Bone Loss In The Elderly Liliana Oakes, M.D. Assistant Professor –Geriatric Division David V....
-
Upload
peter-austin -
Category
Documents
-
view
220 -
download
2
Transcript of Bone Loss In The Elderly Liliana Oakes, M.D. Assistant Professor –Geriatric Division David V....
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
•• EpidemiologyEpidemiology• Risk FactorsRisk 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 2020Year 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
0
1020
30
40
5060
70
8090
100
Age 25 Age 50 Age 65 Age 80
Severe OPOsteoporosisOsteopeniaNormal
Osteoporosis
• Risk FactorsRisk Factors• EpidemiologyEpidemiology• 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 FactorsNon Modifiable
• Age• Race• Gender• Family History• Early Menopause
/Oophorectomy
Osteoporosis Risk FactorsModifiable
• Weight
• Physical Activity• Ca/Vit D Intake• Cigarette Smoking• Glucocorticoids• Sex Hormone
Insufficiency
Osteoporosis
• Introduction• Epidemiology &
Risk Factors• DiagnosisDiagnosis• 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 age-matched 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• TreatmentTreatment
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?