Manifestation of Novel Social Challenges of the European Unionin the Teaching Material ofMedical Biotechnology Master’s Programmesat the University of Pécs and at the University of DebrecenIdentification number: TÁMOP-4.1.2-08/1/A-2009-0011

DISORDERS AND DISEASES OF LOCOMOTOR ORGANSPART 2

Gyula Bakó and Erika PéterváriMolecular and Clinical Basics of Gerontology – Lecture 7

Manifestation of Novel Social Challenges of the European Unionin the Teaching Material ofMedical Biotechnology Master’s Programmesat the University of Pécs and at the University of DebrecenIdentification number: TÁMOP-4.1.2-08/1/A-2009-0011

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Outline• Common diseases of locomotor organs in the

elderly – causes of falls, chronic immobilization and disability- Osteoarthrosis - Rheumatoid arthritis- Gout- CPPD arthritis (pseudo-gout)- Osteoporosis

• Immobilization and remobilization in the elderly

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Rheumatoid arthritis (RA) in the elderlyRA is a chronic, systemic autoimmune inflammatory disorder that may affect many tissues and organs, but principally attacks synovial joints. The ratio of elderly patients with RA increases among people with RA. Onset is most frequent between the ages of 40 and 50. (It may also appear in people over 60. This latter group is characterized by a particular onset.)In RA a rheumatoid factor (a non-specific antibody) is present in the blood. In the active phase We (sedimentation rate) is high with fever. In case of fewer rheumatoid nodes (fibrous tissue surrounding a center of fibrinoid necrosis) and milder systemic symptoms, prognosis is better.

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Rheumatoid arthritis (RA) in the elderlyClinical signs in the joints:• slow, chronic onset • in the elderly, it is frequently associated with

muscle pain, similar to that in polymyalgia rheumatica

• stiffness appears in the joints and muscles all over the body, characteristic morning stiffness

• painful cramps in the limbs• diffuse edema in the hands, wrists and lower

arms• synovitis causing deformity and loss of

function• large joints are more often involved, but the

small joints of the hands are the most severely affected.

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Gout, gouty arthritisDefinition:Chronic inflammatory arthritis caused by Na-urate crystals deposition in joints, tendons, and surrounding tissues. It is characterized by recurrent attacks of acute painful inflammation.Cause:Purine metabolism leads to production of uric acid. Urate precipitation in hyperuricemia may lead to recurrent episodes of inflammation and eventually formation of foreign body granuloma (tophus) in any tissue, except the brain.

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GoutConsequences of urate precipitation: high mortality• kidneys - urolithiasis (hyperuricemia presents a 1,000× risk)- parenchymal damage (chronic sclerotizing interstitial nephritis)

• joints – recurrent arthritis, tophi, arthrosis• arterial wall – atherosclerosis• coronaries – ischemic heart diseaseHyperuricemia greatly increases the risk for gout, but no exclusive causal link between high urate levels and gout (rarely hyperuricemia without gout, lowering of serum urate precipitating an attack ).In arthritis of unknown origin affecting few joints, measure urate level!

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CPPD arthritis (pseudo-gout)CPPD: calcium pyrophosphate dihydrate deposition diseaseIt is caused by deposition of calcium pyrophosphate crystals within the joint (basophilic, rhomboid, bluish yellow, linear crystals, weakly positively birefringent under polarized light).It occurs in around 15% of the population between 65-75 years of age, and in 60% of people over 85. Overall incidence: 9/10,000.Forms: sporadic (idiopathic), hereditary , secondary (associated)It is commonly associated with hyperparathyroidism, hemochromatosis, and advanced age. It is probably associated with arthrosis, amyloidosis, hypermotility syndrome.The clinical signs include either acute or chronic arthritis, acute attacks affect mostly the knees, wrists, shoulders.

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OsteoporosisDefinition:A systemic skeletal disorder characterized by a significant reduction of bone mass, disrupted microarchitecture, and low bone density causing bones to become brittle.Diagnosis of osteoporosis is based on bone density. The term of severe osteoporosis is used if a patient has suffered one or more fractures (most commonly hip and vertebral fractures).

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Diagnosis of osteoporosis

Bone densitometry:

– 2.5

– 1

Osteopenia NormalOsteoporosis0

T-score

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Osteoporosis: epidemiology•75 million people in Europe, the US and in Japan. • Incidence: 9-15%. In Hungary : 20%. •1/3 of postmenopausal women are affected.•Typical onset:-women: 40-50 y-men: 60-65 y (larger “peak bone mass”)• In a 50-year old woman, lifelong mortality risk associated with a hip fracture equals that of breast cancer (2.8%) and exceeds that of carcinoma in the endometrium (0.7%)!

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Osteoporosis: epidemiology

Hip fracture•1990: 1.7 million (2050: 6 million). Hungary: 16,000/year•geographic distribution: North >>> South•Central-Europe: 1-2.5 million / year• female:male = 2:1• survival: 90% 6-12 months, overall mortality: 5-25%

• related costs: -1990: 10 billion USD / 250 thousand cases-2040: 82 billion USD / 500 thousand cases

Vertebral fractures: it is more difficult to diagnose•prevalence: >65 years - females:males = 2:1

TÁMOP-4.1.2-08/1/A-2009-0011Risk factors for osteoporosis:factors that determine bone massGenetic factors (75-80%)• Caucasians and Asians : more fractures• Dominance of females• Polymorphism of vitamin D receptorsAgeHormonal factors (menopause , estrogen or androgen)Life style factors• diet (low Ca, protein deficiency)• alcohol, smoking• sedentary life style/immobilization, slender built Diseases causing osteoporosis• endocrine, metabolic (glucocorticoid excess, diabetes

mellitus)• GI malabsorption, liver-, renal failure• rheumatoid arthritis• drugs, medication (diuretics, antacids, heparin)

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energy/protein deficiency

Osteoporosis

Bone formation

Bone formation can not compensate for bone loss

BONE LOSS

direct effects

indirect

effects

Bone resorption

Secondaryhyperparathyroidism

Ca intake

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Management and prevention of osteoporosis• Lifelong appropriate calcium intake (1,000-1,500

mg/day; cheese, dairy products, broccoli, sardines)• Lifelong appropriate vitamin D intake (400-1,000

NE/day)• Lifelong regular physical activity (resistance and/or

aerobic exercises, exercises requiring coordination)• Elimination of alcohol, smoking, other risk factors • Treatment of secondary osteoporoses (e.g. by steroid

treatment)• Early diagnosis and treatment of hormone deficiencies

(menopausal, perimenopausal hormone replacement therapy)• Early diagnosis and differential diagnosis of

osteopenia, pevention of progression (selective estrogen receptor modulators, bisphosphonates, calcitonin) • Possible prevention of falls

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Immobilization and remobilizationin the elderlyImmobilization in the elderlyTherapeutical measuresRemobilization in the elderly

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Immobilization in the elderlyIndependently from age and age-dependent alterations mentioned above every elderly person is able to walk stairs, to stand up from a squatting position, to walk straight, to stand on one foot, and to execute activities of daily living.Those people who are confined to stay inactive because of an acute disease or are bedridden due to chronic conditions are highly prone to lose their muscle mass and force very quickly. The proportion of the loss can even reach 1.5% per day. The loss is more pronounced in the muscles responsible for sitting up, standing up and standing straight, the muscles essential for everyday life.

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Therapeutic measures•Passive movement and active exercising of joints on a regular basis•Proper positioning of patient•Cautious, gradual mobilization•Respiration exercise, use of expectorants•Replacement of fluids and optimal feeding•Regular emptying of bladder, removal of catheter as soon as possible•Cleaning of skin, prevention of pressure ulcers•Communication, active environment

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Remobilization in the elderlyCertain specialists in geriatric medicine state that one day spent in bed can be compensated by a 2-week workout. Therefore, a personalized exercise program and care must be worked out for every hospitalized, chronically ill patient in order to maintain their physical activity.Maintenance of physical activity as long as possible in the elderly is essential via resistance training and daily activity- and work-oriented special exercises.The ideal frequency, intensity, duration and style of such physical activity have not been fully defined yet. According to the current recommendations, 30-60 min fast walking repeated 3-4 times a week is the most suitable workout during which the pace is slowed down for 5 minutes in every ten minutes.