Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Focus on Osteoporosis (Relates to Chapter 64, “Nursing Management: Musculoskeletal Problems,” in the textbook) Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Osteoporosis Chronic, progressive metabolic bone disease characterized by Porous bone Low bone mass Structural deterioration of bone tissue Increased bone fragility Osteoporosis is known as the “silent thief” because it slowly and insidiously over many years robs the skeleton of its banked resources. Bones can eventually become so fragile that they cannot withstand normal mechanical stress. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 2

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Osteoporosis 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. At least 10 million persons in the United States (80% of them women) have osteoporosis, and with the projected increase in life expectancy, this number is expected to increase. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 3

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Osteoporosis 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. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 4

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Osteoporosis 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). Women >65 years old should be routinely screened for osteoporosis. Screening should begin by age 60 for women at increased risk of osteoporotic fractures. No general recommendations for screening have been made for women who are <60 years old, or for women age 60 to 64 who are not at increased risk for osteoporosis. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 5

Etiology and Pathophysiology Risk factors Female gender Increasing age Low body weight White or Asian ethnicity Family history Early menopause Excess alcohol intake Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 6

Etiology and Pathophysiology 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 Decreased risk is associated with regular weight-bearing exercise and with fluoride, calcium, and vitamin D ingestion. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 7

Etiology and Pathophysiology 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. Heredity may be responsible for up to 70% of a person’s peak bone mass. Bone loss from midlife (age 35 to 40 years) onward is inevitable, but the rate of loss varies. At menopause, women experience rapid bone loss when the decline in estrogen production is the sharpest. This rate of loss then slows, and eventually matches the rate of bone loss in men 65 to 70 years old. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 8

Etiology and Pathophysiology 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 At the time a drug is prescribed, inform the patient of this possible side effect. Long-term corticosteroid use is a major contributor to osteoporosis. When a corticosteroid is taken, loss of bone and inhibition of new bone formation occur. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 9

Normal vs. Osteoporotic Bone A, Normal bone. B, Osteoporotic bone. Fig. 64-9. A, Normal bone. B, Osteoporotic bone. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 10

Etiology and Pathophysiology In osteoporosis, bone resorption exceeds bone deposition. Occurs most commonly in spine, hips, and wrist Bone is continually being deposited by osteoblasts and resorbed by osteoclasts, a process called remodeling. Normally, rates of bone deposition and resorption are equal to each other, so that the total bone mass remains constant. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 11

Etiology and Pathophysiology 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. Loss of bone substance causes the bone to become mechanically weakened and prone to spontaneous fracture or fracture from minimal trauma. A person who has one spinal vertebral fracture due to osteoporosis has a 25% chance of having a second vertebral fracture within 1 year. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 12

Etiology and Pathophysiology Diseases associated with osteoporosis Intestinal malabsorption Kidney disease Rheumatoid arthritis Hyperthyroidism Chronic alcoholism Cirrhosis of the liver Hypogonadism Diabetes mellitus Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 13

Clinical Manifestations Often termed the “silent disease” because there are no symptoms Since no symptoms, the usual first signs are back pain and spontaneous fractures People may not know they have osteoporosis until their bones become so weak that a sudden strain, bump, or fall causes a hip, vertebral, or wrist fracture. Collapsed vertebrae initially may be manifested as back pain, loss of height, or spinal deformities such as kyphosis or severely stooped posture. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 14

Clinical Manifestations Manifestations include Sudden strain Fractures Back pain Loss of height Spinal deformities Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 15

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Diagnostic Studies History and physical exam Bone mineral density (BMD) Quantitative ultrasound Dual-energy x-ray absorptiometry (DEXA) Osteoporosis often goes unnoticed because it cannot be detected by conventional x-ray until more than 25% to 40% of calcium in the bone is lost. Serum calcium, phosphorus, and alkaline phosphatase levels usually are normal, although alkaline phosphatase may be elevated after a fracture. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 16

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Diagnostic Studies 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. More than 14 million women over age 50 have osteopenia. Bone biopsy can be used to differentiate the diagnosis of osteoporosis from osteomalacia. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 17

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Collaborative Care Focus on Proper nutrition Calcium supplements Exercise Prevention of fractures Drug therapy Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 18

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Collaborative Care Prevention and treatment depend on adequate calcium intake. Increased calcium prevents future loss but will not form new bone. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 19

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Collaborative Care Good sources of calcium Milk Yogurt Turnip greens Spinach Cottage cheese Ice cream Sardines Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 20

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Collaborative Care Poor sources of calcium Eggs Beef Cream cheese Poultry Pork Apples and bananas Potatoes and carrots Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 21

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Collaborative Care Exercise should be encouraged to build up and maintain bone mass. Types of exercise Weight bearing Walking Stair climbing Dancing Exercise also increases muscle strength, coordination, and balance. The best exercises are weight-bearing exercises that force an individual to work against gravity. These exercises include walking, hiking, weight training, stair climbing, tennis, and dancing. Walking is preferred to high-impact aerobics and running, both of which may put too much stress on the bones, resulting in stress fracture. Walking 30 minutes, 3 times a week, is recommended. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 22

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Collaborative Care Supplemental vitamin D may be recommended. Patients should be instructed to quit smoking or cut down on alcohol intake to ↓ losing bone mass Vitamin D is important in calcium absorption and function and may have a role in bone formation. Most people get enough vitamin D from the diet or naturally through synthesis in the skin from exposure to sunlight. Being in the sun for 20 min/day is generally enough. However, supplemental vitamin D (400 to 800 IU) may be recommended for older adults, those who are home-bound, and those who have minimal sun exposure. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 23

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Collaborative Care Drug therapy Calcium Vitamin D Calcitonin Calcitonin is secreted by the thyroid gland and inhibits osteoclastic bone resorption by directly interacting with active osteoclasts. Salmon calcitonin (Calcimar) is available in intramuscular, subcutaneous, and intranasal forms. When calcitonin is used, calcium supplementation is necessary to prevent secondary hyperparathyroidism. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 24

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Collaborative Care Drug therapy (cont’d) Bisphosphonates inhibit osteoclast-mediated bone resorption (e.g., etidronate [Didronel], alendronate [Fosamax]). Bisphosphonates inhibit osteoclast-mediated bone resorption, thereby increasing BMD and total bone mass. This group of drugs has been shown to increase BMD by 5%. These drugs include etidronate (Didronel), alendronate (Fosamax), pamidronate (Aredia), risedronate (Actonel), clodronate (Bonefos), tiludronate (Skelid), and ibandronate (Boniva). Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 25

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Collaborative Care Drug therapy (cont’d) Selective estrogen receptor modulators Raloxifene (Evista) Teriparatide (Forteo) Portion of parathyroid hormone First drug to stimulate new bone formation These drugs mimic the effects of estrogen on bone by reducing bone resorption without stimulating the tissues of the breast or uterus. Teriparatide (Forteo) is used for the treatment of osteoporosis in men and postmenopausal women who are at high risk for having a fracture. Teriparatide is a portion of human parathyroid hormone (PTH) and works by increasing the action of osteoblasts. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 26

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Audience Response Question 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. Answer: 2 Rationale: Alendronate is a bisphosphonate that prevents calcium from being taken from the bones by inhibiting osteoclast-mediated bone resorption. Bisphosphonates should be taken with a full glass of water, 30 minutes before food or other medications, and the patient should remain upright for at least 30 minutes after administration. These precautions aid in drug absorption and decrease gastrointestinal side effects (especially esophageal irritation). Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 27

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Audience Response Question 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. Answer: 4 Rationale: Risk factors for osteoporosis include advanced age (>65 years), female gender, low body weight, white or Asian ethnicity, current cigarette smoking, nontraumatic fracture, inactive lifestyle, family history of osteoporosis, diet low in calcium or vitamin D deficiency, excessive use of alcohol (>2 drinks per day), postmenopausal, including premature or surgical menopause, and long-term use of corticosteroids, thyroid replacements, heparin, long-acting sedatives, or antiseizure medications. Long-term corticosteroid (such as prednisone) use is a major contributor to osteoporosis. The other patients have risk factors for osteoporosis, but the 69-year-old female is at highest risk. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 28 28

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Case Study Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 29

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Case Study 65-year-old woman visits her primary care physician for an annual checkup. States “I feel that I am in good health” Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 30

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Case Study 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. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 31

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Case Study She has been postmenopausal for 3 years. She has a small frame and is a healthy weight. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 32

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Case Study Her height is 1.5 inches less than her last recorded height taken 2 years ago. She has slight kyphosis. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 33

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Case Study Her physician orders a dual-energy x-ray absorptiometry. Her T-score indicates she has osteoporosis. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 34

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Discussion Questions What treatment options are available to her? What lifestyle changes can she make to improve her condition? Calcium supplementation, bisphosphonates, calcitonin, selective estrogen receptor modulators. No smoking, get exercise, eat foods with high amounts of calcium. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 35

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Discussion Questions 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? 3. The amount of calcium that she needs is much higher than can be met by milk or dietary intake. Only calcium supplements can meet her need for calcium. Furthermore, calcium has no adverse effects. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 36