F OCUS ON O STEOPOROSIS (Relates to Chapter 64, “Nursing Management: Musculoskeletal Problems,” Lewis, S.L., Heitkemper, M.M., Dirksen, S.R., O’Brien, P.G., & Bucher, L. (2011) Medical surgical nursing. (8 th Ed.). St Louis, MO: Mosby Elsevier Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

O STEOPOROSIS Chronic, progressive metabolic bone disease characterized by  Porous bone  Low bone mass  Structural deterioration of bone tissue  Increased bone fragility Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 2

O STEOPOROSIS At least 10 million people in the United States have osteoporosis. One in two women and one in eight men over 50 will sustain an osteoporosis-related fracture. 3 Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

O STEOPOROSIS More common in women than men for several reasons  Lower calcium intake than men  Less bone mass because of smaller frame  Bone resorption begins earlier and accelerates after menopause. 4 Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

O STEOPOROSIS More common in women than men (cont’d)  Pregnancy and breast feeding deplete woman’s skeletal reserve of calcium.  Longevity increases likelihood of osteoporosis (women live longer than men). 5 Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

E TIOLOGY AND P ATHOPHYSIOLOGY Risk factors  Female gender  Increasing age  Low body weight  White or Asian ethnicity  Family history  Early menopause  Excess alcohol intake 6 Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

E TIOLOGY AND P ATHOPHYSIOLOGY Risk factors (cont’d)  Cigarette smoking  Sedentary lifestyle  Insufficient calcium intake  Long-term use of corticosteroids, thyroid replacement, antiseizure drugs  Low testosterone levels in men 7 Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Identify the risk factors for osteoporosiss in older adults and interventions that can be used to help reduce osteoporosiss in this population. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

E TIOLOGY AND P ATHOPHYSIOLOGY Peak bone mass is achieved before age 20.  Peak mass determined by heredity, nutrition, exercise, and hormone function Bone loss after midlife is inevitable, but rate of loss is variable. 9 Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

E TIOLOGY AND P ATHOPHYSIOLOGY Many drugs can interfere with bone metabolism.  Corticosteroids  Antiseizure drugs (e.g., valproate [Depakote], phenytoin [Dilantin])  Aluminum-containing antacids  Certain cancer treatments  Excessive thyroid hormones 10 Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

N ORMAL VS. O STEOPOROTIC B ONE 11 Fig A, Normal bone. B, Osteoporotic bone. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

E TIOLOGY AND P ATHOPHYSIOLOGY In osteoporosis, bone resorption exceeds bone deposition. Occurs most commonly in spine, hips, and wrist 12 Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

E TIOLOGY AND P ATHOPHYSIOLOGY Wedging and fractures of vertebrae produce gradual loss of height and a humped back known as dowager’s hump or kyphosis. The usual first signs are back pain and spontaneous fractures. 13 Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

E TIOLOGY AND P ATHOPHYSIOLOGY Diseases associated with osteoporosis Intestinal malabsorption Kidney disease Rheumatoid arthritis Hyperthyroidism Chronic alcoholism Cirrhosis of the liver Hypogonadism Diabetes mellitus 14 Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

C LINICAL M ANIFESTATIONS Often termed the “silent disease” because there are no symptoms Since no symptoms, the usual first signs are back pain and spontaneous fractures 15 Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

C LINICAL M ANIFESTATIONS Manifestations include  Sudden strain  Fractures  Back pain  Loss of height  Spinal deformities 16 Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

D IAGNOSTIC S TUDIES History and physical exam Bone mineral density (BMD) Quantitative ultrasound Dual-energy x-ray absorptiometry (DEXA) 17 Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Identify pertinent clinical manifestations of osteoporosis. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

D IAGNOSTIC S TUDIES Osteoporosis is a BMD ≤-2.5 standard deviations below a young adult BMD. Osteopenia is more than normal bone loss but not yet at the level of osteoporosis. 19 Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

C OLLABORATIVE C ARE Focus on  Proper nutrition  Calcium supplements  Exercise  Prevention of fractures  Drug therapy 20 Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

C OLLABORATIVE C ARE Prevention and treatment depend on adequate calcium intake. Increased calcium prevents future loss but will not form new bone. 21 Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

C OLLABORATIVE C ARE Good sources of calcium  Milk  Yogurt  Turnip greens  Spinach  Cottage cheese  Ice cream  Sardines 22 Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

C OLLABORATIVE C ARE Poor sources of calcium  Eggs  Beef  Cream cheese  Poultry  Pork  Apples and bananas  Potatoes and carrots 23 Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

C OLLABORATIVE C ARE Exercise should be encouraged to build up and maintain bone mass. Types of exercise  Weight bearing  Walking  Stair climbing  Dancing 24 Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

C OLLABORATIVE C ARE Supplemental vitamin D may be recommended. Patients should be instructed to quit smoking or cut down on alcohol intake to ↓ losing bone mass 25 Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

C OLLABORATIVE C ARE Drug therapy  Calcium  Vitamin D  Calcitonin 26 Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

C OLLABORATIVE C ARE Drug therapy (cont’d)  Bisphosphonates inhibit osteoclast- mediated bone resorption (e.g., etidronate [Didronel], alendronate [Fosamax]). 27 Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

C OLLABORATIVE C ARE Drug therapy (cont’d)  Selective estrogen receptor modulators Raloxifene (Evista)  Teriparatide (Forteo) Portion of parathyroid hormone First drug to stimulate new bone formation 28 Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Explain collaborative care of osteoporosis. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Alendronate (Fosamax) is prescribed for a patient with osteoporosis. The nurse teaches the patient that: 1. The drug must be taken with food to prevent GI side effects. 2. All of the bisphosphonates prevent calcium from being taken from the bones. 3. Lying down after taking the drug prevents light- headedness and dizziness. 4. Taking the drug with milk enhances the absorption of calcium from the bowel. Audience Response Question 30 Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Which of the following patients would be at greatest risk for developing osteoporosis? 1. A 73-year-old male patient who has five alcoholic drinks per week and limits sun exposure to prevent recurrence of skin cancer. 2. A 55-year-old patient who recently had a hysterectomy with bilateral salpingo-oophorectomy and refuses estrogen therapy. 3. An 84-year-old male patient who has recently been diagnosed with hypothyroidism and is prescribed levothyroxine (Synthroid). 4. A 69-year-old female patient who had a renal transplant 5 years ago and has been taking prednisone to prevent organ rejection. Audience Response Question 31 Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

C ASE S TUDY 32 Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

C ASE S TUDY 65-year-old woman visits her primary care physician for an annual checkup. States “I feel that I am in good health” 33 Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

C ASE S TUDY She recently began taking a multivitamin because she claims she was starting to “feel old.” She has a history of smoking for 20 years, but she quit 10 years ago. 34 Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

C ASE S TUDY She has been postmenopausal for 3 years. She has a small frame and is a healthy weight. 35 Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

C ASE S TUDY Her height is 1.5 inches less than her last recorded height taken 2 years ago. She has slight kyphosis. 36 Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

C ASE S TUDY Her physician orders a dual-energy x-ray absorptiometry.  Her T-score indicates she has osteoporosis. 37 Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

D ISCUSSION Q UESTIONS 1. What treatment options are available to her? 2. What lifestyle changes can she make to improve her condition? 38 Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

D ISCUSSION Q UESTIONS 3. When she is advised to take calcium supplements, she states she is already taking a multivitamin and drinks milk regularly. Therefore, she doesn’t see the need. What can you tell her? 39 Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.