Objectives: What is Osteoporosis 10/8/2015. Bone Health/ Osteoporosis: BASICS OF SCREENING, INTERPRETING, AND TREATING

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1 Bone Health/ Osteoporosis: BASICS OF SCREENING, INTERPRETING, AND TREATING TIFFANY PAUL, APN, CNP, CCD Objectives: Review the diagnosis of Osteoporosis Describe the basics of a bone density exam Identify options of when to treat or not to treat based on bone density results Review basics of treatment What is Osteoporosis Bones are fragile and more likely to break easily Fragility fractures occur with minimal trauma Fractures lead to pain, changes in body shape and disability 1

2 Consequences of Osteoporosis One in two women over the age of 50 will break a bone One in five men over the age of 50 will break a bone *National Osteoporosis Society Who Has Osteoporosis More than 10 million Americans suffer from osteoporosis 80 percent are women 1 in 2 women over age 50 will be diagnosed *National Osteoporosis Society Health Bone/Osteoporotic bone *Source: WebMD 2

3 How bones change with age By Anatomy & Physiology, Connexions Web site. Jun 19, (OpenStax College) [CC-BY-3.0 ( via Wikimedia Commons Men and Osteoporosis Underdiagnosed 2 million men suffer from osteoporosis 80,000 hip fractures each year One-third die one year after fracture Source: National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institute of Health, Department of Health and Human Services What are fragility fractures? Any fall from standing height or less, that results in a fracture. Indicates an underlying cause if a person gets a fracture after falling this distance. Any fracture that is low or no trauma 3

4 Burden of Disease Most patients with hip fractures are hospitalized for about one week. One in four adults who lived independently before their hip fracture have to stay in a nursing home for at least a year after their injury. One in five hip fracture patients die within a year of injury. Source: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention Subsequent fracture JAMA 2007: increased risk persisted for up to 10 years depending on age and sex, with about 50% of surviving men and women having another fracture less than 30% of postmenopausal women and less than 10% of men with prior fracture are treated Are my bones fragile? Signs and symptoms: Osteoporosis is painless unless bones break Fragile bones may break easily without too much force Significant height loss and curvature of the spine may indicate compression fractures Risk factors will make fragile bones more likely A bone density scan will indicate if bones are less dense than average 4

5 Medications which negatively affect bone health Glucocorticosteroids Certain immunosuppressants Thyroid hormone treatment Certain steroid hormones Aromatase inhibitors Certain antipsychotics Certain anticonvulsants Certain antiepileptic drugs Lithium Methotrexate Antacids Proton pump inhibitors Bone Density Scan Bone Density Scan Dual energy x-ray absorptiometry (DXA) Useful for those with significant risk factors to decide whether drug treatment is necessary Per World Health Organization: Measure Bone Mineral Density (BMD) at the lumbar spine, total hip, neck region of the hip (femoral neck), or forearm. Recommendations for Study Women Age 65 or older Postmenopausal women under age 65 with risk factors for fracture Low body weight, prior fracture, high risk medication risk Men Age 70 or older Men under age 70 with clinical risk factors for fracture 5

6 Recommendations for Study Adults Presence of a fragility fracture Disease of condition associated with low bone mass or bone loss Medications associated with low bone mass or bone loss Anyone being considered for pharmacological therapy Anyone being treated to monitor treatment effect Anyone not receiving therapy in whom evidence of bone loss would lead to treatment (Reference: ISCD) Osteoporosis on a DXA bone density scan Source: Wikemedia Commons (Avon Longitudinal Study of Parents and Children/ALSPAC) Osteoporosis on a DXA bone density scan The T-score is a comparison of a person's bone density with that of a healthy year-old of the same sex. Lower scores (more negative) mean lower bone density: A T-score of -2.5 or lower qualifies as osteoporosis. A T-score of -1.0 to -2.5 signifies osteopenia, meaning below-normal bone density without full osteoporosis. 6

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8 Poor Lumbar Study 7/18/2007 7/3/2012 Poor Femur Study 8

9 Poor Femur Study Poor Forearm Study Report vs. Image 2/4/2014 BMD as determined from left hip with a T-score of -0.8 BMD as determined from the right hip is with a T-score of

10 Artifacts on Images Common Degenerative disease Fractures Metal Internal types Aortic calcification, surgical clips, renal stones, vertebroplasty/ kyphoplasty External types Buttons, bra clips, zippers Common Artifact Fracture L1 T-score L1 0.6 L2 0.1 L3-0.7 L4-2.0 Spine Fracture 1)11/2/2012 2) 5/13/2015 L1 BMD BMD

11 Internal Artifact Cyst Additional tests BMP CMP Vit D TSH PTH Testosterone Urinary Calcium Treatment Standards Exercise regularly Ensure a healthy diet Avoid negative lifestyle Identify your risk factors 11

12 Exercise Important for maintenance of bone mass and muscle strength Goal is to increase muscle mass in order to improve muscle function. Weak muscles can contribute to falls and fractures. Exercise should be tailored to the individual needs and capabilities, especially if diagnosis of osteoporosis Types of Exercise Weight bearing -Aerobics, walking, running, dancing Muscle strengthening -Lifting weights, weight machines, stretching Balance, posture and functional exercises -Strengthen muscles, improve posture, everyday activity Healthy Diet Vitamin D Calcium Calcium supplements Other key nutrients Protein Acid-base balance of the diet 12

13 Vitamin D Helps the body use calcium and is essential for healthy bones Sunlight provides the vitamin D we need Exposure daily between May and September increases vitamin D levels Stored by the body in winter months Calcium People need calcium to build and maintain strong bones and teeth Calcium is not made in the body it must be absorbed from the food we eat How much do you need? Woman age 51 to 70 need 1,200 mg per day Men age 51 to 70 need 1,000 mg per day Women and men 70 or older need 1,200 per day Calcium Supplements Recommended for those who do not get enough calcium from diet Multivitamins do not include significant amounts Doctor should recommend amount, based on individual needs Calcium is absorbed more efficiently when taken in doses less than 500 mg 13

14 Other Key Nutrients These contribute to bone health and growth Phosphorus dairy products and meat Magnesium found in calcium supplements as well as dark leafy greens, nuts, seeds, brown rice, avocados and bananas Vitamin K Found in dark leafy greens, broccoli, scallions, asparagus, cabbage and prunes Vitamin C citrus fruits, tomatoes and many vegetables Vitamin A liver, eggs, butter, green leafy vegetables and carrots Protein Body changes after middle age, including increases in fat mass and decreases in muscle mass Protein intake can help Lack of protein is associated with loss of BMD at the hip and spine Protein is found in meat, fish, dairy products and eggs Acid Base Balance of the Diet New research indicates that an acidic environment has negative effects on preservation of bone. Acidosis can occur when the intake of acidproducing foods (cereal grains and protein) is not balanced by enough alkali-producing fruits and vegetables 14

15 Identify Risk Factors Previous fragility fractures Family history of osteoporosis and fractures Medications that negatively affect bone health Diseases of malabsorption Rheumatoid arthritis Early menopause Tendency to fall Lifestyle The negative habits that affect your general health also have a negative impact on bone health Smoking Excessive alcohol intake Overweight These risk factors are modifiable FRAX Score 15

16 FRAX Score Pharmacological treatment Miacalcin Evista Bisphosphonates Prolia Forteo Strontium References The International Society for Clinical Densitometry: Bone Densitometry Course, Center, J. R., Blluc, D., Nguyen, T., Eisman, J. A. (2007) Risk of Subsequent Fracture After Low- Trauma Fracture in Men and Women. JAMA ; 297 (4):