Osteoporosis



OsteoporosisKeressa Clark, Karen Melton, Revonda Watts, Kayla WilliamsKing UniversityOsteoporosisOsteoporosis is a disease that causes the bones to become weak and brittle. According to American Academy of Orthopaedic Surgeons (2014), this disease is a problem because it affects over two hundred people worldwide. In the United States alone, osteoporosis affects over ten million people causing over 1.3 million fractures a year. Osteoporosis is typically considered a silent disease, with little to no warning until a broken bone occurs. It is estimated that 18 million Americans are at risk for this disease and many more are at risk for osteopenia (American Academy of Orthopaedic Surgeons, 2014). It is important to educate the public about osteoporosis, the causes, risk factors, diagnosis, prevention, and treatment before fractures occur. Osteoporosis related fractures are associated with increased healthcare costs, increased hospitalizations, long recovery periods, and increased the morbidity and mortality of people who suffer from hip fractures (American Academy of Orthopaedic Surgeons, 2014).Osteoporosis is a disease of the bone characterized by a decrease in bone mass causing bones to become weak and thin (Uphold & Graham, 2013). There are two types of osteoporosis, primary and secondary. Primary osteoporosis can be bone loss due to normal aging, decreased estrogen in women, abnormal sex hormones in men, and inadequate bone development in childhood and adolescence. Secondary osteoporosis can be caused by genetic factors, diseases that inhibit bone growth or vitamin absorption, and certain medications such as glucocorticoids. (Uphold & Graham, 2013).There are multiple risk factors for developing osteoporosis. The non-modifiable risks for osteoporosis are those risks that the patient has no control over. These risks include: the aging adult, females, certain genetic backgrounds, Asian or Caucasian ethnic backgrounds, family history of osteoporosis, and personal history of fractures. The modifiable risks are factors the patient does have control over. These risks include a low body weight or body mass, smoking, increased alcohol or caffeine intake, vitamin deficiency in calcium and vitamin D, hormone deficient, inactivity, and long term use of medications known to induce osteoporosis (Uphold & Graham, 2013). Late signs and symptoms of osteoporosis may include a stooped posture, back pain, or loss of height. Fractures usually occur before a diagnosis is made. The spine, hip, and wrist are the most common fracture sites caused by osteoporosis (Uphold & Graham, 2013).A diagnosis of osteoporosis is made on the basis of a health history, social history, and family history. A physical exam will need to be done to determine a primary or secondary osteoporosis diagnosis. This exam will assess for height loss, spinal changes, mobility deficits, small testicles, muscle wasting, presence of a buffalo hump, fast heart rate, or thyroid nodule. Laboratory tests may also be obtained to determine whether the patient has primary or secondary osteoporosis. The blood tests may include a complete blood count, calcium level, phosphorus level, creatinine, liver panel, thyroid stimulating hormone, parathyroid function, estrogen, testosterone, and a vitamin D level. A bone density scan may also be performed. This is the most conclusive way to diagnose osteoporosis. This will determine if bone loss has occurred. The scan is usually done on the hip or the spine and is generally repeated every two years depending on the risk factors and severity of the osteoporosis (Uphold & Graham, 2013).Prevention of osteoporosis is ideal. There are several ways to prevent this condition from occurring. It is important the body gets enough calcium daily. Men and women up to age fifty need 1,000 milligrams of calcium a day. After age fifty, women should increase their calcium intake to 1200 milligrams a day, men should increase to this amount after age seventy (Prevention, 2014). Calcium can be obtained by calcium supplements or by dietary intake. Food can affect the bones, knowing about foods that are high in calcium can assist in making healthier eating and overall healthy lifestyle choices. Some foods that are high in calcium include: collard greens, kale, green soy beans, ricotta cheese, yogurt, and almond milk (National Osteoporosis Foundation, n.d). Vitamin D is another way to prevent osteoporosis. The best source of vitamin D is the sun, however most people are not out in the sun long enough to get an adequate amount of vitamin D. Many patients choose to take vitamin D supplements to ensure they are getting enough vitamin D. It is always a good idea to check a patient’s vitamin D level every year to ensure the vitamin D levels are within a normal range. Recent studies have shown a direct link between tobacco use and decreased bone density. Other studies have shown that smoking increases the risk of fractures. The longer a person smokes and the more cigarettes they consume, the greater their risk of a fracture occurring in old age. It has been found that people exposed to secondhand smoke in their youth and early adulthood have an increased risk of developing low bone density. The best thing for smokers to do to protect their bones is to quit smoking. Smoking cessation, even later in life, will help limit smoking related bone loss (NIH Osteoporosis and Related Bone Diseases, 2012). Drinking an excessive amount of caffeine or alcohol can decrease calcium absorption and contribute to bone loss. Alcohol consumption should be limited to no more than 2-3 drinks per day. Caffeine should be consumed in moderation, anything more than 3 cups of coffee a day can interfere with calcium absorption (NOF, n.d). Patients should be aware of medications they may be on that increase their risk of osteoporosis. Many commonly prescribed medications can impact bone density. Some of the more common drugs are steroids, proton pump inhibitors, and selective serotonin reuptake inhibitors. Patients taking these medications should consult their provider and have routine bone density scans performed. A person should maintain a healthy weight of at least 127 pounds. If a person is overly thin, they could be depriving their bones of needed protein (Corbett, 2013).Exercise is an important factor in building and maintaining bone density in everyone, but especially those with osteoporosis. According to the National Osteoporosis Foundation, there are two different types of exercises to utilize in a patient with osteoporosis. As with any exercise, it is important to check with the primary care provider before beginning a new exercise regimen, or if the patient has not exercised in a while.The first type is weight-bearing exercises in which the body moves against gravity while remaining upright (National Osteoporosis Foundation, 2015). These can include high-impact exercises such as tennis, running, dancing, hiking, and high impact aerobics (NOF, 2015). High-impact exercises are generally not recommended for patients with osteoporosis who have already had broken bones. Low-impact exercises include walking, light yoga, elliptical machines, and stair stepping. Weight bearing exercises should be done at least 30 minutes a day on most days of the week (NOF, 2015).When the patient is beginning to exercise, it is important to begin by warming up and stretching. The patient should walk or jog in place for a few minutes and do gentle stretches to loosen the muscles. It is also imperative the patient understands to remain hydrated and drink plenty of water if there are no underlying medical conditions limiting fluid intake. The patient should start low and go slow. If the patient feels tired, be sure to emphasize to rest when needed and stop if pain occurs. As always remind the patient to breathe throughout the exercise (National Institute on Aging at the National Institute of Health, 2015).Balance and flexibility are also very important to remember as well. The National Institute on Aging (NIA) recommends standing on one foot while holding onto a sturdy object, and heel-to-toe walks improve and maintain proper balance (NIA, 2015). For flexibility, the patient can practice bending the left leg back and grasping the foot with their left hand to stretch out the thigh, then repeat on the other side. The patient may also stretch the shoulder and upper arm by stretching a towel with their hands (NIA, 2015). As with any exercise, commitment and consistency will produce the best long term results.Once diagnosed with osteoporosis, what is the next step? Currently, no treatment can completely reverse established osteoporosis (Ross et al., 2011). Early intervention can help prevent it in some people. For patients with established osteoporosis, medical intervention can halt its progression however; therapy should be individualized based on each patient’s clinical scenario, with the risks and benefits of treatment discussed between the clinician and patient. Strategies for fracture prevention include optimization of peak bone mass and prevention of bone loss at menopause and with aging. Genetic, nutritional, and life-style factors influence peak bone mass and may be used to focus preventative efforts. Once peak bone mass is reached, increased bone resorption may be the major pathogenic factor. Calcium plus vitamin D, estrogen replacement therapy, calcitonin, and etidronate are agents currently available for the treatment of osteoporosis. The National Osteoporosis Foundation recommends that pharmacologic therapy be reserved for postmenopausal women and men aged fifty years or older who present with the following: a hip or vertebral fracture; T score of -2.5 or less at femoral neck or spine, or low bone mass, and a ten year probability of a hip fracture of 3% or greater, or a ten year probability of a major osteoporosis-related fracture of 20% or greater based on the US-WHO algorithm (Watts, Lewicki, Miller, & Baim, 2008). The American College of Physicians has reviewed the evidence and has proposed guidelines for pharmacologic treatments for osteoporosis. It is recommended that they are all accompanied by adequate intake of calcium and vitamin D. They include: Bisphosphonates, Raloxifene, Calcitonin, Deosumab, and Teriparatide (Qaseem et al., 2008). Guidelines from the American Association of Clinical Endocrinologists, published in 2010, include the following recommendations for choosing drugs to treat osteoporosis: first-line agents include Alendronate, Risedronate, Zoledronic acid, and Denosumab. Second-line agents include Ibandronate and Raloxifene while Calcitonin is considered the last-line agent. Adequate calcium intake is recommended with any treatment (Hodgson et al., 2010). For patient with a diagnosis of osteoporosis, the minimum daily requirement of vitamin D is 800 IU (Ross et al., 2011).Bisphosphonates are the most common and considered the first-line of treatment for people with osteoporosis. According to Uphold and Graham, bisphosphonates are first-line therapy because they are effective, have a good safety profile, and are more affordable (Uphold & Graham, 2013). Ibandronate, Denosumab, or Zoledronic Acid are useful when oral bisphosphonates are ineffective, contraindicated, associated with side effects (gastrointestinal intolerance), likely to be poorly absorbed, or the patient is unable to remain upright for 30-60 minutes after dosing. Bisphosphonates inhibit osteoclast activity, decrease bone turnover, and shift the balance between bone formation and reabsorption toward formation (Uphold & Graham, 2013).Education for patients taking oral bisphosphonates should include taking the medication first thing in the morning, at least thirty minutes prior to eating or drinking; take with eight ounces of plain water, and remain upright for at least 30-60 minutes after taking the medication and until the first meal of the day (Uphold & Graham, 2013).There are other options for treating osteoporosis including natural remedies and herbal supplements. For example, Fosteum is an all-natural option for treatment. Regardless of treatment options, patients should schedule regular follow-up visits every 3-6 months. Patients on any preventative or therapeutic strategies should have annual reassessments that include complete medical examinations, breast and pelvic examinations, mammograms, and papanicolaou smears if indicated. Repeat Bone Mineral Density (BMD) testing should be performed every 12-24 months until findings are stable, then providers should continue with follow-up laboratory and BMD testing every two years (Uphold & Graham, 2013).Our group addressed the problem by educating a group of adults age 55 and older on the definition, causes, risk factors, symptoms, diagnosis, prevention, and treatment of osteoporosis. This community health promotion project took place at the Slater Senior Center in Bristol, Tennessee. We utilized a variety of educational techniques to ensure adequate understanding of the topic. We used visual aids such as project boards and handouts that included pictures and easy to read material. We also demonstrated the exercises to ensure the audience understood the proper technique of each exercise. Adequate time was allotted after the lecture for a questions and answers session. The group was served ice cream sundaes to promote calcium and Vitamin D intake. We formed a Likert Scale questionnaire to determine the effectiveness of the education provided.ReferencesAmerican Academy of Orthopaedic Surgeons. Osteoporosis/bone health in adults as a national public health priority. (2014). Retrieved May 13, 2015, from , H. C. (2013). 12 Ways to break-proof your bones. Retrieved from , S. F., Watson, N. B., Bilezikian, J. P., Clarke, B. L., Gray, T. K., Harris, D. W., & Luckey, M. M. (2010). American Association of Clinical Endocrinologists Medical Guidelines for Clinical Practice for the Diagnosis and Treatment of Postmenopausal Osteoporosis. Endocrine Practice: Official Journal of the American College of Endocrinology and the American Association of Clinical Endocrinologists, 16. Institute on Aging at the National Institute of Health (2015).Workout to go. Retrieved from Institutes of Health Osteoporosis and Related Bone National Resource Center (2012). Disease smoking and bone health. Retrieved June 15, 2015, from Osteoporosis Foundation (n.d). A guide to calcium-rich foods. Retrieved June 12, 2015, from Osteoporosis Foundation (2015). Exercise for strong bones. Retrieved May 17, 2015, from Osteoporosis Foundation (n.d). Food and your bones. Retrieved from (2014). Diseases and conditions osteoporosis. Retrieved June 17, 2015, from , A., Snow, V., Shekelle, P., Hopkins, R., Forciea, M. A., & Owens, D. K. (2008). Pharmacologic: treatment of low bone density or osteoporosis to prevent fractures A clinical practice guideline from the american college of physicians. Annals of Internal Medicine, 149, 404-415. , A. C., Manson, J. E., Abrams, S. A., Aloia, J. F., Brannon, P. M., Clinton, S. K., ... Shapses, S. A. (2011). The 2011 Report on dietary reference intakes for calcium and vitamin d from the institute of medicine: What clinicians need to know. The Journal of Clinical Endocrinology & Metabolism, 96. , C. R., & Graham, M. V. (2013). Clinical Guidelines in Family Practice (5th ed.). Gainesville, FL: Barmarrae Books.Watts, N. B., Lewicki, E. M., Miller, P. D., & Baim, S. (2008). National osteoporosis foundation 2008 clinician’s guide to prevention and treatment of osteoporosis and the world health organization fracture risk assessment tool (FRAX). Journal of Clinical Densitometry, 11, 472-477. ................
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