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Care of the Elderly > Osteoporosis > Flashcards

Osteoporosis Flashcards

1
Q

Define osteoporosis

A

Disease characterised by low bone mass and structural deterioration of bone with damage to microstructure -> inc bone fragility inc susceptibility to fracture.
Progressive

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2
Q

What are the different types of primary osteoporosis?

A

Type 1 - post-menopausal
Type 2 - age-related

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3
Q

What are the common causes of secondary osteoporosis?

A

Hyperthyroidism
Hyperparathyroidism (High PTH, High Ca, Low P)
Alcohol abuse
Immobilisation
Rheumatoid arthitisis
Malabsorption disease (coeliac or anorexia nervosa)
Chronic Liver Disease

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4
Q

What screening tool can be used to calculate the risk of a bony fracture in the elderly?

A

FRAX tool - risk of major hip or osteoporotic fracture in next ten years
Or QFracture (preferred by NICE) -

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5
Q

What are the main risk factors for osteoporosis?

A

Age (between 40-90yrs) - leads to trabeculisation of cortical bone
Gender - female
Post menopausal
Prolonged untreated amenorrhea
Male hypogonadism
Low calcium or vitamin D intake
Previous fracture or Parent fractured hip
Smoking and alcohol
Glucorticoids (more than 3months)
RA, CKD, hyperthyroidism
Certain medications - SSRIs, PPIs, anti-epileptics and anti-oestrogens.

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6
Q

Who does NICE recommend we assess for osteoporosis?

A

Anyone on long term corticosteroids
Previous fragility fracture
Anyone 50yrs+ with risk factors
All women over 65yrs
All men over 75yrs.

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7
Q

What is the basic pathophysiology of osteoporosis?

A

Increased bone breakdown by osteoclasts
Decreased bone formation by osteoblasts
Causes a loss of bone mass
This can be influenced by collagen type 1A1, Vitamin D receptors and Oestrogen receptor genes/funcationality

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8
Q

How does oestrogen deficiency lead to osteoporosis?

A

Increased number of remodelling units
Premature arrest of osteoblastic synthetic activity and perforation of trabeculae
Loss of resistance to fracture

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9
Q

How do glucocorticoids lead to osteoporosis?

A

Induce a high-turnover state intially
Pronlonged used reduced turn-over rate with net loss of osteoblasts
Typically problematic when 10mg of pred once daily for 3 months or more

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10
Q

What are the key clinical features of osteoporosis?

A

Long latent period before fragility occurs
Pathological or fragility fractures - mechanical method often first presentation

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11
Q

What are the common frailty/pathological fractures?

A

Vertebral compression
Appendicular fractures (proximal femur or distal radius)

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12
Q

How do vertebral compression fractures tend to present?

A

Sudden acute back pain at rest, bending or lifting
Restricted spinal flexion and intensified pain with prolonged standing
Anterior compression in T spine - Dowagers hump - thoracic kyphosis

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13
Q

How do appendicular fractures tend to present?

A

Neck of femur - hip pain, unable to weight bear and shortened and externally rotated leg, pain in groin or hip, may radiate to knee.
Colles - FOOH, wrist pain and reduced range of movement

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14
Q

What scan is used for osteoporosis to identify bone density?
How is this interpreted

A

DEXA scan or DXA scan
Generates a T score - patient bone health compared to SD from normal healthy
>-1.0 normal
>-2.5 osteopenia
< -2.5 is osteoporosis
< -2.5 and fragility fracture = severe osteoporosis

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15
Q

What investigations should be done for a patient with a fragility fracture?

A

Pain radiograph - reveal fractures including previously asymptomatic vertebral deformities

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16
Q

What investigation should be done to rule out secondary osteoporosis?

A

History and physical exam
FBC
ESR - for RA.
U&Es - serum calcium, creatinine, phosphate
LFTs (ALP and transaminases)
TFTs
Vitamin D
Serum testosterone, LH and prolactin
PTH
Radiographs of lateral lumbar and thoracic spine
Protein immunoelectrophoresis and urinary Bence-Jones protein (for myeloma)

17
Q

What tool should be used to help guide treatment of osteoporosis?

A

FRAX tool

18
Q

How does the FRAX tool score influence treatment guidelines?

A

Use NOGG
Uses FRAX risk to calculate level of risk dependent on age and compare this to an intervention threshod
Low risk = lifestyle advice, reassess in 5 yrs max.
Intermediate risk = measure BMD and recalculate risk. If unable to get BMD use intervention threshold to determine if treatment is needed.
High risk = offer treatment to reduce fracture risk.Measure BMD to guide drug choice and provide a baseline for BMD monitoring.
Very high risk = Consider referral to osteoporosis specialist for assessment and consideration parenteral treatment. If a delay anticipated, start oral treatment in meantime as if high risk

19
Q

What are some common differentials for osteoporosis?

A

Osteomalacia - dec mineralisation, may be painful/tender and myopathy
Pagets disease of bone - bone/joint pain + deformities, neurological complications from immature woven bone
Myeloma
Primary and metastatic bone tumours
Lymphoma

20
Q

What conservative treatment is often given for osteoporosis?

A

Falls risk assessment
Weight-bearing and muscles strengthening
Optimum calciuim and VitD uptake from sun, diet or supplement/
Stop smoking, maintains healthy weight, maintain healthy alcohol intake
Reduced medications if needed (corticosteroids)

21
Q

What should bisphosphonates be offered to patients to help with osteoporosis?

A

Is FRAC risk of osteoporotic fragiity fracture >1%.
T-score <2.5 or less at the femoral neck.
T between -1.0 and -2.5 and a FRAX greater than 3%

22
Q

How shoudl bisphosphonates be used to treat osteoporosis?

A

First line
Adhere to hydroxyapatite and inhibit osteoclasts from resorbing bone.
Oral alendronate/risedronate should be given as 1w, zoledronic acid as 1yr infusion.
Should be taken whilst upright, remain upright for 30mins, on empty stomach.
Can cause upper GI problems - oesophagitis and needs monitoring in CKD4/5

23
Q

What is denosumab?
When should it be used in osteoporosis?

A

MAB - targeting RANKL for inhibition - prevents osteoclast activation
Used in extensive osteoporosis.
Sub cut 6/12
Anti-resorptive agent - increases BMD and reduces fracture risk at the spine.

24
Q

What is the key side effect of bisphosphonates?
How do we reduce the risk of these?

A

Osteonecrosis of the jaw - regular dental check ups.
Oesophagitis and GI ulceration - take upright, wash down with water, on an empty stomach
Pathological fracture - spiral fractures in the diaphysis of long bones

25
Q

When might HRT be used for osteoporosis treatment?

A

Early postmenopausal women
Due to breast cancer and cardiovascular risk.

26
Q

What are the key complications of osteoporosis?

A

High fracture risk
Limited mobility - weight gain, inc risk heart disease and diabetes
Depression - due to loss of independence and isolation
Pain - often persistent back pain
High mortality - about 10% of patients with hip fracture die within 1 month

27
Q

Define fragility fracture

A

When a fracture occurs from a force that would not normally cause a fracture in a healthy bone
NICE: force from standing or less to floor.

28
Q

What drugs are associated with a higher risk of osteoporosis?

A

Glucocorticoids
Anticonvulsants
Prolonged heparin therapy
Cytotoxic therapy (chemotherapy)

29
Q

What score on a QFracture indicates that a DEXA scan is needed?

A

> 10%
Risk of osteoporotic fracture and hip fracture in the next 10yrs.

30
Q

How does a vitamin D deficiency affect the parathyroid gland?

A

Low Ca2+ triggers a secondary hyperparathyroidism -> can lead to osteoporosis

31
Q

What anatomy is important to know regarding neck of femur fractures and the blood supply?

A

NOF has a retrograde blood supply.
The lateral and medial circumflex artery supply, just proximal to the intertrochanteric line.
Branches from this anastomosis supply the neck and head of the femur by travelling through the intracapsular space.
Therefore an intracapsular fracture can disrupt this blood supply leading to avascular necrosis of the femoral head.

32
Q

What is the key clinical point of an intra-capsular neck of femur fracture?

A

Risk of avascular necrosis of the neck of the femur.
This must be graded using the Garden classification 1-4

33
Q

What are the different NOK fractures in the Gardener classification?

A

Type 1 - incomplete fracture or valgus impacted
Type 2 - complete fracture without displacement
Type 3 - complete with partial displacement
Type 4 - complete with total displacement, femoral head may rotate back into anatomical position without the rest of the femur.

34
Q

What are the different types of extra-capsular neck of femur fractures?

A

Intertrochanteric - between greater and lesser trochanter
Subtrochanteric - distal to lesser trochanter (within5cm)

35
Q

What are the different types of surgical management for a NOF fracture dependent on the fracture type?

A

Orthogeriatric input - ensure fit for surgery
Surgery should be carried out <48hrs post-injury
Hemi-arthoplasty- replace ball not socket - intracapsular low mobility patients
Total hip replacement - intracapsular, baseline of walking in patient before fracture occured
Internal fixation - capsular none displaced
Dynamic hip screw - intertrochanteric fracture
Intramedullary output - subtrochanteric fracture

36
Q

What is the key presentation of a hip fracture?

A

Shortened
Externally rotated
Abducted

Care of the Elderly (22 decks)

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