Geriatrics: Fall, motor function and gait assessment, Osteoporosis Flashcards

Question

Sensory ataxic Feature

Answer 1

Increased rate of bone remodeling in both cancellous and cortical bone > Increase number of remodeling units > Resorbed cavities too large and newly formed pocket of bone too small > Increased bone loss and negative remodeling balance

Answer 2

800mg/d in adults 1000mg/d for >50y (F) or >70y (M)

Answer 3

Peak bone mass attained in age 20-40y Gradual age-related bone loss after 40y (~1%/y)

Answer 4

Race: Asians, White Body habitus: short stature, ↓BMI Family history of OP or fragility fracture Low oestrogen states: post-menopausal, amenorrhoea >6mo, multiparity Dietary: low dietary calcium or vitamin D Lifestyle: smoking, drinking, sedentary lifestyle

Answer 5

Endocrine: hyperthyroidism, hyperparathyroidism, hypogonadism, Cushing’s syndrome, prolactinoma Drugs: glucocorticoids, anticonvulsants, PPI, heparin, aromatase inhibitor Malignancy: multiple myeloma, leukaemia Inflammatory: IBD, RA GI: gastrectomy, malabsorption, Primary biliary cirrhosis Renal: renal osteodystrophy Others: prolonged immobilization, osteogenesis imperfecta, homocystinuria, Turner syndrome, scurvy

Answer 6

Asymptomatic: presented with incidental finding of XR osteopenia or by screening Fragility fractures: fractures occurring with low energy trauma (eg. fall from level ground) □ Vertebral collapse: acute mechanical LBP ± radiation with height loss and kyphosis □ Trochanter/neck of femur, usually upon fall landing on buttock □ Distal forearm: distal radius/ulna □ Neck of humerus, pelvic (pubis, sacrum), rib

Answer 7

□ Previous Low-trauma/ Low-energy fracture in postmenopausal/ elderly patient □ T-score ≤-2.5 based on BMD measurement by DXA Device: dual energy X-ray absorptiometry (DEXA) at spine and hip (best predictor of fracture risk) Interpretation (WHO 1994): → Normal = T score ≥ -1 → Osteopenia = T score <1 and >-2.5 → Osteoporosis = T score ≤-2.584 → Established osteoporosis = T score ≤-2.5 with fracture Note that by 60y, ~1/2 of women will have low bone mass or osteoporosis

Answer 8

``` Aim: □ Identify risk factors □ Evidence for secondary osteoporosis □ Medications/illnesses that ↑risk of fall and OP □ Family Hx ``` Past health: - History of fractures - Fall risk - Low estrogen state: age of menopause, multiparity... etc - GI disease/ Malabsorption syndromes - Anorexia nervosa - Type I DM Drug history: - OP: glucocorticoids, PPI, anticonvulsants, TZDs - Fall risk: hypnotics, sedatives...etc Social: - Smoking and alcohol (RFs) - Sedentary lifestyle Family Hx: - OP or fragility fractures

Answer 9

Height and weight, any recent acute changes (vertebral fracture, Cushing's syndrome) Dental exam for loss of teeth and dentures (early signs of osteoporosis, risk of osteonecrosis of jaw) Evidence of secondary osteoporosis: → Signs of endocrine diseases, eg. hyperthyroidism, Cushing’s disease → Signs of myeloma, eg. anaemia, hypercalcemia → Signs of hypogonadism Clinical effects of osteoporosis: → Observe posture and estimate degree of kyphosis → Examine for site of tenderness Fall assessment: critical in elderly → Agility, hearing, eyesight, postural sway → Gait → Mobility muscle strength

Answer 10

Adequate dietary Ca, vitamin D intake: → Recommended intake: 1000mg Ca, 600IU vit D (M or premenopausal F); 1200mg Ca, 800IU vit D (post-M F) → Role of supplementation: not much evidence, only in inadequate dietary intake (esp vegans, lactose intolerance) → Note that PPI use can ↓calcium absorption Regular weight bearing exercise Smoking cessation and moderate alcohol consumption Regular exposure to sunlight esp in institutionalized patients

Answer 11

Cheese, Sardine, Almond, Yogurt, Tofu Ca supplements (Calcium carbonate, Calcium citrate) - Taken with food, gastric acidity promote calcium absorption - S/E: Dyspepsia and constipation (increase fluid and fiber intake to mitigate)

Answer 12

Requirement: target 25 hydroxyvitamin D level at 30ng/mL - Mean Vit. D requirement: 1000IU/day - 2000IU /day for obese, limited sun exposure, malabsorption Sources: - Synthesis of cholecalciferol (Vit. D3) in the skin under UV light 10-15 minutes sunlight exposure every day over face, hands, arms - Food/ supplements

Answer 13

Examples: - Brisk walking, jogging, stair climbing, Tai Chi, Dancing Benefits: - Retard bone loss - Increase muscle mass and strength - Improve balance, reduce fall risk - Improve QoL

Answer 14

□ Antiresorptives: oestrogen (HRT), SERM, bisphosphonate, RANKL inhibitor □ Anabolic agent: teriparatide/ Abloparatide (PTH), romosozumab (anti-sclerostin Ab)

Answer 15

1st line: oral bisphosphonate (+ raloxifene or HRT if under 65 without hip fracture) → Raloxifene: generally less effective, more for lower risk pt who prefer to ↓CA breast risk → HRT: NO longer indicated for osteoporosis ALONE, can be used if vasomotor symptoms Add-on therapy: → IV bisphosphonate: if refractory to GI S/E of oral form → Denosumab: refractory to bisphosphonate, poor compliance or CKD → Anabolic agent: severe osteoporosis, fractures or unresponsive to other Tx

Answer 16

Non-operative: - Manipulation and cast application for 4-6 weeks - Conservative wait for symptom improvement in 6 weeks Operative: - Vertebral body augmentation procedures - Open surgery if significant neurological deficit/ kyphotic deformity/ pain

Answer 17

PTH, eg. teriparatide (SC low-dose PTH analogue). Abaloparatide Biphasic action of PTH on bone: → Low dose, intermittent → anabolic action eg. daily IMI can ↑BMD and ↓vertebral fracture risk by 70% → High dose, continuous → catabolic action with resorption of cortical > trabecular bone Effect: ↓vertebral fracture by 70%, ↓non-vertebral fracture by 30% S/E: Mild leg cramps Injection site pain and bruising Hypercalcaemia C/O - Long-term use (osteosarcoma risk) - History of skeletal malignancies/ metastases - History of radiation to bone

Answer 18

RANKL Ab, eg. denosumab MoA: human mAb vs RANKL → interferes with RANKL → ↓osteoclast differentiation and activation Effect: ↓vertebral fracture by 50%, ↓non-vertebral fracture by 30% S/E: rash, atypical femoral fracture (very rare), hypocalcemia, osteonecrosis of jaw (very rare), sudden vertebral collapse if abrupt withdrawal **Can use for poor renal function, unlike bisphosphonate**

Answer 19

Examples: Etidronate, alendronate, risedronate, Zoledronate (IV) MoA: Anti-resorptive Pyrophosphate derivative → binds to bone surface and absorbed by Osteoclasts → competitive inhibitor of PPi-requiring farnesyl pyrophosphate synthase (FPPS) reaction → inhibition of mevalonate pathway (i.e. steroidogenesis pathway) → specific inhibition of bone resorption + induce apoptosis of osteoclasts Effect: ↓fracture risk by 50% in both vertebral and non-vertebral fractures (incl. hip) Precautions: - Poor intestinal absorption, take 30min before meal - C/O Poor renal function (eGFR<30) - Avoid Ca or Vit D supplements >1h before bisphosphate (affect absorption) S/E → Upper GI disturbance (~5%), eg. oesophagitis → Flu-like illness (fever, malaise, generalized myalgia) esp at 1st exposure → Oversuppression of bone turnover due to persistent action → Require drug holidays if undergo dental work (remind pt to ensure good dental hygiene) → Atypical femoral fracture due to excessive bone formation → Osteonecrosis of jaw due to limited bone healing following trauma (eg. dental work)

Answer 20

Selective estrogen receptor modulators (SERMs), eg. raloxifene Indication: Young post-menopausal women with low risk of hip fracture MoA: Estrogen-agonist effect in bone: Decrease bone resorption Estrogen-antagonist effect on breast and endometrium: ↓ER+ breast cancer, no risk of endometrial CA Effect: ↓vertebral fracture risk by 50% but not non-vertebral fracture S/E: Venous thromboembolism Hot flushes Leg cramps ** Discontinue if prolong immobilization**

Answer 21

- Indication: Young woman with Early menopause, concurrent decrease menopausal symptoms, reduce cholesterol - MoA: ↓bone resorption, ↓urinary Ca excretion, ↓stromal cell cytokine production → ↓osteoclastogenesis - S/E: ↑risk of CA endometrium → must add progestogen if uterus intact ↑risk of CA breast and CA cervix Venothrombolic disease