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Bone Loss In The Elderly

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Slide 1 :

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

Slide 2 :

Osteoporosis • Epidemiology Risk Factors Diagnosis Treatment

Slide 3 :

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

Slide 4 :

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

Slide 5 :

Drug Induced Secondary Osteoporosis Corticosteroids Aluminum Containing Antacids Heparin Anticonvulsants (Dilantin, Phenobarb, Primidone) Phenothiazines Furosemide Thyroid Hormone (In Excessive Doses)

Slide 6 :

Bone Quality FX Pathogenesis Involves More Than Bone Mass Bone Density Structural Arrangement Adequacy of Mineralization Presence of Microdamage

Slide 7 :

Osteopenia Scope Year 2020 14 million persons with osteoporosis 61 million with low bone mass Second Only To CVD according to WHO

Slide 8 :

U.S.Women in WHO Categories

Slide 9 :

Osteoporosis Risk Factors Epidemiology Diagnosis Treatment

Slide 10 :

B. Spears 82 yo White Female HTN, CAD, Hearing Loss History of Falls Low Back Pain Smoker

Slide 11 :

Risk Factors What information from Mrs. Spears history will suggest to you she is at risk for osteoporosis?

Slide 12 :

Osteoporosis Risk Factors Non Modifiable Age Race Gender Family History Early Menopause /Oophorectomy

Slide 13 :

Osteoporosis Risk Factors Modifiable • Weight • Physical Activity Ca/Vit D Intake Cigarette Smoking Glucocorticoids Sex Hormone Insufficiency

Slide 14 :

Osteoporosis Introduction Epidemiology & Risk Factors Diagnosis Treatment

Slide 15 :

B. Spears 82 yo White Female HTN, CAD, Hearing Loss History of Falls Low Back Pain Smoker

Slide 16 :

History Hx of Prior Fractures Falls Hx Neurological D-Z Hx Hx of Muscular Weakness Nutritional Hx Medication Hx Functional Hx

Slide 17 :

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

Slide 18 :

Physical Examination Orthostatics Gait & Mobility Height Kyphosis? Clinical Features of Hypercortisolism Hyperthyroid, Hypogonadism

Slide 19 :

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

Slide 20 :

WHO Definition Osteopenia 1-2.5 sd Below Mean Osteoporosis >2.5 sd Below Mean

Slide 21 :

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

Slide 22 :

Indications for DEXA in Men Age=70 Low Trauma FX Prevalent Vertebral Deformities Radiographic Osteopenia Conditions Associated with Bone Loss

Slide 23 :

Indications for Spinal Radiographs Acute or Persistent Bone Pain “Normal” DEXA Hx of Malignancy Kyphosis/Scoliosis Significant Height Loss (=5 cm)

Slide 24 :

Osteoporosis Introduction Epidemiology & Risk Factors Diagnosis Treatment

Slide 25 :

B. Spears 82 yo White Female HTN, CAD, Hearing Loss History of Falls Low Back Pain Smoker

Slide 26 :

Treatment Plan You are discussing a treatment plan with Mrs. Spears. What recommendations you will give to her to treat her osteoporosis.

Slide 27 :

Exercise Weight-Bearing Exercise Vigorous Training vs. Exercise

Slide 28 :

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

Slide 29 :

Calcium 1.5 Grams Per Day Choice of Product Based on Cost and Convenience Lactose Intolerance Avoid Calcium Lactate

Slide 30 :

Calcium Intake Best Absorbed With Meals Evening Meal Best Decrease Caffeine and Sodium Intake Contraindicated Hypercalcuria & Nephrolithiasis Sarcoidosis Hyperparathyroidism Maligancies assoc. with Hypercalcemia

Slide 31 :

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

Slide 32 :

C. E. Estrogen & Progesterone Not Include Estrogen Alone HERS & WHI

Slide 33 :

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

Slide 34 :

Calcitonin Calcitonin-Salmon Calcitonin-Intranasal

Slide 35 :

Biphosphonates Etidronate (Didronel®) Osteomalacia in Pts. With Osteoporosis or Pagets Alendronate (Fosamax®) Risedronate (Actonel®) Pamidronate (Aredia®) Ibandronate ( in trial)

Slide 36 :

Experimental Agents Fluoride Ca Resorption PTH. (Forteo®) Regulates bone metabolism Growth Hormone HCTZ Potassium Bicarbonate Vitamin D Metabolites

Slide 37 :

Vertebral Compression Fx Treatment Short Term Bedrest Weight Bearing Movement ASAP NSAID’s PRN Calcitonin 2 Weeks Rehab

Slide 38 :

Summary Osteoporosis Is Second Only To CVD in Terms Of Morbidity Early Diagnosis Is Critical Therapies Very Effective Remember Elder Men

Slide 39 :

Questions?

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What recommendations you will give to her to treat her osteoporosis. ExerciseOsteoporosis Is Second more What recommendations you will give to her to treat her osteoporosis. ExerciseOsteoporosis Is Second Only To CVD in Terms Of Morbidity; Early Diagnosis ... less

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