Musculoskeletal System Normal Changes of Aging Significant alterations causing musculoskeletal changes in older adults o Human structure o Function

n o Biochemical o Genetic patterns Skeleton: Normal Changes of Aging Two phases of bone loss in normal aging o Type I (menopausal bone loss) Rapid Affects women Occurs first 5 to 10 years after menopause o Type II (senescent bone loss) Slower phase Affects both sexes after midlife Phases eventually overlap in women Other conditions may alter signs of normal aging of skeleton Bones become o Stiff o Weaker o Brittle Changes in appearance are evident after the fifth decade. o Height most obvious 20 to 70 years of age o Lose 1 to 2 cm in height every 2 decades o Shortening of the vertebral column Midlife o Vertebral discs thin Later years o Decrease individual vertebrae height Disproportionate size of long bones of the arm and legs o Eighth and ninth decades More rapid decrease in vertebral height Osteoporotic collapse of the vertebrae Shortening of the trunk with appearance of long extremities

 Additional postural changes o Kyphosis o Backward tilt of the head for eye contact Forward bent posture Hips and knees in flex position Muscles: Normal Changes of Aging Muscle function varies with aging o Trainable into advanced age o Muscle regeneration is normal as age progresses Muscle o Mass Sarcopenia by age 75 o Strength Slow decline Stamina decreased by age 50 Decreased 65 to 85% of midtwenties by age 80 o Tone and tension Decreases after age 30 o Size Decreases causing weakness Type II muscle fibers o Faster contraction but more atrophy Type I o Slower contraction and less atrophy o Help maintain posture o Help perform repetitive exercise s o Shape Distinct More prominent Routine daily activities keep the upper extremities functioning better than walking. Joints, Ligaments, Tendons, and Cartilage: Normal Changes with Aging Cartilage o Hyaline cartilage (joint lining) Normally lines joints Erodes and tears with advancing age

 Causes bone to bone contact o Knee cartilage Experiences normal wear and tear Thins about .25 mm/year o Discomfort and slow joint movement o Diminished joint lubricant o Nonarticular cartilage (ears and nose) Grows throughout life Ligaments, tendons, and joint capsules o Lose elasticity o Less flexible o Joint ROM decreases Risk factors for the older person Metabolic Bone Diseases Osteoporosis o Most common metabolic disease o Affects 50% of women during their lifetimes o 20 million women and 8 million men diagnosed in the United States o 3.8 million women receive adequate care High risk factors for osteoporosis o Increased age o Female sex o White or Asian race o Positive family history o Thin body habitus Additional risk factors for osteoporosis o Low calcium intake o Prolonged immobility o Excessive alcohol intake o Cigarette smoking o Long-term use of corticosteroids, anticonvulsants, or thyroid hormones Pathophysiology of Osteoporosis Low bone mass

 Deterioration of bone tissue compromised bone strength risk for fractures Bone strength reflects integration of bone density and quality o Bone density is grams of mineral per area or volume o Bone quality is based on the Architecture Turnover Damage accumulation Mineralization o Bone strength cannot be directly measured o Bone mineral density (BMD) o Replacement measure for bone strength o Accounts for 70% of bone strength Elder bone loss o Normal BMD within 1 standard deviation of young adult mean o Ostopenia BMD between 1 and 2.5 standard deviations below the young adult mean o Osteoporosis BMD 2.5 standard deviations below the young adult mean Decreased bone mass in older person o Failure to reach peak bone mass in early adulthood o Increased bone resorption o Decreased bone formation Reduced BMD o Highly predictive of spinal and hip fractures o Osteoporotic fractures affect 1.3 million per year in the United States o Vertebrae fractures affect about 500,000 people per year o Hip and wrist fractures affect about 260,000 per year o One in five patients die within 1 year o One third regain their prefracture mobility and independence level Classification of Osteoporosis Primary osteoporosis Type I (menopausal bone loss) Type II (senescent bone loss) Secondary osteoporosis o Hyperparathyroidism o Malignancy

o o o o

Immobilization Gastrointestinal disease Renal disease Drugs causing bone loss such as vitamin D deficiencies and glucocorticoids

Menopausal Bone Loss Before menopause, sex hormones protect from bone loss. After menopause o Overproduction of IL-6 Up to tenfold loss of bone mass Resorption (loss of bone matrix) more than deposition (rapid bone growth) Susceptible women close to age 70 can lose 50% of peripheral cortical bone mass Cause of vertebral and Colles' fractures Senescent Bone Loss Decreased amount of bone during remodeling Occurs in both sexes Caused by aging Decreased trabecular (cancellous) bone wall thickness o Decreased osteoblast formation o Decreased bone mineral density o Decreased rate of bone formation o Cause of vertebral and hip fractures Trajectory of Bone Loss for Women Lower peak bone mass than men Less in the "bone bank because of thinner bones Lose bone mass with lactation Rapid withdrawal from "bone bank" during perimenopause Longer life span increases risk for osteoporosis Signs/symptoms usually absent First sign is often a fracture Osteomalacia Metabolic disease Inadequate mineralization of bone matrix Usually a result of Vitamin D deficiency

 Pathophysiologic Mechanisms o Three mechanisms cause Vitamin D deficiency Abnormal metabolism of vitamin D Phosphate depletion Pathophysiologic Process o Volume of bone remains normal o New bone replacement is soft osteoid versus rigid bone o Deformities of long bones, spine, pelvis, and skull Risk Factors for Osteomalacia o Primarily vitamin D deficiency o Lack of exposure to ultraviolet radiation o Poor dietary intake o Older age Inability to get outdoors Limited dietary intake of milk Aging skin with less vitamin D production Clinical Manifestations o Bone pain and tenderness varies Generalized or localized o Hips o Pelvis o Legs o Ribs o Vertebrae o Fragile bones Fractures occur with minor injuries Difficult to differentiate from osteoporosis Vertebral collapse o Changes in posture and height Deformities (gibbus deformity, leg bowing) o Fatigue Occurs easily Causes unsteady gait o Muscle weakness with severe osteomalacia Lack of vitamin D to muscle cell Low calcium level Low phosphorus level

Vitamin D Metabolism Step 1 o Deficit occurs with inadequate intake or inadequate exposure to sun o Impaired absorption in small bowel Postgastrectomy Small bowel resection Crohns disease Step 2 o Deficit occurs with Severe liver disease Certain drugs o Phenytoin o Barbiturates o Carbamazine Step 3 o Deficit occurs with Severe renal disease Step 4 o Deficit occurs with Lack of calcitriol Pagets Disease Pagets disease (PD), or osteitis deformans o Chronic, localized bone disorder o Unknown etiology in which o Normal bone replaced with abnormal bone. o One or more skeletal lesions Pelvis (68%) Vertebrae (49%) Skull (44%) Femur (55%) o Occurs in men and women o Affects those over 70 years of age o Second most common bone remodeling disease o Affects 1 million to 3 million Americans o Asymptomatic o Serendipitous x-ray diagnosis for unrelated problem Pagets Disease Pathophysiology o Accelerated activity of abnormally large osteoclasts o Resorbtion of bone at specific sites

o Rapid bone formation inferior new bone structure Less compact Vascular Prone to structural deformities, weakness, and pathological fractures Etiology o Unknown o Viral particles, genetics, and hereditary factors implicated Pagets Disease Clinical Manifestations o Determined by affected bone site(s) o Bone pain most common symptom Deep and aching with muscle spasms Pagetic lesion site Osteoarthritic joints (hips and knees) Other sites with mechanical deformities bowing of femur or tibia o Mobility impairments Gait changes Stress fractures o Bony growths Spine kyphosis, cord compression, and paralysis Skull enlargement, disfigurement of cranium CNS complications o Mental deterioration o Dementia o Headaches o Tinnitus o Vertigo Skull interior growth cranial impingement hearing loss and visual changes Jaw deformities dental problems (malocclusion) o Clinical manifestations can affect the quality of life of older people. Joint Disorders: Noninflammatory and Inflammatory Categories Noninflammatory joint disease (osteoarthritis) o lack of synovial inflammation o absence of systemic manifestations o normal synovial fluid

 Inflammatory joint disease (rheumatoid arthritis, gout, and pseudogout) o Synovial inflammation o Systemic manifestations o Abnormal or lack of synovial fluid Noninflammatory Joint Disease: Osteoarthritis Osteoarthritis Statistics o Most common form of arthritis in the United States o Affects more than 50% of people > 65 o Leading cause of disability for > 65 o Chronic disease o Women are affected more than men o Severity varies from insignificance to major life disruption o Nodal disease at middle age associated with knee OA in 60s and 70s o Predicts self-care abilities as older adult o Aging alone does not cause this disease o Other associated factors for OA include Obesity Overuse of a joint Trauma Cold climate Primary or Idiopathic Osteoarthritis o No single, clear cause o Group of similar disorders o Involve complex biomedical, biochemical, and cellular processes o Changes in several joints as a result of various causes Secondary Arthritis o Secondary arthritis involves An underlying condition Trauma Bone disease Inflammatory joint disease o Pathophysiology Progressive erosion of joint articular cartilage o Formation of new bone in joint space o Involved joints Hands

 Weight bearing joints of the knees and hips Central joints of the cervical and lumbar spine How does this happen? o Cartilage thins underlying bone (subchrondal bone) is no longer protected o Cartilage not available to buffer Subchrondral bone becomes irritated degeneration of the joint bone hypertrophy bony spurs (osteophytes) growth and enlargement contours of the joint Small pieces may break off (joint mice) irritate the synovial membrane joint effusion limited movement Clinical Manifestations o 90% of all people have x-ray evidence of primary osteoarthritis in their weight-bearing joints by age 40. o OA symptoms 40% of people with severe OA have pain Most common symptoms Early morning stiffness resolving in 30 minutes Joint pain o Occurs during activity o Relieved by rest With progressive disease o Pain may be present at rest o Interrupt ion of sleep patterns o Source of pain may be unknown, but it needs to be identified in order to provide treatment o Joint involvement Asymmetrical at first Bony appearance of joints Crepitus (a grating sound on movement) Range of motion deficit Muscle weakness o Hands New bone growth o Heberdens nodes (DIPdistal interphalangeal joint) o Bouchards nodes (PIPproximal interphalangeal joint) o Pain with active and passive motion

o Joint damage + chronic pain + muscle weakness impaired balance + decreased activity Inflammatory Joint Disease Rheumatoid arthritis (RA) o Most prevalent inflammatory arthritis of any age group o Common in the elderly o Incidence increases to age 80 o three-to-one ratio for women to men o Course of the disease varies greatly o Mild remitting disease o Severe disability, joint deformity, and even premature death Pathophysiology o Rheumatoid arthritis Chronic syndrome Symmetric inflammation of the peripheral joints pain + swelling Significant morning stiffness General symptoms of fatigue and malaise Unknown cause o Unknown environmental factors trigger autoimmune response o Genetic predisposition Susceptibility Severity of symptoms o Long-term exposure to offending antigen converts antibodies (IgG & IgM) synovial fluid + serum autoantibodies (rheumatoid factors [RFS]) mild cell proliferation neoplasmlike mass in synovium (pannus) bone spurts + osteophytes scar tissue formation shortened tendons + joints subluxation + contractures + joint damage Clinical Manifestations o Course of RA Slow and insidious Acute process affecting several joints (polyarticular) De novo development = first symptoms appear after age 65 o Primary RA clinical manifestations o Disabling morning stiffness

Lasts more than an hour Occurs after period of rest Marked joint pain especially in upper extremities Severe redness Swelling Warmth of the soft tissue Subcutaneous nodules with advanced disease Pressure areas on elbows or sacrum Not attached to bone or underlying skin Nonspecific systemic symptoms Fatigue Malaise Weight loss Fever Occur several weeks or months before typical joint symptoms Symptoms cause Severe pain on movement Limitation of movement Disrupted sleep pattern Systemic and nonarticular manifestations Cutaneous manifestations: rheumatoid nodules, Sjgrens syndrome Ocular manifestations: episcleritis and scleritis Pulmonary involvement: pleurisy with effusion Cardiac: pericarditis and myocarditis Renal involvement Feltys syndrome (neutropenia and splenomegaly) Vasculitis

Gout Statistics o Most common inflammatory joint disease in men > 25 years o Peak onset Males between 40 and 50 years of age Women usually after menopause o Prevalence in adults 2.6 to 8.4 per 1,000 o Older persons between 65 and 74 years of age 6 per 1,000 for the older female

 24 per 1,000 for the older male o Gout is both misdiagnosed and underdiagnosed. Pathophysiology o Cause Linked to purine metabolism and kidney function Genetic abnormality of purine metabolism Underexcretion of uric acid o Serum urate levels > 7 mg/Dl leads to increased risk of gout o Predisposing factors Family history High purine diet Obesity Drugs low urate renal clearance o Alcohol o ASA Decreased renal function o Urate crystals deposit in peripheral joint pain + inflammation + destruction Clinical Manifestations o First signs Acute pain o So severe older person cannot tolerate sheet or blanket weight o Warmth + swelling metatarsophalangeal joint of big toe Mild attack = few hours Severe attack = several weeks Over time attacks continue affects other Joints o Other signs General malaise Fever Chills accompany these painful joint symptoms WBC and ESR elevation Definitive diagnosis is urate crystals in synovial fluid Chronic Gout (Tophaceous Gout) Occurs 3 years to 40 years after initial attack

o Persistent aching joints, soreness, and morning stiffness, especially in hands and feet Urate crystal deposits (tophi) o Cartilage o Synovial membranes o Tendons o Soft tissue Changes o Duration and severity of hyperuricemia o Size varies Irregular lumps Swellings of the joints o Size increases severe movement limitation + hands and feet deformities Pseudogout Pseudogout or calcium pyrophosphate deposition disease (CPPD) o Familial o Occurs in persons > 60 years o Occurs in women > men o Associated with history of hypothyroidism, hyperparathyroidism, or acromegaly Pathophysiology o CPPD calcification of hyaline and fibrous cartilage (chondrocalcinosis) painful asymmetric inflammatory polyarthritis Clinical Manifestations o CPPD crystals form in large joint o Similar goutlike nature with acute attacks of joint o Knee joint commonly affected o Other joints include the shoulder, hip, and elbow Tendonitis and Bursitis Tendonitis and bursitis (rheumatism) o Most common and least understood causes of musculoskeletal pain o Acute pain in joint area with soft tissue injury o Caused by Repetitive injury as a result of age, sports Occupational injuries

 Bursitis o Irritation of subcutaneous tissue o Inflammation of underlying bursae o Acute bursitis o Deep aching pain on movement of structure adjacent to bursae Tendonitis o Inflammation of tendon sheath (tenosynovitis) Falls and the Older Person Major health problem for older persons Implications for medical AND financial outcomes o Most falls occur in home during normal routines o Serious implications for older person o Leading cause of accidental death in the United States o Seventh leading cause of death persons > 65 years in the United States o Deaths as a result of falls increases with age o Serious problem need for ongoing prevention as part of overall care of older person The majority of fractures in older adults caused by falls Most common fall-related injuries o Osteoporotic fractures of hip, spine, and forearm Likelihood of sustaining a hip fracture increases with age Hip fractures cause the greatest number of deaths After hip fracture o One quarter of older people remain in institution for at least a year o Many never return home Falls and the Older Person Prevention of falls is a key goal of gerontological nursing practices o Recognize older persons who are at risk for falling o Identify and correct fall risk factors Improve balance, gait, and mobility Improve functional independence o Reduce or eliminate environmental factors that contribute to fall risk o Evaluate outcomes o Revise plan as needed

Hip Fracture Occur in 1 in 3 women and 1 in 6 men who reach age 90 Causes o Low-energy trauma o Occur in the home o History of falls o Unable to bear weight Hip fractures include upper third of the femur o Intracapsular Located within the joint capsule and are further categorized as femoral neck and subcapital fractures Impair blood to femoral head avascular necrosis + nonunion fracture o Extracapsular Intertrochanteric (in the trochanter) and subtrochanteric (below the trochanter) Acute blood loss from the vascular cancellous bone Assessment o Injured leg shortened o Externally rotated o Extreme pain prevents movement Common nursing diagnoses of older persons Impaired physical mobility related to stiffness, pain, joint contractures, and decreased muscle strength o Defined as the state in which an individual experiences a limitation of ability for independent physical movement o Major defining characteristics Inability to purposefully move within the physical environment Limited range of motion o Minor defining characteristics Decreased muscle strength Less control Inability to sit unsupported Impaired coordination o Related factors for impaired mobility include Decreased strength and endurance External devices, such as casts

Acute or chronic pain Acute pain related to progression of inflammation o Lasts less than 6 months Chronic pain related to joint abnormalities o Persistent for more than a 6-month period Fatigue related to pain and systemic inflammation Body image disturbance related to chronic illness, joint deformities, impaired mobility Ineffective coping related to personal vulnerability in a situational crisis

Pharmacology and Nursing Responsibilities Older person with musculoskeletal dysfunction o Monitor physiological changes of aging o Monitor altered drug metabolism for Serious side effects Drug toxicities o Identify medications and doses o Careful monitoring Pharmacology and Nursing Responsibilities for Osteoporosis Antiresorptive therapy o Preserves or increases bone density o Decreases rate of bone resorption Classifications and special considerations o Bisphosphonates (alendronate [Fosamax] and risedronate [Actonel]) Inhibit osteoclastic activity Decrease postmenopausal vertebral and nonvertebral fractures by 40 to 50% Adverse gastrointestinal symptoms o Esophageal irritation, heartburn o Difficulty swallowing Do not take calcium with bisphosphonates interferes with absorption Selective estrogen receptor modulators (SERMs) o Provide benefits of estrogens without the disadvantages o Raloxifene approved for postmenopausal prevention and treatment of osteoporosis in women o SERMS less effective than bisphosphonates

 Calcitonin o Safe but less effective treatment for osteoporosis o Decreases spinal fractures by up to 35% Hormone replacement therapy (HRT) Pharmacology and Nursing Responsibilities for Osteomalacia FDA approved treatment for Pagets disease o Bisphosphates and calcitonin Goal is to relieve bone pain and prevent progression of deformities o Alendronate (Fosamax) given 40 mg daily for 6 months may produce a prolonged remission o Calcitonin (Miacalcin) by injection 50 to 100 units daily or 3 times a week for 6 months; repeat course can be given after a short rest period Treatment goal to remineralize the bone Vitamin D replacement o 50,000 to 100,000 U/day for 1 to 2 weeks o Followed with daily dose of 400 to 800 U/day older persons monitored for serum and urine calcium Calcidiol and calcitriol for specific vitamin D deficiency Older persons with osteomalacia need calcium intake (1,000 to 1,500 mg/day) Pharmacology and Nursing Responsibilities for Osteoarthritis No therapy will slow or halt progression Current therapy directed at relief of pain and minimizing functional disability Agents for pain relief for OA Topical agents o Capsaicin nonprescription drug o Prevent the reaccumulation of substance P (a neurotransmitter) in peripheral sensory neurons o Applied 2 to 4 times daily to affected area May cause heat or burning Relief may require up to 4 to 6 weeks of applications Systemic oral agents o Acetaminophen (Tylenol) First line pharmacological therapy Give up to 4 gm/day with minimal toxicity Higher doses may cause liver damage

 Ceiling effect = increasing the dose does not increase the analgesic benefit Use alone or as an adjunct to NSAIDs o Nonsteroidal anti-inflammatory drugs (NSAIDs) Most common treatment for pain and inflammation of OA COX-2 inhibitors, a new category of anti-inflammatory drugs o Considered safe for the GI tract o Side effects include renal impairment (see RA section) Adjuvant agents o Intra-articular agents Corticosteroids valuable for synovial inflammation o Synovial effusion removed prior to injections o Limited to 4/year in any one joint Hyaluronic acid o Normal component of the joint for lubrication and nutrition o Decreased pain for longer periods than other intraarticular therapies o Administered in series of 3 to 5 injections Pharmacology and Nursing Responsibilities for Rheumatoid Arthritis Prednisone o Decrease inflammation rapidly o Improve fatigue, pain, and joint swelling o Usual dose is low (2.5 to 7.5 mg per day) Minimal toxicity Low doses take up to 10 years to produce osteoporosis o Good alternative if cannot tolerate other drugs o Discuss long-term risk vs. benefit of steroids NSAIDs o Common drug category for RA o High doses required to relieve the inflammation in the elderly toxic side effects GI bleeding GI perforation Renal failure COX-2 inhibitors o Safer for the GI track

o Damaging side effects include renal impairment o Vioxx withdrawn in 2004 Studies found increased myocardial infarction in older people o Celebrex to be used with caution Lowest dose possible Short periods of time Disease-modifying antirheumatic drugs (DMARDs) o Use after corticosteroid steroid failure o Slow the rate of joint erosion and dysfunction o Benefit if offered early in disease process o Suppress lymphocyte destruction of the synovial membrane Pharmacology and Nursing Responsibilities for Gout Gout o NSAIDs o Oral colchicine loading o Intra-articular steroid injections o Systemic steroids Pseudogout o NSAIDs o Short course of oral corticosteroids o Intra-articular corticosteroids for large joint involvement Chronic gout o Colchicines (0.5 mg) Decrease inflammation May be given long term to reduce repeated attacks of gout Maximum dose lowered for elderly Liver, renal, and bone marrow toxicity If serum urate levels remain high, try other agents o Allopurinol, Probenemid, and Sulfinpyrazone Prevent long-term complications by lowering serum uric acid blood level Probenemid and sulfinpyrazone are uricosuric agents excretion of uric acid Allopurinol is a uric acid synthesis inhibitor lowers formation of uric acid o More versatile than uricosurics and safe at all levels of renal function

 Goal of therapy is to decrease serum urate levels to 6.5 mg/d Pharmacological Treatment of Bursitis Treatment depends on cause o Infection (gram-positive staph or strep, group A) oral antibiotics o Absence of microcrystalline disease and infection aspiration of fluid injection of the bursal sac with corticosteroid o Milder cases Rest joint during acute phases of pain Physical therapy Braces or splints NSAIDs Nonpharmacological management Selected Diagnostic Tests and Values for Musculoskeletal Problems Bone mineral density test (BMD) o Dual energy x-ray absorptiometry (DEXA) Proximal femur predicts hip fracture risk best Gold standard for fracture prediction Other sites tested include spine, wrist, or total body o Results Compared with young adult mean Or compared norm group of same age BMD 1 SD below mean (-1 S) = osteopenia BMD 2.5 SD below mean (-2.5 SD) = severe osteoporosis Bone mineral density test (BMD) o Pitfalls Bone changes also the result of arthritis or disk disease in lumbar spine Arbitrary SD cutoffs to determine diagnosis Results vary with technique and patient position Current criteria based on postmenopausal white women Bone and Joint Radiography X-ray use o Diagnose and stage rheumatic diseases

o Diagnose fractures o Detect musculoskeletal structure, integrity, texture, or density problems o Evaluate disease progression and treatment efficacy Computed tomography (CT)/magnetic resonance imaging (MRI) o Visualize o Inflammation o Musculoskeletal changes Synovitis Edema Bone bruises o Occult fractures and articular damage Computed tomography (CT)/magnetic resonance imaging (MRI) o Advantages Uses a large magnet and radio waves to produce energy field Detailed image Does not use radiation or a contrast medium o Disadvantages More expensive Requires special facilities Cannot show calcification or bone mineralization Client hears soft to thunderous noises and may use earplugs Bone Scan Detects skeletal trauma and disease Determines degree bone matrix takes up radioactive isotope Determines reason for an elevated ALP Blood Serum Tests Electrolytes: calcium level Bone and muscle enzymes: alkaline phosphatase (ALP) Joint tests o Rheumatoid factor (RF) o Acute phase reactants C-reactive protein (CRP) Erythrocyte sedimentation rate (ESR) o Serum uric acid (SUA)

 Special considerations o Electrolytes: serum calcium and phosphorus decreased in the older person o Calcium Increased in Pagets disease, with bone fractures, and with immobility Decreased in osteoporosis and osteomalacia Serum calcium (normal range older adult 8.8 to 10.2 mg/dl) o Phosphorus Phosphorus (normal range for older person > 60 = 2.3 to 3.7 mg/dl) Increased in bone fractures and healing state Decreased in osteomalacia o Serum Uric Acid (SUA) Diagnosis of gout is not established unless SUA is found in tissue or synovial fluid Rheumatoid factor o Antibody (IgM, IgG) binds to Fc fragment of immunoglobin G o RF negative early stages of the disease o 70 to 80% of patients with RA will become RF positive o High RF (positive RF high titers 1:320) predictive Disability Extra-articular disease o RF elevated in other diseases such as liver, lung, and other conditions o RF not diagnostic but with clinical assessment confirms diagnosis o RF does not change rapidly, need not repeat test if titer is high Acute phase reactants C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) o Erythrocyte sedimentation rate Most common measurement of acute phase proteins in rheumatic disease Direct relationship to acute phase proteins Results in 1 hour o C-reactive protein Acute phase reactant determines presence of inflammatory process o Bacterial infection or rheumatic disease

 Increases and returns to normal quicker than ESR Alkaline phosphatase (ALP) o Enzyme associated with bone activity o Normal values: men = 45 to115 U/L, women = 30 to 100 U/L o Values increase after age 50 o Identify increases in osteoblastic activity and inflammatory conditions o Elevated with Pagets disease (> 5x normal) o Isoenzymes ALP1 (liver origin) and ALP2 (bone origin) determine if elevation is bone disease Synovial Fluid Analysis Based on visual inspection of the synovial fluid o Appearance o Volume o Cellular contents 4 classifications o I = clear Noninflammatory Low WBC (< 1,000/ul) Associated with osteoarthritis o II = transluscent Inflammatory Moderate WBC (2,000 to 20,000 /ul) Associated with diseases such as rheumatoid arthritis 4 Classifications o III = opaque Purulent WBC (more than 100,000/ul) Infectious o IV = bloody Bloody fluid from a traumatic event Other factors o Groups II to IV should be cultured for infection o Examine for monosodium urate crystals (MSU, gout) and CPPD crystals (MSU crystals mandatory ) Establishing gout diagnosis Diagnosis of acute arthritis

Lifestyle Changes Increase in exercise Weight loss Eating healthy diets Healthy People 2010 (www.health.gov/healthypeople) o Nations goals and objectives for improved health o Includes an objective for arthritis patient Nonpharmacological treatment of osteoporosis o Assessment of risk factors o Education about prevention Older persons with risk factors Diagnosis of osteoporosis = bone density of -2 SD o Education about positive lifestyle changes Diet, exercise, and other risk modifications Assessment/Prevention of Risk Factors for Osteoporosis o National Osteoporosis Foundation recommendations Educate all women about osteoporosis risk factors Women with fracture history BMD test to determine osteoporosis diagnosis BMD o Any woman under 65 with risk factors for osteoporosis o all women over 65 Preventive activities for older men o Many risk factors same for men o Most men have bigger bones than women so they have increased protection Lifestyle Modification Activities to Prevent or Treat Osteoporosis o Promote diet with adequate calcium and vitamin D o Encourage weight-bearing exercise o Reduce or eliminate smoking o Reduce or eliminate consumption of beverages containing alcohol, caffeine, and phosphorus Nonpharmacological treatment of osteomalacia o Space activities to conserve energy o Monitor safety measures for the home o Evaluate home hazards

 Nonpharmacological treatment of osteoarthritis o Nonpharmacological strategies are applicable to most types of arthritis o Individualize to older persons needs o Educate the older person about the disease o Weight reduction to decrease stress on joints o Exercise to relieve pain and stiffness (and many other benefits) o General and specific rest as needed to control symptoms o Use canes, crutches, and walkers to protect joints o Use assistive technology to help with functional ability o Surgical intervention may include joint replacement (hips and knees) Prevention and Treatment of Osteoarthritis Factors to prevent progression of disease o Weight loss as indicated o Regular exercise may enhance joint health o Rest may ease pain and relieve fatigue for painful joints Weight loss o Single most important risk factor for OA that can be modified is obesity Exercise o Joints depend on surrounding muscles for Strength Joint protection Weight bearing o Muscle disuse atrophy weakness, falls, and mobility limitations Rest o General rest o Adequate seep at night o Rest periods to prevent excessive fatigue common with inflammatory conditions Short periods to prevent stiffness Specific times Proper positioning Limit to prevent disuse of prolonged immobility Additional Nonpharmacological Strategies

 Additional nonpharmacological strategies to enhance comfort with OA or RA o Apply heat to painful joints o Use cold applications to reduce pain and swelling o Use canes, crutches, and walkers to protect joints o Use assistive technology Maintain, increase, or improve function Commercial purchase or custom made Available for general daily living, home management, school, and work activities Nonpharmacological Treatment for Rheumatoid Arthritis Nonpharmacological treatment for RA is focused on o Reducing joint stress o Maintaining joint function o Promoting independence o Managing fatigue Long rest periods morning and afternoon o Strength training reverse muscle wasting Teaching Guidelines for Patient and Family for RA o Education to prevent cure myths or other inappropriate treatment include Contacting Arthritis Foundation Visiting government websites for information Talking with nurse regarding efficacy of advertisements for RA o Exercise and positioning to prevent contractures, muscle weakness, and atrophy include Doing full ROM daily Participating in an exercise program Encouraging patient activity Avoiding positions of deformity o Rest to reduce joint stress during times of inflammation include Resting the painful joint Weight reduction Splint specific joints (fingers, hands, wrist, etc.) Use larger stronger joints when possible o Encourage rest periods to prevent fatigue Plan rest periods in morning and afternoon

 Whole body rest is needed to reduce inflammatory response o Minimize functional limitations with assistive devices Use equipment that will enhance self-care abilities Modify environment to ensure social activities Find tools that allow leisure activities Nonpharmacological Treatment to Prevent Falls and Fall-Related Injuries Assess for risk factors o Changes in vision, balance, judgment o Cardiovascular problems o Medications o Urinary incontinence o Other physical conditions Assessment of functional mobility offers valuable clues to fall risk o Gait o Balance o Position changes Educate to get up from a fall o Turn over on the stomach and crawl on all fours o Scoot on the bottom or side to reach a phone o Crawl to a stairway and climb up until able to stand o If injury does not allow movement, cover self to stay warm Nursing management principles related to the nursing care of older patients with arthritis. Treatment of Hip Fractures Immobilize immediately to prevent further damage Surgery is the treatment of choice Type of surgical procedure depends on o Type of injury o Condition of the person o Preexisting orthopedic conditions With acute or chronic disease risk of surgery may be too great medical management may be the preferred course Treatment of Hip Fractures Fracture Type Surgical Procedure

Nondisplaced subcapital and femoral neck fractures Displaced fractures of subcapital and femoral neck

Internal fixation with multiple pins Open reduction internal fixation (ORIF) ORIF for active and weightbearing elders Moores prosthesis for less active person Total hip replacement with presence of severe arthritis

Intertrochanteric and subtrochanteric femoral fractures

Sliding compression screw and side plate

Nursing care of the older person with THR or internal fixation of the hip o Assessment and prevention for common complications Dislocation of the device Avascular necrosis Infection Delayed healing o General nursing care of postop patient depends on specific surgical procedure