Bone Loss In The Elderly

1. 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 Bone Loss In The Elderly

2. Osteoporosis • Epidemiology • Risk Factors • Diagnosis • Treatment

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

4. 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 Secondary Osteoporosis

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

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

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

8. U.S.Women in WHO Categories

9. Osteoporosis • Risk Factors • Epidemiology • Diagnosis • Treatment

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

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

12. Osteoporosis Risk FactorsNon Modifiable • Age • Race • Gender • Family History • Early Menopause /Oophorectomy

13. Osteoporosis Risk FactorsModifiable • Weight • Physical Activity • Ca/Vit D Intake • Cigarette Smoking • Glucocorticoids • Sex Hormone Insufficiency

14. Osteoporosis • Introduction • Epidemiology & Risk Factors • Diagnosis • Treatment

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

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

17. Deficiency States Calcium Vitamin D Vitamin C Zinc? Manganese? Boron? Excess Intake Insoluble Fiber Animal Protein Phosphate Alcohol Smoking Vitamins D or A Nutritional History

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

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

20. WHO Definition • Osteopenia • 1-2.5 sd Below Mean • Osteoporosis • >2.5 sd Below Mean

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

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

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

24. Osteoporosis • Introduction • Epidemiology & Risk Factors • Diagnosis • Treatment

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

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

27. Exercise • Weight-Bearing Exercise • Vigorous Training vs. Exercise

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

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

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

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

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

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

34. Calcitonin • Calcitonin-Salmon • Calcitonin-Intranasal

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

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

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

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

39. Questions?