Chapter 10 – Safety; Musculo-Skeletal Function

Assessing the musculoskeletal abilities

• The older adult’s risk for falls is related to:
  • Gait speed
  • Balance
• Each of these factors can be evaluated via the Timed Up and Go (TUG) Test (AKA “Get up and go”)

Interpreting the TUG test

• If he or she takes ≥12 seconds, there is a high risk for falling
• Also note:
  • Tentative pace
  • Loss of balance
  • Short strides
  • Little to no arm swing
  • Supporting oneself on walls, objects
  • Shuffling
  • Not using assistive devices properly
  • “En bloc” turning

Correct use of cane

• Top of the cane comes to top of hip bone
• Elbow should be slightly bent
• Cane is held in hand of stronger side
• Cane is brought forward with the weaker leg
• Walking should appear similar to normal walking

Correct use of walker

• Elbows bent comfortably
• Walker is lifted, moved forward about an arm’s length
• All 4 legs planted on floor at same time
• One foot advanced, then the other, completely within the walker
• One foot always slightly in front of the other when standing
• Repeat the cycle

Comprehensive fall assessment

• Mental status evaluation
• Nutritional history and evaluation
• Environmental survey
• Medication
• Pathologic conditions
• Functional assessment
• Usual footwear
• Complete physical exam
  • Vision
  • Musculoskeletal function
  • Neurologic function
  • Cardiovascular status

Nursing interventions

• Education
• Prevention
• Exercise

Exercise/physical activity

• Weight bearing activities improve muscle strength and increase bone strength (preventing osteoporosis)
• Flexibility training improves range of motion
• Aerobic activity prevents muscle mass loss and improves overall functioning

Alternatives to conventional exercise

• Emphasis placed on balance, engaging the mind in the respective activity

Education:  teaching about osteoporosis

• Information regarding risk factors
• Lifestyle changes: daily weight bearing exercise, smoking cessation, limiting alcohol consumption
• Calcium (1000-1200mg/day), vitamin D₃ (800-2000IU/day)
• Address osteoporosis education toward both men & women
• Treatment and prevention with medication:
  • Biphosphonates (alendronate, ibandronate, risedronate, zoledronic acid)
  • Calcitonin
  • Denosumab
  • Estrogen
  • Raloxifene
  • Parathyroid hormone

Preventing falls and injuries

• Must identify those at risk for falling and fall-related injury
• Assess environmental safety
• Strength and balance exercise
• Medication review
• Assess vision and hearing
• Involve family and all caregivers
• Inform regarding personal response systems:

Falls are the leading cause of injury-related deaths

• One out of five falls causes a serious injury
• Each year, 2.5 million older people are treated in emergency departments for fall injuries.
• Over 700,000 patients a year are hospitalized because of a fall injury, most often because of a head injury or hip fracture.
• Each year at least 250,000 older people are hospitalized for hip fractures.
• More than 95% of hip fractures are caused by falling, usually by falling sideways.
• Falls are the most common cause of traumatic brain injuries (TBI). 

Factors contributing to falls

• Age related changes
• Improper use of mobility aids
• Medications
• Unsafe clothing
• Disease related symptoms
• Environmental hazards
• Caregiver factors

Other factors contributing to falls

• Visual changes
• Balance problems
• Cognitive changes
• CV problems
• Medications
• Urinary incontinence, urgency
• Malnutrition
• Musculoskeletal impairment

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

Abnormal changes in
gait in the elderly

• Loss of symmetry of movement
• Difficulty initiating or maintaining gait
• Walking, falling backwards (“retropulsion”)
• Footdrop
• Short step length
• Wide based gait
• Progressive quickening to avoid falling forward (“festination,” Latin festinare [to hurry]) as with Parkinson’s

Common sites of fracture after  a fall

• Neck of the femur
• Colle’s fracture (distal radius)
• Compression fracture of vertebrae
• Assume there is a fracture until proven otherwise!
• Symptoms of fracture
  • Pain
  • Change in shape or length of the limb
  • Abnormal or restricted motion of the limb
  • Edema, discoloration
  • Protrusion of bone

Complications of fractures in the elderly

• Heal more slowly than in younger adults
• Pneumonia
• Thrombus formation
• Renal calculi
• Fecal impaction
• Contractures

Balance exercises for the elderly

• Reinforce balance exercises:

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

Diagnostic tests:  xray, computerized tomography, and magnetic resonance

• Xray is basic test for diagnosing and staging rheumatic disease and diagnosing fractures
• 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

Musculoskeletal conditions:
Planning

• Manage pain
• Prevent injury
• Promote independence