FOCUS ON OSTEOPOROSIS

(Relates to Chapter 64, “Nursing Management: Musculoskeletal Problems,” in the textbook)

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OSTEOPOROSIS

• Chronic, progressive metabolic bone disease characterized by Porous bone Low bone mass Structural deterioration of bone tissue

Increased bone fragility

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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.

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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.

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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).

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ETIOLOGY AND PATHOPHYSIOLOGY

• Risk factors Female gender Increasing age Low body weight White or Asian ethnicity Family history Early menopause Excess alcohol intake

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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

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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.

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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

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NORMAL VS. OSTEOPOROTIC BONE

10

Fig. 64-9. A, Normal bone. B, Osteoporotic bone.

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ETIOLOGY AND PATHOPHYSIOLOGY

• In osteoporosis, bone resorption exceeds bone deposition.

• Occurs most commonly in spine, hips, and wrist

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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.

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ETIOLOGY AND PATHOPHYSIOLOGY

• Diseases associated with osteoporosis

• Intestinal malabsorption• Kidney disease• Rheumatoid arthritis• Hyperthyroidism• Chronic alcoholism• Cirrhosis of the liver• Hypogonadism• Diabetes mellitus

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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

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CLINICAL MANIFESTATIONS

• Manifestations include Sudden strain Fractures Back pain Loss of height Spinal deformities

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DIAGNOSTIC STUDIES

• History and physical exam• Bone mineral density (BMD)

• Quantitative ultrasound• Dual-energy x-ray absorptiometry (DEXA)

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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.

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COLLABORATIVE CARE

• Focus on Proper nutrition Calcium supplements Exercise Prevention of fractures Drug therapy

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COLLABORATIVE CARE

• Prevention and treatment depend on adequate calcium intake.

• Increased calcium prevents future loss but will not form new bone.

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COLLABORATIVE CARE

• Good sources of calcium Milk Yogurt Turnip greens Spinach Cottage cheese Ice cream Sardines

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COLLABORATIVE CARE

• Poor sources of calcium Eggs Beef Cream cheese Poultry Pork Apples and bananas Potatoes and carrots

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COLLABORATIVE CARE

• Exercise should be encouraged to build up and maintain bone mass.

• Types of exercise Weight bearing Walking Stair climbing Dancing

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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

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COLLABORATIVE CARE

• Drug therapy Calcium Vitamin D Calcitonin

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COLLABORATIVE CARE

• Drug therapy (cont’d) Bisphosphonates inhibit osteoclast-mediated bone resorption (e.g., etidronate [Didronel], alendronate [Fosamax]).

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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

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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

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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

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CASE STUDY

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CASE STUDY

• 65-year-old woman visits her primary care physician for an annual checkup.

• States “I feel that I am in good health”

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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.

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CASE STUDY

• She has been postmenopausal for 3 years.

• She has a small frame and is a healthy weight.

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CASE STUDY

• Her height is 1.5 inches less than her last recorded height taken 2 years ago.

• She has slight kyphosis.

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CASE STUDY

• Her physician orders a dual-energy x-ray absorptiometry. Her T-score indicates she has osteoporosis.

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DISCUSSION QUESTIONS

1.What treatment options are available to her?

2.What lifestyle changes can she make to improve her condition?

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DISCUSSION QUESTIONS

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?

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