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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 • • • • 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 – – – – Lo Ca Intake Vit D Deficiency Protein Malnutrition Alcoholism • Neoplastic Diseases – Multiple Myeloma – Lymphoma – Monocytic Leukemia • Endocrine – – – – Cushing’s Hyperthyroidism Hyperparathyroidism Hypogonadism • Systemic – Hepatic Disease – Renal Disease – Rheumatoid Arthritis Drug Induced Secondary Osteoporosis • • • • 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 • • • • 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 • • • • • Age Race Gender Family History Early Menopause /Oophorectomy Osteoporosis Risk Factors Modifiable • • • • • • 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 • • • • • • • Hx of Prior Fractures Falls Hx Neurological D-Z Hx Hx of Muscular Weakness Nutritional Hx Medication Hx Functional Hx Nutritional History • Deficiency States – – – – – – Calcium Vitamin D Vitamin C Zinc? Manganese? Boron? • Excess Intake – – – – – – Insoluble Fiber Animal Protein Phosphate Alcohol Smoking Vitamins D or A Physical Examination • • • • • 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 • • • • 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?