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Age-related Bone Loss and Osteoporosis PowerPoint Presentation

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Description : This medical presentation titled "Age-related Bone Loss and Osteoporosis" provides us information on osteoporosis and related fractures as important health care problem of old age, helps us understand the patho-physiology of age related bone loss, enables us to calculate fracture risk in geriatric patients and treat osteoporosis with an individualized plan for each patient, and also provides knowledge about prevention of age related bone loss and related fractures.

Published on : Apr 26, 2021 | Views : 1593 | Downloads : 7

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Age-related Bone Loss and Osteoporosis Nahid Rianon, MD, DrPH The University of Texas Health Science Center at Houston Assistant Professor, Division of Geriatric and Palliative Medicine, Department of Internal Medicine
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Nahid Rianon, MD, DrPH Dr. Nahid Rianon was a member of the Houston Geriatric Education Center faculty. During her time with the grant, she developed and presented these slides to an interprofessional audience. Dr. Rianon is with The University of Texas Health Science Center at Houston. She is an Assistant Professor, Division of Geriatric and Palliative Medicine, Department of Internal Medicine. 2
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Funded By This project was funded by a grant from the Health Resources and Services Administration (HRSA) of the Department of Health and Human Services. The grant was initially funded in 2007 with renewed funding for five years beginning in 2010. (Grant #UB4HP19058). The grant was successfully completed in June, 2015.
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Learning objectives Attendees will recognize osteoporosis and related fractures as important health care problem of old age Attendees will understand the patho-physiology of age related bone loss Attendees will be able to calculate fracture risk in geriatric patients and treat osteoporosis with an individualized plan for each patient Attendees will be knowledgeable about prevention of age related bone loss & related fractures 5 Rianon- HGEC- Osteoporosis , 2015
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Why Osteoporosis Fractures can decrease quality of life: Physical: pain, compressed abdomen, spinal deformity Functional: decreased mobility Psychosocial: depression Rate of recurrent vertebral fracture after the initial one: ~5-20% 6 Rianon- HGEC-Osteoporosis, 2015 Hip fracture ~50% with hip fractures will never walk w/o assistance ~25% will require long-term care NOF
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Under-recognition of osteoporosis ~10,000 baby boomers turn 65 everyday Number of elderly Americans (≥65 yrs) 34 million in 1998 to ~ 70 million in 2030 Concerns of under-recognition and under-treatment ~20% f/u for treatment after fragility fractureOwn the Bone Fracture- often first sign of presence of osteoporosis ~ half of the osteoporosis related office visits managed by PCPs 5% in 2002 to 20% in 2008 (NHAMCS)Rianon et al., 2013 HTN, ↑ lipid, OA, DM & depression - common in them Barriers For PCPs/Geriatricians: Competing chronic disease priorities & lack of resources Rapidly growing geriatric population – not enough trained specialty care physicians 7 Rianon- HGEC-Osteoporosis, 2014
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Osteoporosis in the elderly Osteoporosis & related fractures - important public health problems of old age ~10 million Americans suffer from osteoporosis NOF ~ 34 million are at risk More than 2 million fractures in the USA in 2005 were attributable to osteoporosis prevalent fractures - vertebral fractures (most common) hip fractures wrist fractures 8 Rianon- HGEC-Osteoporosis, 2015
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Osteoporotic fractures For Women: Incidence of fractures per year exceeds that of stroke, MI & breast cancer combined ~1 in 2 Caucasian women ≥50 years experience a fracture in their lifetime For Men: Fracture risk is higher than that of prostate cancer ~1 in 5 men ≥50 years will experience a fracture 9 Rianon- HGEC-Osteoporosis, 2015 Osteoporosis affects men & women of all races/ethnicities
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Osteoporosis: definition Compromised bone strength that increases risk of fracture Bone Strength is characterized by Bone density & Other bone qualities, e .g., micro-architecture influenced by bone remodeling, bone turnover, mineralization and other factors that are more difficult to quantify, such as “damage accumulation” 10 Rianon- HGEC-Osteoporosis, 2015 (NIH consensus conference 2000)
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Osteoporotic bone Trabecular bone Cortical bone Loss of mineral & microstructure Healthy femur Mineral loss Rianon- HGEC-Osteoporosis, 2015 ©2012 Multimedia Scriptorium, UTHealth Quantitative & qualitative changes Fragility Fractures
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BMD changes with advanced age ASBMR 2011 12 Source: ASBMR using data from Looker A et al., 1998 Osteop. Intl mg/cm2
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Bone Structure: relevant to clinical practice 13 Types Trabecular 20% of skeletal mass Greater surface area than cortical Provides supporting strength to the ends of weight-bearing bones Cortical 80% of skeletal mass Solid outside shaft of long bones Cells http://www.asbmr.org/default.aspx Rianon- HGEC-Osteoporosis, 2015 Osteoblasts Critical to bone formation Osteoclasts Reabsorb bone Osteocytes Exact role is still under investigation- involved in bone turnover
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Physiology- Normal State Normal Bone Remodeling Sequence Resorption = Formation No change in bone mass LEGEND: LC = Lining Cells CL = Cement Line OS = Osteoid BRU = Bone Remodeling Unit OsteoclastPrecursor Osteoclast OsteoblastPrecursors Osteoblast Rianon- HGEC-Osteoporosis, 2015
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Menopause Pathogenesis of age-related bone loss: Unbalanced Remodeling Aging Inadequate calcium or vitamin D Resorption > Formation Net bone loss Medications or diseases Osteoporosis Normal Bone Structure Osteoporotic Bone Structure Rianon- HGEC-Osteoporosis, 2015
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Clinical diagnosis of osteoporosis 16 DXA scan - Left hip Osteoporosis = A T- score of <-2.5 for BMD Osteopenia = A T-score of -1 to -2.5 for BMD Usual sites for DXA are lumbar spine and left hip DXA scan - Lumbar spine Rianon- HGEC-Osteoporosis, 2015
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17 Who should we screen: USPSTF
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18 Screening: other organizations Ann Intern Med. 2011;154:356-364
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WHO Fracture Assessment Toolwww.shef.ac.uk/FRAX
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FRAX risk factors 20 Age (40-90), gender, height & weight, race/ethnicity Previous fracture Hip fracture in parents Current smoking Alcohol Glucocorticoids (oral)≥ 3 months @ dose 5mg daily or more – or equivalent doses of other glucocorticoids Rheumatoid arthritis 2ndary Osteoporosis DM-I, OI in adults, Untreated Hyper or Hypothyroidism, Premature Menopause (<45 yrs), Chronic malnutrition or malabsorption & Chronic liver disease Bone mineral density (BMD) Rianon- HGEC-Osteoporosis, 2015
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When to treat? (Men & Women) Hx of hip fracture Other prior fractures & T-score between -1.0 to -2.5 @ fem. neck, total hip or spine Height loss (vert. frac.)* T-score ≤-2.5 @ fem. neck, total hip or spine 21 T-score between -1.0 to -2.5 @ fem. neck, total hip or spine AND 2ndary cause ↑ risk of fracture Steroid use, total immobilization, men w/androgen deprivation therapy T-score between -1.0 to -2.5 @ fem. neck, total hip or spine AND 10-yr probability of hip fracture ≥ 3% or any major osteoporosis-related fracture ≥ 20% (FRAX) www.nof.org/professionals/clinical-guidelines * Hannan et al., 2012 JBMR Rianon- HGEC-Osteoporosis, 2015
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Treatment Options Bisphosphonates Oral Alendronate 10 mg daily or 70 mg wkly Risedronate 5 mg daily or 35 mg weekly or 150 mg/mo Ibandronate 150 mg/mo Intra-venous Zoledronic acid 5 mg/yr 22 Teriparatide 20 mcg sq daily Recombinant human PTH (not >2 yrs) Contra-indicated in cancer patients) Denosumab 60 mcg sc/q 6 Humanized monoclonal antibody www.nof.org/professionals/clinical-guidelines Calcium (1200-1500 mg) + Vitamin D (800-1000 IU daily) Rianon- HGEC-Osteoporosis, 2015
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Hormones as Treatment Options SERM Raloxifene – not commonly used because it increases risk of DVT & increased hot flashes Estrogen/Progestin Not encouraged due to increased risk of breast cancer, stroke, DVT and coronary diseases 23 Testosterone If hypogonadism is the cause of osteoporosis Caution if history of prostate cancer www.nof.org/professionals/clinical-guidelines Rianon- HGEC-Osteoporosis, 2015
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Calcium and Vitamin D Calcium 1000-1500 mg daily Consider intake with diet Formulation: Carbonate (with meal) Citrate (fasting state) 24 www.nof.org/professionals/clinical-guidelines; IOM & Endocrine society guidelines Vitamin D Screen at-risk patients Check 25 hydroxy vitamin D total Recommended level 30 ng/dl Ergo/Chole-calciferol 800-1000 IU daily Unless <30 – then 50000 IU q weekly for 8-12 wks Rianon- HGEC-Osteoporosis, 2015
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Fracture outcome & side effects of tx 25 Silverman & Christiansen, 2012, Osteop Intl Rianon- HGEC-Osteoporosis, 2015
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Adverse events/Tx Failure?:What to offer next For Bisphosphonates: Atypical fracture Jaw necrosis Severe GERD/gastritis or GI bleed Unimproved BMD despite treatment Fracture while being on tx Intervention Drug holiday Monitor with DXA/1-2 yrs Monitor bone markers/yr 26 Alternate options Switch to other agents Teriparatide: up to 2 years *Rianon N et al., 2011 Rianon- HGEC-Osteoporosis, 2015
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Monitoring Treatment Success DXA Acquired BMD Bone Markers Stable or improved BMD Loss of BMD <%CV showing no significant change over mechanical drift from QA report for DXA machine 27 Suppression of Bone markers Both formation and resorption markers not a standard practice yet Carey J, 2005; Delmas P et al., 2009; ASBMR Rianon- HGEC-Osteoporosis, 2015
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Improving Osteoporosis care: Case identification & follow up Fracture Liaison Services (FLS) Goal: Bringing patients back for DXA Improve rates of f/u Results: Improved follow up and prevention Increased continuity and quality of care 28 Rianon- HGEC-Osteoporosis, 2015
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Results from FLS projects ↑case identification,diagnosis,treatmentBogoch et al.,2006, JBJS-Am Increased BMD test (3-45%)Inderjeeth et al., 2010 MJA Liaison between orthopedics & discharge destination health care team (including PCP) ↑ provider awareness & treatmentSwitzer et al.,2009 JortTrau ↑ treatment with documentation & f/uWard et al., 2007 Osteop Int Fracture prevention algorithm Kaiser Permanente, 2009 No information on BTM Inter-professional team worked together 29 Rianon- HGEC-Osteoporosis, 2015
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Bone Markers Formation Resorption Serum bone specific alkaline phosphatase (BAP) (5.6-29 mcg/L) Serum pro-collagen type 1 amino-terminal propeptide (P1NP) (20-108 mcg/ml) Osteocalcin (8-32 ng/ml) 30 Serum C-terminal cross-linking telopeptide of type I collages (CTX) Urine N-terminal cross-linking telopeptide of type I collagen (NTX) 2nd void sample in the AM (4-64 nmol BCE/mmol creatinine) ASBMR: http://www.asbmr.org Rianon- HGEC-Osteoporosis, 2015
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31 85 year old CF, BMI 21, lost about 4” since age 30s, no hx of cancer/previous fx/other 2ndary risk of osteop, no FHx of osteop or hip fx in parents, former smoker, social drinker, exercises regularly, hx of tx for osteoporosis w/ bisphosphonates for 14 yrs w/o much improvement in BMD. DXA acquired femur neck T scores since 1997 were: U-NTX 18, P1NP 11, Vit D, Calc, PTH, Mg & Phos WNR. What would you do at this point? Case Rianon- HGEC-Osteoporosis, 2015
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32 Patient had osteopenia: In a patient with osteopenia – treatment is indicated if FRAX score indicates treatment or she has a history of fragility fracture FRAX not valid for her due to history of treatment with bisphosphonate Also has a long history (>5 years of bisphosphonate use) Bone markers are suppressed Stop bisphosphonate – start drug holiday, monitor in a year Continue calcium and vitamin D supplementation and weight bearing exercise Case (continued) Rianon- HGEC-Osteoporosis, 2015
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Prevention: Aim at early age 33 http://www.surgeongeneral.gov/library/bonehealth/chapter_6.html#NutritionsImpactonBoneHealthAReviewoftheEvidence
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Prevention Weight bearing exercise Stimulates bone formation 2.5 to 4 hours/wk of moderate to severe intensity physical activity Calcium and Vitamin D Regular supplemental required dose 34 Non-skeletal Environmental/Behavioral Fall prevention Improve balance & gait- PT/OT Smoking cessation Avoid risk level alcohol use Avoid flexion in patients with risk of or hx of vertebral fracture FLS (Fracture Liaison Services) Network within the clinic, or group of providers (2ndary prevention) Chodzko-Zajko WJ et al., 2008 & ASBMR Rianon- HGEC-Osteoporosis, 2015
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Take Home Message Osteoporosis is a progressive & chronic metabolic bone disease that decreases bone density with deterioration of bone structure. Clinical Diagnosis = T- score of <-2.5 for BMD Prevention & treatment with a comprehensive and individualized approach. 35 Rianon- HGEC-Osteoporosis, 2015
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References 36 Rianon- HGEC-Osteoporosis, 2015
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Thank You! 37 Questions? ?