Osteoporosis is a metabolic bone disorder in which the rate of bone resorption accelerates while the rate of bone formation slows down, causing a loss of bone mass. Bones affected by this disease lose calcium and phosphate salts and thus become porous, brittle, and abnormally vulnerable to fractures. Osteoporosis may be primary or secondary to an underlying disease. Primary osteoporosis is commonly called postmenopausal osteoporosis because it typically develops in postmenopausal women.
The cause of primary osteoporosis is unknown; however, a mild but prolonged negative calcium balance, resulting from an inadequate dietary intake of calcium, may be an important contributing factor — as may declining gonadal or adrenal function, faulty protein metabolism due to estrogen deficiency, and sedentary lifestyle. Causes of secondary osteoporosis are many: prolonged therapy with steroids or heparin, total immobilization or disuse of a bone (as with hemiplegia, for example), alcoholism, malnutrition, malabsorption, scurvy, lactose intolerance, osteogenesis imperfecta, Sudeck’s atrophy (localized to hands and feet, with recurring attacks), and endocrine disorders (hypopituitarism, acromegaly, thyrotoxicosis, long-standing diabetes mellitus, hyperthyroidism).
The incidence of osteoporosis is high, with an estimated 10 million U.S. residents suffering from osteoporosis and another 18 million suffering from low bone mass, or osteopenia. Incidence is higher in women than in men, with women older than age 50 accounting for 20% of cases. Another 30% of women have osteopenia, which can deteriorate into osteoporosis.
Osteoporosis is usually discovered incidentally on roentgenograms; the patient may have been asymptomatic for years. Vertebral collapse, causing a backache with pain that radiates around the trunk, is the most common presenting feature. Any movement or jarring aggravates the backache.
In another common pattern, osteoporosis can develop insidiously, with increasing deformity, kyphosis, and loss of height. Sometimes a dowager hump is present. As bones weaken, spontaneous wedge fractures, pathologic fractures of the neck or femur, Colles’fractures after a minor fall, and hip fractures become increasingly common.
Osteoporosis primarily affects the weight-bearing vertebrae. Only when the condition is advanced or severe, as in Cushing’s syndrome or hyperthyroidism, do comparable changes occur in the skull, ribs, and long bones.
Differential diagnosis must exclude other causes of rarefying bone disease, especially those affecting the spine, such as metastatic cancer and advanced multiple myeloma. The differential diagnosis should also exclude osteomalacia, osteogenesis imperfecta tarda, skeletal hyperparathyroidism, and hyperthyroidism. Initial evaluation attempts to identify the specific cause of osteoporosis through the patient history.
❑ Bone mineral density testing is performed in dual-energy X-ray absorptiometry (DEXA) and measures the mineralization of bones. It’s the gold standard for evaluating osteoporosis.
❑ A spine computed tomography scan shows demineralization. Quantitative computed tomography can evaluate bone density but is less available and more expensive than DEXA.
❑ X-rays show fracture or vertebral collapse in severe cases.
❑ Urine calcium can provide evidence of bone turnover but is limited in value. Newer tests include urinary N-telopeptide to help diagnose osteoporosis.
Treatment aims to slow down or prevent bone loss, prevent additional fractures, and control pain. A physical therapy program that emphasizes gentle exercise and activity is an important part of the treatment. Medications may include bisphosphonates, such as alendronate and risedronate, to prevent bone loss and reduce the risk of fractures. The physician may also recommend adequate calcium and vitamin D intake. Raloxifene and calcitonin have also been prescribed. Weakened vertebrae should be supported, usually with a back brace. Surgery can correct pathologic fractures of the femur by open reduction and internal fixation. Colles’fracture requires reduction with plaster immobilization for 4 to 10 weeks.
The incidence of primary osteoporosis may be reduced through adequate intake of dietary calcium and regular exercise. Fluoride treatments may also offer some preventive benefit. Hormone replacement therapy (HRT) with estrogen and progesterone may retard bone loss and prevent the occurrence of fractures; however, this therapy remains controversial. HRT decreases bone reabsorption and increases bone mass. Secondary osteoporosis can be prevented through effective treatment of the underlying disease as well as corticosteroid therapy, early mobilization after surgery or trauma, careful observation for signs of malabsorption, and prompt treatment of hyperthyroidism. Decreased alcohol consumption and caffeine use, as well as smoking cessation, are also helpful preventive measures.
Your care plan should focus on the patient’s fragility, stressing careful positioning, ambulation, and prescribed exercises.
❑ Check the patient’s skin daily for redness, warmth, and new sites of pain, which may indicate new fractures. Encourage activity; help the patient walk several times daily. As appropriate, perform passive range-of-motion exercises or encourage the patient to perform active exercises. Make sure the patient regularly attends scheduled physical therapy sessions.
❑ Impose safety precautions. Keep the side rails of the patient’s bed in raised position. Move the patient gently and carefully at all times. Explain to the patient’s family and ancillary health care personnel how easily an osteoporotic patient’s bones can fracture.
❑ Provide a balanced diet, high in nutrients that support skeletal metabolism: vitamin D, calcium, and protein. Administer analgesics and heat to relieve pain.
❑ Make sure the patient and her family clearly understand the prescribed drug regimen. Tell them how to recognize significant adverse effects and to report them immediately. The patient should also report any new pain sites immediately, especially after trauma, no matter how slight. Advise the patient to sleep on a firm mattress and avoid excessive bed rest. Make sure she knows how to wear her back brace.
❑ Thoroughly explain osteoporosis to the patient and her family. If the patient and her family don’t understand the nature of this disease, they may feel the fractures could have been prevented if they had been more careful.
❑ Teach the patient to use good body mechanics — to stoop before lifting anything and to avoid twisting movements and prolonged bending.
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Copyright Details: Professional Guide to Diseases (Eighth Edition), Copyright © 2008 Williams & Wilkins.
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Title: Professional Guide to Diseases (Eighth Edition)
Authors: Springhouse
Publisher: Lippincott Williams & Wilkins
Copyright: 2005
ISBN: 1-58255-370-X
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