This document provides information on osteoporosis and geriatric physical therapy. It defines osteoporosis as a disease characterized by low bone mass and deterioration of bone tissue, leading to increased bone fragility. It discusses the two types of bone, bone cells, mineralization process, and hormonal influences. It provides guidelines for determining osteoporosis, describes the two main types, risk factors, evaluation methods, treatment options including calcium/vitamin D, bisphosphonates, and exercise, guidelines for treatment, and importance of falls prevention.

1. Geriatric
Physical Therapy

3. Osteoporosis

4. What is Osteoporosis?
0Loss in total mineralized bone
0Disruption of normal balance of bone breakdown
and build up
0Osteoclasts: bone resorption, stimulated by PTH
0Calcitonin: inhibits osteoclastic bone resorption
0Major mechanisms:
0 Slow down of bone build up: osteoporosis seen in older
women and men (men after age 70)
0 Accelerated bone breakdown: postmenopausal
0 Normal loss .5% per year after peak in 20s
0 Up to 5% loss/year during first 5 years after menopause

5. Defining Osteoporosis
0 Osteoporosis as a disease characterized by low bone
mass and micro architectural deterioration of bone
tissue, leading to increased bone fragility and a
consequent increase in fracture risk. One in three
women and one in twelve men over 50 years of age
are affected. Early menopause (age <45)

6. Two components of the bone
0Cortical Bone
0 Dense and compact
0 Runs the length of the long bones, forming a hollow
cylinder
0Trabecular bone
0 Has a light, honeycomb structure
0 Trabeculae are arranged in the directions of tension
and compression
0 Occurs in the heads of the long bones
0 Also makes up most of the bone in the vertebrae

8. Bone cells
0Osteocytes - derived
from osteoprogenitor
cells
0Osteoblasts
0Osteoclasts

9. Mineralization of the bone
0 Calcification occurs by extracellular deposition of
hydroxyapatite crystals
0 Trapping of calcium and phosphate ions in
concentrations that would initiate deposition of calcium
phosphate in the solid phase, followed by its conversion
to crystalline hydroxyapatite

10. Hormonal Influence
0 Vitamin D
0 Parathyroid Hormone
0 Calcitonin
0 Estrogen
0 Androgen

11. Vitamin D
0Osteoblast have receptors for (1,25-(OH)2-D)
0Increases activity of both osteoblasts and
osteoclasts
0Increases osteocytic osteolysis (remodeling)
0Increases mineralization through increased
intestinal calcium absorption
0Feedback action of (1,25-(OH)2-D) represses
gene for PTH synthesis

12. Parathyroid Hormone
0 Accelerates removal of calcium from bone to increase
Ca levels in blood
0 PTH receptors present on both osteoblasts and
osteoclasts
0 Osteoblasts respond to PTH by
0 Change of shape and cytoskeletal arrangement
0 Inhibition of collagen synthesis
0 Stimulation of IL-6, macrophage colony-stimulating factor
secretion

13. Calcitonin
0 C cells of thyroid gland secrete calcitonin
0 Straight chain peptide - 32 aa
0 Synthesized from a large preprohormone
0 Rise in plasma calcium is major stimulus of calcitonin
secretion
0 Plasma concentration is 10-20 pg/ml and half life is 5 min
0 Osteoclasts are target cells for calcitonin
0 Major effect of calcitonin is rapid fall of plasma calcium
concentration caused by inhibition of bone resorption
0 Magnitude of decrease is proportional to the baseline rate
of bone turnover

14. Other systemic hormones
0 Estrogens
0 Increase bone remodeling
0 Androgens
0 Increase bone formation
0 Growth hormone
0 Increases bone remodeling
0 Glucocorticoids
0 Inhibit bone formation
0 Thyroid hormones
0 Increase bone resorption
0 Increase bone formation

15. WHO guidelines for determining
osteoporosis
0Normal: Not less than 1 SD below the avg. for
young adults
0Osteopenia: -1 to -2.5 SD below the mean
0Osteoporosis: More than 2.5 SD below the
young adult average
0Severe osteoporosis
0 More than 2.5 SD below with fractures

16. Osteoporosis
0 Mechanisms causing osteoporosis
0 Imbalance between rate of resorption and formation
0 Failure to complete 3 stages of remodeling
0 Types of osteoporosis
0 Type I
0 Type II

17. Osteoporosis - types
0 Postmenopausal osteoporosis (type I)
0 Caused by lack of estrogen
0 Causes PTH to overstimulate osteoclasts
0 Excessive loss of trabecular bone
0 Age-associated osteoporosis (type II)
0 Bone loss due to decreased bone turnover
0 Mal-absorption
0 Mineral and vitamin deficiency

18. When to Measure BMD in
Postmenopausal Women
0 All women 65 years and older
0 Postmenopausal women <65 years of age:
0 If result might influence decisions about
intervention
0 One or more risk factors
0 History of fracture

19. When Measurement of BMD Is
Not Appropriate
0 Healthy premenopausal women
0 Healthy children and adolescents
0 Women initiating ET/HT for menopausal
symptom relief (other osteoporosis therapies
should not be initiated without BMD
measurement)

20. Who Should Be Considered
for Prevention or Treatment?
0 Postmenopausal women with T-score below –2.0
with no risk factors
0 Postmenopausal women with T-score below –1.5
with one or more risk factors

21. Prevention of Bone Loss
Prevention of Bone Loss
0 Calcium
0 HRT
0 SERMS [Selective estrogen receptor modulators]
0 Calcitonin
0 Bisphosphonates

22. Who Gets Osteoporosis?
0 Age
0 Estrogen deficiency
0 Testosterone deficiency
0 Family history/genetics
0 Female sex
0 Low calcium/vitamin D intake
0 Poor exercise
0 Smoking
0 Alcohol
0 Low body weight/anorexia
0 Hyperthyroidism

23. Factors
0 Hyperparathyroidism
0 Prednisone use
0 Liver and renal disease (think about vit d synthesis)
0 Low sun exposure
0 Medications (antiepileptics, heparin)
0 Malignancies (metastatic disease; multiple myeloma can
present as osteopenia!)
0 Hemiplegia / immobility
0 Physical inactivity
0 Thin body type
0 Rheumatological conditions e.g. rheumatoid arthritis, ankylosing
spondylitis
0 High caffeine intake

24. Methods to evaluate for
osteoporosis
0Quantitative Ultrasonography
0Quantitative computed tomography
0Dual Energy X-ray Absorptiometry (DEXA)
0 ”gold standard”
0 Measurements vary by site
0 Heel and forearm: easy but less reliable (outcome of
interest is fracture of vertebra or hip!)
0 Hip site: best correlation with future risk hip fracture
0 Vertebral spine: predict vertebral fractures; risk of
falsely HIGH scores if underlying OA/osteophytes

25. Fracture Reduction
0 Goal: prevent fracture, not just treat BMD
0 Osteoporosis treatment options
0 Calcium and vitamin D
0 Calcitonin
0 Bisphosphonates
0 Estrogen replacement
0 Selective Estrogen Receptor Modulators
0 Parathyroid Hormone

26. Osteoporosis Treatment: Calcium and
Vitamin D
0Calcium and vit D supplementation shown to
decrease risk of hip fracture in older adults
01000 mg/day standard; 1500 mg/day in
postmenopausal women/osteoporosis
0Vitamin D (25 and 1,25): 400 IU day at least;
0 Frail older patients with limited sun exposure may
need up to 800 IU/day

27. Osteoporosis Treatment:
Calcitonin
0 Likely not as effective as bisphosphonates
0 200 IU nasally/day
0 Decrease pain with acute vertebral compression
fracture

28. Osteoporosis Treatment:
Bisphosphonates
0Decrease bone resorption
0Multiple studies demonstrate decrease in hip
and vertebral fractures
0Alendronate, risodronate
0Ibandronate (boniva): once/month
0Those at highest risk of fracture (pre-existing
vertebral fractures) had greatest benefit with
treatment

29. Bisphosphonate Associated Osteonecrosis
(BON)
0 Jaw osteonecrosis
0 Underlying significant dental disease
0 Usually associated with IV formulations
0 Case reports associated with oral formulations
Bisphosphonates: Contraindications
0 Renal failure
0 Esophageal erosions

30. Osteoporosis Treatment: Estrogen
Replacement
0 Reduction in bone resorption
0 Proven benefits in treatment
0 Increased cardiac risk, increased risk cancer

31. Osteoporosis Treatment: Selective
Estrogen Receptor Modulators
0 Raloxifene
0 Decrease bone resorption like estrogen
0 No increased risk cancer (decrease risk breast cancer)
0 Increase in vasomotor symptoms associated with
menopause

32. Reducing Fractures
0 1. Decrease osteoporosis/improve BMD
0 2. Decrease risk of break: hip protectors
0 3. Decrease risk of fall

33. Hip Protectors
0 Padding that fits under clothing
0 Multiple studies demonstrate effectiveness at
preventing hip fractures
0 Likely cost effective

34. Falls Reduction
0 Falls are a marker of frailty
0 Hip fracture is a marker of frailty
0 Mortality after hip fracture:?due to hip fracture or hip fracture
as marker for those who are declining?
0 Increased risk of falls:
0 Prior fall (fear of falling)
0 Cognitive decline
0 Loss of vision
0 Peripheral neuropathy
0 Weakness
0 Stroke
0 Medications: anticholinergics…

35. Current Guidelines
0 US Preventive Task Force
0 Test Bone Mineral Density in all women over age 65,
younger postmenopausal women with at least one risk
factor, and postmenopausal women with a history of
fracture
0 Treat patients with T score <-2 and no risk factors, T
score <1.5 if any risk factors, and anyone with prior
vertebral/hip fracture

36. Who is left out?
0 Older men
0 Not included in recommendations
0 Screening not recommended or paid for
0 Significant problem, risk of osteoporosis, risk of
fracture, especially after age 70, even more so after age
80
0 Significant evidence that men with osteoporosis benefit
from treatment

37. 0 For the purpose of these guidelines a pragmatic decision
was made to separate the target client groups into 3 broad
categories:
0 1. Those with normal bone mass concerned with reducing
the risk together with people with mild bone changes
(osteopenia).
0 2. People with a clinical diagnosis of osteoporosis without
any history of fracture (#).
0 3. A frailer group with advanced bone changes usually
having sustained fractures (#).

38. Diet
Exercises
0 Prevent fracture
0 Aid bone density
Strength muscles , balance , coordination
0 High impact exercises jogging effect hip . Knee and spine
0 Weight lifting…..wrist

39. Exercises
0 According to the National Osteoporosis Foundation,
the best exercises for building and maintaining
bone density are:
0 Weight-bearing exercise, such as walking, that makes
you work against gravity while staying upright.
0 Muscle-strengthening exercise, such as weight lifting,
that makes you work against gravity in a standing,
sitting, or prone position.

40. THANXS