Osteoporosis in women over 55 years of age

James Ford
DPT student Kathleen Mongiovi FNP student Michelle Gideon FNP student

(Google Images. Osteoporosis)

Overview
In evaluating the health needs of women over 55 there are many health conditions that need to be addressed

Cardiovascular disease, colorectal and breast cancer, and osteoporosis take the forefront of health screening for women who are postmenopausal

As the aging woman experiences the lower levels of estrogen there can be a significant decline in the patients overall function, especially when they experience a fracture

(Riley, Dobson, Jones, and Kirst, 2013)

Overview
As a woman enters menopause, the health maintenance regimen changes to reflect her health status change.
U. S. Preventative Services Task Force (USPSTF) and the American College of Obstetricians and Gynecologists (ACOG) have identified guidelines regarding health maintenance that include:

Mammography recommended biennially in women 50-74

Yearly health maintenance examination Tobacco, Alcohol, Cage and AUDIT-C screenings Screenings for STIs, and HIV up to age 65 Screenings for cardiovascular disease, obesity, hypertension, dyslipidemia and diabetes Pap smears to continue up to age 65 Colorectal screenings begin at age 50
(Riley et al., 2013)

Overview

The incidence of fracture increases as a woman ages The potential for low trauma fracture reaches levels of > 50% of women over 65 Leading to: Worsened quality of life Substantial health costs Premature mortality
(The Royal Australian College of General Practitioners (RACGP) , 2010)

Overview
As a result: It is imperative that practitioners be mindful of the risks and incorporate as many preventative measures and health maintenance activities into the screening of older women

Most notably:
Osteoporosis screenings need to begin at age 65 or earlier in women who are at risk for fractures that include features of the FRAX tool, developed by the World Health Organization (WHO)

(World Health Organization [WHO], n.d.)

So, what is osteoporosis?

Osteoporosis is defined as a systemic skeletal disease

characterized by low bone mass and microarchitectural

deterioration of bone tissue, with a consequent increase in bone fragility and a susceptibility to fracture.

(Kanis, McCloskey, Johansson,

Cooper, and Rizzoli, 2013, para 2)

Clinical Symptoms

Osteoporosis is considered a silent disorder because there is no outward presentation of symptoms until their is a symptomatic fracture
Sometimes presents as a loss of vertical height Often defined as loss of > 20% of vertebral height

Occurs in 5% of people over age 50 and 50% of those over age 80

It is estimated that 90% of hip fractures occur in women over age 50 (RACGP, 2010)

Consequences

The risk for death following an osteoporotic fracture is greatest within the first 6 months especially in those who have suffered a hip fracture

Effects on mortality last up to 5 years after a vertebral fracture, even earlier for hip fractures

Many patients lose their ability to live independently and are required to move into skilled nursing facilities, assisted care, or live with relatives leading to depression and dependence

(RACGP, 2010)

Facts about osteoporosis

Density and mass of bone reduced

Most common metabolic disease 50% of women 20 million women in the US Bone loss begins before menopause Usually undiagnosed until after fracture

(Tabloski, 2006, p.56) (McCance, Huether, Brashers, and Rote, 2010) (Google Images. Osteoporosis)

Risk Factors

Modifiable low calcium intake prolonged immobility excessive alcohol intake cigarette use

Non-modifiable increased age female white and asian-ethnicity consideration family history Thin/petite

long-term use of thyroid hormones, anticonvulsants, and corticosteroids

Physical findings

History of loss of height

Diminished range of motion (ROM) particularly with internal rotation or flexion of hips

Low body weight Subtle collagen defects such as short fifth digits, hyperlaxity, and bunions

Thoracic kyphosis or Dowagers hump or scoliosis

Decreased balance control Acute pain in back after bending, lifting, or coughing (may also be asymptomatic)

Treatment and management

Because of the significant risk of disability, morbidity and mortality, and expenses, due to fractures in the elderly, the American College of Physicians (ACP) has made recommendations aimed at prevention including the use of weight-bearing and musclestrengthening exercise, modification of lifestyle factors, and improving calcium and vitamin D intake The National Osteoporosis Foundation (NOF) recommends that further medication management be reserved for use in postmenopausal women rather than prophylactically administered Included in the care of the patient with osteoporosis would be the administration of bisphosphonates, parathyroid hormone, raloxifene, and estrogens

(Jacobs-Kosmin and Shanmugam, 2013)

Medication management
Bisphosphonates
Both oral and parenteral preparations of bisphosphonates have shown to slow the progression of osteoporosis in postmenopausal women Alendronate reduces the rate of hip fracture at the spine, hip, and wrist by 50% according to well-controlled clinical trials

Compliance can be difficult because it must be taken on an empty stomach and the patient must be able to sit up for at least 30 minutes before eating
Also available in combination with Vitamin D3 Parenteral administration of zoledronic acid or ibandronate is also available as an IV infusion to those who are intolerant of oral administration

(Jacobs-Kosmin and Shanmugam, 2013)

Medication management
Selective estrogen receptor modulator (SERM) Raloxifene prevents bone loss and causes a 35% reduction in the risk of vertebral fractures Shown to reduce the prevalence of invasive breast cancer Useful in younger postmenopausal women without severe osteoporosis because the endometrium was not stimulated thereby reducing the need for progesterones. Most common side effect were hot flashes Most common risks are blood clots, emphasize mobility and not smoking
(Jacobs-Kosmin and Shanmagam, 2013)

Medication management
Hormone replacement therapy (HRT)/Estrogen
Considered first line treatment in the past Very effective but adverse events outweigh benefits from combination use of estrogen and progesterone
Breast cancer, myocardial infarction, stroke, and thromboemboli Lowest/Shortest

(Jacobs-Kosmin and Shanmagam, 2013)

Dietary measures
Adequate calcium intake is imperative to the prevention and treatment of osteoporosis Postmenopausal women should receive 1000 mg of calcium daily

Dietary sources include:

Dairy products, sardines, nuts, sunflower seeds, tofu, vegetables and fortified foods

Adults older than 50 should receive 800-1000 IU of Vitamin D3

Excessive alcohol can increase the production of PTH thereby inhibiting Vitamin D3

(Jacobs-Kosmin and Shanmagam, 2013)

Tests
Dual Energy X-ray Absorptiometry
The Gold standard for diagnosing osteoporosis Use of X-rays working at two energy levels assessing the bone mineral density at any area needed. Able to localize to specific bone density of areas like lumbar spine and proximal femur Takes 20 minutes and involves the same radiation exposure as a normal X-ray Gives objective BMD data Can also measure Body Fat %

Computerized Tomography (CT Scan)

Can detail a better picture of trabecular vs cortical bone Higher amount of radiation (Winzenburg T, Jones G, 2011)

DXA Test

Exercise Protocol
In postmenopausal women, the emphasis should be on maintenance of bone mass, which can be achieved through weight bearing physical activity Frequency: Weight-bearing endurance activities 3-5 times per week, resistance exercise 2-3 times per week Intensity: Moderate to high intensity in order to place adequate stress on the bone for remodeling Time: 30-60 minutes per day Type: Weight-bearing endurance activities, especially any that involve jumping or exercise against resistance Wolffs Law: As loading is applied to a bone, the bone will remodel itself to become stronger to resist that stress in the future. Inversely, when bone does not receive loading it will become weaker. (Kohrt, Bloomfield et al, 2004)

Exercise Examples
Some common ways for women over 55 to meet the requirements for bone density maintenance are through sports and membership to a gym. Walking/jogging programs Tennis Weight/resistance training at gym or at home Aerobics/ Dance classes

Screening Tool

Screening Questions: 1. How old are you? 2. What is your height and weight? 6. What kind of medications are you taking? 7. Have you ever had a BMD test performed? 8. How many servings of calcium do you consume everyday? 9. Do you do weight bearing exercises at least 3-5 per week and resistance training 2-3 per week?

3. Do you or your family members

have a history of fractures and/or osteoporosis? 4. Do you smoke? 5. How much alcohol do you consume?

Screening Tool continued

Physical Findings Tests Referrals

1. A decrease in height
2. Low body weight 3. Tenderness of the vertebrae 4. Decreased ROM 5. Decrease in balance

1. DEXA
2. CT

1. Endocrinologist
2. Rheumatologist 3. Orthopedic/spinal surgeon 4. Dietician 5. Physical therapist

6. Counselor

Recommendations
Eat a balanced diet high in fruits, vegetables, calcium and vitamins Increase intake of calcium Get enough Vitamin D including adequate but safe exposure to sunlight Avoid excessive alcohol consumption Smoking cessation Maintain healthy body weight Be physically active and include weight bearing and muscle strengthening exercises Consider medications Eliminate environmental factors that contribute to accidents

Be aware of side effects of current medications

Referral process
Endocrinologist or Rheumatologist

Orthopedic surgeon or spine surgeon

Dieticians

Physical Therapist

Counselor

Online Resources
National Osteoporosis Foundation- Learn, Live, Connect www.nof.org

International Osteoporosis Foundation- Research, Information, Publications www.iofbonehealth.org

References

International Osteoporosis Foundation. http://www.iofbonehealth.org/osteoporosis Jacobs-Kosmin, D., & Shanmugam, S. (2013). Osteoporosis treatment and management. Retrieved from Medscape: http://emedicine.medscape.com/article/330598treatment

Kanis, J. A., Mc Closkey, E. V., Johansson, H., Cooper, C., Rizzoli, R., & Reginster, J.-Y. (2012). European guidance for the diagnosis and management of osteoporosis in postmenopausal women .Retrieved from Osteoporosis International: doi: 10.1007/s00198-012-2074-y
McCance, K. L., Huether, S. E., Brashers, V. L., and Rote, N. S. (2010). Pathophysiology: The biological basis for disease in adults and children. 6th ed. Mosby: Maryland Heights, MI. National Osteoporosis Foundation. http://nof.org/resources Riley, M., Dobson, M., Jones, E., & Kirst, N. (2013). Health maintenance in women. American Family Physician, pp. 87(1), p30-27, from http://www.aafp.org/afp/2013/0101/p30.html.

References

Tabloski, P. A. (2006). Gerontological Nursing. Pearson: Upper Saddle River, NJ.

The Royal Australian College of General Practitioners (2010). Clinical Guideline for the Prevention and Treatment of Osteoporosis in Postmenopausal Women and Older Men, http://www.racgp.org.au/download/documents/Guidelines/Musc uloskeletal/racgp_osteo_guideline.pdf

World Health Organization. (n.d.). FRAX: WHO Fracture Risk Assessment Tool. Retrieved from World Health Organization Collaborating Center for Metabolic Bone Diseases: http://www.shef.ac.uk/FRAX/tool.aspx?country=9
Winzenberg T, Jones G. Dual energy X-ray absorptiometry. Australian Family Physician. 2011;40:43-44. Kohrt WM, Bloomfield SA, Little KD, Nelsen ME, Yingling VR. Physical activity and bone health. Med. Sci. Sports Exerc. 2004;1985-1996.