Overview

Name: Osteoporosis

Description:

This casebook is published and has been read 98 times.

The author of this casebook has identified the following medical topics as being highly relevant to this casebook.

• Osteoporosis -- Reduction of bone mass without alteration in the composition of bone, leading to fractures. Primary osteoporosis can be of two major types: postmenopausal osteoporosis (OSTEOPOROSIS, POSTMENOPAUSAL) and age-related or senile osteoporosis.
  
  
• Osteoporosis, Postmenopausal -- Metabolic disorder associated with fractures of the femoral neck, vertebrae, and distal forearm. It occurs commonly in women within 15-20 years after menopause, and is caused by factors associated with menopause including estrogen deficiency.
  
  
• Disuse osteoporosis -- a form of osteoporosis due to immobilization or inactivity.
  
  

Notes

Who Gets Osteoporosis?

In the United States, 10 million people have osteoporosis. Millions more have low bone mass (called osteopenia), placing them at risk for osteoporosis and broken bones.

Osteoporosis can strike at any age, but it is most common in older women. Eighty percent of the people in the United States with osteoporosis are women. One out of every two women and one in four men over age 50 will break a bone in their lifetime due to osteoporosis.

What Causes Osteoporosis?

Many risk factors can lead to bone loss and osteoporosis. Some of these things you cannot change and others you can.

Risk factors you cannot change include:

• Gender. Women get osteoporosis more often than men.
• Age. The older you are, the greater your risk of osteoporosis.
• Body size. Small, thin women are at greater risk.
• Ethnicity. White and Asian women are at highest risk. Black and Hispanic women have a lower risk.
• Family history. Osteoporosis tends to run in families. If a family member has osteoporosis or breaks a bone, there is a greater chance that you will too.

Other risk factors are:

• Sex hormones. Low estrogen levels due to missing menstrual periods or to menopause can cause osteoporosis in women. Low testosterone levels can bring on osteoporosis in men.
• Anorexia nervosa. This eating disorder can lead to osteoporosis.
• Calcium and vitamin D intake. A diet low in calcium and vitamin D makes you more prone to bone loss.
• Medication use. Some medicines increase the risk of osteoporosis.
• Activity level. Lack of exercise or long-term bed rest can cause weak bones.
• Smoking. Cigarettes are bad for bones, heart, and lungs.
• Drinking alcohol. Too much alcohol can cause bone loss and broken bones.

Can Osteoporosis Be Prevented?

There are many steps you can take to keep your bones healthy. To keep your bones strong and slow down bone loss, you can:

• Eat a diet rich in calcium and vitamin D
• Exercise
• Not drink in excess or smoke.

Nutrition

A diet with enough calcium and vitamin D helps make your bones strong. Many people get less than half the calcium they need. Good sources of calcium are:

• Low-fat milk, yogurt, and cheese
• Foods with added calcium such as orange juice, cereals, and breads

Vitamin D is needed for strong bones. Your body makes vitamin D in the skin when you are out in the sun. Some people get all the vitamin D they need from sunlight. Others need to take vitamin D pills.

Exercicse

 

Exercise helps your bones grow stronger. To increase bone strength, you can:

• Walk
• Hike
• Jog
• Climb stairs
• Lift weights
• Play tennis
• Dance.

Health Lifestyle

Smoking is bad for bones as well as the heart and lungs. Also, people who drink a lot of alcohol are more prone to bone loss and broken bones due to poor diet and risk of falling.

What Are the Symptoms of Osteoporosis?

Osteoporosis is called the "silent disease" because bone is lost with no signs. You may not know that you have osteoporosis until a strain, bump, or fall causes a bone to break.

How Is Osteoporosis Diagnosed?

A bone mineral density test (called a DXA) is the best way to check your bone health. This test can:

• Diagnose osteoporosis
• Check bone strength
• See if treatments are making the bones stronger.

How Is Osteoporosis Treated?

Treatment for osteoporosis includes:

• A balanced diet rich in calcium and vitamin D
• An exercise plan
• A healthy lifestyle
• Medications, if needed.

How Can I Prevent Falls?

Men and women with osteoporosis need to take care not to fall down. Falls can break bones. Some reasons people fall are:

• Poor vision
• Poor balance
• Certain diseases that affect how you walk
• Some types of medicine, such as sleeping pills.

Some tips to help prevent falls outdoors are:

• Use a cane or walker
• Wear rubber-soled shoes so you don't slip
• Walk on grass when sidewalks are slippery
• In winter, put salt or kitty litter on icy sidewalks.

Some ways to help prevent falls indoors are:

• Keep rooms free of clutter, especially on floors
• Use plastic or carpet runners on slippery floors
• Wear low-heeled shoes
• Do not walk in socks, stockings, or slippers
• Be sure carpets and area rugs have skid-proof backs or are tacked to the floor
• Be sure stairs are well lit and have rails on both sides
• Put grab bars on bathroom walls near tub, shower, and toilet
• Use a rubber bath mat in the shower or tub
• Keep a flashlight next to your bed
• Use a sturdy step stool with a handrail and wide steps
• Add more lights in rooms
• Buy a cordless phone to keep with you so that you don't have to rush to the phone when it rings and so that you can call for help if you fall.

 

Osteoporosis Overview

Osteoporosis, or porous bone, is a disease characterized by low bone mass and structural deterioration of bone tissue, leading to bone fragility and an increased risk of fractures of the hip, spine, and wrist. Men as well as women are affected by osteoporosis, a disease that can be prevented and treated.

Facts and Figures

• Osteoporosis is a major public health threat for 44 million Americans, 68 percent of whom are women.
• In the United States today, 10 million individuals already have osteoporosis and 34 million more have low bone mass, placing them at increased risk for this disease.
• One out of every two women and one in four men age 50 and older will have an osteoporosis-related fracture in their lifetime.
• More than 2 million American men suffer from osteoporosis, and millions more are at risk. Each year, 80,000 men have a hip fracture, and one-third of these men die within a year.
• Osteoporosis can strike at any age.
• Osteoporosis is responsible for more than 1.5 million fractures annually, including approximately 300,000 hip fractures, 700,000 vertebral fractures, 250,000 wrist fractures, and more than 300,000 fractures at other sites.
• Based on figures from hospitals and nursing homes, the estimated national direct expenditures for osteoporosis and related fractures total $14 billion each year.

What Is Bone?

Bone is living, growing tissue. It is made mostly of collagen, a protein that provides a soft framework, and calcium phosphate, a mineral that adds strength and hardens the framework.

This combination of collagen and calcium makes bone both flexible and strong, which in turn helps bone to withstand stress. More than 99 percent of the body’s calcium is contained in the bones and teeth. The remaining 1 percent is found in the blood.

Throughout one’s lifetime, old bone is removed (resorption) and new bone is added to the skeleton (formation). During childhood and teenage years, new bone is added faster than old bone is removed. As a result, bones become larger, heavier, and denser. Bone formation outpaces resorption until peak bone mass (maximum bone density and strength) is reached around age 30. After that time, bone resorption slowly begins to exceed bone formation.

For women, bone loss is fastest in the first few years after menopause, and it continues into the postmenopausal years. Osteoporosis—which mainly affects women but may also affect men—will develop when bone resorption occurs too quickly or when replacement occurs too slowly. Osteoporosis is more likely to develop if you did not reach optimal peak bone mass during your bone-building years.

Risk Factors

Certain risk factors are linked to the development of osteoporosis and contribute to an individual’s likelihood of developing the disease. Many people with osteoporosis have several risk factors, but others who develop the disease have no known risk factors. Some risk factors cannot be changed, but you can change others.

Risk factors you cannot change:

• Gender. Your chances of developing osteoporosis are greater if you are a woman. Women have less bone tissue and lose bone faster than men because of the changes that happen with menopause.
• Age. The older you are, the greater your risk of osteoporosis. Your bones become thinner and weaker as you age.
• Body size. Small, thin-boned women are at greater risk.
• Ethnicity. Caucasian and Asian women are at highest risk. African American and Hispanic women have a lower but significant risk.
• Family history. Fracture risk may be due, in part, to heredity. People whose parents have a history of fractures also seem to have reduced bone mass and may be at risk for fractures.

Risk factors you can change:

• Sex hormones. Abnormal absence of menstrual periods (amenorrhea), low estrogen level (menopause), and low testosterone level in men can bring on osteoporosis.
• Anorexia nervosa. Characterized by an irrational fear of weight gain, this eating disorder increases your risk for osteoporosis.
• Calcium and vitamin D intake. A lifetime diet low in calcium and vitamin D makes you more prone to bone loss.
• Medication use. Long-term use of glucocorticoids and some anticonvulsants can lead to loss of bone density and fractures.
• Lifestyle. An inactive lifestyle or extended bed rest tends to weaken bones.
• Cigarette smoking. Smoking is bad for bones as well as the heart and lungs.
• Alcohol intake. Excessive consumption of alcohol increases the risk of bone loss and fractures.

Prevention

To reach optimal peak bone mass and continue building new bone tissue as you age, you should consider several factors.

Calcium: An inadequate supply of calcium over a lifetime contributes to the development of osteoporosis. Many published studies show that low calcium intake appears to be associated with low bone mass, rapid bone loss, and high fracture rates. National nutrition surveys show that many people consume less than half the amount of calcium recommended to build and maintain healthy bones. Food sources of calcium include low-fat dairy products, such as milk, yogurt, cheese, and ice cream; dark green, leafy vegetables, such as broccoli, collard greens, bok choy, and spinach; sardines and salmon with bones; tofu; almonds; and foods fortified with calcium, such as orange juice, cereals, and breads. Depending upon how much calcium you get each day from food, you may need to take a calcium supplement.

Calcium needs change during one’s lifetime. The body’s demand for calcium is greater during childhood and adolescence, when the skeleton is growing rapidly, and during pregnancy and breastfeeding. Postmenopausal women and older men also need to consume more calcium. Also, as you age, your body becomes less efficient at absorbing calcium and other nutrients. Older adults also are more likely to have chronic medical problems and to use medications that may impair calcium absorption.

Vitamin D: Vitamin D plays an important role in calcium absorption and bone health. It is synthesized in the skin through exposure to sunlight. Food sources of vitamin D include egg yolks, saltwater fish, and liver. Many people obtain enough vitamin D naturally, by getting about 15 minutes of sunlight each day; however, studies show that vitamin D production decreases in the elderly, in people who are housebound, and for people in general during the winter. They may need vitamin D supplements to achieve the recommended intake of 400 to 600 IU (International Units) daily.

Exercise: Like muscle, bone is living tissue that responds to exercise by becoming stronger. Weight-bearing exercise is the best for your bones because it forces you to work against gravity. Examples include walking, hiking, jogging, climbing stairs, weight training, tennis, and dancing.

Smoking: Smoking is bad for your bones as well as your heart and lungs. Women who smoke have lower levels of estrogen compared with nonsmokers, and they often go through menopause earlier. Smokers also may absorb less calcium from their diets.

Alcohol: Regular consumption of 2 to 3 ounces a day of alcohol may be damaging to the skeleton, even in young women and men. Those who drink heavily are more prone to bone loss and fracture, because of both poor nutrition and increased risk of falling.

Medications that cause bone loss: The long-term use of glucocorticoids (medications prescribed for a wide range of diseases, including arthritis, asthma, Crohn’s disease, lupus, and other diseases of the lungs, kidneys, and liver) can lead to a loss of bone density and fracture. Bone loss also can result from long-term treatment with certain antiseizure drugs, such as phenytoin (Dilantin)¹ and barbiturates; gonadotropin-releasing hormone (GnRH) drugs used to treat endometriosis; excessive use of aluminum-containing antacids; certain cancer treatments; and excessive thyroid hormone. It is important to discuss the use of these drugs with your doctor and not to stop or change your medication dose on your own.

¹ Brand names included in this publication are provided as examples only, and their inclusion does not mean that these products are endorsed by the National Institutes of Health or any other Government agency. Also, if a particular brand name is not mentioned, this does not mean or imply that the product is unsatisfactory.

Preventive medications: Various medications are available for preventing and treating osteoporosis. See “Therapeutic Medications” section.

Symptoms

Osteoporosis is often called a silent disease because bone loss occurs without symptoms. People may not know that they have osteoporosis until their bones become so weak that a sudden strain, bump, or fall causes a hip to fracture or a vertebra to collapse. Collapsed vertebrae may initially be felt or seen in the form of severe back pain, loss of height, or spinal deformities such as kyphosis (severely stooped posture).

Detection

Following a comprehensive medical assessment, your doctor may recommend that you have your bone mass measured. A bone mineral density (BMD) test is the best way to determine your bone health. BMD tests can identify osteoporosis, determine your risk for fractures (broken bones), and measure your response to osteoporosis treatment. The most widely recognized BMD test is a dual-energy x-ray absorptiometry, or DXA test. It is painless—a bit like having an x ray, but with much less exposure to radiation. It can measure bone density at your hip and spine. BMD tests can:

• Detect low bone density before a fracture occurs.
• Confirm a diagnosis of osteoporosis if you already have one or more fractures.
• Predict your chances of fracturing in the future.
• Determine your rate of bone loss, and monitor the effects of treatment if the test is conducted at intervals of a year or more.

Treatment

A comprehensive osteoporosis treatment program includes a focus on proper nutrition, exercise, and safety issues to prevent falls that may result in fractures. In addition, your doctor may prescribe a medication to slow or stop bone loss, increase bone density, and reduce fracture risk.

Nutrition: The foods we eat contain a variety of vitamins, minerals, and other important nutrients that help keep our bodies healthy. All of these nutrients are needed in balanced proportion. In particular, calcium and vitamin D are needed for strong bones and for your heart, muscles, and nerves to function properly. (See “Prevention” section for recommended amounts of calcium.)

Exercise: Exercise is an important component of an osteoporosis prevention and treatment program. Exercise not only improves your bone health, but it increases muscle strength, coordination, and balance, and leads to better overall health. Although exercise is good for someone with osteoporosis, it should not put any sudden or excessive strain on your bones. As extra insurance against fractures, your doctor can recommend specific exercises to strengthen and support your back.

Therapeutic Medications:

Several medications are available for the prevention and treatment of osteoporosis:

• Bisphosphonates. Alendronate (Fosamax), risedronate (Actonel), and ibandronate (Boniva) are medications from the class of drugs called bisphosphonates. These bisphosphonates are approved for both prevention and treatment of postmenopausal osteoporosis. Alendronate is also approved to treat bone loss that results from glucocorticoid medications such as prednisone or cortisone and is approved for treating osteoporosis in men. Risedronate is approved to prevent and treat glucocorticoid-induced osteoporosis and to treat osteoporosis in men. Another bisphosphonate, zoledronic acid (Reclast), is approved for the treatment of postmenopausal osteoporosis, to increase bone mass in men with osteoporosis, for the prevention of fractures in patients who have recently had a low-trauma hip fracture, and for the prevention and treatment of glucocorticoid-osteoporosis in men and women.

  Side effects of oral bisphosphonates include gastrointestinal problems such as difficulty swallowing, inflammation of the esophagus, and gastric ulcer.

  Side effects of intravenous bisphosphonates include flu-like symptoms, fever, pain in muscles or joints, and headache. These side effects can occur shortly after receiving an infusion and generally stop within 2 to 3 days.

  There also have been rare reports of osteonecrosis of the jaw and of visual disturbances in people taking oral and intravenous bisphosphonates.

  Some bisphosphonates are marketed with calcium and vitamin D supplements. These nutrients are important for everyone, and people should include adequate amounts of them in their diets.

• Raloxifene. Raloxifene (Evista) is approved for the prevention and treatment of postmenopausal osteoporosis. It is from a class of drugs called estrogen agonists/antagonists, commonly referred to as selective estrogen receptor modulators (SERMs). Although side effects are not common with raloxifene, those reported include hot flashes and blood clots in the veins, the latter of which is also associated with estrogen therapy.
• Calcitonin. Calcitonin (Miacalcin, Fortical) is a naturally occurring hormone involved in calcium regulation and bone metabolism. It is approved for the treatment of osteoporosis in women who are at least 5 years past menopause. Although it does not affect other organs or systems in the body, injectable calcitonin may cause an allergic reaction and unpleasant side effects including flushing of the face and hands, frequent urination, nausea, and skin rash. The only side effect reported with nasal calcitonin is nasal irritation.
• Teriparatide. Teriparatide (Forteo) is an injectable form of human parathyroid hormone. It is approved for postmenopausal women and men with osteoporosis who are at high risk for having a fracture. Unlike the other drugs used in osteoporosis, teriparatide acts by stimulating new bone formation. Side effects include nausea, dizziness, and leg cramps. Teriparatide is approved for use for up to 24 months.
• Estrogen/hormone therapy. Estrogen/hormone therapy (ET/HT) is approved for preventing postmenopausal osteoporosis and is most commonly administered in the form of a pill or skin patch. When estrogen—also known as estrogen therapy or ET—is taken alone, it can increase a woman’s risk of developing cancer of the uterine lining (endometrial cancer). To eliminate this risk, doctors prescribe the hormone progestin—also known as hormone therapy or HT—in combination with estrogen for those women who have not had a hysterectomy. Side effects of ET/HT include vaginal bleeding, breast tenderness, mood disturbances, blood clots in the veins, and gallbladder disease.

 

The Women’s Health Initiative (WHI), a large Government-funded research study, recently demonstrated that the drug Prempro (estrogen combined with progestin), which is used in hormone therapy, is associated with a modest increase in the risk of breast cancer, stroke, and heart attack. The WHI also demonstrated that in patients who had a hysterectomy, estrogen therapy alone was associated with an increase in the risk of stroke, but not of breast cancer or cardiovascular disease. A large study from the National Cancer Institute indicated that long-term use of estrogen therapy may be associated with an increased risk of ovarian cancer.

Estrogen therapy is approved for treatment of menopausal symptoms but should be prescribed for the shortest period of time possible. When used solely for the prevention of postmenopausal osteoporosis, any ET/HT regimen should be considered only for women at significant risk of osteoporosis, and nonestrogen medications should be carefully considered first.

Fall Prevention

Preventing falls is a special concern for men and women with osteoporosis. Falls can increase the likelihood of fracturing a bone in the hip, wrist, spine, or other part of the skeleton. In addition to the environmental factors listed below, falls can also be caused by impaired vision or balance, chronic diseases that affect mental or physical functioning, and certain medications, such as sedatives and antidepressants. It is important that individuals with osteoporosis be aware of any physical changes that affect their balance or gait, and that they discuss these changes with their health care provider. Here are some tips to help eliminate the environmental factors that lead to falls.

Outdoors:

• Use a cane or walker for added stability.
• Wear rubber-soled shoes for traction.
• Walk on grass when sidewalks are slippery.
• In winter, carry salt or kitty litter to sprinkle on slippery sidewalks.
• Be careful on highly polished floors that become slick and dangerous when wet.
• Use plastic or carpet runners when possible.

Indoors:

• Keep rooms free of clutter, especially on floors.
• Keep floor surfaces smooth but not slippery.
• Wear supportive, low-heeled shoes even at home.
• Avoid walking in socks, stockings, or slippers.
• Be sure carpets and area rugs have skid-proof backing or are tacked to the floor.
• Be sure stairwells are well lit and that stairs have handrails on both sides.
• Install grab bars on bathroom walls near tub, shower, and toilet.
• Use a rubber bath mat in shower or tub.
• Keep a flashlight with fresh batteries beside your bed.
• If using a step stool for hard-to-reach areas, use a sturdy one with a handrail and wide steps.
• Add ceiling fixtures to rooms lit by lamps.
• Consider purchasing a cordless phone so that you don’t have to rush to answer the phone when it rings, or so that you can call for help if you do fall.

 

Bookmarks The following information, which has been distilled by the casebook author from this and other websites is particularly relevant to this casebook.