Osteoporosis Overview Jane Anthony Peterson, MSN, RN, CS, ARNP, FNP-C

CE Article Instructions to CE enrollees: The closed-book, multiple-choice examination that follows this article is designed to test your understanding of the educational objectives listed below. The answer form is on page 23. On completion of this article, the reader should be able to: 1. Discuss risk factors for osteoporosis 2. Identify characteristics of osteoporosis in women 3. Discuss strategies to reduce the effects of osteoporosis Osteoporosis Overview Jane Anthony Peterson, MSN, RN, CS, ARNP, FNP-C Abstract Osteoporosis, a disease characterized by low bone mass, microarchitectural deterioration of bone, and susceptibility to bone fractures, can lead to debilitating pain and deformity. The disease represents a major health problem, particularly in older women. Approximately 1.5 million people in the United States suffer osteoporosisrelated fractures annually, and many never gain full recovery. The direct annual health expenditures related to osteoporosis fractures were estimated at $13.3 billion in 1994, but quality of life costs related to osteoporosis are even more profound. Identifying people at risk for osteoporosis and early treatment can minimize its destructive effects. Nurses play an important role in the development of strategies to reduce the incidence of osteoporosis and osteoporosis-related fractures, pain, and deformity to help older adults lead healthy, productive lives in their later years. (Geriatr Nurs 2001;22:17-23) Geriatric Nursing 2001 Volume 22 Number 1 17

Osteoporosis is one of the most common yet unrecognized and undertreated conditions in older women. Although typically considered a disease of elders, it actually begins in younger women but is not evident until old age. Osteoporosis affects 8 million Americans; another 17 million have low bone mass, increasing their risk for the disease, and that number will continue to rise as the population ages. 1 Osteoporosis is a systemic skeletal disease characterized by low bone mass and microarchitectural deterioration of bone tissue with a consequent increase in bone fragility and fracture susceptibility. Bone mass increases through the radial growth of bones with bone formation exceeding bone resorption until peak mass is reached at approximately 30. A transient period of bone stability occurs until age-related bone loss begins at about 35. Gradual bone loss frequently is not noted by patients or health providers until the disease is well advanced and bone fractures occur. ASSESSMENT Hazel is a pleasant 65-year-old white woman who comes to the primary clinic for health care. Over the years that she has been seen in the clinic, she has suffered from a few minor illnesses. Hazel had a hysterectomy with a bilateral oopherectomy at age 48, one episode of major depression with marked weight loss after her husband s death last year, and a fracture of the right wrist after a fall on ice 3 months ago. Hazel s assessment reveals that she was a homemaker most of her life, smoked for 40 years, drank alcohol and caffeine regularly, and did not participate in exercise activities. She says her mother had a hump back and bone fractures. During the past several years, she has appeared increasingly frail, lost stature, and developed slumped posture, prompting a review of the risk factors for osteoporosis outlined in Table 1. Hazel s physician has told her that she has the disease, which is classified as primary or secondary. 2 Primary osteoporosis occurs with two distinct mechanisms of bone loss: rapid (primary osteoporosis Type I) and slow (primary osteoporosis Type II). Rapid bone loss is osteoclast-mediated (bone resorption) and occurs in women within the first 5 to 10 years after menopause when estrogen decline is marked. 3 Primary Type I (postmenopausal) osteoporosis is related to estrogen deficiency and causes trabecular bone loss in the vertebrae, hips, and wrists, predisposing these sites to fractures. Estrogen is responsible for stimulating calcitonin and inhibiting bone resorption and also may have a vital role in osteoblastic activity. Primary osteoporosis Type II, slow bone loss, is osteoblastic-mediated (bone formation) and occurs in women and men older than 70. This type of loss is insidious, resulting in a gradual loss of cortical bone, and is a Table 1. Risk Factors for Osteoporosis Amenorrhea, excessive exercise, or anorexia Caucasian or Asian race Deficient calcium intake Excessive caffeine/alcohol use Family history Female Menopause, hysterectomy, or oopherectomy before age 40 Smoking Sedentary lifestyle Thin, small frame Adapted from Whipple B. Common questions about osteoporosis and menopause. Am J Nurs 1995;95:69-70 predisposing factor for hip fracture. Secondary osteoporosis usually occurs as a result of another disease or medication. Table 2 features a list of the common causes of secondary osteoporosis. FRACTURES Hazel already has fractured her right forearm, known as a Colles fracture. The first visible sign of osteoporosis often is a bone fracture, most commonly the wrist, hip, or compression fractures of the spine. Osteoporosis affects 25 million Americans, predisposing them to 1.5 million fractures annually. Even more common than hip fractures that occur with this condition are vertebral compression fractures more than 500,000 occur each year. 4 Vertebral fractures can occur after minimal or no trauma to the individual. When a vertebra compresses, it becomes wedge-shaped, with the narrow angle on the anterior side of the vertebral body. Over time, the affected woman s posture curves forward, resulting in kyphosis or the dowager s hump. 5 Besides losing stature, the woman s abdomen begins to protrude. She may perceive her abdomen as fat and further restrict her nutritional intake, which may be limited already. Disturbed body image is common in women with osteoporosis. Severe pain often accompanies acute vertebral fractures. Back pain caused by vertebral compression fracture may become chronic in nature, indicating poor healing of the acute injury or chronic straining in the same area. Chronic fracture-related pain greatly curtails the woman s activities and diminishes her quality of life. DIAGNOSIS Hazel was diagnosed with osteoporosis after she suffered a bone fracture. With the advent of bone-den- 18 Geriatric Nursing 2001 Volume 22 Number 1

sity testing, women at risk for fracture can be identified and measures can be implemented to reduce future risk. Table 3 outlines the indications for bone-density testing. Bone density may be assessed by several techniques, but the dual-energy x-ray absorpitometry (DEXA) scan often is used to compare the patient s bone density with the peak value in young adults. 6 DEXA is a painless, noninvasive test in which a machine passes over the patient positioned on an examination table. In the central DEXA scan, the patient s spine and hip bone density measurements are obtained to more accurately determine osteoporosis than a peripheral scan of the forearm, calcaneus, phalanges, or tibia. 6 Results of a DEXA scan are reported within the standard deviation (SD) of the bone density mean of the normal young adult. Refer to Table 4 for interpretation of DEXA scan results. 6 A number of biochemical markers have been identified to measure the balance of bone resorption and formation. Bone formation markers can be used to identify rapid bone loss and monitor responses to therapy with antiresorptive drugs. Serum biochemical markers, including alkaline phosphatase, osteocalcin, and the urinary hydroxyproline, and newer collagen crosslinks (pyridinoline, deoxypyridinoline, N-telopeptides, and C-telopeptides) have been proposed to help identify people likely to sustain fractures. 7 Biochemical markers have been found to be of limited use in the clinical setting, however. TREATMENT Hazel wants to avoid further bone fractures and realizes that various lifestyle changes will be necessary to achieve this goal. Osteoporosis cannot be cured, but women at risk can be identified and interventions implemented before devastating fractures occur. Prevention counseling strategies should be individualized to the age and gender of the client. Children and adolescents need education on the importance of a diet rich in calcium and vitamin D and regular weight-bearing exercise. Premenopausal adult women and postmenopausal women on hormonal replacement therapy (HRT) should have a calcium intake of at least 1000 mg/day. 7 Postmenopausal women not on HRT are at greatest risk for osteoporosis and require an intake of 1500 mg of calcium daily. 7 Flavored soft chewable calcium supplements (500 mg and 22 calories per square) are on the market and may be more appealing than large, difficult-to-swallow tablets. All women should engage in regular weight-bearing exercise and avoid smoking and excess alcohol and caffeine consumption. Vitamin D 400 to 800 IU per day should be added for women 65 years or older. 8 Falls and injuries must be avoided. Table 5 summarizes lifestyle changes to reduce the risks of osteoporosis. Table 2. Causes of Secondary Osteoporosis Alcoholism Cushing s disease Hyperparathyroidism Hyperthyroidism Hypogonadism Long-term use of these drugs: Aluminum-containing antacids Corticosteroids Heparin Methotrexate Phenytoin Malnutrition and malabsorption disorders Neoplasms Prolonged immobility Table 3. Indications for Bone Density Testing Estrogen-deficient women at clinical risk for osteoporosis Individuals with vertebral abnormalities Individuals receiving long-term glucocorticoid (steroid) therapy Monitoring of osteoporosis therapy PHARMACOLOGIC THERAPY Hazel admits her reluctance to take HRT after her hysterectomy, although studies clearly demonstrate the preventive effects of HRT on osteoporosis. 8,9 Accurate information delineating the benefits and minimal risks associated with HRT should be presented to women approaching menopause or having surgical menopause. For women already experiencing osteoporosis, other pharmacologic options and instructions on drug therapy should be discussed by health professionals. Some current drug therapies include calcitoninsalmon (Calcimar or Miacalcin), used in postmenopausal osteoporosis for its antiosteoclastic action to slow bone resorption. 8,10 Calcitonin may be taken intranasally (alternating nostrils daily) or by injection. Aldrendronate sodium (Fosamax), a bisphonate, also is available for postmenopausal osteoporosis. 8,11 Fosamax improves spinal bone density and reduces the rate of bone loss. Because of its potential for esophagitis, however, the person must take the drug on initial rising in the morning with a full glass of water, wait at least 30 Geriatric Nursing 2001 Volume 22 Number 1 19

Table 4. Interpreting Results of DEXA Assessment Results Within 1 SD of young adult mean Between 1 and 2.5 SD below mean, repeat in 2 years Greater than 2.5 SD below mean Greater than 2.5 SD below mean and one or more fragility fractures Diagnosis Normal Low bone mass (osteopenia) Osteoporosis Severe osteoporosis Note: Results can be affected by body position during the DEXA scan, presence of current or former fractures, arthritis, and extraneous calcifications. Tresolini CP, Gold DT Lee LS, editors. Working with patients to prevent, treat, and manage osteoporosis: a curriculum guide for the health professions. San Francisco: National Fund for Medical Education; 1996. Reprinted with permission. Table 5. Interventions for Osteoporosis Lifestyle Changes Adequate calcium and vitamin D intake Avoidance of deep spinal flexion and compressive forces to spine Balanced diet Fall prevention No smoking Reduced caffeine and alcohol intake Regular exercise Pharmacologic Interventions Biposphonates Calcitonin Hormonal replacement therapy Selective estrogen receptor modulators minutes before taking any other drug, and remain upright for 30 minutes afterward. A newer therapy for osteoporosis is a preventive drug called raloxifene (Evista). Raloxifene is a new class of drugs called selective estrogen receptor modulators that act like estrogen in some tissues but not in others. 8,12 Studies indicate the drug does increase bone mass, especially in the hip and spine, and was shown to be associated with a significant decrease in vertebral fracture. Raloxifene therapy does not cause breast stimulation and may provide a protective effect against certain types of breast cancer. Raloxifene does not elevate serum lipid levels linked with cardiovascular disease and may be taken at any time during the day without regard to other drug intake. Minor side effects include hot flashes and leg cramps. Serious side effects are rare and similar to the adverse effects of estrogen therapy. Table 5 also lists pharmacologic options to manage of osteoporosis. NURSING INTERVENTIONS Hazel is concerned about her ability to manage safely at home without sustaining another fall or injury. Because most people with osteoporosis are elderly and strength has been identified as a risk factor for injurious falls, all clients should be screened for fall risks, and interventions should be implemented to avoid falls and resulting fractures. Intrinsic factors that increase the risk of falls include balance, gait and strength, medications that cause dizziness or drowsiness, alcohol, sensory problems (eg, poor hearing and vision), mental status changes, decreased functional capacity, and chronic illness affecting strength, balance, sensation, and mobility. Extrinsic factors increasing the risk of falls include environmental hazards, such as clutter, uneven surfaces, poor lighting, unsafe bathrooms, and poorly maintained equipment in and around the home. Education and intervention should be implemented to minimize the risk of falls and injury. Although clients need to be cautioned about the risk of falling, health providers must avoid instilling a fear of all physical activity. Exercise regimens that increase strength, balance, endurance, and body and environmental awareness reduce these risks. When counseled about exercise, Hazel should be told to avoid spinal flexion because bending the vertebral column forward potentiates compression spinal fractures. Rotation of the spinal column increases forces on the vertebral body. 6 Combined rotation and flexion can be especially dangerous and predispose people to vertebral fractures. Clients should be told to avoid heavy lifting and use good body mechanics in exercise and daily activities. Prescribed exercise should be weight-bearing, minimize the risk of injury, and bring the client pleasure. Golf and tennis are linked with an increased risk of vertebral fracture, although golf with putting only may be safe. Hazel expresses embarrassment about her protruding abdomen and kyphosis. Exercises that stretch the pectoral and hip flexor muscles, regain trunk extension flexibility, and strengthen the abdominal, erector spinae, and scapular muscles will help the patient minimize deformity and resume an erect posture. These exercises can be done early in the disease process to prevent kyphosis. Clothing should not constrain the abdomen because this could cause gastrointestinal or respiratory distress. Clinicians should suggest comfortable yet supportive undergarments and clothing fitting 20 Geriatric Nursing 2001 Volume 22 Number 1

closely around the neck to minimize the gapes caused by a rounded posture. On-line resources available to assist Hazel with her adjustment to osteoporosis include the National Osteoporosis Foundation (www.nof.org), Osteoporosis & Related Bone Diseases National Resource Center (www.osteo.org), and Office of Medical Application Research at the National Institutes of Health (text.nlm.nih.gov). Osteoporosis is a painful, debilitating illness predominately seen in older women. The devastating effects of osteoporosis can be minimized when health professionals and patients collaborate. Nurses have a unique role in empowering women to preserve and restore their bone mass. REFERENCES 1. National Resource Center. Osteoporosis and related bone diseases. Fast facts on osteoporosis. Washington (DC): Osteoporosis and Related Bone Diseases National Resource Center;1996. 2. McCance KL, Huether SE. Pathophysiology: the biologic basis for diseases in adults and children. 2nd ed. St. Louis: CV Mosby; 1994. 3. Nordin BE, Need AG, Horowitz M, Morris HA. Treatment of osteoporosis in the elderly. Clin Geriatr Med 1994;10:625-46. 4. Murray C, O Brien K. Osteoporosis work-up: evaluating bone loss and risk of fractures. Geriatrics 1995;50:41-53. 5. Galsworth TD,Wilson PL. Osteoporosis it steals more than bone.am J Nurs 1996;96:27-33. 6.Tresolini CP, Gold DT Lee LS, editors.working with patients to prevent, treat, and manage osteoporosis: a curriculum guide for the health professions. 2nd ed. San Francisco: National Fund for Medical Education; 1998. 7. Whipple B. Common questions about osteoporosis and menopause. Am J Nurs 1995;95:69-70. 8. Libanati C, Miller P, Rosen CJ. Prevention and treatment of osteoporosis. Primary Care Reports 1999;5:27-34. 9. Scarbo-DeHaan M. Management strategies for hormone replacement therapy. Nurse Practitioner 1994;19:47-57. 10. Whitmore SM. Rebuilding bone an overview of developments in osteoporosis management. Advance Nurse Practitioners 1998;6:30-5. 11. Herfindal ET, Gourley DR. Textbook of therapuetics drug and disease management. 6th ed. Baltimore: Williams and Wilkins; 1996. 12. Delmas P, Bjarmason N, Mitlak B, et al. Effects of raloxifene on bone mineral density, serum cholesterol concentrations and uterine endometrium in postmenopausal women. N Engl J Med 1997;337:1641-7. JANE ANTHONY PETERSON, MSN, RN, CS, ARNP, FNP-C, is an assistant professor in the graduate nursing studies family nurse practitioner program at Fort Hays State University in Hays, Kan. Copyright 2001 by Mosby, Inc. 0197-4572/2001/$8.00 + 0 34/1/113534 doi:10.1067/mgn.2001.113534 Geriatric Nursing 2001 Volume 22 Number 1 21

CE Contact hours: 1.0 Minimum passing score: 70% Test processing fee: $9 Test ID: G113534 1. Bone mass reaches its peak at which age? A. 30 B. 35 C. 50 D. 65 2. Age-related bone loss begins at which age? A. 30 B. 35 C. 50 D. 65 3. Primary osteoporosis Type I is characterized by all of the following EXCEPT: A. Rapid bone loss B. Osteoclast-mediated C. Beginning 5-10 years after menopause D. Osteoblastic-mediated 4. Primary osteoporosis Type II is characterized by all of the following EXCEPT: A. Slow bone loss B. Osteoblastic-mediated C. Beginning after age 70 D. Osteoclast-mediated 5. Which fractures associated with osteoporosis are most common? A. Hip B. Vertebral compression C. Colles D. Ankle 7. What is the recommended daily dose of calcium for postmenopausal women NOT taking HRT? A. 500 mg B. 1000 mg C. 1500 mg D. 2000 mg 8. Which risk factor was not listed as being associated with osteoporosis? A. Smoking B. Excessive caffeine C. Excessive alcohol use D. Obesity 9. Lifestyle changes recommended to lessen the effects of osteoporosis include the following EXCEPT: A. Regular exercise B. Adequate intake of vitamin A and E C. Fall prevention D. Avoiding deep spinal flexion 10.Pharmacologic interventions in osteoporosis treatment include the following EXCEPT: A. Corticosteroids B. Biposphonates C. Calcitonin D. Selective estrogen receptor modulators 6. What is the recommended daily dose of calcium for postmenopausal women on hormone replacement therapy (HRT)? A. 500 mg B. 1000 mg C. 1500 mg D. 2000 mg 22 Geriatric Nursing 2001 Volume 22 Number 1

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