Osteoporosis

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Osteoporosis is the most

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prevalent bone disease in the world

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More than 10 million Americans have

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osteoporosis and an

estimated 33.6 million have osteopenia (precursor to osteoporosis)

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The consequence of osteoporosis is

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bone fracture

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It is projected that

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one out of every two Caucasian women and

one out of every five men

will have osteoporosis-related fractures

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Cost incurred from treating osteoporosis related fractures in the US is

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$20 billion annually

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Prevention of Osteoporosis

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Peak adult bone mass is achieved between: 18-25 (both females/males and is affected by genetic factors)

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Bone mass (18-25) is affected by

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nutrition
physical activity
medications
endocrine status
general health

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Primary osteoporosis

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occurs in Women after menopause between the ages of

45 and 55 years

men - later in life

not just a consequence of aging

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Failure to develop optimal peak bone mass during

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childhood, adolescence and young adulthood contributes to the development of osteoporosis

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Early identification of at risk teenagers and young adults

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including increased calcium intake
participation in regular weight bearing
modification of lifestyle (caffeine, cigarettes, carbonated soft drinks, alcohol)

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Secondary osteoporosis is the result of

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MEDICATIONS or other conditions and diseases that affect bone metabolism

menopause (early age)
family hx
white or asian
small boned
smoking
excessive alcohol
multiparity
low sunlight
high fat
excessive caffeine intake
inadequeate calcium

Specific disease states:
Celiac disease
hypogonadism

Medications:
Corticosteroid
Antiseizure

placing patients at risk need to be identified and therapies instituted to reverse

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Degree of osteoporosis is related to

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the duration of medication therapy

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When the therapy is discontinued or the metabolic problem is corrected

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the progression stops but restoration of lost bone does not occur

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The prevalence of osteoporosis in women older than

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80 is 50%

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The average 75 year old women has lost

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25% of her cortical bone

40% of her trabecular bone

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With the aging population, the incidence of bone fractures

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(more than 1.5 million per year)
pain
disability

is increasing

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Most residents of long-term care facilities have a

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low bone mineral density (BMD) are are at risk for

bone fracture!

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It is estimated that the number of

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hip fractures and their associated costs will at least

double by the year 2040

d/t projected aging of the US population

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Asymptomatic osteoporotic-related vertebral fractures are associated with

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loss of height
respiratory dysfunction
increased risk of mortality
increased risk of subsequent fractures

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Elderly men are also at heightened risk for

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osteoporosis and fractures

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ONE THIRD OF ALL HIP FRACTURES OCCUR

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AMONG MEN and tend to be more LETHAL than those seen in women

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Men are more likely than women to have

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secondary causes of osteoporosis that may lead to

fractures!!!

Mainly d/t use of CORTICOSTEROIDS AND EXCESSIVE ALCOHOL INTAKE!!!

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Elderly people absorb dietary calcium

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less efficiently and excrete it more readily through their kidneys; therefore,

postmenopausal women and the elderly need to consume

approximately 1200 MG OF DAILY CALCIUM

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Quantities larger than this may place patients at heightened risk for

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renal calculi (kidney stones) or cardiovascular disease

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Genetics (predisposed to low bone mass)

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Caucasian or Asian
Female
Family history
Small frame

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Age (hormones (estrogen, calcitonin, and testosterone) inhibit bone loss

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Postmenopause
Advanced age
Low testosterone in men
Decreased calcitionin

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Nutrition (reduces nutrients needed for bone remodeling)

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Low calcium
Low Vitamin D
HIGH PHOSPHATE INTAKE (BAD!!!) cokes!!!!
Inadequate calories

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Physical exercise (bones need stress for bone maintenance)

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Sedentary
Lack of weight bearing
Low weight and BMI

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Lifestyle choices (reduces ostogenesis in bone remodeling)

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Caffeine
Alcohol
Smoking
Lack of exposure to sunlight

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Medications (affects calcium absorption and metabolism)

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Corticosteroids
Antiseizure Meds
Heparin
Thyroid hormone

Comorbidity:
Anorexia Nervosa
Hyperthyroidism
Malabsorption syndrome
Renal failure

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Osteoporosis is characterized by

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reduced bone mass
deterioration of bone matrix
diminished bone architectural strength

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Normal hemeostatic bone turnover is altered;

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the rate of bone resorption that is maintained by osteoclasts is greater than the rate of bone formation that is maintained by osteoblasts

resulting in reduced total bone mass

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The bones become progressively

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porous
brittle
fragile
fracture easily under stresses that would not break normal bone

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These increase susceptibility to fracture, which occur most commonly as

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COMPRESSION FRACTURES of the

thoracic and lumbar spine
hip fractures
Colles' fracture of the wrist

These fractures may be the first clinical manifestation of osteoporosis

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Gradual collapse of vertebra may be asymptomatic;

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observed as PROGRESSIVE KYPHOSIS

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With the development of kyphosis (DOWAGER'S HUMP);

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there is an associated loss of height

postural changes w/kyphosis result in:

relaxation of the abdominal muscles and a
protruding abdomen

may also cause pulmonary insufficiency

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Age-related loss begins soon after the peak bone mass is achieved

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usually in the fourth decade

CALCITONIN (which inhibits bone resportion and promotes bone formation) IS DECREASED

ESTROGEN (which inhibits bone breakdown) DECREASES

On the other hand, parathyroid hormone (PTH) INCREASES WITH AGING, increasing bone turnover and resportion

CONSEQUENCE: net loss of bone mass over time

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The withdrawal of estrogens at menopause or with oophoretomy causes an

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accelerated bone resorption that continues during menopause

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Women develop osteoporosis more frequently and more extensively than

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men d/t lower peak bone mass and the effect of estrogen loss during menopause

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More than half of all women

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older than 50 years show evidence of osteopeniaa

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Small-framed, nonobese Caucasian women are at greatest risk for

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osteoporosis

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Asian women of slight build are at risk for

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low peak BMD

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African women, who have a greater bone mass than Caucasian,

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are less susceptible to osteoporosis

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Men have a greater peak bone mass and do not experience

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sudden estrogen reduction

as a result, osteoporosis occurs in men at a lower rate and at an older age

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TESTOSTERONE AND ESTROGEN ARE IMPORTANT IN

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achieving and maintaining bone mass in men

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Nutrional factors contribute to the development of osteoporosis...a diet that includes

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adequate calories and nutrients needed to maintain bone:

Calcium and Vitamin D

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Vitamin D is necessary for

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calcium absorption and

bone mineralization

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Dietary calcium and Vitamin D must be

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adequate to maintain bone remodeling and body functions

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The best source of calcium and Vitamin D is

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fortified milk

A cup of milk or calcium-fortified orange juice contains about 300mg of calcium

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The RAI (recommended adequate intake) of calcium

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for all individuals is: 1000 to 1200mg daily

For adults 50 years of age or older is: 800 to 1000 international units (IU) daily

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Patients who have bariatric surgery are at increased risk for osteoporosis

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as the duodenum is bypassed, primary site of calcium absorption as are patients with

gastrointestinal disease that causes malabsorption (celiac disease)

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Bone formation is enhanced by the stress of

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weight and muscle activity

Resistance and impact exercises are most beneficial in developing and maintain bone mass

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Immobility contributes to the development of osteoporosis,

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when immobilized by casts, general inactivity, paralysis or other disability:

the bone is resorbed faster than it is formed

osteoporosis!

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Osteoporosis may be undetectable on routine x-rays until

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25 to 40% demineralization, resulting in

radiolucency of the bones

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When the vertebrae collapse,

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the THORACIC vertebrae become WEDGE shaped and the

LUMBAR vertebrae become BICONCAVE

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Osteoporosis is diagnosed by

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dual-energy x-ray absorptiometry (DXA) which provides information about

BMD at the spine and hip

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The DXA scan data are analyzed and

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reported as T scores (the number of standard deviations) from normal for a young, healthy Caucasian

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BMD testing is recommended for all

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women older than 65 years of age

for all men older than 70

for postmenopausal women and men older than 50 with osteoporosis risk factors

for all people that have had a fracture thought to have occurred due to osteoporosis

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BMD studies are useful in identifying

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osteopenic and osteoporotic bone and in

assessing response to therapy

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Through early screening,

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assessment of risk factors
BMD scans
promotion of adequate dietary intake of calcium and Vitamin D
lifestyle changes
early institution of preventative meds

bone loss and osteoporosis can be reduced

reduced incidence of fracture

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Lab studies:

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Serum calcium
Serum phosphate
Serum alkaline phosphatase
Urine calcium excretion
Urinary hydroxyproline excretion
Hct
ESR
X-ray studies to exclude other possible disorders (multiple myeloma, osteomalacia, hyperparathyroidism, malignancy

that may also contribute to bone loss

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Medical Management

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A diet rich in calcium and Vitamin D throughout life

increased calcium intake during adolescence, young adulthood and middle years

protects against skeletal demineralization

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Such a diet includes:

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three glass of skim or whole vitamin D-enriched milk or

cheese and other dairy products
steamed broccoli
canned salmon with bones daily

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Regular weight bearing exercise promotes

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bone formation

20 to 30 minutes of aerobic exercise (walking) three days or more a week is recommended

Exercise improves balance reducing the incidence of falls and fractures

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Weight training stimulates an

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increase in BMD

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First-line medications used to treat and prevent osteoporosis include

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calcium
vitamin D
Bisphophonates

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To ensure adequate calcium intake, a calcium supplement

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Caltrate
Citracal with Vitamin D may be prescribed

take with meals or with a beverage high in Vitamin C to promote absorption

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The recommend daily dose should be

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split and not taken as a single dose

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Common side effects of calcium supplements are

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abdominal distention and constipation.

Other meds that might be prescribed after these meds are:

Calcitonin
Seletive Estrogen Receptor Modulators
Anabolic Agents

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Bisphophonates

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Daily or weekly oral preps:
Aldendronate (Fosamax)
Risedronate (Actonel

Monthly oral preps:
Ibandronate (Boniva)

Yearly IV infusions:
Zoledronic Acid (Reclast)

increase bone mass and decrease bone loss by stopping osteoclast formation

Cost effective as they reduce fractures

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Adequate calcium and Vitamin D intake is needed

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for maximum effect but these supplements should not be taken at the same day of the day as

biphosphonates

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Side effects of biphosphonates:

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Gastrointestinal symptoms (dyspepsia, nausea, flatulence, diarrhea, constipation

Some patients may develop:
esophageal ulcers
gastric ulcers
osteonecrosis of the jaw

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Patients who take bisphosphonates must take these medications on an

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empty stomch
on arising in the morning
with a full glass of water
and must sit upright for 30 to 60 minutes

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Calcitonin (Mialcalcin) directly inhibits

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osteoclasts, thereby reducing bone loss and increasing BMD

Calcitonin is administered by nasal spray or subctuaneous or intramuscular injection

Side effects of Calcitonin:
Nasal irritation
Flushing
Gastrointestinal Disturbances
urinary frequency

Do not give Calcitonin if you have a seafood allergy

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Selective Estrogen Receptor Modulators (SERMs); such as Raloxifene (Evis

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reduce the risk of osteoporosis by preserving BMD without estrogenic effects on the UTERUS

They are indicated for both prevention and treatment of osteo

Contraindicated in women with history of venous thromboembolism

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Teriparatide (Fortea) is administered

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sub-Q

Anabolic Agent

Once daily

As a recombinant PTH, it stimulates osteoblasts to build bone matrix and facilitates overall calcium absorption

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Fractures of the hip d/t osteoporosis

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are managed surgically by

joint replacement or by

closed or open reduction with

internal fixation

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Osteoporotic compression fractures of the vertebra are

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managed conservatively

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Additional fractures and progressive kyphosis is

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common

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Pharmacologic and dietary treatments are aimed at

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increasing vertebral bone density

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Most patients who experience compression fractures are

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asymptomat and do not require acute care

Patients with pain acute pain management is necessary

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Percutaneous vertebroplaty or kyphoplasty (injection of polymethylmethacrylate bone CEMENT into the fractured vertebra

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followed by inflation of a pressurized balloon to restore the shape of the affected vertebra can provide rapid relief of acute pain

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Patients who do not respond to first-line are considered

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for percutaneous vertebroplasty

contraindicated in the presence of

infection
old fractures
certain coagulopathies

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Assessment osteoporosis:

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Questions concerning the occurrence of osteopenia and osteoporosis

previous fractures

dietary consumption of calcium

exercise

onset of menopause

corticosteroid use

alcohol, smoking, caffeine

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Any symptoms the patient is experiencing including:

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back pain
constipation
altered body image

are explored

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Physical exam may disclose a

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fracture
kyphosis of the thoracic spin
short stature

problems in mobility and breathing

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NANDA

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Risk for constipation related to immobility or development of ileus (intestinal obstruction)

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Major goals may include

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knowledge about osteoporosis
relief of pain
improved bowel elimination
absence of additional fractures

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Relief of back pain from compression fracture may include

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resting in bed in a supine or side lying position several times a day

mattress should be firm and nonsagging

Knee flexion increases comfort by relaxing back muscles

intermittent local heat and back rubs promote muscle relaxation

Move trunk as unit and avoid twisting

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When patient is out of the bed,

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a trunk orthosis (lubosacral corset) may be worn for temporary support and immobilization....poorly tolerated by patients

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Constipation r/t immobility and medications

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High fiber diet
increased fluids
prescribed stool softeners

IF VERTEBRAL COLLAPSE INVOLVES THE T10-L2 VERTEBRAE, THE PATIENT MAY DEVELOP A PARALYTIC ILEUS

Monitor intake, bowel sounds and bowel activity

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Isometric exercises can

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strengthen trunk muscles

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Osteopenia

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bone density below normal but above level for osteoporosis

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Osteoporosis

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low bone mass density and microarchitectural deterioration of one tissue, which increases risk/incidence of skeletal fracture and breaks

Education the same for osteopenia/osteoporosis

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Bone scan - DECA scan

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Green - normal bone density
Yellow-orange - low bone mass
Red - presence of osteoporosis

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Primary type 1 and 2
Secondary

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Bone densitometry
ultasound
quantitative computer

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If menopause

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dexa scan 1-2 years

if osteopenia DEXA scan every 12-18 months