IMRE SEMSEI PhD

Faculty of Health

University of Debrecen

Hungary

GERIATRICS Alterations with age, diseases, treatment IV.

Bones-joints, hematopoiesis, mouth and chin bones

ALTERATIONS

OF BONES,

JOINTS AND

CARTILAGE

AS A FUNCTION

OF AGE

The bone mass is a result of a dynamic balance of the bone generation and breakdown of the bones. In case the breakdown is dominating it leads to the loss of bones, i.e. to osteoporosis.

Millions of fractures happens yearly and 2 million of them is the break of the femoral neck. The death rate of these fractures in a period of half a year is about 12-20%.

Substantial vitamin D deficiency causes myopathy that leads to uncertainty of walking and increased chance of falls. A mild deficiency result only in osteoporosis and the serious one (<15 ng/ml) in osteomalacia.

About 20% of the adult population has certain symptoms of arthrosis but people above 55 years of age has more than 80% involvement. This is a disease of heterogenic symptoms due mainly to aging , in which the degenerative processes alters not only the upper layer cartilage but the subcondral bones, the synovial membrane, the ligaments, the meniscuses, the joint case, the surrounding muscles and nerves as well.

Metabolism of the bones is regulated by genetic factors (60-70%) and environmental ones (30-40%).

Primer prevention of osteoporosis is based on: adequate diet, physical activity and the avoidance of factors, which negatively influences the bones, such as alcohol, smoking, etc. If the disease already exists (secondary prevention) one has to pay high attention to the prevention of the breaks of bones.

ALTERATIONS OF BONES, JOINTS AND

CARTILAGE AS A FUNCTION OF AGE

OSTEOPOROSIS

• At the beginning there are not

any physical symptoms.

• Progression result in a typical

posture and decreased

bone density.

• Prevention and treatment:

•appropriate diet, physical

activity

• Calcium and vitamin D

supply

DISEASES OF BONES, JOINTS AND

CARTILAGE AS A FUNCTION OF AGE

Most important risk factors:

female gender

age

Caucasian race

bone fracture caused by a negligible factor in anamnesis

positive familiar anamnesis

immobilization

increased activity of bone desorption (increased amount of

collagen crosslink in serum or urine)

hypogonadism

early menopaose

Small body mass

loss of more than 10% of the body mass

hyperthyreosis

hyper production of glucocorticoids

malnutrition, malabsorption

chronic diseases of kidney and liver

conditions after organ tarnsplantation

medicines (glucocorticoids, cytostatics, tyroxin,

anticonvulsants, heparin, etc.)

OSTEOMALACIA

Serious vitamin D

deficiency (<15 ng/ml)

Symptoms: muscle

weakness, joint complaints,

uncertainty of walking,

higher incidence of

malignancy, hypertension,

easily formed heart

insufficiency, decreasing

tolerance of carbohydrates,

accelerated process of

dementia

DISEASES OF BONES, JOINTS AND

CARTILAGE AS A FUNCTION OF AGE

Heterogenic disease type, parts involved:

• upper layer of cartilage

• subcondral bone

•Synovial membrane

• ligaments

•meniscuses

• joint case

• surrounding muscles and nerves

Parts of the body involved: knee, hip,

hand

ARTHROSIS

CAUSES

• endocrine diseases

• aging and diseases of the

immune system

• metabolic diseases

• diseases of the joints: arthritis,

osteonecrosis, osteo-

chondromatosis

DISEASES OF BONES, JOINTS AND

CARTILAGE AS A FUNCTION OF AGE

Cellularity of bone marrow substantially decreases with age (even by 30%), and the activity of erythropoesis also declines. The low cellularity is caused and could be explained partly by the increase of apoptosis or age-related deregulation of cytokine production.

Size of the red blood cells slightly increases with age, however metabolic activity and life span of these cells decline. Hemoglobin level in one quarter of old but healthy people could be as low as in case of anemia.

HEMATOPOIESIS

IN OLD AGE

In old age remarkable alterations can be noticed from point of view of rheology and coagulation as well, i.e. increase of fibrinogen level, elevation of plasma viscosity, increased red blood cell rigidity or the early activation of the coagulation cascade. All these contribute to the deterioration of the micro circulation.

The numbers of white blood cells do not change with age but activity and mobilization capability of thegranulocytes decline. In case of a serious infectious disease of an old people, in a paradox way, even leucopenia could be formed. Clinically, the aging of the lympho-hematopoetic system is accompanied by increase of the incidence of several malignant and autoimmune diseases.

Number of bone marrow progenitors decreases in old age and the microenvironment of the bone marrow also changes, moreover, production of the growth factors slightly declines too.

HEMATOPOIESIS

IN OLD AGE

ANEMIA (12-13 g/dl) Causes: deficiencies in iron, folic acid,

or B12 vitamin, moreover, insufficiency of kidney or chronic inflammations

Incidence: 20% of men (above 85 years of age) and 25% of women

Physiological or pathological? Anemia should not be a characteristic

of the normal aging process.

Anemia --- higher incidence of death

Etiology of anemia Iron deficiency (20%; <12 ug/l)

Vitamin B12 and folic acid deficiency (inappropriate diet, disturbance of nutritional absorption)

Decreased level of erythropoietin (kidney disease – decrease of EPO )

Inflammatory anemia (ACI, 20%; associated to chronic inflammation, malignant and autoimmune processes)

HEMATOPOIESIS

IN OLD AGE

Mouth,

teeth,

chin bones

AGE-RELATED CHARACTERISTIC

ALTERATIONS OF THE MOUTH, TEETH AND

CHIN BONES

Mucosal membranes and the tong

Atrophy of the mucosal membrane is characteristic of old age and it is accompanied by a decrease of the epithelial cells and the increase of the keratinization. Ratio of the elastic fibers decreases in the connective tissue but the numbers of keratin fibers increases. As a function of the deterioration of arterioles the oxygen supply of the mucosal membrane declines.

Number of glands responsible for tasting declines by 80%!

Microbiological characteristics of the mouth

Microbiological environment of the mouth is formed by bacteria, fungi, viruses, mycoplasms, and protozoones. Inside the mouth the composition of the micro flora alters at different locations, i.e. at crown of teeth, in sulcus gingivalis and at the tong.

• Alterations formed in chin bones

• Characteristic alterations of the chin bones are

connected to osteoporosis of old age that is aggravated

by bone atrophy of inactivity caused by the loss of teeth.

• Neuromuscular system

•Contractile elements in the masseter (chewing muscle)

decreases with advanced age and they are replaced by

fibro-adiposal tissues that results in a decrease of the

chewing strength.

• Alterations of the salivary glands

•Old age is characterized by a substantial atrophy of the

gland parenchyma. Acinuses are shrinked, and the

transformation of the fibro-adiposal tissues is more

pronounced. Number of glands that produce the saliva

decreases and the function of the gland tissue remained

also declines with age. This is one of the causes of the

frequent xerostomia of the old people.

AGE-RELATED CHARACTERISTIC

ALTERATIONS OF THE MOUTH, TEETH AND

CHIN BONES

Alteration in the composition of the teeth Enamel

Enamel becomes more fragile. Frequencies and extents of different types of abrasion increases with age.

Dentin The continuous increase of the secondary dentine happens during life.

However, this new dentin has lower numbers and irregularly formed tubules compared to the primer dentin.

Pulp The pulp cave will be more and more smaller due to the formation of

secondary and tertiary dentin as a function of age. Atherosclerosis is also enhanced in the blood vessels of the pulp.

Cement Primarily, thickening of the periapicial and inter radical fields of the cement

can be noticed due to the aging process.

Caries Number of caries decreases with increasing age and its localization changes.

Alterations of the parodontium The atherosclerosis is enhanced in the periodontal blood vessels too. The

fibers of membrane of the tooth roots are thickened, substance of inter febrile matrix decreases and the ratio of collagen is also higher.

AGE-RELATED CHARACTERISTIC

ALTERATIONS OF THE MOUTH, TEETH AND

CHIN BONES