PHYSIOLOGICAL BASIS OF THE CARE OF THE ELDERLY CLIENT The
Musculoskeletal System 1
Slide 2
Patient scenario 2 J.H. is a 76 year old female brought in by
her granddaughter with whom she lives. The granddaughter states
J.H. complains of her joints hurting and she is mean and wont
listen to her. J.H. states all her joints hurt and shed rather just
stay in bed all day. She is afraid J.H. will hurt herself as she
has fallen twice while the granddaughter is at work.
Slide 3
Informal evaluation 3 What additional information do you need?
Subjective information Objective information Psychosocial
information
Slide 4
Structure and function of joints 4 Point at which 2 bones are
attached Provide stability and mobility to the skeleton A joint
that is unstable or immobile is ineffective! Nursing diagnoses
originate from cause of the ineffective joint: Impaired physical
mobility Acute pain or chronic pain Fatigue
Slide 5
Age related changes 5 Decreased range of motion Shrinking
vertebral discs and loss of bone mass contribute to decrease in
height Muscle atrophy, exacerbated by disuse Decrease in lean body
mass Joint degeneration Postural instability contributes to balance
difficulties Difficulty maintaining balance
Slide 6
Incredible shrinking people 6 After age 40, loss of 1 cm in
height every decade is normal Vertebral deterioration due to
osteoporosis 23 spinal compress during the day and reabsorb fluid
during night, causing a half- inch variation With age, the discs
flatten reducing height permanently
Slide 7
Sarcopenia 7 Loss of muscle mass, strength, function Maximum
muscle strength can decrease by 85% Occurs in up to 50% patients 80
years +
Slide 8
Treatment for sarcopenia 8 The primary treatment for sarcopenia
is exercise. Resistance training with resistance bands Strength
training with weights Effective for both prevention and treatment
of sarcopenia Positive influence on Neuromuscular system Hormone
concentrations Can increase protein synthesis rates in older adults
in as little as two weeks.
Osteoporosis (Metabolic bone disease ) 10 Low bone mass
Deterioration of bone tissue Affects 50% of women Contributors to
decreased bone mass in the elderly 1) failure to achieve peak bone
mass in early adulthood 2) increased bone resorption 3) decreased
bone formation
Slide 11
Risk factors for osteoporosis 11 Risk factors include:
Increased age Female White or Asian Family history Thin body build
Also implicated: low calcium intake, smoking, alcohol, caffeine,
stress, long term corticosteroids, anticonvulsants, thyroid
medications
Slide 12
Diagnostics for osteoporosis 12 Bone mineral density study
recommended for: Postmenopausal women below age 65 with risk
factors for osteoporosis. All women aged 65 and older.
Postmenopausal women with fractures Women with medical conditions
associated with osteoporosis. Women whose decision to use
medication might be aided by bone density testing. Men age 70 or
older. Men ages 50-69 with risk factors for osteoporosis.
Slide 13
Diagnostic tests: bone mineral density study 13 Used to predict
fracture Recommended for most women > 65 years of age
Recommended for those < 65 if: Chronic rheumatoid arthritis
Fracture Early menopause Smoking Family history of osteoporosis
Taking corticosteroids Consume > 3 drinks of alcohol per
day
Slide 14
Lifestyle modifications for the patient with osteoporosis Diet
with adequate calcium and vitamin D Weight bearing exercise
(increase bone density) Smoking cessation Reduction of alcohol,
caffeine 14
Slide 15
Medications for osteoporosis 15 Biphosphates Alendronate
(Fosamax)daily or weekly Ibandronate (Boniva)daily or monthly or q
3 months IV Estrogen agonists/antagonists Raloxifene (Evista)daily
Calcitonin (Miacalcin)daily
Slide 16
Examples of weight bearing exercise Dumbells Resistance band
Bodyweight exercise Calisthenics Weight machine exercise 16
Slide 17
Pharmacological prevention & treatment of osteoporosis 17
Ibandronate (Boniva) Once a month or IV every 3 months Alendronate
(Fosamax) Once weekly Empty stomach Upright for at least 30 minutes
Raloxifene hydrochloride (Evista) Once daily May take without
regard for food May cause flushing Increased risk of thromboembolic
events Weight bearing exercise important in all cases!
Slide 18
Osteomalacia ( Metabolic bone disease) 18 Softening of the
bones: volume of bone is adequate, replacement is soft and not
rigid Defective bone mineralization Inadequate available phosphorus
and calcium Can be caused by increased resorption of calcium due to
hyperparathyroidism
Slide 19
Diagnostics for osteomalacia 19 Bone density studies Alkaline
phosphatase is elevated Serum calcium is low
Slide 20
Treatment of osteomalacia 20 Goal is to remineralize the bone
Vitamin D replacement 50,000-100,000 units/day for 1-2 weeks 400 to
800 units daily Must have adequate calcium intake 1000 to 1500
mg/day Monitor serum and urine calcium levels
Slide 21
Pagets disease (Metabolic bone disease) 21 Chronic, localized
disorder Normal bone removed, replaced with abnormal bone Cause is
unknown Often an incidental finding Common symptom is bone pain at
site or adjacent joints
Slide 22
Diagnostics for Pagets disease 22 Xrays, bone scan, CT Serum
calcium low or normal May require bone biopsy:
Slide 23
Treatment of Pagets disease 23 Deformities are irreversible
Treatment goals Relieve bone pain Prevent progression Medications
of choice Alendronate (Fosamax) Risendronate (Actonel)
Slide 24
Osteoarthritis (Joint diseasenoninflammatory) 24 Most common
form of arthritis in the US Chronic Women > men Progressive
erosion of articular cartilage of the joint New bone forms in the
joint space
Diagnostics for osteoarthritis 26 Xrayjoint space narrowing,
spur formation
Slide 27
Treatment goals 27
Slide 28
Rheumatoid arthritis (Joint diseaseinflammatory) 28 Most common
inflammatory arthritis of any age group Women:men 3:1 Chronic
syndrome Symmetrical inflammation of peripheral joints Likely an
autoimmune response to unidentified antigen
Slide 29
Clinical manifestations of rheumatoid arthritis 29 Commonly
occurs in: Joints of upper extremities Knees Ankles Feet Systemic
symptoms: Fatigue, malaise Weight loss Fever
Slide 30
Diagnostics for rheumatoid arthritis 30 Xraysymmetrical disease
Synovial fluid aspiration WBC and ESR in 80% of cases Rheumatoid
factor (RF) in 50% of cases
Slide 31
Osteoarthritis vs rheumatoid arthritis 31
Slide 32
Osteoarthritis vs rheumatoid arthritis 32
OsteoarthritisRheumatoid Arthritis Red, swollen, tender Affects
internal organs Most common form Wear and tear Bilateral symmetry
Morning stiffness >30 min Pain improves during day Nodules
(Bouchards) Primarily in cartilage Primarily in synovium
Slide 33
Pharmacological interventions for osteoarthritis 33 NSAIDs are
most common treatment Acetaminophen 500 mg2-4 grams per day
Capsaicintopical analgesic
Slide 34
Nonpharmacological treatment of osteoarthritis 34 Weight
reduction Active range of motion daily Weight bearing exercise Rest
to control symptoms Use of assistive devices if necessary
Slide 35
Importance of exercise 35 Maintain overall function Maintain
muscle strength Maintain coordination Maintain balance Maintain
flexibility Maintain endurance
Pharmacological interventions for rheumatoid arthritis 37
Corticosteroids (e.g., prednisone) to decrease inflammation May
have long-term adverse effects NSAIDs Quick relief important to
preserve independence
Slide 38
Nonpharmacological treatment of rheumatoid arthritis 38
Strength training to address muscle wasting Range of motion of
joints Regular exercise if no inflammation or exacerbation Rest to
reduce joint stress
Slide 39
In profile, should be a slight reverse S Posteriorly, midline
without deviation, shoulders even 39 Spine
Slide 40
Standing Uneven shoulder height Unequal distance between arms
and body Asymmetrical waistline Uneven hip height Sideways lean
Bending over Asymmetrical thoracic spine Prominent rib cage/hump on
either side Asymmetrical waistline 40 Testing for scoliosis
Slide 41
Gout (joint diseaseinflammatory) 41 Excessive uric acid in
blood Crystals accumulate in joints Warmth, redness, swelling, pain
Low purine diet Diagnosisurate crystals in affected joint
Slide 42
Treatment of gout 42 Acute attacks: NSAIDs Colchicine Steroids
Long term manage- ment: Colchicine Allopurinol (Zyloprim)
Probenicid Indomethacin (Indocin)
Slide 43
Pseudogout (joint diseaseinflammatory) 43 Actually a form of
arthritis Formation of calcium pyrophosphate-dihydrate crystals in
large joints 60 years+ Women > men Develops in families Affects
several joints Diagnosed by joint fluid aspiration
Slide 44
Falls 44 Most occur in the home during normal activities
Leading cause of accidental death Commonly result in fractures of
hip, spine, forearm Of all fall-related fractures, hip fracture is
most likely
Balance exercises for the elderly 46 Reinforce balance
exercises:
Slide 47
Treatment of hip fractures 47 Surgery is preferred treatment
Should be performed without delay if tolerable May not be an option
for severely debilitated patient Total joint replacement performed
if severe arthritis is present
Slide 48
Fall assessment: Get up and go test 48 Technique: Direct
patient to do the following Rise from sitting position Walk 10 feet
Turn around Return to chair and sit down Interpretation Patient
takes 30 seconds to complete test Suggests higher dependence and
risk of falls
Slide 49
Diagnostic tests: computerized tomography vs magnetic resonance
49 Computerized tomography (CT) Can detect inflammation and
degeneration not visible on xray Can show subtle fractures and
articular damage Magnetic resonance imaging (MRI) More detailed
image Does not require radiation or contrast Can detect soft tissue
changes
Slide 50
Gait changes in the elderly 50 Gait velocity unchanged until
about 70 years Cadence (steps per minute) does not change Time with
both feet on the ground increases from 18% in young adults to about
26% healthy elderly Anterior pelvic rotation increases partly due
to weak pelvic muscles Joint motion changes slightly
Slide 51
Abnormal changes in gait in the elderly 51 Loss of symmetry of
movement Difficulty initiating or maintaining gait Walking, falling
backwards (retropulsion) Footdrop Short step length Wide based gait
Progressive quickening to avoid falling forward (festination) as
with Parkinsons
Slide 52
Formal evaluation What is your nursing diagnosis for J.H.? What
is your desired outcome? What are appropriate interventions
pertinent to your desired outcome? 52
