Nurse to Nurse Hospital or Hiking: You choose

Transcription

1 Nurse to Nurse Hospital or Hiking: You choose 24TH BIENNIAL PRNABC CONFERENCE GWEN ELLERT, MEd, RN HEALTH CARE EDUCATOR TRELLE ENTERPRISES INC. MAY 8, 2014

2 You will learn Osteoarthritis (OA): how to assess your risk how to prevent and mange OA what complementary and drug therapies might help how to follow-up Osteoporosis (OP): how to assess your bone health how to strengthening your bones how to assess your risk of a fragility fracture what complementary and drug therapies might help how to follow-up

3 Jack and Mary

4 Osteoarthritis (OA)

5 What percentage of the adult population have knee OA? 1. 6% for knee OA 1. 14% for knee OA 2. 24% for knee OA 3. 30% for knee OA

6 What percentage of the adult population have hip OA? 1. 4% for hip OA, 2. 11% for hip OA, 3. 25% for hip OA, 4. 39% for hip OA,

7 A= bone B= articular cartilage C= joint D= ligaments E= synovial membrane F= joint space containing synovial fluid

8 Step 1: Self assessment what is happening? Primary: genetic factors family history Secondary: constitutional factors: age, sex, obesity biomechanical factors: injury, occupational, malalignment, laxity healthy joint cartilage damage narrowed joint space

9 Jack: Age: 65 Gender: male Height: 183cm Weight: 80kg BMI: 23.7 Occupation: Supervisor Postal Service Situation has a sore rt knee

10 Signs and Symptoms: Rt knee pain, stiffness esp. after rising from bed in am Unable to complete normal running and weightlifting program due to pain Knee often swollen after activity

11 What could Jack do for his sore knee?

12 What could Jack do for his sore knee? Weight loss - how? Exercise - what kind? Pain management - how much pain is too much? OTC meds for pain and swelling - which ones? Aids and devices OT, canes, poles, what helps? Complementary therapies PT, yoga, massage? Alternative therapies e.g. glucosamine?

13 4 months later. The OTC, icing, exercising, PT, new shoes, knee brace and Jack is still not sleeping well due to pain and swelling at night. What would you suggest Jack do?

14 Step 2: Clinical evaluation (no test reliable for diagnosis) Medical history Physical exam ROM, strength, muscle wasting X-ray - to rule out other causes Lab tests to rule out other causes Treatment options.

15 Mild or moderate OA Usual treatment, if no other comorbidities or issues: Acetaminophen max. 4 g per day (up to 1 g x 4/day) lower if liver disease, alcohol abuse, or elderly NSAIDs (OTC or Rx) /Cox 2 inhibitors watch adverse effects with patient history avoid long-term use Stomach protection consider risks and benefits Joint aspiration and/or hyaluronic acid injections Topicals (capsaicin or NSAIDs) adapted from BCMA guidelines

16 Severe OA other treatments plus Use combination of therapies as above and reassess Intra-articular corticosteroid injections In complex or difficult cases consider referral adapted from BCMA guidelines

17 Jack is diagnosed with moderate OA What can Jack do now to manage his disease?

18 Aides and Devices

19 Step 3: Follow-up and management Its up to you! Follow-up: for mild, moderate, severe Weight loss and diet plan, exercise routine Non-pharmacological therapy: OT, PT, massage, yoga Adherence and compliance of pharmacologic therapy Referrals

20 Joint Health Care Program Age Gender Weight Height BMI Step 1: Self-assessment: Genetic factors (family history): Risk or Constitutional factors: (age sex obesity) Biomechanical factors: (injury, occupational, laxity) Step 2: Clinical evaluation: Medical history: X-ray (rule out other causes): Lab tests; (rule out other causes): Treatment options: Step 3: Follow-up and management: It is up to you! Weight loss and diet plan, exercise routine: Non-pharmacological therapy : Pharmacological therapy(mild, moderate, severe): Follow-up (mild, moderate, severe): Adherence and compliance: Weight loss and diet plan, exercise routine: Referrals:

21 Osteoporosis (OP)

22 OP affects approximately how many women over the age of 50 in Canada? 1. 1 in in in in 5

23 What is the annual incidence of osteoporotic fractures? , , ,500, Over 2,000,000

24 Approximately how many patients are unable to walk independently, one year after a hip fracture? 1. 1 out of out of out of out of 5

25 Step 1: Self assessment what is happening? Primary osteoporosis aging, age-related post-menopausal women Secondary osteoporosis immobile or less mobile from disease conditions from certain medications made lifestyle choices

26 Bone strength and fracture risk 2010 OC guidelines Fracture risk Bone density & quality Vitamin D

27 Mary: Risk factors Age: 59 Gender: female Family history: mother fx Medical history: asthma Lifestyle choices: coffee Situation IT manager, worried about OP since mother just broke her hip;

28 Is Mary at risk of fracture? Occupation: IT manager Post-menopausal Caring for mother with new hip replacement Little time for exercise except walking/hiking Had severe asthma as a child

29 Peak Bone Mass Age 15 to 25 Age 48 to 51 Age 65+

30 Warning Signs Height loss Wrist fracture Gait and posture Family history Falls Frailty

31 Vertebral collapse often silent and painless

32 What can Mary do to maintain her bone health?

33 mg x 4 = 1200 mg/day read the label!

34 Calcium and Vitamin D Diet preferably: 1200 mg/day Choosing a supplement read the label! Food Sunshine Supplement

35 Other vitamins and minerals Vitamin A Vitamin K Phosphorus Magnesium Alkaline (basic) or acid-producing foods and bone health

36 Exercises and safe movements Best for bones are bone loading: Weight-bearing and non-weight bearing Strength, flexibility, stability and balance Upper body (spine) Remember: Posture, gait Osteofit programs tm

37 LBD: avoid bending forward, lifting and twisting Caution: - these moves stress the hip and spine, keep your back flat Crunches Yoga: Spine twists Pilates: Rollups Curl ups Forward folds Rollovers Touching toes Ploughs Short spine (seated or standing) Shoulder stands Used with permission from American Bone Health

38 Step 2: Clinical evaluation Medical history Family history Lab tests DXA FRAX Treatment options: non-pharmacological pharmacological

39 BMD DXA with FRAX BMD DXA (t score) normal: ( 1SD) 10% 20% low normal: ( 1to 2.5SD) < 25% (4x) osteoporosis: ( 2.5 SD) > 25% (8X) 10 year fracture risk: FRAX low: less than 10% moderate: 10% 20% high: over 20%

40 To treat or not to treat that is the question? DXA (bone mass) / FRAX (10 year fx risk): Treat? normal / low : (probably no) low normal / moderate: (difficult to say -??) osteoporosis / high: (probably yes) or prior fragility fracture of hip or spine

41 Mary age 59, diagnosis low normal (osteopenia) and moderate risk BMD:DXA = -1.9 is low normal (-1SD to -2.5) FRAX: 10 year fracture risk is moderate at 11%, (10%-20%) 10 year Major fracture risk assessment 10 year Hip fracture risk assessment

42 What can Mary do now to protect her bones as she ages?

43 6 years later Now age 65 Still walking/hiking Plans to retire next year DXA -2.4 Lost 2.5 cm (1 ) in 5 years Mother is now in a long term care facility after fracturing her other hip

44 Mary is diagnosed with a moderate risk of fracture. (4-8 X increased risk) What can Mary do to manage her disease? What impact will this have on her occupation and lifestyle? What is her prognosis? Choices

45 Drug therapies options: Look at: Mechanism of action Route of administration Benefit, risk and cost factors Side effects and rare events

46 What percentage of patients adhere to their osteoporosis therapy for more that 1 year? 1. Less than 10% 2. Less than 25% 3. Less than 45% 4. Less than 55%

47 Step 3: Reassessment and adherence Follow-up in 1 year or sooner Adherence and compliance

48 Bone Health Care Plan Age Gender Step 1: To support self-assessment Calcium: Vitamin : Exercise program: Lifestyle: Family history: Medical history: Fracture risk assessment: Step 2: The clinical evaluation process Medical history: DXA: FRAX/CAROC: Treatment options: Step 3: Reassessment, adherence and post fracture care follow-up in 1 year or sooner: adherence and compliance:

49 Review Joint health and Osteo arthritis Bone health and Osteo porosis

50 Thank you QUESTIONS.. COMMENTS.. DISCUSSION? SPECIAL THANKS TO DAVE HANCOCK, ILLUSTRATOR