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Musculoskeletal Disorders in Older Persons
Christopher PattersonMcMaster University,
Hamilton, OntarioCanada
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 (OH, arrhythmias,
blocks…)
• Seizures (may be akinetic…)
• Endocrine (hypoglycemia…)
Illnesses that cause falls in older people
Neurological disorders
• Movement disorders ( Parkinson’s disease and –ism, PSP, CBD…)
• 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…)
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, BZP, antipsychotics…)
• Anticholinergics
• And many others
Calculating risk of fallsTinetti 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
Bed rest and muscle strength
Muscle strength (MVC) lost at 2-5% per day
Harper & Lyles. JAGS 1998; 36: 1047
DECONDITIONINGConsequences
• Conversion of an individual barely able to rise from a chair to a bedridden state
• Resulting immobility promotes incontinence
• Increases risk of falls
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 restConvertino V et al. Am J Med Sci 2007; 334: 72
DECONDITIONINGthe essence
• Loss of muscle strength
• Altered cardiovascular responses
But there is more, much more…
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
Similarities…Bedrest Spaceflight
Orthostatic hypotension
Increased
Balance, stability Reduced
Coordination, gait Reduced
Muscle strength Reduced
MV 02 Reduced 20-25%
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
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
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)
Women’s 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
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
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