Download Physiological basis of the care of the care of the elderly

1
PHYSIOLOGICAL
BASIS OF THE CARE
OF THE ELDERLY
CLIENT
The Musculoskeletal System
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 won’t listen to her.
J.H. states all her joints hurt and she’d 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.
Informal evaluation
3
What additional information do you need?



Subjective information
Objective information
Psychosocial information
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
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
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 halfinch variation
 With age, the discs
flatten reducing height permanently

Sarcopenia
7
Loss of muscle mass, strength, function
 Maximum muscle strength can decrease by 85%
 Occurs in up to
50% patients
80 years +

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.
Classification of musculoskeletal
illnesses
9
Metabolic
bone disease
Joint disease
Osteoporosis
Osteoarthritis
(noninflammatory)
Osteomalacia
Rheumatoid arthritis
(inflammatory)
Paget’s
disease
Gout
(inflammatory)
Pseudogout
(inflammatory)
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

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
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.
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

Lifestyle modifications for the patient
with osteoporosis
14
Diet with adequate calcium and vitamin D
 Weight bearing exercise (increase bone density)
 Smoking cessation
 Reduction of alcohol,
caffeine

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
Examples of weight bearing exercise
16





Dumbells
Resistance band
Bodyweight exercise
Calisthenics
Weight machine exercise
Pharmacological prevention &
treatment of osteoporosis
17

Ibandronate (Boniva)


Alendronate (Fosamax)




Once a month or IV every 3 months
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!
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

Diagnostics for osteomalacia
19



Bone density studies
Alkaline phosphatase is elevated
Serum calcium is low
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
Paget’s 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

Diagnostics for Paget’s disease
22



Xrays, bone scan, CT
Serum calcium low or normal
May require bone biopsy:
Treatment of Paget’s disease
23


Deformities are irreversible
Treatment goals
 Relieve
bone pain
 Prevent progression

Medications of choice
 Alendronate
(Fosamax)
 Risendronate (Actonel)
Osteoarthritis
(Joint disease—noninflammatory)
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

Clinical manifestations osteoarthritis
25

Characteristic nodule formation:
Diagnostics for osteoarthritis
26

Xray—joint space narrowing, spur formation
Treatment goals
27
Rheumatoid arthritis
(Joint disease—inflammatory)
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
Clinical manifestations of rheumatoid
arthritis
29

Commonly occurs in:
 Joints
of upper extremities
 Knees
 Ankles
 Feet

Systemic symptoms:
 Fatigue,
malaise
 Weight loss
 Fever
Diagnostics for rheumatoid arthritis
30
Xray—symmetrical disease
 Synovial fluid aspiration
 WBC and ESR ↑
in 80% of cases
 Rheumatoid factor
(RF) ↑ in 50%

of cases
Osteoarthritis vs rheumatoid arthritis
31
Osteoarthritis vs rheumatoid arthritis
32
Osteoarthritis
Red, swollen, tender
Affects internal organs
Most common form
“Wear and tear”
Bilateral symmetry
Morning stiffness >30 min
Pain improves during day
Nodules (Bouchard’s)
Primarily in cartilage
Primarily in synovium
Rheumatoid Arthritis
Pharmacological interventions for
osteoarthritis
33



NSAIDs are most common treatment
Acetaminophen 500 mg—2-4 grams per day
Capsaicin—topical analgesic
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

Importance of exercise
35






Maintain overall function
Maintain muscle strength
Maintain coordination
Maintain balance
Maintain flexibility
Maintain endurance
Exercise programs…
36


Require clearance by PCP
Start slow, low impact, gradually increase
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
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
Spine
39


In profile, should be a slight reverse “S”
Posteriorly, midline without deviation, shoulders even
Testing for scoliosis
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

Gout (joint disease—inflammatory)
41





Excessive uric acid in blood
Crystals accumulate in joints
Warmth, redness, swelling, pain
Low purine diet
Diagnosis—urate crystals in
affected joint
Treatment of gout
42

Acute attacks:
 NSAIDs
 Colchicine
 Steroids

Long term management:
 Colchicine
 Allopurinol
(Zyloprim)
 Probenicid
 Indomethacin
(Indocin)
Pseudogout (joint disease—inflammatory)
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
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

Contributing factors to falls
45








Visual changes
Balance problems
Cognitive changes
CV problems
Medications
Urinary incontinence, urgency
Malnutrition
Musculoskeletal impairment
Balance exercises for the elderly
46

Reinforce balance
exercises:
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
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 <20 seconds to complete test


Adequate for independent transfers and mobility
Patient requires >30 seconds to complete test

Suggests higher dependence and risk of falls
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
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
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 Parkinson’s
Formal evaluation
52



What is your nursing
diagnosis for J.H.?
What is your desired
outcome?
What are appropriate
interventions pertinent
to your desired outcome?