Prevention Treatment of Osteoporosis in Geriaterics

1. Prevention Treatment of Osteoporosis in Geriaterics Dr H. Soleimani Department of Rheumatology Shahid Sadughi Hospital

2. Intervention Thresholds Treatment Follow-up But, do I really have to take those medicines? Fracture Risk Assessment Will I end up like my mother? I saw on the News last night.....

3. Pharmacotherapy(antiresorptives and anabolics) Address Secondary Factors(drugs and diseases) Lifestyle Changes(nutrition, physical activity, and fall prevention) Leading the Effort to Help Prevent and Treat Osteoporosis Pyramid for Osteoporosis Prevention and Treatment What does this mean for your patients? US Department of Health and Human Services. Bone Health and Osteoporosis: A Report of the Surgeon General. US Department of Health and Human Services, Office of the Surgeon General; 2004.

4. A Few Facts about Osteoporosis and Bone Density Measurement

5. Osteoporosis Osteoporosis is defined as a skeletal disorder characterized by compromised bone strength predisposing to an increased risk of fracture. NIH Consensus Development Conference, March 2000 Normal Bone Osteoporotic Bone

6. Fractures in Women Are Common:Incidence of Chronic Diseases 2.0 1,500,000 1.5 1.0 Annual Incidence, million 373,000 345,000 0.5 250,000 211,240 0 Fracture1 Hip fracture1 Heart attack2 Stroke2 Breast cancer3 All women Women with osteoporosis Risk of osteoporotic fracture in 1 year is greater than combined risk of heart attack, stroke, and breast cancer. 1. Riggs BL, Melton LJ III. Bone. 1995;17(suppl):505S–511S. 2.American Stroke Association. Heart disease and stroke statistics––2005 update. Available at: http://www.americanheart.org. Accessed August 24, 2005. 3. American Cancer Society. Cancer facts & figures; 2005. Available at: http://www.cancer.org. Accessed August 24, 2005.

8. Practical Definition of Osteoporosis • A fall from a sitting or standing height that causes a fracture

9. Bone Mineral Density Testing“Quantitating the Bone Mass”

10. Central Devices GE Lunar Prodigy Hologic Delphi

11. Central DXA Measures bone density at the hip and spine DXA image of the hip DXA image of the lumbar spine

12. NOF 2008 GuidelinesWho Should be Tested? Women age 65 and older Men age 70 and older Women and men over 50 with risk factors Patients with a fracture after age 50

13. Vertebral Fracture Assessment Lateral Spine Imaging with Fan-ArrayDual Energy X-ray Absorptiometry

15. Pharmacotherapy(antiresorptives and anabolics) Address Secondary Factors(drugs and diseases) Lifestyle Changes(nutrition, physical activity, and fall prevention) Leading the Effort to Help Prevent and Treat Osteoporosis Surgeon General’s Report on Bone Health and Osteoporosis Pyramid for Osteoporosis Prevention and Treatment What does this mean for your patients? US Department of Health and Human Services. Bone Health and Osteoporosis: A Report of the Surgeon General. US Department of Health and Human Services, Office of the Surgeon General; 2004.

16. Lifestyle Issues • Tobacco- eliminate it • Alcohol – moderate it • Food – eat it • Exercise – do it • Fall Prevention – work on it

17. Lifestyle Issues Tobacco - eliminate it Alcohol – moderate it Nutrition - adequate weight, protein-- magnesium, trace elements....multivite Exercise – strength, aerobic, flexibility, balance Fall prevention- home safety, shoes, walking aids, glasses

18. Nutrition • Appropriate Body Weight • BMI 22 - 25 • Adequate nutrition • Protein • Multi-vitamin daily • C, D, K, Copper, Manganese, Zinc, Phosphorus • Nutritional supplements • Ensure, Boost

19. Nutrition Milk, Yogurt • Calcium, magnesium, potassium, phosphorus, zinc, protein, vitamin A, vitamin D, vitamin B12, riboflavin Risk reduction for • Osteoporosis, hypertension, obesity, colon cancer, diabetes, metabolic syndrome

20. What are the therapeutic options? • Exercise and prevention of falls improve quality of life improve muscle strength and balance moderate walking reduced risk of hip Fx* treat cataract Use of hip protectors*

21. Exercise • Walking reduces hip fracture risk • 4 hours per week reduced hip fracture by 41% in a study of 61,200 women JAMA 2002 • Activity of any type reduces fracture risk- Balance, Strength, Flexibility, Aerobic

22. Exersice • 1. Exercises involving resistance training appropriate for the individual’s age and functional capacity and/or weightbearing aerobic exercises are recommended for those with osteoporosis or at risk for osteoporosis [grade B].

23. Exersice • Exercises to enhance core stability and thus to compensate for weakness or postural abnormalities are recommended for individuals who have had vertebral fractures [grade B].

24. Exersice • Exercises that focus on balance, such as tai chi, or on balance and gait training should be considered for those at risk of falls [grade A].

25. Falling • Medications, Alcohol • Balance programs • Strength training • Safety at home • Hip protectors • Walking aids

26. Hip Protectors

27. Hip Protector • Use of hip protectors should be considered for older adults residing in long-term care facilities who are at high risk for fracture [grade B].

28. Calcium 1200 mg “Calcium has been singled out as a major health concern today because it is critically important to bone health and the average American consumes levels of calcium that are far below the amount recommended for optimal bone health.” General’s Report on Bone Health 2004

29. Calcium 1200 mg • Dietary • Fortified foods • Calcium citrate • Taken with or without food • Calcium carbonate • Taken with food • Divided doses

30. Calcium • The total daily intake of elemental calcium (through diet and supplements) for individuals over age 50 should be 1200 mg [grade B].

31. Vitamin D 800-2000 IU ? “Vitamin D is important for good bone health because it aids in the absorption and utilization of calcium. There is a high prevalence of Vitamin D deficiency in nursing home residents, hospitalized patients, and adults with hip fractures.” …..and many others General’s Report on Bone Health 2004

32. Vitamin D Sufficiency > 32 ng/ml Comfort zone- 40s, 50s Many wellness relationships Insufficiency < 32 ng/ml Disease states New England Journal of Medicine July 19 2007 Medical Progress: Vitamin D Deficiency M F Holick 800-1000 IU daily for patients 50 + ...although some elderly patients may require 2000 IU/day...... NOF Clinician’s Guide 2008

33. Vit D • For healthy adults at low risk of vitamin D deficiency, routine supplementation with 400–1000 IU (10–25 μg) vitamin D3 daily is recommended [grade D].

34. Vit D • For adults over age 50 at moderate risk of vitamin D deficiency, supplementation with 800–1000 IU (20–25 μg) vita min D3 daily is recommended. To achieve optimal vitamin D status, daily supplementation with more than 1000 IU (25 μg) may be required. Daily doses up to 2000 IU (50 IU (25 μg) may be required. Daily doses up to 2000 IU (50 μg) are safe and do not necessitate monitoring [grade C].

35. Vit D • For individuals receiving pharmacologic therapy for osteoporosis, measurement of serum 25-hydroxyvitamin D should follow three to four months of adequate supplementation and should not be repeated if an optimal level • (≥ 75 nmol/L) is achieved [grade D].

36. Vitamin D • Improves calcium absorption • Direct action on building bone matrix • Decreases FALLS • Increases muscle mass and strength • Etc etc................

37. Pharmacotherapy(antiresorptives and anabolics) Address Secondary Factors(drugs and diseases) Lifestyle Changes(nutrition, physical activity, and fall prevention) Leading the Effort to Help Prevent and Treat Osteoporosis Pyramid for Osteoporosis Prevention and Treatment What does this mean for your patients? US Department of Health and Human Services. Bone Health and Osteoporosis: A Report of the Surgeon General. US Department of Health and Human Services, Office of the Surgeon General; 2004.

38. WHO Risk Factors Age (50-90), gender and clinical risk factors: • BMI • Prior fragility fracture • Parental history of hip fracture • Current tobacco smoking • Ever long-term use of glucocorticoids • Rheumatoid arthritis or other secondary causes • Alcohol intake 3 or more units daily Kanis Osteoporos Int 2008;19:385-397

40. Frailty Factor Acute Medical Illnesses Chronic Medical Illnesses Inactivity Falling

41. Medication Check Corticosteroids Anticonvulsants Aromatase inhibitors Thyroid hormone SSRIs • DepoProvera • Lupron • Narcotics • Cancer Chemo • Lithium • Thiazolidinediones

42. Check Lab Tests

43. Check Lab Tests“Secondary Cause Work Up” Blood count (CBC) Chemistries (CMP) Calcium, Phosphorus Kidney tests Liver tests Alk Phos Vitamin D (25hydroxyD) Thyroid (TSH) Parathyroid (intact PTH) Celiac (IgA anti-t-TGase antibody) Malabsorption/Hypercalciuria (24 hr Urine Calcium) Myeloma (SPIEP) Arthritis (ESR etc.) Hormones (Testosterone) Bone Turnover markers (NTX,CTX)

44. Pharmacotherapy(antiresorptives and anabolics) Address Secondary Factors(drugs and diseases) Lifestyle Changes(nutrition, physical activity, and fall prevention) Leading the Effort to Help Prevent and Treat Osteoporosis Pyramid for Osteoporosis Prevention and Treatment What does this mean for your patients? US Department of Health and Human Services. Bone Health and Osteoporosis: A Report of the Surgeon General. US Department of Health and Human Services, Office of the Surgeon General; 2004.

45. “Pharmacotherapy” (Medications)

46. Medications • Prevent and Treat Thresholds 1. The Fracture Patient or < or = -2.5 T score 2. Bone density = or < - 2.0 3. Bone density = or < -1.5 with risk factors • Guidelines for post menopausal women • And men over 50

47. 2010 clinical practice guidelines for the diagnosisand management of osteoporosis in Canada: summaryAlexandra Papaioannou MD MSc, Suzanne Morin MD MSc, Angela M. Cheung MD PhD,Stephanie Atkinson PhD, Jacques P. Brown MD, Sidney Feldman MD, David A. Hanley MD,Anthony Hodsman MD, Sophie A. Jamal MD PhD, Stephanie M. Kaiser MD, Brent Kvern MD,Kerry Siminoski MD, William D. Leslie MD MSc; for the Scientific Advisory Council ofOsteoporosis Canada

48. 2008 NOF Clinician’s Guide&FRAX www.nof.org/professionals/Clinicians_Guide.htm http://www.shef.ac.uk/FRAX

49. NOF 2008GuidelinesWho Should Be Treated? • Fragility fracture- hip or spine • T-score ≤ -2.5 • T-score -1.0 to -2.5 (osteopenia) and • 10-year all major osteoporosis-related fracture probability of ≥ 20% or a • 10-year hip fracture probability ≥ 3% (FRAX) www.nof.org

50. WHO Risk Factors Age (50-90), gender and clinical risk factors: • BMI • Prior fragility fracture • Parental history of hip fracture • Current tobacco smoking • Ever long-term use of glucocorticoids • Rheumatoid arthritis or other secondary causes • Alcohol intake 3 or more units daily Kanis Osteoporos Int 2008;19:385-397