disorders and diseases of locomotor organs Part 1

1. Manifestation of Novel Social Challenges of the European Unionin the Teaching Material ofMedical Biotechnology Master’s Programmesat the University of Pécs and at the University of Debrecen Identification number: TÁMOP-4.1.2-08/1/A-2009-0011

2. Manifestation of Novel Social Challenges of the European Unionin the Teaching Material ofMedical Biotechnology Master’s Programmesat the University of Pécs and at the University of Debrecen Identification number: TÁMOP-4.1.2-08/1/A-2009-0011 Gyula Bakó and Erika Pétervári Molecular and Clinical Basics of Gerontology – Lecture 6 disorders and diseases of locomotor organsPart 1

3. Outline • Changes of the musculoskeletal system in the elderly • Common diseases of locomotor organs in the elderly – causes of falls, chronic immobilization and disability • Immobilization and remobilization in the elderly

4. Geriatric Giants Immobility(Falls) Incompetence (Confusion) Incontinence Impaired homeostasis Iatrogenicdisorders

5. Factors adversely affecting locomotor organs in the elderly • Organ damage • Pain, rigidity of joints and muscles • Impaired renal function • Associated chronic diseases • Multiple medications ,higher risk for side effects • Impaired fluid and food intake • Failing memory, deterioration of cognitive function • Functional disorders • Gait disturbances • Impaired self-reliance • Impaired ability to carry out household duties • Limited leisure activities • Social difficulties • Financial problems • Inappropriate housing • Death of spouse/caretaker • Social isolation(scattered family)

6. Changes of the musculoskeletal system in the elderly • IChanges and dysfunction of the skeletal muscles in the elderly • II Aging-associated changes in the joints • III Aging-associated changes in the bones

7. I: Changes of the skeletal muscles: sarcopenia in the elderly • Body weight decreases between 30-75 years of age, mainly due to a progressive decrease in the number and size of muscle fibers and that of muscle mass. • Causes: • reduced physical activity • changes in CNS and peripheral nervous system within which a decreased number of active motor units are found • decrease in protein synthesis in skeletal muscle fibers • reduced protein intake in the elderly • relative scarcity of anabolic hormones (GH, IGF-I, testosterone, DHEA)

8. Pathogenesis of skeletal muscle dysfunction in the elderly • I Neurological causes(pronounced in peripheral neuropathies) • Reduced number and size of motor neurons in the spinal cord • Decrease in the axonal conductivity • Decrease in the neuromuscular transmission • number of neuromuscular end plates • number of acetylcholine receptors • release of neurotransmitters

9. Pathogenesis of skeletal muscle dysfunction in the elderly • II Primary muscle damage • Injury induced by contractures • Altered signal transduction in the muscle (impaired effects of trophic factors, hormone resistance) • Reduced number of type II muscle fibers Age-related changes in body composition: muscle loss

10. Loss of type II muscle fibers • About 50% of the muscle mass is lost by the time we develop sarcopenia due to old age. It affects mostly type II (fast twitch) muscle fibers in contrast to type I (slow twitch) muscle fibers. • Type II muscle fibers are responsible for fast, intensive contractions, while type I fibers are responsible for slow, long lasting movements. • Due to the loss of muscle fibers with age, 20% of the maximal isometric contraction force is lost by the age of 60. By the age of 75 the loss is about 50%.

11. Pathogenesis of skeletal muscle dysfunction in the elderly (cont.) • III Combined neuromuscular mechanisms • Disorders of the electric discharge of muscle fibers • The stimulus- contraction process is disrupted • IV Common abnormal biochemical processes affecting the muscle • oxidative stress • mutation in the mitochondrial DNA • vasculopathies developing with age

12. II: Aging-associated changesin the joints • Cartilage coating the bone endings contains chondrocytes, which produce collagen fibers, hyaluronic acid and proteoglycans building a high water-containing, elastic substance. • The proteoglycans attached to hyaluronic acid and aggregated within the collagen network are saturated with water and thus provide the cartilage with the capacity to resist compression and to re-expand after compression. • In the elderly, the amount and water content of the cartilage mass decrease, its resistance against mechanical impacts is less effective. • Impacts from every direction destroy the joints as the ligaments become more rigid. (Overweight.)

13. Aging of thejoints arthrosis • water binding of hyaluronic acid • changed composition (not the amount) of proteoglycans •  • Reduced water content (in arthrosis it increases) and amount of cartilage mass lead to less resilient cartilage. • Without the protective effects of the proteoglycans, the collagen fibers of the cartilage become susceptible to degradation. • Decreased viscosity of the synovial fluid.

14. Aging in soft tissues • Impairment of collagene synthesis, that of post-translational modification of collagene • Alterations in the quantity and quality of intercellular matrix (menisci, intervertebral discs) • Deposition of calcium crystals in connective tissue Mechanical resistance of soft tissues are decreased

15. III: Aging-associated changesin the bones • Bone mass decreases from the age of 55 by around 1%/year in men and by 3-4%/year in women (peak bone mass is reached at 25-35 years of age, its value is higher in men). • During the course of aging metabolic activity of osteoblasts is decreasing. • Causes of deterioration of bone mass: • inactivity, vitamin D deficiency; hormones: estrogen, progesterone, calcitonin, parathormone (secondaryhyperparathyroidism), cortisol; alcohol; smoking. • Consequences: • osteopenia, osteoporosis, fractures.

16. Common diseases of locomotor organs in the elderly • Osteoarthrosis, the most common disease of locomotor organs of people over 50 • Rheumatoid arthritis • Gout • CPPD arthritis (pseudo-gout) • Osteoporosis

17. Osteoarthrosis(OA)degenerative joint disease • Definition: • Each element of the joint becomes gradually and progressively injured causing swelling, pain, stiffness and functional loss. • A degenerative process leads to incongruence of the articular cartilage surfaces, inflammation of the joint capsule (synovitis), muscle atrophy and a crackling noise (called “crepitus”) when the affected joint is moved. • It commonly affects the large weight bearing joints (hips, knees).

18. Osteoarthrosis(OA)focal degeneration of the joints • New bone outgrowths: • beneath the lesion (subchondral) • at the edge, called “spurs” or osteophytes narrowing of the joint space • Calcification of lax tendons (ligaments) Thickened bone “Spurs” or osteophytes Cartilage particles Loss of cartilage

19. Osteoarthrosis(OA)degenerative joint disease • Prevalence: • It affects 30% of the adult population. 90% of people over 60 have radiological signs of arthrosis. • Incidence: • 88 (hip joints), 20 (knee), and 300 (hand)/100,000/year • Significance: • It is the most common cause of disablement and NSAIDs’ (non-steroidal anti-inflammatory drugs) prescriptions.

20. OA a multifactorial degenerative joint disease • Causes: • Basic causes: • bipedalism (erect posture and work), increased burden on the joints at the knees • extended life span • Risk factors for faster progression: • Mechanical causes: obesity, congenital disorders, macro- and microtrauma, overuse, previous inflammation of the joints and bone necrosis. • Metabolic causes: defects in collagen synthesis, diabetes, hyperthyroidism, hypothyroidism, hyperparathyroidism, hemochromatosis, acromegaly, ochronosis, etc.

21. Clinical signs of OA • Usually above 40 years of age • Moderate pain in one or more joints • Pain at initiation of movement • In the beginning, the pain ameliorates at rest, later it is aggravated by rest • Morning stiffness < 30 minutes • Impaired function: instability, diminished movements , decrease in muscle strength • Crepitation, crackling noise • Swelling, deformity • Abnormal alteration of the axis • Lack of systemic symptoms

22. Therapeutic measures Pharmacological treatment • Pain killers/analgetics • NSAID • Intra-articularsteroids Psycho-social treatment • Patient education • Improvement of life-style and diet • Psychological support • Patient clubs • Weight reduction • Consultations with patients • Orthoses(amputee knee shell, knee brace, orthotic heel support, arch support ) • Other treatments • Physiotherapy • Surgical intervention