Nursing 407 - Geriatric Healthcare
Chapter 9 – Musculo-Skeletal Function
Structure and function of joints
- Point at which 2 bones are attached
- Provide stability and mobility to the skeleton
- Connections maintained by tendons and ligaments
- 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
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
Nutrition and musculoskeletal health
- Rich protein and mineral diet
- Minimum 1500 mg calcium daily in men and women if not taking estrogen
- Weight reduction to IBW
- Vitamin D supplements (2000 mg/day)
Incredible shrinking people
- After age 40, loss of 1 cm in height every decade is normal
- Vertebral deterioration due to osteoporosis
- 23 spinal discs compress during the day and reabsorb fluid during night, causing a half-inch variation
- With age, the discs flatten reducing height permanently
Sarcopenia
- Loss of muscle mass, strength, function
- Maximum muscle strength can decrease by 85%
- Occurs in up to 50% patients 80 years +
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.
Normal bone metabolism (remodeling)
- Lifelong process
- Mature bone removed from skeleton by osteoclasts (resorption)
- New bone tissue is formed by osteoblasts (ossification)
- Replace bone in fractures and in micro-damage (during normal activity)
- Activity, particularly weight bearing activity, then, promotes formation of newer, stronger bone!
Wolff’s law
- Healthy bone adapts to the applied physiologic load
- Both internal and external architecture change
- Correlates with the principle of bone remodeling
- If loading increases, bone will remodel to become stronger to resist that load
- Conversely, if loading decreases, bone will become weaker
Osteoporosis
(Metabolic bone disease)
- Altered bone metabolism
- 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
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
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.
Bone mineral density study for patients < 65
- Chronic rheumatoid arthritis
- Fracture
- Early menopause
- Smoking
- Family history of osteoporosis
- Taking corticosteroids
- Consume > 3 drinks of alcohol per day
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
Examples of weight bearing exercise
- Best for bone health
- Running
- Jumping rope
- Basketball, baseball, tennis, etc.
- Weightlifting
- Hiking
- Less effective but beneficial
- Walking
- Low-impact aerobics
- Cardio machines
- Least beneficial
- Swimming
- Cycling
- Yoga, pilates
Exercise programs for the elderly
- Must include:
- Cardiovascular endurance
- Flexibility
- Strength training
- Performance is affected by:
- Decreased stroke volume causes accelerated heart rate
- Reduced vital capacity
- Increased body fat—susceptible to heat stroke
- Decreased total body fluid—susceptible to dehydration
- Must match the individual’s interests and needs!
- Accommodations
- Avoid fatigue and muscle cramping
- Longer recovery time
Pharmacological prevention & treatment of osteoporosis
- Ibandronate (Boniva)
- Once a month or IV every 3 months
- Alendronate (Fosamax)
- 35-75 mg once weekly, or
- 5-10 mg once daily
- Empty stomach in the morning
- Upright for at least 30 minutes
- Raloxifene hydrochloride (Evista)
- 60 mg once daily
- May take without regard for food
- May cause flushing
- Increased risk of thromboembolic events
- Weight bearing exercise important in all cases!
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
Diagnostics for osteoarthritis
- Xray—joint space narrowing, spur formation
Treatment goals
- Maintain function
- Maintain independence
- Prevent complications
Pharmacological interventions for osteoarthritis
- NSAIDs are most common treatment
- Acetaminophen 500 mg—2-4 grams per day
- Capsaicin—topical analgesic
Nonpharmacological treatment of osteoarthritis
- Weight reduction
- Active range of motion daily
- Weight bearing exercise
- Rest to control symptoms
- Use of assistive devices if necessary
Importance of exercise
- Maintain overall function
- Maintain muscle strength
- Maintain coordination
- Maintain balance
- Maintain flexibility
- Maintain endurance
Exercise programs…
- Require clearance by PCP
- Start slow, low impact, gradually increase
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:
- Patient has high levels of rheumatoid factor (RF, antibody to immunoglobulin G [IgG])
- RF interacts with circulating IgG to form immune complexes
- Complexes deposit in the synovial fluid of joints
- Lysosomal enzymes are released that destroy surrounding tissue
- Synovial space fills with scar tissue
Clinical manifestations of rheumatoid arthritis
- Commonly occurs in:
- Joints of upper extremities
- Knees
- Ankles
- Feet
- Systemic symptoms:
- Fatigue, malaise
- Weight loss
- Fever
Diagnostics for rheumatoid arthritis
- Xray—symmetrical disease
- Synovial fluid aspiration
- WBC and ESR ↑ in 80% of cases
- Rheumatoid factor (RF) ↑ in 50% of cases
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
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 and fatigue
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
Treatment of gout
- Acute attacks:
- NSAIDs
- Colchicine
- Steroids
- Long term management:
- Colchicine
- Allopurinol (Zyloprim)
- Probenicid
- Indomethacin (Indocin)