Feature Article
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A Multidisciplinary Approach to Managing Osteoporosis A Multidisciplinary Approach to Managing Osteoporosis
LaDonna S. Hale, PharmD, and Meri Goehring, PT, MHS, GCS
Dr. Hale is Assistant Professor, Department of Physician Assistants, Wichita State University, and Clinical Pharmacist, Wesley Medical Center, Wichita, KS. Ms. Goehring is Instructor, Department of Physical Therapy, Northern Illinois University, DeKalb, IL. Address for correspondence: LaDonna Hale, PharmD, Wichita State University, Department of Physician Assistants, 1845 Fairmount, Box 43, Wichita, KS 67260-0043.
Proper prevention and management of osteoporosis is best provided by a multidisciplinary team: the physician diagnoses the problem and selects and coordinates care; the dietitian assesses diet and nutritional status; the nurse also coordinates care and monitors the person’s changing health status; the pharmacist evaluates the medication and prevention plan and reduces medications predisposing to falls and osteoporosis; the physical and occupational therapists provide an exercise regimen, and fall prevention and home safety evaluation; and the psychologist supports the patient and family regarding psychological issues. With appropriate therapy it is possible to prevent, delay, and even partially reverse the effects of osteoporosis. (Annals of Long-Term Care: Clinical Care and Aging 2003;11[6]:40-47)
Osteoporosis fractures are a frequent cause of disability, morbidity, and mortality in older men and women. The consequences of osteoporosis not only adversely affect the patient, but the patient’s family and community. Anxiety and depression are commonly associated with osteoporosis, especially after a fracture has occurred.1 Proper prevention and management of osteoporosis is best provided by a multidisciplinary effort of health professionals who attend to the “whole” patient. The physician, pharmacist, dietitian, physical therapist, occupational therapist, nurse, and psychologist each have an important role in the total osteoporosis treatment and prevention program. Osteoporosis is defined as a disease of low bone density and deterioration of bone tissue, leading to enhanced bone fragility and consequent increased fracture risk, most often in the hip, spine, and wrist.2 Because bone is living tissue, it can be modified. With the right diet, exercise, and medication, it is possible to prevent, delay, and even partially reverse the effects of osteoporosis. Finding the right treatment regimen can be challenging, but well worth the effort.
Osteoporosis is often called the “silent disease,” because bone loss occurs without symptoms. Patients often do not know that they have osteoporosis until a fracture occurs. Even minimal trauma, such as a sudden strain, bump, quick movement, or strong cough can cause a fracture or a vertebra to collapse. Collapsed vertebrae may initially be felt or seen in the form of severe back pain, loss of height, or spinal deformities such as kyphosis or stooped posture. In the United States, nearly 17 million postmenopausal women have low bone mass, and 7 million women and 2 million men have osteoporosis. Osteoporosis is common, with a 70% prevalence rate in women over age 80 years.2 Although the majority of people with osteoporosis are over age 50, the disease also affects younger people who are put at risk by such factors as early menopause, eating disorders, crash dieting, and use of certain medications. In 1995, osteoporotic fractures resulted in 432,000 hospital admissions, 2.5 million physician visits, and 180,000 nursing home admissions, with direct medical expenditures estimated at $13.8 billion.3 Thirty-six percent of men and 21% of women will die within 1 year of suffering a hip fracture. Of the survivors, 40% will be unable to walk independently, and 60% will require assistance with activities of daily living.2
Diagnosing Osteoporosis and Identifying Risk Factors
Diagnosis of osteoporosis is usually done through a bone density test. The usual cost is approximately $150-250 and is covered by Medicare.2 However, a low bone density measurement is only one risk factor and does not absolutely predict a fracture. Other risk factors should also be considered. The National Osteoporosis Foundation recommends bone density screening in all postmenopausal women with a recent fracture or with any other risk factor for osteoporosis. Bone density tests are also recommended for all women older than age 65 years regardless of risk factors.3 Since osteoporosis is a silent disease, most men and women with risk factors have never been screened. Identification of patients at risk for osteoporosis and fractures can be done by any member of the health care team by simply ascertaining the patient’s past medical history, social history, family history, general health, and fall risk ( Table I). The physician will order necessary screening to make the final diagnosis and prescribe appropriate treatment. The plan of action to prevent, delay, or partially reverse osteoporosis may differ based on the health status of each individual, with the input of the health care team.
Medications to Treat and Prevent Osteoporosis
Pharmacists can provide a medication review for individuals who may take drugs that predispose to osteoporosis or falls (Tables II, III). This is a key factor in prevention of unnecessary fractures. Additionally, pharmacists work with physicians to prescribe the optimal medication to prevent and treat osteoporosis. To understand how these medications work, it is important to understand the dynamics of bone turnover or remodeling. Bone remodeling occurs throughout life and is critical to the maintenance of normal, healthy bone. Two major cell types within the bones, osteoblasts and osteoclasts, perform remodeling. Osteoblasts lay new bone (bone formation), while osteoclasts are responsible for recycling old bone (bone resorption). The rate of bone resorption exceeds the rate of formation in older adults, thus predisposing to osteoporosis. Since resorption releases recycled calcium into the bloodstream, the rate is increased by low serum calcium levels. Most medications used to treat and prevent osteoporosis act by inhibiting bone resorption. These include bisphosphonates, calcitonin, estrogens, and raloxifene (Table IV).
Alendronate, and Risedronate
Alendronate and risedronate are bisphosphonates. Alendronate is dosed either 10 mg once daily or 70 mg once weekly and costs approximately $65–70 per month.4 Risedronate is dosed at 5 mg daily at approximately the same cost. Due to extremely poor oral absorption and risk of esophageal erosion, patients and nurses must be aware of the stringent administration instructions for this class of drugs. They must be taken on an empty stomach, first thing in the morning, before any food, beverage, or other medications, and with a full, 8-ounce glass of water. No other beverage may be used. The person must then remain upright, standing or sitting, for at least 30 minutes after the dose to assure that the pill does not lodge in the esophagus. For this reason, the bisphosphonates may not be appropriate for bedridden residents or those prone to aspiration. These difficult administration instructions are a major complaint of persons taking a bisphosphonate. Taking alendronate once weekly helps to alleviate compliance issues, but rates of upper gastrointestinal erosions are similar to those of daily administered bisphosphonates.5 Due to the extremely long benefits of these drugs, studies are underway to investigate the efficacy of annual or biannual bisphosphonate injections.6 Oral bisphosphonates are relatively safe; most common side effects include headache, flatulence, and acid regurgitation. Although all prescription medications have been shown to increase bone density and to reduce vertebral fractures, bisphosphonates and estrogens are the only classes of drugs shown in large randomized trials to reduce the rate of hip fractures.3,7,8 As hip fractures are the most debilitating type of fracture, this makes bisphosphonates a first-line therapy for osteoporosis prevention and treatment in men, premenopausal and postmenopausal women, and patients receiving glucocorticoids.3,7,8
Calcitonin-Salmon
Calcitonin-Salmon is not absorbed orally. It is administered as a nasal spray, dosed at one spray daily, with a cost of $70 per month.4 Side effects are minimal—most commonly nasal dryness (< 15%), nose bleeds (< 15%), and occasionally mild nasal ulcerations (< 5%). Keeping the nozzle in a straight line with the nasal passageway and alternating nostrils with each dose will help to minimize nasal side effects. Therapy may be resumed when the ulceration heals. Rarely, serious allergic reactions have been reported. Efficacy data for calcitonin is not as strong as that of the bisphosphonates. Therefore, calcitonin is a second-line therapy in men, premenopausal and postmenopausal women, and patients receiving glucocorticoids.3,7,8 It is a first-line therapy for reducing pain associated with fractures.7
Hormone Replacement Therapy and Estrogens
Estrogen deficiency is the main cause of postmenopausal osteoporosis, with the majority of bone loss occurring within the first 5 years after menopause.9 Thus, until recently, hormone replacement therapy (HRT) was considered the most effective prevention for postmenopausal-induced osteoporosis in women.3,7 Two recent, large, randomized studies, The Heart and Estrogen/progestin Replacement Study (HERS) and the Women’s Health Initiative (WHI) have both shown problems with long-term (> 5 years) combination estrogen/progestin HRT. Data from HERS showed more coronary events in the women receiving HRT compared with placebo in the first year of treatment.10 The WHI trial showed that HRT might actually increase the risk of coronary heart disease.11 Also, the WHI trial confirmed a 26% increase risk of invasive breast cancer with estrogen/progestin therapy. In absolute terms, for every 10,000 women receiving HRT each year, one can expect five fewer hip fractures, but eight more cases of invasive breast cancer. Since the risks of long-term HRT may outweigh its benefits, changes may be seen in current consensus guidelines regarding HRT and osteoporosis.
Raloxifene
Raloxifene has some estrogen-like effects; it inhibits bone resorption and decreases total and LDL cholesterol like estrogens but has antiestrogen effects on the breast and uterus tissue. Therefore, it does not increase the risk of invasive breast cancer or endometrial cancer.7,9 The drug is dosed at 60 mg per day, with a cost of $70–75 per month.4 Most common side effects are hot flashes and leg cramps. Raloxifene is contraindicated in pregnancy, breast feeding, and a past history of venous thromboembolic events. It would not be appropriate for males. Since raloxifene is less effective than bisphosphonates at increasing bone density, it is best suited for the prevention of postmenopausal bone loss or the treatment of mild osteoporosis.9
Dietary Calcium and Calcium Supplements
Even without prescription medications, calcium plus vitamin D effectively increases total body bone mineral density. Adequate calcium and vitamin D intake is essential for any prescription medication to be effective. Calcium plus vitamin D, therefore, is the cornerstone of any osteoporosis treatment regimen.
A dietitian can assess the dietary needs of each individual, assuring adequate dietary calcium and maintenance of appropriate body weight. The National Institutes of Health recommends at least 1500 mg of elemental calcium per day plus 800 international units of vitamin D in both men and women over age 65 years and postmenopausal women under age 65 who are not receiving estrogen.3,12 For postmenopausal women receiving estrogen, the recommendation is 1000 mg calcium plus vitamin D.
Although increasing consumption of calcium-rich foods would be ideal, calcium supplements are usually required (Table V). The typical elderly American receives only about 400 mg elemental calcium daily from diet. There are several types of calcium supplements available. Close attention to the labels and the content of elemental calcium is important, as they vary in the amount of elemental calcium, absorption rates, and costs.13 The most commonly used calcium supplement, calcium carbonate, contains a high percentage of elemental calcium and is the least expensive. However, since calcium carbonate requires an acidic environment for best absorption, the carbonate form should be taken with meals to enhance absorption. It also may not be the best choice in elderly residents—who often already have low stomach acidity—and those taking acid-reducing medications, such as cimetidine, ranitidine, omeprazole, or other acid reducers.
Calcium citrate is a more expensive alternative. It contains less elemental calcium per tablet, but may have better absorption than calcium carbonate. Studies in this area are inconclusive.13 Calcium should be taken with plenty of fluids and taken in small doses throughout the day, no more than 500 mg per dose. The most common side effect of calcium is constipation. Calcium cannot be absorbed orally without enough vitamin D. Most residents can get enough vitamin D from spending 15 minutes in the sun daily, drinking a quart of vitamin D-fortified milk, eating vitamin D-rich foods, or taking a vitamin D supplement.14 This is especially important for institutionalized or homebound persons with poor diets and inadequate exposure to sunlight.
Lifestyle Changes
Lifestyle changes can help prevent osteoporosis fractures by preventing development of osteoporosis or preventing falls that may result in fractures. Some osteoporosis risk factors are modifiable through lifestyle choices—such as smoking, alcohol consumption, and physical activity—or through medication changes. Other osteoporosis risk factors are unavoidable, such as age, gender, race, and family history. Reduction of falls is important in reducing the number of serious fractures in persons with osteoporosis. Falls can be avoided by implementing a multidisciplinary fall prevention assessment and intervention program.15 The program should include provision of staff education programs, gait training, and advice on assistive devices. A pharmacist can perform a pharmaceutical review to detect commonly used medications associated with falls, which include blood pressure medications, antidepressants, and opioid pain medications.16 Exercise programs, especially those incorporating balance training, are beneficial for persons with recurrent falls and home environmental assessments and modifications for persons returning home after hospitalization. Physical and occupational therapists and nurses are well-positioned to provide such interventions within the home, assisted living, and long-term care environment.
Exercise and Risk Reduction
Exercise improves cardiovascular, metabolic, endocrine, and psychological health and is associated with a decrease in morbidity and mortality.17 Weight- bearing exercise specifically decreases bone density loss, reduces hip and vertebral fractures, and decreases falls. In addition to its impact on these disease processes themselves, exercise improves general health and well-being, enhances quality of life, and preserves physical independence.18 However, up to 75% of older adults do not exercise at recommended levels.17
Physical and occupational therapists can recommend the correct exercise program. Exercise that includes postural control activities to the daily routine is often recommended. Unfortunately, walking on level surfaces has not been shown to significantly increase bone density. A gentle weight lifting regimen, stair climbing, and specific posture exercises should be initiated. As little as 10 minutes a day of resistance activities, such as weight lifting, has been shown to increase bone density.19
Knowing how to exercise properly is important. The ideal exercise to stimulate improvement in bone density appears to be progressive resistance training using several slow repetitions at 70-80% of the one repetition maximum until the muscles feel fatigued. The one repetition maximum should be adjusted monthly, and all of the proximal large muscle groups should be exercised.20 It is important to note that following this regimen may be too strenuous and potentially dangerous for elderly persons with other health problems. Beginning such a program too quickly, with too much weight, may cause injury, and the wrong exercises can hurt rather than help. For example, people with thinning bones of the spine should not do exercises that include excessive forward bending or flexion.21 A well-trained health care professional, such as a physical therapist, can provide the best information on how to exercise safely.
An exercise program should be performed at least three times per week for 30 minutes each time. Additionally, a therapist can instruct individuals with osteoporosis in techniques to improve balance and posture, make recommendations on home or long-term facility safety, and recommend necessary adaptive devices to prevent falls. For those individuals who may already have osteoporosis, poor posture, balance problems, or pain, treatment is available. Therapists can also provide information to activity directors in long-term care facilities on specific exercise routines that can provide the correct exercise progression for residents. Use of a personal trainer may be beneficial to individuals who live alone if they are unlikely to continue exercises or if they are a safety risk when performing exercises unsupervised. Prospective research studies have documented that both aerobic exercise and weight training can be effective in the maintenance and building of bone mineral density in postmenopausal women. Additional benefits of weight training include increased muscular strength, coordination, and balance, which could decrease risk for falling and subsequent fractures.22
Psychological Care
In addition to the physical complications of vertebral deformity, men and women with osteoporosis often suffer from anxiety and depression. Anxiety and depression stem from several factors, including immobility, fear of falling, decreased self-image and self-esteem, social isolation, and the perception that osteoporosis marks the nearing end of their life. Osteoporosis may prevent older persons from performing in their traditional social roles, such as cooking, housekeeping, caring for a spouse or grandchildren, and working. This leads to frustration and sometimes social isolation. All members of the health care team should be on the alert for these issues and refer patients for appropriate counseling with a physician or psychologist if necessary. Antidepressants or anxiolytics may need to be prescribed. Exercise has been shown to improve mood and reduce anxiety surrounding falling.1,2
Coordination and Implementation of Care
Once an appropriate medication regimen, proper diet, and exercise for osteoporosis prevention and treatment are selected, implementation and coordination of care follows. The physician is often the key coordinator of care, especially in the primary care setting. In the hospital, long-term care, or home health care setting, it is often nursing that coordinates care. Nursing is a vital component in provision of care of the elderly. Nurses are the health professionals that most often recognize health condition changes that can cause a fall, such as postural hypotension. They may identify symptoms such as abnormal back pain that may be caused by an osteoporotic fracture. They also provide important health information, such as monitoring height, weight, and other vital signs. Nurses can recommend and coordinate involvement of the other health care team members. Physical and occupational therapists are expected to coordinate with nursing activity directors for provision of appropriate group exercise programs and exercise activities that can be incorporated into the individual routine of each person. Nurses coordinate important care when falls occur, which also aids in preventing further falls. Nurses monitor medication use and can respond to any reported side effects that may result, can educate an individual about the disease process, can encourage adoption of recommended dietary guidelines, can assist on how to modify diet and cope with digestive problems that may result from increased dietary or supplemental calcium, and can assist in reducing barriers to implementation of recommendations of other health professionals.14
Conclusion
The optimum approach to prevention and treatment of osteoporosis necessitates a multidisciplinary approach to care. With proper evaluation of diet, pharmaceutical treatment, an individualized exercise program, initiation of fall prevention techniques, and psychological care, many complications of osteoporosis can be avoided or alleviated.
References
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