Osteoporosis

I. General
Metabolic bone disorder
A reduction in bone mass sufficient enough to interfere with the mechanical function of the bone.
A decrease in bone mass increases fracture risk due to porous, brittle bone.
Bone resorption exceeds bone formation
A Multifactoral disease having two main causes:
o Calcium deficiency – as result of chronic inadequate dietary calcium ingestion
o Estrogen deficiency – secondary to menopause

II. Epidemiology
Affects more than 25 million Americans
Women – eight times more likely than men
Occurs in men at an older age & lower rate
Caucasian post-menopausal, petite female
Asian women of slight build at risk for low BMD
90% of women have disease by age 75

III. Patho
bone density & Ca absorption decrease after age 35- can be slowed with dietary & estrogen replacement
therapy
resorption (act of removal by absorption) exceeds bone formation resulting in decreased bone density
Ca must be carried by blood to be available for bone growth & metabolism
over time, thin, weakened bones may lead to crippling effect
regulation in body
calcitonin is a hormone secreted by the thyroid gland in response to increased serum Ca levels
(hypercalcemia); it decreases serum levels by increasing its deposition in the bone
parathyroid gland secretes parathormone which makes it possible for the blood to carry dissolved
Ca secondary to hypocalcemia; Ca is pulled from the bone & reabsorbed to the blood

IV. Causative factors

Medications – Corticosteroids and heparin; alters Ca utilization or decreases GI uptake of CA
Cigarette smoking – one pack a day throughout adulthood can lower bone density by 10% in women
Excessive caffeine ingestion – over 2 cups/day
Endocrine disorders- thyroid disorders, diabetes
Prolonged bed rest- not putting stress on bones so no increase in bone cell production
Liver disease
Alcoholism
Soft drink consumption- Phosphorous inhibits Ca absorption; 3-4 cans a day “bone threatening”
Normal aging process- bones thinning; decrease in mobility; decrease of ROM, joint stiffness
Withdrawal of estrogen at menopause- no hormone in history of breast cancer
Lack of weight bearing exercise
Family history of osteoporosis
Small, thin framed female
Caucasian or Asian heritage
Low calcium diet

V. Risk Factors
Small, framed, nonobese white women and at increased risk
o Lack weight bearing, smoking, caffeine, alcohol
African American because greater bone mass are less susceptible
 Men > peak bone mass, do not experience sudden hormonal changes occur lower rate, at older age
Nutritional factors
o Vitamin D – Ca absorption, normal bone mineralization
o Dietary Ca, vitamin D adequate to maintain bone remodeling, body functions
o Best source Ca / Vitamin D = fortified milk
Bone formation enhanced by stress of weight, muscle activity
Immobility contributes to development
When immobilized by casts, paralysis, general inactivity, bone resorbed faster than formed, osteoporosis
occurs
Coexisting medical conditions
o Malabsorption syndromes, Lactose intolerance
o Alcohol abuse, renal failure, liver failure
o Cushing’s Syndrome, Hyperthyroidism
o Hyperparathyroidism
Medications – Can affect the body’s use and metabolism of Ca
o Corticosteriods, Isoniazid, heparin, tetracycline
o Aluminum containing antacids
o Furosemide, anticonvulsants, thyroid supplements
o Lithium – Long term
o Chemotherapy agents

VI. Dietary Calcium & Vitamin D

What is Calcium? 8.5-10
A mineral which is important to blood coagulation, enzyme activation, acid-base balance, give
firmness and rigidity to bones and teeth, functioning of nerves and muscles including
myocardium and maintenance of membrane permeability. The body will steal calcium
from the bones if there is a chronic shortfall
Excellent sources include milk, yogurt, cheese and ice cream
Good sources include canned salmon and sardines, broccoli, tofu, rhubarb, almonds, and figs.
swiss cheese, nonfat cottage cheese, parmesan cheese, nonfat yogurt*, collards
* for every oz of protein over 4 oz need an extra 100 mg of Ca
Adequate calcium intake
o 9-19 years of age: 1300 mg/day
o 19-51 years of age: 1000
o 51 +: 1200-1500
Moderate consumption of alcohol and caffeine
Stop smoking
Weight bearing exercise to promote bone formation (20-30 min., 3 days/wk)- elderly can walk
Vitamin D
Is the “traffic Cop” that flags down calcium as it makes it way through your digestive tract and
channels it into the bloodstream and bones. The cheapest way to get the daily
requirement of 400 IU is get some sun

VII. Assessment and Diagnosis

X-rays identify osteoporosis when there is a 25% to 40% demineralization- looks like honeycomb
Lab studies including calcium and phosphorus lvls
Dual energy x-ray absorptiometry (DEXA) provides information about spine and hip bone mass and bone
mineral density (BMD)
DEXA data is analyzed and reported by T-scores- the number of Standard deviations (SD) above or below
the recommended BMD
Bone density scan- checks area of body for signs of mineral loss & bone thinning

VIII. Clinical Manifestations

Height loss of 1-6 inches due to collapse of vertebrae
 Dorsal Kyphosis or “dowager’s hump” – an exaggeration of normal posterior curvature of spine, or
Humpback- thoracic area
Cervical lordosis – abnormal anterior convexity
Could experience respiratory problems due to vertebral collapse
Back pain- lower back
Fracture- b/c not in proper alignment

IX. Medical Management

Strengthen bone to prevent patient from suffering fracture
Adequate, balanced diet rich Ca, Vitamin D throughout life – (1000 – 1500mg)
o Increase Ca intake during adolescence, young adulthood, and middle age to protect against
skeletal demineralization
Tums - Cheapest Ca supplement
3 glasses skim or whole vitamin D milk or other food high in Ca (cheese, other dairy products, steamed
broccoli, canned salmon with bones) daily
o 1C Plain nonfat yogurt – 400mg; 1oz C. Cheese; 1oz M. Choc – 25mg; Collar greens 1C 289mg
o Adults 1000mg/day
o Postmenopausal 1000-1500mg/day
Ca supplement (Ca carbonate) taken with meals or beverage high in vitamin C to promote absorption
o Take one hour before meals
o Common side effects Ca supplements
§ Abdominal distention
§ Constipation (teach to increase H20 and fiber)
Regular weight bearing exercise (20-30 minutes aerobic exercise) Walking 3 days or more a week.
o Exercise improves balance, reducing falls, fractures
Sunlight increases vitamin D absorption

X. Pharmacologic Therapy
HRT with Estrogen, Progesterone to retard bone loss, Prevents occurrence of Fracture
o Estrogen: Decreases bone reabsorption, Increases bone mass reducing incidence of osteoporotic
fractures
§ Been associated with slightly increase incidence breast, endometrial cancer
§ Using lowest effective dose decreases cancer risk
§ Combined with progesterone diminish potential risk for endometrial cancer
o HRT contraindicated with pregnant or who have undiagnosed vaginal bleeding; active
thrombophlebitis; endometrial, breast cancer, Estrogen dependent tumors, and acute liver disease
§ Examine breast monthly
§ Pelvic Exam with Pap smear, Endometrial bx – 1 to 2 times a year
Common Side effects of HRT- caution pt of risk involved with estrogen use
o Periodic bleeding or spotting
o GI upset
o Breast tenderness
o Mood swings
o Fluid retention
o Weight gain
o Designer Estrogens such as Raloxifene (Evista) decrease the risk for osteoporosis without
increasing the risk for breast cancer
o Fluorinated toothpaste / H20 increases bone formation
Alendronate (Fosamax) & Risedronate (Actonel)
o Alternative to HRT
o Produces increase in bone mass by inhibiting osteoclast function (Dec bone loss)
o Taken early AM with 8oz of water while sitting up. 30-60 minutes before food (must be on empty
stomach) or before other meds for maximum absorption
o Adequate Ca, Vitamin D needed for max effect
Common Side Effects of Fosamax
 § Dyspepsia, Nausea, Flatulence
§ Diarrhea, Constipation
Calcitonin- inhibits bone resorption
o Suppresses bone loss through direct action on osteoclasts, decreasing bone turnover
o Administer by nasal spray, SQ (some irritation) or IM
§ Alternate nares
§ SQ at HS cause flush of face
Common Side Effects of Calcitonin
o Nasal irritation
o Flushing, GI disturbances, Urinary frequency
SERMS: Raloxifene (Evista)
estrogen receptor modulator that increases BMD without stimulating endometrium indicated both for
prevention & treatment of osteoporosis
administer daily without regard to food
monitor for possible long term effects including cancer & thrombosis

XI. Pain Treatment

Firm mattress, Back rubs
Heat
No twisting motion – move as one unit
Home: Clutter free with grab bars / shower stool