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Loss of bone and muscle with advancing age represent a huge threat to loss of
independence in later life.
Osteoporosis represents a major public health problem through its association
with fragility fractures.
Sarcopenia, the age related loss of muscle mass and function, may add to
fracture risk by increasing falls risk.
In the context of muscle aging, it is important to remember that it is not just a
decline in muscle mass which contributes to the deterioration of muscle
function.
Other factors underpinning muscle quality come into play, including muscle
composition, aerobic capacity and metabolism, fatty infiltration, insulin
resistance, fibrosis and neural activation.
1Curtis E; Litwic A; Cooper C; Dennison E. Determinants of Muscle and Bone Aging. Journal of Cellular
Physiology. 230(11):2618-25, 2015
Remember that the key focus of aged care is on the maintenance of function.
Musculoskeletal disorders that limit mobility have a significant adverse effect on
function.
The main age-related changes in the musculoskeletal system are loss of muscle
mass, loss of mineral density & osteoarthritis.
The "use it or lose it" rule applies to muscle strength in the aged.
The end result of these changes may be the development of sarcopaenia (which
literally means a deficiency of flesh).
2
Bell KE; von Allmen MT; Devries MC; Phillips SM. Muscle Disuse as a Pivotal Problem in Sarcopenia-related Muscle Loss and
Dysfunction. The Journal of Frailty & Aging. 5(1):33-41, 2016.
Sarcopenia is a loss of skeletal muscle mass in the elderly that is an
independent risk factor for falls, disability, postoperative complications, and
mortality.
Although its cause is not completely understood, sarcopenia generally results
from a complex bone-muscle interaction in the setting of chronic disease and
aging.
Sarcopenia cannot be diagnosed by muscle mass alone.
Effects of ageing on the nervous system may contribute to the loss of muscle
strength.
3 Bokshan SL; DePasse JM; Daniels AH. Sarcopenia in Orthopedic Surgery. Orthopedics. 39(2):e295-300, 2016
Endocrine changes that cause a relative deficiency of anabolic hormones, such
as growth hormone (GH) and testosterone might also contribute to the loss of
muscle strength.
The reduction in muscle mass and the relative increase in the proportion of
slow twitch muscle fibres contribute to a slower walking speed, which may
have implications for daily activities such as crossing a road.
It is good to have an idea of what a healthy older person can normally do.
They can usually
easily climb stairs,
rise from a squatting position,
walk along a straight line,
hop on either foot, and
perform typical activities of daily living.
Hospitalised elderly people, especially those who are bedridden, require early
and individualised exercise regimens (=a set of rules about food and exercise or
medical treatment that you follow in order to stay healthy or to improve your
health).
For 1 day of absolute bed rest, up to 2 wk of reconditioning may be necessary to
return to baseline function.
Exercises which focus on improving core body strength have been shown to be
most helpful in all elderly people in restoring and maintaining muscle strength
and preventing falls.
drug storage
- a decrease in muscle mass may increase the effective circulating
concentration of drug, increasing the risk of adverse reactions;
regulation of nutrient intake
- loss of muscle mass may cause a decrease in food intake which in turn may
cause nutritional deficiencies.
2. THE SKELETON
Normal physiological changes in the ageing bone
The most important age related change in the bone is the loss of mineral, which
results in loss of strength.
This is osteoporosis.
Osteoporosis is a disease in which bone mass is reduced.
The bone that is present is generally normal, although some changes to its
micro architecture occur.
Its not specifically diseased-it is best to imagine that there is just less bone than
usual.
The loss of bone mass causes a loss of bone strength, which increases the risk
of fracture.
Adolescence is a critical period for bone health because the amount of bone
mineral gained during this period typically equals the amount lost throughout
the remainder of adult life.
Peak bone mass is reached in the thirties, and declines from then.
After 4050 years of age, bone loss may progress slowly in both sexes, with a
period of more rapid loss in women during the menopause accounting for bone
loss of 1220% over a period of 5 years.
Thereafter, age-related bone loss is modest (0.6% per year), but because of long
life expectancy, both sexes may lose a total of 40% of bone over their lifetime. 4
Pathologic factors may also contribute to the loss of bone mass in either sex.
Pathological fractures occur as a result of disease-related damage to the bone
that decreases its strength.
That means that pathological fractures can occur when very small forces are
applied to the bone.
The risk factors include high circulating levels of glucocorticoids and thyroxine,
alcoholism, prolonged immobilization, gastrectomy, malabsorption, renal
disease (hypercalciuria), some types of cancer, and cigarette smoking.
Fractures occur commonly at the proximal ends of long bones (e.g. head of
femur) and the spine, often with minimal trauma.
The effects of these fractures may range from the obvious to more subtle signs
such as chronic pain and hunching (=bend the top part of your body forward
and raise your shoulders and back) of the shoulders, which limits the capacity of
the lungs.
In Western societies approximately 40% of women and 13% of men will
experience a hip, spine or wrist fracture.
In women, wrist fractures commonly occur during the sixth decade of life,
vertebral fractures occur during the seventh decade and hip fractures occur
during the eighth decade of life.
In men, osteoporotic fractures occur at a more advanced age.
One approach to decreasing the risk of adverse events is the use of drug
holidays after 3 to 5 years of bisphosphonate treatment.
Because bisphosphonates are stored in the bone there anti-reabsorbed if
effects continue after their use has stopped.
It appears that this effect may last for up to one year.
Adequate vitamin D levels and dietary calcium intake are needed for effective
primary fracture prevention with greatest benefits occurring in the elderly with
vitamin D deficiency and/or low dietary calcium intakes.
For secondary fracture prevention, i.e. preventing further fractures in the
elderly who have already sustained a fragility fracture, specific anti-osteoporosis
treatment is necessary.
However, to maximise the benefits of these medications, vitamin D deficiency
should be corrected and adequate dietary calcium consumed. 5
5Winzenberg T. van der Mei I. Mason RS. Nowson C. Jones G. (2012) Vitamin D and the musculoskeletal
health of older adults. Australian Family Physician. 41(3):92-9
Vitamin D supplementation (=the act of adding something to something else in
order to improve or complete it) above normal requirements has not shown any
benefit in the treatment or prevention of osteoporosis.
Although vitamin D does not appear to have the expected effect on the
skeleton, it does seem to have many other benefits for aged people.
Vitamin D supplementation can prevent falls, particularly in the vitamin D
deficient elderly.
Statins
Statins are used to treat patients with acute coronary syndromes or established
cardiovascular disease, diabetes mellitus, chronic renal disease-all common
conditions affecting the aged.
Statins decrease cholesterol concentrations in the blood, and improve lipid
profiles, reducing the risk of cardiovascular disease.
Describe how musculoskeletal reserve capacity changes with age and explain
the factors that contribute to this change.
What are the similarities between the answer to this question and causes of
changes in reserve capacity in other body systems?
6 Camerino GM. Pellegrino MA. Brocca L. Digennaro C. Camerino DC. Pierno S. Bottinelli R. (2011) Statin or
fibrate chronic treatment modifies the proteomic profile of rat skeletal muscle.Biochemical Pharmacology.
81(8):1054-64.
As predicted ageing results in a decrease in reserve capacity in the
musculoskeletal system.
This is due to changes in the muscle and the that are a normal part of ageing,
and can be exacerbated disease affecting different systems.
There is also a decrease in muscle mass and also bone strength.
As has been observed previously in other systems, these changes can be direct
(occurring specifically in the musculoskeletal system), or can be compensated
changes occurring as a result of changes in other parts of the body.
You should return to your concept map, and try to integrate changes in
musculoskeletal function with some of the more general changes that are
observed in an aged person.
A loss of muscle mass can result in changes in drug storage in the body.
This increases the risk of adverse events related to drugs.
Common adverse events include falls, depression, insomnia, loss of appetite, and
cognitive decline.