Musculoskeletal Disorders in

Elderly

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 (Ortostatic
Hypotension, arrhythmias, blocks)

Seizures (may be akinetic)

Endocrine (hypoglycemia)

Illnesses that cause falls in older

people
Neurological disorders
Movement disorders ( Parkinsons
disease, )
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)

Muscle and age

Muscle mass and age

Kehayias J et al. Am J Clin Nutr 1997;66:904

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,
Benzodiacepine, antipsychotics)
Anticholinergics
And many others

Environmental causes of falls

Calculating risk of falls

Tinetti 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

Consequences of falls in older

people
Fractures
Soft tissue injuries
Fear of falling

6%
24%
>20%

Consequences of falls in older

people

Muscle weakness

Immobility

Fear of falling

Bed rest and muscle strength

Muscle strength (MVC) lost at
2-5% per day
Harper & Lyles. JAGS 1998; 36: 1047

Lower limb muscle strength and

unloading for 10 days
Acta Physiol Scand 1996; 157:63

DECONDITIONING:
a simple definition
The adverse physiological
consequences of
too much rest

DECONDITIONING
Consequences
Conversion of an individual barely able to
rise from a chair to a bedridden state
Resulting immobility promotes
incontinence
Increases risk of falls

DECONDITIONING
Consequences

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 rest

Convertino V et al. Am J Med Sci 2007; 334: 72

DECONDITIONING
the essence
Loss of muscle strength
Altered cardiovascular responses
But there is more, much more

Bed rest and calcium balance

Bone Mineral Content and rest

Rittweger J et al. J Physiol 2006; 577: 331

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

DECONDITIONING:
Similar terms
Functional decline
Dysfunction syndrome
Weightlessness effects

What do they have in common?

Similarities
Bedrest
Orthostatic
hypotension

Increased

Balance, stability

Reduced

Coordination, gait Reduced

Muscle strength

Reduced

MV 02

Reduced 20-25%

Spaceflight

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

Effect of 8 weeks resistance

exercise on 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

Multi factorial intervention to reduce

falls

Tinetti M et al N Engl J Med 1994; 331:821

Multi factorial intervention to reduce

falls

Osteoporosis and fractures

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)
Womens 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

N-terminal PTH and Vitamin D

levels

Harinaryan C et al. Indian J Med Res 2008; 127:211

Vitamin D levels: Andhra Pradesh

Harinaryan C et al. Indian J Med Res 2008; 127:211

Bone mineral density and fracture risk

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

Risedronate

Harris ST, Watts NB, Genant HK, et al. JAMA 1999.

Raloxifene

Ettinger B et al JAMA 1999

Calcitonin

Chesnut CH et al Am J Med 2000

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

How did we do?