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Mobility spring 2013 abridged

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  • 1. Objectives Describe the effects of aging on Mobility musculoskeletal function List the benefits of activity Describe factors contributing to, symptoms, NURS 4100 Care of the Older Adult treatment, and related nursing care for Spring 2013 fractures, osteoporosis, and osteoarthritis Joy Shepard, PhD(c), MSN, RN, CNE, BC Identify ways to reduce risks of injury associated with musculoskeletal problems 1 Normal Changes of Aging Musculoskeletal System (pp 55-56) Decreased height Decreased ROM jointsNormal Changes of Aging Increased postural sway/ difficulty balance Shrinking vertebral discs, slight kyphosis Loss of bone mass, bones more brittle (increased resorption) Muscle atrophy/ decreased lean body mass Joint degeneration (cartilage surface) Foot problems: bunions, corns, calluses 3 4 Effects of Aging: Muscles Effects of Aging: MusclesDecline in size & Decline in endurance/number of muscle fibers staminaSarcopenia: reduction in Decreased by age 50muscle mass & function Decreased 65-85% of(by age 75) midtwenties by age 80 Reduction in protein Can lead to disability synthesis Causes Increase in muscle Tone & tension protein degeneration Decreases after age 30Decreased strength Reduced flexibility Slow decline 5 6
  • 2. Joints, Ligaments, Tendons, and Wear & Tear on KneeCartilage: Normal Changes with Aging CartilageCartilage Knee cartilage Normal wear/ tear Hyaline cartilage Thins ~ 0.25 mm/year (joint lining) Discomfort, slow Lines joints joint movement Diminished joint Erodes/ tears with lubricant advancing age Nonarticular cartilage Bone to bone (ears & nose) contact Grows throughout life 7 Ears & Nose Continue to Grow Joints, Ligaments, Tendons, & Throughout Life Cartilage: Normal Changes with Aging Ligaments, tendons, and joint capsules Lose elasticity Less flexible Joint ROM decreases 10 Menopausal Osteoporosis: Vertebral Skeleton: Trajectory of Bone Loss Compression with Diminished HeightTwo phases bone loss Phases eventually overlap Type I (menopausal bone Other conditions may alter loss) Rapid normal aging of skeleton Affects women Occurs first 5-10 years after menopause Type II (senescent bone loss) Slower phase Affects both sexes after midlife 11
  • 3. Effects of Aging: Skeleton Effects of Aging: Skeleton Changes in MidlifeBones become Vertebral discs thin appearance evident Later years Stiff after fifth decade. Decrease individual Height most obvious vertebrae height Weaker 20 to 70 years of age Brittle Lose 1-2 cm in height every 2 decades Shortening of the vertebral column 13 14 Effects of Aging: Skeleton Effects of Aging: SkeletonDisproportionate size Additional posturalof long bones of arm changesand legs Kyphosis Eighth & ninth decades Backward tilt of head Rapid decrease in for eye contact vertebral height Collapse of vertebrae Forward bent Shortening of trunk posture Appearance of long Hips and knees in extremities flex position 15 16 Question Can You Spot the Differences?All of the following are normal age-related A remarkable person who has takenchanges in the musculoskeletal system ownership of his health and agedEXCEPT: successfully(A) Decreased lean body mass 50 years ago:(B) Joint inflammation http://www.youtube.com/watch?v=isLJ024EdMA(C) Loss of bone density(D) Reduction in height Recent: http://www.youtube.com/watch?v=iEdClu1KeC8&featu(E) Shortening of vertebrae re=related
  • 4. Prevention of InactivityMusculoskeletal Health Deconditioning effects of inactivityPromotion (Box 24-3, p. 306) Compensate for age-related changes Public education Education for caregivers Creative activities to stimulate movement 19 Older Adults: Promotion of Older Adults: Promotion of Activity ActivityBenefits of exercise: Local resources to promote activity Strengthens bones Capacities, limitations, and interests Reduced constipation Improved sleep Avoid stereotyping Lower blood pressure/ cholesterol Good nutrition Weight loss Weight reduction SocializationEnhance motivation Older Adults: Promotion of Older Adults: Promotion of Activity ActivityMuscle function Lower extremityvaries with aging muscles atrophy earlier than upper Trainable into extremity advanced age Upper extremities: Muscle Routine daily regeneration is activities normal as age Lower extremities: Walking progresses 23 24
  • 5. Exercises for Older Adults QuestionLifts for Elderly (Part 1) Is the following statement true or false?Lifts for Elderly (Part 2) Choosing an exercise program for an older adult can be achieved by identifying common activities that older adults enjoy and implementing a program based on your findings from the literature. QuestionThe gerontological nurse understands thatall of the following are the effects of Osteoporosisinactivity in older adults EXCEPT:(A) Calcium loss from bones(B) Decreased falls(C) Functional decline(D) Pressure ulcers(E) Reduced muscle strength 28 Osteoporosis OsteoporosisChronic, progressive metabolic 50% of postmenopausalbone disease women Low bone mass 20% men older than 65 Deterioration of bones yrs of ageMost prevalent metabolic bone 10 million Americansdisease (20% men)Kyphosis, lumbar spine pain, & 34 million more – lowfractures bone massOften asymptomatic Most common sites of1st 5 – 7 yrs after menopause: osteoporotic fx:some women lose 20% of vertebrae, wrist, & hipsbone mass Understanding Osteoporosis 30
  • 6. Osteoporosis: Causes Osteoporosis: CausesDecreased bone mass in older person Inactivity or immobility Failure to reach peak bone mass in early Diseases: Cushing syndrome, adulthood Increased bone resorption (osteoclasts) hyperthyroidism, diverticulitis, ESRD Decreased bone formation (osteoblasts) Reduction in estrogen/ testosteroneAny health problem associated with: Diet: Insufficient calcium, vitamin D, Inadequate calcium intake protein Excessive calcium loss Drugs: Corticosteroids, thyroid hormone, Poor calcium absorption anticonvulsants Osteoporosis and DietOsteoporosis Nutrition and Osteoporosis Pathophysiology of Osteoporosis Osteoporosis: PathophysiologyLow bone massDeterioration of bone tissuecompromised bone strength riskfor fracturesBone strength = bone density &quality Bone density = grams of mineral per area or volume (BMD) 33 34 A. Normal bone B. Osteopenia Osteoporosis & Osteopenia C. OsteoporosisNormal BMD within 1standard deviation ofyoung adult meanOstopenia - BMDbetween 1 & 2.5standard deviationsbelow young adult meanOsteoporosis - BMD 2.5standard deviationsbelow young adult mean 35 36
  • 7. Osteoporosis: BMD & Hip Fracture: Fractures Highest Morbidity & MortalityReduced BMD Of the people who suffer from Highly predictive of spinal & hip fractures osteoporosis, 20 percent die Osteoporotic fractures affect 1.5 million within a year after sustaining per year in US Vertebrae fractures ~ 700,000 people per a hip fracture year Hip fractures affect ~ 300,000 per year Wrist fractures ~ 250,000 per yearVertebral Fractures The Physical Consequences of Fractures 37 Osteoporosis: Nonmodifiable Risk Factors (KNOW!)A womans chances of dying Increased age Female from an osteoporosis Caucasian or Asian related fracture is greater race than her risk of cervical, Positive family history uterine and breast cancer Small & thin Certain diseases combined Osteoporosis Risk Factors 40 Osteoporosis: Modifiable Risk Factors (KNOW!)Low calcium & vitamin Dintake, lack of sunlightexposureSedentary lifestyle (inactive,immobility)Alcohol abuseSmokingCaffeine, soft drinks(phosphoric acid)Corticosteroids,anticonvulsants (Dilantin orphenobarbital), or thyroidhormones How to Prevent Osteoporosis 41
  • 8. WHO Fracture Risk Assessment Tool (FRAX) Classification of Osteoporosis Please answer the questions below to Primary osteoporosis Type I (menopausal bone loss) calculate the ten year probability of fracture Type II (senescent bone loss) with BMD. Secondary osteoporosis Caucasian Hyperparathyroidism Malignancy Black Immobilization Gastrointestinal disease Hispanic Renal disease Asian Vitamin D deficiency Drugs causing bone loss such as glucocorticoids, thyroid hormone (Synthroid), or phenytoin (Dilantin) 44 Normal Vertebral Column vsColles’ Fracture Compression FractureAffects Wrist X-Ray of Colles’ Fracture 45Vertebral Compression Fractures Trabecular (Cancellous) BoneWeak, Fragile from Bone Loss Compression Spinal Fracture Fractures in the spine or vertebral column can lead to loss of height, severe back pain, and deformity. 47
  • 9. Trajectory of Bone Loss for Trajectory of Bone Loss for Women WomenLower peak bone mass than men Loss of bone massLess in the "bone bank” because of thinner with age inbones cancellousRapid withdrawal from "bone bank" during (trabecular) versusperimenopause cortical boneLonger life expectancy: increased risk for Location of fracturesosteoporosis that resultSigns/symptoms usually absent Typical ages in which fractures occurFirst sign often a fracture 49 Trajectory of Bone Loss for Women Osteoporosis – Collaborative Care Collaborative care focuses onCollaborative Care assessment of risk factors, proper nutrition, calcium/ vitamin D supplementation, exercise, prevention of fractures, and medications. 53
  • 10. Nonpharmacological Treatment of OsteoporosisNonpharmacological Assessment of risk factorsTreatment/ Prevention Education about prevention Older persons with risk factors Diagnosis of osteoporosis = bone density of –2.5 SD (below average for young people) Education about positive lifestyle changes Diet, exercise, and other risk modifications How to Prevent Osteoporosis 55 56 Assessment/Prevention of Risk Lifestyle Modification Activities to Factors for Osteoporosis Prevent or Treat OsteoporosisEducate all women about osteoporosis risk factors Promote diet with adequate calcium (1,500 mg) & vitaminWomen with fx history BMD test for D (400-800 IU) dailyosteoporosis Dairy products, green leafy vegetables, broccoli, sardines Sunlight exposure to skinBMD test Avoid immobility, staying in bed too long Any woman under 65 with risk factors for osteoporosis All women over 65 Encourage weight-bearing & low-level resistance exercise Walking (best), dancing, weight training, stair climbing,Preventive activities for older men tennis, gardeningMany risk factors same for men Avoid isometric or high-impact aerobic exercisesMost men have bigger bones than women so they Reduce/ eliminate smokinghave increased protection Reduce/ eliminate beverages: alcohol, caffeine, phosphorus How to Give your Bones a Work-Out 57 58 Question Avoid SodasA 67-year-old woman Phosphorusis lactose intolerantand at risk for contributes toosteoporosis. What bone loss byfoods other than dairy inhibiting theproducts can the absorption ofnurse suggest to thispatient to increase her calciumcalcium intake?
  • 11. Avoid Aluminum-Containing Low-Level Resistance Antacids Exercises (Box 24-2; Fig 24-3) Maalox Mylanta AmphojelOsteoporosis Medicine Risks Weight-Bearing, ROM & Resistance Exercises Brisk Walking: One of the Best Swimming: Not a Weight- Weight-Bearing Exercises Bearing Exercise Question When assessing a client with osteoporosis the nurse should recognize that most observable changes will occur in: A. Facial bones B. The long bones C. The vertebral column D. Joints of the hands and feet
  • 12. Antiresorptive Medications: Slow Bone Loss Goal: Prevent bone loss, lower risk of fxPharmacology Bisphosphonates Calcitonin Estrogen therapy, hormone replacement therapy (HRT) Selective estrogen receptor modulators (SERMs) Osteoporosis Treatment Options 67 Treatment Options for Osteoporosis 68 Bisphosphonates BisphosphonatesAlendronate Inhibits osteoclasts (bone-resorbing cells) –(Fosamax), prevents resorptionibandronate (Boniva),risedronate (Actonel) Decreases postmenopausal vertebral &Preserves or nonvertebral fx by 40-50 % (relative risk)increases bone or 1-2% (absolute risk reduction)density Do not take calcium with bisphosphonatesDecreases rate ofbone resorption interferes with absorptionDecreases fractures 69 70 BisphosphonatesSide effects: digestive problems, bone & musclepain, osteonecrosis of the jawThigh bone or femur fx in some women usingbisphosphonates for more than 5 yrsAdverse gastrointestinal symptoms Esophageal irritation, heartburn, gastritisContraindicated: Dysphagia, esophageal disease,gastritis, ulcers; severe renal insufficiency 71
  • 13. Increased Risk Femur Fx Osteonecrosis of the Jaw –long-term use of bisphosphonates Atypical subtrochanteric femur fractures Dull aching thigh pain weeks to months before fracture occurs Taking Fosamax (alendronate) for more than five years could cause spontaneous fractures Bisphosphonates: KNOW! Question The physician prescribes alendronate sodium (Fosamax) for a 72-year old woman. Which(1) Take on empty stomach, first thing in the information should the nursemorning with 8 oz of water; include in teaching the patient(2) Remain upright for 30 minutes; and about this drug?(3) Not eat or drink anything else for 30 minutes 75 Hormone Replacement Calcitonin (Fortical, Miacalcin) Therapy (HRT)Hormone – Regulates Estrogen or estrogen with progestin therapy (to preventcalcium, bone processes uterine CA)IM, Subcut, Intranasal Estrogen: protective effect on boneSafe, effective tx for Accelerates death of osteoclasts, prolongs life of osteoblastsosteoporosis ↑ Bone density spine & hip Decreases vertebral ↓ Spine & hip fractures fractures by up to 35% Risk: heart attack, stroke, breast CA, blood clotsSide effects:Hypocalcemia (all FDA: if a woman needs a medicine for osteoporosis, butroutes), nasal irritation does not require estrogen for menopause symptoms, then(intranasal) a non-estrogen alternative should be used http://www.nof.org/awareness2/2007/images/Bone_Tool_Kit.pdf 77 78
  • 14. Selective Estrogen Receptor Modulators (SERMs) “Mock” Estrogen Benefits of estrogens without disadvantages Raloxifene (Evista) postmenopausal prevention & treatment of osteoporosis in women SERMs less effective than bisphosphonates Reduce bone loss, decrease fracture risk (esp spine) Side effects: blood clots, hot flashes 79 80 Bone mineral density test (BMD): Secondary Prevention Dual energy x-ray absorptiometry (DEXA)Diagnostic Tests Femoral neck predicts hip fx risk best Gold standard for fracture prediction Other sites: spine, wrist, or total body Results (compared with young adult mean) BMD 1 SD below mean (-1 S) = osteopenia BMD 2.5 SD below mean (-2.5 SD) = osteoporosis How to Diagnose Osteoporosis 81 82 Bone Mineral Density Test (BMD)
  • 15. Question 2.5 Standard DeviationsThe typical screening for osteoporosisinvolves:(A) Blood tests(B) Colonoscopy(C) Papanicolau test(D) Tonometry(E) Dual-energy x-ray absorptiometry Quick Case StudyMs. Youngs mother hadosteoporosis. She isconcerned about her own Nursing Interventionsrisk of osteoporosis. Herhealth history revealed adiet low in calcium and aninactive lifestyle most ofher life. She is white, 65years old, and small-framed. She hashypothyroidism.What are her risk factors?What do you recommendfor her? 88 Nursing InterventionsAvoid heavy lifting, jumping, and other activitiesthat could result in a fracture OsteoarthritisPrevent falls Slip-resistant footwear, adequate lighting, clutter-free environment, toilet grab bars, bedside commode Avoid: low seats, poor illumination, slippery floorsHandle gently when moving, exercising or liftingto avoid fractures Use lift sheet to reposition clientRange-of-motion exercises, ambulation 90
  • 16. Osteoarthritis: Degeneration of Osteoarthitis – Anatomical Joints DistributionLeading physical disability Several joints(older adults)Number one cause of pain Weight-bearing(older adults)Deterioration of joint joints (mostcartilage with formation of affected)new painful bone spurs(osteophytes) Can affect any jointRisks: older age, female, hxjoint injuries, obesity, Common: Knees,excessive use hips, vertebrae,Incidence fingersCauses Osteoarthritis: Tx & Nursing Osteoarthritis: Signs & Symptoms Interventions (NCP 24-1, pp 313-4)No systematic Goal: Relieve pain, preserve joint function, slow progression of diseasesymptoms Analgesics: acetaminophen, NSAIDsCrepitation Topical analgesics (capsaicin creams & rubs)Heberden nodes Rest, heat or ice, massage, acupunctureIncreased pain: Splints, braces, & canesdamp weather, Analgesic medication before therapies/activitiesextended use Proper body alignment, good body mechanics Nutritional considerations Osteoarthritis: Secondary/ Osteoarthritis: Primary Prevention Tertiary PreventionMaintain appropriate body weight; Weight reductionwarm-up exercises; good body Homemaker servicesmechanics; nutrition Physical therapy Joint replacement surgery (severeSensible exercise joint damage)Avoid repetitive stress, trauma Hip & knee most common Post-surgical care
  • 17. Nursing Diagnoses & Quick Case Study Interventions (NCP 24-1, p. 313)Marie is a 62-year old woman who was diagnosed with Chronic Pain r/t joint inflammation, stiffness, andosteoarthritis. She is 40 pounds overweight. fluid accumulationShe states that pain interferes with recreational activitiesand work. Weight management is difficult; she cannot Impaired Physical Mobility r/t pain and limitedjump or dance. Arthritis is affecting her knees, hips, joint movementhands, wrists and neck. Self-Care Deficit r/t pain or joint immobility20 years ago, Marie was in a car accident and spent Body Image Disturbance r/t joint abnormality,several months in the hospital. She had a steel rod placedin her left femur and a full cast on her right leg. She was immobility, altered self-care abilityin traction for two months. Self-Esteem Disturbance r/t changes in bodyWhat are her risk factors? appearance and functionWhat do you recommend for her? Key OutcomesThe patient will: Experience increased comfort & decreased pain Express positive feelings about himself or herself Perform ADLs within the confines of the disease

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