OsteoporosisOsteoporosisMetabolic Bone DiseaseMetabolic Bone Disease

OsteoporosisOsteoporosisCharacterized by low bone mass and structural deterioration

Normal homeostatic bone remodeling is altered – the rate of bone resorption is greater than the rate of bone formation.

OsteoporosisOsteoporosisChronic, progressive metabolic bone Chronic, progressive metabolic bone disease characterized bydisease characterized by– Porous bonePorous bone– ___ ____ _______ ____ ____– Structural deterioration of bone tissueStructural deterioration of bone tissue– Increased bone fragilityIncreased bone fragility

OsteoporosisOsteoporosis

Eight times more common in women than Eight times more common in women than men for several reasonsmen for several reasons

1.1. Lower calcium intake than menLower calcium intake than men2.2. Less bone mass because of smaller frameLess bone mass because of smaller frame3.3. Bone resorption begins earlier and Bone resorption begins earlier and

accelerates after menopauseaccelerates after menopause

4.4. Pregnancy and breastfeeding deplete Pregnancy and breastfeeding deplete woman’s skeletal reserve of calciumwoman’s skeletal reserve of calcium

5.5. Longevity increases likelihood of Longevity increases likelihood of osteoporosis; women live longer than menosteoporosis; women live longer than men

EtiologyEtiology

Risk factors (non-modifiable) Risk factors (non-modifiable) – Female genderFemale gender– Increasing ageIncreasing age– Family historyFamily history– White or Asian ethnicityWhite or Asian ethnicity– Small statureSmall stature– Early menopauseEarly menopause

EtiologyEtiology

Risk factors (cont’d) Risk factors (cont’d) – Excess alcohol intakeExcess alcohol intake– Cigarette smokingCigarette smoking– Anorexia Anorexia – OophorectomyOophorectomy– Sedentary lifestyleSedentary lifestyle– Insufficient calcium intakeInsufficient calcium intake– Low testosterone levels (hypogonadism Low testosterone levels (hypogonadism

in men)in men)

Etiology and PathophysiologyEtiology and PathophysiologyPeak bone mass is achieved before age 20Peak bone mass is achieved before age 20–

Bone loss after midlife is inevitable but Bone loss after midlife is inevitable but rate of loss is variablerate of loss is variable

BBone resorption exceeds bone depositionone resorption exceeds bone deposition

Bones become weakened and prone to Bones become weakened and prone to fracture, loss of height, and kyphosis.fracture, loss of height, and kyphosis.

Etiology and PathophysiologyEtiology and Pathophysiology

Diseases associated with Diseases associated with osteoporosisosteoporosis

Intestinal malabsorptionIntestinal malabsorptionKidney diseaseKidney diseaseRheumatoid arthritisRheumatoid arthritisHyperthyroidismHyperthyroidismChronic alcoholismChronic alcoholismCirrhosis of the liverCirrhosis of the liverHypergonadismHypergonadismDiabetes mellitusDiabetes mellitus

OsteoporosisOsteoporosisDiagnostic StudiesDiagnostic Studies

Clinical ManifestationsClinical Manifestations– Known as silent diseaseKnown as silent disease

DiagnosisDiagnosis– Bone Mineral Density (BMD)Bone Mineral Density (BMD)– Dual-energy x-ray absorptiometry (DEXA)Dual-energy x-ray absorptiometry (DEXA)– History and physicalHistory and physical– Quantitative ultrasoundQuantitative ultrasound

OsteoporosisOsteoporosis

Can the disease be Can the disease be prevented?prevented?

Treatment and Nursing CareTreatment and Nursing CareDiet TherapyDiet Therapy–

Weight bearing ExercisesWeight bearing Exercises–

Decrease Risk FactorsDecrease Risk Factors– Quit smoking and decrease consumption of alcoholQuit smoking and decrease consumption of alcohol

Drug Treatment of OsteoporosisDrug Treatment of Osteoporosis

Estrogen Replacement TherapyEstrogen Replacement Therapy

Calcium & Vitamin D supplementsCalcium & Vitamin D supplements

CalcitoninCalcitonin

Biphosphonates (Fosamax, Didronel, Biphosphonates (Fosamax, Didronel, Actonel, Boniva, Aredia, Bonefos, Skelid)Actonel, Boniva, Aredia, Bonefos, Skelid)

Selective Estrogen receptor modulator – Selective Estrogen receptor modulator – EvistaEvista

Teriparatide (Forteo)Teriparatide (Forteo)– Portion of parathyroid hormonePortion of parathyroid hormone

First drug to stimulate new bone formationFirst drug to stimulate new bone formation

Medications Used in Treatment Medications Used in Treatment of Osteoporosisof Osteoporosis

Hormone Replacement Therapy Hormone Replacement Therapy – Estrogen– Estrogen– Controversy over use. Should discuss with health care Controversy over use. Should discuss with health care

providerprovider

CalciumCalcium– There are a variety of calcium supplements There are a variety of calcium supplements

available (See Table 64-16, p. 1689). available (See Table 64-16, p. 1689). They should be taken with _______ _ to aid in They should be taken with _______ _ to aid in absorption. absorption.

Also if taking large doses i.e. 1000 mg. / day – take in Also if taking large doses i.e. 1000 mg. / day – take in divided doses of 500mg BID for better absorptiondivided doses of 500mg BID for better absorption

Medications Used in Treatment Medications Used in Treatment of Osteoporosisof Osteoporosis

Calcitonin Calcitonin

– If calcitonin inhibits bone resorption by If calcitonin inhibits bone resorption by opposing the effects of parathyroid opposing the effects of parathyroid hormone, how does that affect serum hormone, how does that affect serum calcium levels?calcium levels?

– What is needed to counter that effect?What is needed to counter that effect?

Medications Used in Treatment Medications Used in Treatment of Osteoporosisof Osteoporosis

Bisphosphenates – (Fosamax)Bisphosphenates – (Fosamax)– Inhibit osteoclast-mediated bone resorption thereby Inhibit osteoclast-mediated bone resorption thereby

increasing BMD and total bone mass. increasing BMD and total bone mass.

– Side effects – anorexia, weight loss, gastritisSide effects – anorexia, weight loss, gastritis

– Patient TeachingPatient Teaching

Medications Used in Treatment Medications Used in Treatment of Osteoporosisof Osteoporosis

Selective Estrogen Receptor Selective Estrogen Receptor ModulatorsModulators– Mimic effect of estrogen on bone by Mimic effect of estrogen on bone by

reducing bone resorption without reducing bone resorption without stimulating the breasts or uterus. stimulating the breasts or uterus.

– Side effectsSide effects

Leg crampsLeg cramps

Hot flashesHot flashes

OsteomalaciaOsteomalaciaMetabolic Bone DiseaseMetabolic Bone Disease

OsteomalaciaOsteomalaciaDecalcification and softening of the boneDecalcification and softening of the bone

Caused mainly by: vitamin D deficiencyCaused mainly by: vitamin D deficiency **Vitamin D is required for the absorption of **Vitamin D is required for the absorption of calcium from the intestine and calcium is calcium from the intestine and calcium is responsible for mineralization of boneresponsible for mineralization of bone

EtiologyEtiology– Lack of exposure to __________ ____ Lack of exposure to __________ ____ – GI malabsorption, extensive burns, chronic diarrhea, GI malabsorption, extensive burns, chronic diarrhea,

pregnancy, drugs such as Dilantin. pregnancy, drugs such as Dilantin.

Osteomalacia Osteomalacia Signs & SymptomsSigns & Symptoms

Most CommonMost Common– ____ ________ ____– Difficulty rising from a chairDifficulty rising from a chair– Difficulty walkingDifficulty walking

Additional Signs and SymptomsAdditional Signs and Symptoms– Low back pain, muscle weaknessLow back pain, muscle weakness– Weight loss, progressive deformitiesWeight loss, progressive deformities

DiagnosisDiagnosisBlood workBlood work– Decreased serum calcium or phosphorusDecreased serum calcium or phosphorus– Decreased serum 25-hydroxyvitamin DDecreased serum 25-hydroxyvitamin D– Elevated alkaline phosphataseElevated alkaline phosphatase

X-RaysX-Rays– Show Show loose’rs transformation zone – loose’rs transformation zone – – ribbons of decalcification in boneribbons of decalcification in bone

OsteomalaciaOsteomalaciaTreatment and Nursing CareTreatment and Nursing Care

Drug TherapyDrug Therapy– –

Diet TherapyDiet Therapy– Milk, yogurt, cheeseMilk, yogurt, cheese– Dark green leafy vegetables, okra, broccoliDark green leafy vegetables, okra, broccoli– Fish and seafoodFish and seafood– AlmondsAlmonds

Paget’s DiseasePaget’s Disease

Paget’s DiseasePaget’s DiseaseExcessive bone resorption followed by Excessive bone resorption followed by replacement of normal marrow by replacement of normal marrow by vascular, fibrous connective tissue. vascular, fibrous connective tissue.

The new bone is ______, ____________,The new bone is ______, ____________,

___ _________ ______

Most often affect the pelvis, Most often affect the pelvis,

long bones, spine,long bones, spine,

ribs, sternum, and craniumribs, sternum, and cranium

Clinical ManifestationsClinical Manifestations

In milder form, noneIn milder form, none

Common early symptom--Common early symptom--

FatigueFatigue

Waddling gaitWaddling gait

Loss of heightLoss of height

Increased head sizeIncreased head size

ComplicationsComplications

Pathological fractures (may be a first Pathological fractures (may be a first sign of disease)sign of disease)

Bone tumorsBone tumors

Paget’s DiseasePaget’s Disease

DiagnosisDiagnosis– Elevated serum alkaline phosphataseElevated serum alkaline phosphatase

– X-ray will show increase in bone sizeX-ray will show increase in bone size

– Bone scan shows increased uptake in Bone scan shows increased uptake in affected bonesaffected bones

Drug Treatment for Paget’sDrug Treatment for Paget’s

Drug TherapyDrug TherapyCalcitonin-salmon (Miacalcin)Calcitonin-salmon (Miacalcin)– Bone is in a constant state of remodeling, Bone is in a constant state of remodeling,

whereby old bone is removed by osteoclasts, whereby old bone is removed by osteoclasts, and new bone is laid down by osteoblasts. and new bone is laid down by osteoblasts. Calcitonin inhibits bone removal by Calcitonin inhibits bone removal by osteoclasts, and promotes bone formation by osteoclasts, and promotes bone formation by osteoblastsosteoblasts. .

NSAIDSNSAIDS

BisphosphonatesBisphosphonates

Paget’s DiseasePaget’s DiseaseOther treatments and Nursing CareOther treatments and Nursing Care– Back support by firm mattressBack support by firm mattress– Teaching about use of splints or braces to Teaching about use of splints or braces to

support bones and joints and help support bones and joints and help prevent weakened bones - skin care, prevent weakened bones - skin care, circulation, etc.circulation, etc.

– Teach how to correctly use canes or Teach how to correctly use canes or walkerswalkers

– Physical therapyPhysical therapy– Diet high in…what?Diet high in…what?