Other Diseases of the Body

Rheumatic Diseases

Rheumatic diseases are "disorders of connective tissue, especially the joints and related structures, characterized by inflammation, degeneration, or metabolic derangement" (MDO n.d.). There are over 100 rheumatic diseases, many of which have historically been lumped under the term rheumatism. The discussion here is limited to those that most commonly occur to people age sixty or older, although they may also occur at other ages.

Osteoarthritis

Osteoarthritis is the most common type of arthritis---70% of those over seventy years old have x-ray evidence of this malady (Srikulmontree 2008). Osteoarthritis chiefly affects the tissue, known as cartilage, which pads the ends of bones within a joint. Osteoarthritis takes place when cartilage begins to wear or fray, sometimes completely wearing away, leaving a bone-on-bone joint (NIAMS n.d.a).

Some predispositions to osteoarthritis are:

·        Age

·        Being overweight or obese

·        Injury and/or stress to the joint(s)

·        Family history of osteoarthritis

Symptoms of osteoarthritis can include the following joint problems (WD 2009):

·        Joint pain or tenderness

·        Joint stiffness, reduced motion

·        Slow, often painful, movement

·        Crunching sound

·        Swollen joints

·        Joints that lock

·        A crunching or grinding sound

Other symptoms can include (WD 2009):

·        Fever

·        Weight loss

·        Fatigue

·        Trouble breathing

·        Rash and/or itch

Osteoarthritis may also cause disability which usually happens when the spine, knees, or hips are affected.

Treatments for osteoarthritis are fourfold:

v    Physical resources:

à       Exercise

à       Support devices

à       Thermal therapy

à       Alternative therapies, e.g., chiropractic, acupuncture, or massage

v    Drug therapy:

à       Topical agents, e.g., capsaicin cream

à       Oral pain relievers, e.g., acetaminophen

à       Nonsteroidal anti-inflammatory drugs (NSAIDs) for swelling and inflammation

à       Narcotics for severe pain

à       Joint injections with corticosteroids or a form of lubricant called hyaluronic acid (HA) derivatives

v    Surgery:

à       Arthroscopy

à       Joint replacement

v    Nutritional supplements:

à       Chondroitin/glucosamine sulfate supplementation is recommended by the National Institutes of Health (NIH 2009), with the caution to consult a pharmacist or physician to avoid drug interactions.

Osteoporosis

Osteoporosis is a disease manifested by a decrease in bone strength; this leads to a greater risk of fractures, or broken bones (NIAMS n.d.b, 1). Osteoporosis is the primary underlying cause of fractures in postmenopausal women and the elderly. Bones of the hip, spine, and wrist more frequently sustain fractures, but any bone can be affected. Some fractures can be permanently crippling, especially if they are in the hip.

The first plan of attack is to aid your clients in preventing osteoporosis. The following are some of the ways an individual can help prevent and/or treat osteoporosis (NIAMS n.d.b, 17ff, 32ff):

·        Adequate calcium consumption (the earlier in life this can be started, the better the result). Calcium needs vary from time to time in one's life; supplements may be beneficial. For adult men and women, the following amounts (in milligrams) are recommended:

19–50 years    1,000

51–70 years    1,200

Over 70 years 1,200

·        Adequate Vitamin D consumption (like calcium, the earlier in life this begins, the better the result); supplements may be helpful. For adult men and women, the following amounts (in International Units) are recommended:

19–50 years    200

51–70 years    400

Over 70 years 600

·        Overall nutrition---a balanced, nutritious diet with a large quantity and variety of fruits and vegetables, plus enough calories

·        Exercising and keeping other facets of a balanced life, including sleep

Pseudogout

Deposits of crystals, calcium pyrophosphate dihydrate (CPPD), in and around joints, cause pseudogout---a type of arthritis (inflammation of joints). The symptoms of pseudogout are the same as those of gout; however, gout is cause by crystals called monosodium urate. These two types of crystals have very different appearances when joint fluid containing them is observed under a microscope, and the treatment is different (MedicineNet n.d.). Almost 50% of people age ninety and older have CPPD crystals in their joints. However, most of them do not experience indications or symptoms of pseudogout (Mayo 2008).

 Calcium Phosphate

         Crystals 

One of the risk factors of pseudogout is older age (Mayo 2008), whereas that is not as true of gout (Mayo 2007).  Other risk factors of pseudogout are:

·        Joint trauma

·        Genetic disorder

·        Excess iron stored in the body (hemochromatosis)  

Polymyalgia Rheumatica

An inflammatory disorder, polymyalgia rheumatica (PMR) causes widespread muscle pain and stiffness, especially in one's neck, shoulders, upper arms, thighs, and hips. Symptoms may appear gradually or very suddenly. The exact cause of PMR is not known, but it is possibly a problem with the immune system; it may involve both genetic and environmental aspects. There may also be a link with particular viruses (Mayo 2008a):

o       Adenovirus, which causes respiratory infections ranging from the common cold to pneumonia

o       Human parvovirus B19, the source of an infection that primarily affects children

o       Human parainfluenza virus

PMR is diagnosed through blood tests: sed rate, rheumatoid factor (RF), C-reactive protein, and other blood tests. Polymyalgia rheumatica will usually resolve itself in one to two years, but symptoms may be improved with medications and self-care strategies.

Symptoms may include:

·        Aching and stiffness in the neck, shoulders, upper arms, thighs, and hips

·        Fatigue

·        Unintentional weight loss

·        General feeling of malaise or weakness

·        A slight fever at times

·        Anemia---low red blood cell count

Risk factors that may increase the likelihood of an individual getting PMR are (Mayo 2008a):

o       Age---that average age of onset is seventy

o       Sex---women are twice as likely to develop PMR as are men

o       Race---anyone can get PMR, but most are white, and people of Northern European and Scandinavian origin are especially at risk

o       Giant cell arteritis---approximately half of those having giant cell arteritis also have polymyalgia rheumatica

Doctors may treat the disease with nonsteroidal anti-inflammatory drugs (NSAIDs) or oral corticosteroid drugs such as prednisone, but they prefer not to use either of these medications over a long period of time because of potential side effects. Other things clients can do to help are:

·        Exercise (surprise, surprise!)

·        Eat a healthy diet (another surprise!)

·        Pace themselves. Try to interchange demanding or repetitious tasks with easier ones to avoid straining painful muscles.

About seven out of one thousand of those over 50 have PMR (WD n.d.), and anywhere from 15-25% of those also have Giant Cell Arteritis (GCA) (Werner 2008), another rheumatic disease. Because of its relatively small percent of incidence, GCA will not be discussed in this course, but healthcare workers are urged to learn more about it "just in case."

Paget's Disease of Bone

Bones, as other parts of the body, continually rebuild themselves. When this happens at an accelerated rate, the bones can become misshapen and soft, a condition called Paget's disease of bone. If a bone has become soft through this condition, it can cause the involved pelvis, spine, hips, thighs, head, or arms to bend and be weak. If the bone is misshapen or enlarged, it is prone to arthritis and fractures and may cause hearing loss and discomfort (Altman 2006).

This is a condition that is seldom diagnosed before age forty, and the frequency of diagnosis increases in each progressive age group to 10% by age 80 (WD n.d.a). For this reason, the symptoms are often assumed to be simply part of the aging process. Fortunately, the condition does not spread from bone to bone and is usually limited to one or a few bones of the pelvis, spine, hips, thighs, head, or arms (Altman 2006). Very rarely, in less than 1% of those with Paget's, it can lead to cancer---osteosarcoma---although this usually happens only after the individual has had Paget's for a long time. Osteoarthritis and congestive heart failure are more common complications of Paget's disease (Mayo 2008b).

The only known risk factors are age and heredity, although men are more likely to get Paget's than are women. It is diagnosed through an alkaline phosphatase blood test, an x-ray---usually taken for unrelated reasons, and/or a bone scan.

Symptoms, if any, will depend on the part of the skeletal system that is involved, and can include (Mayo 2008b):

·        Pain in the affected bone(s)---the most common symptom. It may be a constant, deep ache, and it may be worse at night.

·        Pain, swelling, and/or stiffness in the joints

·        Pain from nerve compression---usually more intense pain than that in the bone

·        Numbness, tingling, weakness, hearing loss, and double vision may occur from nerve compression.

·        Warmth in the skin over the affected area

·        Neurological problems such as headache, hearing loss, and occasionally vision loss

·        Bone deformities (bowed legs, enlarged head)

·        Fractures

·        Loss of bladder or bowel control accompanied by weakness in the legs---this can indicate severe spinal damage

One of two kinds of bone-regulating medications, bisphosphonates and calcitonin, may be prescribed. Nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin may be prescribed for inflammation, and acetaminophen (e.g., Tylenol) may be used to reduce pain. In a very few cases, the patient may need surgery to aid in the healing of fractures, to replace

damaged joints, to realign deformed bones, or to reduce pressure on nerves (Mayo 2008c).

In addition to the anticipated healthy diet and exercise, Paget's patients need to take extra care to avoid falls.

Diabetes Mellitus

Almost twenty-four million Americans are estimated to have diabetes mellitus (ADA n.d.), and more than half of those are over sixty years of age. Of folks over age sixty-five, almost 20% have diabetes (NDIC 2002).

Glucose, or blood sugar, is the body's primary fuel source used to give energy to the cells that comprise the muscles and other body tissues. The pancreas secretes insulin, a protein-type hormone, to convert foods such as sugars and starches into glucose. If an individual has diabetes, there is too much glucose in the blood, although the reasons may differ. Too much glucose can cause serious health problems, such as (Mayo 2009):

·        Cardiovascular disease---if someone has diabetes they are twice as likely to get heart disease such as angina, heart attack, stroke and narrowing of arteries (atherosclerosis)

·        Neuropathy (nerve damage)---tingling, numbness, burning, or pain in fingers or toes that spreads upwards, sometimes ending in loss of all feeling in the affected limbs; neuropathy in the digestive system can cause nausea, vomiting, diarrhea, or constipation, lead to erectile dysfunction for men

·        Nephropathy (kidney damage)---severe damage can have the end results of kidney failure or irreversible end-stage kidney disease, which requires dialysis or even a kidney transplant

·        Eye damage (diabetic retinopathy)--this can lead to blindness

·        Skin and mouth conditions such as bacterial infections, fungal infections and itching

·        Bone and joint problems such as osteoporosis

There are two types of diabetes (Mayo 2009; Inzucchi et al 2007a; Inzucchi et al 2007b):

v    Type 1 diabetes is an immune system problem. Instead of fighting harmful viruses or bacteria, which is the job of the immune system, it attacks and destroys insulin-producing cells in the pancreas, leaving the individual with little or no insulin. This causes the blood sugar to build up in the bloodstream rather than being transported into the cells. Type 1 diabetes most commonly develops during childhood or adolescence, but can develop at any age.

v    Prediabetes is the forerunner of type 2 diabetes in which the cells resist the action of insulin; the pancreas cannot make enough insulin to surmount this resistance. This causes the blood sugar to build up in the bloodstream rather than being transported into the cells, just as in type 1 diabetes. Although the cause of this is unknown, factors seem to include excess fat---particularly abdominal fat---and inactivity. Type 2 diabetes is the most common type. It can develop at any age, and is often preventable.

As a person ages, insulin production tends to decrease because of age-related cell damage (including in the pancreas) causing a reduction of insulin output. Other tissues tend to become less sensitive to insulin.

The risk factors for diabetes include (Mayo 2009):

·        Weight. The more fatty tissue there is, the more resistant the cells become to insulin.

·        Inactivity. Physical activity helps control weight, uses up glucose as energy and makes cells more sensitive to insulin.

·        Family history. Risk increases if a parent or sibling has type 2 diabetes.

·        Race. Although it's unclear why, people of certain races---including blacks, Hispanics, American Indians and Asian-Americans---are at higher risk.

·        Age. The risk increases as one gets older, especially after age 45.

·        Gestational diabetes. If someone developed gestational diabetes when they were pregnant, the risk of developing prediabetes and type 2 diabetes later increases. If birth was given to a baby weighing more than 9 pounds, they're also at risk of type 2 diabetes.

It is most important that your clients be aware of potential symptoms of diabetes (Mayo 2009):

·        Increased thirst

·        Frequent urination

·        Extreme hunger

·        Unexplained weight loss

·        Fatigue

·        Blurred vision

·        Slow-healing sores

·        Frequent infections

The physician may use one or more of the following tests to diagnoses diabetes (Mayo 2009):

·        Fasting blood sugar test---A blood sample is taken after an overnight fast. A blood sugar level from 100 to 125 mg/dL (5.6 to 6.9 mmol/L) is considered prediabetes. If it's 126 mg/dL (7 mmol/L) or higher on two separate tests, the diagnosis will be diabetes.

·        Oral glucose tolerance test, usually used when prediabetes is suspected. A blood sample is taken after a fast of at least eight hours. Then the patient drinks a sugary solution, and the blood sugar level is measured again after two hours. A blood sugar level less than 140 mg/dL (7.8 mmol/L) is normal. A blood sugar level from 140 to 199 mg/dL (7.8 to 11 mmol/L) is considered prediabetes. A blood sugar level of 200 mg/dL (11.1 mmol/L) or higher may indicate diabetes.

·        Random blood sugar test---A blood sample is taken at a random time. Regardless of when the individual last ate, a blood sugar level of 200 milligrams per deciliter (mg/dL)---11.1 millimoles per liter (mmol/L)---or higher suggests diabetes.

As with most classes of diseases, there is some commonality between treatments but specific types of the disease may have special prescriptions and/or regimens. And, as with most of the diseases discussed in this program, for any type of diabetes a healthy diet and exercise should be considered part of the treatment plan. Additionally, someone with diabetes basically needs to monitor their blood sugar and to take insulin as prescribed.

Incontinence

In the elderly population, incontinence is a potentially disabling condition that is both common and disruptive. It is defined as the involuntary loss of urine or stool in an amount large enough to be a social and/or health problem (Kane et al 2004, 173). Urinary incontinence (UI), much more common than stool incontinence, affects 8-34% of the non-institutionalized elderly population (Merck n.d.) and 50-84% of the geriatric population in long-term care facilities (Ogundele et al 2006).

Urinary incontinence is a medical condition with numerous possible causes, but it is not a normal part of aging or, in women, an inevitable consequence of childbirth or change after menopause. It can result in lifestyle changes---changes in activities, work life, social and personal life---and in skin problems and urinary tract infections (Mayo 2007a).

There are several kinds of urinary incontinence (Mayo 2007a):

v    Those that are temporary and can be resolved by a change in habits:

§        Alcohol

§        Over-hydration

§        Dehydration

§        Caffeine

§        Bladder irritation that can be caused by carbonated drinks, tea, coffee (caffeinated or decaffeinated), citrus fruits and juices, and artificial sweeteners

§        Some medications

§        Other illness or injury

v    Those that are caused by easily treatable medical conditions;

§        Urinary tract infections

§        Constipation

v    Those that are caused by factors that lead to chronic incontinence:

§        Pregnancy and childbirth

§        Changes with aging (e.g., aging bladder muscle, blood vessel disease, high blood pressure, overweight)

§        Hysterectomy

§        Interstitial cystitis (rare cause)

§        Prostatitis (not typically a cause)

§        Enlarged prostate

§        Prostate cancer

§        Bladder stones or bladder cancer

§        Neurological disorders (multiple sclerosis, Parkinson's disease, stroke, a brain tumor or a spinal injury can interfere with nerve signals involved in bladder control)

§        Obstruction (urinary stones or a tumor)

There are several risk factors, some that are changeable, and some that are not (Mayo 2007a):

·        Sex---women are more likely to have incontinence, except for men that have prostate gland problems

·        Age

·        Obesity

·        Smoking

·        Vascular disease

·        Kidney disease

·        Diabetes

There are six types of incontinence with their own symptoms (Mayo 2007a):

1.   Stress incontinence. This is loss of urine when one coughs, sneezes, laughs, exercises, or lifts something heavy. When these things are done, pressure (stress) is put on the bladder. Stress incontinence occurs because the sphincter muscle at the bladder is weakened. If the bladder gets too full, the problem will be particularly evident.

2.   Urge incontinence. This is a sudden, intense urge to urinate, followed by an involuntary loss of urine. The bladder muscle contracts and may give a warning of only a few seconds to a minute to reach a toilet. With urge incontinence, one may also need to urinate often. The need to urinate may even wake a person up several times a night. Some people with urge incontinence have a strong desire to urinate when they hear water running or after they drink only a small amount of liquid. Simply going from sitting to standing may even cause urine leakage.

3.   Overflow incontinence. If there is a frequent or continual dribble of urine, overflow incontinence is likely the cause. This is lack of ability to empty the bladder, leading to overflow.

4.   Functional incontinence. Many older people, particularly those in nursing homes, have incontinence because a physical or mental impairment keeps them from getting to the toilet in time. For example, someone with severe arthritis may be unable to unbutton his or her pants quickly enough; a person with Alzheimer's disease may not be able to plan well enough to get to the toilet on time. This type of incontinence is called functional incontinence.

5.   Gross total incontinence. This term describes constant urine leakage, day and night, or intermittent large amounts of urine and uncontrollable leaking. This person's bladder has little or no storage capacity. The person may have been born with an anatomical defect, had a spinal cord injury, or an injury to the urinary system from surgery. A fistula---abnormal opening---between the bladder and a structure next to it, such as the vagina, may also cause this type of urinary incontinence.

6.   Mixed incontinence. If a person experiences symptoms of more than one kind of urinary incontinence, e.g., stress incontinence and urge incontinence, he/she has mixed incontinence. Usually one kind is more of a bother than the other kind is.

Procedures that have a good chance of preventing urinary incontinence are:

·        Maintaining a healthy weight

·        Not smoking

·        Avoiding bladder irritants

·        Eating more fiber

·        Being active

There are a number of treatments for UI, depending on the kind of incontinence the individual has, the severity of the problem, and the fundamental cause of the problem (Mayo 2007a).

v    Behavioral techniques

§        Pelvic floor muscle exercises (Kegel exercises)

§        Bladder training

§        Scheduled toilet trips

§        Fluid and diet management

v    Medications

§        Anticholinergic (antispasmodic) drugs

§        Imipramine (Tofranil)

§        Antibiotics

§        Other medications

v    Electrical stimulation. Electrodes are temporarily inserted into the rectum or vagina to stimulate and strengthen pelvic floor muscles. This can be effective for stress incontinence and urge incontinence, but it takes several months and multiple treatments to work. It can also cause side effects, e.g. abdominal cramps, diarrhea and bleeding. This method is usually used only for people with severe urge incontinence who have been unable to respond to behavioral techniques or medications.

v    Medical devices

§        Urethral inserts

§        Pessaries

v    Surgery

v    Absorbent pads and catheters

Many people do not tell their doctors about the urinary incontinence. They may be "used to it" and assume it is a necessary part of aging, or they may be embarrassed. You will need to be on the lookout for signs---verbal or otherwise---of UI, or you may need to ask in order to help your client find the best resolution to this problem.