GERON Musc - Skeletal

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Gerontological Nursing 1
Normal Changes of Aging
ignificant alterations causing musculoskeletal
changes in older adults
± Human structure
± Function
± Biochemical
± Genetic patterns
keleton: Normal Changes of Aging
÷ o phases of bone loss in normal aging
± ÷pe I (menopausal bone loss)
Rapid
Affects omen
Occurs first 5 to 10 ears after menopause
± ÷pe II (senescent bone loss)
lo er phase
Affects both sexes after midlife
Phases eventuall overlap in omen
Other conditions ma alter signs of normal aging of
skeleton
Bones become
± tiff
± Weaker
± Brittle
Changes in appearance are evident after the
fifth decade.
± Height most obvious
20 to 70 ears of age
± Lose 1 to 2 cm in height ever 2 decades
± hortening of the vertebral column
Midlife
± Vertebral discs thin
Later ears
± Decrease individual vertebrae height
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
hortening of the trunk ith appearance of long
extremities
Additional postural changes
± Kphosis
± Back ard tilt of the head for ee contact
For ard bent posture
Hips and knees in flex position
Muscles: Normal Changes of Aging
Muscle function varies ith aging
± ÷rainable into advanced age
± Muscle regeneration is normal as age progresses
Muscle
± Mass
arcopenia b age 75
± trength
lo decline
tamina decreased b age 50
Decreased 65 to 85% of midt enties b age 80
± ÷one and tension
Decreases after age 30
Muscle
± ize
Decreases causing eakness
÷pe II muscle fibers
± Faster contraction but more atroph
÷pe I
± lo er contraction and less atroph
± Help maintain posture
± Help perform repetitive exercise s
± hape
Distinct
More prominent
Routine dail activities keep the upper
extremities functioning better than alking.
Joints, Ligaments, ÷endons, and Cartilage:
Normal Changes ith Aging
Cartilage
± Haline cartilage (joint lining)
Normall lines joints
Erodes and tears ith advancing age
Causes bone to bone contact
± Knee cartilage
Experiences normal ear and tear
÷hins about 025 mm/ear
± Discomfort and slo joint movement
± Diminished joint lubricant
± Nonarticular cartilage (ears and nose)
Gro s throughout life
Joints, Ligaments, ÷endons, and Cartilage:
Normal Changes ith Aging
Ligaments, tendons, and joint capsules
± Lose elasticit
± Less flexible
± Joint ROM decreases
Metabolic Bone Diseases
Osteoporosis
± Most common metabolic disease
± Characterized b lo bone mass and deterioration
of bone tissue.
± Bone strength is compromised increasing risk for
fractures.
± Affects 50% of omen during their lifetimes
± 20 million omen and 8 million men diagnosed in
the United tates
± 3.8 million omen receive adequate care
Osteoporosis
High risk factors for osteoporosis
± Increased age
± Female sex
± White or Asian race
± Positive famil histor
± ÷hin bod habitus
Osteoporosis
Additional risk factors for osteoporosis
± Lo calcium intake
± Prolonged immobilit
± Excessive alcohol intake
± Cigarette smoking
± Long-term use of corticosteroids, anticonvulsants,
or throid hormones
Pathophsiolog of Osteoporosis
Reduced BMD
± Highl predictive of spinal and hip fractures
± Osteoporotic fractures affect 1.3 million per ear
in the United tates
± Vertebrae fractures affect about 500,000 people
per ear
± Hip and rist fractures affect about 260,000 per
ear
± One in five patients die ithin 1 ear
± One third regain their prefracture mobilit and
independence level
Classification of Osteoporosis
Primar osteoporosis
÷pe I (menopausal bone loss)
÷pe II (senescent bone loss)
econdar osteoporosis
± Hperparathroidism
± Malignanc
± Immobilization
± Gastrointestinal disease
± Renal disease
± Drugs causing bone loss such as vitamin D deficiencies and
glucocorticoids
Menopausal Bone Loss
(÷pe 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
gro th)
usceptible omen close to age 70 can lose 50% of
peripheral cortical bone mass
Cause of vertebral and Colles' fractures
enescent Bone Loss
(÷pe 2)
Decreased amount of bone during remodeling
Occurs in both sexes
Caused b aging
Decreased trabecular (cancellous) bone all
thickness
± Decreased osteoblast formation
± Decreased bone mineral densit
± Decreased rate of bone formation
± Cause of vertebral and hip fractures
÷rajector of Bone Loss for Women
Lo er peak bone mass than men
Less in the "bone bank͟ because of thinner bones
Lose bone mass ith lactation
Rapid ithdra al from "bone bank" during
perimenopause
Longer life span increases risk for osteoporosis
igns/smptoms usuall absent
First sign is often a fracture
Pharmacolog and Nursing
Responsibilities for Osteoporosis
Antiresorptive therap
± Preserves or increases bone densit
± Decreases rate of bone resorption
Classifications and special considerations
± Bisphosphonates (alendronate [Fosamax] and
risendronate [Actonel])
Inhibit osteoclastic activit
Decrease postmenopausal vertebral and nonvertebral fractures b
40 to 50%
Adverse gastrointestinal smptoms
± Esophageal irritation, heartburn
± Difficult s allo ing
Do not take calcium ith bisphosphonates interferes ith
absorption
elective estrogen receptor modulators (ERMs)
± Provide benefits of estrogens ithout the disadvantages
± Raloxifene approved for postmenopausal prevention and
treatment of osteoporosis in omen
± ERM less effective than bisphosphonates
Calcitonin
± afe but less effective treatment for osteoporosis
± Decreases spinal fractures b up to 35%
Hormone replacement therap (HR÷)

Primar or Idiopathic Osteoarthritis
No single, clear cause
Group of similar disorders
Involve complex biomedical, biochemical, and
cellular processes
Changes in several joints as a result of various
causes
econdar Arthritis
econdar arthritis involves
± An underling condition
± ÷rauma
± Bone disease
± Inflammator joint disease
Pathophsiolog
Progressive erosion of joint articular cartilage
± Formation of ne bone in joint space
± Involved joints
Hands
Weight bearing joints of the knees and hips
Central joints of the cervical and lumbar spine
Ho does this happen?
± Cartilage thins underling bone (subchrondal bone) is no
longer protected
Pathophsiolog
Cartilage not available to buffer
± ubchrondral bone becomes irritated
degeneration of the joint bone hpertroph
bon spurs (osteophtes) gro th and
enlargement contours of the joint
± mall pieces ma break off (joint mice) irritate
the snovial membrane joint effusion limited
movement
Clinical Manifestations
90% of all people have x-ra evidence of primar
osteoarthritis in their eight-bearing joints b age 40.
OA smptoms
± 40% of people ith severe OA have pain
± Most common smptoms
± Earl morning stiffness resolving in 30 minutes
± Joint pain
Occurs during activit
Relieved b rest
± With progressive disease
Pain ma be present at rest
Interrupt ion of sleep patterns
ource of pain ma be unkno n, but it needs to be identified
in order to provide treatment
Joint involvement
± Asmmetrical at first
± Bon appearance of joints
± Crepitus (a grating sound on movement)
± Range of motion deficit
± Muscle eakness
Hands
± Ne bone gro th
Heberden͛s nodes (DIPͶdistal interphalangeal joint)
Bouchard͛s nodes (PIPͶproximal interphalangeal joint)
Pain ith active and passive motion
Joint damage + chronic pain + muscle
eakness impaired balance + decreased
activit
Responsibilities for Osteoarthritis
No therap ill slo or halt progression
Current therap directed at relief of pain and
minimizing functional disabilit
Agents for pain relief for OA
NAIDs
÷opical agents
± Capsaicin nonprescription drug
± Prevent the reaccumulation of substance P (a
neurotransmitter) in peripheral sensor neurons
± Applied 2 to 4 times dail to affected area
Ma cause heat or burning
Relief ma require up to 4 to 6 eeks of applications
stemic oral agents
± Acetaminophen (÷lenol)
First line pharmacological therap
Give up to 4 gm/da ith minimal toxicit
Higher doses ma cause liver damage
Ceiling effect = increasing the dose does not increase
the analgesic benefit Use alone or as an adjunct to
NAIDs
Nonsteroidal anti-inflammator drugs
(NAIDs)
± Most common treatment for pain and
inflammation of OA
± COX-2 inhibitors, a ne categor of anti-
inflammator drugs
Considered safe for the GI tract
ide effects include renal impairment (see RA section)
Adjuvant agents
Intra-articular agents
± Corticosteroids valuable for snovial inflammation
novial effusion removed prior to injections
Limited to 4/ear in an one joint
± Haluronic acid
Normal component of the joint for lubrication and nutrition
Decreased pain for longer periods than other intra-articular
therapies
Administered in series of 3 to 5 injections
elected Diagnostic ÷ests and Values for
Musculoskeletal Problems
Bone mineral densit test (BMD)
± Dual energ x-ra absorptiometr (DEXA)
Proximal femur predicts hip fracture risk best
Gold standard for fracture prediction
Other sites tested include spine, rist, or total bod
± Results
Compared ith oung adult mean
Or compared norm group of same age
BMD 1 D belo mean (-1 ) = osteopenia
BMD 2.5 D belo mean (-2.5 D) = severe osteoporosis
elected Diagnostic ÷ests and Values for
Musculoskeletal Problems
Bone mineral densit test (BMD)
± Pitfalls
Bone changes also the result of arthritis or disk disease
in lumbar spine
Arbitrar D cutoffs to determine diagnosis
Results var ith technique and patient position
Current criteria based on postmenopausal hite
omen
Bone and Joint Radiograph
X-ra use
± Diagnose and stage rheumatic diseases
± Diagnose fractures
± Detect musculoskeletal structure, integrit,
texture, or densit problems
± Evaluate disease progression and treatment
efficac
Computed tomograph (C÷)/magnetic
resonance imaging (MRI)
± Visualize
± Inflammation
± Musculoskeletal changes
novitis
Edema
Bone bruises
± Occult fractures and articular damage
Computed tomograph (C÷)/magnetic resonance
imaging (MRI)
± Advantages
Uses a large magnet and radio aves to produce energ field
Detailed image
Does not use radiation or a contrast medium
± Disadvantages
More expensive
Requires special facilities
Cannot sho calcification or bone mineralization
Client hears soft to thunderous noises and ma use earplugs
Bone can
Detects skeletal trauma and disease
Determines degree bone matrix ͞takes up͟
radioactive isotope
Determines reason for an elevated ALP
Blood erum ÷ests
Electroltes: calcium level
Bone and muscle enzmes: alkaline
phosphatase (ALP)
Joint tests
± Rheumatoid factor (RF)
± Acute phase reactants
C-reactive protein (CRP)
Erthrocte sedimentation rate (ER)
± erum uric acid (UA)
Blood erum ÷ests
pecial considerations
± Electroltes: serum calcium and phosphorus
decreased in the older person
± Calcium
Increased in Paget͛s disease, ith bone fractures, and
ith immobilit
Decreased in osteoporosis and osteomalacia
erum calcium (normal range older adult 8.8 to 10.2
mg/dl)
Blood erum ÷ests
pecial 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
± erum Uric Acid (UA)
Diagnosis of gout is not established unless UA is found
in tissue or snovial fluid
Blood erum ÷ests
Acute phase reactants C-reactive protein (CRP) and
erthrocte sedimentation rate (ER)
± Erthrocte 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 inflammator
process
± Bacterial infection or rheumatic disease
Increases and returns to normal quicker than ER
Blood erum ÷ests
Alkaline phosphatase (ALP)
± Enzme associated ith bone activit
± Normal values: men = 45 to115 U/L, omen = 30 to 100
U/L
± Values increase after age 50
± Identif increases in osteoblastic activit and inflammator
conditions
± Elevated ith Paget͛s disease (> 5x normal)
± Isoenzmes ALP1 (liver origin) and ALP2 (bone origin)
determine if elevation is bone disease
Lifestle Changes
Increase in exercise
Weight loss
Eating health diets
^ealthy People 2010
( .health.gov/healthpeople)
± Nation͛s goals and objectives for improved health
± Includes an objective for arthritis patient
Additional Nonpharmacological
trategies
Additional nonpharmacological strategies to enhance
comfort ith OA
± Appl heat to painful joints
± Use cold applications to reduce pain and s elling
± Use canes, crutches, and alkers to protect joints
± Use assistive technolog
Maintain, increase, or improve function
Commercial purchase or custom made
Available for general dail living, home management, school, and
ork activities

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