Normal changes of aging often bring about complaints of musculoskeletal pain and various joint limitations that may result in the loss of independence for the older person. Increased bone resorption and decreased bone formation causes the bones to lose calcium and decreases bone density. Significant alterations in human structure, function, biochemical patterns, and genetic patterns are responsible for the changes that are evident in the muscles, tendons, bones, and joints of the older person.
Significant alterations in human structure, function, biochemistry, and genetic patterns are responsible for the changes in the muscles, tendons, bones, and joints of the older person. An increasing challenge facing individuals as they age is the reduction of muscle mass and/or function, resulting from a reduction of protein synthesis and an increase in muscle protein degradation. This process is known as sarcopenia. By age 75, most people lose one half of the skeletal muscle mass they had at the age of 30. The decline in the number and size of muscle fibers and subsequent reduction in muscle mass decreases body strength: grip strength endurance declines. Muscle strength declines slowly, but by 50 years of age a decline in stamina is often noticed. *Healthy older adults experience only a slight decrease or decline in overall musculoskeletal function, but they can compensate for these minor functional consequences by maintaining an active lifestyle. * Physical activity is important for older adults to maintain health, preserve the ability to perform ADLs, and improve the general quality of life.
Muscle strength declines slowly, but by 50 years of age a decline in stamina is often noticed. By 80 years of age, the maximum muscle strength that the individual had in the mid-20s has decreased 65% to 85%. When added to the impaired capacity for muscle regeneration that occurs in late life, this can lead to disability, particularly in patients with diseases or organ impairment. Connective tissue changes reduce the flexibility of joints and muscles. Immobility and lack of exercise, increased levels of proinflammatory cytokines, increased production of oxygen free radicals or impaired detoxification, low anabolic hormone output, malnutrition and reduced neurological drive have been advocated as being responsible for sarcopenia. Muscle tone and tension decreases steadily after the third decade. * Physical activity is important for older adults to maintain health, preserve the ability to perform ADLs, and improve the general quality of life.
Hyaline cartilage, which lines the joints, erodes and tears with advancing age, allowing bones to be in direct contact with one another. Knee cartilage is subjected to a great deal of wear and tear, and the result is a thinning of about 0.25 mm per year. Thinning, damaged cartilage and diminished lubricating fluid result in discomfort and slowness of joint movement. Nonarticular cartilage, such as the ears and nose, grows throughout life, which may cause the nose to look large in relation to the face.
Each knee has two menisci. They are commonly called “the cartilages”, although this is not strictly accurate. There is one on the medial (inner) side of the knee and one on the lateral (outer) side of the knee. They are C or crescent shaped and serve to cup the femur as it sits on the tibia to improve the congruity of the joint. In some ways they act as shock absorbers of the knee. They are made up of a tough gristly material called fibrocartilage.
Ligaments, tendons, and joint capsules lose elasticity and become less flexible. There is a decrease in the range of motion of the joints due to changes in ligaments and muscles. Help with that ROM exercises. AVOID isometric exercises, however, in which the joint and muscle length do not change during contraction. These types of exercises do not increase joint flexibility, as they do not take the joint through the whole range of motion. Isometric exercises can also unduly strain the cardiovascular system of an older adult. During an isometric hold, blood pressure rises rapidly, and an overly long hold, or one performed with poor breath control, may result in fainting, stroke, or other injury. Examples of isometric exercise: static holds in some yoga positions, pilates, plank bridge, and side bridge.
The bone loss of normal aging has been described in two distinct phases. Type I, or menopausal bone loss, and type II, senescent bone loss. Menopausal bone loss is a rapid phase of bone loss that affects women in the first 5 to 10 years after menopause. Senescent bone loss is a slower phase that affects both sexes after midlife. These two phases are distinct in their clinical features, but in women there is eventual overlap, which leads to increased difficulty in differentiating the two phases. Other conditions may also contribute to skeletal deterioration in the older person and may alter the clinical symptoms.
With aging, bones become stiff, weak, and brittle, causing changes in appearance that are evident after the fifth decade.
Changes in appearance are evident after the fifth decade, and changes in height are the most obvious. At about 50 years of age the long bones of the arms and legs appear disproportionate in size due to the shrinking stature. An average loss of height is 1 to 2 cm every two decades, from about 20 to 70 years of age. The change in height is due to various processes that result in shortening of the vertebral column. Thinning of the vertebral discs occurs more commonly in midlife; in later years, there is a decrease in the height of individual vertebrae. As the older person enters the eighth and ninth decades, there is a more rapid decrease in vertebral height due to osteoporotic collapse of the vertebrae. The result is a shortening of the trunk and the appearance of long extremities.
As the older person enters the eighth and ninth decades, there is a more rapid decrease in vertebral height due to osteoporotic collapse of the vertebrae. The result is a shortening of the trunk and the appearance of long extremities.
Additional postural changes are kyphosis and a backward tilt of the head to make eye contact. The result is a forward bent, or “jutting out” posture, with the hips and knees assuming a flex position.
Joint pain and inflammation are not normal age-related changes in the musculoskeletal system .
Deleterious effects of inactivity – Changes in physiologic function: reduced pulse rate; increased cardiac workload; decreased aerobic capacity; decreased chest expansion and ventilation; reduced muscle strength, tone, and endurance; demineralization of bones (fractures); slower GI motility; slower metabolism & lymphatic circulation (swelling) Increased risk of complications: postural hypotension; hypostatic pneumonia; pressure ulcers; poor appetite; obesity; constipation; fecal impaction; incontinence; renal stone formation; urinary tract infection; joint stiffness, limited ROM Changes in mood and self-concept: increased feelings of helplessness, depression; perception of self as incapable, frail Increased dependency Reduced opportunities for socialization Maintaining a physically active state is an increasingly difficult task not only for older adults but also for many younger people. Fewer occupations require hard physical labor, and those that do often use technological innovations to perform the more strenuous tasks. Television viewing and spectator sports are popular forms of recreation. Automobiles, taxicabs, and buses provide transportation to destinations once conveniently reached by walking. Elevators and escalators minimize stair climbing. Modern appliances have considerably eased the physical energy expended in household chores. Youth are spending considerable amounts of time sitting in front of computer screens and playing video games. Growing numbers of Americans find that it is challenging to find the time for jogging or trips to the gym. Educating and encouraging persons of all ages to exercise regularly is an important way that gerontological nurses can influence the health of today’s and future generations of older people. All exercise programs should address: cardiovascular endurance, flexibility, and strength training. Essential to every health assessment is a review of the quality and quantity of exercise. Nurses should address identified exercise deficits by reviewing desirable exercise goals and strategies. Helping people to develop good exercise habits today promotes a healthier senior population in the future. Be creative in suggesting past-times that can stimulate movement. Regular physical activity can delay or prevent some of the age-related losses in cardiovascular function and improve maximal oxygen uptake. It can also lower resting systolic and diastolic blood pressure. Physical activity can increase muscle strength and flexibility and slow the rate of bone loss. Exercise can improve body tone, circulation, appetite, digestion, elimination, respiration, immunity, sleep, and self-concept. Participation in exercise programs can also provide opportunities for socialization and recreation.
The role of regular exercise in promoting health and preventing disease cannot be sufficiently emphasized. Benefits of physical activity include: Strengthens bones. Reduced risk of osteoporosis Reduced constipation/ improved digestion – getting up and moving around Promotion of more restful sleep. Improved sleep/ improved pain control Prevention of heart disease Reduction of elevated blood pressure Lower cholesterol levels Promotion of appropriate weight Enhanced opportunities for socialization Exercise preserves mobility – Promotes muscle strength and joint flexibility. Reduces the risk of falling by increasing agility. Motivation is important. Despite the many benefits of exercise among older adults, the amount of exercise generally decreases as one ages. Interventions to promote exercise include helping older adults to choose an exercise program that they enjoy and in which they are motivated to participate.
Investigate local resources to promote activity. Exercise programs are best followed if they match the individual’s interests and needs. Some people dislike playing organized sports but enjoy dancing, so helping them to find church and community groups that regularly sponsor evenings of dancing may do more to promote exercise than describing all the benefits of joining a tennis or bowling team. Likewise, people who may not be able or willing to work out at a gym may be open to lifting weights or jogging on a mini-trampoline in their homes. A range of options should be considered, such as walking, swimming, and strength training, yoga, and aerobic exercises. People can take advantage of opportunities to enhance physical activity during daily routines, such as climbing stairs instead of taking an elevator, parking the car farther away from the destination to increase walking, taking the dog on a longer route during regular walks, and doing one’s own yard work and housecleaning. It is advisable to pace exercises throughout the day and avoid fatigue from exercising because of potential muscle pain and cramping. Morning stretching exercises loosen stiff joints and muscles, which encourages activity, whereas bedtime exercise promote relaxation and encourage sleep. If an older person is not accustomed to a great deal of physical activity, they should begin exercises gradually and increase them according to individual progress. Longer periods must be allowed for the older person to perform exercises, and rest periods should follow activity. Warm water and warm washcloths or towels wrapped around the joints may ease joint motion and facilitate exercising. The thinner, weaker, and more brittle bones of older people heighten the risk for fractures. Exercise that stress an immobilized joint, strenuous sports, and running and jumping exercises must be avoided to prevent trauma. Older adults with cardiac or respiratory problems should seek advice from their physician about the amount and type of exercise best suited for their unique capacities and limitations. People who are unable to participate in an aggressive exercise program can stretch and exaggerate movements during routine activities to promote joint mobility and circulation. See pp 304-305. Nutrition – adequate calcium (minimum 1500 mg daily); well-balanced diet; lose weight – obesity places strain on the joints. Weight reduction will ease musculoskeletal discomforts and reduce limitations and should be promoted as a sound health practice for persons of all ages.
There is a great deal of individual variation in muscle function in the older person. Muscle function remains trainable well into advanced age, and the regenerative function of muscle tissue remains normal in the older person. Jack LaLanne, now age 94. Jack La Lanne hosted a nationally syndicated TV exercise show from 1951 until 1985, preaching good nutrition and physical fitness long before it was popular in the United States. Impressed by a lecture on nutrition which he heard at age 15, La Lanne eventually opened a health club in Oakland, California in 1936. He invented what are considered to be the first modern weight machines for exercising, and his TV show was decades ahead of its time. To draw attention to the powers of physical fitness, La Lanne performed many famous publicity stunts over the years, including doing 1,033 push-ups in 23 minutes and, on his 70th birthday, towing 70 boats carrying 70 people while swimming handcuffed and shackled.
The lower extremity muscles tend to atrophy earlier than those of the upper extremity. Routine daily activities most likely keep the upper extremities functioning on a regular basis. By comparison, walking may be limited to a small living area and for short periods of time. Despite age-related change in muscle strength, the older adult can usually perform functional activities of daily living and demonstrate adequate muscle function when climbing stairs, walking a straight line, and rising from a sitting or squatting position.
False. An older adult’s unique capacities and limitations, as well as interests, will dictate the appropriate activities for that individual. Stereotyping older adults by assuming they all enjoy exactly the same activities violates the underlying principle of individualized care and severely limits the opportunities available for older persons. “First Job” exercise – Job as RN @ Senior Citizen Center. Box 24-2, page 302 – Guidelines for Exercise Programs for Older Adults. Drink water before and after exercise – to prevent dehydration. Clothing should allow for easy movement and perspiration. Athletic shoes – for support and protection. Avoid outdoor exercise in extremely hot or extremely cold weather. Enclosed shopping malls – sheltered places for walking during extremes of weather. Exercise with a partner – encouragement, socialization, and safety. Stop exercising and seek help if you experience chest pain/ tightness, shortness of breath, dizziness or lightheadedness, or palpitations during exercise. Need longer rest periods, warm up periods, cool down periods.
“ B” Inactivity increases the risk of falls, due to the loss of strength and mobility.
Osteoporosis is the most prevalent metabolic disease of the bone; it primarily affects adults in middle to later life, with some groups being at higher risk than others. Demineralization of the bone occurs, evidenced by a decrease in the mass and density of the skeleton. Osteoporosis may cause kyphosis and a reduction in height. Kyphosis is a convex curvature of the spine that causes loss of height and chronic back pain as well as abdominal protuberance, gastrointestinal discomfort, and pulmonary insufficiency. The person may experience spinal pain, especially in the lumbar region. The bones tend to fracture more easily. However, patients are often asymptomatic and unaware of the problem until it is detected by radiography or there is a pathologic fracture.
Osteoporosis is the most common metabolic disease, affecting 50% of women during their lifetime. Current estimates suggest that 44 million people in the US have osteoporosis. 19% are receiving adequate care. Osteoporotic fractures are those that occur in situations where healthy people would not normally break a bone; they are therefore regarded as fragility fractures . Typical fragility fractures occur in the vertebral column, hip and wrist.
The three factors most likely to contribute to decreased bone mass in the older person are (1) failure to reach peak bone mass in early adulthood, (2) increased bone resorption, and (3) decreased bone formation. Any health problem associated with inadequate calcium intake, excessive calcium loss, or poor calcium absorption can cause osteoporosis.
Many of the following potential causes are problems commonly found among older persons: Inactivity or immobility – A lack of muscle pull on the bone can lead to a loss of minerals, especially calcium and phosphorus. This particularly may be a problem for limbs in a cast. Diseases – Cushing syndrome; hyperthyroidism; diverticulitis; diabetes mellitus; end-stage renal disease Reduction in estrogen or testosterone (anabolic sex hormones) – Decreased production or loss of estrogens and androgens may be responsible for insufficient bone calcium; therefore, postmenopausal women are at high risk Diet – insufficient amount of calcium, vit D, vit C, protein, and other nutrients. Excessive consumption of caffeine or alcohol decreases the body’s absorption and retention of calcium. Drugs – heparin, furosemide, thyroid supplements, corticosteroids, and magnesium- and aluminum-based antacids can lead to osteoporosis.
Osteoporosis is characterized by low bone mass and deterioration of bone tissue leading to compromised bone strength that increases the risk for fractures. The bone strength reflects the integration of bone density and quality. Bone density is defined as grams of mineral per area or volume. Bone quality is explained as the architecture, turnover, and damage accumulation and mineralization. At present, bone strength cannot be directly measured. Bone mineral density (BMD) is a replacement measure that accounts for 70% of the bone strength.
Bone loss in the older person is considered normal when bone mineral density is within 1 standard deviation (SD) of the young adult mean. Bone density between 1 and 2.5 SD below the young adult mean is termed osteopenia. Osteoporosis is defined as bone density 2.5 SD below the young adult mean.
Normal and osteoporotic bone structure
Osteopenia and osteoporosis result in high mortality and morbidity. Estimated health costs are over $14 billion annually. Reduced BMD is highly predictive of spinal and hip fractures in women and men. In the United States, the number of osteoporotic fractures is 1.5 million annually. The greatest majority are fractures of the vertebrae, with about 700,000 individuals suffering from this injury each year. Hip fractures affect 300,000 people annualy and wrist fractures about 250,000.
20% of persons (1 in 5) who have an osteoporosis-related fracture die within 1 year of the hip fracture occurrence. 25% are in nursing home for AT LEAST one year. Only one third (33%) regain their prefracture mobility and independence level.
Nonmodifiable risk factors for osteoporosis include increased age; female sex; white or Asian race; positive family history of osteoporosis; thin body habitus.
Modifiable risk factors for osteoporosis include low calcium intake, prolonged immobility, excessive alcohol intake, cigarette smoking, and long-term use of corticosteroids, anticonvulsants, or thyroid hormones.
The FRAX ® tool has been developed by WHO to evaluate fracture risk of patients. It is based on individual patient models that integrate the risks associated with clinical risk factors as well as bone mineral density (BMD) at the femoral neck. The FRAX ® models have been developed from studying population-based cohorts from Europe, North America, Asia and Australia. In their most sophisticated form, the FRAX ® tool is computer-driven and is available on this site. Several simplified paper versions, based on the number of risk factors are also available, and can be downloaded for office use. The FRAX ® algorithms give the 10-year probability of fracture. The output is a 10-year probability of hip fracture and the 10-year probability of a major osteoporotic fracture (clinical spine, forearm, hip or shoulder fracture).
Osteoporosis is a slow-acting metabolic bone disorder in which bone tissue mass is reduced causing weakness in the skeletal system and an increase in the risk of bone fractures. Primary osteoporosis is the most common condition. It is associated with the aging process and lifestyle. Some factors include menopause, lack of exercise, nutritional deficiency, tobacco smoking, excessive alcohol consumption. Primary osteoporosis is divided into type I, menopausal bone loss; and type II, senescent bone loss. Before menopause, sex hormones (estrogen in women and testosterone in men) protect the body from bone loss. After menopause in women (or after castration in men), there is an increased loss of bone mass of up to 10-fold. The loss of bone matrix (resorption) occurs more rapidly than bone growth (deposition), resulting in the loss of bone density or osteoporosis. * Women lose 2% of their bone mass every year in the first five years after menopause. This is due to increased bone resorption and decreased bone formation. By age 70, susceptible women have lost an average of 50% of their peripheral cortical bone mass from the shafts of the long bones. Vertebral and Colles’ fractures are the result of menopausal bone loss. In senescent bone loss, there is a decrease in the actual amount of bone formed during remodeling. This occurs in both sexes and is due to the aging process. Osteoblast formation, bone mineral density, and the rate of bon formation continuously decrease, leading to a decrease in bone wall thickness – especially in trabecular (Cancellous) bone. Trabecular bone mass is found in the vertebrae, pelvis, and shafts of long bones. Vertebral and hip fractures may be the result of senescent bone loss. Secondary osteoporosis is associated with other types of medical conditions and treatment like: hypogonadism , cancer, chemotherapy and gastrectomy. Secondary osteoporosis, which is less common in elderly adults, may be caused by hyperparathyroidism, malignancy, immobilization, gastrointestinal disease, renal disease, or drugs that cause bone loss. Specific causes of secondary osteoporosis that commonly affect elderly adults are vitamin D deficiencies and the use of glucocorticoid drugs.
A break across the end of both of the lower arm bones, a Colles' fracture results in a backward and outward position of the hand in relation to the wrist.
Cortical & trabecular (cancellous) bone mass loss. Fractures in the spine or vertebral can lead to loss of height, severe back pain, and deformity.
In most cases, women in their third decade have lower peak bone mass than men. Women generally have thinner bones, so they have less in the “bone bank.” In the fifth decade during perimenopause, rapid withdrawal from the bone bank leaves the woman’s bones even more depleted. The longer life span for women further extends the risk for osetoporosis. Signs and symptoms of osteoporosis are usually absent. Osteoporosis is a silent disease; the first sign is often a fracture.
Kyphosis has caused this elderly woman to stoop very low. This reduction of chest cavity size makes oxygen exchange difficult.
Non-pharmacological treatment of osteoporosis for the older person focuses on assessment of risk factors and education to promote positive behaviors related to healthy bones.
Lifestyle changes such as increase in exercise, weight loss, and eating a healthy diet are important for all elderly adults. They are especially indicated for those with musculoskeletal problems to prevent disuse caused by immobility. Older persons should see their primary care provider, nurse, or other health professional for instructions or limitations related to fitness before beginning or changing normal routines. Nonpharmacological treatment of osteoporosis for the older person focuses on assessment of risk factors and education to promote positive behaviors related to healthy bones. Modifiable risk factors include low calcium intake, prolonged immobility, excessive alcohol intake, and cigarette smoking. Prevention programs should be aimed at older persons with risk factors and those with osteoporosis as determined by bone density of 2 SD below the young adult mean. However, all older people will benefit from positive lifestyle changes for osteoporosis such as diet, exercise, and other risk modifications. The National Osteoporosis Foundation recommendations include the following: All women should be educated on the risk factors for osteoporosis. One-half of all White women will experience an osteoporotic fracture during their lifetime. Any woman who has had a fracture should have a BMD test to determine osteoporosis diagnosis. Any woman under 65 who has any risk factors for osteoporosis should have a BMD test, and all women over 65 should have a BMD test. Preventive activities are important for older men (especially those on steroids). Many risk factors (with the exception of estrogen) are the same for men. Most men have bigger bones than women so they have increased protection.
Although loss of bone cannot be significantly reversed, further loss can be prevented if the patient follows a regimen of calcium and vitamin D supplementation and exercise. Efforts should be made to keep patients with osteoporosis ambulatory to prevent further loss of bone substance as a result of immobility. The following lifestyle modification activities to prevent or treat osteoporosis may be suggested by the gerontological nurse: Promote a diet with adequate calcium and vitamin D Calcium intake tends to decrease in older people, sometimes due to lactose intolerance. In addition, decreased absorption of calcium from the gastrointestinal tract and changes in vitamin D metabolism contribute to the decrease in calcium absorption of the older person. All older persons should obtain an adequate intake of dietary calcium and vitamin D. Calcium supplements may slow the rate of bone loss. Calcium intake of at least 1,500 mg/day is recommended. Patients should be instructed to take calcium with food to minimize side effects and enhance absorption. Vitamin D is necessary for calcium absorption into the bloodstream. The vitamin D requirement is 400 to 800 IU/ day. Elderly adults, in whom vitamin D absorption may be reduced, should take 800 U of vitamin D daily. Many supplement options are available. To obtain vitamin D naturally through synthesis in the skin from exposure to sunlight requires being in the sun more than 20 minutes a day. A diet rich in protein and calcium is encouraged. Encourage weight-bearing exercise . The older person should participate in weight-bearing exercises to improve muscles strength, mobility, and agility, and to reduce the risks of falls. Moderate amounts of exercise are important to build up and maintain bone mass. Weight-bearing exercises stimulate bone formation (osteoblasts) and strengthen bones by increasing bone density. The best exercises are weight-bearing exercises that force an individual to work against gravity. These exercises include walking, dancing, weight training, stair climbing, tennis, and gardening. Walking is preferred to high-impact aerobics or running, both of which may put too much stress on the bones and result in stress fractures. Walking 30 minutes, three times a week, is recommended. Swimming and water aerobics are not weight-bearing exercises. These don’t have the impact bones need to reduce mineral loss. Isometric exercise – joint and muscle length do not change during contraction. Done in static “yoga-type” positions, rather than full range of motion. Not the best way for elders to maintain muscle and bone tissue, and places undue strain on the cardiovascular system (can elevate blood pressure and induce fainting). Astronauts and weightlessness (spaceflight osteopenia) – Bone demineralization and muscle loss and deconditioning. In space, astronauts lose calcium primarily from the weight-bearing bones like the hips, spine, ankles and upper femur. It was noted on the Skylab missions of the 1970s and by the crews of the Russian space station Mir that calcium loss begins about ten days into the flight. It takes 2.5 times longer than the duration of the flight to recover lost bone. One group of Mir space station crew members, after a 115-day flight, took three months for their bodies' calcium and bone levels to return to normal. Reduce or eliminate smoking . Cigarette smokers tend to be thinner and experience more fractures. Smoking depletes the body of ascorbic acid and exposes it to toxins that damage bone and interfere with calcium absorption. Tobacco use is associated with decreased bone mass and an increased risk of hip fracture in both men and women. Reduce or eliminate consumption of beverages containing alcohol, caffeine, and phosphorus. Regular consumption of 2 to 3 ounces of alcohol a day may increase the degree of osteoporosis, even in young men and women. Alcohol abuse is responsible for decreased bone mass and increased fractures. In addition, older persons with chronic alcoholism frequently use aluminum-containing antacids to treat gastrointestinal symptoms, which leads to calcium loss. The combination of alcohol and aluminum-containing antacids contributes to osteoporosis development.
Exercise is especially important for older clients. Exercise slows muscle atrophy that occurs with normal aging and promotes flexibility and strength , which improves balance and mobility and decreases the likelihood of falls . Weight-bearing exercises help build bone strength and prevent osteoporosis. A weight-bearing exercise is any activity that requires you to move around and stand on your own two feet. Exercise in which you support your weight or lift weights. When your feet and legs bear all of your weight -- as they do when you're walking -- your muscles and bones become stronger because they're working against gravity. A brisk walk is one of the best weight-bearing exercises. Emphasize exercises that focus on good speed and rhythm. Low weights, high repetitions. Keep resistance exercises at a low level. Avoid isometric exercises – These are muscle-building exercises (or a system of musclebuilding exercises) involving muscular contractions against resistance. Be creative in suggesting past-times that can stimulate movement.
Near “zero-gravity” in the water.
Treatment depends on the underlying cause of the disease and may include calcium supplements, vitamin D supplements, progesterone, estrogen, anabolic agents, fluoride, or phosphate. Bisphosphonates (biz-phos-phon-ates), selective estrogen receptor modulators (SERMS), and calcitonin are antiresorptive drugs prescribed for the treatment and prevention of osteoporosis in both men and women. Antiresorptive therapy preserves or increases bone density, and decreases the rate of bone resorption.
Bisphosphonates, selective estrogen receptor modulators (SERMS), and calcitonin are antiresorptive drugs prescribed for the treatment and prevention of osteoporosis in both men and women. Antiresorptive therapy preserves or increases bone density, and decreases the rate of bone resorption. Bisphosphonates are another beneficial new category of drugs that are primarily antiresorptive (I.e., they prevent or significantly slow the normal osteoclastic activity responsible for the resorption of bone.)
Bisphosphonates – alendronate (Fosamax) and risedronate (Actonel) – are potent drugs that inhibit osteoclastic activity and have decreased the incidence of vertebral and nonvertebral fractures by 40% to 50% in postmenopausal women. When the manufacturers of Fosamax say that the drug can reduce fractures by up to 50% in high-risk women, they are referring to results of a 2004 study showing relative risk reduction among women who, as a group, are already highly likely to fracture before they are even selected for the study. The study reveals that out of thousands of high-risk postmenopausal women (those with osteoporotic bone density and a history of previous fracture), about twice as many (2.2%) of the placebo group will fracture as those taking the drug (1.1%). Because 1.1% indeed is half of 2.2%, the drug’s manufacturer can advertise that the drug reduces hip fractures by 50% — which is the relative risk reduction (that is, a comparison of the number of people who fractured in both groups). But let’s not forget that both groups contained many more people who did not fracture at all , and if you include them in your comparison, you get what’s called the absolute risk reduction — a paltry 1.1% (2.2 minus 1.1) — in those taking Fosamax compared to those not taking anything. A 2008 review of more than 40 years’ worth of data on more than 12,000 women using alendronate shows that overall, there was a mere 1-2% absolute risk reduction with its use. Both of these drugs have been approved for the prevention of postmenopausal osteoporosis in women and for the treatment of osteoporosis in men and postemenopausal women. Many people who take these drugs experience adverse gastrointestinal symptoms, such as esophageal irritation, heartburn, and difficulty swallowing. Calcium should not be taken at the same time as bisphosphonates since this will interfere with the absorption of the drug.
These biphosphonate drugs are the same chemicals that are used to clean the soap scum from your bath tub. They work by killing osteoclasts in the bone which are responsible for remodeling the bone. The theory is that if you can prevent bone loss you will have stronger bone. Unfortunately, the theory doesn't hold up. The osteoclasts are metabolically poisoned (killed) and the bone does become denser. Unfortunately the dense bone does not translate to stronger bone. Although the bone is denser it is actually more brittle and more susceptible to fracture.
Osteonecrosis of the jaw is a rare, but serious problem which may develop following dental procedures, such as tooth extractions. The gums fail to heal, leading to exposed jaw bone and infection. As a result, it is often necessary for dead or decayed portions of the jaw bone to be surgically removed. Fosamax inhibits bone turnover, which could lead to permanent bone decay. Studies have shown that the popular osteoporosis drug could increase the risk of the painful and potentially disfiguring jaw injury, known as osteonecrosis of the jaw (ONJ, Dead Jaw or Bis-Phossy Jaw) . Other studies have indicated that the medication could also lead to necrosis of the hip, knee and shoulder.
September 14 2010 An expert panel has concluded that use ofcertain bisphosphonate drugs such as Fosamax® , Boniva® & Actonel® used to treat osteoporosis can increase the risk of a specific type of rare leg fracture.
FOSAMAX must be taken at least one-half hour before the first food, beverage, or medication of the day with plain water only. Waiting less than 30 minutes, or taking FOSAMAX with food, beverages (other than plain water) or other medications will lessen the effect of FOSAMAX by decreasing its absorption into the body. FOSAMAX should only be taken upon arising for the day. To facilitate delivery to the stomach and thus reduce the potential for esophageal irritation, a FOSAMAX tablet should be swallowed with a full glass of water (6-8 oz). Patients should not lie down for at least 30 minutes and until after their first food of the day. FOSAMAX should not be taken at bedtime or before arising for the day. Failure to follow these instructions may increase the risk of esophageal adverse experiences.
Fosamax should be taken weekly, 30 minutes before the intake of food or fluids. For the first 30 minutes after taking a Fosamax tablet, the patient should not lie down or recline, not eat or drink anything other than a full glass of plain water, and should not take any other medicines or preparations including vitamins, calcium, or antacids.
A relatively recent drug that has been shown beneficial in producing modest increases in bone mass is a synthetic form of calcitonin, a hormone produced in the thyroid that is a powerful inhibitor of osteoclastic activity (the cells that reabsorb bone). Calcitonin is generally considered to be a safe but less effective treatment for osteoporosis than bisphosphonates. It has been found to decrease spinal fractures by up to 35%. It may be given intranasally or subcutaneously. It is approved for women who are at least 5 years post-menopausal.
Estrogen is usually prescribed with progestin because taking estrogen by itself increases a woman’s risk for cancer of the uterus. Estrogen accelerates the death of osteoclasts, while prolonging the life of osteoblasts. In postmenopausal women between the ages of 50 and 60, there is a decrease in estrogen levels, bone resorption increases and the formation process cannot keep up. Bone replacement with new tissue will be slowed and bone mass will be gradually decreased. Estrogens also increase intestinal absorption of calcium and reabsorption of calcium from the renal tubule. Although estrogen can reduce bone loss, large studies have found that it increases a woman’s risk of stroke, blood clots, and other problems. As a result, the FDA strongly recommends that if you need a medicine for osteoporosis and you do not require estrogen for menopause symptoms, then you should look for a non-estrogen alternative.
For many years, hormone replacement therapy (HRT) has been taken by post-menopausal women to reduce the risk of fractures and treat the symptoms of menopause. Many women believed that they gained extra benefits such as a reduction of cardiac events, cognitive changes, and mortality. However, many of those assumptions have been challenged. In 2000, the FDA withdrew its support of estrogen replacement for the treatment of osteoporosis. More recent research results continue to raise concerns. Recent results have demonstrated that postmenopausal women taking estrogen plus progesterone have an increased risk of heart attack, stroke, breast cancer, and blood clots.
“ Mock” estrogen. SERMs have been developed to provide the benefits of estrogens without the disadvantages. Mechanism of action: Binds to estrogen receptors, producing estrogen-like effects on bone, resulting in reduced resorption of bone and decreased bone turnover. Raloxifene (Evista) has been approved by the US Food and Drug Administration (FDA) for the prevention and treatment of osteoporosis in postmenopausal women. SERMs are less effective antiresorptive drugs than bisphosphonates, but do reduce bone loss and decrease fracture risk. The only SERM approved for osteoporosis is raloxifene (Evista®). Raloxifene increases the risk of blood clots, swelling, and hot flashes.
Various laboratory and radiological tests can assist in the diagnosis and evaluation of various musculoskeletal problems in the older adult. Some of the laboratory and radiological tests that can assist in the diagnosis and evaluation of musculoskeletal problems in the older adult include the following: Bone mineral density test/ bone and joint scanning Bone mass can be assessed through several different types of noninvasive techniques including single-photon absorptiometry (SPA); dual-photon absorptiometry (DPA); bone and joint radiography and quantitative computerized tomography (CT); and dual-energy x-ray absorptiometry (DEXA), which is the most widely used and recommended method. Bone Mineral Density Test – Dual energy x-ray absorptiometry (DEXA) is a common method to measure bone mineral density. DEXA of the proximal femur (femoral neck) predicts hip fracture risk best and is the gold standard for fracture prediction. Other sites tested include spine, wrist, or total body. Bone mineral density is measured by having the patient lie on a table. An arm of the machine passes over the body part that is being tested. There is no contact of the machine with the patient, and radiation exposure is minimal. The results are expressed in standard deviations, and compare the patient’s results with the young adult mean. Results can also be compared with a norm group of the same age. For instance, a BMD of 1 SD below the (-1 SD) indicates osteopenia. A BMD of 2.5 SD below the mean (-2.5 SD) indicates severe osteoporosis, according to the World Health Organization. There are many pitfalls in the current densitometry systems. 1. Elderly adults often have bone changes due to arthritis or disk disease in the lumbar spine, which complicates the measurement of the BMD. 2. The cutoffs to determine diagnosis (-1 SD, etc.) are arbitrary and must be considered in light of other factors. 3. The site of the measurement changes the relative risk. Femoral neck considered most accurate. BMD results vary with technique and the position of the patient Current criteria are based on postmenopausal White women and do not reflect sexual or cultural diversity.
Bone density tests are usually done on bones in the spine (vertebrae), hip, forearm, wrist, fingers and heel.
Dual-energy x-ray absorptiometry is used to screen bones to see if they have become dangerously porous.
1-2.5 osteopenia 2.5 and beyond – osteoporosis
The nurse must advise the patient to avoid heavy lifting, jumping, and other activities that could result in a fracture. Persons providing care for these patients must remember to be gentle when moving, exercising, or lifting them because fractures can occur easily. Compression fractures of the vertebrae are a potential complication of osteoporosis. Range-of-motion exercises and ambulation are important to maintain function and prevent greater damage. The bodies of persons with osteoporosis must be handled gently to avoid fractures.
Osteoarthritis is the leading cause of physical disability in older people. It is the number one cause of pain among older adults. Osteoarthritis is a predominately degenerative joint disease, affecting more people than any other form of arthritis. It is not a systemic disease like rheumatoid arthritis. It is a degenerative cartilage disorder, plus a problem involving of all the tissues involved in maintaining joint stability - the functional joint unit. Osteoarthritis is characterized by progressive loss of cartilage and formation of new bone (painful bone spurs) at the joint surfaces. The body is trying to compensate with the formation of the new bone to better distribute weight across a joint surface. However, the bone spurs only make things worse as bone spurs can become restrictive and painful. As the joint surface wears away it sheds wear particles which stimulate the joint lining to produce fluid, causing the knee to swell. When the articular cartilage wears through, the underlying bone becomes exposed. The bone loses shape and thickens at the rims of the joint, producing bony spurs called osteophytes. The exposed bone rubs against exposed bone when walking and this causes pain - often described as a toothache type pain. As these things happen, the joint loses its smooth functioning, becoming stiff and painful. In advanced stages of osteoarthritis the joint may be destroyed altogether and/or become dislocated. This problem occurs increasingly with advanced age and affects most persons over age 55 to some extent. It affects approximately 46.4 million Americans, 8.8% of whom report an arthritis-related disability. Factors that increase your risk of osteoarthritis include: Older age (over 50). Osteoarthritis typically occurs in older adults. People under 40 rarely experience osteoarthritis; Sex. It occurs in women more than men. Bone deformities. Joint injuries. Injuries, such as those that occur when playing sports or from an accident, may increase the risk of osteoarthritis; Obesity. Carrying more body weight places more stress on your weight-bearing joints, such as your knees; Certain occupations. If your job includes tasks that place repetitive stress on a particular joint, that may predispose that joint toward eventually developing osteoarthritis; Other diseases. Having gout, rheumatoid arthritis, Paget's disease of bone or septic arthritis can increase your risk of developing osteoarthritis. Unlike rheumatoid arthritis, osteoarthritis does not cause symmetrical inflammation. It is not systemic and not an autoimmune condition. The problem is acquired as a consequence of metabolic, genetic, mechanical and other influences. The involvement by the disease on the cartilage, results in secondary effect on the joint capsule, synovium, and periosteal nerve endings. It is these processes that result in pain, with further impact by stress, depression or other psychological factors that influence chronic pain. Causes: Excessive use of the joint, trauma, obesity, low vitamin D and C levels, and genetic factors.
Usually, osteoarthritis affects several joints rather than a single one. Weight-bearing joints are most affected, the common sites being the knees, hips, vertebrae, and fingers.
Systemic symptoms do not accompany osteoarthritis. Crepitation on joint motion may be noted, and the distal joints may develop bony nodules (bony bumps on the joint closest to the fingernail - Heberden nodes; bony bumps on the middle joint of the finger are known as Bouchard’s nodes, more typical of rheumatoid arthritis). The patient may notice that the joints are more uncomfortable during damp weather and periods of extended use. Although isometrics and mild exercises are beneficial, excessive exercise will cause more pain and degeneration.
Nursing goal for treatment of OA is aimed at: relieving pain and preserving or restoring function. Analgesics may be prescribed to control pain. Acetaminophen is the first drug of choice because of its safety over nonsteroidal anti-inflammatory drugs (NSAIDs). Because individual response to analgesics varies, nurses should assess the effectiveness of various analgesics for the patient. Topical analgesics (e.g., creams or rubs), which are available without a prescription, may be applied directly to the affected joint to help relieve pain. Topical analgesics should not be used in combination with heat therapy, because of an increased risk for serious burns. Rest, heat or ice, ultrasound, and gentle massage help relieve joint aches. Acupuncture is becoming more popular as a nonpharmacological management strategy. It has been shown to bring about short-term relief. Splints, braces, and canes provide support and rest to the joints. Some research suggests that oral calcitonin may effectively protect postmenopausal women from the ongoing pain and ultimate disability of joint destruction associated with osteoarthritis and may provide some hope. Adequate pain medication before therapies and activities and monitor for results. The nurse should emphasize the importance of maintaining proper body alignment and using good body mechanics when educating the patient. Cold water fish and other foods high in the essential fatty acids have anti-inflammatory effects and should be abundant in the diet. Vitamins C, D, and E have shown some evidence of reducing symptoms. The OTC supplements glucosamine and chondroitin have proved helpful for some people. Nurses must exercise caution in the administration of supplements and provide teaching regarding the possible danger of these complimentary therapies because little is known about the interaction of these medications with prescription or OTC medications.
Primary/ secondary prevention: appropriate body weight; warm-up exercises; maintain proper body alignment; good body mechanics; proper nutrition Sensible exercise Avoid repetitive stress, trauma
Weight reduction may improve the obese patient’s status and should be encouraged. Homemaker service – relive patient of strenuous activities that cause the joints to bear weight. Occupational and physical therapists can be consulted for assistive devices to promote independence in self-care activities. If other treatments fail to improve the condition or the person suffers severe functional limitation or pain, arthroplasty may be indicated. Arthroplasty, or joint replacement, can be done to restore joint motion, improve function, and reduce pain. Joint replacement surgery involves the reconstruction or replacement of a joint, commonly the hip or knee. However, arthroplasty can be performed on any joint, if needed. This procedure usually is performed in patients who have severe disease and are over the age of 50. Following surgery, the new joint (which is comprised of man-made components) usually lasts 20 to 30 years. Joint replacement among older adults with OA is gaining in popularity. At one time, older people were not considered good candidates for arthroplasty; however, thinking has changed and increasing numbers of people over the age of 65 are having joint replacements. Older adults in their 80s and 90s typically have these procedures. Although the rehabilitation may be long and intense, joint replacements bring new mobility and have the potential to greatly improve quality of life. This procedure is not advised for patients with neutropenic joints, joint sepsis, or persons who are morbidly obese or have dementias or other conditions that would interfere with their ability to cooperate with rehabilitation therapy. Conditions such as peripheral vascular disease and diabetes mellitus increase the risk for infection and interfere with wound healing. Hip replacement surgery is common and greatly decreases pain and improves mobility among older adults. Prosthesis may become dislodged if early adduction of hip is sustained. As moderate to severe pain often is present postoperatively, analgesics are administered around the clock. Arthroplasty is associated with a high risk of DVT and pulmonary embolism for older patients; Lovenox or warfarin may be used prophylactically. Need to advice of precautions related to anticoagulation therapy. Patients receive specific instructions pertaining to their exercise, weight-bearing, and activity restrictions. Nurses must see that patients and their caregivers understand instructions and adhere to the plan of care to ensure a successful outcome for the surgery.
Low-intensity but regular activity (water exercise, aerobic walking)
The most common nursing diagnosis (ND) for the older person with musculoskeletal problems is impaired physical mobility. Defined as “the state in which an individual experiences a limitation of ability for independent physical movement” Major defining characteristics Inability to purposefully move within the physical environment Limited range of motion Acute pain related to progression of inflammation; (c) chronic pain related to joint abnormalities fatigue related to pain and systemic inflammation; (e) body image disturbance related to chronic illness, joint deformities, and impaired mobility; and, (f) ineffective coping related to personal vulnerability in a situational crisis.
Mobility spring 2012 abridged
Mobility NURS 4100 Care of the Older Adult Spring 2012 Joy Shepard, PhD(c), MSN, RN, CNE, BC
Objectives <ul><li>Describe the effects of aging on musculoskeletal function </li></ul><ul><li>List the benefits of activity </li></ul><ul><li>Describe factors contributing to, symptoms, treatment, and related nursing care for fractures, osteoporosis, and osteoarthritis </li></ul><ul><li>Identify ways to reduce risks of injury associated with musculoskeletal problems </li></ul>
Normal Changes of Aging Musculoskeletal System (pp 55-56) <ul><li>Decreased height </li></ul><ul><li>Decreased ROM joints </li></ul><ul><li>Increased postural sway/ difficulty balance </li></ul><ul><li>Shrinking vertebral discs, slight kyphosis </li></ul><ul><li>Loss of bone mass, bones more brittle (increased resorption) </li></ul><ul><li>Muscle atrophy/ decreased lean body mass </li></ul><ul><li>Joint degeneration (cartilage surface) </li></ul><ul><li>Foot problems: bunions, corns, calluses </li></ul>
Effects of Aging: Muscles <ul><li>Decline in size & number of muscle fibers </li></ul><ul><li>Sarcopenia: reduction in muscle mass & function (by age 75) </li></ul><ul><ul><li>Reduction in protein synthesis </li></ul></ul><ul><ul><li>Increase in muscle protein degeneration </li></ul></ul><ul><li>Decreased strength </li></ul><ul><ul><li>Slow decline </li></ul></ul>
Effects of Aging: Muscles <ul><li>Decline in endurance/ stamina </li></ul><ul><ul><li>Decreased by age 50 </li></ul></ul><ul><ul><li>Decreased 65-85% of midtwenties by age 80 </li></ul></ul><ul><li>Can lead to disability </li></ul><ul><li>Causes </li></ul><ul><li>Tone & tension </li></ul><ul><ul><li>Decreases after age 30 </li></ul></ul><ul><ul><li>Reduced flexibility </li></ul></ul>
<ul><li>Cartilage </li></ul><ul><ul><li>Hyaline cartilage (joint lining) </li></ul></ul><ul><ul><ul><li>Lines joints </li></ul></ul></ul><ul><ul><ul><li>Erodes/ tears with advancing age </li></ul></ul></ul><ul><ul><ul><li>Bone to bone contact </li></ul></ul></ul><ul><ul><li>Knee cartilage </li></ul></ul><ul><ul><ul><li>Normal wear/ tear </li></ul></ul></ul><ul><ul><ul><li>Thins ~ 0 . 25 mm/year </li></ul></ul></ul><ul><ul><ul><ul><li>Discomfort, slow joint movement </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Diminished joint lubricant </li></ul></ul></ul></ul><ul><ul><li>Nonarticular cartilage (ears & nose) </li></ul></ul><ul><ul><ul><li>Grows throughout life </li></ul></ul></ul>Joints, Ligaments, Tendons, and Cartilage: Normal Changes with Aging
<ul><li>Ligaments, tendons, and joint capsules </li></ul><ul><ul><li>Lose elasticity </li></ul></ul><ul><ul><li>Less flexible </li></ul></ul><ul><ul><li>Joint ROM decreases </li></ul></ul>Joints, Ligaments, Tendons, & Cartilage: Normal Changes with Aging
Skeleton: Trajectory of Bone Loss <ul><li>Two phases bone loss </li></ul><ul><ul><li>Type I (menopausal bone loss) </li></ul></ul><ul><ul><ul><li>Rapid </li></ul></ul></ul><ul><ul><ul><li>Affects women </li></ul></ul></ul><ul><ul><ul><li>Occurs first 5-10 years after menopause </li></ul></ul></ul><ul><ul><li>Type II (senescent bone loss) </li></ul></ul><ul><ul><ul><li>Slower phase </li></ul></ul></ul><ul><ul><ul><li>Affects both sexes after midlife </li></ul></ul></ul><ul><li>Phases eventually overlap </li></ul><ul><li>Other conditions may alter normal aging of skeleton </li></ul>
Menopausal Osteoporosis: Vertebral Compression with Diminished Height
Effects of Aging: Skeleton <ul><li>Bones become </li></ul><ul><ul><li>Stiff </li></ul></ul><ul><ul><li>Weaker </li></ul></ul><ul><ul><li>Brittle </li></ul></ul>
Effects of Aging: Skeleton <ul><li>Changes in appearance evident after fifth decade. </li></ul><ul><ul><li>Height most obvious </li></ul></ul><ul><ul><ul><li>20 to 70 years of age </li></ul></ul></ul><ul><ul><ul><ul><li>Lose 1-2 cm in height every 2 decades </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Shortening of the vertebral column </li></ul></ul></ul></ul><ul><ul><ul><li>Midlife </li></ul></ul></ul><ul><ul><ul><ul><li>Vertebral discs thin </li></ul></ul></ul></ul><ul><ul><ul><li>Later years </li></ul></ul></ul><ul><ul><ul><ul><li>Decrease individual vertebrae height </li></ul></ul></ul></ul>
<ul><li>Disproportionate size of long bones of arm and legs </li></ul><ul><ul><li>Eighth & ninth decades </li></ul></ul><ul><ul><ul><li>Rapid decrease in vertebral height </li></ul></ul></ul><ul><ul><ul><li>Collapse of vertebrae </li></ul></ul></ul><ul><ul><ul><li>Shortening of trunk </li></ul></ul></ul><ul><ul><ul><li>Appearance of long extremities </li></ul></ul></ul>Effects of Aging: Skeleton
Effects of Aging: Skeleton <ul><li>Additional postural changes </li></ul><ul><ul><li>Kyphosis </li></ul></ul><ul><ul><li>Backward tilt of head for eye contact </li></ul></ul><ul><ul><ul><li>Forward bent posture </li></ul></ul></ul><ul><ul><ul><li>Hips and knees in flex position </li></ul></ul></ul>
Question <ul><li>All of the following are normal age-related changes in the musculoskeletal system EXCEPT: </li></ul><ul><li>(A) Decreased lean body mass </li></ul><ul><li>(B) Joint inflammation </li></ul><ul><li>(C) Loss of bone density </li></ul><ul><li>(D) Reduction in height </li></ul><ul><li>(E) Shortening of vertebrae </li></ul>
Can You Spot the Differences? <ul><li>A remarkable person who has taken ownership of his health and aged successfully </li></ul><ul><li>50 years ago: </li></ul><ul><ul><li>http:// www.youtube.com/watch?v =isLJ024EdMA </li></ul></ul><ul><li>Recent: </li></ul><ul><ul><li>http:// www.youtube.com/watch?v =iEdClu1KeC8&feature=related </li></ul></ul>
Prevention of Inactivity <ul><li>Deconditioning effects of inactivity (Box 24-3, p. 306) </li></ul><ul><li>Compensate for age-related changes </li></ul><ul><li>Public education </li></ul><ul><li>Education for caregivers </li></ul><ul><li>Creative activities to stimulate movement </li></ul>
Older Adults: Promotion of Activity <ul><li>Benefits of exercise: </li></ul><ul><ul><li>Strengthens bones </li></ul></ul><ul><ul><li>Reduced constipation </li></ul></ul><ul><ul><li>Improved sleep </li></ul></ul><ul><ul><li>Lower blood pressure/ cholesterol </li></ul></ul><ul><ul><li>Weight loss </li></ul></ul><ul><ul><li>Socialization </li></ul></ul><ul><li>Enhance motivation </li></ul>
Older Adults: Promotion of Activity <ul><li>Local resources to promote activity </li></ul><ul><li>Capacities, limitations, and interests </li></ul><ul><li>Avoid stereotyping </li></ul><ul><li>Good nutrition </li></ul><ul><li>Weight reduction </li></ul>
Older Adults: Promotion of Activity <ul><li>Muscle function varies with aging </li></ul><ul><ul><li>Trainable into advanced age </li></ul></ul><ul><ul><li>Muscle regeneration is normal as age progresses </li></ul></ul>
Exercises for Older Adults <ul><li>Lifts for Elderly (Part 1) </li></ul><ul><li>Lifts for Elderly (Part 2) </li></ul>
Question <ul><li>Is the following statement true or false? </li></ul><ul><li>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. </li></ul>
Question <ul><li>The gerontological nurse understands that all of the following are the effects of inactivity in older adults EXCEPT: </li></ul><ul><li>(A) Calcium loss from bones </li></ul><ul><li>(B) Decreased falls </li></ul><ul><li>(C) Functional decline </li></ul><ul><li>(D) Pressure ulcers </li></ul><ul><li>(E) Reduced muscle strength </li></ul>
Osteoporosis <ul><li>Most prevalent metabolic bone disease </li></ul><ul><li>Kyphosis, lumbar spine pain, & fractures </li></ul><ul><li>Often asymptomatic </li></ul><ul><li>1 st 5 – 7 yrs after menopause: some women lose 20% of bone mass </li></ul>
<ul><li>50% of postmenopausal women </li></ul><ul><li>20% men older than 65 yrs of age </li></ul><ul><li>10 million Americans (20% men) </li></ul><ul><li>34 million more – low bone mass </li></ul><ul><li>Most common sites of osteoporotic fx: vertebrae, wrist, & hips </li></ul>Osteoporosis Understanding Osteoporosis
Osteoporosis: Causes <ul><li>Decreased bone mass in older person </li></ul><ul><ul><li>Failure to reach peak bone mass in early adulthood </li></ul></ul><ul><ul><li>Increased bone resorption (osteoclasts) </li></ul></ul><ul><ul><li>Decreased bone formation (osteoblasts) </li></ul></ul><ul><li>Any health problem associated with: </li></ul><ul><ul><li>Inadequate calcium intake </li></ul></ul><ul><ul><li>Excessive calcium loss </li></ul></ul><ul><ul><li>Poor calcium absorption </li></ul></ul>Osteoporosis
Osteoporosis: Causes <ul><li>Inactivity or immobility </li></ul><ul><li>Diseases: Cushing syndrome, hyperthyroidism, diverticulitis, ESRD </li></ul><ul><li>Reduction in estrogen/ testosterone </li></ul><ul><li>Diet: Insufficient calcium, vitamin D, protein </li></ul><ul><li>Drugs: Corticosteroids, thyroid hormone, anticonvulsants </li></ul>Osteoporosis and Diet Nutrition and Osteoporosis
Pathophysiology of Osteoporosis <ul><li>Low bone mass </li></ul><ul><li>Deterioration of bone tissue compromised bone strength risk for fractures </li></ul><ul><li>Bone strength = bone density & quality </li></ul><ul><ul><li>Bone density = grams of mineral per area or volume (BMD) </li></ul></ul>
Osteoporosis & Osteopenia <ul><li>Normal BMD within 1 standard deviation of young adult mean </li></ul><ul><li>Ostopenia - BMD between 1 & 2.5 standard deviations below young adult mean </li></ul><ul><li>Osteoporosis - BMD 2.5 standard deviations below young adult mean </li></ul>
Osteoporosis: BMD & Fractures <ul><li>Reduced BMD </li></ul><ul><ul><li>Highly predictive of spinal & hip fractures </li></ul></ul><ul><ul><li>Osteoporotic fractures affect 1.5 million per year in US </li></ul></ul><ul><ul><ul><li>Vertebrae fractures ~ 700,000 people per year </li></ul></ul></ul><ul><ul><ul><li>Hip fractures affect ~ 300,000 per year </li></ul></ul></ul><ul><ul><ul><li>Wrist fractures ~ 250,000 per year </li></ul></ul></ul>Vertebral Fractures
Of the people who suffer from osteoporosis, 20 percent die within a year after sustaining a hip fracture Prevent Falls Hip Fracture: Highest Morbidity & Mortality The Physical Consequences of Fractures
A woman's chances of dying from an osteoporosis related fracture is greater than her risk of cervical, uterine and breast cancer combined
Osteoporosis: Nonmodifiable Risk Factors (KNOW!) <ul><li>Increased age </li></ul><ul><li>Female </li></ul><ul><li>Caucasian or Asian race </li></ul><ul><li>Positive family history </li></ul><ul><li>Small & thin </li></ul><ul><li>Certain diseases </li></ul>Osteoporosis Risk Factors
Osteoporosis: Modifiable Risk Factors (KNOW!) <ul><li>Low calcium & vitamin D intake, lack of sunlight exposure </li></ul><ul><li>Sedentary lifestyle (inactive, immobility) </li></ul><ul><li>Alcohol abuse </li></ul><ul><li>Smoking </li></ul><ul><li>Caffeine, soft drinks (phosphoric acid) </li></ul><ul><li>Corticosteroids, anticonvulsants (Dilantin or phenobarbital), or thyroid hormones </li></ul>How to Prevent Osteoporosis
WHO Fracture Risk Assessment Tool (FRAX) <ul><li>Please answer the questions below to calculate the ten year probability of fracture with BMD. </li></ul><ul><li>Caucasian </li></ul><ul><li>Black </li></ul><ul><li>Hispanic </li></ul><ul><li>Asian </li></ul>
Classification of Osteoporosis <ul><li>Primary osteoporosis </li></ul><ul><ul><li>Type I (menopausal bone loss) </li></ul></ul><ul><ul><li>Type II (senescent bone loss) </li></ul></ul><ul><li>Secondary osteoporosis </li></ul><ul><ul><li>Hyperparathyroidism </li></ul></ul><ul><ul><li>Malignancy </li></ul></ul><ul><ul><li>Immobilization </li></ul></ul><ul><ul><li>Gastrointestinal disease </li></ul></ul><ul><ul><li>Renal disease </li></ul></ul><ul><ul><li>Vitamin D deficiency </li></ul></ul><ul><ul><li>Drugs causing bone loss such as glucocorticoids, thyroid hormone (Synthroid), or phenytoin (Dilantin) </li></ul></ul>
Colles’ Fracture <ul><li>Affects Wrist </li></ul><ul><li>X-Ray of Colles’ Fracture </li></ul>
Normal Vertebral Column vs Compression Fracture
Vertebral Compression Fractures <ul><li>Weak, Fragile from Bone Loss </li></ul><ul><li>Compression Spinal Fracture </li></ul>Fractures in the spine or vertebral column can lead to loss of height, severe back pain, and deformity.
Trajectory of Bone Loss for Women <ul><li>Lower peak bone mass than men </li></ul><ul><li>Less in the "bone bank” because of thinner bones </li></ul><ul><li>Rapid withdrawal from "bone bank" during perimenopause </li></ul><ul><li>Longer life expectancy: increased risk for osteoporosis </li></ul><ul><li>Signs/symptoms usually absent </li></ul><ul><li>First sign often a fracture </li></ul>
Trajectory of Bone Loss for Women <ul><li>Loss of bone mass with age in cancellous (trabecular) versus cortical bone </li></ul><ul><li>Location of fractures that result </li></ul><ul><li>Typical ages in which fractures occur </li></ul>
Nonpharmacological Treatment of Osteoporosis <ul><li>Assessment of risk factors </li></ul><ul><li>Education about prevention </li></ul><ul><li>Older persons with risk factors </li></ul><ul><ul><li>Diagnosis of osteoporosis = bone density of </li></ul></ul><ul><ul><li>– 2.5 SD (below average for young people) </li></ul></ul><ul><li>Education about positive lifestyle changes </li></ul><ul><ul><li>Diet, exercise, and other risk modifications </li></ul></ul>How to Prevent Osteoporosis
Assessment/Prevention of Risk Factors for Osteoporosis <ul><li>Educate all women about osteoporosis risk factors </li></ul><ul><li>Women with fx history BMD test for osteoporosis </li></ul><ul><li>BMD test </li></ul><ul><ul><li>Any woman under 65 with risk factors for osteoporosis </li></ul></ul><ul><ul><li>All women over 65 </li></ul></ul><ul><li>Preventive activities for older men </li></ul><ul><li>Many risk factors same for men </li></ul><ul><li>Most men have bigger bones than women so they have increased protection </li></ul>
Lifestyle Modification Activities to Prevent or Treat Osteoporosis <ul><li>Promote diet with adequate calcium (1,500 mg) & vitamin D (400-800 IU) daily </li></ul><ul><ul><li>Dairy products, green leafy vegetables, broccoli, sardines </li></ul></ul><ul><ul><li>Sunlight exposure to skin </li></ul></ul><ul><li>Avoid immobility, staying in bed too long </li></ul><ul><li>Encourage weight-bearing & low-level resistance exercise </li></ul><ul><ul><li>Walking (best), dancing, weight training, stair climbing, tennis, gardening </li></ul></ul><ul><ul><li>Avoid isometric or high-impact aerobic exercises </li></ul></ul><ul><li>Reduce/ eliminate smoking </li></ul><ul><li>Reduce/ eliminate beverages: alcohol, caffeine, phosphorus </li></ul>How to Give your Bones a Work-Out
Question <ul><li>A 67-year-old woman is lactose intolerant and at risk for osteoporosis. What foods other than dairy products can the nurse suggest to this patient to increase her calcium intake? </li></ul>
Avoid Sodas <ul><li>Phosphorus contributes to bone loss by inhibiting the absorption of calcium </li></ul>
Avoid Aluminum-Containing Antacids <ul><li>Maalox </li></ul><ul><li>Mylanta </li></ul><ul><li>Amphojel </li></ul>Osteoporosis Medicine Risks
Question <ul><li>When assessing a client with osteoporosis the nurse should recognize that most observable changes will occur in: </li></ul><ul><ul><li>A. Facial bones </li></ul></ul><ul><ul><li>B. The long bones </li></ul></ul><ul><ul><li>C. The vertebral column </li></ul></ul><ul><ul><li>D. Joints of the hands and feet </li></ul></ul>
Antiresorptive Medications: Slow Bone Loss <ul><li>Goal: Prevent bone loss, lower risk of fx </li></ul><ul><li>Bisphosphonates </li></ul><ul><li>Calcitonin </li></ul><ul><li>Estrogen therapy, hormone replacement therapy (HRT) </li></ul><ul><li>Selective estrogen receptor modulators (SERMs) </li></ul>Osteoporosis Treatment Options Treatment Options for Osteoporosis
Bisphosphonates <ul><li>Alendronate (Fosamax), ibandronate (Boniva), risedronate (Actonel) </li></ul><ul><li>Preserves or increases bone density </li></ul><ul><li>Decreases rate of bone resorption </li></ul><ul><li>Decreases fractures </li></ul>
Bisphosphonates <ul><li>Inhibits osteoclasts (bone-resorbing cells) – prevents resorption </li></ul><ul><li>Decreases postmenopausal vertebral & nonvertebral fx by 40-50 % (relative risk) or 1-2% (absolute risk reduction) </li></ul><ul><li>Do not take calcium with bisphosphonates interferes with absorption </li></ul>
Bisphosphonates <ul><li>Side effects: digestive problems, bone & muscle pain, osteonecrosis of the jaw </li></ul><ul><li>Thigh bone or femur fx in some women using bisphosphonates for more than 5 yrs </li></ul><ul><li>Adverse gastrointestinal symptoms </li></ul><ul><ul><li>Esophageal irritation, heartburn, gastritis </li></ul></ul><ul><li>Contraindicated: Dysphagia, esophageal disease, gastritis, ulcers; severe renal insufficiency </li></ul>
Increased Risk Femur Fx –long-term use of bisphosphonates <ul><li>Atypical subtrochanteric femur fractures </li></ul><ul><li>Dull aching thigh pain weeks to months before fracture occurs </li></ul><ul><li>Taking Fosamax (alendronate) for more than five years could cause spontaneous fractures </li></ul>
Bisphosphonates: KNOW! <ul><li>(1) Take on empty stomach, first thing in the morning with 8 oz of water; </li></ul><ul><li>(2) Remain upright for 30 minutes; and </li></ul><ul><li>(3) Not eat or drink anything else for 30 minutes </li></ul>
Question <ul><li>The physician prescribes alendronate sodium (Fosamax) for a 72-year old woman. Which information should the nurse include in teaching the patient about this drug? </li></ul>
Calcitonin (Fortical, Miacalcin) <ul><li>Hormone – Regulates calcium, bone processes </li></ul><ul><li>IM, Subcut, Intranasal </li></ul><ul><li>Safe, effective tx for osteoporosis </li></ul><ul><ul><li>Decreases vertebral fractures by up to 35% </li></ul></ul><ul><li>Side effects: Hypocalcemia (all routes), nasal irritation (intranasal) </li></ul>
Hormone Replacement Therapy (HRT) <ul><li>Estrogen or estrogen with progestin therapy (to prevent uterine CA) </li></ul><ul><li>Estrogen: protective effect on bone </li></ul><ul><ul><li>Accelerates death of osteoclasts, prolongs life of osteoblasts </li></ul></ul><ul><li> Bone density spine & hip </li></ul><ul><li> Spine & hip fractures </li></ul><ul><li>Risk: heart attack, stroke, breast CA, blood clots </li></ul><ul><li>FDA: if a woman needs a medicine for osteoporosis, but does not require estrogen for menopause symptoms, then a non-estrogen alternative should be used </li></ul><ul><li>http://www.nof.org/awareness2/2007/images/Bone_Tool_Kit.pdf </li></ul>
Selective Estrogen Receptor Modulators (SERMs) “Mock” Estrogen <ul><li>Benefits of estrogens without disadvantages </li></ul><ul><li>Raloxifene (Evista) postmenopausal prevention & treatment of osteoporosis in women </li></ul><ul><li>SERMs less effective than bisphosphonates </li></ul><ul><li>Reduce bone loss, decrease fracture risk (esp spine) </li></ul><ul><li>Side effects: blood clots, hot flashes </li></ul>
Bone mineral density test (BMD): Secondary Prevention <ul><li>Dual energy x-ray absorptiometry (DEXA) </li></ul><ul><li>Femoral neck predicts hip fx risk best </li></ul><ul><ul><li>Gold standard for fracture prediction </li></ul></ul><ul><li>Other sites: spine, wrist, or total body </li></ul><ul><li>Results (compared with young adult mean) </li></ul><ul><ul><li>BMD 1 SD below mean (-1 S) = osteopenia </li></ul></ul><ul><ul><li>BMD 2.5 SD below mean (-2.5 SD) = osteoporosis </li></ul></ul>How to Diagnose Osteoporosis
Quick Case Study <ul><li>Ms. Young's mother had osteoporosis. She is concerned about her own risk of osteoporosis. Her health history revealed a diet low in calcium and an inactive lifestyle most of her life. She is white, 65 years old, and small-framed. She has hypothyroidism. </li></ul><ul><li>What are her risk factors? </li></ul><ul><li>What do you recommend for her? </li></ul>
Nursing Interventions <ul><li>Avoid heavy lifting, jumping, and other activities that could result in a fracture </li></ul><ul><li>Prevent falls </li></ul><ul><ul><li>Slip-resistant footwear, adequate lighting, clutter-free environment, toilet grab bars, bedside commode </li></ul></ul><ul><ul><li>Avoid: low seats, poor illumination, slippery floors </li></ul></ul><ul><li>Handle gently when moving, exercising or lifting to avoid fractures </li></ul><ul><ul><li>Use lift sheet to reposition client </li></ul></ul><ul><li>Range-of-motion exercises, ambulation </li></ul>
Osteoarthritis: Degeneration of Joints <ul><li>Leading physical disability (older adults) </li></ul><ul><li>Number one cause of pain (older adults) </li></ul><ul><li>Deterioration of joint cartilage with formation of new painful bone spurs (osteophytes) </li></ul><ul><li>Risks: older age, female, hx joint injuries, obesity, excessive use </li></ul><ul><li>Incidence </li></ul><ul><li>Causes </li></ul>
Osteoarthritis: Tx & Nursing Interventions (NCP 24-1, pp 313-4) <ul><li>Goal: Relieve pain, preserve joint function, slow progression of disease </li></ul><ul><li>Analgesics: acetaminophen, NSAIDs </li></ul><ul><li>Topical analgesics (capsaicin creams & rubs) </li></ul><ul><li>Rest, heat or ice, massage, acupuncture </li></ul><ul><li>Splints, braces, & canes </li></ul><ul><li>Analgesic medication before therapies/activities </li></ul><ul><li>Proper body alignment, good body mechanics </li></ul><ul><li>Nutritional considerations </li></ul>
Osteoarthritis: Primary Prevention <ul><li>Maintain appropriate body weight; warm-up exercises; good body mechanics; nutrition </li></ul><ul><li>Sensible exercise </li></ul><ul><li>Avoid repetitive stress, trauma </li></ul>
Osteoarthritis: Secondary/ Tertiary Prevention <ul><li>Weight reduction </li></ul><ul><li>Homemaker services </li></ul><ul><li>Physical therapy </li></ul><ul><li>Joint replacement surgery (severe joint damage) </li></ul><ul><ul><li>Hip & knee most common </li></ul></ul><ul><li>Post-surgical care </li></ul>
Quick Case Study <ul><li>Marie is a 62-year old woman who was diagnosed with osteoarthritis. She is 40 pounds overweight. </li></ul><ul><li>She states that pain interferes with recreational activities and work. Weight management is difficult; she cannot jump or dance. Arthritis is affecting her knees, hips, hands, wrists and neck. </li></ul><ul><li>20 years ago, Marie was in a car accident and spent several months in the hospital. She had a steel rod placed in her left femur and a full cast on her right leg. She was in traction for two months. </li></ul><ul><li>What are her risk factors? </li></ul><ul><li>What do you recommend for her? </li></ul>
Nursing Diagnoses & Interventions (NCP 24-1, p. 313) <ul><li>Chronic Pain r/t joint inflammation, stiffness, and fluid accumulation </li></ul><ul><li>Impaired Physical Mobility r/t pain and limited joint movement </li></ul><ul><li>Self-Care Deficit r/t pain or joint immobility </li></ul><ul><li>Body Image Disturbance r/t joint abnormality, immobility, altered self-care ability </li></ul><ul><li>Self-Esteem Disturbance r/t changes in body appearance and function </li></ul>
Key Outcomes <ul><li>The patient will: </li></ul><ul><ul><li>Experience increased comfort & decreased pain </li></ul></ul><ul><ul><li>Express positive feelings about himself or herself </li></ul></ul><ul><ul><li>Perform ADLs within the confines of the disease </li></ul></ul>