1

Mobility

NURS 4100 Care of the Older Adult Spring 2014Joy Shepard, PhD(c), MSN, RN, CNE, BC

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

Normal Changes of Aging

4

Normal Changes of Aging Musculoskeletal System (pp 58-59)

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

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

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

7

Cartilage Hyaline cartilage

(joint lining) Lines joints Erodes/ tears

with advancing age

Bone to bone contact

Knee cartilage Normal wear/ tear Thins ~ 0.25 mm/year

Discomfort, slow joint movement

Diminished joint lubricant

Nonarticular cartilage (ears & nose)

Grows throughout life

Joints, Ligaments, Tendons, and Cartilage: Normal Changes with Aging

Wear & Tear on Knee Cartilage

Ears & Nose Continue to Grow Throughout Life

10

Ligaments, tendons, and joint capsules Lose elasticity Less flexible Joint ROM

decreases

Joints, Ligaments, Tendons, & Cartilage: Normal Changes with Aging

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

Menopausal Osteoporosis: Vertebral Compression with Diminished Height

13

Effects of Aging: Skeleton

Bones become Stiff Weaker Brittle

14

Effects of Aging: Skeleton Changes in

appearance evident after fifth decade. Height most obvious

20 to 70 years of age Lose 1-2 cm in

height every 2 decades

Shortening of the vertebral column

Midlife Vertebral discs

thin Later years

Decrease individual vertebrae height

15

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

Effects of Aging: Skeleton

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

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

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

Musculoskeletal Health Promotion

Assessment Musculoskeletal Function

Review Assessment GuideReview Assessment Guide 24-1, p. 335

General observation Interview Physical examination

Prevention of Inactivity Deleterious effects of inactivityDeleterious effects of inactivity

(ReviewReview - Box 24-3, p. 331) Compensate for age-related

changes Public education Education for caregivers Creative activities to stimulate

movement

Older Adults: Promotion of Activity

Benefits of exercise: Strengthens bones Reduced constipation Improved sleep Lower blood pressure/ cholesterol Weight loss Socialization

Enhance motivation

Older Adults: Promotion of Activity

Local resources to promote activity Capacities, limitations, and

interests Avoid stereotyping Good nutrition Weight reduction

25

Older Adults: Promotion of Activity

Muscle function varies with aging Trainable into

advanced age Muscle

regeneration is normal as age progresses

26

Older Adults: Promotion of Activity

Lower extremity muscles atrophy earlier than upper extremity Upper extremities:

Routine daily activities

Lower extremities: Walking

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 by identifying common activities that older adults enjoy and implementing a program based on your findings from the literature.

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

30

Osteoporosis

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

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

32

Osteoporosis

Understanding Osteoporosis

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 absorptionOsteoporosis

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, anticonvulsantsOsteoporosis and DietNutrition and Osteoporosis

35

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)

Osteoporosis: Pathophysiology

36

37

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

38

A. Normal bone B. Osteopenia C. Osteoporosis

39

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 yearVertebral Fractures

Of the people who suffer from osteoporosis, 20 percent die within a year after sustaining a hip fracture

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!) Box 24-4

Increased age Female Caucasian or Asian

race Positive family

history Small & thin Certain diseases

42

Osteoporosis Risk Factors

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

43

How to Prevent Osteoporosis

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

46

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)

Colles’ FractureAffects Wrist X-Ray of Colles’ Fracture

47

Normal Vertebral Column vs Compression Fracture

Vertebral Compression FracturesWeak, Fragile from Bone Loss Compression Spinal Fracture

49

Fractures in the spine or vertebral column can lead to loss of height, severe back pain, and deformity.

Trabecular (Cancellous) Bone

51

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

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

Trajectory of Bone Loss for Women

54

Collaborative Care

Osteoporosis – Collaborative Care

Collaborative care focuses on assessment of risk factors, proper nutrition, calcium/ vitamin D supplementation, exercise, prevention of fractures, and medications.

56

Nonpharmacological Treatment/ Prevention

57

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

58

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

59

Lifestyle Modification Activities to Prevent or Treat Osteoporosis

Promote diet with adequate calcium (1,500 mg) & vitamin D (400-800 IU) daily

Dairy products, green leafy vegetables, broccoli, sardines Sunlight exposure to skin

Avoid immobility, staying in bed too long Encourage weight-bearing & low-level resistance

exercise 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 Work-Out

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?

Avoid Sodas

Phosphorus contributes to bone loss by inhibiting the absorption of calcium

Avoid Aluminum-Containing Antacids

MaaloxMylantaAmphojelOsteoporosis Medicine Risks

Weight-Bearing, ROM & Resistance Exercises

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

Brisk Walking: One of the Best Weight-Bearing Exercises

Swimming: Not a Weight-Bearing Exercise

Question When assessing a client with

osteoporosis the nurse should recognize that most observable changes will occur in: A. Facial bones B. The long bones C. The vertebral column D. Joints of the hands and feet 

70

Pharmacology

71

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 OptionsTreatment Options for Osteoporosis

72

Bisphosphonates Alendronate

(Fosamax), ibandronate (Boniva), risedronate (Actonel)

Preserves or increases bone density

Decreases rate of bone resorption

Decreases fractures

73

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

74

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

Osteonecrosis of the Jaw

Increased Risk Femur Fx –long-term use of bisphosphonates

Atypical subtrochanteric 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

78

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

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?

80

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)

81

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

82

83

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

84

Diagnostic Tests

85

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) =

osteoporosisHow to Diagnose Osteoporosis

Bone Mineral Density Test (BMD)

Question The typical screening for

osteoporosis involves: (A) Blood tests (B) Colonoscopy (C) Papanicolau test (D) Tonometry (E) Dual-energy x-ray absorptiometry

2.5 Standard Deviations

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?

91

Nursing Interventions

Nursing Interventions Avoid heavy lifting, jumping, and other

activities that could result in a fracture Prevent falls

Slip-resistant footwear, adequate lighting, clutter-free environment, toilet grab bars, bedside commode

Avoid: low seats, poor illumination, slippery floors Handle gently when moving, exercising or

lifting to avoid fractures Use lift sheet to reposition client

Range-of-motion exercises, ambulation

93

Osteoarthritis

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

Osteoarthitis – Anatomical Distribution

Several joints Weight-bearing

joints (most affected)

Can affect any joint

Common: Knees, hips, vertebrae, fingers

Osteoarthritis: Signs & Symptoms

No systematic symptoms

Crepitation Heberden nodes Increased pain:

damp weather, extended use

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

Osteoarthritis: Primary Prevention

Maintain appropriate body weight; warm-up exercises; good body mechanics; nutrition

Sensible exercise Avoid repetitive stress, trauma

Osteoarthritis: Secondary/ Tertiary Prevention

Weight reduction Homemaker services Physical therapy Joint replacement surgery (severe

joint damage) Hip & knee most common

Post-surgical care

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?

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

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