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Bone Loss In The Elderly
Liliana Oakes, M.D.
Assistant Professor –Geriatric Division
David V. Espino, M.D.
Professor and Vice Chair, Dept. of Family. & Comm. Medicine
University of Texas Health Science Center, San Antonio
Osteoporosis
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Epidemiology
Risk Factors
Diagnosis
Treatment
Osteoporosis: Epidemiological
Classification
• Type I (Postmenopausal)
– Women, Trabecular Bone, Fx Vertebra, Distal Radius
• Type II (Senile)
– Men/Women, Cortical & Trabecular Bone, Fx Hip,
Vertebra, Humerus Tibia, Pelvis
• Type III (Secondary)
– Men/Women, Cortical & Trabecular Bone, Fx of
Vertebra
Secondary Osteoporosis
• Nutritional
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Lo Ca Intake
Vit D Deficiency
Protein Malnutrition
Alcoholism
• Neoplastic Diseases
– Multiple Myeloma
– Lymphoma
– Monocytic Leukemia
• Endocrine
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–
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Cushing’s
Hyperthyroidism
Hyperparathyroidism
Hypogonadism
• Systemic
– Hepatic Disease
– Renal Disease
– Rheumatoid Arthritis
Drug Induced Secondary Osteoporosis
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Corticosteroids
Aluminum Containing Antacids
Heparin
Anticonvulsants
– (Dilantin, Phenobarb, Primidone)
• Phenothiazines
• Furosemide
• Thyroid Hormone
– (In Excessive Doses)
Bone Quality
• FX Pathogenesis
Involves More Than
Bone Mass
– Bone Density
– Structural Arrangement
– Adequacy of
Mineralization
– Presence of
Microdamage
Osteopenia Scope
• Year 2020
– 14 million persons
with osteoporosis
– 61 million with low
bone mass
• Second Only To CVD
according to WHO
U.S.Women in WHO Categories
100
90
80
70
60
50
40
30
20
10
0
Age 25
Severe OP
Osteoporosis
Osteopenia
Normal
Age 50
Age 65
Age 80
Osteoporosis
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Risk Factors
Epidemiology
Diagnosis
Treatment
B. Spears
• 82 yo White Female
• HTN, CAD, Hearing
Loss
• History of Falls
• Low Back Pain
• Smoker
Risk Factors
• What information from Mrs. Spears history
will suggest to you she is at risk for
osteoporosis?
Osteoporosis Risk Factors
Non Modifiable
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Age
Race
Gender
Family History
Early Menopause
/Oophorectomy
Osteoporosis Risk Factors
Modifiable
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Weight
Physical Activity
Ca/Vit D Intake
Cigarette Smoking
Glucocorticoids
Sex Hormone
Insufficiency
Osteoporosis
• Introduction
• Epidemiology &
Risk Factors
• Diagnosis
• Treatment
B. Spears
• 82 yo White Female
• HTN, CAD, Hearing
Loss
• History of Falls
• Low Back Pain
• Smoker
History
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Hx of Prior Fractures
Falls Hx
Neurological D-Z Hx
Hx of Muscular Weakness
Nutritional Hx
Medication Hx
Functional Hx
Nutritional History
• Deficiency States
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Calcium
Vitamin D
Vitamin C
Zinc?
Manganese?
Boron?
• Excess Intake
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–
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Insoluble Fiber
Animal Protein
Phosphate
Alcohol
Smoking
Vitamins D or A
Physical Examination
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Orthostatics
Gait & Mobility
Height
Kyphosis?
Clinical Features of
– Hypercortisolism
– Hyperthyroid, Hypogonadism
Laboratory Evaluation
• CBC, TFT’s
• Chem Profile to include:
– Albumin (Nutritional?)
– Renal/Liver function
– Calcium (Elevated in
Hyperparathyroid)
– Phosphate (Low in
Osteomalacia)
– Alk Phos (Elevated in
Osteomalacia)
• 24 Hour Urine for Calcium &
Creatinine
• ESR (with back pain)
• DEXA
WHO Definition
• Osteopenia
– 1-2.5 sd Below Mean
• Osteoporosis
– >2.5 sd Below Mean
Dual Energy X-Ray Absorptiometry
[DEXA]
•
Z-score
– the number of standard
deviations from the agematched average value
of healthy women,
•
T-score
– the number of standard
deviations from the value
at peak bone density of a
young (25-30 year old)
Caucasian woman.
– Alone Does Not Predict
FX or Guide Therapy
Indications for DEXA in Men
• Age≥70
• Low Trauma FX
• Prevalent Vertebral
Deformities
• Radiographic
Osteopenia
• Conditions Associated
with Bone Loss
Indications for Spinal
Radiographs
• Acute or Persistent
Bone Pain
• “Normal” DEXA
• Hx of Malignancy
• Kyphosis/Scoliosis
• Significant Height
Loss (≥5 cm)
Osteoporosis
• Introduction
• Epidemiology &
Risk Factors
• Diagnosis
• Treatment
B. Spears
• 82 yo White Female
• HTN, CAD, Hearing
Loss
• History of Falls
• Low Back Pain
• Smoker
Treatment Plan
• You are discussing a treatment plan with
Mrs. Spears.
• What recommendations you will give to her
to treat her osteoporosis.
Exercise
• Weight-Bearing
Exercise
• Vigorous Training vs.
Exercise
Vitamin D
• Most MVI’s contain
400 U
• Dietary Sources
– Sardines,Salmon,
Butter,Organ Meats,
Egg Yolks, Fortified
Foods
• Vitamin D Def.
– 800 U
– Monitor Ca Levels
Calcium
• 1.5 Grams Per Day
• Choice of Product
Based on Cost and
Convenience
• Lactose Intolerance
– Avoid Calcium Lactate
Calcium Intake
• Best Absorbed With Meals
• Evening Meal Best
• Decrease Caffeine and Sodium
Intake
• Contraindicated
– Hypercalcuria &
Nephrolithiasis
– Sarcoidosis
– Hyperparathyroidism
– Maligancies assoc. with
Hypercalcemia
Dietary Calcium
• Repka’s Rule of 300s
– 8 oz. of Yogurt =300
mg Ca
– 8 oz. Of OJ
= 300 mg Ca
– 8 oz. of Milk
=300 mg Ca
C. E. Estrogen & Progesterone
• Not Include Estrogen
Alone
• HERS & WHI
Selective Estrogen Receptor
Modulators (SERM’s)
• Tamoxifen
• Raloxifene
– Reduces vertebral fractures
– No effect on nonvertebral Fx’s
– Increases Thromboembolism,
Hot Flashes
– No increase in Uterine CA
– Positive Lipid and Breast CA
benefits
– Perimenopausal or Early
Menopausal (55-65) Time
• Vertebral Fxs common, Hip
are not
Calcitonin
• Calcitonin-Salmon
• Calcitonin-Intranasal
Biphosphonates
• Etidronate (Didronel®)
– Osteomalacia in Pts. With
Osteoporosis or Pagets
• Alendronate (Fosamax®)
• Risedronate (Actonel®)
• Pamidronate (Aredia®)
– Ibandronate ( in trial)
Experimental Agents
• Fluoride
– Ca Resorption
• PTH. (Forteo®)
Regulates bone
metabolism
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Growth Hormone
HCTZ
Potassium Bicarbonate
Vitamin D Metabolites
Vertebral Compression Fx Treatment
• Short Term Bedrest
• Weight Bearing
Movement ASAP
• NSAID’s PRN
• Calcitonin
– 2 Weeks
• Rehab
Summary
• Osteoporosis Is Second Only To CVD in
Terms Of Morbidity
• Early Diagnosis Is Critical
• Therapies Very Effective
• Remember Elder Men
Questions?