Physiological basis of the care of the elderly client

1. Physiological basis of the care of the elderly client The Musculoskeletal System

2. Patient scenario • J.H. is a 76 year old female brought in by her granddaughter with whom she lives. • The granddaughter states J.H. complains of her joints hurting and she is mean and won’t listen to her. • J.H. states all her joints hurt and she’d rather just stay in bed all day. • She is afraid J.H. will hurt herself as she has fallen twice while the granddaughter is at work.

3. Informal evaluation What additional information do you need? • Subjective information • Objective information • Psychosocial information

4. Structure and function of joints • Point at which 2 bones are attached • Provide stability and mobility to the skeleton • A joint that is unstable or immobile is ineffective! • Nursing diagnoses originate from cause of the ineffective joint: • Impaired physical mobility • Acute pain or chronic pain • Fatigue

5. Age related changes • Decreased range of motion • Shrinking vertebral discs and loss of bone mass contribute to decrease in height • Muscle atrophy, exacerbated by disuse • Decrease in lean body mass • Joint degeneration • Postural instability contributes to balance difficulties • Difficulty maintaining balance

6. Incredible shrinking people • After age 40, loss of 1cm in height every decade is normal • Vertebral deterioration due to osteoporosis • 23 spinal compress during the day and reabsorb fluid during night, causing a half- inch variation • With age, the discs flatten reducing height permanently

7. Sarcopenia • Loss of muscle mass, strength, function • Maximum muscle strength can decrease by 85% • Occurs in up to 50% patients 80 years +

8. Treatment for sarcopenia • The primary treatment for sarcopenia is exercise. • Resistance training with resistance bands • Strength training with weights • Effective for both prevention and treatment of sarcopenia • Positive influence on • Neuromuscular system • Hormone concentrations • Can increase protein synthesis rates in older adults in as little as two weeks.

9. Classification of musculoskeletal illnesses

10. Osteoporosis(Metabolic bone disease) • Low bone mass • Deterioration of bone tissue • Affects 50% of women • Contributors to decreased bone mass in the elderly 1) failure to achieve peak bone mass in early adulthood 2) increased bone resorption 3) decreased bone formation

11. Risk factors for osteoporosis • Risk factors include: • Increased age • Female • White or Asian • Family history • Thin body build • Also implicated: low calcium intake, smoking, alcohol, caffeine, stress, long term corticosteroids, anticonvulsants, thyroid medications

12. Diagnostics for osteoporosis Bone mineral density study recommended for: • Postmenopausal women below age 65 with risk factors for osteoporosis. • All women aged 65 and older. • Postmenopausal women with fractures • Women with medical conditions associated with osteoporosis. • Women whose decision to use medication might be aided by bone density testing. • Men age 70 or older.  • Men ages 50-69 with risk factors for osteoporosis.

13. Diagnostic tests: bone mineral density study • Used to predict fracture • Recommended for most women > 65 years of age • Recommended for those < 65 if: • Chronic rheumatoid arthritis • Fracture • Early menopause • Smoking • Family history of osteoporosis • Taking corticosteroids • Consume > 3 drinks of alcohol per day

14. Lifestyle modifications for the patient with osteoporosis • Diet with adequate calcium and vitamin D • Weight bearing exercise (increase bone density) • Smoking cessation • Reduction of alcohol, caffeine

15. Medications for osteoporosis • Biphosphates • Alendronate (Fosamax)—daily or weekly • Ibandronate (Boniva)—daily or monthly or q 3 months IV • Estrogen agonists/antagonists • Raloxifene (Evista)—daily • Calcitonin (Miacalcin)—daily

16. Examples of weight bearing exercise • Dumbells • Resistance band • Bodyweight exercise • Calisthenics • Weight machine exercise

17. Pharmacological prevention & treatment of osteoporosis • Ibandronate (Boniva) • Once a month or IV every 3 months • Alendronate (Fosamax) • Once weekly • Empty stomach • Upright for at least 30 minutes • Raloxifene hydrochloride (Evista) • Once daily • May take without regard for food • May cause flushing • Increased risk of thromboembolic events Weight bearing exercise important in all cases!

18. Osteomalacia(Metabolic bone disease) • Softening of the bones: volume of bone is adequate, replacement is soft and not rigid • Defective bone mineralization • Inadequate available phosphorus and calcium • Can be caused by increased resorption of calcium due to hyperparathyroidism

19. Diagnostics for osteomalacia • Bone density studies • Alkaline phosphatase is elevated • Serum calcium is low

20. Treatment of osteomalacia • Goal is to remineralize the bone • Vitamin D replacement • 50,000-100,000 units/day for 1-2 weeks • 400 to 800 units daily • Must have adequate calcium intake • 1000 to 1500 mg/day • Monitor serum and urine calcium levels

21. Paget’s disease(Metabolic bone disease) • Chronic, localized disorder • Normal bone removed, replaced with abnormal bone • Cause is unknown • Often an incidental finding • Common symptom is bone pain at site or adjacent joints

22. Diagnostics for Paget’s disease • Xrays, bone scan, CT • Serum calcium low or normal • May require bone biopsy:

23. Treatment of Paget’s disease • Deformities are irreversible • Treatment goals • Relieve bone pain • Prevent progression • Medications of choice • Alendronate (Fosamax) • Risendronate (Actonel)

24. Osteoarthritis(Joint disease—noninflammatory) • Most common form of arthritis in the US • Chronic • Women > men • Progressive erosion of articular cartilage of the joint • New bone forms in the joint space

25. Clinical manifestations osteoarthritis • Characteristic nodule formation:

26. Diagnostics for osteoarthritis • Xray—joint space narrowing, spur formation

27. Treatment goals

28. Rheumatoid arthritis(Joint disease—inflammatory) • Most common inflammatory arthritis of any age group • Women:men 3:1 • Chronic syndrome • Symmetrical inflammation of peripheral joints • Likely an autoimmune response to unidentified antigen

29. Clinical manifestations of rheumatoid arthritis • Commonly occurs in: • Joints of upper extremities • Knees • Ankles • Feet • Systemic symptoms: • Fatigue, malaise • Weight loss • Fever

30. Diagnostics for rheumatoid arthritis • Xray—symmetrical disease • Synovial fluid aspiration • WBC and ESR ↑ in 80% of cases • Rheumatoid factor (RF) ↑ in 50% of cases

31. Osteoarthritis vs rheumatoid arthritis

32. Osteoarthritis vs rheumatoid arthritis

33. Pharmacological interventions for osteoarthritis • NSAIDs are most common treatment • Acetaminophen 500 mg—2-4 grams per day • Capsaicin—topical analgesic

34. Nonpharmacological treatment of osteoarthritis • Weight reduction • Active range of motion daily • Weight bearing exercise • Rest to control symptoms • Use of assistive devices if necessary

35. Importance of exercise • Maintain overall function • Maintain muscle strength • Maintain coordination • Maintain balance • Maintain flexibility • Maintain endurance

36. Exercise programs… • Require clearance by PCP • Start slow, low impact, gradually increase

37. Pharmacological interventions for rheumatoid arthritis • Corticosteroids (e.g., prednisone) to decrease inflammation • May have long-term adverse effects • NSAIDs • Quick relief important to preserve independence

38. Nonpharmacological treatment of rheumatoid arthritis • Strength training to address muscle wasting • Range of motion of joints • Regular exercise if no inflammation or exacerbation • Rest to reduce joint stress

39. Spine • In profile, should be a slight reverse “S” • Posteriorly, midline without deviation, shoulders even

40. Testing for scoliosis • Standing • Uneven shoulder height • Unequal distance between arms and body • Asymmetrical waistline • Uneven hip height • Sideways lean • Bending over • Asymmetrical thoracic spine • Prominent rib cage/hump on either side • Asymmetrical waistline

41. Gout (joint disease—inflammatory) • Excessive uric acid in blood • Crystals accumulate in joints • Warmth, redness, swelling, pain • Low purine diet • Diagnosis—urate crystals in affected joint

42. Treatment of gout • Acute attacks: • NSAIDs • Colchicine • Steroids • Long term manage- ment: • Colchicine • Allopurinol (Zyloprim) • Probenicid • Indomethacin (Indocin)

43. Pseudogout(joint disease—inflammatory) • Actually a form of arthritis • Formation of calcium pyrophosphate-dihydrate crystals in large joints • 60 years+ • Women > men • Develops in families • Affects several joints • Diagnosed by joint fluid aspiration

44. Falls • Most occur in the home during normal activities • Leading cause of accidental death • Commonly result in fractures of hip, spine, forearm • Of all fall-related fractures, hip fracture is most likely

45. Contributing factors to falls • Visual changes • Balance problems • Cognitive changes • CV problems • Medications • Urinary incontinence, urgency • Malnutrition • Musculoskeletal impairment

46. Balance exercises for the elderly • Reinforce balance exercises:

47. Treatment of hip fractures • Surgery is preferred treatment • Should be performed without delay if tolerable • May not be an option for severely debilitated patient • Total joint replacement performed if severe arthritis is present

48. Fall assessment: Get up and go test • Technique: Direct patient to do the following • Rise from sitting position • Walk 10 feet • Turn around • Return to chair and sit down • Interpretation • Patient takes <20 seconds to complete test • Adequate for independent transfers and mobility • Patient requires >30 seconds to complete test • Suggests higher dependence and risk of falls

49. Diagnostic tests: computerized tomography vs magnetic resonance • Computerized tomography (CT) • Can detect inflammation and degeneration not visible on xray • Can show subtle fractures and articular damage • Magnetic resonance imaging (MRI) • More detailed image • Does not require radiation or contrast • Can detect soft tissue changes

50. Gait changes in the elderly • Gait velocity unchanged until about 70 years • Cadence (steps per minute) does not change • Time with both feet on the ground increases from 18% in young adults to about 26% healthy elderly • Anterior pelvic rotation increases partly due to weak pelvic muscles • Joint motion changes slightly