2. 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

3. Osteoporosis Epidemiology Epidemiology Risk FactorsRisk Factors Diagnosis Treatment

4. 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

5. 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

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

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

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

9. U.S.Women in WHO Categories

10. Osteoporosis Risk FactorsRisk Factors EpidemiologyEpidemiology Diagnosis Treatment

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

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

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

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

15. Osteoporosis Introduction Epidemiology & Risk Factors DiagnosisDiagnosis Treatment

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

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

18. 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

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

20. 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

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

22. 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

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

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

25. Osteoporosis Introduction Epidemiology & Risk Factors Diagnosis TreatmentTreatment

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

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

28. Exercise Weight-Bearing Exercise Vigorous Training vs. Exercise

29. 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

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

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

32. 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

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

34. 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

35. Calcitonin Calcitonin-Salmon Calcitonin-Intranasal

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

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

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

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

40. Questions?