Mobility
NURS 4100 Care of the Older Adult
Spring 2014
Joy Shepard, PhD(c), MSN, RN, CNE, BC
1
Objectives
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Describe the effects of aging on
musculoskeletal function
List the benefits of activity
Describe fac...
Normal Changes of
Aging

3
Normal Changes of Aging
Musculoskeletal System (pp 5859)
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Decreased height
Decreased ROM joints
Incre...
Effects of Aging: Muscles
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Decline in size &
number of muscle fibers
Sarcopenia: reduction in
muscle mass & function
...
Effects of Aging: Muscles


Decline in endurance/
stamina
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Decreased by age 50
Decreased 65-85% of
midtwenties...
Joints, Ligaments, Tendons, and Cartilage:
Normal Changes with Aging
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Cartilage
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Normal wear/ tear



Hya...
Wear & Tear on Knee
Cartilage
Ears & Nose Continue to
Grow Throughout Life
Joints, Ligaments, Tendons, & Cartilage:
Normal Changes with Aging


Ligaments,
tendons, and joint
capsules

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Lose e...
Skeleton: Trajectory of Bone
Loss


Two phases bone loss
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Type I (menopausal bone
loss)

Rapid

Affects women
 Oc...
Menopausal Osteoporosis:
Vertebral Compression with
Diminished Height
Effects of Aging: Skeleton


Bones become
Stiff
 Weaker
 Brittle
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13
Effects of Aging: Skeleton
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Changes in
appearance evident
after fifth decade.
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Height most obvious
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Midlife
 ...
Effects of Aging: Skeleton


Disproportionate size of
long bones of arm and
legs
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Eighth & ninth decades


Rapid decre...
Effects of Aging: Skeleton


Additional postural
changes

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Kyphosis
Backward tilt of head
for eye contact
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Forwar...
Question
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All of the following are normal age-related
changes in the musculoskeletal system
EXCEPT:
(A) Decre...
Can You Spot the
Differences?




A remarkable person who has taken
ownership of his health and aged
successfully
50 yea...
Musculoskeletal
Health Promotion

19
Assessment Musculoskeletal
Function
Review Assessment Guide
24-1, p. 335
 General observation
 Interview
 Physical exam...
Prevention of Inactivity
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Deleterious effects of inactivity


(Review - Box 24-3, p. 331)

Compensate for age-related c...
Older Adults: Promotion of
Activity


Benefits of exercise:









Strengthens bones
Reduced constipation
Improv...
Older Adults: Promotion of
Activity
Local resources to promote activity
 Capacities, limitations, and interests
 Avoid s...
Older Adults: Promotion of
Activity


Muscle function
varies with aging
Trainable into
advanced age
 Muscle
regeneration...
Older Adults: Promotion of
Activity


Lower extremity
muscles atrophy
earlier than upper
extremity




Upper extremitie...
Exercises for Older Adults



Lifts for Elderly (Part 1)
Lifts for Elderly (Part 2)
Question




Is the following statement true or false?
Choosing an exercise program for an older
adult can be achieved b...
Question








The gerontological nurse understands that
all of the following are the effects of
inactivity in old...
Osteoporosis

30
Osteoporosis


Chronic, progressive metabolic
bone disease










Low bone mass
Deterioration of bones

Most pre...
Osteoporosis








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50% of postmenopausal
women
20% men older than 65 yrs of
age
10 million Americans (20%
men)
34...
Osteoporosis: Causes
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Decreased bone mass in older person
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Failure to reach peak bone mass in early
adulthood
...
Osteoporosis: Causes

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Inactivity or immobility
Diseases: Cushing syndrome,
hyperthyroidism, diverticulitis, ESR...
Pathophysiology of Osteoporosis
Low bone mass
 Deterioration of bone tissue 
compromised bone strength  risk
for fractu...
Osteoporosis:
Pathophysiology

36
Osteoporosis & Osteopenia


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Normal BMD within 1
standard deviation of
young adult mean
Ostopenia - BMD
between 1 & ...
A. Normal bone B. Osteopenia
C. Osteoporosis

38
Osteoporosis: BMD &
Fractures


Reduced BMD

Highly predictive of spinal & hip fractures
 Osteoporotic fractures affect ...
Hip Fracture:

Morbidity & Mortality

Highest

Of the people who suffer from
osteoporosis, 20 percent die
within a year af...
A woman's chances of
dying from an osteoporosis
related fracture is greater
than her risk of cervical,
uterine and breast ...
Osteoporosis: Nonmodifiable
Risk Factors (KNOW!) Box 244
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Increased age
Female
Caucasian or Asian
race
Positi...
Osteoporosis: Modifiable Risk
Factors (KNOW!) Box 24-4
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Low calcium & vitamin D
intake, lack of sunlight
ex...
WHO Fracture Risk
Assessment Tool (FRAX)
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Please answer the questions below to
calculate the ten year probabili...
Classification of Osteoporosis
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Primary osteoporosis
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Type I (menopausal bone loss)
Type II (senescent bone loss)...
Colles’ Fracture
Affects Wrist

X-Ray of Colles’
Fracture

47
Normal Vertebral Column vs
Compression Fracture
Vertebral Compression
Fractures
Weak, Fragile from Bone
Loss

Compression Spinal
Fracture

Fractures in the spine or verte...
Trabecular (Cancellous) Bone
Trajectory of Bone Loss for
Women
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

Lower peak bone mass than men
Less in the "bone bank” because of thinner...
Trajectory of Bone Loss for
Women


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Loss of bone mass with
age in cancellous
(trabecular) versus
cortical bone
Loca...
Trajectory of Bone Loss for
Women
Collaborative Care

54
Osteoporosis – Collaborative
Care


Collaborative care focuses
on assessment of risk
factors, proper nutrition,
calcium/ ...
Nonpharmacological
Treatment/ Prevention

56
Nonpharmacological
Treatment of Osteoporosis
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
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Assessment of risk factors
Education about prevention
Older persons wi...
Assessment/Prevention of
Risk Factors for Osteoporosis
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Educate all women about osteoporosis risk
factors
Women wi...
Lifestyle Modification Activities to
Prevent or Treat Osteoporosis


Promote diet with adequate calcium (1,500 mg) & vita...
Question


A 67-year-old woman
is lactose intolerant
and at risk for
osteoporosis. What
foods other than dairy
products c...
Avoid Sodas


Phosphorus
contributes to
bone loss by
inhibiting the
absorption of
calcium
Avoid Aluminum-Containing
Antacids

Maalox
 Mylanta
 Amphojel


Osteoporosis Medicine
Risks
Low-Level Resistance Exercises (Box
24-2; Fig 24-3)

Weight-Bearing, ROM & Resistance Exercises
Brisk Walking: One of the Best
Weight-Bearing Exercises
Swimming: Not a WeightBearing Exercise
Question


When assessing a client with
osteoporosis the nurse should
recognize that most observable
changes will occur i...
Pharmacology

70
Antiresorptive Medications:
Slow Bone Loss
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Goal: Prevent bone loss, lower risk of fx
Bisphosphonates
Calcitoni...
Bisphosphonates
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Alendronate
(Fosamax),
ibandronate (Boniva),
risedronate (Actonel)
Preserves or
increases bone...
Bisphosphonates
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Inhibits osteoclasts (bone-resorbing cells) –
prevents resorption
Decreases postmenopausal verteb...
Bisphosphonates




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Side effects: digestive problems, bone & muscle
pain, osteonecrosis of the jaw
Thigh bone or femu...
Osteonecrosis of the Jaw
Increased Risk Femur Fx
–long-term use of bisphosphonates
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Atypical subtrochanteric
femur fractures
Dull aching th...
Bisphosphonates: KNOW!

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(1) Take on empty stomach, first thing in the
morning with 8 oz of water;
(2) Remain uprig...
Question


The physician prescribes
alendronate sodium (Fosamax) for
a 72-year old woman. Which
information should the nu...
Calcitonin (Fortical, Miacalcin)



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Hormone – Regulates
calcium, bone processes
IM, Subcut, Intranasal
Safe, effectiv...
Hormone Replacement
Therapy (HRT)
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Estrogen or estrogen with progestin therapy (to prevent
uterine CA)
Estrogen: prot...
82
Selective Estrogen Receptor
Modulators (SERMs) “Mock”
Estrogen
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Benefits of estrogens without
some of the di...
Diagnostic Tests

84
Bone mineral density test
(BMD): Secondary Prevention
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Dual energy x-ray absorptiometry (DEXA)
Femoral neck predicts h...
Bone Mineral Density Test
(BMD)
Question
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The typical screening for osteoporosis
involves:
(A) Blood tests
(B) Colonoscopy
(C) Papanicolau te...
2.5 Standard Deviations
Quick Case Study
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


Ms. Young's mother had
osteoporosis. She is
concerned about her own
risk of osteoporosis. Her
hea...
Nursing Interventions

91
Nursing Interventions




Avoid heavy lifting, jumping, and other activities
that could result in a fracture
Prevent fal...
Osteoarthritis

93
Osteoarthritis: Degeneration of
Joints
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Leading physical disability
(older adults)
Number one cause of pai...
Osteoarthitis – Anatomical
Distribution

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Several joints
Weight-bearing
joints (most
affected)
Can affect any joi...
Osteoarthritis: Signs & Symptoms
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No systematic
symptoms
Crepitation
Heberden nodes
Increased pain:
damp weather,...
Osteoarthritis: Tx & Nursing
Interventions (NCP 24-1, pp. 338-339)
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Goal: Relieve pain, preserve joint fu...
Osteoarthritis: Primary
Prevention
Maintain appropriate body weight;
warm-up exercises; good body
mechanics; nutrition
 S...
Osteoarthritis: Secondary/
Tertiary Prevention
Weight reduction
 Homemaker services
 Physical therapy
 Joint replacemen...
Quick Case Study
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Marie is a 62-year old woman who was diagnosed with
osteoarthritis. She is 40 pounds overwe...
Nursing Diagnoses &
Interventions (Table 24-3, p. 334; NCP
24-1, pp. 338-9)
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Chronic Pain r/t joint inflammat...
Key Outcomes
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The patient will:
Experience increased comfort &
decreased pain
 Express positive feelings about himself
...
Mobility spring 2014 abridged
Mobility spring 2014 abridged
Mobility spring 2014 abridged
Mobility spring 2014 abridged
Mobility spring 2014 abridged
Mobility spring 2014 abridged
Mobility spring 2014 abridged
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Mobility spring 2014 abridged

  1. 1. Mobility NURS 4100 Care of the Older Adult Spring 2014 Joy Shepard, PhD(c), MSN, RN, CNE, BC 1
  2. 2. Objectives     Describe the effects of aging on musculoskeletal function List the benefits of activity Describe factors contributing to, symptoms, treatment, and related nursing care for fractures, osteoporosis, and osteoarthritis Identify ways to reduce risks of injury associated with musculoskeletal problems
  3. 3. Normal Changes of Aging 3
  4. 4. Normal Changes of Aging Musculoskeletal System (pp 5859)         Decreased height Decreased ROM joints 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 4
  5. 5. Effects of Aging: Muscles   Decline in size & number of muscle fibers Sarcopenia: reduction in muscle mass & function (by age 75)    Reduction in protein synthesis Increase in muscle protein degeneration Decreased strength  Slow decline 5
  6. 6. Effects of Aging: Muscles  Decline in endurance/ stamina      Decreased by age 50 Decreased 65-85% of midtwenties by age 80 Can lead to disability Causes Tone & tension   Decreases after age 30 Reduced flexibility 6
  7. 7. Joints, Ligaments, Tendons, and Cartilage: Normal Changes with Aging  Cartilage      Normal wear/ tear  Hyaline cartilage (joint lining)  Knee cartilage Thins ~ 0.25 mm/year  Lines joints Erodes/ tears with advancing age Bone to bone contact   Discomfort, slow joint movement Diminished joint lubricant Nonarticular cartilage (ears & nose)  Grows throughout life 7
  8. 8. Wear & Tear on Knee Cartilage
  9. 9. Ears & Nose Continue to Grow Throughout Life
  10. 10. Joints, Ligaments, Tendons, & Cartilage: Normal Changes with Aging  Ligaments, tendons, and joint capsules    Lose elasticity Less flexible Joint ROM decreases 10
  11. 11. Skeleton: Trajectory of Bone Loss  Two phases bone loss   Type I (menopausal bone loss)  Rapid  Affects women  Occurs first 5-10 years after menopause Type II (senescent bone loss)  Slower phase  Affects both sexes after midlife   Phases eventually overlap Other conditions may alter normal aging of skeleton 11
  12. 12. Menopausal Osteoporosis: Vertebral Compression with Diminished Height
  13. 13. Effects of Aging: Skeleton  Bones become Stiff  Weaker  Brittle  13
  14. 14. Effects of Aging: Skeleton  Changes in appearance evident after fifth decade.  Height most obvious    Midlife  Vertebral discs thin Later years  Decrease individual vertebrae height 20 to 70 years of age  Lose 1-2 cm in height every 2 decades  Shortening of the vertebral column 14
  15. 15. Effects of Aging: Skeleton  Disproportionate size of long bones of arm and legs  Eighth & ninth decades  Rapid decrease in vertebral height  Collapse of vertebrae  Shortening of trunk  Appearance of long extremities 15
  16. 16. Effects of Aging: Skeleton  Additional postural changes   Kyphosis Backward tilt of head for eye contact   Forward bent posture Hips and knees in flex position 16
  17. 17. Question       All of the following are normal age-related changes in the musculoskeletal system EXCEPT: (A) Decreased lean body mass (B) Joint inflammation (C) Loss of bone density (D) Reduction in height (E) Shortening of vertebrae
  18. 18. Can You Spot the Differences?   A remarkable person who has taken ownership of his health and aged successfully 50 years ago:   http://www.youtube.com/watch?v=isLJ024EdMA Recent:  http://www.youtube.com/watch? v=iEdClu1KeC8&feature=related
  19. 19. Musculoskeletal Health Promotion 19
  20. 20. Assessment Musculoskeletal Function Review Assessment Guide 24-1, p. 335  General observation  Interview  Physical examination 
  21. 21. Prevention of Inactivity  Deleterious effects of inactivity  (Review - Box 24-3, p. 331) Compensate for age-related changes  Public education  Education for caregivers  Creative activities to stimulate movement 
  22. 22. Older Adults: Promotion of Activity  Benefits of exercise:        Strengthens bones Reduced constipation Improved sleep Lower blood pressure/ cholesterol Weight loss Socialization Enhance motivation
  23. 23. Older Adults: Promotion of Activity Local resources to promote activity  Capacities, limitations, and interests  Avoid stereotyping  Good nutrition  Weight reduction 
  24. 24. Older Adults: Promotion of Activity  Muscle function varies with aging Trainable into advanced age  Muscle regeneration is normal as age progresses  25
  25. 25. Older Adults: Promotion of Activity  Lower extremity muscles atrophy earlier than upper extremity   Upper extremities: Routine daily activities Lower extremities: Walking 26
  26. 26. Exercises for Older Adults   Lifts for Elderly (Part 1) Lifts for Elderly (Part 2)
  27. 27. Question   Is the following statement true or false? 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.
  28. 28. Question       The gerontological nurse understands that all of the following are the effects of inactivity in older adults EXCEPT: (A) Calcium loss from bones (B) Decreased falls (C) Functional decline (D) Pressure ulcers (E) Reduced muscle strength
  29. 29. Osteoporosis 30
  30. 30. Osteoporosis  Chronic, progressive metabolic bone disease       Low bone mass Deterioration of bones Most prevalent metabolic bone disease Kyphosis, lumbar spine pain, & fractures Often asymptomatic 1st 5 – 7 yrs after menopause: some women lose 20% of bone mass
  31. 31. Osteoporosis      50% of postmenopausal women 20% men older than 65 yrs of age 10 million Americans (20% men) 34 million more – low bone mass Most common sites of osteoporotic fx: vertebrae, wrist, & hips Understanding Osteoporosis 32
  32. 32. Osteoporosis: Causes  Decreased bone mass in older person     Failure to reach peak bone mass in early adulthood Increased bone resorption (osteoclasts) Decreased bone formation (osteoblasts) Any health problem associated with:    Inadequate calcium intake Excessive calcium loss Poor calcium absorption Osteoporosis
  33. 33. Osteoporosis: Causes      Inactivity or immobility Diseases: Cushing syndrome, hyperthyroidism, diverticulitis, ESRD Reduction in estrogen/ testosterone Diet: Insufficient calcium, vitamin D, protein Drugs: Corticosteroids, thyroid hormone, anticonvulsants Osteoporosis and Diet Nutrition and Osteoporosis
  34. 34. Pathophysiology of Osteoporosis Low bone mass  Deterioration of bone tissue  compromised bone strength  risk for fractures  Bone strength = bone density & quality   Bone density = grams of mineral per area or volume (BMD) 35
  35. 35. Osteoporosis: Pathophysiology 36
  36. 36. Osteoporosis & Osteopenia    Normal BMD within 1 standard deviation of young adult mean Ostopenia - BMD between 1 & 2.5 standard deviations below young adult mean Osteoporosis - BMD 2.5 standard deviations below young adult mean 37
  37. 37. A. Normal bone B. Osteopenia C. Osteoporosis 38
  38. 38. Osteoporosis: BMD & Fractures  Reduced BMD Highly predictive of spinal & hip fractures  Osteoporotic fractures affect 1.5 million per year in US  Vertebrae fractures ~ 700,000 people per year  Hip fractures affect ~ 300,000 per year  Wrist fractures ~ 250,000 per year  Vertebral Fractures 39
  39. 39. Hip Fracture: Morbidity & Mortality Highest Of the people who suffer from osteoporosis, 20 percent die within a year after sustaining a hip fracture The Physical Consequences of Fractures
  40. 40. A woman's chances of dying from an osteoporosis related fracture is greater than her risk of cervical, uterine and breast cancer combined
  41. 41. Osteoporosis: Nonmodifiable Risk Factors (KNOW!) Box 244       Increased age Female Caucasian or Asian race Positive family history Small & thin Certain diseases Osteoporosis Risk Factors 42
  42. 42. Osteoporosis: Modifiable Risk Factors (KNOW!) Box 24-4       Low calcium & vitamin D intake, lack of sunlight exposure Sedentary lifestyle (inactive, immobility) Alcohol abuse Smoking Caffeine, soft drinks (phosphoric acid) Corticosteroids, anticonvulsants (Dilantin or phenobarbital), or thyroid hormones How to Prevent Osteoporosis 43
  43. 43. WHO Fracture Risk Assessment Tool (FRAX)      Please answer the questions below to calculate the ten year probability of fracture with BMD. Caucasian Black Hispanic Asian
  44. 44. Classification of Osteoporosis  Primary osteoporosis    Type I (menopausal bone loss) Type II (senescent bone loss) Secondary osteoporosis        Hyperparathyroidism Malignancy Immobilization Gastrointestinal disease Renal disease Vitamin D deficiency Drugs causing bone loss such as glucocorticoids, thyroid hormone (Synthroid), or phenytoin (Dilantin) 46
  45. 45. Colles’ Fracture Affects Wrist X-Ray of Colles’ Fracture 47
  46. 46. Normal Vertebral Column vs Compression Fracture
  47. 47. Vertebral Compression Fractures Weak, 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. 49
  48. 48. Trabecular (Cancellous) Bone
  49. 49. Trajectory of Bone Loss for Women       Lower peak bone mass than men Less in the "bone bank” because of thinner bones Rapid withdrawal from "bone bank" during perimenopause Longer life expectancy: increased risk for osteoporosis Signs/symptoms usually absent First sign often a fracture 51
  50. 50. Trajectory of Bone Loss for Women    Loss of bone mass with age in cancellous (trabecular) versus cortical bone Location of fractures that result Typical ages in which fractures occur
  51. 51. Trajectory of Bone Loss for Women
  52. 52. Collaborative Care 54
  53. 53. Osteoporosis – Collaborative Care  Collaborative care focuses on assessment of risk factors, proper nutrition, calcium/ vitamin D supplementation, exercise, prevention of fractures, and medications.
  54. 54. Nonpharmacological Treatment/ Prevention 56
  55. 55. Nonpharmacological Treatment of Osteoporosis    Assessment of risk factors 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 57
  56. 56. Assessment/Prevention of Risk Factors for Osteoporosis    Educate all women about osteoporosis risk factors Women with fx history  BMD test for osteoporosis BMD test      Any woman under 65 with risk factors for osteoporosis All women over 65 Preventive activities for older men Many risk factors same for men Most men have bigger bones than women so they have increased protection 58
  57. 57. Lifestyle Modification Activities to Prevent or Treat Osteoporosis  Promote diet with adequate calcium (1,500 mg) & vitamin D (400-800 IU) daily     Avoid immobility, staying in bed too long Encourage weight-bearing & low-level resistance exercise     Dairy products, green leafy vegetables, broccoli, sardines Sunlight exposure to skin Walking (best), dancing, weight training, stair climbing, tennis, gardening Avoid isometric or high-impact aerobic exercises Reduce/ eliminate smoking Reduce/ eliminate beverages: alcohol, caffeine, phosphorus How to Give your Bones a WorkOut 59
  58. 58. Question  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?
  59. 59. Avoid Sodas  Phosphorus contributes to bone loss by inhibiting the absorption of calcium
  60. 60. Avoid Aluminum-Containing Antacids Maalox  Mylanta  Amphojel  Osteoporosis Medicine Risks
  61. 61. Low-Level Resistance Exercises (Box 24-2; Fig 24-3) Weight-Bearing, ROM & Resistance Exercises
  62. 62. Brisk Walking: One of the Best Weight-Bearing Exercises
  63. 63. Swimming: Not a WeightBearing Exercise
  64. 64. 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  
  65. 65. Pharmacology 70
  66. 66. Antiresorptive Medications: Slow Bone Loss      Goal: Prevent bone loss, lower risk of fx Bisphosphonates Calcitonin Estrogen therapy, hormone replacement therapy (HRT) Selective estrogen receptor modulators (SERMs) Osteoporosis Treatment Options Treatment Options for 71
  67. 67. Bisphosphonates     Alendronate (Fosamax), ibandronate (Boniva), risedronate (Actonel) Preserves or increases bone density Decreases rate of bone resorption Decreases fractures 72
  68. 68. Bisphosphonates    Inhibits osteoclasts (bone-resorbing cells) – prevents resorption Decreases postmenopausal vertebral & nonvertebral fx by 40-50 % (relative risk) or 1-2% (absolute risk reduction) Do not take calcium with bisphosphonates  interferes with absorption 73
  69. 69. Bisphosphonates    Side effects: digestive problems, bone & muscle pain, osteonecrosis of the jaw Thigh bone or femur fx in some women using bisphosphonates for more than 5 yrs Adverse gastrointestinal symptoms   Esophageal irritation, heartburn, gastritis Contraindicated: Dysphagia, esophageal disease, gastritis, ulcers; severe renal insufficiency 74
  70. 70. Osteonecrosis of the Jaw
  71. 71. Increased Risk Femur Fx –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 fx
  72. 72. Bisphosphonates: KNOW!    (1) Take on empty stomach, first thing in the morning with 8 oz of water; (2) Remain upright for 30 minutes; and (3) Not eat or drink anything else for 30 minutes 78
  73. 73. Question  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?
  74. 74. Calcitonin (Fortical, Miacalcin)    Hormone – Regulates calcium, bone processes IM, Subcut, Intranasal Safe, effective tx for osteoporosis   Decreases vertebral fractures by up to 35% Side effects: Hypocalcemia (all routes), nasal irritation (intranasal) 80
  75. 75. Hormone Replacement Therapy (HRT)   Estrogen or estrogen with progestin therapy (to prevent uterine CA) Estrogen: protective effect on bone       Accelerates death of osteoclasts, prolongs life of osteoblasts ↑ Bone density spine & hip ↓ Spine & hip fractures Risk: heart attack, stroke, breast CA, blood clots 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 http://www.nof.org/awareness2/2007/images/Bone_Tool_Kit.pdf 81
  76. 76. 82
  77. 77. Selective Estrogen Receptor Modulators (SERMs) “Mock” Estrogen      Benefits of estrogens without some of the 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, stroke, hot flashes, night sweats, endometrial cancer, leg swelling 83
  78. 78. Diagnostic Tests 84
  79. 79. Bone mineral density test (BMD): Secondary Prevention   Dual energy x-ray absorptiometry (DEXA) 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 85
  80. 80. Bone Mineral Density Test (BMD)
  81. 81. Question       The typical screening for osteoporosis involves: (A) Blood tests (B) Colonoscopy (C) Papanicolau test (D) Tonometry (E) Dual-energy x-ray absorptiometry
  82. 82. 2.5 Standard Deviations
  83. 83. Quick Case Study    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. What are her risk factors? What do you recommend for her?
  84. 84. Nursing Interventions 91
  85. 85. Nursing Interventions   Avoid heavy lifting, jumping, and other activities that could result in a fracture Prevent falls    Handle gently when moving, exercising or lifting to avoid fractures   Slip-resistant footwear, adequate lighting, clutter-free environment, toilet grab bars, bedside commode Avoid: low seats, poor illumination, slippery floors Use lift sheet to reposition client Range-of-motion exercises, ambulation
  86. 86. Osteoarthritis 93
  87. 87. Osteoarthritis: Degeneration of Joints       Leading physical disability (older adults) Number one cause of pain (older adults) Deterioration of joint cartilage with formation of new painful bone spurs (osteophytes) Risks: older age, female, hx joint injuries, obesity, excessive use Incidence Causes
  88. 88. Osteoarthitis – Anatomical Distribution     Several joints Weight-bearing joints (most affected) Can affect any joint Common: Knees, hips, vertebrae, fingers
  89. 89. Osteoarthritis: Signs & Symptoms     No systematic symptoms Crepitation Heberden nodes Increased pain: damp weather, extended use
  90. 90. Osteoarthritis: Tx & Nursing Interventions (NCP 24-1, pp. 338-339)         Goal: Relieve pain, preserve joint function, slow progression of disease Analgesics: acetaminophen, NSAIDs Topical analgesics (capsaicin creams & rubs) Rest, heat or ice, massage, acupuncture Splints, braces, & canes Analgesic medication before therapies/activities Proper body alignment, good body mechanics Nutritional considerations
  91. 91. Osteoarthritis: Primary Prevention Maintain appropriate body weight; warm-up exercises; good body mechanics; nutrition  Sensible exercise  Avoid repetitive stress, trauma 
  92. 92. Osteoarthritis: Secondary/ Tertiary Prevention Weight reduction  Homemaker services  Physical therapy  Joint replacement surgery (severe joint damage)    Hip & knee most common Post-surgical care
  93. 93. Quick Case Study      Marie is a 62-year old woman who was diagnosed with osteoarthritis. She is 40 pounds overweight. 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. 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. What are her risk factors? What do you recommend for her?
  94. 94. Nursing Diagnoses & Interventions (Table 24-3, p. 334; NCP 24-1, pp. 338-9)      Chronic Pain r/t joint inflammation, stiffness, and fluid accumulation Impaired Physical Mobility r/t pain and limited joint movement Self-Care Deficit r/t pain or joint immobility Body Image Disturbance r/t joint abnormality, immobility, altered self-care ability Self-Esteem Disturbance r/t changes in body appearance and function
  95. 95. Key Outcomes  The 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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