1. Mobility
NURS 4100 Care of the Older Adult
Spring 2014
Joy Shepard, PhD(c), MSN, RN, CNE, BC
1

2. Objectives




Describe the effects of aging on
musculoskeletal function
List the benefits of activity
Describe factors contributing to, symptoms,
treatment, and related nursing care for
fractures, osteoporosis, and osteoarthritis
Identify ways to reduce risks of injury
associated with musculoskeletal problems

3. Normal Changes of
Aging
3

4. Normal Changes of Aging
Musculoskeletal System (pp 5859)








Decreased height
Decreased ROM joints
Increased postural sway/
difficulty balance
Shrinking vertebral discs, slight
kyphosis
Loss of bone mass, bones
more brittle (increased
resorption)
Muscle atrophy/ decreased
lean body mass
Joint degeneration (cartilage
surface)
Foot problems: bunions, corns,
calluses
4

5. Effects of Aging: Muscles


Decline in size &
number of muscle fibers
Sarcopenia: reduction in
muscle mass & function
(by age 75)



Reduction in protein
synthesis
Increase in muscle
protein degeneration
Decreased strength

Slow decline
5

6. Effects of Aging: Muscles

Decline in endurance/
stamina





Decreased by age 50
Decreased 65-85% of
midtwenties by age 80
Can lead to disability
Causes
Tone & tension


Decreases after age 30
Reduced flexibility
6

7. Joints, Ligaments, Tendons, and Cartilage:
Normal Changes with Aging

Cartilage





Normal wear/ tear

Hyaline cartilage
(joint lining)

Knee cartilage
Thins ~ 0.25 mm/year

Lines joints
Erodes/ tears with
advancing age
Bone to bone
contact


Discomfort, slow
joint movement
Diminished joint
lubricant
Nonarticular cartilage
(ears & nose)

Grows throughout life
7

8. Wear & Tear on Knee
Cartilage

9. Ears & Nose Continue to
Grow Throughout Life

10. Joints, Ligaments, Tendons, & Cartilage:
Normal Changes with Aging

Ligaments,
tendons, and joint
capsules



Lose elasticity
Less flexible
Joint ROM
decreases
10

11. Skeleton: Trajectory of Bone
Loss

Two phases bone loss


Type I (menopausal bone
loss)

Rapid

Affects women
 Occurs first 5-10 years
after menopause
Type II (senescent bone
loss)
 Slower phase

Affects both sexes after
midlife


Phases eventually overlap
Other conditions may alter
normal aging of skeleton
11

12. Menopausal Osteoporosis:
Vertebral Compression with
Diminished Height

13. Effects of Aging: Skeleton

Bones become
Stiff
 Weaker
 Brittle

13

14. Effects of Aging: Skeleton

Changes in
appearance evident
after fifth decade.

Height most obvious



Midlife
 Vertebral discs thin
Later years
 Decrease individual
vertebrae height
20 to 70 years of age
 Lose 1-2 cm in
height every 2
decades
 Shortening of the
vertebral column
14

15. Effects of Aging: Skeleton

Disproportionate size of
long bones of arm and
legs

Eighth & ninth decades

Rapid decrease in
vertebral height

Collapse of vertebrae

Shortening of trunk

Appearance of long
extremities
15

16. Effects of Aging: Skeleton

Additional postural
changes


Kyphosis
Backward tilt of head
for eye contact


Forward bent
posture
Hips and knees in
flex position
16

17. Question






All of the following are normal age-related
changes in the musculoskeletal system
EXCEPT:
(A) Decreased lean body mass
(B) Joint inflammation
(C) Loss of bone density
(D) Reduction in height
(E) Shortening of vertebrae

18. Can You Spot the
Differences?


A remarkable person who has taken
ownership of his health and aged
successfully
50 years ago:


http://www.youtube.com/watch?v=isLJ024EdMA
Recent:

http://www.youtube.com/watch?
v=iEdClu1KeC8&feature=related

19. Musculoskeletal
Health Promotion
19

20. Assessment Musculoskeletal
Function
Review Assessment Guide
24-1, p. 335
 General observation
 Interview
 Physical examination


21. Prevention of Inactivity

Deleterious effects of inactivity

(Review - Box 24-3, p. 331)
Compensate for age-related changes
 Public education
 Education for caregivers
 Creative activities to stimulate
movement


22. Older Adults: Promotion of
Activity

Benefits of exercise:







Strengthens bones
Reduced constipation
Improved sleep
Lower blood pressure/ cholesterol
Weight loss
Socialization
Enhance motivation

24. Older Adults: Promotion of
Activity
Local resources to promote activity
 Capacities, limitations, and interests
 Avoid stereotyping
 Good nutrition
 Weight reduction


25. Older Adults: Promotion of
Activity

Muscle function
varies with aging
Trainable into
advanced age
 Muscle
regeneration is
normal as age
progresses

25

26. Older Adults: Promotion of
Activity

Lower extremity
muscles atrophy
earlier than upper
extremity


Upper extremities:
Routine daily
activities
Lower extremities:
Walking
26

27. Exercises for Older Adults


Lifts for Elderly (Part 1)
Lifts for Elderly (Part 2)

28. Question


Is the following statement true or false?
Choosing an exercise program for an older
adult can be achieved by identifying
common activities that older adults enjoy
and implementing a program based on your
findings from the literature.

29. Question






The gerontological nurse understands that
all of the following are the effects of
inactivity in older adults EXCEPT:
(A) Calcium loss from bones
(B) Decreased falls
(C) Functional decline
(D) Pressure ulcers
(E) Reduced muscle strength

30. Osteoporosis
30

31. Osteoporosis

Chronic, progressive metabolic
bone disease






Low bone mass
Deterioration of bones
Most prevalent metabolic bone
disease
Kyphosis, lumbar spine pain, &
fractures
Often asymptomatic
1st 5 – 7 yrs after menopause:
some women lose 20% of
bone mass

32. Osteoporosis





50% of postmenopausal
women
20% men older than 65 yrs of
age
10 million Americans (20%
men)
34 million more – low bone
mass
Most common sites of
osteoporotic fx: vertebrae,
wrist, & hips
Understanding
Osteoporosis
32

33. Osteoporosis: Causes

Decreased bone mass in older person




Failure to reach peak bone mass in early
adulthood
Increased bone resorption (osteoclasts)
Decreased bone formation (osteoblasts)
Any health problem associated with:



Inadequate calcium intake
Excessive calcium loss
Poor calcium absorption
Osteoporosis

34. Osteoporosis: Causes





Inactivity or immobility
Diseases: Cushing syndrome,
hyperthyroidism, diverticulitis, ESRD
Reduction in estrogen/ testosterone
Diet: Insufficient calcium, vitamin D, protein
Drugs: Corticosteroids, thyroid hormone,
anticonvulsants
Osteoporosis and Diet
Nutrition and Osteoporosis

35. Pathophysiology of Osteoporosis
Low bone mass
 Deterioration of bone tissue 
compromised bone strength  risk
for fractures
 Bone strength = bone density &
quality


Bone density = grams of mineral per
area or volume (BMD)
35

36. Osteoporosis:
Pathophysiology
36

37. Osteoporosis & Osteopenia



Normal BMD within 1
standard deviation of
young adult mean
Ostopenia - BMD
between 1 & 2.5
standard deviations
below young adult mean
Osteoporosis - BMD 2.5
standard deviations
below young adult mean
37

38. A. Normal bone B. Osteopenia
C. Osteoporosis
38

39. Osteoporosis: BMD &
Fractures

Reduced BMD
Highly predictive of spinal & hip fractures
 Osteoporotic fractures affect 1.5 million
per year in US

Vertebrae fractures ~ 700,000 people per
year
 Hip fractures affect ~ 300,000 per year
 Wrist fractures ~ 250,000 per year

Vertebral Fractures
39

40. Hip Fracture:
Morbidity & Mortality
Highest
Of the people who suffer from
osteoporosis, 20 percent die
within a year after sustaining a
hip fracture
The Physical Consequences of
Fractures

41. A woman's chances of
dying from an osteoporosis
related fracture is greater
than her risk of cervical,
uterine and breast cancer
combined

42. Osteoporosis: Nonmodifiable
Risk Factors (KNOW!) Box 244






Increased age
Female
Caucasian or Asian
race
Positive family history
Small & thin
Certain diseases
Osteoporosis Risk Factors
42

43. Osteoporosis: Modifiable Risk
Factors (KNOW!) Box 24-4






Low calcium & vitamin D
intake, lack of sunlight
exposure
Sedentary lifestyle (inactive,
immobility)
Alcohol abuse
Smoking
Caffeine, soft drinks
(phosphoric acid)
Corticosteroids,
anticonvulsants (Dilantin or
phenobarbital), or thyroid
hormones
How to Prevent
Osteoporosis
43

45. WHO Fracture Risk
Assessment Tool (FRAX)





Please answer the questions below to
calculate the ten year probability of fracture
with BMD.
Caucasian
Black
Hispanic
Asian

46. Classification of Osteoporosis

Primary osteoporosis



Type I (menopausal bone loss)
Type II (senescent bone loss)
Secondary osteoporosis







Hyperparathyroidism
Malignancy
Immobilization
Gastrointestinal disease
Renal disease
Vitamin D deficiency
Drugs causing bone loss such as glucocorticoids,
thyroid hormone (Synthroid), or phenytoin (Dilantin)
46

47. Colles’ Fracture
Affects Wrist
X-Ray of Colles’
Fracture
47

48. Normal Vertebral Column vs
Compression Fracture

49. Vertebral Compression
Fractures
Weak, Fragile from Bone
Loss
Compression Spinal
Fracture
Fractures in the spine or vertebral column can lead to loss of
height, severe back pain, and deformity.
49

50. Trabecular (Cancellous) Bone

51. Trajectory of Bone Loss for
Women






Lower peak bone mass than men
Less in the "bone bank” because of thinner
bones
Rapid withdrawal from "bone bank" during
perimenopause
Longer life expectancy: increased risk for
osteoporosis
Signs/symptoms usually absent
First sign often a fracture
51

52. Trajectory of Bone Loss for
Women



Loss of bone mass with
age in cancellous
(trabecular) versus
cortical bone
Location of fractures
that result
Typical ages in which
fractures occur

53. Trajectory of Bone Loss for
Women

54. Collaborative Care
54

55. Osteoporosis – Collaborative
Care

Collaborative care focuses
on assessment of risk
factors, proper nutrition,
calcium/ vitamin D
supplementation, exercise,
prevention of fractures, and
medications.

56. Nonpharmacological
Treatment/ Prevention
56

57. Nonpharmacological
Treatment of Osteoporosis



Assessment of risk factors
Education about prevention
Older persons with risk factors
Diagnosis of osteoporosis = bone density of
–2.5 SD (below average for young people)


Education about positive lifestyle changes

Diet, exercise, and other risk modifications
How to Prevent
Osteoporosis
57

58. Assessment/Prevention of
Risk Factors for Osteoporosis



Educate all women about osteoporosis risk
factors
Women with fx history  BMD test for
osteoporosis
BMD test





Any woman under 65 with risk factors for osteoporosis
All women over 65
Preventive activities for older men
Many risk factors same for men
Most men have bigger bones than women so they
have increased protection
58

59. Lifestyle Modification Activities to
Prevent or Treat Osteoporosis

Promote diet with adequate calcium (1,500 mg) & vitamin
D (400-800 IU) daily




Avoid immobility, staying in bed too long
Encourage weight-bearing & low-level resistance exercise




Dairy products, green leafy vegetables, broccoli, sardines
Sunlight exposure to skin
Walking (best), dancing, weight training, stair climbing,
tennis, gardening
Avoid isometric or high-impact aerobic exercises
Reduce/ eliminate smoking
Reduce/ eliminate beverages: alcohol, caffeine,
phosphorus
How to Give your Bones a WorkOut
59

62. Question

A 67-year-old woman
is lactose intolerant
and at risk for
osteoporosis. What
foods other than dairy
products can the
nurse suggest to this
patient to increase her
calcium intake?

63. Avoid Sodas

Phosphorus
contributes to
bone loss by
inhibiting the
absorption of
calcium

64. Avoid Aluminum-Containing
Antacids
Maalox
 Mylanta
 Amphojel

Osteoporosis Medicine
Risks

65. Low-Level Resistance Exercises (Box
24-2; Fig 24-3)
Weight-Bearing, ROM & Resistance Exercises

66. Brisk Walking: One of the Best
Weight-Bearing Exercises

67. Swimming: Not a WeightBearing Exercise

69. Question

When assessing a client with
osteoporosis the nurse should
recognize that most observable
changes will occur in:
A. Facial bones
 B. The long bones
 C. The vertebral column
 D. Joints of the hands and feet


70. Pharmacology
70

71. Antiresorptive Medications:
Slow Bone Loss





Goal: Prevent bone loss, lower risk of fx
Bisphosphonates
Calcitonin
Estrogen therapy, hormone replacement
therapy (HRT)
Selective estrogen receptor modulators
(SERMs)
Osteoporosis Treatment
Options
Treatment Options for
71

72. Bisphosphonates




Alendronate
(Fosamax),
ibandronate (Boniva),
risedronate (Actonel)
Preserves or
increases bone
density
Decreases rate of
bone resorption
Decreases fractures
72

73. Bisphosphonates



Inhibits osteoclasts (bone-resorbing cells) –
prevents resorption
Decreases postmenopausal vertebral &
nonvertebral fx by 40-50 % (relative risk) or
1-2% (absolute risk reduction)
Do not take calcium with bisphosphonates
 interferes with absorption
73

74. Bisphosphonates



Side effects: digestive problems, bone & muscle
pain, osteonecrosis of the jaw
Thigh bone or femur fx in some women using
bisphosphonates for more than 5 yrs
Adverse gastrointestinal symptoms


Esophageal irritation, heartburn, gastritis
Contraindicated: Dysphagia, esophageal disease,
gastritis, ulcers; severe renal insufficiency
74

76. Osteonecrosis of the Jaw

77. Increased Risk Femur Fx
–long-term use of bisphosphonates



Atypical subtrochanteric
femur fractures
Dull aching thigh pain
weeks to months before
fracture occurs
Taking Fosamax
(alendronate) for more
than five years could
cause spontaneous fx

78. Bisphosphonates: KNOW!



(1) Take on empty stomach, first thing in the
morning with 8 oz of water;
(2) Remain upright for 30 minutes; and
(3) Not eat or drink anything else for 30 minutes
78

79. Question

The physician prescribes
alendronate sodium (Fosamax) for
a 72-year old woman. Which
information should the nurse
include in teaching the patient
about this drug?

80. Calcitonin (Fortical, Miacalcin)



Hormone – Regulates
calcium, bone processes
IM, Subcut, Intranasal
Safe, effective tx for
osteoporosis


Decreases vertebral fractures by
up to 35%
Side effects: Hypocalcemia
(all routes), nasal irritation
(intranasal)
80

81. Hormone Replacement
Therapy (HRT)


Estrogen or estrogen with progestin therapy (to prevent
uterine CA)
Estrogen: protective effect on bone






Accelerates death of osteoclasts, prolongs life of osteoblasts
↑ Bone density spine & hip
↓ Spine & hip fractures
Risk: heart attack, stroke, breast CA, blood clots
FDA: if a woman needs a medicine for osteoporosis, but
does not require estrogen for menopause symptoms, then
a non-estrogen alternative should be used
http://www.nof.org/awareness2/2007/images/Bone_Tool_Kit.pdf
81

82. 82

83. Selective Estrogen Receptor
Modulators (SERMs) “Mock”
Estrogen





Benefits of estrogens without
some of the disadvantages
Raloxifene (Evista)
postmenopausal prevention &
treatment of osteoporosis in
women
SERMs less effective than
bisphosphonates
Reduce bone loss, decrease
fracture risk (esp spine)
Side effects: blood clots, stroke,
hot flashes, night sweats,
endometrial cancer, leg swelling
83

84. Diagnostic Tests
84

85. Bone mineral density test
(BMD): Secondary Prevention


Dual energy x-ray absorptiometry (DEXA)
Femoral neck predicts hip fx risk best



Gold standard for fracture prediction
Other sites: spine, wrist, or total body
Results (compared with young adult mean)


BMD 1 SD below mean (-1 S) = osteopenia
BMD 2.5 SD below mean (-2.5 SD) =
osteoporosis
How to Diagnose
Osteoporosis
85

87. Bone Mineral Density Test
(BMD)

88. Question






The typical screening for osteoporosis
involves:
(A) Blood tests
(B) Colonoscopy
(C) Papanicolau test
(D) Tonometry
(E) Dual-energy x-ray absorptiometry

89. 2.5 Standard Deviations

90. Quick Case Study



Ms. Young's mother had
osteoporosis. She is
concerned about her own
risk of osteoporosis. Her
health history revealed a
diet low in calcium and an
inactive lifestyle most of her
life. She is white, 65 years
old, and small-framed. She
has hypothyroidism.
What are her risk factors?
What do you recommend for
her?

91. Nursing Interventions
91

92. Nursing Interventions


Avoid heavy lifting, jumping, and other activities
that could result in a fracture
Prevent falls



Handle gently when moving, exercising or lifting
to avoid fractures


Slip-resistant footwear, adequate lighting, clutter-free
environment, toilet grab bars, bedside commode
Avoid: low seats, poor illumination, slippery floors
Use lift sheet to reposition client
Range-of-motion exercises, ambulation

93. Osteoarthritis
93

94. Osteoarthritis: Degeneration of
Joints






Leading physical disability
(older adults)
Number one cause of pain
(older adults)
Deterioration of joint cartilage
with formation of new painful
bone spurs (osteophytes)
Risks: older age, female, hx
joint injuries, obesity,
excessive use
Incidence
Causes

95. Osteoarthitis – Anatomical
Distribution




Several joints
Weight-bearing
joints (most
affected)
Can affect any joint
Common: Knees,
hips, vertebrae,
fingers

96. Osteoarthritis: Signs & Symptoms




No systematic
symptoms
Crepitation
Heberden nodes
Increased pain:
damp weather,
extended use

97. Osteoarthritis: Tx & Nursing
Interventions (NCP 24-1, pp. 338-339)








Goal: Relieve pain, preserve joint function, slow
progression of disease
Analgesics: acetaminophen, NSAIDs
Topical analgesics (capsaicin creams & rubs)
Rest, heat or ice, massage, acupuncture
Splints, braces, & canes
Analgesic medication before therapies/activities
Proper body alignment, good body mechanics
Nutritional considerations

98. Osteoarthritis: Primary
Prevention
Maintain appropriate body weight;
warm-up exercises; good body
mechanics; nutrition
 Sensible exercise
 Avoid repetitive stress, trauma


99. Osteoarthritis: Secondary/
Tertiary Prevention
Weight reduction
 Homemaker services
 Physical therapy
 Joint replacement surgery (severe joint
damage)



Hip & knee most common
Post-surgical care

100. Quick Case Study





Marie is a 62-year old woman who was diagnosed with
osteoarthritis. She is 40 pounds overweight.
She states that pain interferes with recreational activities
and work. Weight management is difficult; she cannot
jump or dance. Arthritis is affecting her knees, hips,
hands, wrists and neck.
20 years ago, Marie was in a car accident and spent
several months in the hospital. She had a steel rod placed
in her left femur and a full cast on her right leg. She was in
traction for two months.
What are her risk factors?
What do you recommend for her?

101. Nursing Diagnoses &
Interventions (Table 24-3, p. 334; NCP
24-1, pp. 338-9)





Chronic Pain r/t joint inflammation, stiffness, and
fluid accumulation
Impaired Physical Mobility r/t pain and limited joint
movement
Self-Care Deficit r/t pain or joint immobility
Body Image Disturbance r/t joint abnormality,
immobility, altered self-care ability
Self-Esteem Disturbance r/t changes in body
appearance and function

102. Key Outcomes

The patient will:
Experience increased comfort &
decreased pain
 Express positive feelings about himself
or herself
 Perform ADLs within the confines of the
disease
