deddy musculoskeletal.ppt

7/23/2019 Deddy musculoskeletal.ppt

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Musculoskeletal Disorders in

Elderly



Objectives

• Falling: list causes and prevention

strategies in the individual

•Define deconditioning and its relation torest

• Briefly review osteoporosis



etting the scene!

• "n #$ year old wo%an falls in the kitchen&

injuring her right ar%'

• Believing it to be broken& she seeks %edical

care& and is reassured that there is no fracture'• (eturning ho%e she )s afraid to walk and

despite encourage%ent fro% her fa%ily& she

takes to her bed'• One week later she beco%es incontinent and

unable to walk!



Falls in older people

• "bout *+, older people fall each year

• Many healthy younger people also fall

each year but %ost falls areinconse-uential

• , principal reasons for falling

enescent gait )llnesses

Environ%ental ha.ards



Falls in older people

Senescent gait

• lower gait speed

• /ider base of support• 0ower step height

• 1entre of gravity forward

• 0ess ar%swing



)llnesses that cause falls in older

people

0oss of consciousness

• yncope or presyncope 2Ortostatic

3ypotension& arrhyth%ias& blocks!4

• ei.ures 2%ay be akinetic!4

• Endocrine 2hypoglyce%ia!4




people

5eurological disorders

• Move%ent disorders 2 6arkinson7s

disease& !4• 3e%iparesis and spasticity

• 6eripheral neuropathy 2%otor& sensory''4

• "ta8ia 2 central or peripheral!4• 9estibular disorders




people

1ognitive disorders

• 1onditions which affect judge%ent

2de%entias& depression''4• 1onditions that affect spatial orientation

2strokes& posterior degenerations!4




people

Musculoskeletal disorders

• 6ainful lower li%b conditions

• (estriction of joint %ove%ent• Muscular weakness 2sarcopenia& disuse&

%yopathy!4



Muscle and age



Muscle %ass and ageehayias ; et al' "% ; 1lin 5utr *<<=>??:<@A



"ging and loss of %uscle

%ass+strength 2sarcopenia4

• Muscle strength declines by *C per

decade in ?th and =th decade

• Declines by ,@C per decade thereafter

illewich& 0' ;ournal of "%erican 1ollege of urgeons&$@@?& $@,:




people

pecial senses

• 9ision 2acuity& depth perception!4

• 3earing



Drugs that cause falls in older

people

• "ntihypertensives

• 6sychotropic agents 2antidepressants&

Ben.odiacepine& antipsychotics!4

• "nticholinergics

• "nd %any others



Environ%ental causes of falls



1alculating risk of fallsinetti M et al 5 Engl ; Med *<##> ,*<:*=@*

• 6rospective ) year study

• ,,? co%%unity dwelling people over aged

=

• 1areful %onitoring of falls& detailed

e8a%ination for risk factors

• (isk of falls #C with no risk factors• (isk of falls =#C with A or %ore risk

factors



1alculating risk of falls

(isk factor (elative risk of falling

edative drugs $#',

1ognitive i%pair%ent '@Disability of lower li%b ,'#

6al%ar %ental refle8 ,'@

"bnor%al balance or gait *'<

Foot proble% *'#

inetti M et al 5 Engl ; Med *<##> ,*<:*=@*



1onse-uences of falls in older

people

Fractures ?C

oft tissue injuries $AC

Fear of falling $@C



1onse-uences of falls in older

people

Fear of falling

)%%obility

Muscle weakness



Bed rest and %uscle strength

Muscle strength 2M914 lost at

$C per day

3arper G 0yles' ;"H *<<#> ,?: *@A=



0ower li%b %uscle strength and

unloading for *@ days "cta 6hysiol cand *<<?> *=:?,



DECONDITIONING:

a simple definition

he adverse physiological

conse-uences of

too %uch rest



DE1O5D))O5)5H

1onse-uences

• 1onversion of an individual barely able to

rise fro% a chair to a bedridden state

• (esulting i%%obility pro%otes

incontinence

• )ncreases risk of falls



DE1O5D))O5)5H

1onse-uences



Bedrest: effects on cardiovascular

syste%

(eduction in plas%a volu%e

(educed stroke volu%e and cardiac

output

Orthostatic hypotension

(esults in falls& syncope

1onvertino 9 et al' "% ; Med ci $@@=> ,,A: =$

illewich 0' ; "% 1oll urg $@@?> $@,:



6las%a volu%e and bed rest1onvertino 9 et al' "% ; Med ci $@@=> ,,A: =$

http://ovidsp.tx.ovid.com.libaccess.lib.mcmaster.ca/spb/ovidweb.cgi?View+Image=00000441-200707000-00023%7CFF4&S=CNJAFPFLMODDKCCONCHLHBMLEHJEAA00&WebLinkReturn=Full+Text%3DL%7CS.sh.15.16.18.40%7C0%7C00000441-200707000-00023

http://ovidsp.tx.ovid.com.libaccess.lib.mcmaster.ca/spb/ovidweb.cgi?View+Image=00000441-200707000-00023%7CFF4&S=CNJAFPFLMODDKCCONCHLHBMLEHJEAA00&WebLinkReturn=Full+Text%3DL%7CS.sh.15.16.18.40%7C0%7C00000441-200707000-00023



DE1O5D))O5)5H

the essence

• 0oss of %uscle strength

• "ltered cardiovascular responses

But there is %ore& %uch %ore!



Bed rest and calciu% balance



Bone Mineral 1ontent and rest(ittweger ; et al' ; 6hysiol $@@?> ==: ,,*



DECONDITIONING

• Muscle weakness

• 1irculatory changes

• Many other conse-uences includingnegative calciu% balance 2effects on bone4catabolic state 2effects on nutrition4pressure effects on skin 2risk of ulceration4

insulin resistance& infla%%atory responsesetc'

• 1hanges %ay occur soon after rest



DE1O5D))O5)5H

" co%ple8 process of physiological

change following a period of inactivity&bedrest or sedentary lifestyle& which

results in functional losses'

Brand 1 et al' $@@, www'%h'org'au+1linicalEpide%iology

http://www.mh.org.au/Clinical

http://www.mh.org.au/Clinical



DECONDITIONING:

Similar terms

• Functional decline

• Dysfunction syndro%e• /eightlessness effects



/hat do they have in co%%onI



i%ilarities!

Bedrest paceflight

Orthostatichypotension

)ncreased

Balance& stability (educed

1oordination& gait (educed

Muscle strength (educed

M9 @2 (educed $@$C



i%ilarities!

Bedrest paceflight

Orthostatichypotension

)ncreased )ncreased

Balance& stability (educed (educed

1oordination& gait (educed (educed& wide

Muscle strength (educed (educed

M9 @2 (educed $@$C (educed *$C



o& how do we treat the lady who

fell at ho%eI

• (esistance training increases %uscle

strength and volu%e by *C per day

2re%e%ber that it is lost at $C per day4

•More i%portantly& resistance trainingincreases spontaneous activity



Effect of # weeks resistance

e8ercise on spontaneous activity

Multi factorial intervention to reduce




falls

• a%e co%%unity dwelling cohort

• )ntervention by protocols targeting riskfactors identified in previous study

• )nvolving nurse& physiotherapist G

physician

inetti M et al 5 Engl ; Med *<<A> ,,*:#$*




falls

inetti M et al 5 Engl ; Med *<<A> ,,*:#$*




falls



Osteoporosis and fractures



Osteoporosis definitions

• Osteopenia score * to $'

• Osteoporosis score $'• evere osteoporosis score$' plus

fragility fracture

reva ence o steopen a an



reva ence o steopen a anOsteoporosis 2;a%%u4

/o%en7s clinic G welfare

har%a et al' )nd ; Med ci $@@?> ?@24:*#,



Osteoporosis: (isk factors

• Hender 2* in A wo%en& * in # %en over age @4

• "ge

• Jnderweight

• Early %enopause• 1aucasian or "sian

• Diet 2low calciu%&I high ani%al protein& coffee'''4

•)nactivity• %oking

• Medications 2anticonvulsants& corticosteroids''4



9ita%in D levels in "ndhra 6radesh

• 1onvenience sa%ple

• <A, healthy urban adults

• $@ healthy rural adults

9ita%in D levels:

• Deficient K $@ ng+%l 2@ n%ol+04

• )nsufficient $@,@ ng+%l 2@= n%ol+04

• ufficient ,@ ng+%l 2= n%ol+04

3arinaryan 1 et al' )ndian ; Med (es $@@#> *$=:$**

5 t i l 63 d 9it i D



5ter%inal 63 and 9ita%in D

levels




9ita%in D levels: "ndhra 6radesh




Bone %ineral density and fracture risk



reat%ent of osteoporosis

• "de-uate calciu% in diet 2total *@@ %gele%ental calciu% per day4

• 9ita%in D #@@*@@@ units daily

• Bisphosphonates 2%oving towards %orepotent drugs in 5" alendronate&risedronate& .oledronic aci

• (alo8ifene 23(4• riperidide 2634

• 1alcitonin



)ndications for bisphosphonates

• BMD scores tscore less than $ or $'

•Over age = with fragility fracture

• 1hronic corticosteroid use , %onths



(isedronate

•3arris & /atts 5B& Henant 3& et al' ;"M" *<<<'



(alo8ifene

Ettinger B et al ;"M" *<<<



1alcitonin

1hesnut 13 et al "% ; Med $@@@



6rogress in osteoporosis

• (ate of hip fractures is stabili.ing

• 6ublic awareness is increasing

•6rogra%s being established 2e'g' FO6Fracture: think osteoporosisL4

• 3ope to see as a historical disease in a

generation 2or two4



JMM"(

• Falls are co%%on and serious: structuredapproach to investigation and%anage%ent

• Deconditioning is co%%on and serious:aggressive %obili.ation is essential

• Osteoporosis is a loo%ing threat: %ost

i%portant point: 9ita%in D supple%ents forall older people #@@*@@@ units daily atleast



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