This was a lecture in the course "Significant Medical Conditions in Seniors" presented at Peer Learning in Chapel Hill, NC, USA in 2016 by Michael C. Joseph, MD, MPH.

1. Osteoporosis
Michael C. Joseph, MD, MPH
12 October 2016
(Peer Learning)

2. Outline
 OSTEOPOROSIS
─ Definition
─ Epidemiology
─ Symptoms
─ Treatment
─ Research
 RESOURCES
 CREDITS

3. Osteoporosis - Definition
 Metabolic bone disorder causing:
─decreased bone mass
─porous, brittle bones
─increased risk of bone fractures
─stooped posture
─loss of height
─chronic pain
─reduction in mobility.

4. Epidemiology
 Whites and Asians are at greater risk.
 More common with age:
─15% of Whites in their 50’s, and 70% of those
over 80 affected.
 More common in women (4-5x):
─In the U.S. in 2010, about 8 million women
and 2 million men affected.

5. Bone Mass by Age-Sex

6. Peak Bone Mass
 The risk of developing osteoporosis
depends on how much bone mass is
attained between ages 25 and 35 (peak
bone mass).
 The higher the peak bone mass the more
“bones in the bank” and the lower the
likelihood of later osteoporosis.

7. Height Changes with Age

8. Osteoporosis – Bone Changes

9. Calcium Metabolism

10. Risk Mechanisms (I)

11. Risk Mechanisms (II)

12. Most Common Fracture Sites

13. Osteoporotic Fractures
 Fractures from osteoporosis are twice as
common in women as in men.
 The risk accelerates in women after
menopause (about age 45), after the
withdrawal of estrogen.
 The risk is greater in men after age 75.
 Studies have shown protection against
fractures with both Calcium and Vitamin D
supplementation, but not with either
alone.

14. Hip Fractures
 Responsible for the most serious
consequences of osteoporosis.
 More than 250,000 annually in the U.S.
 1 in 6 lifetime risk for a 50-year old white
woman.
 Among both men and women:
─Risk increases each decade after age 50
─Highest incidence after age 80.

15. Vertebral Fractures
 More than 700,000 occur annually in the
U.S., but only a third are recognized.
 Studies show that between 35-50% of all
women over 50 have had at least one
vertebral fracture.
 In a study of 9,704 women aged 69 on
average, who were studied for 15 years:
─324 had a vertebral fracture on entry
─17% (1 in 6) developed a vertebral fracture
─41 % had a repeat vertebral fracture.

16. Other Osteoporotic Fractures
 Wrist:
─250,000 cases annually in the U.S.
─1 in 6 lifetime risk for white women
─20% of women have had at least one wrist fracture by
age 70
 Ribs:
─Common in men as young as 35
─Often overlooked
─Occur most often during physical activity
─“Fragility” considered the main cause
─Lab testing can rule out low testosterone levels and
indicate replacement therapy

17. Diagnosis of Osteoporosis (I)
 Symptoms are usually vague:
─stiffness, pain, weakness.
 Must rule out other diseases of bone,
especially the spine (such as metastatic
carcinoma, advanced multiple
myeloma).
 X-rays show changes only after 30% to
60% loss of bone.

18. Diagnosis of Osteoporosis (II)
 DEXA (Dual energy X-ray absorptiometry):
of the spine, hip, and wrist:
─the “gold standard” for diagnosing and monitoring
bone mineral density (BMD);
─A T-score of -2.5, or less (meaning that BMD is less
than 2.5 standard deviations below that of a 30-40
year old healthy female reference population) is
decisive for osteoporosis.

19. Indications for DEXA
 Older than 65, regardless of risk factors.
 Postmenopausal, with at least one risk factor
 Vertebral abnormality…
 Use of medications such as prednisone (SIOP
–> Steroid Induced Osteoporosis).
 Type I diabetes, liver disease, kidney disease,
or a family history of osteoporosis
 Early menopause (hysterectomy).

20. Treatment
Biphosphonates
Biphosphonates are antiresorptive medicines, which slow the natural process that
dissolves bone tissue, resulting in increased bone density and strength.
Examples: Fosamax®, Boniva®, Actonel®, Reclast®.
They reduce the risk of repeat fractures by 25-70%, depending on the bone involved.
Osteonecrosis of the jaw is a rare, serious, adverse event
Selective Estrogen Receptor Modulators (SERMs)
SERMs are approved for the prevention and treatment of osteoporosis in post-
menopausal women while avoiding the hormone’s potential side effects, such as the increased risk
of uterine cancer.
Example: Evista®
Calcium and Vitamin D Supplements
The combination supports normal bone metabolism.

21. Prevention
 Regular aerobic, weight-bearing, and resistance exercise.
 Add soy in the diet: plant estrogens found in soy help to maintain bone
density.
 Avoid smoking: it can reduce the levels of estrogen.
 Avoid excessive alcohol: it weakens bones and decreases mechanical
functions.
 Avoid caffeine: it increases risk of hip fractures in elderly women (?).
 Avoid diuretics and aluminum-containing antacids (chronic phosphate
binding).
 A gluten-free diet, with heavy calcium and Vitamin D supplementation, in
those with major intestinal surgery, Celiac Disease, or other GI
malabsorption syndromes.
 Consider HRT (Hormone Replacement Therapy).

22. National Osteoporosis Foundation
Guidelines (I)
 Counsel all women on risk factors for
osteoporosis.
 Perform Bone Mineral Density (BMD) tests
on all postmenopausal women with
fractures.
 Recommend BMD for:
─postmenopausal women <65 years old with 1
or more risk factors;
─all women >65 years old

23. National Osteoporosis Foundation
Guidelines (II)
 Calcium intake 1200 mg/day;
 Vitamin D 400-800 IU/day for high-risk patients;
 Regular weight-bearing, muscle-strengthening exercise;
 Avoid smoking (increased breakdown of estrogen, lower
body weight, earlier menopause);
 Moderate alcohol consumption (increases bone density);
 Consider prophylactic treatment if:
─ T-score below -2.0
─ T-score below -1.5, with risk factors;
 HRT is first-line therapy.

24. RESOURCES
 Arthritis Foundation:
─ http://www.arthritis.org/about-arthritis/types/osteoporosis/
 National Institute of Arthritis and Musculoskeletal
and Skin Diseases (NIAMS) (NIH):
─ www.niams.nih.gov
─ National Osteoporosis Foundation:
─ https://www.nof.org/
 World Health Organization Collaborating Centre for
Metabolic Bone Diseases, University of Sheffield, UK
(FRAX Tool)

25. CREDITS
 Arthritis Foundation:
─ http://www.arthritis.org/about-arthrosis
 National Institute of Arthritis and Musculoskeletal and
Skin Diseases (NIAMS) (NIH):
─ http://www.niams.nih.gov/Health_Info//Osteoporosis/default.asp
─ https://en.wikipedia.org/wiki/Osteoporosis
 SLIDESHARE.NET:
─ http://www.slideshare.net/reynel89/osteoporosis-
7146795?utm_source=slideshow02&utm_medium=ssemail&utm_campaign
=share_slideshow
─ http://www.slideshare.net/drshama65/osteoporosis-
edited?utm_source=slideshow02&utm_medium=ssemail&utm_campaign=s
hare_slideshow
 World Health Organization Collaborating Centre for
Metabolic Bone Diseases, University of Sheffield, UK
─ https://www.shef.ac.uk/FRAX/tool.jsp