Specific Considerations in Geriatric Athletes


• Aluminum

• Aromatase inhibitors

• Anticonvulsants (phenobarbital, phenytoin, valproate)

• Cytotoxic drugs

• Ethanol (excess use)

• Glucocorticoids

• Gonadotropin-releasing hormone agonists

• Heparin (long-term use)

• Lithium

• Progesterone (parenteral, long-acting)

• Thyroxine (supra-physiologic doses)



The fracture risk assessment tool (FRAX ) was developed by the World Health Organization to predict the risk of osteoporotic fracture for a person over the next 10 years and the calculator can be found online at http://​www.​sheffield.​ac.​uk/​FRAX/​. The output is a 10-year probability of hip fracture and the 10-year probability of a major osteoporotic fracture (clinical spine, forearm, hip, or shoulder fracture).


Osteoporosis Evaluation

A thorough history is the most important part of the evaluation for osteoporosis. Using the FRAX tool can help quantify a patient’s risk factors as it takes into account age, sex, body mass index, previous low-trauma fracture, parental hip fracture, current smoking status, corticosteroid use, alcohol use, rheumatoid arthritis, and other secondary causes of osteoporosis. The FRAX algorithm should be used in conjunction with clinical judgement as there are some items from a patient’s history it does not capture such as a personal history of multiple fractures or a significant fall history.

A physical exam , looking for risk factors for falling, such as decreased mobility or strength (e.g., unable to rise from a chair without using hands), decreased proprioception, decreased visual acuity, signs of osteoporosis (i.e., evidence of vertebral compression fractures with loss of height, kyphosis, and overly protuberant abdomen) should be done. The physical exam should also rule out signs of other possible causes of metabolic disease (i.e., cushingoid features, goiter, jaundice, etc).

The information gathered from the history and physical will help identify patients for whom further diagnostic imaging is indicated.

The United States Preventative Services Task Force (USPSTF ) recommends screening for osteoporosis in women aged 65 years or older and in younger women whose fracture risk is equal to or greater than that of a 65-year-old white woman with no additional risk factures [5]. (SOR-B) Dual energy X-ray absorptiometry (DEXA) is currently considered the gold standard for measuring BMD [3]. The areal unit of measurement is grams per square centimeter (g/cm2), although it is usually reported as a T-score, which is a standard deviation without units of measurement. The World Health Organization (WHO) has defined osteoporosis on the basis of BMD as measured by DEXA. BMD that is greater than 2.5 standard deviations below the mean for a young, white, healthy female is defined as osteoporosis. BMD 1.0–2.5 standard deviations below the mean is defined as low bone mass (previously called osteopenia).

Other methods used to measure BMD include quantitative computed tomography (QCT) and quantitative ultrasound (QUS). However, DEXA of the hip is the best predictor of future hip fracture and the only imaging recommended for serial evaluations of patients being treated for osteoporosis .

Once the diagnosis of osteoporosis has been made, there are a number of pharmacological and nonpharmacological treatments available. Some of the treatments are also used for the prevention of osteoporosis in high-risk individuals. Non-pharmacological interventions for treatment and prevention of osteoporosis are listed in Table 8.2.


Table 8.2
Nonpharmacologic interventions that may help prevent osteoporosis-related fractures

























• Diet with adequate calories, protein, and nutrients

• Weight-bearing exercise

• Strength-training exercise

• Balance-training exercise

• Tobacco cessation

• Reducing excessive alcohol intake

• Vision correction

• Assessment of any medical conditions that may decrease bone density or increase the risk for falls

• Assessment of any medications that may decrease bone density or increase the risk for falls

• Elimination of tripping hazards in the home, work, and social environments

Pharmacological treatments used to prevent and treat osteoporosis include antiresorptive drugs such as the bisphosphonates (alendronate, risedronate, ibandronate), calcitonin, estrogen, and partial estrogen agonists and antagonists (previously known as selective estrogen receptor modulators or SERMs), such as raloxifene. The bisphosphonates reduce bone turnover and subsequently prevent bone loss. Calcitonin inhibits osteoclasts, and previous studies have shown a decrease in the incidence of vertebral fractures as well as an analgesic effect when administered after acute vertebral fractures [4]. Currently, there is no significant information on the effect of calcitonin on early menopausal BMD, so it is not recommended within the first 5 years of menopause. Estrogen also inhibits bone resorption, increases total hip BMD, and reduces the risk of fracture at the hip, spine, and wrist, and is currently approved for prevention, but not treatment for osteoporosis. Raloxifene is able to exert estrogen-like effects on the skeleton, although not as effectively as estrogen or the bisphosphonates [4]. Calcium and vitamin D supplementation is also important therapy and can be prescribed for prevention of osteoporosis, and should be prescribed for any patients taking bisphosphonates for prevention or treatment of osteoporosis. Not all medications used to treat osteoporosis have data supporting reduced fractures of all kinds (spine, hip, nonvertebral fractures). Specifically, ibandronate (Boniva) does not show reduced hip and nonvertebral fractures. Calcium carbonate and gluconate will require an acidic environment, so patients on PPIs will need calcium citrate supplementation, which is effective in acidic or alkaline environment [6].

The fundamental goal of managing patients at high risk for osteoporosis is to prevent fractures and loss of function, and also to prevent or decrease pain. While there is evidence of increased bone density and decreased risk of fracture with pharmacologic intervention, there are still remaining questions about the effectiveness of interventions in asymptomatic populations [4, 7].

While there is general consensus that women over the age of 65 should have a BMD test, for women under age 65, BMD testing is generally reserved for those considered to be “at risk” for osteoporosis [4, 7]. What defines “at risk” is not universally agreed upon, and any data on using medications to prevent bone loss in perimenopausal women with normal BMD are extremely limited. Also, the risk factors, testing, and treatment of osteoporosis in populations other than postmenopausal white women need to be further investigated.



8.2.2 Muscle


It is well established that muscular strength declines with age [8]. Sarcopenia is a multifactorial physiologic change in aging that is caused by a loss of type II muscle fibers and therefore, a loss in muscle mass. It is estimated that muscle mass decreases 30–40 % in relation to body weight between the ages of 30 and 80 [9]. How much of the muscle mass and strength loss is directly related to aging and how much is related to disuse is unclear.

Studies have shown that resistance training can minimize, and in some case reverse, this loss of strength and muscle mass, but much more research needs to be done in order to determine the best management strategy. At this time, an operational definition of sarcopenia and what is “pathological” and puts a patient at increased risk for a bad outcome such as a fall, fracture, or loss of independence versus what is normal physiological loss of muscle mass and does not increase a patient’s risk is not clear. The Foundation for the National Institutes of Health Sarcopenia Project is working on establishing definitions, evidence-based endpoints, and functional limitations to be used in future clinical trials.


8.2.3 Cartilage, Ligaments, and Tendons


Aging leads to a decrease in the quantity and quality of synovial fluid and a decrease in cartilage proteoglycan conten t. This leads to decreased water content and elasticity of the cartilage in weight-bearing joints, including the hip [10].

Elasticity of the connective tissue of ligaments and tendons declines with age, most likely secondary to changes in collagen, elastin, and water content. This can lead to aging collagen being more subject to overload failure as well as leading to increased stress and force across the joint because of decreased flexibility and decreased range of motion [10].


8.2.4 Balance


Balance can be defined as the ability of an individual to maintain his or her center of gravity within specific boundaries and may be either static or dynamic [11]. The visual, vestibular, and proprioceptive system are all important in maintaining balance, and all can suffer degenerative changes with aging. One of the most serious outcomes of poor balance is falls.

The accumulative exposure of degenerative, infective, and injurious processes to the sensory, motor, and adaptive systems, combined with slowed protective reflexes, leads to a decreased ability to withstand unexpected perturbations with advancing age [11, 12].

At least 18 % of the community-dwelling population over the age of 70 has substantial visual impairment from conditions such as cataracts, glaucoma, or macular degeneration [12]. Three case–control studies demonstrated a significant increase in falls and hip fractures among both men and women with impaired vision [12].

Aging has a significant effect on the vestibular system , with an estimated neuronal loss of 3 % per decade after age 40 [11].

Age-associated changes in postural control, muscle strength, and step height can impair a person’s ability to avoid a fall after an unexpected trip or while reaching or bending. These changes can be due to arthritis or decreased range of motion secondary to loss of elasticity in muscle, tendon, or ligaments.

The most common causes of falls in older person are listed in Table 8.3. The most common risk factors for falls are listed in Table 8.4.
Dec 2, 2017 | Posted by in SPORT MEDICINE | Comments Off on Specific Considerations in Geriatric Athletes

Full access? Get Clinical Tree

Get Clinical Tree app for offline access