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Osteoporosis Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Osteoporosis Chronic, progressive metabolic bone disease characterized by Porous bone Low bone mass Structural deterioration of bone tissue Increased bone fragility Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Osteoporosis At least 10 million people in the United States have osteoporosis One in two women and one in eight men over 50 will sustain an osteoporosis-related fracture Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Osteoporosis Eight times more common in women than men for several reasons 1. Lower calcium intake than men 2. Less bone mass because of smaller frame 3. Bone resorption begins earlier and accelerates after menopause Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Osteoporosis More common in women than men (cont’d) 4. Pregnancy and breastfeeding deplete woman’s skeletal reserve of calcium 5. Longevity increases likelihood of osteoporosis; women live longer than men Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Etiology Risk factors Female gender Increasing age Family history White or Asian ethnicity Small stature Early menopause Excess alcohol intake Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Etiology Risk factors (cont’d) Cigarette smoking Anorexia Oophorectomy Sedentary lifestyle Insufficient calcium intake Low testosterone levels in men Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Etiology and Pathophysiology Peak bone mass is achieved before age 20 Peak mass determined by heredity, nutrition, exercise, and hormone function Bone loss after midlife is inevitable but rate of loss is variable Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Normal vs. Osteoporotic Bone Fig. 64-10 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Etiology and Pathophysiology In osteoporosis, bone resorption exceeds bone deposition Occurs most commonly in spine, hips, and wrist Many drugs can interfere with bone metabolism Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Etiology and Pathophysiology Diseases associated with osteoporosis • Intestinal malabsorption • Kidney disease • Rheumatoid arthritis • Hyperthyroidism • Chronic alcoholism • Cirrhosis of the liver • Hypergonadism • Diabetes mellitus Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Collaborative Care Focus on proper nutrition, calcium supplements, exercise, prevention of fractures, and drugs Prevention and treatment depend on adequate calcium intake Increased calcium prevents future loss but will not form new bone Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Collaborative Care Good sources of calcium Milk Yogurt Turnip greens Spinach Cottage cheese Ice cream Sardines Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Collaborative Care Poor sources of calcium Eggs Beef Cream cheese Poultry Pork Apples and bananas Potatoes and carrots Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Collaborative Care Supplemental vitamin D may be recommended Weight bearing exercise should be encouraged to build up and maintain bone mass Patients should be instructed to quit smoking or cut down on alcohol intake to decrease loss of bone mass Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Diagnostic Studies History and physical exam Bone mineral density (BMD) Quantitative ultrasound Dual-energy x-ray absorptiometry (DEXA) Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Diagnostic Studies Osteoporosis is a BMD of at least 2.5 standard deviations below that of a young adult BMD Osteopenia is more than normal bone loss but not yet at the level of osteoporosis Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Clinical Manifestations Often termed the “silent disease” because there are no symptoms Since no symptoms, the usual first signs are back pain and spontaneous fractures Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Clinical Manifestations Manifestations include Sudden strain Fractures Back pain Loss of height Spinal deformities (Dowager’s hump) Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Collaborative Care Drug therapy Estrogen replacement after menopause Calcitonin Bisphosphonates inhibit osteoclastmediated bone resorption (e.g., etidronate (Didronel), alendronate (Fosamax) Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Collaborative Care Drug therapy (cont’d) Selective estrogen receptor modulators • Raloxifene (Evista) Teriparatide (Forteo) • Portion of parathyroid hormone • First drug to stimulate new bone formation Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Osteomalacia Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Osteomalacia A rare condition of adult bone associated with Vitamin D deficiency, resulting in decalcification and softening of bone. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Etiologies Lack of exposure to sunlight GI malabsorption Extensive burns Chronic diarrhea Pregnancy Kidney disease Dilantin (phenytoin) Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Symptoms Localized bone pain Difficulty rising from a chair Difficulty walking Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Treatment Increase vitamin D and calcium intake, either dietary or supplemental Increase exposure to sunlight Weight bearing exercise Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Paget’s Disease Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Paget’s Disease A skeletal muscle disorder in which there is excessive bone resorption followed by replacement of normal marrow by vascular, fibrous connective tissue The new bone is larger and weaker Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Incidence Men affected 2:1 over women Rarely seen in men under age 40 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Etiology Unknown Possible viral cause Probable genetic component Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Clinical Manifestations In milder form, none Common early symptom – bone pain Fatigue Waddling gait Loss of height Increased head size Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Complications Pathological fractures (may be a first sign of disease) Bone tumors Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Diagnostic Testing Elevated alkaline phosphatase in advanced disease X-ray abnormalities Bone scan shows increased uptaake in affected bones Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Collaborative Care Symptomatic and supportive Correction of secondary deformities by surgery or braces Calcitonin and osteoporotic drugs can slow bone resorption Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Collaborative Care Firm, supportive mattress Corset or back brace Teach patent to minimize activities that involve lifting or twisting, to use good body mechanics Diet high in calcium and vitamin D Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.