Osteoporosis and Falls Flashcards
Define osteopenia
decreased radiographic density of bone
Define osteoporosis
decreased bone - “osteoid” tissue
Define osteomalacia
decreased mineralization of bone
What are the first bones that start to fracture?
Vertebral
Where are the most common vertebral crush fractures?
lumbar up to mid thoracic
When do vertebral fractures have a preponderance for females?
beginning in 50s
What do you do if the pain from a vertebral crush fracture doesn’t remit?
vertebroplasty
What is a progression or consequence of osteoporosis?
decrease in height
What is the first sign of osteoporosis?
no early warnings, fracture is often first sign
What is dorsal kyphosis usually associated with?
“dowager’s hump”
What are other clinical features of osteoporosis?
protuberant abdomen
chronic back pain
pulmonary dysfunction
low skeletal mass and/or atraumatic fractures
What percentage of women and men have suffered hip fractures?
32% of women and 17% of men will have suffered a hip fracture
What scares us about hip fractures?
High mortality rate, many patients never regain previous level of mobility.
What are the HIGH risk factors for osteoporosis?
Caucasian or asian, elderly, female and thin/petite
What are the increased risk factors of osteoporosis?
+ FHx, alcohol use, smoking, sedentary, low dietary calcium intake
In general when do you stop growing bone?
30
What does bone mass depend on?
age, sex, race, height, weight
When does bone mass peak?
approx at 35
What is a caveat about women with bone mass?
women lose 1% of bone mass per year after age 35 (accelerated for 5 years post menopause)
Theories of etiology
senile: decrease Ca+ and 1, 25 Vit D lead to a decrease in Ca absorption and increase in PTH and thus an increase in resorption
post-menopausal: decrease in estrogen leads to a decrease in calcitonin and an increase in calcium mobilization which decreases PTH and thus decreases 1, 25 Vit D and Ca absorption
When men age what do we have to monitor in regards to osteoporosis?
See if they have low T levels
With women what is the likely cause of their bone loss?
idiopathic
Causes of osteomalacia
malabsorption renal failure use of dilantin inadequate exposure of light renal tubular abscess hypophosphatemia (hyperparathyroidism, Al-containing antacids)
How do you know if you have osteoporosis?
DXA scan, look at T score
What are the diagnostic categories for interpreting bone mass measurement reports?
Osteopenia (low bone mass)- more than 1 SD but less than
Osteoporosis- A value 2.5 SD or more below mean peak value
In general when should all females get a dxa scan?
at 65, 5 years early if you have a high risk factor
Difficulties in clinically studying treatment of osteoporosis:
- low fracture incidence
- uncertainty as to significance of change in bone mineral content
- alterations in bone dynamics often don’t persist
- mixture of type I and II patients in treatment group
What are the treatments for osteoporosis?
exercise
Bisphosphonates
1 perscription drugs for osteoporosis
What do bisphosphonates do?
bind to hydroxyapatite
Potent inhibitors of bone resorption- slow down osteoclasts and limit bone resorption
low oral availability- take on an empty stomach
rem this is what bakers wife was on, they didn’t like it!
What are the adverse side effects of bisphosphonates?
GI disturbances are the most frequent kind of adverse experiences
How long does FOSAMAX stay in your bones?
Years!, works even after you stop
What are foods that have calcium in them?
most is in the form of milk BUT: turnips broccli pork and beans egg wheat
How much calcium is an an 8oz glass of milk?
whole- 291 mg
What are the important take homes of Vitamin D?
first 6 month no effect BUT 18 months later huge decrease in fractures
Who needs the most calcium?
kids, 1300 mg
What is my daily requirement of calcium?
1000 mg
How much Vitamin D do you need up to 70 yrs old? Over 70?
600 IU
1000 IU
Does milk have a lot of vitamin D?
not really
What does estrogen do?
increase intestinal calcium absorption
increase serum 1, 25 Vit D synthesis
Increase calcitonin secretion
What is the main reason to give estrogen?
decrease menopausal vasomotor symptoms
What is a SERMs?
Selective estrogen receptor modulator
What does a SERM do?
Acts as estrogen agonist at certain organs (bone) but as antagonist at others (breast and uterus, worsens menopausal symptoms).
Less effect on bone than estrogen or a bisphosphonate.
How do you take Calcitonin?
Nasal injection
Compare bone loss in men to that of women
Males lose bone at approximatley 1/2 to 2/3 the rate of females
How do you prevent or treat osteoporosis in men?
CHECK T LEVELS (treat hypogonadism) maintain muscle mass keep calcium intake >800 mg/day keep alcohol intake < 3oz/day don't smoke avoid hypercorticolism check for fat malabsorption routine Vit D supplementation in elderly
What is a negative side effect of SERMs?
Reduces breast cancer but increases risk of thromboembolic events.
What are the predisposing factors for falls that are intrinsic?
muscle weakness (ankle dorsiflexion), balance problems
impaired vision (night>day)
postural dizziness, postural hypotension (few non-syncopal falls related to arrhythmias)
neuropathology (stroke, Parkinson’s, periperal neuropathy)
medication (sedatives), poly pharmacy per se
foot problems
Death from falls
falls have skyrocketed to be a leading cause of death in those > 70
What are good ways to test muscle strength for falls?
hip abductors and ankle dorsiflexion
What are extrinsic factors for predisposing falls?
lighting stairs bathroom chairs (too low, without armrests) footwear (soft sole, high heels) improper walking aids (cane, walker) loose rugs
How do we manage falls?
a. detect a faller before injury, ASK!!
b. observe gait and balance (get up and go, nudge test)
c. assess fall circumstances; premonitory symptoms, location
d. manage intrinsic and extrinsic factors
