MUSCULOSKELETAL DISEASES IN ELDERLY

Musculoskeletal diseases are the most common problems and prevalent conditions affecting the elderly worldwide and can cause significant disability if not taken seriously. Musculoskeletal tissues show increased bone fragility, loss of cartilage resilience, reduced ligament elasticity, loss of muscular strength, and fat redistribution decreasing the ability of the tissues to carry out their normal functions. Loss of mobility and physical independence from arthropathies and fractures can be devastating. This affects them physically and psychologically thus increasing mortality rates.

The diseases may include the following;

  1. Osteoarthritis

Osteoarthritis is disease that affects the articular cartilage, subchondral bone, ligaments, joint capsule, synovial membrane, and periarticular muscles. Pathological changes can include fibrillation of cartilage, disruption of collagen fibers, and changes in proteoglycan staining. It is a common joint disease in people 65 years of age and above, with a prevalence of about 90% in women and 80% in men. Etiology factors may include female gender, genetics, metabolism, and excessive mechanical stress. It frequently leads to decreased function and loss of independence. The joints of the hand, knee and hip are the most commonly affected.

Signs and Symptoms

         Shoulder osteoarthritis and rotator cuff are associated with shoulder pain and disability related to decreased shoulder movement.

         Tears of large rotator cuff.

        Inflammatory in joints with low back pain.

Diagnosis

The diagnosis is based on clinical history and physical examination. Plain radiographs can help confirm both the diagnosis and grade the severity of the condition. The cardinal radiographic features of osteoarthritis non-uniform narrowing of the joint space in the areas subjected to the most pressure, subchondral cysts, subchondral sclerosis, and osteophytes.

Also surgical treatment is done on lumbar and cervical spine in order to improve on pain. Ultrasound is also done to assess the rotator cuff tendons.

  1. Infection

This is an area where the elderly patients are more prone since there is an increased incidence of predisposing disorders such as diabetes mellitus, peripheral vascular disease, and poor dentition. Others include immunosuppressant and surgical procedures used like dental extractions and open heart surgery. The infectious agents in elderly people not different those affecting the young persons, although the elderly are prone to them than others. In people over 80 years of age, the knee, spine, shoulder, and hip are the most frequently affected. A close attention should paid on the diagnosis of tuberculosis and malignancy as TB may affect the spine which may be a consequences of any joint resulting to deformity. It should be noted that elderly men may present with bone lesions, as a manifestation of reactivation of the disease.

Diagnosis and Treatment

Imaging signs of musculoskeletal tuberculosis and other infections may lack, a diagnosis by biopsy and culture, chest radiographs and skin tests may be recommended. Magnetic resonance imaging may be suitable for soft tissues musculoskeletal infections. Ultrasound can be used to collect fluids in the joints or soft tissue, the evaluation of orthopedic structures and assessment of small peripheral joints. A mobile ultrasound device can be moved close to elderly beds. Computed tomography, radiography and nuclear medicine studies are considered to be ancillary and can be used to diagnose the infections.

  1. Paget’s disease

This is the excessive breakdown and formation of bone leading to disorganized bone remodeling. This results to weakening, pain, fractures, and arthritis in the joints near the affected bones. Persons over 50 years of age, varying according to geographic areas are affected. In a minority of cases, sarcomatous degeneration may develop, mainly in the humerus, pelvis and proximal femur.

Signs and Symptoms

There is an advancing wedge of bone resorption, an accentuation and coarsening of the bone trabeculae along lines of stress, cortical thickening, and enlargement of the bone. Secondary osteoarthritis, fractures, bowing of the bones, and spinal cord or nerve root compression can be observed. But many patients do not know they have the disease, because there are rarely symptoms to be observed. And if they may occur they are confused with those of arthritis or other disorders.

Diagnosis and Treatment

Diagnosis can be done through an elevated level of alkaline phosphatase in the blood in combination with normal calcium, phosphate and aminotranferase levels. Also bone scans are useful in determining the extent and activity of the condition. If a bone scan suggests Paget’s disease, the affected bones are X-rayed to confirm the diagnosis. Markers of bone turnover in urine like pyridinoline are used in diagnosis.

Drug therapy can relieve bone pain and prevent the progression of the disease. Medical therapy prior to surgery helps to decrease bleeding and other complications. Patients who are having surgery should discuss treatment with their physician. Exercise is very important in maintaining skeletal health, avoiding weight gain, maintaining joint mobility, avoided stress on affected bones and discusses any exercise program with their physicians before beginning.

  1. Fractures

They are often in the elderly persons due to effects of falls and osteoporosis. Low-impact falls from a standing height are the most common cause of injury in elderly. Can be due to impaired mobility, loss of muscular strength, poor visual acuity or even medication. Osteoporosis leads to bone fragility and increased risk of fractures. Prevalence of osteoporosis in women is more as opposed to males. Also mineral bone density is higher in black women and lowers in Asian women, while in white women evidence shows an intermediate value.

Vertebral compression fractures are the most common osteoporotic fractures, with a greater incidence in women over 60 years of age. The fractures are associated with higher mortality and significant morbidity. Other important sites of fractures are the hip and the pelvis, which are associated with increased mortality and specific diagnostic problems in the elderly people.

Signs and Symptoms

  • Sudden, severe back pain.
  • Worsening of pain when standing or walking.
  • Difficulty and pain when bending or twisting
  • Loss of height
  • Deformity of the spine — the curved, “hunchback” shape also known as dowager’s hump

Diagnosis and Treatment

Dual energy X-ray absorptiometry is used to diagnose osteoporosis, predict the risk of fracture, determine therapeutic intervention, and monitor response to treatment. A value less than 2.5 times the standard deviation below the young adult mean, is considered to indicate osteoporosis. The main radiographic features of osteoporosis are increased radiolucency and cortical thinning, mainly in the spine, giving rise to a well demarcated outline of the vertebral body.  An increased biconcavity of the vertebral end plates can be observed with a protrusion of the intervertebral disk into the vertebral body.Diagnosis of the hip and the pelvis fractures are conventional radiography, particularly fractures of the proximal femur.

Treatment can be through immobilization (aligning the bone, through reduction in good position and verifying the improved alignment with an X-ray), pain management, surgery and a times bone grafting.

  1. Microcrystal disorders

It characterized by gout and calcium pyrophosphate dihydrate deposition (CPDD) arthropathy. Gout is the most common inflammatory arthritis in the elderly and is characterized by a disturbance of purine metabolism, with deposits in the joints, cartilage, and kidneys. The radiographic features include eccentric nodular soft tissue masses, close erosions and preservation of the joint space. Ultrasound may be particularly help to demonstrate more tophi and erosions than plain films. Calcium pyrophosphate dihydrate deposition (CPDD) on other hand is disease is characterized by articular and periarticular tissue deposits also in the spine. Unlike gout, in which the increase in serum leads to supersaturation and deposits in the joints,the calcium deposits in CPDD, usually appear in the cartilage in the absence of any serum abnormality.

  1. Osteoporosis

It is a degenerative arthritis or porous bone which is a disease characterized by low bone mass and structural deterioration of bone tissue, leading to frail bones and an increased risk of fractures of the hip, spine, and wrist. When too much calcium is dissolved from bones or not enough replaced, bones lose density and are easily fractured. Elderly people are most affect by this disease but it can be prevented and treated if early noticed. Osteoporosis is responsible for million bone fractures, including hip fractures, vertebral fractures, wrist fractures, and more other fractures of the body. Once the ovaries stop producing the estrogen hormone, women are at higher risk of developing osteoporosis.

Signs and Symptoms

Osteoporosis itself has no symptoms its main consequence is the increased risk of bone fractures. Osteoporotic fractures occur in situations where healthy people would not normally break a bone; they are therefore regarded as fragility fractures. Typical fragility fractures occur in the vertebral column, rib, hip and wrist.

Diagnosis and Management

The diagnosis can be done using conventional radiography and by measuring the bone mineral density. Dual-energy x-ray absorptiometry is done. Depending on the likelihood of an underlying problem, investigations for cancer with metastasis to the bone should be done.

Lifestyle prevention can be through tobacco smoking cessation and moderation of alcohol intake. Elderly should have a better diet. Medication through bisphosphonates is useful in decreasing the risk of future fractures in those who have already sustained a fracture due to osteoporosis.

Effects of Exercise on Musculoskeletal Diseases

Elderly with joints problems should do it in moderation, especially within one’s cardiac tolerance. Excessive exercise may induce injury to musculoskeletal structures. Rest periods may also be helpful to relax the structures involved, as well as to regain energy lost with exercise. Exercises which could have kept the cartilage from becoming thin and damaged are hindered. This makes them vulnerable to injury or degenerative joint disease.

Activities that strengthen tendons are affected. The stretching and recoiling of tendons which help in transmission of force produced by muscles to the bones stops. Exercise amplifies their strength, preventing them from becoming physically injured.

Without exercise, the ligaments can loosen up. Exercise can help them maintain their power and durability. Due to old age, inactive nature of these people weakens the bones making them susceptible to all sorts of physical injuries.

General Diagnosis and Treatment of musculoskeletal diseases

The diagnosis of musculoskeletal diseases requires knowledge of the diseases which affect this age group, well knowing the signs and symptoms, and a working knowledge of laboratory and radiographic abnormalities.

Treatment is based on the principles of pain relief and maintenance of function. Physical therapy, patient education, psychological support and the use of medications is also recommended. Anti-inflammatory drugs are the most used as they are effective in relieving pain and improving function in most patients. However there is increased risk for anti-inflammatory drugs induced toxicity, and therefore an individual should choose carefully. On that note potential precaution on toxicity must be weighed against realistic benefits before and during actual therapy. 

References

Fonda, D., & National Health and Medical Research Council (Australia). (1994). Musculoskeletal disorders in the older person: Report of the Health Care Committee Expert Panel for Health Care of the Elderly. Canberra: A.G.P.S.

Perry, H. M., Morley, J. E., & Coe, R. M. (1993). Aging and musculoskeletal disorders: Concepts, diagnosis, and treatment. New York: Springer Pub. Co.

Reichel, W. (1995). Care of the elderly: Clinical aspects of aging. Baltimore: Williams & Wilkins.

Reichel, W., & Arenson, C. (2009). Reichel’s care of the elderly: Clinical aspects of aging. Cambridge: Cambridge University Press.

Rothstein, D. E. (1992). The interrelationships among physical activity status, musculoskeletal variables, and gait in the elderly.

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