Foundations of Orthopaedic Nursing Care, Part Four: Metabolic Bone Disease, highlighting Osteoporosis and Paget s Disease Conflict of Interest I hereby certify that, to the best of my knowledge, no aspect of my current personal or professional situation might reasonably be expected to affect significantly my views on the subject on which I am presenting. Jennifer Drake, DNP, RN, ONC Learner Outcome As a result of this learning activity, the participant will gain confidence and apply knowledge and skills to practice in the care of the Orthopaedic patient who has a metabolic bone disease. Objectives Discuss foundations of bone development Identify key elements to maintain bone stability Discuss scope of osteoporosis Discuss key factors of Paget s disease Discuss other metabolic bone disease 1
Poll Question Where do you work? A. Inpatient-acute care B. Outpatient-clinics C. Schools D. OR Bone Remodeling Bone remodeling (or bone metabolism) is a lifelong process where mature bone tissue is removed from the skeleton (bone resorption) and new bone tissue is formed (ossification or new bone formation). The two stages-resorption and formation involves osteoblasts and osteoclasts Usually, the removal and formation of bone are in balance and maintain skeletal strength and integrity Bone Cells Osteoblasts Responsible for bone matrix synthesis Secrete collagen rich ground substance needed for mineralization Have estrogen receptors. Estrogen can increase the number of osteoblasts, increasing therefore collagen production Bone Cells Osteocytes Play a role in controlling the extracellular concentration of calcium and phosphate Directly stimulated by calcitonin Inhibited by PTH 2
Bone Cells Osteoclasts nibbles and breaks down bone Responsible for bone resorption In osteoporosis, rate of resorption exceeds rate of bone formation Bone Cell Mnemonics OsteoBlasts Baby Bone Cells Building Blocks OsteoCLasts Clean Up Cells OsteoCYtes Cycle of Bone Hormone Regulation Thyroid Gland Two Lobes on Either Side of Trachea Thyroxine, Triiodothyronine & Calcitonin Regulated by Plasma Levels of Calcium Parathyroid Gland Four Bodies Posterior to Thyroid Gland Para hormone PTH (Protein Hormone) Regulated by Serum Ionized Calcium Levels 3
Hormone Regulation Anterior Pituitary Gland ACTH / TSH / FSH / LH / Prolactin Regulated by Hypothalamus Adrenal Cortex Secretes: Glucocorticoids Mineralocorticoids Androgens & Estrogens S mulated by ACTH Cholesterol & Steroidogenesis Hormone Regulation Estrogen Osteoblast Ac vity Bone Matrix Retention of Calcium and Phosphate Func on with Age Minerals in the bone When it is all in balance Calcium and phosphate are major minerals Homeostatic balance must be maintained 98% of calcium and 85% of phosphorus in body, are found in bone Calcium and phosphate enter body from intestine 4
What is Metabolic Bone Disease? Osteoporosis Metabolic bone diseases are disorders of bone strength, usually caused by abnormalities of minerals (such as calcium or phosphorus), vitamin D, bone mass or bone structure. The most common metabolic bone disorder is osteoporosis. Osteoporosis Types of Osteoporosis Osteoporosis is a disease in which the density and quality of bone are reduced, leading to weakness of the skeleton and increased risk of fracture, particularly of the spine, wrist and hip. Osteoporosis and associated fractures are an important cause of mortality and morbidity Postmenopausal osteoporosis (type I) Caused by lack of estrogen Causes PTH to over stimulate osteoclast Predominately females Age-associated osteoporosis Common after age 70 Related to nutrition and decreased activity Secondary Affects males or females Occurs at any age Result of disease process or medical treatment 5
What are Some Examples of Secondary Osteoporosis? Acromegaly Multiple myeloma Addison s disease Multiple sclerosis Amyloidosis Rheumatoid arthritis Anorexia Sarcoidosis COPD Severe liver disease Hyperparathyroidism Thalessemia Lymphoma and Thyrotoxicosis leukemia Malabsorption states Spinal cord injury Poll Question What are Some Examples of Secondary Osteoporosis that You See? A. Multiple sclerosis B. Rheumatoid arthritis C. Malabsorption states D. Spinal cord injury Cost of Osteoporosis Scope of Problem Osteoporosis is the most common bone disease in humans, representing a major public health problem. Characterized by low bone mass deterioration of bone tissue disruption of bone architecture, compromised bone strength increase in the risk of fracture. 6
Risk Factors Osteoporosis is a risk factor for fracture just as hypertension is for stroke. 25% of older adults Greatest incidence occurs among white females between ages 50 and 70 Secondary to other disorders Postmenopausal status Long-term corticosteroid use Prolonged immobilization Nutritional deficiency Pathophysiology In osteoporosis, the rate of bone loss (i.e. resorption) exceeds bone formation, resulting in a decrease in total bone mass. Bones affected by osteoporosis lose calcium and phosphate salts, resulting in porous, brittle bones that are susceptible to fractures. 7
Assessment/Clinical Manifestations/Signs & Symptoms Fractures particularly vertebral compression fractures, hip fractures, and long bone fractures Pain Visible deformity (kyphosis) Loss of height Constipation Assessment/Clinical Manifestations/Signs & Symptoms Laboratory and diagnostic study findings Dual-energy x-ray absorptiometry (DEXA) provides bone mineral density (BMD) Most commonly used! Various sites can be used Heel and forearm: easy but less reliable (outcome of interest is fracture of vertebra or hip) Hip site: best correlation with future risk of hip fracture Vertebral spine: predict vertebral fractures, risk of falsely HIGH scores if underlying OA/osteophytes Assessment/Clinical Manifestations/Signs & Symptoms Laboratory Limited value in diagnosis More useful in monitoring effects of treatment than diagnosis Helpful to exclude secondary causes Hyperthyroidism Hyperparathyroidism Malignancy Multiple myeloma Estrogen or testosterone deficiency Calcium/vitamin D deficiency Fractures and their complications are the relevant clinical sequelae of osteoporosis. 8
Mortality Increased risk of death following a hip fracture, a spine fracture, and other major fractures for 5 years post-fracture. Medical Management Medical Management Recommend regular weight-bearing and musclestrengthening exercise to improve agility, strength, posture and balance and reduce the risk of falls and fractures. Assess risk factors for falls and offer appropriate modifications home safety assessment, balance training exercises, Correction of vitamin D insufficiency, Eat foods rich in calcium Advise on cessation of tobacco smoking and avoidance of excessive alcohol intake. Measure height annually 9
Nursing Diagnosis Deficient knowledge of osteoporotic process and treatment regimen Pain related to fracture and muscle spasm Constipation related to immobility or development of ileus Risk for injury: fracture related to osteoporotic bone Nursing Management Prevent fractures - Use caution when turning, lifting, and transferring the patient to prevent fracture. Promote spinal stability by applying a lumbosacral corset, if indicated; avoid appliances that can decrease mobility. Patient Teaching Encouraged increased intake of foods high in calcium (e.g. milk, cheese, salmon, spinach, broccoli), vitamin D, fiber and protein. Patient Teaching Suggest that the patient sleep on a firm, nonsagging mattress. Encourage a regular, moderate exercise regimen Teach the patient about the disease process and prevention of progression. Teach safety measures to prevent injury from falls. 10
Paget s Disease What is Paget s? Bones grow too large and weak Can be in any bones, but most often in spine, pelvis, skull or leg bones. May not be in entire skeleton Bones fracture easily Can lead to other health problems Named after the England Surgeon Sir James Paget Also known as Osteitis Deformans Pathophysiology Aggressive, focal bone resorption, rapid, disorganized bone formation Leads to osteoblast recruitment and overactive osteoblastic activity Abnormal osteoclasts quan ty size ac vity Pathophysiology New bone is Coarse, disorganized, irregular, woven Less resistant to forces Prone to deformity and fracture 11
Who Get s Paget s Disease Approximately 1 million people in USA have Paget s More often men than women Northern European descent Can run in the family Symptoms of Paget s Pain Enlarged bones Broken bones Damaged cartilage 80% asymptomatic Symptoms of Paget s Paget s in bones of the skull Headaches Hearing loss Large head size Clinical Presentation and Complications Usually asymptomatic Bone pain Bone/limb deformity 12
Clinical Presentation and Complications Fracture Arthropathy Impacts Joints Skin temperature Hypervascularity due to bone turnover ac vity bone turnover causes cardiac demands and may lead to high-output heart failure Clinical Presentation and Complications Neurologic complaints Hearing loss/vertigo temporal bone involvement with auditory nerve compression Cranial nerve palsies Spine involvement Mechanical cord compression Clinical Presentation and Complications Malignant transformation Secondary Osteosarcoma Chondrosarcoma Incidence compared to population (1 to 10%?) Prognosis dismal normal Clinical Presentation and Complications Hypercalcemia Rare Usually inactive or bed-ridden patients Signs & Symptoms Nausea, vomiting, MSK aches, hyperreflexia, weakness, polyuria, headache, lethargy, altered mental status, coma 13
Diagnostic Testing Plain Radiographs Localized Demineralization (Early) Bone Overgrowth (Later) Classic picture frame appearance in pagetic vertebra (marginal sclerosis) Diagnostic Testing Bone Scan Isotope uptake in involved bone, typically very hot Assessment of disease extent and activity Often positive before radiographic changes CT/MRI Diagnostic Testing Lab Data Serum Alk Phos Enzyme found in osteoblastic membrane Indicator of osteoblastic ac vity, in Paget s, but can be normal Levels correlate with disease extent and activity ESR - elevation may indicate malignant transformation C-reactive protein--inflammation Ca - hypercalcemia may occur in Paget s 25-hydroxyvitamin D - rule out osteomalacia Liver function tests - rule out liver disease Medical Management Many treatments used for Osteoporosis are used for Paget s Three common ways to treat Paget s Biophosphonates Surgery Diet & Exercise 14
Medical Management Specialist for Paget s Disease Control Symptoms Prevent long term complications If asymptomatic Monitor patient If symptomatic Bisphosphonates Calcitonin NSAIDs / Tylenol Surgical Intervention Correction of Malalignment/Bowing Total Joint Arthroplasty Orthopaedics For Fracture Treatment Total Joint Arthroplasty Rheumatologist If No Response to Treatment Neurologist Spinal Stenosis Loss of Function Hydrocephalus ENT Conductive Loss of Hearing Interventions for Paget s Disease Pain prevention Medications Gentle massage Heat application ROM Fall prevention increased risk of fractures Use of assistive devices Handrails Remove floor rugs Interventions for Paget s Disease Diet Increase calcium and vitamin D Smoking cessation Smoking can increase bone loss Avoid alcohol Inhibits formation of bone and ability to absorb calcium Increase risk of fall Exercise 15
Exercises for Patients with Osteoporosis or Paget s Disease Walking Dancing Tai Chi Low impact aerobics Weight training using free weights Resistance training Water aerobics Poll Question How Much Calcium Do you need? A. Women over 50 yr 1200 mg B. Women over 50 yr 1000 mg C. Men over 50 1200 D. Everyone over 40 yr 1400mg References Whyte, Paget s Disease of Bone, NEMJ, vol. 355, 2006. Klein and Parvizi, Surgical Manifestations of Paget s Disease, JAAOS, vol. 14, 2006. http://www.niams.nih.gov/health_info/bone/pagets/pagets_disease_ff.as p http://orthoinfo.aaos.org/topic.cfm?topic=a00008 http://www.merckmanuals.com/home/sec05/ch071/ch071c.html D'Amico, D., & Barbarito, C. (2007). Health and Physical Assessment in Nursing (2nd ed.). Upper Saddle River, New Jersey: Pearson Education, Inc. 16