Understanding Osteoporosis

• Osteoporosis is a common chronic metabolic bone disorder resulting in low bone density
• More than 10 million people in the United States are estimated to have osteoporosis
• Osteoporosis occurs when bone resorption (osteoclast cells) exceeds bone formation (osteoblast cells)
• This results in fragile bone tissue and can lead to fractures

Common Fracture Sites

• Wrists
• Hips
• Spine
• Any bone can sustain a fracture

Osteoporosis Classification

• Primary (genetic or environmental factors)
• Secondary (medical conditions or chronic medication use)
• Osteopenia, the precursor to osteoporosis, is low bone mineral density relative to age and sex
• Bone mineral density peaks from ages 18 to 30
• After peak years, bone density decreases
• There is a significant increase in the rate of loss in postmenopausal clients due to estrogen loss

Prevention and Management Tips

• Limit excess caffeine, alcohol, and carbonated beverages to reduce bone loss
• Consume adequate protein, magnesium, vitamin K, and other minerals for bone formation
• Avoid slippery surfaces and wear rubber-bottomed shoes
• Exercise, with guidance, reduces risk for vertebral fractures
• Isometric exercises help strengthen the core
• Avoid activities increasing body stress (jarring activities, strenuous lifting)

Medications for Osteoporosis

• Calcium and vitamin D can slow or prevent osteoporosis
• Combinations of these medications can be used

Calcitonin (salmon)

• Decreases bone resorption by inhibiting osteoclast activity
• Treats osteoporosis, hypercalcemia, and Paget’s disease of the bone

Teriparatide

• Contraindicated for hypercalcemia, bone cancer history, radiation, or Paget’s disease
• Adverse effects include nausea, back pain, arthralgia, and leg cramps
• Orthostatic hypotension can occur up to 4 hr after receiving the medication
• Parathyroid hormone that stimulates osteoblasts to increase new bone formation and bone mass
• Stimulates calcium absorption
• Limited use for clients at high risk for fractures and those with prolonged corticosteroid use
• Administer subcutaneously only
• Can only be used for 2 years, then bisphosphonates are started

Estrogen Hormone Supplements

• Replaces estrogen lost due to menopause or surgical removal of ovaries
• Estrogen should be given with progesterone in clients who still have their uterus
• Potential complications include breast and endometrial cancers and deep-vein thrombosis (DVT)
• Perform monthly breast self-examinations

Selective Estrogen Receptor Modulators

• Raloxifene decreases osteoclast activity, decreasing bone resorption and increasing bone mineral density
• Prevents and treats postmenopausal osteoporosis and breast cancer
• Avoid for clients with a history of DVT
• Monitor liver function tests
• Discontinue use 72 hr before prolonged bed rest
• Report unusual calf pain or tenderness, acute migraine, insomnia, UTI, or vaginal burning/itching
• Take calcium and vitamin D supplements

Calcium Supplement

• Supplements calcium consumed in food to promote healthy bones (not to slow osteoporosis)
• Give with food in divided doses with 6 to 8 oz of water
• Supplements can cause GI upset
• Monitor for constipation and of hypercalcemia

Vitamin D Supplement

• Increases absorption of calcium from the intestinal tract and availability of calcium in the blood needed for remineralization of bone
• Needed by individuals not exposed to adequate sunlight or who do not meet daily requirements
• Being a fat-soluble vitamin, toxicity can occur
• Findings of toxicity include weakness, fatigue, nausea, constipation, and kidney stones

Bisphosphonates

• Decreases the number and actions of osteoclasts, subsequently inhibiting bone resorption to prevent and treat osteoporosis, hypercalcemia, and Paget’s disease of the bone
• Monitor calcium levels in clients receiving IV preparations
• There is a risk for esophagitis and esophageal ulcers with oral preparations, so indigestion, chest pain, difficulty swallowing, or bloody emesis should be immediately reported
• Take with 8 oz of water in the early morning before eating
• Remain upright for 30 min after taking oral medication
• Clients using IV preparations should have dental examinations and preventative treatment prior to starting therapy to minimize the risk of osteonecrosis of the jaw

Receptor Activator of Nuclear Factor Kappa-B Ligand (RANKL) Inhibitors

• Denosumab is contraindicated for clients who have hypocalcemia
• Clients should have dental exams and preventative treatment prior to starting therapy to minimize the risk of osteonecrosis of the jaw
• Reduces bone resorption and increases bone density
• Limited use in clients who are at high risk for fractures
• Monitor calcium levels
• Administer subcutaneously into the upper arm, upper thigh, or abdomen
• Notify the provider if manifestations of infection develop

Orthotic Devices

• Orthotic devices are available for immobilization of the spine immediately after a compression fracture of the spine (a trunk orthosis or lumbosacral corset)
• The device provides support and decreases pain
• A physical therapist fits the device for the client and teaches them how to apply it
• Check for skin breakdown under the orthotic device
• Use good posture and body mechanics
• Log roll when getting out of bed
• Use heat and back rubs to promote muscle relaxation

Joint Repair or Joint Arthroplasty

• Can be necessary to repair or replace a joint weakened by osteoporosis
• This is most often the hip joint

Vertebroplasty or Kyphoplasty

• Minimally invasive procedures performed by a surgeon or radiologist
• Used after other conservative measures to treat fractures have proven ineffective
• Bone cement is injected into the fractured space of the vertebral column with or without balloon inflation
• Balloon inflation of the fracture is to contain the cement and add height to the fractured vertebra
• Mild sedation is used
• The client lies in a supine position for 1 to 2 hr following the procedure
• The client might be discharged within 4 hr
• Monitor vital findings for shortness of breath and the puncture site for bleeding
• Complete a neurologic assessment
• Apply cold therapy to the injection site
• Avoid driving for 24 hr following the procedure
• Keep the dressing dry, and remove it the day following the procedure
• Monitor the site for findings of infection
• Resume activities (walking) the day following the procedure and gradually increase activity level as tolerated
• Encourage the client to increase fluid intake and consume foods high in fiber to prevent constipation

General Nursing Care

• Instruct the client regarding dietary calcium food sources
• Provide information regarding calcium and vitamin D supplementation (take with food)
• Reinforce the need for exposure to vitamin D (moderate sun exposure using sunscreen, fortified milk)
• Encourage weight-bearing exercises (at least 30 min, three to five times a week) to improve strength and reduce bone loss
• Assess the home environment for safety (remove throw rugs, provide adequate lighting, clear walkways) to prevent falls, which can result in fractures
• Reinforce the use of safety equipment and assistive devices
• Clearly mark thresholds, doorways, and steps

Radiography

• Radiographs of the spine and long bones reveal low bone density and fractures

Dual-Energy X-Ray Absorptiometry (DEXA)

• A DEXA scan is used to screen for early changes in bone density and is usually done on the hip or spine
• A peripheral DEXA scan is used to assess the bone density of the heel, forearm, or finger
• DEXA uses two beams of radiation
• Findings are analyzed by a computer and interpreted by a radiologist
• Clients receive a score that relates their amount of bone density that of young, healthy adults (T score)
• Another reading, a Z score, compares the client’s readings with those of a group of age-matched clients who serve as a control
• The client will lie on an x-ray table while a scan of a selected area is done
• Clothing is not removed for the test, but metallic objects that might interfere with the scanning procedure should be removed

Peripheral Quantitative Ultrasound (pQUS)

• An ultrasound, usually of the heel, tibia, and patella, is performed
• pQUS is an inexpensive, portable, and low-risk method to determine osteoporosis and assess the risk of fracture, especially in men (sex assigned at birth) over age 70 years

Quantitative Computed Tomography

• Quantitative computer tomography, as well as CT-based absorptiometry, is used to measure bone density, especially in the vertebral column
• Used to predict spinal or hip fractures
• Require more radiation than DXA scanning

Magnetic Resonance Imaging (MRI) and Magnetic Resonance Spectroscopy (MRS)

• These provide information about bone density without exposing the client to radiation
• Areas of osteoporosis show decreased perfusion
• Fat marrow content is higher if the client has reduced bone mineral density
• MRS provides a graph to quantify bone marrow adipose tissue

Lab Tests

• Blood calcium, vitamin D, phosphorus, hematocrit, ESR, and alkaline phosphatase levels are drawn to rule out other metabolic bone diseases (Paget’s disease or osteomalacia)
• Blood calcium and vitamin D should be checked yearly for females (sex assigned at birth) at high risk and yearly after age 50 for males (sex assigned at birth) at high risk
• 24-hr urine can evaluate the rate of calcium excretion
• Bone turnover markers measure bone formation and resorption activity

Expected Findings

• Reduced height of 5 to 7.5 cm (2 to 3 in)
• Acute back pain after lifting or bending (worse with activity, relieved by rest)
• Restriction in movement and spinal deformity
• History of fractures (wrist, femur, thoracic spine)
• Thoracic (kyphosis) of the dorsal spine
• Pain upon palpation over affected area

Risk Factors

• Ethnicity: Asian American and White American
• Age greater than 50
• Family history, and thin, lean body build are precursors to low bone density
• Females (sex assigned at birth) have a higher risk for primary osteoporosis, and the decline in estrogen levels following menopause or ovary removal increases the rate of bone resorption
• Males (sex assigned at birth) have a higher risk for the secondary osteoporosis, and a decrease in testosterone can lead to decreased bone mass
• History of low calcium intake with suboptimal levels of vitamin D decreases bone formation (causes calcium to be removed from bones
• Clients who limit protein have a reduced ability to use calcium because up to 50% of calcium is bound to protein and clients who follow a high-protein, low- carbohydrate diet can eliminate important nutrients (calcium-rich foods)
• Tobacco smoke exposure (active or passive) and high alcohol intake (three or more drinks per day) causes decreased bone formation and increased bone absorption
• Excess caffeine consumption causes excretion of calcium in the urine
• History of malabsorption disorders (anorexia nervosa, celiac disease, bariatric surgery) limits the amount of calcium available
• Lack of physical activity or prolonged immobility increases risk
• Secondary osteoporosis results from medical conditions
• Comorbidities (hyperparathyroidism, hyperthyroidism, diabetes mellitus, Cushing’s syndrome, rheumatoid arthritis, bone cancer, female hypogonadism, growth hormone deficiency, chronic airway disorders that affect calcium absorption and bone development [COPD, asthma])
• Medication use over a prolonged period (loop diuretics, corticosteroids, thyroid medications, anticonvulsants) affects calcium absorption and bone metabolism
• Long-term lack of weight-bearing (spinal cord injury, sedentary lifestyle)
• Older adult clients have an increased risk of falls related to impaired balance, generalized weakness, gait changes, and impaired vision and hearing, and adverse medication effects can cause orthostatic hypotension, urinary frequency, or confusion
• The body does not absorb and use calcium as efficiently, but it does excrete calcium more readily than occurs in the younger adult
• High phosphorus intake increases the rate of calcium loss and drinking more than 40 oz/day of carbonated beverages increases osteoporosis risk due to the amount of phosphorus consumed

Dietary Recommendations

• Consume adequate amounts of calcium and vitamin D from food or supplements, especially during young adulthood
• Read food labels for sources of calcium
• Foods rich in vitamin D are most fish, egg yolks, fortified milk, and cereal
• Foods rich in calcium are milk products, green leafy vegetables, fortified orange juice and cereals, red and white beans, and figs
• Some soy and rice products are fortified with vitamin D and calcium

Lifestyle Recommendations

• Spend time outdoors to increase the body’s production of vitamin D, and wear sunscreen to avoid getting a sunburn
• Tobacco cessation
• Limit consumption of alcohol
• Consider engaging in weight-bearing exercises (walking, lifting weights) to promote bone rebuilding and maintenance

Complications

• Fractures are the leading complication of osteoporosis
• Early recognition and treatment is essential
• Support the client’s knees in a flexed position to relieve back pain
• Move the trunk as a unit and avoid twisting to relieve pain from vertebral fractures
• Physical therapy can be used to establish an exercise regimen: 20 to 30 min of aerobic exercise (such as walking) at least three times per week in addition to weightlifting
• Clients can need rehabilitation if fractures cause immobilization or disability
• Most hip fractures are due to osteoporosis, and joint repair or joint arthroplasty requires physical therapy for a full recovery