Metabolic Bone Disorders Prevention PDF

11/27/23, 4:40 AM Realizeit for Student Metabolic Bone Disorders Prevention Peak adult bone mass is achieved between the ages of 18 and 25 years in both women and men and is affected by genetic factors, nutrition, physical activity, medications, endocrine status, and general health (IOF, 2017). Me...

11/27/23, 4:40 AM Realizeit for Student Metabolic Bone Disorders Prevention Peak adult bone mass is achieved between the ages of 18 and 25 years in both women and men and is affected by genetic factors, nutrition, physical activity, medications, endocrine status, and general health (IOF, 2017). Men typically develop larger, heavier bones than women; therefore, they manifest osteoporosis at more advanced ages. Primary osteoporosis occurs in women after menopause (usually by age 51) but it is not merely a consequence of aging. Failure to develop optimal peak bone mass and low vitamin D levels contribute to the development of osteopenia without associated bone loss (Drezner, 2019). Early identification of at-risk teenagers and young adults, increased calcium and vitamin D intake, participation in regular weight-bearing exercise, and modification of lifestyle (e.g., reduced use of caffeine, tobacco products, carbonated soft drinks, and alcohol) are interventions that decrease the risk of fractures and associated disability later in life (Black, Cauley, Wagman, et al., 2017) (see Chart 36-10). https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IT%2f2%2bt0zmWpgA%2fttBl%2bYliu9txYeiNyhjGIrXvrN… 1/8 11/27/23, 4:40 AM Realizeit for Student Secondary osteoporosis is the result of medications or diseases that affect bone metabolism. Men are more likely than women to have secondary causes of osteoporosis, including the use of corticosteroids (especially if they receive doses in excess of 5 mg of prednisone daily for more than 3 months) and excessive alcohol intake. Specific disease states (e.g., celiac disease, hypogonadism) and medications such as anticonvulsants (e.g., phenytoin), thyroid replacement agents (e.g., levothyroxine), antiestrogens (e.g., medroxyprogesterone), androgen inhibitors (e.g., leuprolide), selective serotonin receptor inhibitors (SSRIs; e.g., fluoxetine) and proton pump inhibitors (e.g., esomeprazole) place patients at risk; these diseases and medications need to be identified and therapies instituted to halt the development of osteoporosis (Robinson, 2020). The degree of bone loss is related to the duration of medication therapy. When the drugs are discontinued or the metabolic problem is corrected, the progression is halted but restoration of lost bone mass may not occur. https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IT%2f2%2bt0zmWpgA%2fttBl%2bYliu9txYeiNyhjGIrXvrN… 2/8 11/27/23, 4:40 AM Realizeit for Student Gerontologic Considerations The prevalence of osteoporosis in women older than 80 years is 50%. The average 75-year-old woman has lost 25% of her cortical bone and 40% of her trabecular bone. Most residents of longterm care facilities have a low BMD and are at risk for bone fracture. One third of all hip fractures occur among men, and men have a higher mortality rate than women after sustaining a hip fracture (Rapp, Büchele, Dreinhőfer, et al., 2019). It is estimated that the number of hip fractures and their associated costs will at least double by the year 2040 because of the projected aging of the U.S. population. A fragility fracture is defined as one that occurs when a person falls from their natural height (or less) or with low velocity. Frequently, an underlying disease or metabolic alteration makes the bone more likely to fracture. Osteoporosis and osteopenia are the most frequently cited risks of fragility fractures. The aging of the population, the increased use of medications that contribute to falls risk, and a lack of caregivers contribute to the rising risk of fragility fractures. Inadequate staffing related to a worsening nursing shortage may result in gaps in care that increase the incidence of fragility fractures; decreased staffing may delay nursing assessments and follow-up and increase the likelihood that patients try to get up unsupervised, resulting in falls (Brent, Hommel, Maher, et al., 2018). Routine vertebral fracture screenings are not recommended for older adults. However, 80% to 90% of these fractures can be seen incidentally on chest x-rays taken for other purposes. It is estimated that only one third of vertebral fractures are diagnosed. Vertebral fracture risk is five times higher among patients who have had prior fractures. Furthermore, 20% of women who are postmenopausal and have a vertebral fracture will have another one within 1 year (Pouresmaeili, Kamalidehghan, Kamerehei, et al., 2018). Nurses are the team members who frequently are first to uncover vertebral fractures by identifying a change in a patient’s height during routine exams conducted in office or clinic settings. Older adults absorb dietary calcium less efficiently and excrete it more readily through their kidneys. Women who are postmenopausal and older adults need to consume approximately 1200 mg of daily calcium. Quantities larger than this may place patients at heightened risk of renal calculi or cardiovascular disease (United States Preventive Services Task Force [USPSTF], 2018). Though bone density increases with calcium intake, the rate of fractures does not decrease in women who are postmenopausal and who routinely take calcium supplements (Bailey, Zou, Wallace, et al., 2020). https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IT%2f2%2bt0zmWpgA%2fttBl%2bYliu9txYeiNyhjGIrXvrN… 3/8 11/27/23, 4:40 AM Realizeit for Student Pathophysiology Osteoporosis is characterized by reduced bone mass, deterioration of bone matrix, and diminished bone architectural strength. Normal homeostatic bone turnover is altered; the rate of bone resorption that is maintained by osteoclasts is greater than the rate of bone formation that is maintained by osteoblasts, resulting in a reduced total bone mass. The bones become progressively porous, brittle, and fragile. They fracture easily under stresses that would not break normal bone. This occurs most commonly as compression fractures (see Fig. 36-11) of the thoracic and lumbar spine, hip fractures, and Colles fractures of the wrist. These fractures may be the first clinical manifestation of osteoporosis (Black et al., 2017). https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IT%2f2%2bt0zmWpgA%2fttBl%2bYliu9txYeiNyhjGIrXvrN… 4/8 11/27/23, 4:40 AM Realizeit for Student https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IT%2f2%2bt0zmWpgA%2fttBl%2bYliu9txYeiNyhjGIrXvrN… 5/8 11/27/23, 4:40 AM Realizeit for Student The gradual collapse of a vertebra may be asymptomatic. With the development of kyphosis (i.e., Dowager hump), there is an associated loss of height. The postural changes result in relaxation of the abdominal muscles and a protruding abdomen. The deformity may also produce pulmonary insufficiency and increase the risk for falls related to balance issues. Age-related loss begins soon after the peak bone mass is achieved (i.e., in the fourth decade). Calcitonin, which inhibits bone resorption and promotes bone formation, is decreased. Estrogen, which inhibits bone breakdown, also decreases with aging. On the other hand, parathyroid hormone (PTH) increases with aging, thus increasing bone turnover and resorption. The consequence of these changes is net loss of bone mass over time. The withdrawal of estrogens at menopause or with oophorectomy causes an accelerated bone resorption within the first 5 years after cessation of menses. Most women lose 10% of their bone mass. More than half of all women older than 50 years show evidence of osteopenia (Black et al., 2017; MQIC, 2020). Risk Factors Small-framed women are at greatest risk for osteoporosis. In terms of ethnicity, Asian and Caucasian women are at highest risk. Although African American women tend to have higher mineral mass when younger, they are still at risk due to the prevalence of sickle cell and autoimmune diseases in this population. In addition, many African American women also have poor calcium intake due to lactose intolerance (National Institute of Arthritis and Musculoskeletal and Skin Diseases [NIAMSD], 2018). The use of aromatase inhibitors is an additional risk for women with breast cancer (Robinson, 2020). Men have a greater peak bone mass and do not experience a sudden midlife estrogen reduction. As a result, osteoporosis occurs about one decade later, but one in four men still sustain an osteopenic fracture (Pouresmaeili et al., 2018). It is believed that both testosterone and estrogen are important in achieving and maintaining bone mass in men, although the risk profile for men is not as well established as it is for women (Pouresmaeili et al., 2018) Nutritional factors contribute to the development of osteoporosis. A diet that includes adequate calories and nutrients needed to maintain bone, calcium, and vitamin D must be consumed. Patients who have had bariatric surgery are at increased risk for osteoporosis as the duodenum is bypassed, which is the primary site for absorption of calcium. Patients who have gastrointestinal (GI) diseases that cause malabsorption (e.g., celiac disease, alcoholism) may benefit from additional magnesium supplements (Rondanelli, Faliva, Gasparri, et al., 2019). However, in adults who follow a strict gluten free diet, magnesium supplements are currently not recommended. Autoimmune diseases also contribute to poor bone health. Many of them are associated with nutritional deficiencies (e.g., celiac, autoimmune liver disease). Furthermore, many patients with https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IT%2f2%2bt0zmWpgA%2fttBl%2bYliu9txYeiNyhjGIrXvrN… 6/8 11/27/23, 4:40 AM Realizeit for Student autoimmune diseases are prescribed corticosteroid medications and, as a consequence of their disease processes, are relatively sedentary. These factors also can cause weak bones (Arase, Tsuruya, Hirose, et al., 2020). Bone formation is enhanced by the stress of weight and muscle activity. When immobilized by casts, general inactivity, paralysis, or other disability, the bone is resorbed faster than it is formed, and osteoporosis results (McCance & Huether, 2019). Immobility contributes to the development of osteoporosis. Resistance and impact exercises are most beneficial in developing and maintaining bone mass. Assessment and Diagnostic Findings Osteoporosis may be undetectable on routine x-rays until there has been significant demineralization, resulting in radiolucency of the bones (Black et al., 2017). When the vertebrae collapse, causing compression fractures, the thoracic vertebrae become wedge shaped and the lumbar vertebrae become biconcave. Osteoporosis is diagnosed by dual-energy x-ray absorptiometry (DEXA), which provides information about BMD at the spine and hip. The DEXA scan data are analyzed and reported https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IT%2f2%2bt0zmWpgA%2fttBl%2bYliu9txYeiNyhjGIrXvrN… 7/8 11/27/23, 4:40 AM Realizeit for Student as T-scores (the number of standard deviations above or below the average BMD value for a 30-yearold healthy adult of the same sex). Baseline DEXA testing is recommended for all women older than 65 years, for women who are postmenopausal older than 50 years with osteoporosis risk factors, and for all people who have had a fracture thought to occur as a consequence of osteoporosis (Black et al., 2017). BMD studies are also useful in assessing response to therapy and are recommended 3 months post any osteoporotic fracture. There is no evidence to support basic screening of men younger than 70 years of age or to determine the optimal time interval to repeat studies in either gender following a normal baseline report (USPSTF, 2019). Female fracture risk can be estimated using the World Health Organization (WHO) Fracture Risk Assessment Tool (FRAX) (Cass, Shepard, Asirot, et al., 2016). These FRAX tables typically underestimate the bone loss risk in men. The Male Osteoporosis Risk Estimation Score (MORES) generates a more gender-specific evaluation than the standard FRAX score in men. Treatment for both genders is now reserved for those with a 10-year risk of more than 3% for hip fracture or 20% risk for other major fractures. Risk scores are based on BMD, personal and family history of fractures, BMI, gender, age, and secondary factors such as medication use, smoking, and history of rheumatoid disease. Impaired glucose tolerance and diabetes are now also recognized as additional risk factors (Robinson, 2020). Laboratory studies (e.g., serum calcium, serum phosphate, serum alkaline phosphatase [ALP], urine calcium excretion, urinary hydroxyproline excretion, hematocrit, erythrocyte sedimentation rate [ESR]), and x-ray studies are used to exclude other possible disorders (e.g., multiple myeloma, osteomalacia, hyperparathyroidism, malignancy) that contribute to bone loss. In men, low testosterone levels may be part of the cause. https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IT%2f2%2bt0zmWpgA%2fttBl%2bYliu9txYeiNyhjGIrXvrN… 8/8