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?