Musculoskeletal Disorders in Older Persons

Christopher PattersonMcMaster University,

Hamilton, OntarioCanada

Objectives

• Falling: list causes and prevention strategies in the individual

• Define deconditioning and its relation to rest

• Briefly review osteoporosis

Setting the scene…

• An 82 year old woman falls in the kitchen, injuring her right arm.

• Believing it to be broken, she seeks medical care, and is reassured that there is no fracture.

• Returning home she Is afraid to walk and despite encouragement from her family, she takes to her bed.

• One week later she becomes incontinent and unable to walk…

Falls in older people

• About 1/3 older people fall each year

• Many healthy younger people also fall each year but most falls are inconsequential

• 3 principal reasons for falling

Senescent gait

Illnesses

Environmental hazards

Falls in older people

Senescent gait

• Slower gait speed

• Wider base of support

• Lower step height

• Centre of gravity forward

• Less armswing

Illnesses that cause falls in older people

Loss of consciousness• Syncope or presyncope (OH, arrhythmias,

blocks…)

• Seizures (may be akinetic…)

• Endocrine (hypoglycemia…)

Illnesses that cause falls in older people

Neurological disorders

• Movement disorders ( Parkinson’s disease and –ism, PSP, CBD…)

• Hemiparesis and spasticity

• Peripheral neuropathy (motor, sensory..)

• Ataxia ( central or peripheral…)

• Vestibular disorders

Illnesses that cause falls in older people

Cognitive disorders

• Conditions which affect judgement (dementias, depression..)

• Conditions that affect spatial orientation (strokes, posterior degenerations…)

Illnesses that cause falls in older people

Musculoskeletal disorders

• Painful lower limb conditions

• Restriction of joint movement

• Muscular weakness (sarcopenia, disuse, myopathy…)

Muscle and age

Muscle mass and ageKehayias J et al. Am J Clin Nutr 1997;66:904

Aging and loss of muscle mass/strength (sarcopenia)

• Muscle strength declines by 15% per decade in 6th and 7th decade

• Declines by 30% per decade thereafter

Killewich, L. Journal of American College of Surgeons,2006, 203:5

Illnesses that cause falls in older people

Special senses

• Vision (acuity, depth perception…)

• Hearing

Drugs that cause falls in older people

• Antihypertensives

• Psychotropic agents (antidepressants, BZP, antipsychotics…)

• Anticholinergics

• And many others

Environmental causes of falls

Calculating risk of fallsTinetti M et al N Engl J Med 1988; 319:1701

• Prospective I year study

• 336 community dwelling people over aged 75

• Careful monitoring of falls, detailed examination for risk factors

• Risk of falls 8% with no risk factors

• Risk of falls 78% with 4 or more risk factors

Calculating risk of falls

Risk factor Relative risk of falling

Sedative drugs 28.3

Cognitive impairment 5.0

Disability of lower limb 3.8

Palmar mental reflex 3.0

Abnormal balance or gait 1.9

Foot problem 1.8

Tinetti M et al N Engl J Med 1988; 319:1701

Consequences of falls in older people

Fractures 6%

Soft tissue injuries 24%

Fear of falling >20%

Consequences of falls in older people

Fear of falling

Immobility

Muscle weakness

Bed rest and muscle strength

Muscle strength (MVC) lost at 2-5% per day

Harper & Lyles. JAGS 1998; 36: 1047

Lower limb muscle strength and unloading for 10 days

Acta Physiol Scand 1996; 157:63

DECONDITIONING: a simple definition

The adverse physiological

consequences of

too much rest

DECONDITIONINGConsequences

• Conversion of an individual barely able to rise from a chair to a bedridden state

• Resulting immobility promotes incontinence

• Increases risk of falls

DECONDITIONINGConsequences

Bedrest: effects on cardiovascular system

Reduction in plasma volume Reduced stroke volume and cardiac

output Orthostatic hypotension Results in falls, syncope

Convertino V et al. Am J Med Sci 2007; 334: 72

Killewich L. J Am Coll Surg 2006; 203: 5

Plasma volume and bed restConvertino V et al. Am J Med Sci 2007; 334: 72

DECONDITIONINGthe essence

• Loss of muscle strength

• Altered cardiovascular responses

But there is more, much more…

Bed rest and calcium balance

Bone Mineral Content and restRittweger J et al. J Physiol 2006; 577: 331

DECONDITIONING

• Muscle weakness• Circulatory changes• Many other consequences including

negative calcium balance (effects on bone) catabolic state (effects on nutrition) pressure effects on skin (risk of ulceration) insulin resistance, inflammatory responses etc.

• Changes may occur soon after rest

DECONDITIONING

A complex process of physiological change following a period of inactivity, bedrest or sedentary lifestyle, which results in functional losses.

Brand C et al. 2003 www.mh.org.au/ClinicalEpidemiology

DECONDITIONING:Similar terms

• Functional decline

• Dysfunction syndrome

• Weightlessness effects

What do they have in common?

Similarities…Bedrest Spaceflight

Orthostatic hypotension

Increased

Balance, stability Reduced

Coordination, gait Reduced

Muscle strength Reduced

MV 02 Reduced 20-25%

Similarities…Bedrest Spaceflight

Orthostatic hypotension

Increased Increased

Balance, stability Reduced Reduced

Coordination, gait Reduced Reduced, wide

Muscle strength Reduced Reduced

MV 02 Reduced 20-25% Reduced 12%

So, how do we treat the lady who fell at home?

• Resistance training increases muscle strength and volume by 1% per day (remember that it is lost at 2-5% per day)

• More importantly, resistance training increases spontaneous activity

Effect of 8 weeks resistance exercise on spontaneous activity

Multi factorial intervention to reduce falls

• Same community dwelling cohort

• Intervention by protocols targeting risk factors identified in previous study

• Involving nurse, physiotherapist & physician

Tinetti M et al N Engl J Med 1994; 331:821

Multi factorial intervention to reduce falls

Tinetti M et al N Engl J Med 1994; 331:821

Multi factorial intervention to reduce falls

Osteoporosis and fractures

Osteoporosis definitions

• Osteopenia T-score -1 to -2.5

• Osteoporosis T-score >-2.5

• Severe osteoporosis T-score>-2.5 plus fragility fracture

Prevalence of Osteopenia and Osteoporosis (Jammu)

Women’s clinic & welfare

Sharma S et al. Ind J Med Sci 2006; 60(5):183

Osteoporosis: Risk factors

• Gender (1 in 4 women, 1 in 8 men over age 50)• Age• Underweight • Early menopause• Caucasian or Asian• Diet (low calcium,? high animal protein, coffee...)• Inactivity• Smoking• Medications (anticonvulsants, corticosteroids..)

Vitamin D levels in Andhra Pradesh

• Convenience sample • 943 healthy urban adults• 205 healthy rural adults

Vitamin D levels: • Deficient < 20 ng/ml (50 nmol/L)• Insufficient 20-30 ng/ml (50-75 nmol/L)• Sufficient >30 ng/ml (>75 nmol/L)

Harinaryan C et al. Indian J Med Res 2008; 127:211

N-terminal PTH and Vitamin D levels

Harinaryan C et al. Indian J Med Res 2008; 127:211

Vitamin D levels: Andhra Pradesh

Harinaryan C et al. Indian J Med Res 2008; 127:211

Bone mineral density and fracture risk

Treatment of osteoporosis

• Adequate calcium in diet (total 1500 mg elemental calcium per day)

• Vitamin D 800-1000 units daily• Bisphosphonates (moving towards more

potent drugs in NA alendronate, risedronate, zoledronic aci

• Raloxifene (HRT)• Triperidide (PTH)• Calcitonin

Indications for bisphosphonates

• BMD scores t-score less than -2 or -2.5

• Over age 75 with fragility fracture

• Chronic corticosteroid use >3 months

Risedronate

•Harris ST, Watts NB, Genant HK, et al. JAMA 1999.

Raloxifene

Ettinger B et al JAMA 1999

Calcitonin

Chesnut CH et al Am J Med 2000

Progress in osteoporosis

• Rate of hip fractures is stabilizing

• Public awareness is increasing

• Programs being established (e.g. FTOP Fracture: think osteoporosis!)

• Hope to see as a historical disease in a generation (or two)

SUMMARY

• Falls are common and serious: structured approach to investigation and management

• Deconditioning is common and serious: aggressive mobilization is essential

• Osteoporosis is a looming threat: most important point: Vitamin D supplements for all older people 800-1000 units daily at least

How did we do?