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Landon Center on Aging  :  Geriatric Education & Training

Osteoporosis

Instructor: Shelley Bhattacharya, DO, MPH
Edited by: Shelley Bhattacharya, DO, MPH
Module developed by: Holly Cranston, MD
Reviewed by: Doug Woolley, MD, MPH

 

Specific Learning Objectives

A. Introduction

Before reviewing the learning objectives and content, please take the Pre-Test. Please review the Objectives, Content material, and Cases before our class session. We will apply the tasks in the Skills objectives to the cases, and you should think about them ahead of time.

B. Attitudes - the student will recognize that:

1. Osteoporosis is a growing problem worldwide.
2. The management and treatment of osteoporosis involves more than medication.
3. Multiple medication use can put a patient at risk for developing osteoporosis.

C. Knowledge - The student should be able to:

1. Describe the effect of age and sex on bone density.
2. Define DEXA.
3. Define T-score.
4. Define Z-score.
5. Explain the difference between osteopenia and osteoporosis.

D. Skills

E. Readings

F. Module Content

1. Osteoporosis
2. Epidemiology of Osteoporosis
3. Osteoporosis in Men
4. Bone Mineral Density
5. A few facts about bone
6. Risk for Osteoporotic Fractures
7. History and Physical Exam
8. Lab Work Up
9. Exercise
10. Calcium
11. Vitamin D
12. Bisphosphonates
13. Conditions associated with higher osteoporosis risk
14. Summary

G. Cases

• Case #1
• Case #2

 

I. OSTEOPOROSIS

Systemic skeletal disease characterized by low bone mass and micro-architectural deterioration of bone tissue.

World Health Organization definition -

• Osteopenia:
  • BMD 1-2.5 standard deviations below young normal female mean (T score)
• Osteoporosis:
  • BMD over 2.5 standard deviations below young normal female mean

National Osteoporosis Foundation definition –

• Osteopenia:
  • Up to 2 standard deviations below young normal females
• Osteoporosis:
  • Below 2 standard deviations

T-score is the comparison of the patients BMD in relation to that of a healthy young female.

Z-score is the expected BMD for individuals of the same age and gender.

II. EPIDEMIOLOGY OF OSTEOPOROSIS

The prevalence of osteopenia in 2000 was estimated to be at 14 million and for osteoporosis, the numbers were only slightly lower at 10 million.  In 2015, the prevalence for osteopenia is estimated at 80 million and for osteoporosis, the number is 41 million.  This drastic increase in the number of people afflicted with this bone disease is due to the baby boomer generation.

• 300,000 new cases per year in men and women
• 1.7 million in Europe per year
• 50% of women over age 50 will sustain a fracture in their lifetime
  

III. OSTEOPOROSIS IN MEN

• Awareness growing
• Hypogonadism
• Alcoholism
• Glucocorticoid use
• Hypercalciuria

The following is a table that explains how bone mass is attained over the human lifetime. The table, although aimed at women, can be utilized in both women and men.

• Peaks at age 30 (in women)
• Estrogen protects against osteoclastic activity
• Loss worsens after menopause
• Resorption exceeds reabsorption and more bone is lost than gained

 IV. BONE MINERAL DENSITY

• Accounts for about 70% of bone strength
• Measured by DEXA Scan  (dual-energy x-ray absorptiometry)
• A DEXA scan is an enhanced form of x-ray technology that is used to measure bone loss.
• The DEXA machine sends a thin, invisible beam of low-dose x-rays with two distinct energy peaks through the bones being examined. One peak is absorbed mainly by soft tissue and the other by bone. The soft tissue amount can be subtracted from the total and what remains is a patient's bone mineral density.
  • Measures density in radius, lumbar spine and greater trochanter
  • Mass of bone mineral in the path of the beam divided by the cross sectional area of the beam, expressed as g/cm2

  

• When the BMD drops by 1 SD, the fracture risk increases by 2.6% 
• 10% increase fracture risk with -2.5 drop SD in BMD

This table represents a 10 year probability of fracture in women with relation to age and T-score

Data from Kanis JA, et al. Osteoporos Int. 2001;12:989-995

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V. A FEW FACTS ABOUT BONE

• Men have about 30% more bone mass than women
• African Americans get 10% higher peak bone mass than do Caucasians.

In osteoporotic bone fractures, you will usually see fractures in the distal forearm, hip, or spine. The distal forearm is the most common non-vertebral fracture in white women until age 75.

Spinal fractures are usually from compressive loading and can be painless or severely painful. (Each patient will experience the fracture differently, but if they are in pain, certainly take the complaint seriously and treat the pain symptoms. Do not forget that vertebroplasty/kyphoplasty is an option for a new onset vertebral fracture that may help to control pain, and helps to stabilize the spine and unload some of the anterior pressure on the remaining vertebrae.)

The following are pictures of normal bone and osteoporotic bone for comparison:

VI. RISK FACTORS FOR OSTEOPOROTIC FRACTURES

Nonmodifiable

Personal hx of fracture as an adult
Female sex
Advanced age
Caucasian race
Dementia

Potentially Modifiable

Current Tobacco/Cigarette use
Low body weight (< 130 pounds)
Estrogen deficiency
Early menopause or early oophorectomy
Prolonged premenstrual amenorrhea (<1yr)
Low calcium intake
Alcoholism
Recurrent falls
Low or no physical activity
Medication use (specific meds known to contribute to osteoporosis)

VII. HISTORY AND PHYSICAL EXAM

• Question pt about dietary calcium intake
• Past history or current signs of steroid use
• Height, weight
• Gait, mobility
• Kyphosis evaluation
• Percussion of spine
  

VIII. LAB WORK UP

• Complete Metabolic Panel
• CBC
• UA
• TSH
• Vit D
• If high calcium, do PTH
• If male, do free testosterone
• If suspect Multiple Myeloma: SPEP/UPEP (serum and urine protein electrophoresis)

The following list shows the different supplements or medications used to treat or prevent osteoporosis:

• Exercise
• Calcium
• Vitamin D
• Bisphosphonates
• Calcitonin
• PTH
• Estrogen
  

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IX. EXERCISE

A study published in the Annals of Internal Medicine in 1999 by Gregg found that by expending 750kcal/wk, there was a reduction of hip fractures by 36%.

• Weight bearing, 30-60 min., 3-4x/wk
• Strength training 2x/wk
  

X. CALCIUM

The following are the recommended daily calcium intake for:

• Adolescents: 1200mg/d
• Non pregnant adults: 1200 mg/d
• Menopausal women: 1200 mg/d
• Women and men over 65: 1500 mg/d
• Usually given as CaCo3 600 bid with dietary intake or 500 tid without dietary intake
• Use for osteopenia, osteoporosis, and poor Ca intake patients
• Can be constipating
• Ca Citrate with or without meals
• Take with Vitamin D

Product	# of Servings	Calcium Content	Total Calcium (mg)
Milk (8oz)	1	300mg/serving	300
Fortified citrus juice (8oz)	0.5	300mg/serving	150
Fortified cereal (no milk)	0	100mg/serving	0
Fortified cereal with 4oz milk	0	250mg/serving	0
Yogurt (8oz)	2	400mg/serving	800
Cheese (1oz)	2	200mg/serving	400
Other non-dietary sources		250mg/day	250
TOTAL	CALCIUM	INTAKE	1900

XI. VITAMIN D

Vitamin D is converted in the body  to a usable form via sunlight exposure of the skin.  Ultraviolet light causes the conversion of  7-dehydrocholesterol to cholecalciferol (Vit D3).  As a person ages, the skin becomes frail and there is often decreased sun exposure, thus leading to a deficiency of vitamin D. 

This decrease in vitamin D causes a decreased absorption of calcium, and a vicious cycle ensues.  When serum calcium levels are low, the parathyroid hormone is activated to stimulate bone resorption in an attempt to increase the amount of serum calcium.

There have been recent advances in the study of the effect of Vitamin D on calcium absorption and bone health.  The NOF currently recommends 400-800 IU/day, but the consensus is that in the future, the recommendations will officially change to 800 IU/day.

• From NHANES III data of 3444 women 51 and older, over 70% of the women 51-70 years of age did not meet adequate Vitamin D intake guidelines
• 90% of women over 70 did not meet guidelines
• 8oz Vit. D fortified milk has 100 IU of Vit D
• Other sources of Vit D include - Cereals, egg yolk, seaweed, liver
  

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XII. BISPHOSPHONATES

 Alendronate (Fosamax), Ibandronate (Boniva), Risedronate (Actonel)

• Inhibits osteoclastic activity, thus reducing bone resorption and turnover
• Use when T score below 2.0 SD from normal
• Poorly absorbed
  • Take in AM, 30 minutes before eating or drinking
  • Must be able to remain upright, either standing up or upright in bed for at least 30 minutes
  • Take with 8oz plain water (no juice, no other meds)
  • Do not eat or drink for 30 minutes after taking the medication
• Medication dosing is either daily, weekly, or monthly
• Use with Calcium/Vitamin D

The following is a list of medications that are approved for use in  Osteoporosis:

Medication	Dosage	Cost	Special considerations
Alendronate (Fosamax)	10mg/day or 70mg/week or 5mg/day for prevention	30- 90 dollars/ month	Bisphosphonate – pt must be able to tolerate dosing instructions Binds to hydroxyapetite and inhibits osteoclast activity
Ibandronate (Boniva)	150mg/month PO or IV	200 - 230 dollars/ month	Bisphosphonate – pt must be able to tolerate dosing instructions Binds to hydroxyapetite and inhibits osteoclast activity
Risedronate (Actonel)	5mg/day	70 -190 dollars/ month	Bisphosphonate – pt must be able to tolerate dosing instructions Binds to hydroxyapetite and inhibits osteoclast activity
Raloxifene (Evista)	60mg/day	70- 90 dollars/month	Selective Estrogen Receptor Modulator Inhibits bone resporption
Calcitonin	200IU/day - nasal spray or 50- 100 IU   3 to 5 times/wk IM	50 - 100 dollars/ month	Directly inhibits osteoclast activity. Mostly beneficial for analgesic puropses, not treatment.
Teriparatide* (Forteo)	20ug/day IM	750 dollars/ month	Parathyroid Hormone Increases bone formation
Estrogen	dosing varies	10- 30 dollars/month	Can cause increased risk of breast cancer, heart disease, stroke, DVT
Calcium	500mg BID or TID	5-10 dollars/month	Dietary supplement used by the body for mineralization of  bone
Vitamin D	400IU BID	5 – 10 dollars/ month	Vitamin that aids absorption of Calcium

*Parathryoid hormone can lead to increased bone absorption when chronically elevated.  However, when intermittently administered, it can cause an increase in bone mass, trabecular connectivity, and mechanical strength.  Teriparatide is currently only approved for use in those who have failed other more conventional treatments.

XIII. CONDITIONS ASSICATED WITH HIGHER OSTEOPOROSIS RISK

• AIDS/HIV
• COPD
• Cushing’s Syndrome
• Eating Disorders, Inadequate diet
• Gastrectomy, Malabsorption Syndromes
• Hemophilia
• Hyperparathyroidism
• Hypogonadism
• Insulin dependant DM
• Lymphoma & leukemia
• Multiple sclerosis
• Rheumatoid arthritis
• Severe liver disease
• Weight loss
  

XIV. SUMMARY

• Always think of osteoporosis in a geriatric patient
• Evaluate for risk factors
• Don’t forget the men!
• Order DEXA at baseline (age 65) and every 2 years
  • Earlier if risk factors indicate
  • Do not wait for fracture first
• Treat based on DEXA findings
• Encourage nicotine cessation, steroid weaning, exercise, and increased calcium consumption
  

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Osteoporosis

CASE STUDY #1

Ms. G is a 65 year old female who presents to clinic with the complaint of back pain.  She states that she had a similar pain about 3 months ago, but did not come in to clinic at that time because the pain went away about a week later.  She is a pleasant Hispanic female who you have seen in clinic twice previously when you took over care after her insurance changed and she had to seek a new physician.  She is not very active and most of her hobbies are done indoors.

Her past medical history is significant for hypertension, hyperthyroidism (with radioactive iodine ablation 15 years ago), and osteoarthritis.  She is a G0P0.  Her first menses started at age 17 and she went through surgical menopause at age 39 due endometriosis. 

Her surgical history is hysterectomy, appendectomy, cholecystectomy, right wrist fracture with surgical fixation.

Her medications include - synthroid 75mcg daily, lisinopril 20mg daily, acetaminophen 500mg BID and PRN.

Alternative therapies - Chiropractor, MVI

Her allergies are NKDA.

Social history - single, no children, lives alone.  Recently retired from Burlington Northern Railroad as a secretary.

Habits - no tobacco, no ETOH, no illicit drug use.

Questions

1. Can you identify any data from her history thus far that might put her at risk for osteopenia or osteoporosis?

She notes that she recently saw her chiropractor and she asked for copies of the x-rays that he took last week before her manipulation.  She presents the packet to you and you notice that the films were dated from 2003 - 2007.  You take a look at the films and note the following:

2003	2005	2007
Normal	Osteopenia	Wedge Deformity

2. What are the differences - if any - that you can see in these x-rays?

You then review the patient's labs and there are no significant abnormalities noted.  Calcium is in the low-normal range, TSH and Free T4 are within normal limits.

Your physical exam reveals a well developed, overweight female.  HEENT/Neck: PERRL, MMM, TM's pearly, neck supple, no thyromegally noted, no nodules palpated; Cardiovascular exam is S1, S2 without murmur; Pulmonary: CTA bilaterally; Abd: NABS, obese, no HSM palpated; Ext: no pedal edema, pulses 2+ in bilateral lower extremities, strength intact on upper and lower extremities; Back: TTP noted over spinous processes of T10 - 12, slight kyphosis noted.

3. What is your next step in treatment of this patient?
   
   
4. What is your next step in diagnostic work up of this patient?

The patient’s BMD report is significant for a lumbar spine T-score of - 2.7, at her hip the T-score is -2.1.

5. What do these scores mean?
   
   
6. What is your choice for therapy for this patient?  Why?
   
   
7. She is started on your chosen therapy and she is to have a follow up bone density in how many months?

She had an abdominal operation and has difficulty sitting up for prolonged periods of time.  She continues to take all of her medications as directed despite her current debilitated state.  A few weeks later, you see her in the skilled rehab unit (she is there due to deconditioning) and she is complaining of trouble swallowing.  You review her medications and they are as follows:  Lisinopril, HCTZ, Alendronate, Percocet, Pepcid, Diphenhydramine, Simethicone, Acetaminophen, Mylanta, Calcium, Vitamin D, MVI, Ferrous Sulfate.

8. What do you think could be a cause of her dysphagia?
   
   
9. What are you going to do about her acute complaint?

She goes to see the specialist and gets the recommended test - now what - Which of her meds to you change - and why?

You change her medication and she is doing much better.

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CASE STUDY #2

Mr. S. is a 67 year old male who presents to clinic with the chief complaint of fatigue.  He states that he has noticed that he just feels like he has “lost his pep”.  He notes that his wife has pointed out that he seems sluggish lately, and doesn’t get chores done as quickly as usual.

When questioned further, he notes that he feels a little frustrated because he cannot do heavy chores.  Mr. S has been asking his son to help him lift and carry things he could carry a year ago.

          Questions

1. Based on the above presentation, what further questions should be asked?

Mrs. S. jumps in to the conversation and states, “Well, he may get mad at me, but I am going to ask a question anyway.  Do you think he is depressed?  He just isn’t his normal self.  We talk and he seems to have a hard time following the conversation, or is slow to answer questions.  And another thing – he is going to be so mad – but our intimate relationship has really suffered the past year.  He used to be more interested than me, but lately, he hasn’t been interested, and things don’t seem to be working correctly.”

Mr. S. seems embarrassed, but admits that his wife is telling the truth about their intimate relationship.   He states that the problem has been slowly worsening over the past year and a half.  He was too embarrassed to bring it up in conversation at his previous appointments.  He figured it could be a normal part of aging since, “everything else stops working right”.

2. What is on your list for differential diagnosis?

PMHx -  HTN, Hyperthyroidism (treated with radioactive Iodine ablation – at age 35)
PSHX -  Choleycystectomy, Tonsillectomy
Social Hx – Married x 45 years, 2 children – both healthy.  
Farmer – now only doing about ½ of his previous work – his son has taken over a lot of the farming.
Tob – none; ETOH – 1 beer a night; Drugs – never

Meds – Lisinopril 20mg Qday; Levothyroxine 75mcg Qday; ASA 81mg Qday; MVI Qday

Allergies – PCN – anaphylactic reaction

PE – BP 125/72, HR 75, RR 14, O2 99% RA, Wt – 175#, Ht – 6’1”
Gen – WD, WN male, NAD
HEENT – PERRLA, MMM, OP clear, dentition good, TM’s with sclerosis bilaterally, Facial hair noted.
Neck – supple, no thyromegally noted
Pulm/Chest– CTA bilaterally, no gynecomastia
CV – S1, S2 without murmur, rub, gallop; 4/4 pedal pulses
Abd – NABS, soft, NT, ND
Ext – no clubbing, cyanosis, edema
Genital exam – Normal adult male hair pattern, Testicles –firm, no masses 6cm bilaterally
Rectal exam – Prostate 25 grams – no nodules

3. What work up do you order for this patient?

The lab results are as follows:

• Total Testosterone = 220ng/dL – (normal =300-800ng/dL)
• T4 = 7.4ug/dL – (normal = 4.5 – 11.5ug/dL)
• TSH (thyroid stimulating hormone) = 2.5uU/mL – (normal = 0.5 – 5.0 uU/mL)
• FSH (follicle stimulating hormone) = 30.8 uU/mL – (normal = < 10 uU/mL)
• LH (luteinizing hormone) = 10 uU/mL – (normal = <10uU/mL)
• Prolactin = 4.5ng/mL – (normal = <20ng/mL)

DEXA scan = T-score of -2.1 at the lumbar spine and T-score of -2.3 at the hip.

4. Based on these findings, what is his diagnosis?
   
   
5. What therapy would you prescribe for this patient?

• The goal of testosterone replacement is normalization of the serum testosterone level.  For the patient, the main objective for treatment is improving symptoms of hypogonadism; i.e., improved sexual function, restoration of intellectual capacity, improved energy level.  The clinician is interested in improving the patient’s overall symptoms, but also maintaining or improving the bone mineral density and thus potentially reducing fracture risk.
• Contraindications for testosterone replacement–
  • Prostate cancer
  • Prior hx of male breast cancer
  • Elevated Hematocrit – greater than 55%

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