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    Deddy Musculoskeletal

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    mayza
    This document discusses musculoskeletal disorders in elderly patients. It covers causes of falls such as senescent gait, illnesses, and environmental hazards. Deconditioning is defined as the adverse physiological consequences of too much rest, such as loss of muscle strength and altered cardiovascular responses. Osteoporosis is also reviewed, including risk factors, prevalence, and treatment options like bisphosphonates and calcium/vitamin D supplementation. The key messages are that falls require a structured approach, deconditioning necessitates aggressive mobilization to prevent further losses, and ensuring adequate vitamin D levels is critical for bone health.

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    Deddy Musculoskeletal

    Uploaded by

    mayza
    149 views59 pages
    This document discusses musculoskeletal disorders in elderly patients. It covers causes of falls such as senescent gait, illnesses, and environmental hazards. Deconditioning is defined as the adverse physiological consequences of too much rest, such as loss of muscle strength and altered cardiovascular responses. Osteoporosis is also reviewed, including risk factors, prevalence, and treatment options like bisphosphonates and calcium/vitamin D supplementation. The key messages are that falls require a structured approach, deconditioning necessitates aggressive mobilization to prevent further losses, and ensuring adequate vitamin D levels is critical for bone health.

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    This document discusses musculoskeletal disorders in elderly patients. It covers causes of falls such as senescent gait, illnesses, and environmental hazards. Deconditioning is defined as the adverse physiological consequences of too much rest, such as loss of muscle strength and altered cardiovascular responses. Osteoporosis is also reviewed, including risk factors, prevalence, and treatment options like bisphosphonates and calcium/vitamin D supplementation. The key messages are that falls require a structured approach, deconditioning necessitates aggressive mobilization to prevent further losses, and ensuring adequate vitamin D levels is critical for bone health.

    Copyright:

    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    149 views59 pages

    Deddy Musculoskeletal

    Uploaded by

    mayza
    This document discusses musculoskeletal disorders in elderly patients. It covers causes of falls such as senescent gait, illnesses, and environmental hazards. Deconditioning is defined as the adverse physiological consequences of too much rest, such as loss of muscle strength and altered cardiovascular responses. Osteoporosis is also reviewed, including risk factors, prevalence, and treatment options like bisphosphonates and calcium/vitamin D supplementation. The key messages are that falls require a structured approach, deconditioning necessitates aggressive mobilization to prevent further losses, and ensuring adequate vitamin D levels is critical for bone health.

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    © All Rights Reserved
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    of 59

    Musculoskeletal Disorders in

    Elderly

    Objectives
    Falling: list causes and prevention
    strategies in the individual
    Define deconditioning and its relation to
    rest
    Briefly review osteoporosis

    Setting the scene


    An 82 year old woman falls in the kitchen,
    injuring her right arm.
    Believing it to be broken, she seeks medical
    care, and is reassured that there is no fracture.
    Returning home she Is afraid to walk and
    despite encouragement from her family, she
    takes to her bed.
    One week later she becomes incontinent and
    unable to walk

    Falls in older people


    About 1/3 older people fall each year
    Many healthy younger people also fall
    each year but most falls are
    inconsequential
    3 principal reasons for falling
    Senescent gait
    Illnesses
    Environmental hazards

    Falls in older people


    Senescent gait
    Slower gait speed
    Wider base of support
    Lower step height
    Centre of gravity forward
    Less armswing

    Illnesses that cause falls in older


    people
    Loss of consciousness
    Syncope or presyncope (Ortostatic
    Hypotension, arrhythmias, blocks)

    Seizures (may be akinetic)


    Endocrine (hypoglycemia)

    Illnesses that cause falls in older


    people
    Neurological disorders
    Movement disorders ( Parkinsons
    disease, )
    Hemiparesis and spasticity
    Peripheral neuropathy (motor, sensory..)
    Ataxia ( central or peripheral)
    Vestibular disorders

    Illnesses that cause falls in older


    people
    Cognitive disorders
    Conditions which affect judgement
    (dementias, depression..)
    Conditions that affect spatial orientation
    (strokes, posterior degenerations)

    Illnesses that cause falls in older


    people
    Musculoskeletal disorders
    Painful lower limb conditions
    Restriction of joint movement
    Muscular weakness (sarcopenia, disuse,
    myopathy)

    Muscle and age

    Muscle mass and age


    Kehayias J et al. Am J Clin Nutr 1997;66:904

    Aging and loss of muscle


    mass/strength (sarcopenia)
    Muscle strength declines by 15% per
    decade in 6th and 7th decade
    Declines by 30% per decade thereafter
    Killewich, L. Journal of American College of Surgeons,2006, 203:5

    Illnesses that cause falls in older


    people
    Special senses
    Vision (acuity, depth perception)
    Hearing

    Drugs that cause falls in older


    people
    Antihypertensives
    Psychotropic agents (antidepressants,
    Benzodiacepine, antipsychotics)
    Anticholinergics
    And many others

    Environmental causes of falls

    Calculating risk of falls


    Tinetti M et al N Engl J Med 1988; 319:1701

    Prospective I year study


    336 community dwelling people over aged
    75
    Careful monitoring of falls, detailed
    examination for risk factors
    Risk of falls 8% with no risk factors
    Risk of falls 78% with 4 or more risk
    factors

    Calculating risk of falls


    Risk factor

    Relative risk of falling

    Sedative drugs

    28.3

    Cognitive impairment

    5.0

    Disability of lower limb

    3.8

    Palmar mental reflex

    3.0

    Abnormal balance or gait

    1.9

    Foot problem

    1.8
    Tinetti M et al N Engl J Med 1988; 319:1701

    Consequences of falls in older


    people
    Fractures
    Soft tissue injuries
    Fear of falling

    6%
    24%
    >20%

    Consequences of falls in older


    people

    Muscle weakness

    Immobility

    Fear of falling

    Bed rest and muscle strength


    Muscle strength (MVC) lost at
    2-5% per day
    Harper & Lyles. JAGS 1998; 36: 1047

    Lower limb muscle strength and


    unloading for 10 days
    Acta Physiol Scand 1996; 157:63

    DECONDITIONING:
    a simple definition
    The adverse physiological
    consequences of
    too much rest

    DECONDITIONING
    Consequences
    Conversion of an individual barely able to
    rise from a chair to a bedridden state
    Resulting immobility promotes
    incontinence
    Increases risk of falls

    DECONDITIONING
    Consequences

    Bedrest: effects on cardiovascular


    system
    Reduction in plasma volume
    Reduced stroke volume and cardiac
    output
    Orthostatic hypotension
    Results in falls, syncope
    Convertino V et al. Am J Med Sci 2007; 334: 72
    Killewich L. J Am Coll Surg 2006; 203: 5

    Plasma volume and bed rest


    Convertino V et al. Am J Med Sci 2007; 334: 72

    DECONDITIONING
    the essence
    Loss of muscle strength
    Altered cardiovascular responses
    But there is more, much more

    Bed rest and calcium balance

    Bone Mineral Content and rest


    Rittweger J et al. J Physiol 2006; 577: 331

    DECONDITIONING
    Muscle weakness
    Circulatory changes
    Many other consequences including
    negative calcium balance (effects on bone)
    catabolic state (effects on nutrition)
    pressure effects on skin (risk of ulceration)
    insulin resistance, inflammatory responses
    etc.
    Changes may occur soon after rest

    DECONDITIONING
    A complex process of physiological
    change following a period of inactivity,
    bedrest or sedentary lifestyle, which
    results in functional losses.
    Brand C et al. 2003 www.mh.org.au/ClinicalEpidemiology

    DECONDITIONING:
    Similar terms
    Functional decline
    Dysfunction syndrome
    Weightlessness effects

    What do they have in common?

    Similarities
    Bedrest
    Orthostatic
    hypotension

    Increased

    Balance, stability

    Reduced

    Coordination, gait Reduced


    Muscle strength

    Reduced

    MV 02

    Reduced 20-25%

    Spaceflight

    Similarities
    Bedrest

    Spaceflight

    Orthostatic
    hypotension

    Increased

    Increased

    Balance, stability

    Reduced

    Reduced

    Coordination, gait Reduced

    Reduced, wide

    Muscle strength

    Reduced

    Reduced

    MV 02

    Reduced 20-25% Reduced 12%

    So, how do we treat the lady who


    fell at home?
    Resistance training increases muscle
    strength and volume by 1% per day
    (remember that it is lost at 2-5% per day)
    More importantly, resistance training
    increases spontaneous activity

    Effect of 8 weeks resistance


    exercise on spontaneous activity

    Multi factorial intervention to reduce


    falls
    Same community dwelling cohort
    Intervention by protocols targeting risk
    factors identified in previous study
    Involving nurse, physiotherapist &
    physician

    Tinetti M et al N Engl J Med 1994; 331:821

    Multi factorial intervention to reduce


    falls

    Tinetti M et al N Engl J Med 1994; 331:821

    Multi factorial intervention to reduce


    falls

    Osteoporosis and fractures

    Osteoporosis definitions
    Osteopenia T-score -1 to -2.5
    Osteoporosis T-score >-2.5
    Severe osteoporosis T-score>-2.5 plus
    fragility fracture

    Prevalence of Osteopenia and


    Osteoporosis (Jammu)
    Womens clinic & welfare

    Sharma S et al. Ind J Med Sci 2006; 60(5):183

    Osteoporosis: Risk factors

    Gender (1 in 4 women, 1 in 8 men over age 50)


    Age
    Underweight
    Early menopause
    Caucasian or Asian
    Diet (low calcium,? high animal protein, coffee...)
    Inactivity
    Smoking
    Medications (anticonvulsants, corticosteroids..)

    Vitamin D levels in Andhra Pradesh


    Convenience sample
    943 healthy urban adults
    205 healthy rural adults
    Vitamin D levels:
    Deficient < 20 ng/ml (50 nmol/L)
    Insufficient 20-30 ng/ml (50-75 nmol/L)
    Sufficient >30 ng/ml (>75 nmol/L)
    Harinaryan C et al. Indian J Med Res 2008; 127:211

    N-terminal PTH and Vitamin D


    levels

    Harinaryan C et al. Indian J Med Res 2008; 127:211

    Vitamin D levels: Andhra Pradesh

    Harinaryan C et al. Indian J Med Res 2008; 127:211

    Bone mineral density and fracture risk

    Treatment of osteoporosis
    Adequate calcium in diet (total 1500 mg
    elemental calcium per day)
    Vitamin D 800-1000 units daily
    Bisphosphonates (moving towards more
    potent drugs in NA alendronate,
    risedronate, zoledronic aci
    Raloxifene (HRT)
    Triperidide (PTH)
    Calcitonin

    Indications for bisphosphonates


    BMD scores t-score less than -2 or -2.5
    Over age 75 with fragility fracture
    Chronic corticosteroid use >3 months

    Risedronate

    Harris ST, Watts NB, Genant HK, et al. JAMA 1999.

    Raloxifene

    Ettinger B et al JAMA 1999

    Calcitonin

    Chesnut CH et al Am J Med 2000

    Progress in osteoporosis
    Rate of hip fractures is stabilizing
    Public awareness is increasing
    Programs being established (e.g. FTOP
    Fracture: think osteoporosis!)
    Hope to see as a historical disease in a
    generation (or two)

    SUMMARY
    Falls are common and serious: structured
    approach to investigation and
    management
    Deconditioning is common and serious:
    aggressive mobilization is essential
    Osteoporosis is a looming threat: most
    important point: Vitamin D supplements for
    all older people 800-1000 units daily at
    least

    How did we do?

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