geron musc.skeletal

8/7/2019 GERON Musc.Skeletal

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MANILA DOCTORS COLLEGECOLLEGE OF NURSING

GERONTOLOGYMUSCULOSKELETAL DISORDERS

Dr. Michael J. Catarroja

Lecturer

Gerontological Nursing 1


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Gerontological Nursing

Normal Changes of Aging

Significant alterations causing musculoskeletal

changes in older adults

Human structure Function

Biochemical

Genetic patterns

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Skeleton: Normal Changes of Aging

Two phases of bone loss in normal aging

Type I (menopausal bone loss)

Rapid

Affectswomen

Occurs first 5 to 10 years after menopause

Type II (senescent bone loss)

Slower phase

Affects both sexes after midlife

Phases eventually overlap in women Other conditions may alter signs of normal aging of

skeleton

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Bones become

Stiff

Weaker Brittle

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Changes in appearance are evident after the

fifth decade.

Height most obvious 20 to 70 years of age

Lose 1 to 2 cm in height every 2 decades

Shortening of the vertebral column

Midlife

Vertebral discs thin

Later years

Decrease individual vertebrae height

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Disproportionate size of long bones of the arm

and legs

Eighth and ninth decades More rapid decrease in vertebral height

Osteoporotic collapse of the vertebrae

Shortening of the trunk with appearance of long

extremities


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Additional postural changes

Kyphosis

Backward tilt of the head for eye contact Forward bent posture

Hips and knees in flex position

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Muscles: Normal Changes of Aging

Muscle function varies with aging

Trainable into advanced age

Muscle regeneration is normal as age progresses

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Muscle

Mass

Sarcopenia by age 75

Strength Slow decline

Stamina decreased by age 50

Decreased 65 to 85% of midtwenties by age 80

Tone and tension Decreases after age 30

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Muscle

Size

Decreases causing weakness

Type II muscle fibers

Faster contraction but more atrophy

Type I

Slower contraction and less atrophy

Help maintain posture

Help perform repetitive exercise s

Shape Distinct

More prominent


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Routine daily activities keep the upper

extremities functioning better than walking.


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Cartilage

Hyaline cartilage (joint lining)

Normally lines joints

Erodes and tears with advancing age

Causes bone to bone contact

Knee cartilage

Experiences normal wear and tear

Thins about 0.25 mm/year

Discomfort and slow joint movement

Diminished joint lubricant

Nonarticular cartilage (ears and nose)

Grows throughout life

Joints, Ligaments, Tendons, and Cartilage:

Normal Changes with Aging

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Ligaments, tendons, and joint capsules

Lose elasticity

Less flexible Joint ROM decreases

Joints, Ligaments, Tendons, and Cartilage:Joints, Ligaments, Tendons, and Cartilage:

Normal Changes with AgingNormal Changes with Aging

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Osteoporosis

Most common metabolic disease

Characterized by low bone mass and deterioration

of bone tissue.

Bone strength is compromised increasing risk for

fractures.

Affects 50% ofwomen during their lifetimes

20 million women and 8 million men diagnosed in

the United States

3.8 million women receive adequate care

Metabolic Bone Diseases

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Osteoporosis

High risk factors for osteoporosis

Increased age

Female sex White or Asian race

Positive family history

Thin body habitus

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Osteoporosis

Additional risk factors for osteoporosis

Low calcium intake

Prolonged immobility Excessive alcohol intake

Cigarette smoking

Long-term use of corticosteroids, anticonvulsants,

or thyroid hormones

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Reduced BMD Highly predictive of spinal and hip fractures

Osteoporotic fractures affect 1.3 million per yearin the United States

Vertebrae fractures affect about 500,000 peopleper year

Hip and wrist fractures affect about 260,000 peryear

One in five patients die within 1 year

One third regain their prefracture mobility andindependence level

Pathophysiology of Osteoporosis

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Classification of Osteoporosis

Primary osteoporosis

Type I (menopausal bone loss)

Type II (senescent bone loss)

Secondary osteoporosis Hyperparathyroidism

Malignancy

Immobilization

Gastrointestinal disease

Renal disease

Drugs causing bone loss such as vitamin D deficiencies andglucocorticoids

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Menopausal Bone Loss

(Type 1)

Before menopause, sex hormones protect from bone

loss.

After menopause

Overproduction of IL-6

Up to tenfold loss of bone mass

Resorption (loss of bone matrix) more than deposition (rapid bone

growth)

Susceptible women close to age 70 can lose 50% ofperipheral cortical bone mass

Cause of vertebral and Colles' fractures

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Senescent Bone Loss

(Type 2)

Decreased amount of bone during remodeling

Occurs in both sexes

Caused by aging

Decreased trabecular (cancellous) bone wallthickness

Decreased osteoblast formation

Decreased bone mineral density

Decreased rate of bone formation Cause of vertebral and hip fractures

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Trajectory of Bone Loss for Women

Lower peak bone mass than men

Less in the "bone bank because of thinner bones

Lose bone mass with lactation

Rapid withdrawal from "bone bank" duringperimenopause

Longer life span increases risk for osteoporosis

Signs/symptoms usually absent

First sign is often a fracture

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Pharmacology and Nursing

Responsibilities for Osteoporosis

Antiresorptive therapy

Preserves or increases bone density

Decreases rate of bone resorption

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Classifications and special considerations

Bisphosphonates (alendronate [Fosamax] and

risendronate [Actonel])

Inhibit osteoclastic activity

Decrease postmenopausal vertebral and nonvertebral fractures by

40 to 50%

Adverse gastrointestinal symptoms

Esophageal irritation, heartburn

Difficulty swallowing

Do not take calcium with bisphosphonates interferes with

absorption

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Selective estrogen receptor modulators (SERMs) Provide benefits of estrogens without the disadvantages

Raloxifene approved for postmenopausal prevention andtreatment of osteoporosis in women

SERMS less effective than bisphosphonates

Calcitonin Safe but less effective treatment for osteoporosis

Decreases spinal fractures by up to 35%

Hormone replacement therapy (HRT)

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OSTEOARTHRITIS



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Primary or Idiopathic Osteoarthritis

No single, clear cause

Group of similar disorders

Involve complex biomedical, biochemical, andcellular processes

Changes in several joints as a result of various

causes

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Secondary Arthritis

Secondary arthritis involves

An underlying condition

Trauma

Bone disease

Inflammatory joint disease

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Pathophysiology

Progressive erosion of joint articular cartilage

Formation of new bone in joint space

Involved joints

Hands Weight bearing joints of the knees and hips

Central joints of the cervical and lumbar spine

How does this happen?

Cartilage thins underlying bone (subchrondal bone) is no

longer protected

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Cartilage not available to buffer

Subchrondral bone becomes irritated

degeneration of the joint bone hypertrophy

bony spurs (osteophytes) growth and

enlargement contours of the joint

Small pieces may break off (joint mice) irritate

the synovial membrane

joint effusion

limitedmovement

Pathophysiology

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Clinical Manifestations

90% of all people have x-ray evidence of primaryosteoarthritis in their weight-bearing joints by age 40.

OA symptoms 40% of people with severe OA have pain

Most common symptoms Earlymorning stiffness resolving in 30 minutes

Joint pain Occurs during activity

Relieved by rest

With progressive disease

Pain may be present at rest Interrupt ion of sleep patterns

Source of pain may be unknown, but it needs to be identifiedin order to provide treatment

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Joint involvement

Asymmetrical at first

Bony appearance of joints

Crepitus (a grating sound on movement)

Range of motion deficit

Muscle weakness


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Hands

New bone growth

Heberdens nodes (DIPdistal interphalangeal joint)

Bouchards nodes (PIPproximal interphalangeal joint) Pain with active and passive motion

Joint damage + chronic pain + muscleweakness impaired balance + decreased

activity


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Responsibilities for Osteoarthritis

No therapywill slow or halt progression

Current therapy directed at relief of pain andminimizing functional disability

Agents for pain relief for OA NSAIDs

Topical agents Capsaicin nonprescription drug

Prevent the reaccumulation of substance P (a

neurotransmitter) in peripheral sensory neurons Applied 2 to 4 times daily to affected area

May cause heat or burning

Relief may require up to 4 to 6 weeks of applications

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Systemic oral agents

Acetaminophen (Tylenol)

First line pharmacological therapy

Give up to 4 gm/daywith minimal toxicity

Higher doses may cause liver damage

Ceiling effect = increasing the dose does not increase

the analgesic benefit Use alone or as an adjunct to

NSAIDs



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Nonsteroidal anti-inflammatory drugs

(NSAIDs)

Most common treatment for pain and

inflammation of OA

COX-2 inhibitors, a new category of anti-

inflammatory drugs

Considered safe for the GI tract Side effects include renal impairment (see RA section)



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Adjuvant agents

Intra-articular agents

Corticosteroids valuable for synovial inflammation

Synovial effusion removed prior to injections

Limited to 4/year in any one joint

Hyaluronic acid

Normal component of the joint for lubrication and nutrition

Decreased pain for longer periods than other intra-articulartherapies

Administered in series of 3 to 5 injections



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Selected Diagnostic Tests and Values for

Musculoskeletal Problems

Bone mineral density test (BMD)

Dual energy x-ray absorptiometry (DEXA)

Proximal femur predicts hip fracture risk best

Gold standard for fracture prediction Other sites tested include spine, wrist, or total body

Results

Compared with young adult mean

Or compared norm group of same age

BMD 1 SD belowmean (-1 S) = osteopenia

BMD 2.5 SD below mean (-2.5 SD) = severe osteoporosis

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Bone mineral density test (BMD)

Pitfalls

Bone changes also the result of arthritis or disk disease

in lumbar spine

ArbitrarySD cutoffs to determine diagnosis

Results varywith technique and patient position

Current criteria based on postmenopausal white

women

Selected Diagnostic Tests and Values for

Musculoskeletal Problems

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Bone and Joint Radiography

X-ray use

Diagnose and stage rheumatic diseases

Diagnose fractures

Detect musculoskeletal structure, integrity,

texture, or density problems

Evaluate disease progression and treatment

efficacy

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Computed tomography (CT)/magnetic

resonance imaging (MRI)

Visualize

Inflammation

Musculoskeletal changes

Synovitis

Edema Bone bruises

Occult fractures and articular damage


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Computed tomography (CT)/magnetic resonanceimaging (MRI) Advantages

Uses a large magnet and radio waves to produce energy field

Detailed image Does not use radiation or a contrast medium

Disadvantages More expensive

Requires special facilities

Cannot show calcification or bone mineralization Client hears soft to thunderous noises and may use earplugs


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Bone Scan

Detects skeletal trauma and disease

Determines degree bone matrix takes up

radioactive isotope

Determines reason for an elevated ALP

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Blood Serum Tests

Electrolytes: calcium level

Bone and muscle enzymes: alkalinephosphatase (ALP)

Joint tests

Rheumatoid factor (RF)

Acute phase reactants

C-reactive protein (CRP) Erythrocyte sedimentation rate (ESR)

Serum uric acid (SUA)

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Special considerations

Electrolytes: serum calcium and phosphorus

decreased in the older person

Calcium

Increased in Pagets disease, with bone fractures, and

with immobility

Decreased in osteoporosis and osteomalacia

Serum calcium (normal range older adult 8.8 to 10.2

mg/dl)

Blood Serum Tests

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Special considerations

Phosphorus

Phosphorus (normal range for older person > 60 = 2.3

to 3.7 mg/dl)

Increased in bone fractures and healing state

Decreased in osteomalacia

Serum Uric Acid (SUA)

Diagnosis of gout is not established unless SUA is found

in tissue or synovial fluid

Blood Serum Tests

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Acute phase reactants C-reactive protein (CRP) anderythrocyte sedimentation rate (ESR) Erythrocyte sedimentation rate

Most common measurement of acute phase proteins in rheumatic

disease Direct relationship to acute phase proteins

Results in 1 hour

C-reactive protein Acute phase reactant determines presence of inflammatory

process Bacterial infection or rheumatic disease

Increases and returns to normal quicker than ESR

Blood Serum Tests

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Alkaline phosphatase (ALP)

Enzyme associated with bone activity

Normal values: men = 45 to115 U/L, women = 30 to 100

U/L Values increase after age 50

Identify increases in osteoblastic activity and inflammatory

conditions

Elevated with Pagets disease (> 5x normal)

Isoenzymes ALP1 (liver origin) and ALP2 (bone origin)

determine if elevation is bone disease

Blood Serum Tests

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Lifestyle Changes

Increase in exercise

Weight loss

Eating healthy diets Healthy People 2010

(www.health.gov/healthypeople)

Nations goals and objectives for improved health

Includes an objective for arthritis patient

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Additional Nonpharmacological

Strategies

Additional nonpharmacological strategies to enhance

comfort with OA

Apply heat to painful joints

Use cold applications to reduce pain and swelling Use canes, crutches, and walkers to protect joints

Use assistive technology

Maintain, increase, or improve function

Commercial purchase or custom made

Available for general daily living, home management, school, and

work activities

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