Disease Process And Management Of Osteoporosis
Osteoporosis is a metabolic bone disorder characterized by bone mass loss, increased bone fragility and increased fracture risk. It is estimated that over 200 million people worldwide are diagnosed with osteoporosis. 30% are post-menopausal women in the United States and Europe, and 40% will sustain one or more fragility fracture. And 15-30% is osteoporotic men. According to Eriksen 2010, 20% of our bone tissues are replaced annually by a set of new bone tissues. Not only is it both significant and costly global health issue. But it is also a chronic disease which may lead to fracture. In which, the severity of fracture and the impact of it will depend on one’s age. According to the year 2013’s report by International Osteoporosis Foundation, it is estimated that by 2050, more than half of the world’s hip fracture will happen in Asia. Bone remodeling is important as it maintains plasma calcium homeostasis. Not only it helps in adjusting bone structure to meet the constant changing of mechanical needs but also repairing of micro damage in bone matrix to prevent old bones from accumulating. This involves sequential osteoclastic resorption and formation of osteoblastic bones. The remodeling cycle begins from re-absorption, during which the osteoclasts digest the old bones; reversal, when mononuclear cells appear on the bone surface; and formation, when new bones are laid down by osteoblasts until the bone is fully replaced. There are many factors which affects bone metabolism, for example: Calcitonin affects bone growth, calcitrol affects calcium absorption and estrogen decreases bone re-absorption.
The pathophysiology of osteoporosis begins after the peak bone mass reached in early adulthood of 35 years, and slowly decline thereafter. This happens when the osteoblasts are unable to refill the re-absorption rate in each remodelling event, decreasing in osteoclast and osteoblast activity. Therefore the bones become more fragile and fracture easily. Usually it goes undetectable until complication arises. The clinical signs are loss of height, progressive bone deformity and lower back pain. Modifiable risk factors are: Excessive alcohol intake, Smoking, Low calcium and Vitamin D intake, Physical inactivity, Medications such as Glucocorticoid and Anti-epileptic. Non-modifiable are: Age, Women after menopause, family history, previous fracture, body frame and co-morbidities.
There are several ways of diagnosing if one is osteoporotic, they are FRAX tool to determine the need for BMD, Bone Mineral Density (BMD) test, which includes the Dual-energy X-ray absorptiometry (DXA) and Quantitative Computed Tomography, Lastly, the Osteoporosis Self Assessment Tool for Asia (OSATA). FRAX is web-based tool used to assessment risk of fracture. It combines individual risk factors and reports a 10 year likelihood of any major osteoporotic or hip fracture. DXA is done at the spine, hip and forearm. This is the most effective method to identify any changes in the BMD after a while. Fracture risk and BMD measured by DXA shows a strong relationship. The result for BMD is that if the T-score is less than -2. 5 or lower, one may be diagnosis as osteoporotic. Quantitative Computed Tomography measures the volumetric BMD (vBMD) in mg/cm3 at the spine and hip. And for OSATA, if one is above 65years and weight is 50 to 54kg, one may be high risk for osteoporosis.
After one is diagnosed with osteoporosis, starting of medical intervention will be appropriate. As it can slow down osteoporosis progression and decrease risk of fracture due to low bone mineral density. However, treatable secondary causes, for example: women receiving thyroid hormone therapy, should be addressed first before beginning osteoporosis-specific treatment. Women with fractures or T-score result less than 2. 5, below the mean are at higher risk of sustaining potential fracture. Therefore it is recommended that they receive treatment. When one is diagnosed with osteoporosis, risk of complications may occur. This includes hip, wrist and spine fractures. Common fractures are neck of femur, supracondylar, femur, colles, radial neck and vertebrae body. It is often accompanied by pain, disability, deformity and postural changes associated with vertebral compression fracture. Therefore management of complications is important. Firstly, assess and manage pain. Serve appropriate medications such as analgesias for pain management. Secondly, stabilize the fracture site by apply splint or cast appropriately, this is to support, prevent further complication and reduce pain. Lastly, monitor for signs and symptoms of fat embolism such as respiratory insufficiency, this is a medical emergency which is a complication of fracture. Admit to an acute hospital appropriately to receive the necessary treatment.
Treatment includes pharmacological and non-pharmacological. For pharmacological, Oral Bisphosphonates is the first choice of treatment. They block the osteoclast activity and prevents reabsorption. A Randomized control trial showed that there is a decrease of vertebrae and hip fracture in both men and women when taking Alendronate or Risedronate. Other medication includes Raloxifene Calcitonin Teriparatide and Denosumab which reduces vertebrae. Combination therapy did not show that it reduces fracture. A study conducted by The Women's Health Initiative shows that hormone therapy: estrogen with or without progesterone, decrease the risk of hip and vertebrae fracture slightly. However the complications (stroke, coronary heart disease, breast cancer and venous thromboembolism) rate are higher compared to the benefits. Ergocalciferol (Vitamin D2) Cholecalciferol (Vitamin D3) are supplements for Vitamin D. Studies have recommended to supplement with Vitamin D3 instead of Vitamin D2, as it increases an important serum more effectively compared to Vitamin D2. As for non-pharmacological treatment, includes educating one on osteoporosis. It is important as it helps to prevent complications and will improve one’s knowledge and how to manage this condition. Firstly, educate on the appropriate diet. Diet not only has to consist of calcium and vitamin D, but also include protein, phosphorus, magnesium, vitamin K and C. As they work together to build and strengthen the bones. In order to get Vitamin D, the best way is to be exposed to the Sun light between 10am and 3pm for 5 to 15 minutes. Secondly, educate on the food rich in calcium. Dairy products such as ricotta, plain yoghurt, and low fat milk contain calcium of 335mg, 310mg, and 300mg per serving respectively. According to the National Osteoporosis Foundation (2018), the amount of calcium intake for women below the age of 50 and above 51 is 1000mg and 1200mg respectively. As for men, below the age of 70 and above the age of 71 is 1000mg and 1200mg respectively. Thirdly, educate on what food to avoid. Such as high in trans fats, saturated fats, sugar and high in cholesterol. All these reduce calcium absorption and lead to bone loss. Many studies have shown the influence of dietary fat and sugar affecting bone metabolism. And have confirmed that bone health complications are affected by dietary nutrition. Fourthly, exercise. There are two types or exercises. One is weight bearing exercises, such as tai-chi, dancing, aerobics, skipping, hiking and brisk-walking. This produces the highest mechanical weight on the bone, and will increase the Bone Mineral Density. Second is resistance exercise, such as weight-lifting, push ups, standing and rising on your toes. These are strength training and are used to increase muscle strength, improve bone mass, balance and mobility. This will result in better quality of life. Lastly, educate on fall prevention by explaining the need of wearing of anti-slip foot wear, using of walking aids or visual aids if necessary. An occupational therapist should assess one’s home and do home modifications such as installing grab bars in the restroom. Ensure adequate lighting in the house and ensure the floors are free from any clutters to prevent falls.
In conclusion, not only we have to understand the disease process and management, but also to understand the consequences and the burden of osteoporosis. We have to also consider one’s mental state, family and social background. This is to tailor management plan for individuals and to prevent further complications which may lead to financial and emotional burdens of this disease.
