Osteoporosis the Silent Thief

Author: Mark Parkinson RPh:  President  AFC CE

Credit Hours 2- Approximate time required: 120 min

Educational Objectives:

1. Define Osteoporosis.

2. Present the anatomy and physiology on the Bone

3. Explain the natural aging process of bone loss

4. Expound the details of Osteoporosis.

 5. Set forth the Roll of Adult Foster Care Providers

6.  Present principle of fall prevention.

 

Procedure:           

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 Disclaimer

The information presented in this activity is not meant to serve as a guideline for patient management. All procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this article should not be used by care providers without evaluation of their patients’ Doctor. Some conditions and possible contraindications may be of concern. All applicable manufacturers’ product information should be reviewed before use. The author and publisher of this continuing education program have made all reasonable efforts to ensure that all information contained herein is accurate in accordance with the latest available scientific knowledge at the time of acceptance for publication. Nutritional products discussed are not intended for the diagnosis, treatment, cure, or prevention of any disease.

 

Osteoporosis, the Silent Thief

 

     About 20 years ago when I had my Adult Foster Care Homes, one of my residents was an 80-something resident named Martha (named changed). Martha was a typical adult foster care client.  No major health concerns, not wobbly on her feet.  She pretty much took care of herself and continually stayed in a little alcove which we had set up for her.  Overall, she was a quiet, stable patient with just the occasional grouchiness.  Just the kind of client you want to fill your home with.

   One day I was in the kitchen doing my duties when I heard what sounded like a bag of potatoes that had been dropped on the floor. Being an experienced caregiver, I knew what the sound was – one of my clients had fallen. I hurried to where the sound came from and found Martha on the floor of her room.  Martha was a bit embarrassed and started babbling that she did not lose her balance or trip on anything. She had just stood up and heard a click, and down she went. I asked her if she was hurt anywhere and she said that she was okay. I assured her that it wasn’t all that bad and I would help her up. I couldn’t have been more wrong.

      When we couldn’t get her up I knew that things were a bit more serious than I had originally thought.  We ended up sending her to the hospital, where an x-ray showed a broken hip.  After further examination the Doctor concluded that the hip had broken before she had fallen.  He explained further, saying that the hip was very fragile and just snapped when she stood up.  He diagnosed Martha as having a spontaneous fracture caused by a severe case of osteoporosis.   I was shocked.  I thought, “How was that possible? How can you break a hip just by standing up.” 

     The doctor fixed the hip and put her in a nursing home to recover. She did not do well, there. She never came back home again and died in that nursing home within a year.  It was hard to lose a stable, easy-to-care-for patient.  I did not know what more I could have done to prevent this tragedy.  It was not until many years later that I finally found out what more I could have done.  Now, I am passing that info on to you.  Hopefully, it will help you to prevent future Marthas happening in your home.

 

What is Osteoporosis?

 

     The Bantam Medical Dictionary defines osteoporosis as a “loss of bony tissue, resulting in bones that are brittle and liable to fracture… Generalized osteoporosis is common in the elderly.”   

     Bones are the support system of our bodies. They allow us to stand erect, move and do work. The skeletal system serves as scaffolding that provides anchors for our muscles and supports and protects our organs. It also acts as a storehouse for many vitally important minerals, like calcium, phosphorous and magnesium.  Each bone is a hard, semi-rigid material derived mainly from connective tissue covered with dense inorganic mineral deposits.  Normally, they are made to be strong and not easily broken, but in osteoporosis their strength has been robbed.

     Osteoporosis literally means porous bone. Viewed under a microscope the osteoporotic bone is a matrix full of holes – voids where bone material is suppose to be. It’s as if something came along and stole the bone material. As a result, the bone is robbed of its strength. It becomes brittle and prone to fracture. Activities and impact occurrences that were once considered of no consequence are now considerable risk factors for broken bones. Where did the bone material go and how did it happen?

     Let’s begin with a short lesson in bone anatomy and physiology and how it relates to the mystery of osteoporotic bone loss.  As you know, your bones are the semi-rigid skeletal organs of your body.  Most of us think of our bones as solid, hard, unchanging objects.  Really, bones are a living part of your body, complete with a rigid, mineralized structure, marrow, a blood supply, a slight nervous system presence and cartilage. The hard part of the bone is a complex matrix of minerals, caliginous material and several different types of bone cells. The mineral portion of the bone is composite material formed mostly of calcium phosphate.  All together, the bone is referred to as osseous tissue. When properly formed and maintained, our bones are lightweight, yet hard and strong. 

     It may surprise you to know that your bones are not static, but are in constant flux. They are going through a perpetual turnover of material called remodeling. It is a continuous process of bone formation and bone breakdown. Remodeling is done by specialized bone cells, of which there are three main types.

  1. Osteoblasts are bone builders, responsible for laying down the deposits of minerals.
  2. Osteoclasts break down the bone in a process known as reabsorption. Reabsorption is a necessary function. It releases the minerals we need from the bone.
  3. Osteocytes are more or less responsible for bone maintenance.

      Each cell operates constantly and their numbers and functions are balanced based on the needs of the body.  When we are young the balance is tipped toward bone formation, which peaks in our early 20’s and starts to level off in our 30’s.  After the formation and growth period, the balance tips toward maintenance. The bone is broken down and built up at about the same rate. If we need stronger bones (like in heavy work), stimulation tips the balance toward formation again. If we aren’t working hard the formation stimulus is turned off.  The balance tips back toward maintenance and the unneeded bone mass is reabsorbed . 

     If the balance tips too far toward reabsorption for too long, we start to lose too much bone material.  The osteoclasts eat away at the bone, leaving behind ever increasing voids. Your bones don’t shrink, so the continued bone loss results in more and more porous bones.  If too much bone mass is lost, we fall into the condition of osteoporosis.  The mystery of osteoporosis is that our own body processes are robbing us of the bone strength we need.

 

Natural Aging process and bone loss 

 

     There is a natural loss of bone strength over the length of our lives. Up to 10% of all bone mass may be undergoing remodeling at any point in time. As we age, a number of factors combine that prevent us from replacing what is lost.

Reduced Bone Builders

As we age, the number of new osteoblasts starts to decline.

Reduced Hormone Activity

The hormones estrogen and testosterone are very important in maintaining our bones.  They are part of the signals involved in increasing the amount of bone material being deposited, while decreasing its breakdown.  When we age there is a natural reduction in hormone production.  Women are particularly at risk after menopause, when estrogen production plummets to low levels.  With reduced hormone levels, the reabsorption process begins to dominate.

Physical Inactivity

As we age we are less likely to engage in physical activity, reducing the need for bone mass.  The old saying goes, “When you don’t use them, you lose them.”  Plus, natural decline is felt in other body processes, hampering efforts at exercising our bodies at previous levels.

Poor Nutrition

Our bone cells need materials to make bones.  If the minerals like calcium aren’t in the foods we eat, new bone cannot be made.  Our diets in general are veering away from calcium rich foods, such as dairy products, broccoli and spinach.  The eating habits of the elderly tend to be deficient and they tend to eat less.

Another area of poor bone nutrition comes from an unusual source.  In order to absorb calcium into our system we need plenty of vitamin D.  Sunlight hitting our skin is a major source of vitamin D.  The elderly are less likely to have sufficient exposure to the sun.  Even if they do go out, they hide themselves from the sun under layers of clothes, sweaters and hats.

 

Why does Osteoporosis happen?

 

     Bone mass loss is a natural part of the aging process, but Osteoporosis does not happen to everyone. Osteoporosis develops when there is an inadequate peak bone mass to offset natural bone loss, excessive bone reabsorption, and inadequate formation of new bone during remodeling. To some it just randomly occurs, while others make choices that allow problems to arise. Factors that can increase the likelihood of an individual developing this condition are lifestyle choices, body size, genetics, gender, certain medicines and diseases.   

 

Lifestyle choices

     These are factors that are under our conscious control. They are choices we make regardless of their negative impact on our health.

Alcohol Use

High levels of alcohol use speeds bone loss through several different factors.  It changes protein and calcium metabolism, decreases hormone production, reduces the activity levels and leads to a poorer diet.  Alcohol also has direct toxic effect on the osteoblasts.

Cigarette Smoking

Smoking leads to weakened bones. The exact reason for this is not well understood. Smoking does lead to a reduced body size. It also promotes an early onset of menopause and may speed up the breakdown of the estrogen.

Sedentary Lifestyle and Improper Diet

An inactive lifestyle and poor diet at any age contribute to the lack of bone build-up, reducing the peak bone mass an individual will obtain.  It is noteworthy that eating disorders like anorexia put people at particular risk.

 

Inherited Factors

     Some factors are not under our control, but are due to the characteristics of the body we were born with.

Body size

People who are small or very thin may not develop sufficient peak bone mass to draw from as their bodies age.

Genetics

You are at greater risk if you are White, Asian or have a family history of Osteoporosis.

Gender

It is estimated that men will lose 4% of their bone mass every decade.  Unfortunately, women will lose 15% per decade after menopause.

 

Health Related Factors

     Reduced activity levels due to chronic illness certainly contribute to reduced peak bone mass. In addition, there are certain illnesses and medications that have a more direct effect on bone loss.                                                                                    

Chronic Illness

Diseases prevent the body from functioning normally, which can have an ill effect on our bones.  The diseases that effect bones the most are Hyperthyroidism,  Rheumatoid Arthritis, Chronic Kidney Diseases, and eating or digestion disorders (as many as 30% to 60% of people with Crohn's disease or ulcerative colitis have lower-than-average bone density).

Medication

As we get older we tend to use more medications, which sometimes have the unfortunate side effect of depleting our bone mass .  The culprit medicines are the corticosteroids (prednisone, methylprednisolone, dexamethasone ), anti-consultants (phenytion), chemotherapy agents (methotrexate, aromitase inhibitors), aluminum containing antacids (Amphojel, Maalox, Mylanta),long term blood thinner use, and excessive thyroid replacement therapy. 

 

How Many People Have Osteoporosis?

 

     In the United States today it is estimated that 44 million people have osteoporosis.  More than half of all adults aged 50 and older have the condition.  Another 34 million have osteopenia, a precursor of osteoporosis.  The actual number might be even higher, because the condition is considered a “silent disease”, meaning that there are no obvious signs or symptoms. Often patients are unaware that they have significant bone loss until they experience a fracture.

 

What Are The Consequences of Osteoporosis?

 

The main consequence of weak bones is fractures. Broken bones are responsible for considerable pain, decreased quality of life, and disability. Up to 30% of patients suffering a hip fracture will require long-term nursing-home care.  Osteoporosis has even been linked with an increased risk of death. Some 20% of women with a hip fracture will die within a year as an indirect result of the fracture. Most often fractures are due to falls and are seen most often in the hip, legs or wrist. 

     Some fractures just happen and are due to the bone being too weak for the weight put on them.  Some can be dramatic, as in the case of Martha, but most are not. They are called spontaneous, collapse or compression fractures.  They are often seen in the spine.  Between 35-50% of all women over 50 have had at least one vertebral fracture.  Compression fractures can be very small without any signs that they have occurred. As the fracturing continues their effects start to accumulate and outward symptoms may occur, such as unexplained pain, height loss or curving of the spine.

 

How Can You Tell If A Person Has Osteoporosis?

 

     A body can’t feel bone loss. So many people go about life with extremely fragile bones and don’t know about it. If the problem was known, then therapy could be applied before bones are broken.  So how can you tell if a person suffers from major bone loss, so you can give them therapy?

     The proper question is, “How can you tell which one of your clients is at risk for bone loss related problems?”  The answer would be, “All of them are at risk!”.  Because age and inactivity are risk factors, it can be assumed that most of the elderly in Adult Foster Care homes either have or, without proper therapy, will have significant bone loss.

     Naturally, some have more bone loss than others. Those you can expect to have more problems are clients who have one or more of the following:

1) family history of broken bones

2) weight less than 127 lbs.

3) significant loss in total height

4) unexplained lower back or neck pain

5) have been on long term oral corticosteroids

6) suffer from Kyphosis (an abnormal curvature of the spine that makes you look like a hump back)

If you suspect that any of your clients are at greater risk of a major fracture they should be sent to the Doctor.

 

What Can the Doctor Do?

 

      Doctors today have a wide variety of tests that they can do to measure the density of our bones.  Medicare pays for these tests every 2 years.  They are painless and as easy to do as an X-ray.

     The gold standard test is the dual-energy X-ray (DXA). Using X-rays, bone mineral density is measured and divided by the volume of the measured bones.  The doctor then compares the measurement to the population average – either a T-score or a Z-score.  A T-score (young normal score) is calculated by comparing density measurements to a healthy same-gender 30-year-old.  The lower the score, the worse it is.  A T-score of 1 or higher indicates normal bone density.  A scores of -1 to -2.5 indicates Osteopenia, while a score of -2.5 or lower indicates Osteoporosis.  The Z-score (age-matched) is a comparison with a healthy same-gender person of the same age as the patient. 

     Doctors could also take some blood tests to measure the amounts of calcium, phosphorous and vitamin D in the blood to see if anything is lacking.  Once the examinations are complete, the Doctor can prescribe the appropriate therapies.

 

Outlook (Prognosis)

 

     Unlike 20 years ago, in cases like Martha’s, considerable advances have been made in the management of Osteoporosis and the outlook is very good.  There are better diagnostic tools for the Doctors, better medicines that treat the underlying causes, and better aids to help the patient improve bone health.

      Though vertebrae that have already collapsed cannot be reversed, new techniques have been developed that can minimize the pain and reduce the disability. A procedure called Vertebroplasty injects fast hardening glue into the small fractures in the spine, strengthening the area.  Even with severe Kyphosis  physiatrists (rehabilitation physicians), physical therapists and occupational therapists  can help the patient learn to control the pain and manage their disability. If a major fracture occurs, newer surgical techniques have been developed that have shorter recovery times. As a result, death rates associated with indirect problems arising from Osteoporosis are falling.

 

Osteoporosis Therapies

 

     There are a number of Osteoporosis therapies available to the patient’s Doctor and caregivers. Some manage the underlying health problems that have occurred, while others attempt to modify behaviors that have contributed to the problem.  The goals of therapy are to eliminate or slow down events that accelerate bone loss, maintain proper bone health, prevent fractures, and control the consequences of fractures that have already happened.  

 

Medicines

     There are two types of medicines that help in treating Osteoporosis: medicines that treat the underlying causes, and supplements to replace essential nutrients and hormones that are lacking.

Bisphosphonates

     Bisphosphonates slow the bone breakdown process and are considered drugs of first choice by most doctors (1st line agents). They are Alendronate (Fosamax), Risendronate (Actonel), Ibandronate (Boniva) and Zoledronic acid (Reclast).  Food interferes with Bisphosphonates. Also an additional concern is if the pill gets lodged in the throat, it cancause serious harm. Therefore Bisphosphonates  should be taken on an empty stomach and the patient must remain upright for 30 minutes. Do not crush or chew theses meds. The main side effects are nausea and heartburn.

     Alendronate is the only available generic med. Alendronate (Fosamax), and Risendronate (Actonel) come in a daily or weekly tablet. Ibandronate (Boniva) comes as a monthly tablet or an IV (intravenous) that lasts for 3 months. Zoledronic acid (Reclast) is a once-a-year IV infusion.  For those who have difficulty chewing or swallowing medications, Fosamax liquid or the IV preparations should be considered.

Estrogen (Hormone Replacement Therapy- HRT)

     Replacing the missing hormones is quite effective at reducing fractures, but is not used as a primary osteoporosis medication anymore, because of the increased risk of cancer, strokes or venous thrombosis.

Selective Estrogen Receptor Modulators (SERM)

     SERMs mimics estrogen in the body, but its use reduces the dangerous secondary effects of the hormone. Raloxifene (Evista) is the only available osteoporosis SERM and it comes as a generic. The major side effects are hot flashes and leg cramps. Raloxifene can be crushed.

Calcitonin

     Calcitonin (Miacalcin or Fortical) is a drug that binds to osteoclasts and slows them down. It comes as a nasal spray or as an injectable and is available generically. If used within a month it can be stored at room temperature. Storage longer than 30 days requires refrigeration.  Side effects are headaches and nasal problems.  Calcitonin appears to reduce bone fracture pain. 

Parathyroid Hormone

    The synthetic parathyroid hormone teriparatide (Forteo) stimulates bone formation in addition to reducing reabsoprtion. There is no generic for Forteo and it may cause bone cancer.  Side effects are insomnia, nausea and dizziness. Forteo is a once-a-day injection and should be refrigerated in between uses.

Calcium Supplements

     Adequate Calcium intake is essential to bone heath and patients should receive 1200 to 1500 mg a day, considering all sources. Along with a proper diet, supplementation may be required. There are many forms of calcium supplements. Many are available in OTC preparations, including chewables and a liquid form of coral calcium. In my opinion, unless there is a specific metabolic need, any calcium supplement would be adequate. The major side effect of calcium is constipation.    

Vitamin D (Calciferol)

     Vitamin D is needed in order to absorb calcium in the intestine. Our bodies produce it when sunlight shines thru fat reserves in our skin.  Supplements are measured in international units (IU) and it is recommended that we get 400 IUs a day.  If supplements are required, they can be obtained in several OTC strengths. There are several Rx versions, including a mega dose of 50,000 IU. Vitamin D is well tolerated.

 

Nonpharmaceutical Therapies

     Many factors under our control affect the development of Osteoporosis and its occurrence is the result of a lifetime of choices. Long term therapies are based on control of these factors and attempt to build up as much as possible our peak bone mass. Therapies utilized in geriatrics concentrate mainly on proper diet, sun exposure, bone-building exercises and fracture-reducing movement and posturing. 

 

Adult Foster Care and Osteoporosis

 

     Adult foster care can play a very important role in keeping our graying population healthy and strong.  But in my opinion, adult foster care is a largely an underutilized and underappreciated segment of our healthcare industry.  Who else actually lives with their patients 24/7?  Who else can implement and maintain the necessary lifestyle changes and therapies that are required, and do so month after month, year after year?

     Adult Foster Care providers are particularly useful in the treatment of osteoporosis.  Bone building and bone health are long term processes and consistent long term efforts are needed. Proper medication management, diets and exercise must be encouraged for the rest of the patient’s life. In addition, supervision is needed to ensure the use of walking aids that prevent falls and the correction of improper postures that cause fractures.  AFC providers must also maintain a safe “slip and trip” free environment while still maintaining a homelike lifestyle. It is in this safe and supportive lifestyle that the AFC home provides what is truly needed by the osteoporotic patient. 

 

     I would recommend that every resident of your homes gets a bone density screening at least every two years. It would also be beneficial to question each resident to see if there is a family history of broken bones.

 

Preventing Falls

 

     Each year about one-third of all persons over age 65 will fall.  Fall prevention is a basic part of your caregiving responsibilities. If you have patients that are osteoporotic, fall prevention is particularly important. In some cases it could be the difference between a comfortable life and a slow, lingering death. Remember the Martha story?

 

Your Home

     You must make you home free from slip and trip hazards. Because things get moved around, you must periodically inspect your home for these hazards.

 

Outdoor safety

     Install stair hand railings or wheelchair ramps. Keep sidewalks free of leaves, clutter, snow and ice. Make sure that home approaches are well lit and maintained.  Have a loaner wheelchair the resident can borrow for outside trips. Inexpensive ones can be obtained at second-hand stores.

 

Indoor safety

      Remove all loose wires and cords. Watch the placement of footstools, end tables, magazine racks and other trip hazards. Maintain proper lighting day and night. Keep a clutter-free floor. Install grab bars by the tub, shower and toilet. Keep commodes close to the bed at night and promptly remove them in the morning.  Use skid-free area rugs on slick floors and replace them when they are worn. Clean up spills promptly. Use a shower or tub chair for bathing. Mark the top and bottom of steps with bright tape.

 

The patient

     Watch the patient for signs of drowsy or dizzy behaviors. Regularly monitor blood pressures, blood sugars and oxygen levels, if required. Make sure the resident has proper foot wear. Discourage feet shuffling. Escort residents with walking problems. Assist in transferring.  Place items within reach so the patient doesn’t have to bend, stoop or reach too high. Consider the use of toilet risers, transfer boards or long-handled grasping devices.  Encourage the resident to get up slowly.

Make sure the patient has proper and clean eyeglasses.

 

Conclusion

 

     As our population grows older, elderly bodies start wearing down.  Some even break.  The Adult Foster Care industry must step up to meet this ever-increasing need.  It will take caring, well-educated professionals, who know what to do, how to do it and do it consistently.  Adult foster care can play a very important role in keeping our graying population healthy and strong. 

 

 

More resources can be found at the National Osteoporosis Foundation (NOF)

at  http://www.nof.org

 

 

References

1.   National Osteoporosis Foundation.

http://www.nof.org/

2.   Osteoporosis. Wikipedia The Free Encyclopedia.

http://en.wikipedia.org/wiki/Osteoporosis

3.   Osteoporosis, Thin Bones . Pub Med Health.

 http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001400/

4.   Human Skeleton. Wikipedia The Free Encyclopedia.

http://en.wikipedia.org/wiki/Human_skeleton

5.   Bone, Answer.com Reference answers

http://www.answers.com/topic/bone

6.   R.L Jilka, Osteoblast Progenitor Fate and Age-related Bone Loss, J Musculoskel Neuron Interact 2002; 2(6):581-583 http://www.ismni.org/jmni/pdf/10/28Jilka.pdf

7.   Osteoporosis. MedicineNet.com

http://www.medicinenet.com/osteoporosis/page2.htm

8.   Jane E. Brody, Osteoporosis. Health Guide, New York Times (May 9, 2011).  http://health.nytimes.com/health/guides/disease/osteoporosis/overview.html

9.   Drugs A-Z RxList the Internet drug Index.  

http://www.rxlist.com

10. Vitamin D. Wikipedia The Free Encyclopedia.

http://en.wikipedia.org/wiki/Vitamin_D

11. Osteoporosis MedLine Plus NIH National Institute of Health.

http://www.nlm.nih.gov/medlineplus/osteoporosis.html

12. Joanne Fleuer PharmD MSPH Osteoporosis: “Need-to-Knows” for Pharmacists About Bone
Health. Pharmacy Times Special Issue: Women’s Health. (06,2009)

 

Osteoporosis the Silent Thief

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