Bone Loss In The Elderly Liliana Oakes, M.D. Assistant Professor –Geriatric Division David V. Espino, M.D. Professor and Vice Chair, Dept. of Family. & Comm. Medicine University of Texas Health Science Center, San Antonio

Osteoporosis Epidemiology Epidemiology Risk FactorsRisk Factors Diagnosis Treatment

Osteoporosis: Epidemiological Classification Type I (Postmenopausal) –Women, Trabecular Bone, Fx Vertebra, Distal Radius Type II (Senile) –Men/Women, Cortical & Trabecular Bone, Fx Hip, Vertebra, Humerus Tibia, Pelvis Type III (Secondary) –Men/Women, Cortical & Trabecular Bone, Fx of Vertebra

Secondary Osteoporosis Nutritional –Lo Ca Intake –Vit D Deficiency –Protein Malnutrition –Alcoholism Neoplastic Diseases –Multiple Myeloma –Lymphoma –Monocytic Leukemia Endocrine –Cushing’s –Hyperthyroidism –Hyperparathyroidism –Hypogonadism Systemic –Hepatic Disease –Renal Disease –Rheumatoid Arthritis

Drug Induced Secondary Osteoporosis Corticosteroids Aluminum Containing Antacids Heparin Anticonvulsants –(Dilantin, Phenobarb, Primidone) Phenothiazines Furosemide Thyroid Hormone –(In Excessive Doses)

Bone Quality FX Pathogenesis Involves More Than Bone Mass –Bone Density –Structural Arrangement –Adequacy of Mineralization –Presence of Microdamage

Osteopenia Scope Year 2020Year 2020 –14 million persons with osteoporosis –61 million with low bone mass Second Only To CVD according to WHO

U.S.Women in WHO Categories

Osteoporosis Risk FactorsRisk Factors EpidemiologyEpidemiology Diagnosis Treatment

B. Spears 82 yo White Female HTN, CAD, Hearing Loss History of Falls Low Back Pain Smoker

Risk Factors What information from Mrs. Spears history will suggest to you she is at risk for osteoporosis?

Osteoporosis Risk Factors Non Modifiable Age Race Gender Family History Early Menopause /Oophorectomy

Osteoporosis Risk Factors Modifiable Weight Physical Activity Ca/Vit D Intake Cigarette Smoking Glucocorticoids Sex Hormone Insufficiency

Osteoporosis Introduction Epidemiology & Risk Factors DiagnosisDiagnosis Treatment

B. Spears 82 yo White Female HTN, CAD, Hearing Loss History of Falls Low Back Pain Smoker

History Hx of Prior Fractures Falls Hx Neurological D-Z Hx Hx of Muscular Weakness Nutritional Hx Medication Hx Functional Hx

Nutritional History Deficiency States –Calcium –Vitamin D –Vitamin C –Zinc? –Manganese? –Boron? Excess Intake –Insoluble Fiber –Animal Protein –Phosphate –Alcohol –Smoking –Vitamins D or A

Physical Examination Orthostatics Gait & Mobility Height Kyphosis? Clinical Features of –Hypercortisolism –Hyperthyroid, Hypogonadism

Laboratory Evaluation CBC, TFT’s Chem Profile to include: –Albumin (Nutritional?) –Renal/Liver function –Calcium (Elevated in Hyperparathyroid) –Phosphate (Low in Osteomalacia) –Alk Phos (Elevated in Osteomalacia) 24 Hour Urine for Calcium & Creatinine ESR (with back pain) DEXA

WHO Definition Osteopenia –1-2.5 sd Below Mean Osteoporosis –>2.5 sd Below Mean

Dual Energy X-Ray Absorptiometry [DEXA] Z-score –the number of standard deviations from the age- matched average value of healthy women, T-score –the number of standard deviations from the value at peak bone density of a young (25-30 year old) Caucasian woman. –Alone Does Not Predict FX or Guide Therapy

Indications for DEXA in Men Age≥70 Low Trauma FX Prevalent Vertebral Deformities Radiographic Osteopenia Conditions Associated with Bone Loss

Indications for Spinal Radiographs Acute or Persistent Bone Pain “Normal” DEXA Hx of Malignancy Kyphosis/Scoliosis Significant Height Loss (≥5 cm)

Osteoporosis Introduction Epidemiology & Risk Factors Diagnosis TreatmentTreatment

B. Spears 82 yo White Female HTN, CAD, Hearing Loss History of Falls Low Back Pain Smoker

Treatment Plan You are discussing a treatment plan with Mrs. Spears. What recommendations you will give to her to treat her osteoporosis.

Exercise Weight-Bearing Exercise Vigorous Training vs. Exercise

Vitamin D Most MVI’s contain 400 U Dietary Sources –Sardines,Salmon, Butter,Organ Meats, Egg Yolks, Fortified Foods Vitamin D Def. –800 U –Monitor Ca Levels

Calcium 1.5 Grams Per Day Choice of Product Based on Cost and Convenience Lactose Intolerance –Avoid Calcium Lactate

Calcium Intake Best Absorbed With Meals Evening Meal Best Decrease Caffeine and Sodium Intake Contraindicated –Hypercalcuria & Nephrolithiasis –Sarcoidosis –Hyperparathyroidism –Maligancies assoc. with Hypercalcemia

Dietary Calcium Repka’s Rule of 300s –8 oz. of Yogurt =300 mg Ca –8 oz. Of OJ = 300 mg Ca –8 oz. of Milk =300 mg Ca

C. E. Estrogen & Progesterone Not Include Estrogen Alone HERS & WHI

Selective Estrogen Receptor Modulators (SERM’s) Tamoxifen Raloxifene –Reduces vertebral fractures –No effect on nonvertebral Fx’s –Increases Thromboembolism, Hot Flashes –No increase in Uterine CA –Positive Lipid and Breast CA benefits –Perimenopausal or Early Menopausal (55-65) Time Vertebral Fxs common, Hip are not

Calcitonin Calcitonin-Salmon Calcitonin-Intranasal

Biphosphonates Etidronate (Didronel®) –Osteomalacia in Pts. With Osteoporosis or Pagets Alendronate (Fosamax®) Risedronate (Actonel®) Pamidronate (Aredia ®) –Ibandronate ( in trial)

Experimental Agents Fluoride –Ca Resorption PTH. (Forteo ®) Regulates bone metabolism Growth Hormone HCTZ Potassium Bicarbonate Vitamin D Metabolites

Vertebral Compression Fx Treatment Short Term Bedrest Weight Bearing Movement ASAP NSAID’s PRN Calcitonin –2 Weeks Rehab

Summary Osteoporosis Is Second Only To CVD in Terms Of Morbidity Early Diagnosis Is Critical Therapies Very Effective Remember Elder Men

Questions?