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  1. 1. Osteoporosis Osteoporosis KEY TERMS Definition Bouchard’s nodes—Swelling of the middle joint of the finger. The word osteoporosis literally means “porous bones.” It occurs when bones lose an excessive amount Cartilage—Elastic connective tissue that covers of their protein and mineral content, particularly calci- and protects the ends of bones. um. Over time, bone mass, and therefore bone strength, Primary osteoarthritis—OA that results from is decreased. As a result, bones become fragile and break hereditary factors or stresses on weight-bearing easily. Even a sneeze or a sudden movement may be joints. enough to break a bone in someone with severe osteo- Secondary osteoarthritis—OA that develops fol- porosis. lowing joint surgery, trauma, or repetitive joint injury. Description Subchondral cysts—Fluid-filled sacs that form Osteoporosis is a serious public health problem. inside the marrow at the ends of bones as part of Some 28 million people in the United States are affected the development of OA. by this potentially debilitating disease, which is responsi- ble for 1.5 million fractures (broken bones) annually. These fractures, which are often the first sign of the dis- NUTRITIONAL SUPPLEMENTS In recent years, a com- ease, can affect any bone, but the most common locations bination of glucosamine and chondroitin sulfate has been are the hip, spine, and wrist. Breaks in the hip and spine studied as a dietary supplement to help the body maintain are of special concern because they almost always and repair cartilage. These substances are nontoxic and require hospitalization and major surgery, and may lead do not require prescriptions, but studies continue to be to other serious consequences, including permanent dis- conducted to evaluate their effectiveness. Other supple- ability and even death. ments that may be helpful in the treatment of OA include To understand osteoporosis, it is helpful to under- the antioxidant vitamins A, C, and E, and minerals sele- stand the basics of bone formation. Bone is living tissue nium and zinc. that is constantly being renewed in a two-stage process (resorption and formation) that occurs throughout life. In Resources the resorption stage, old bone is broken down and BOOKS removed by cells called osteoclasts. In the formation Hellman, David B. “Arthritis & Musculoskeletal Disorders.” stage, cells called osteoblasts build new bone to replace In Current Medical Diagnosis and Treatment, edited by the old. During childhood and early adulthood, more Lawrence M. Tierney, Jr., et al. Stanford, CT: Appleton & bone is produced than removed, reaching its maximum Lange, 1998. mass and strength by the mid-30s. After that, bone is lost Neustadt, David H. “Osteoarthritis.” In Merck Manual of at a faster pace than it is formed, so the amount of bone Diagnosis and Theory, edited by Robert E. Rakel. in the skeleton begins to slowly decline. Most cases of Philadelphia: W. B. Saunders Company, 1998. osteoporosis occur as an acceleration of this normal aging PERIODICALS process—a form referred to as primary osteoporosis. The Gelber A.C., et al. “Joint injury in young adults and risk for condition can also be caused by other disease processes subsequent knee and hip osteoarthritis.” Annals of or prolonged use of certain medications that result in Internal Medicine 133 (2000): 321-328. bone loss—a form called secondary osteoporosis. Manek, N.J., and N. Lane. “Osteoarthritis.” Current Concepts in Diagnosis and Management 61 (2000): 1796-1804. Osteoporosis occurs most often in older people and in women after menopause. It affects nearly half of all OTHER men and women over the age of 75. Women, however, National Library of Medicine. Medline Plus Health are five times more likely than men to develop the dis- Information. <http://www.nih.gov/medlineplus/ ease. They have smaller, thinner bones than men to begin druginfo/antiinflammatorydrugsnonsteroi202743.html>. (May 8, 2001). with, and they lose bone mass more rapidly after menopause (usually around age 50), when they stop pro- Michele R. Webb ducing a bone-protecting hormone called estrogen. In the five to seven years following menopause, women can Osteogenic sarcoma see Sarcomas lose about 20% of their bone mass. By age 65 or 70, G A L E E N C Y C L O P E D I A O F N U R S I N G A N D A L L I E D H E A LT H 1782
  2. 2. though, men and women lose bone mass at the same rate. fractures of the spine. These can happen even after a Osteoporosis seemingly normal activity, such as bending or twisting to As an increasing number of men reach an older age, they pick up a light object. The fractures can cause severe are becoming more aware that osteoporosis is an impor- back pain, but sometimes they go unnoticed—either tant health issue for them as well. way, the vertebrae collapse down on themselves, and the person actually loses height. The hunchback appearance Causes and symptoms of many elderly women, sometimes called “dowager’s A number of factors increase the risk of developing hump” or “widow’s hump,” is due to this effect of osteo- osteoporosis. They include: porosis on the vertebrae. • Age. Osteoporosis is more likely as people grow older Diagnosis and their bones lose tissue. • Gender. Women are more likely to have osteoporosis Certain types of doctors may have more training and because they are smaller and so start out with less bone. experience than others in diagnosing and treating people They also lose bone tissue more rapidly as they age. with osteoporosis. These include geriatricians, who spe- While women commonly lose 30–50% of their bone cialize in treating the aged; endocrinologists, who spe- mass over their lifetimes, men lose only 20–33% of cialize in treating diseases of the body’s endocrine sys- theirs. tem (glands and hormones); and orthopedic surgeons, who treat fractures, such as those caused by osteoporosis. • Race. Caucasian and Asian women are at higher risk for the disease than women of African or Hispanic ethnic- Before making a diagnosis of osteoporosis, the doc- ities. tor usually takes a complete medical history, conducts a physical exam, and orders x-rays, as well as blood and • Figure type. Women with small bones and those who urine tests, to rule out other diseases that cause loss of are thin are more liable to have osteoporosis. bone mass. The doctor may also recommend a bone den- • Early menopause. Women who stop menstruating early sity test. This is the only way to determine if osteoporo- because of heredity, surgery or a lot of physical exer- sis is present. It can also show how far the disease has cise may lose large amounts of bone tissue early in life. progressed. Conditions such as anorexia and bulimia may also lead Several diagnostic tools are available to measure the to early menopause and osteoporosis. density of a bone. The most accurate and advanced of the • Lifestyle. People who smoke or drink too much, or do densitometers uses a technique called DEXA (dual ener- not get enough exercise have an increased chance of gy x-ray absorptiometry). With the DEXA scan, a double getting osteoporosis. x-ray beam takes pictures of the spine, hip, or entire body. It takes about 20 minutes to do, is painless, and exposes • Diet. Those who do not get enough calcium or protein the patient to only a small amount of radiation—about may be more likely to have osteoporosis. People who one-fiftieth that of a chest x ray. The ordinary x ray is constantly diet are more prone to the disease. It has one, though it is the least accurate for early detection of been shown that adolescent girls (but not boys) have osteoporosis, because it does not reveal bone loss until the insufficient calcium intake levels in the diet. This calci- disease is advanced and most of the damage has already um deficiency occurs during a period of rapid bone been done. Other tools that are more likely to catch osteo- growth, stunting the peak bone mass ultimately porosis at an early stage are computed tomography scans achieved; thus, these individuals are at greater risk of (CT scans) and machines called densitometers, which are developing osteoporosis. designed specifically to measure bone density. The CT • Genetics. People with a family history of osteoporosis scan, which takes a large number of x rays of the same are more likely to contract the disease. spot from different angles, is an accurate test, but uses • Chronic use of medication. Certain types of medica- higher levels of radiation than other methods. tion, such as steroids, interfere with the body’s ability People should talk to their doctors about their risk to absorb calcium or accelerate calcium depletion, factors for osteoporosis and if, and when, they should get damaging bone density. the test. A woman should have bone density measured at Osteoporosis is often called the “silent” disease, menopause, and periodically afterward, depending on the because bone loss occurs without symptoms. People condition of their bones. Men should be tested around often do not know they have the disease until a bone age 65. Men and women with additional risk factors, breaks, frequently in a minor fall that would not normal- such as those who take certain medications, may need to ly cause a fracture. A common occurrence is compression be tested earlier. 1783 G A L E E N C Y C L O P E D I A O F N U R S I N G A N D A L L I E D H E A LT H
  3. 3. Osteoporosis mone replacement therapy (HRT). Many women partici- pate in HRT when they undergo menopause, to alleviate symptoms such as hot flashes, but hormones have other important roles as well. They protect women against heart disease, the number one killer of women in the United States, and they help to relieve and prevent osteo- porosis. HRT increases a woman’s supply of estrogen, which helps build new bone, while preventing further bone loss. Some women, however, do not want to take or are not candidates for hormones, because some studies show they are linked to an increased risk of breast cancer or uterine cancer. Other studies reveal that risk is due to increasing age. (Breast cancer tends to occur more often as women age.) Whether or not a woman takes hormones is a decision she should make carefully with her doctor. Women should talk to their doctors about personal risks for osteoporosis, as well as their risks for heart disease and breast cancer. Novel delivery systems of HRT have been devel- oped. For example, Vivelle is a estradiol transdermal sys- tem that is used for prevention of osteoporosis. It uses a “patch” to continously deliver the hormone estradiol through the skin. Studies have shown women who started taking HRT within five years of menopause show significantly reduced rates of hip fractures than women who began HRT more than five years postmenopausal. However, even while taking HRT, 10 to 20% of women continue to A scanning electron micrograph (SEM) of cancellous lose bone density and therefore may require additional (spongy) bone from an osteoporosis patient. Osteoporosis intervention. is characterized by increased brittleness of the bones and For people who cannot or will not take estrogen, a greater risk of fractures. This is reflected here in the thin appearance of the bony network of the cancellous bone other agents can be good choices. These include: that forms the core of the body’s long bones (Photograph • bisphosphonates by Professor P. Motta, Photo Researchers, Inc. Reproduced by permission.) • calcitonin Treatment • selective estrogen receptor modulators • sodium fluoride There are a number of good treatments for primary osteoporosis, most of them medications. In addition, cal- • androgens cium (0.5 to 2 g/day) and vitamin D (400 to 800 IU/day) Although there are a number of bisphosphonates supplementation can reduce the rate of bone loss in used for the treatment of various forms of osteoporosis women who are more than five years postmenopausal. and resorptive bone diseases, alendronate (sold under the Fracture reduction efficacy of calcium and vitamin D brand name Fosamax), etidronate (sold under the brand supplementation, administered independently, has been name Didronel), and risedronate (sold under the brand demonstrated in women older than 75 years of age. name Actonel) are some of the agents most commonly For people with secondary osteoporosis, treatment used for therapeutic treatment of postmenopausal osteo- may focus on curing the underlying disease. porosis. Biphosphonates act by decreasing bone resorp- tion or breakdown. For example, alendronate attaches Drugs itself to bone that has been targeted by bone-eating osteo- clasts. It protects the bone from these cells. Osteoclasts For most women who have gone through help the body break down old bone tissue. menopause, the best treatment for osteoporosis is hor- G A L E E N C Y C L O P E D I A O F N U R S I N G A N D A L L I E D H E A LT H 1784
  4. 4. Alendronate has shown to be an effective agent in The treatments currently available are antiresorptive, Osteoporosis which limits the ability to increase bone mass. Other preventing bone loss and building bone in recently post- bone-building agents are under investigation including menopausal women and is especially useful in women parathyroid hormone which has been clinically evaluated who have contraindications for HRT. It has been licensed but is still awaiting FDA approval as of March 2001. The for the treatment and prevention of vertebral and nonver- biphosphonates have demonstrated the most dramatic tebral postmenopausal osteoporosis. Alendronate has reduction in fracture rates and may be the best choice for proven safe in very large, multi-year studies, but not women with severe osteoporosis. Estrogen’s effect may much is known about the effects of its long-term use. be similar, but has not been established in large random- Side effects are generally minimal with abdominal pain, ized trials. Raloxifene may be particularly useful in nausea, dyspepsia, constipation and diarrhea occurring women who wish to benefit from a breast cancer risk in 3% to 7% of patients treated with alendronate. It can reduction. Calcitonin may be the least potent but may be be taken daily, and now a new formulation has been useful in women who cannot tolerate other therapies. developed that can be taken weekly. Etidronate has been shown to reduce the rate of new Surgery vertebral and nonvertebral fractures. It appears to be well Unfortunately, treatment for osteoporosis is usually tolerated in clinical studies. tied to fractures that result from advanced stages of the Calcitonin is a hormone that has been used as an disease. For complicated fractures, such as broken hips, injection for many years. It is also marketed as a nasal hospitalization and a surgical procedure are required. In spray. It also slows down bone-eating osteoclasts. Side hip replacement surgery, the broken hip is removed and effects are minimal, but calcitonin builds bone by only replaced with a new hip made of plastic, or metal and 1.5% a year, which may not be enough for some women plastic. Though the surgery itself is usually successful, to recover the bone they lose. complications of the hip fracture can be serious. Those individuals have a 5%–20% greater risk of dying within Selective estrogen receptor modulators (SERMs) the first year following that injury than do others in their such as raloxifene, droloxifene, idoxifene, and tamoxifen age group. A large percentage of those who survive are are used as alternatives to hormone replacement therapy unable to return to their previous level of activity, and (HRT) which commonly use estrogen. SERMs have been many end up moving from self-care to a supervised liv- shown to protect against postmenopausal bone loss with- ing situation or nursing home. Getting early treatment out the estrogenic side effects. Raloxifene was the first and taking steps to reduce bone loss are vital. SERM to be approved in the osteoporosis market for pre- vention and treatment of osteoporosis. Raloxifene binds Alternative treatment to estrogen receptors and mimics estrogen’s action on bone by preventing bone loss, and improving cholesterol Alternative treatments for osteoporosis focus on metabolism, therefore acting as an agonist. It also acts as maintaining or building strong bones. A healthy diet low an estrogen antagonist in the uterus and the breasts, by in fats and animal products and containing whole grains, not imitating the action of estrogen. These drugs may fresh fruits and vegetables, and calcium-rich foods (such thus improve blood lipid profiles and protect against as dairy products, dark-green leafy vegetables, sardines, breast cancer. There is an enhanced risk of venous throm- salmon, and almonds), along with nutritional supple- boembolic events during raloxifene therapy, especially ments (such as calcium, magnesium, and vitamin D), and weight-bearing exercises are important components of during the first four months of therapy. It also has a both conventional prevention and treatment strategies and propensity to induce hot flashes, and leg pain. alternative approaches to the disease. In addition, alterna- Sodium fluoride has been used as an anabolic agent tive practitioners recommend a variety of botanical med- to stimulate bone formation. However, a high incidence icines or herbal supplements. Herbal supplements of side effects, mainly gastrointestinal symptoms and designed to help slow bone loss emphasize the use of cal- lower extremity pain syndrome have occurred in clinical cium-containing plants, such as horsetail (Equisetum trials. arvense), oat straw (Avena sativa), alfalfa (Medicago Androgens have been used for reducing bone loss. sativa), licorice (Glycyrrhiza galbra), marshmallow Androgens are classified as anabolic steroids, which (Althaea officinalis), and yellow dock (Rumex crispus). include nandrolone, stanozolol and testosterone, are used Homeopathic remedies focus on treatments believed to as antiresorptive agents. Androgens are important for help the body absorb calcium. These remedies are likely postmenopausal women as they serve as a substrate for to include such substances as Calcarea carbonica (calci- the peripheral production of estrogens. um carbonate) or silica. In traditional Chinese medicine, 1785 G A L E E N C Y C L O P E D I A O F N U R S I N G A N D A L L I E D H E A LT H
  5. 5. Osteoporosis Prognosis KEY TERMS There is no cure for osteoporosis, but it can be con- trolled. Most people who have osteoporosis fare well Alendronate—A nonhormonal drug used to treat once they get treatment. The medicines available now osteoporosis in postmenopausal women. build bone, protect against bone loss, and halt the Anticonvulsants—Drugs used to control seizures, progress of this disease. such as in epilepsy. Biphosphonates—Compounds (like alendronate) Health care team roles that slow bone loss and increase bone density. Doctors, nurses, physical therapists, radiation tech- Calcitonin—A hormonal drug used to treat post- nologists, and dietitians all play roles in the process of menopausal osteoporosis. controlling osteoporosis. Because osteoporosis is treat- Estrogen—A female hormone that also keeps able but not curable, the main responsibility for control- bones strong. After menopause, a woman may ling the progress of the disease rests with the patient. All take hormonal drugs with estrogen to prevent of these team members play an important role in identi- bone loss. fying risk of osteoporosis before it strikes and in con- Glucocorticoids—Any of a group of hormones vincing the patient to take appropriate steps (including (like cortisone) that influence many body func- lifestyle modification) to minimize the dangers of frac- tions and are widely used in medicine, such as for turing major bones. treatment of rheumatoid arthritis inflammation. Hormone replacement therapy (HRT)—Also Prevention called estrogen replacement therapy, this contro- versial treatment is used to relieve the discomforts Building strong bones, especially before the age of of menopause. Estrogen and another female hor- 35, and maintaining a healthy lifestyle are the best ways mone, progesterone, are usually taken together to of preventing osteoporosis. To build as much bone mass replace the estrogen no longer made by the body. as early as possible in life, and to help slow the rate of It has the added effect of stopping bone loss that bone loss later in life: occurs at menopause. Menopause—The ending of a woman’s menstrual Get calcium in foods cycle, when production of bone-protecting estro- Experts recommend 1,500 milligrams (mg) of calci- gen decreases. um per day for adolescents, pregnant or breast-feeding Osteoblasts—Cells in the body that build new women, older adults (over 65), and postmenopausal bone tissue. women not using hormone replacement therapy. All oth- Osteoclasts—Cells that break down and remove ers should get 1,000 mg per day. Foods are the best old bone tissue. source for this important mineral. Milk, cheese, and Selective estrogen receptor modulator—A hor- yogurt have the highest amounts. Other foods that are monal preparation that offers the beneficial effects high in calcium are green leafy vegetables, tofu, shell- of hormone replacement therapy without the fish, Brazil nuts, sardines, and almonds. increased risk of breast and uterine cancer associ- ated with HRT. Take calcium supplements Many people, especially those who do not like or cannot eat dairy foods, do not get enough calcium in their practitioners recommend herbs thought to slow or prevent diets and may need to take a calcium supplement. bone loss, including dong quai (Angelica sinensis) and Supplements vary in the amount of calcium they contain. Asian ginseng (Panax ginseng). Natural hormone thera- py, using plant estrogens (from soybeans) or progesterone Those with calcium carbonate have the most amount of (from wild yams), may be recommended for women who useful calcium. Supplements should be taken with meals cannot or choose not to take synthetic hormones. and accompanied by six to eight glasses of water a day. Calcium supplements and antacids interfere with It should be noted, however, that very few clinical absorption of alendronate and should be taken at least trials are conducted on alternate therapies and therefore efficacy cannot be established. one half hour later. G A L E E N C Y C L O P E D I A O F N U R S I N G A N D A L L I E D H E A LT H 1786
  6. 6. Get vitamin D Otoscope PERIODICALS Feder, G., et al. “Guidelines for the Prevention of Falls in Vitamin D helps the body absorb calcium. People People over 65.” British Medical Journal 321 (2000): can get vitamin D from sunshine with a quick (15–20 1007-1011. minutes) walk each day or from foods such as liver, fish McClung, Michael R., et al. “Effect of Risedronate on the oil, and vitamin-D fortified milk. During the winter Risk of Hip Fracture in Elderly Women.” The New months it may be necessary to take supplements England Journal of Medicine 344, no. 5 (2001): 333-40. (400–800 IU/day). ORGANIZATIONS Arthritis Foundation, 1330 W. Peachtree St., PO Box 7669, Avoid smoking and alcohol Atlanta, GA 30357-0669. (800) 283-7800. <http://www.arthritis.org>. Smoking reduces bone mass, as does heavy drink- National Center for Complementary and Alternative Medicine ing. To reduce risk, do not smoke and limit alcoholic (NCCAM), 31 Center Dr., Room #5B-58, Bethesda, MD drinks to no more than two per day. An alcoholic drink is 20892-2182. (800) NIH-NCAM. Fax: (301) 495-4957. 1.5 oz (44 mL) of hard liquor, 12 oz (355 mL) of beer, or <http://nccam.nih.gov>. 5 oz (148 mL) of wine. National Osteoporosis Foundation, 1150 17th Street, Suite 500 NW, Washington, DC 20036-4603. (800) 223-9994. Exercise <http://www.nof.org>. Exercising regularly builds and strengthens bones. Osteoporosis and Related Bone Diseases-National Resource Center. 1150 17th St., NW, Ste. 500, Washington, DC Weight-bearing exercises—where bones and muscles 20036-4603. (800) 624-BONE. <http://www.osteo.org>. work against gravity—are best. These include aerobics, dancing, jogging, stair climbing, tennis, walking, and lift- Crystal Kaczkowski, MSc ing weights. People who have osteoporosis may want to attempt gentle exercise, such as walking, rather than jog- ging or fast-paced aerobics, which increase the chance of falling. Try to exercise three to four times per week for 20–30 minutes each time. As physical activity improves muscle strength and coordination it may also aid in Otoscope reducing the risk of fall-related fractures. Definition Those at risk should avoid medications known to compromise bone density, such as glucocorticoids, thy- An otoscope is a hand-held device for visual exami- roid hormones and chronic heparin therapy. nation of the auditory canal, inner ear, and tympanic membrane. Resources Purpose BOOKS Adams, John S. and Barbara P. Lukertet. Osteoporosis: An otoscope is designed to enable the health care Genetics, Prevention and Treatment. Boston: Kluwer professional to view the auditory canal, inner ear, and Academic, 1999. tympanic membrane as part of a normal physical exam- Kessler, George J., et al. The Bone Density Diet: 6 Weeks to a ination. It is also used if infection of the auditory canal Strong Body and Mind. New York: Ballantine Books, is suspected, if there is a blockage due to the presence of 2000. a foreign object or build up of wax, and to inspect the Krane, Stephen M., and Michael F. Holick. “Metabolic Bone tympanic membrane for signs of rupture, puncture, or Disease: Osteoporosis.” In Harrison’s Principles of hearing loss. Internal Medicine. 14th ed. Ed. by Anthony S. Fauci, et al. New York: McGraw-Hill, 1998. Lane, Nancy E., ed. The Osteoporosis Book. New York: Description Oxford University Press, 1998. An otoscope consists of a handle with power source, McIlwain, Harris, et al. Osteoporosis Cure: Reverse the an optical head with fiberoptic strands, a lens, specula, a Crippling Effects With New Treatment. New York: Avon small light bulb, a polished reflector, and may have pneu- Books, 1998. moscopy bellows as an option. The unit is designed to be Notelovits, Morris, et al. Stand Tall! Every Woman’s Guide to operated by one hand, enabling the other hand to manip- Preventing and Treating Osteoporosis. 2nd ed. ulate the patient’s ear. Gainesville, FL: Triad Publishing Co., 1998. 1787 G A L E E N C Y C L O P E D I A O F N U R S I N G A N D A L L I E D H E A LT H