Part of aging is an anticipated decrease in physiologic reserves that is not related to any disease. Studies show that healthy lifestyles account for approximately 20% to 30% of the increase in the probability of reaching the age of 100 years (Bickley & Szilagyi, 2009). These findings demonstrate the need to promote optimal nutrition, exercise and strength training, and designing daily function for the elderly in order to delay the decrease in physiologic reserves.
Musculoskeletal changes start occurring in the adulthood. People start experiencing reductions in their height soon after maturity. Flexion at the hips and knees may lead to a shortened stature, but, for the most part, loss of height is attributed to the thinning of intervertebral discs in the spinal column, shortening of vertebral bodies, or even to the vertebral collapse caused by osteoporosis (Bickley & Szilagyi, 2009). Chiefly, significant shortening is evident in the people of considerably old age. Moreover, skeletal muscles decrease in power and bulk, and ligaments lose tensile strength with aging. Range of motion becomes limited, partly due to osteoarthritis (OA).
This loss in muscle mass and quality leads to reduced muscle strength with unfavourable impact on functional capacity and mobility what makes it a strong independent predictor of mortality (Longo, Fausi, Kasper, Hauser, Jameson, & Loscalzo, 2011). The progressive demineralization and modification of bone architecture result into a decrease in bone strength, which, in turn, increases the risk of fracture.
Osteoporosis happens when there is decreased strength in the bones which results in the increased chance of fractures. On the micro level, a decline in quality of the bone microarchitecture is the result of bone tissue loss. According to Archana, Saurav, & Latika (2010), “the World Health Organization … operationally defines osteoporosis as a bone density that falls 2.5 standard deviations (SD) below the mean for young healthy adults of the same sex—also referred to as a T-score of –2.5. Postmenopausal women who fall at the lower end of the young normal range (a T-score <–1.0) are defined as having low bone density” which puts these patients in a category with higher chances of falling ill with osteoporosis (Longo et al., 2011). This translates to a prevalence that reaches beyond 50% of osteoporotic fractures in the group of older females with decreased skeletal density.
Osteoporosis may occur at any age. However, those at risk are 42% of men and 15% of US Caucasian women who are at least 50 years old, 12% in African American women, and 18% in Mexican American women. One in two women and one in four men who are at least 50 years old will have an osteoporosis-related fracture. Mortality is as high as 20% for patients with osteoporotic hip fractures (Bickley and Szilagyi, 2009).
These gender differences in bone demineralization are due to the effects of gonadal hormones on bones’ mineral density and sex differences in peak bone mass. When compared to men, women lose bone mineral density earlier and more quickly reach the threshold of low bone strength which increases risk of fracture (Longo et al., 2011).
Distal radius fractures, which happen when patients fall and stretch their arms out to cushing the fall, are more common among people below the age of 50. Hip fractures, on the other hand, are more common among people who reached the age of 70. Crush fractures of the vertebra are reported less since patients may remain asymptomatic and this kind of fractures may only be found incidentally while conducting an X-ray examination with regard to another condition.
The following are risk factors for osteoporosis: postmenopausal women, 50 years old or older, weight less than 70 kg, family history of fracture in a first-degree relative, personal history of fracture, high intakes of alcohol, delayed menarche or early menopause, smoking, low levels of 25-hydroxyvitamin D, corticosteroid use of more than 2 months, inflammatory disorders such as celiac sprue, chronic renal disease, hypogonadism, and anorexia nervosa (Bickley & Szilagyi, 2009).
Recommendations for nutritional supplementation include calcium, which is proven to delay loss and prevent high turnover of bones. Human body has the capacity to produce vitamin D with the help of ultraviolet light from sunlight, but not everyone gets enough exposure to the sun. Hence, supplementation with vitamin D has also been recommended. Pharmacologic therapy includes treatment with oestrogen and newer drugs such as calcitonin, bisphosphonates, and PTH, all of which help ameliorate bone resorption and directly increase bone mass. Treatment should also include the selective oestrogen response modulators (SERMS). Non-pharmacologic therapy includes placement of protectors for the hips worn just outside the thighs that may cushion the femur and pelvic bones during the fall and may also prevent osteoporotic fractures.
The examination of elderly patients should be started right after the patient entered the clinic. Specialist should start the general examination by assessing appearance, ease of movement, and body proportions. Case taking and conducting physical examination of older patients is different from procedures applied in the case of the younger people. Instead of only being focused on the disease itself, a special emphasis should be given to determining the general functional status of older patients, which is considered as the “sixth vital sign” (Bickley & Szilagyi, 2009). It is important to evaluate daily functions and the risk of falling, which may be a cause of increased morbidity and mortality among the older population. This will also help to determine the limitations that have to be expected during the actual physical examination.
When examining major joints, specialist should inspect for joint symmetry, bony deformities, and alignment. Inspect and palpate the surrounding tissues for skin changes, crepitus, nodules, and muscle atrophy. Test the active and passive phases of range of motion, and execute manoeuvrers to check for joint stability, function, the integrity of tendons, ligaments, and bursae. Also assess for arthritis, especially if there are signs of inflammation. If the patient complains of pain on movement, conduct all examination procedures gently or allow patients move themselves. It is advised to have an X-ray examination done in case if there is a history of trauma.
Fall is a definite health concern and is believed to be a major cause of morbidity and mortality among the elderly patients. Approximately 35% to 40% of healthy older adults experience falls each year (Bickley & Szilagyi, 2009). Fall increases the risk of fractures, so it is important to assess the risk factors for fall such as impaired vision, gait, and cognition as well as motor and sensory deficits and medications that may affect balance.
It is important to get as much details on how the fall happened as possible and identify the risk factors, functional status, medical comorbidities, and environmental risks present. This will serve as foundation for guidance for providing interventions in order to prevent future accidents. Specialist should advise patients and their families on how to modify ill-fitting shoes, poor lighting, slippery or irregular surfaces, stairs, chairs at awkward heights, and other environmental dangers that can often be easily corrected (Bickley & Szilagyi, 2009).
Home safety tips for older adults include but not limited to: customized banisters at the sides of staircases and balconies to prevent falls, well-lit stairways, paths, walkways, and non-slip mat or safety strips in the shower (Bickley & Szilagyi, 2009).
Increased physical activity helps improve physical function, muscle strength, metabolic rate, sleep, and mood in older adults. Aerobic and strength training exercise programs can be accomplished and are beneficial even to very old and frail individuals. Regular, moderate-intensity exercises can reduce the rate of age-associated decline in physical functions. The U.S. Centers for Disease Control and Prevention (CDC) recommend older people to spend a minimum of 150 min per week doing aerobic activity of moderate intensity (e.g., brisk walking). Moreover, older people are advised to engage in muscle-strengthening activities which will help to set all major muscle groups in motion (hips, legs, back, chest, abdomen, arms, and shoulders). These activities should be performed at least 2 days a week (Longo et al., 2011). More intense and prolonged physical activity provides higher benefits, provided there are no contraindications.
Functional status relates to a person’s ability to perform tasks and fulfil social roles associated with daily living across a wide range of complexity (Bickley & Szilagyi, 2009). The goal of functional assessment is to preserve and optimize patient’s functional status.
Asking and learning how older patients go about their daily activities is an important step in understanding their functional status. These questions will pertain to their capacity to do basic activities of daily living as well as the instrumental activities of daily living. Specialist should ask whether these activities are performed independently by the patient, with some help from his friends and family, or the patient is incapable of carrying out these activities on his own without considerable help.
The basic activities of daily living (ADLs) consist of the following self-care tasks: dressing and undressing, personal hygiene, eating, moving from bed to chair and back, ability to voluntarily control faecal and urinary discharge, using the toilet, and moving around as opposite to being bedridden. Instrumental activities of daily living (IADLs) are not necessary for fundamental functioning, but they let an individual live independently in a community. Examples are light housework, preparing meals, taking medications, shopping, using telephone, managing money etc (Longo et al., 2011).