard, transparent plate of keratin called nail and it overlies the skin. The nail protects the finger and toes and aids in packing up the small objects.

Glands of the skins

There are two main types of gland which are 

Sebaceous gland (which are associated with hair follicle, which  secretes sebum 

Sweat gland (which secretes sweat and there are two types of sweat glands)

Functions of the skins 

Protection

Temperature regulation

Sensation 

Fluid balance 

Vitamin protection 

Immune response function

AGE RELATED CHANGES AFFECTING THE INTEGUMENTARY SYSTEM 

The skin undergoes many physiological changes associated with normal aging. A lifestyle of excessive sun exposure, systemic disease and poor nutrition can increase the range of skin conditions and the rapidity with which they appear, also certain medications is implicated. (Brunner and Suddarth, 2017 )

The major change in the skin of the elderly include wrinkling, dryness, uneven pigmentation and various proliferative lesions. Cell growth, differentiation and division decrease with age, and cells found in the skin are also affected. The cellular changes associated with aging results in thinning at the junction of the dermis and epidermis leading to thinning of the few anchoring sites between them; this make these layers prone to shearing away from each other at the least stress or minor injury; making the skin vulnerable to trauma. With increasing age, the epidermis and dermis thin and flatten causing wrinkles, sags and overlapping skin folds. (Brunner and Suddarth, 2017 ).

Loss of subcutaneous tissues, its substance of elastin, collagen and fat, diminishes the cushioning of underlying tissues and organs, also results in the loss of insulating properties of the fat.

With aging, the skin becomes transparent (due to reduced number of melanocytes), the blood supply also changes with age. Vascular changes contribute to the delayed wound healing commonly seen in the elderly. Sweat and sebaceous glands decrease in number and functional capacity leading to dry and scaly skin. 

Hair growth gradually diminishes especially over the lower legs and dorsum of the feet. Thinning is most common in the scalp, axilla and pubic areas. There is graying of the hair due to reduced deposition of melanin, there may be pronounced alopecia, which results from diminished cellular functions.

Also there is barrier function of the skin, sensory perception and thermoregulation photoaging has detrimental effects on the normal aging of skin.

However many skin lessons are part of normal aging these are normal and required no special attention unless the skin becomes infected or irritated.

DISORDERS OF THE INTEGUMENTARY SYSTEM AFFECTING THE ELDERLY 

With aging, the outer skin layer (epidermis) thins, even though the number of cell layers remains unchanged.

The number of pigment-containing cells (melanocytes) decreases. The remaining melanocytes increase in size. Aging skin looks thinner, paler, and clear (translucent). Large pigmented spots, including age spots, liver spots, or lentigos, may appear in sun-exposed areas.

Changes in the connective tissue reduce the skin's strength and elasticity. This is known as elastosis. It is more noticeable in sun-exposed areas (solar elastosis). Elastosis produces the leathery, weather-beaten appearance common to farmers, sailors, and others who spend a large amount of exposure to sun

The blood vessels of the dermis become more fragile. This leads to bruising, bleeding under the skin (often called senile purpura), cherry angiomas, and similar conditions.

Sebaceous glands produce less oil as you age. Men experience a minimal decrease, most often after the age of 80. Women gradually produce less oil beginning after menopause. This can make it harder to keep the skin moist, resulting in dryness and itchiness.

The subcutaneous fat layer thins so it has less insulation and padding. This increases your risk of skin injury and reduces your ability to maintain body temperature. Because you have less natural insulation, you can get hypothermia in cold weather. Some medicines are absorbed by the fat layer. Losing this layer changes the way that these medicines work.

The sweat glands produce less sweat. This makes it harder to keep cool. Your risk for overheating or developing heat stroke increases.

Growths such as skin tags, warts, rough patches (keratoses), and other blemishes are more common in older people.

Effect of the changes on the integumentary system of the elderly

As one ages, one is at increased risk for skin injury. Your skin is thinner, more fragile, and you lose the protective fat layer. You also may be less able to sense touch, pressure, vibration, heat, and cold.

Rubbing or pulling on the skin can cause skin tears. Fragile blood vessels can break easily. Bruises, flat collections of blood (purpura), and raised collections of blood (hematomas) may form after even a minor injury.

Pressure ulcers can be caused by skin changes, loss of the fat layer, reduced activity, poor nutrition, and illnesses. Sores are most easily seen on the outside surface of the forearms, but they can occur anywhere on the body.

Aging skin repairs itself more slowly than younger skin. Wound healing may be up to 4 times slower. This contributes to pressure ulcers and infections. Diabetes, blood vessel changes, lowered immunity, and other factors also affect healing.

COMMON PROBLEMS, TREATMENTS AND PREVENTION 

Skin disorders are so common among older people that it is often hard to tell normal changes from those related to a disorder. More than 90% of all older people have some type of skin disorder.

Causes

Skin disorders can be caused by many conditions, including:

• Blood vessel diseases, such as arteriosclerosis

• Diabetes

• Heart disease

• Liver disease

• Nutritional deficiencies

• Obesity

• Reactions to medicines

• Stress

Other causes of skin changes:

• Allergies to plants and other substances

• Climate

• Clothing

• Exposures to industrial and household chemicals

• Indoor heating

Sunlight can cause:

• Loss of elasticity (elastosis)

• Noncancerous skin growths (keratoacanthomas)

• Pigment changes such as liver spots

• Thickening of the skin

Types of common skin problems 

Skin changes that accompany aging include:

   *Roughened or dry skin

   *Benign growths such as seborrheic keratoses and cherry angiomas

   *Loose facial skin, especially around the eyes, cheeks, and jowls (jawline)

   *Transparent or thinned skin

   *Bruising easily from less elasticity

~Wrinkles: are the most visible sign of aging skin. They follow chronic sun exposure and form when the skin loses its flexibility. Smokers tend to have more wrinkles than nonsmokers.

~Facial movement lines: often known as "laugh lines" and "worry lines," become more visible as the skin loses its elasticity (in your 40's or 50's). The lines may be horizontal on the forehead, vertical above the nose, or curved on the temples, upper cheeks, and around the mouth and eyes.

~Dry and itching skin: is a common problem among adults, especially with age. The loss of oil glands (which help to keep the skin soft) is the main cause of dry skin. Rarely, dry, itchy skin may be a sign of diabetes, kidney disease, or liver disease.

~Skin cancer: Sun exposure (UV radiation) is the most common cause of pre-cancers and skin cancer, either basal cell carcinoma or squamous cell carcinoma. Many Americans (a million each year) will develop a skin cancer by age 65. 

(National Institutes for Health (NIH), 2019)

Sun exposure has also been directly linked to skin cancers, including basal cell cancer, squamous cell carcinoma, and melanoma. (Jaliman, 2018)

~Age spots: "Age spots" are brown patches that appear on sun-exposed parts of the body (face, hands, and forearms), usually during the adult years.

~Bedsores: Bedsores (also known as pressure ulcers) are skin ulcers that develop from pressure when people lie in bed or sit in a chair for long periods of time. Bedsores are a fairly common problem in people who have trouble moving on their own. People with diabetes are more prone to bedsores because of their poor circulation and decreased feeling in their skin. Frequent rotation or re-positioning helps to prevent bedsores.(Jaliman, 2018)

TREATMENTS

 *Wrinkles: Wrinkles can't be "cured," but their appearance can be "softened" through the use of tretinoin (Renova), especially in wrinkles caused by sun damage.

 *Dry skin: The best treatment for dry skin is to lubricate, via the regular use of over-the-counter lotions. Moisturizers help to hydrate (trap moisture) the skin. Humidifiers also help to hydrate the skin. Frequent bathing can aggravate dry skin.

*Bed Sore: Regular turning of the elderly; massage and proper care of the pressure areas should be done. Very wet or very moist skin should be avoided.

*Skin cancer: A "changing mole" or new skin growth deserves evaluation by a dermatologist, perhaps with a biopsy if skin cancer is a concern.  (Jaliman, 2018)

PREVENTIONS

Because most skin changes are related to sun exposure, prevention is a lifelong process. Although nothing can really undo sun damage, but the skin can occasionally repair itself. Use these tips to help keep your skin healthy at any age.

Prevent sunburn if at all possible.

Use a good quality sunscreen when outdoors, even in the winter.

Wear protective clothing and a hat when needed.

Use sunscreen creams or ointment or hat when outdoors. Sunscreen with an SPF of 30 or more provides the most protection.

Wear a hat, long sleeves and pants when outdoors and sunglasses that block UV rays.

 Avoid the use of tanning booths and sunlamps.

                           (Jaliman, 2018)

For other skin problems, do the following:

Check yourself regularly for "changing moles" and new growths.

Good nutrition and adequate fluids are also helpful. Dehydration increases the risk of skin injury. Sometimes minor nutritional deficiencies can cause rashes, skin lesions, and other skin changes, even if you have no other symptoms.

Keep skin moist with lotions and other moisturizers.

Do not use soaps that are heavily perfumed. Bath oils are not recommended because they can cause you to slip and fall. Moist skin is more comfortable and will heal more quickly. (NIH, 2019)

REFERENCES

Brunner, L.S Suddarth, D.S & Smeltizer, S.C.O(2017). Brunner & Suddarth’s Textbook of Medical- Surgical Nursing  (14th ed.) Philadelphia: Lippincott Williams & Wilkins

Jaliman, Debra 2018, skin problems and treatments. Accessed on 30th March, 2019; Retrieved from http://www.webmd.com/skin-problems-and-treatments/elderly-skin-conditions.

National Institutes of Health, 2019. Aging changes in skin. Accessed on 29th March, 2019. Retrieved from http://www.medlineplus.gov/ency/article/004014.htm