There are a number of changes that occur in the skin of the hands of older adults. The layers of the skin, both dermis and epidermis, become thinner and less elastic. This effect is often most obvious on the dorsum of the hand (Watkins, 2011). The skin becomes more vulnerable to injury, especially with shear forces. When the skin of the hand of an older adult is injured it will tend to heal more slowly (Nazarko, 2005). Other conditions that can result in prolonged healing time of skin lesions include diabetes, hypertension, cardiac disease, a history of smoking and those who have had excessive exposure to the sun (Helfrich et al., 2008).

The effects of aging skin have been linked to changes that occur with collagen synthesis. The collagen in skin breaks down more readily and synthesizes less readily, resulting in thinner, more fragile skin. Long-term use of corticosteroids, especially topical corticosteroid use, can also lead to further collagen breakdown and thinning of the skin. These patients bruise very easily and their skin can become more prone to damage. This effect is often most evident on the skin of the dorsum of the hand and forearms.

Fingernail growth diminishes with aging. Often fingernails will become thicker and rougher with a yellow discoloration. Fingernails will become more brittle and more prone to fungal infections (Carmeli et al., 2003). Certain changes in fingernails may be warning signs of underlying disease. Clubbing of the nails may be a sign of longstanding cardiopulmonary disease. Spoon shaped nails may be a sign of longstanding anemia. Beau’s lines, deep grooved lines running across the nails may be a sign of past trauma, exposure to severe cold or malnutrition. Muehrcke’s lines, white lines under the nail beds, may be a sign of renal disease. Pitting of the nails may be a sign of a connective tissue disorder (Fawcett et al., 2004).

The aging process of bone involves demineralization of the bone (see Chapters 3 and 18). Demineralization occurs in both males and females; however, this is especially true of elderly females. Demineralization in females has been linked to estrogen deficiency associated with menopause. Bone becomes less ductile and more brittle resulting in a higher incidence of fracture. Postmenopausal females, especially those over 65 years of age and those who have experienced previous fractures related to osteoporosis, are at a higher risk for experiencing future fractures (Tremollieres, 2012).

Any of the bones in the wrist and hand complex are at a greater risk to fracture due to trauma. The distal radius has been reported to be one of the most common fractures experienced by older adults (Obert, 2012). One of the most common ways to fall is forward, landing on an outstretched hand with the forearm in pronation and the wrist extended. Initial contact with the ground forces the scaphoid and lunate into the concave distal radius. This can result in the distal radius fracturing and the distal fragment displacing dorsally. This dorsal displacement is known as a Colles’ fracture.

When the individual falls backwards they may impact the ground with the forearm in supination and the wrist in flexion. If the distal radius fractures the distal fragment will displace palmarly. This is known as a Smith’s fracture. Both the Smith’s and Colles’ fractures may result in significant deformity depending on the amount of bone compression and displacement. Either may require surgical intervention and a prolonged period of immobilization. One of the most common complications of the injury is the involvement of the median nerve at or proximal to the carpal tunnel. This can affect median nerve sensation to the lateral four digits and weakness of thumb flexion, opposition and abduction. Diminished or lost sensation to these fingers makes it much more difficult for individuals to perform fine motor control activates and gives them a tendency to drop small objects.

Falling on an outstretched hand can also result in a fracture of the scaphoid, lunate, pisiform or hook of the hamate (Skirven et al., 2011). When the scaphoid fractures, it is often missed on initial radiographs. This can be especially true if the fracture is at the waist of the scaphoid. If this fracture is missed, it can lead to necrosis of the proximal portion resulting in severe wrist pain during upper extremity weight bearing activities, and diminished strength and range of motion. Fractures to the pisiform or hook of the hamate can result in ulnar nerve involvement resulting in diminished strength of pinch and grip.

Articular cartilage is primarily made up of type 2 collagen. This type of collagen is rich in glycosaminoglycans (GAGS). GAGS are hydrophilic and give articular cartilage viscoelastic properties that aid in the ability of articular cartilage to tolerate compressive forces. As articular cartilage ages it tends to lose GAGS and therefore articular cartilage is less resistant to compressive forces (see Chapter 4). The loss of viscoelastic properties leads to articular cartilage breakdown resulting in osteoarthritis.

Osteoarthritis of the wrist and hand is a very common occurrence of the older adult. Stukstette et al. (2011) reported that elderly women (>70 years of age) are twice as likely to have symptomatic arthritic changes effecting the hand than elderly men. The most common joints of the wrist and hand to experience osteoarthritis are the radiocarpal joints, MCP joints, IP joints and the trapezium with the base of the first metacarpal. The DIP joints were the joints most frequently reported to cause pain and reported to be tender with palpation. Osteoarthritis of the DIP joints is often accompanied by the formation of Bouchard’s nodes. Bouchard’s nodes are calcific spurs that form around the periphery of the joints. Heberden’s nodes are the name given to the same nodes that form around the periphery of the PIP joints (Slatkowsky-Christensen, 2010). Osteoarthritis can lead to a significant loss of hand function due to joint stiffness, pain and limited range of motion. Many will also experience diminished strength in the wrist and hand due to disuse atrophy.

Rheumatoid arthritis (RA) in the wrist and hand often affects the older adult. RA is a systemic autoimmune disease that can occur at any age and comes in multiple forms. The effects of RA in the elderly may be long standing or may be a form known as elderly onset rheumatoid arthritis. This form of RA occurs in individuals over the age of 60 and is estimated to comprise between 10% and 30% of all cases of RA (Olivieri et al., 2005). The effects of RA on the hand can range from mild to severe and include pain, swelling, limited range of motion, joint instability and deformity.

Ligaments, tendons and joint capsules are all made up of connective tissue that experiences changes with aging. As connective tissue ages there is an increase in cross links between collagen fibers and degeneration of elastin fibers (Avery & Bailey, 2005). The changes, known as the Maillard reaction, occur with articular cartilage, tendons, ligaments and joint capsules. The result is loss of flexibility, joint stiffness and diminished range of motion and significant loss of wrist and hand function. This process is accelerated in individuals with diabetes mellitus.

A decrease in muscle strength has been well documented in the literature to occur with aging. The decrease in muscle strength has been attributed to a loss of muscle mass that occurs with aging (Newman et al., 2003; Goodpaster et al., 2006). Jansen et al. (2008) report that both grip and pinch strength decreased for both men and women after the age of 65. In the younger age groups men were found to have greater pinch and grip strength than women. But as age increases, men were found to have a greater decrease in strength. By the time both genders were in the oldest age group, above 85 years of age, the strength of grip and pinch of both genders was about equal (Jansen et al., 2008).

Peripheral nerves that innervate the hand undergo significant changes with aging (see Chapter 32). Thakur et al. (2010) reported that both sensory and motor peripheral nerve function diminishes with aging. Sensory receptors are also affected with aging. Shaffer and Harrison (2007) report changes in the function of muscle spindles, Golgi tendon organs, cutaneous receptors and joint proprioceptors. Diminished function of all of these structures can have a significant effect on overall hand function.

Peripheral nerves are also much more likely to become entrapped with aging. The median nerve can become entrapped between the two heads of the pronator teres or at the carpal tunnel. The radial nerve can become entrapped between the two heads of the supinator and the ulna nerve at the elbow or at the tunnel of Guyon (Skirven et al., 2011). These entrapments become more common with aging due to the thickening that commonly occurs in the surrounding connective tissues.

Peripheral neuropathy is a problem of the older adult. Peripheral neuropathy is linked to diminished blood supply of the small blood vessels to myelin sheaths and axons of the most distal nerves of the upper and lower extremities. Peripheral nerve function to the hand can be especially affected for those older adults with diabetes mellitus or alcoholics (Gries et al., 2003). Peripheral neuropathy will affect all the nerves innervating the hand from distal to proximal. The first signs of peripheral neuropathy will be paresthesiae in the fingertips. The paresthesiae will spread proximally over time and can progress to anesthesia, resulting in complete loss of sensation in the area affected. Pain may also be a symptom of peripheral neuropathy to the hand. Often this pain is described as burning in nature. Motor changes with peripheral neuropathy will generally occur from distal to proximal regardless of the nerves involved. The initial result will be weakness of the intrinsic muscles of the hand. In severe cases there could be paralysis of the muscles of the hand resulting in a claw-hand deformity. These individuals will lack the ability to abduct their thumbs adequately to grab cylinder-shaped objects or to extend the IP joints on any of the four medial digits. They will experience weakness in all pinches and grips.

Peripheral neuropathy that affects the autonomic nervous system can affect peripheral blood flow to the hand. This can result in an individual’s inability to adjust to changes in temperature and make it more likely to experience a burn at a lower than normal temperature or frostbite at a higher than normal temperature. Effects on the autonomic nervous system can result in anhydrosis leading to dry, cracked skin, which may result in infection.