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Osteoporosis

Oct 03, 20249 min read

A metabolic disease in which bone demineralization results in decreased density and subsequent pathologic fractures; the bones become progressively porous, brittle, and fragile. By far, it is the most prevalent bone disease in the world, contributing more than 1.5 million osteoporotic fractures every year. More patients have osteopenia, a precursor to osteoporosis.

  • It is projected that one of every three women and one of every five men over the age of 50 will have an osteoporosis-related fracture at some point in their lives.

Pathophysiology

Osteoporosis is characterized by reduced bone mass, deterioration of bone matrix, and diminished bone architectural strength.

  • The rate of resorption that is maintained by osteoclasts become greater than the rate of bone formation by osteoblasts, reducing total bone mass and bone mineral density (BMD); altered homeostatic bone turnover. This initially presents as osteopenia, progressing to osteoporosis. Bones start to fracture under stresses that would not break normal bone.
  • The most common form of osteoporotic fracture is of compression fractures of the thoracic and lumbar spine, hip fractures, and Colles fractures of the wrist, potentially being the first clinical manifestation of osteoporosis.
    • The gradual collapse of vertebra may be asymptomatic. Kyphosis related to osteoporosis is associated with a loss of height and postural changes resulting in a protruding abdomen, potential pulmonary insufficiency, and increased risk for falls related to loss of balance.
  • Aging is related to increased parathyroid hormone (inc. bone resorption), decreased calcitonin (dec. bone resorption inhibition), and decreased estrogen (also inhibits bone breakdown).

Risk Factors

  • Being female
  • Aging
  • African American women are at risk due to the prevalence of Sickle Cell and autoimmune diseases, and poor calcium intake due to lactose intolerance.
  • Patients with autoimmune diseases, often associated with nutritional deficiencies e.g. celiac, autoimmune liver disease. Many patients are prescribed corticosteroid medications, and have a resultant sedentary lifestyle, resulting in weak bones.
  • Alcohol intake of 3 or more drinks daily, and use of tobacco products
  • Family history
  • Immobility
  • Impaired glucose tolerance and diabetes

Diagnostic Examination

  • In significant demineralization, patients exhibit bone radiolucency, and osteoporosis may be detected in routine x-rays.
  • Osteoporosis is diagnosed by dual-energy x-ray absorptiometry (DEXA), which provides information about the BMD at the spine and hip, reporting its results as T-scores standardized around a 30-year-old healthy adult of the same sex.
    • This is recommended for baseline testing for all women over the age of 65, are postmenopausal and older than 50 years with osteoporosis risk factors, and for all people who have had a fracture suspected to be related to osteoporosis.
    • This may also be used for tracking treatment progress.
  • Fracture Risk may be assessed through the World Health Organization (WHO) Fracture Risk Assessment Tool (FRAX). This tool may underestimate risk for men, and so the Male Osteoporosis Risk Estimation Score (MORES) is used for a more gender-specific evaluation compared to FRAX for men.
    • Treatment is reserved for those with a 3% 10-year risk for a hip fracture or a 20% risk for other major fractures.

Prevention

Peak adult bone mass is achieved between 18 and 25 years in both ages, with men having thicker, larger, and heavier bones, resulting in men become osteoporotic later than women. Peak bone mineral density (BMD), which defines bone strength, occurs between 30 and 35 years of age.

  • Primary osteoporosis occurs in postmenopausal women as lowered estrogen contribute to rapid reduction in BMD. This also contributes to kyphosis related to aging and shortening in stature.

Management

  1. Medical:
    • A diet rich in calcium and Vitamin D throughout life, with an increased calcium intake during adolescence and middle years, protects against skeletal demineralization. These include skimmed vitamin D-enriched milk or other foods high in calcium (cheese and other dairy products), steamed broccoli, canned salmon with bones, etc., consumed daily.
      • A cup of milk or calcium-fortified orange juice contains 300 mg of calcium. The recommended daily intake of calcium for men 50 to 70 years is 1000 mg daily, going up to 1200 at 71 and above, and 1200 for women aged 51 and older.
      • The required Vitamin D intake is 400 to 1000 IU daily.
    • Regular weight-bearing exercise promoted bone formation. Recommendations include 20 to 30 minutes of aerobic, bone-stressing exercise daily. Weight training stimulates an increase in BMD. In addition, balance is improved, counteracting the incidence of falls and fractures.
  2. Pharmacologic Therapy:
    • Supplementation of Calcium with Vitamin D, combined with a drink rich in Vitamin C to aid in absorption. These only supplement treatment; they are not a primary form of prevention or treatment of osteoporosis.
    • Synthetic Human PTH Analogues: used in patients with advanced osteoporosis, and are treatment resistant.
    • Calcitonin: a thyroid hormone that inhibits osteoclastic activity, decreasing bone loss. This drug loses effectivity after 2 or more years of use, requiring break periods.
      • IM or SQ salmon calcitonin; intranasal Miacalcin may be used for convenience, to increase compliance, and minimize side effects. Alternate nostrils to prevent side effects e.g. nasal mucosal irritation.
    • Biphosphonate Therapy: not used in osteopenia; these medications bind with crystal elements in (especially spongy) bone tissue, and are given on empty stomachs only with water, while seated upright for at least 30 minutes after ingestion. Biphosphonate carries many gastric and esophageal risks, including gastritis, ulceration, and GI bleeding. It has also been linked to atrial fibrillation, osteonecrosis of the jaw, and subtrochanteric fractures.
      • Three common forms are Alendronate (Fosamax), Ibandronate (Boniva), and Risedronate (Actonel).
    • SERMs (Selective Estrogen Receptor Modulators) mimics estrogen while also blocking its effect elsewhere, reducing BMD loss in aging women. Raloxifene (Evista)
  3. Fracture Management:
    • Osteoporotic fractures of the hip are surgically managed by joint replacement or by closed or open reduction with internal fixation.
    • Colles fracture management is detailed here
    • Osteoporotic compression fractures of the vertebrae are managed conservatively. These findings should be reported to an osteoporosis specialist. Patients are often asymptomatic, but those who experience pain require acute care management.
      • A percutaneous vertebroplasty or kyphoplasty, an injection of polymethymethacrylate (PMMA) bone cement into the fractured vertebra, followed by inflation of a pressurized balloon is used to restore the shape of the affected vertebra. This management is highly contested in medical literature. This reduces pain and improves quality of life, but may contribute as another alteration in spinal mechanics. This is contraindicated by infection, multiple old fractures, and some coagulopathies.

Nursing Process

The Patient with a Spontaneous Vertebral Fracture Related to Osteoporosis

Assessment

  • Recognize the risks and problems associated with osteoporosis. Health history focuses on family history, previous factures, dietary consumption of calcium, exercise patterns, onset of menopause, and the use of certain medications such as corticosteroids.
  • Recognize symptoms of osteoporosis, such as back pain, constipation, and altered body image. Localized pain, kyphosis, and shortened stature may be discovered upon physical examination. Problems with mobility and breathing may exist as a result of changes in posture and weakened muscles.

Diagnosis

  1. Lack of knowledge about the osteoporotic process and treatment regimen
  2. Acute pain associated with fracture and muscle spasm
  3. Risk for constipation associated with immobility or development of ileus
  4. Risk for injury: additional fractures associated with osteoporosis

Planning, Goals, and Interventions

The major goals for the patient may include knowledge about osteoporosis and the treatment regimen, relief of pain, improved bowel elimination, and absence of additional fractures.

  1. Promoting the Understanding of Osteoporosis and the Treatment Regimen: focus on factors influencing the development of the disease, interventions to arrest or slow the process, and measures to relieve symptoms. Emphasize that all individuals require adequate calcium, vitamin D, and weight-bearing exercise to slow the progression of osteoporosis. Patients should also understand medication therapy. Stress that the existence of one fracture increases the probability of sustaining another.
  2. Relieving Pain: relief of back pain resulting from compression fracture may be accomplished by short periods of resting in a supine or side-lying. Use a supportive mattress, and maintain knee-flexion during rest and intermittent local heat and backrubs for muscle relaxation.
    • Instruct the patient to move their trunk as a whole, avoiding twisting. They may use a lumbosacral corset or other trunk orthoses for temporary support and immobilization, but this is often poorly tolerated, especially in older adults.
  3. Improving Bowel Elimination: institute a high-fiber diet with increased fluids, with prescribed stool softeners.
    • If a paralytic ileus is involved (as in a T10 to L2 vertebrae collapse), the nurse monitors patient intake, bowel sounds, and bowel activity.
  4. Preventing Injury: physical activity is essential to strengthen muscles, improve balance, prevent disuse atrophy, and retard progressive bone demineralization. Isometric exercises can strengthen the trunk muscles. Walking, good body mechanics, and good posture are all encouraged. Daily weight-bearing activity, preferably done outdoors (promote Vitamin D activation), is encouraged. Avoid sudden bending, jarring, and strenuous lifting.

Evaluation

  1. Acquires knowledge about osteoporosis and the treatment regimen: states relationship of calcium and vitamin D intake and exercise to bone mass, consumes adequate dietary calcium and vitamin D, and takes prescribed medications with proper administration.
  2. Achieves pain relief: experiences pain relief at rest, minimal discomfort during ADLs, and diminished tenderness at fracture site.
  3. Demonstrates usual pattern of bowel movements
  4. Experiences no new fractures: maintains good posture, good body mechanics, engages in weight-bearing exercises (e.g. walking daily), creates a safe home environment, and accepts assistance and supervision as needed.

Review Questions

  1. A patient may have osteoporosis unknowingly because:
    • Most women die before it becomes a problem.
    • Fractures resulting from osteoporosis are rare.
    • There is no way to determine the mineral content of the bone.
    • There are no clear warning signs and symptoms.
  2. Which of the following diagnostic tests best evaluate the severity of a patient’s osteoporosis.
    • Computed tomography scan
    • Bone Scan
    • Magnetic Resonance Imaging
    • Dual-energy X-Ray Absorptiometry
  3. Nursing intervention in Biphosphonate medication includes:
    • Advise clients to lie down after taking the drug
    • Advise the client to take the drug at night
    • Advise the client to remain upright 30 minutes after taking the drug
    • Instruct the client to take the drug with meals
  4. Which medication is administered to suppress bone loss, and increase bone mineral density?
    • NSAIDs
    • Corticosteroids
    • Calcitonin
    • Glucocorticoids
  5. All are true about the drug therapy for osteoporosis except:
    • Calcium alone is a form of treatment
    • Biphosphates inhibit bone resorption
    • SERMs mimic estrogen in some parts of the body
    • Calcitonin inhibits osteoclastic activity

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