METABOLIC BONE DISORDERS
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OSTEOPOROSIS
● Is the most prevalent bone disease in the world.
● More than 1.5 million osteoporotic fractures occur every year
● More than 10 million Americans have osteoporosis, and an additional 33.6 million
have osteopenia (low bone mineral density (BMD)) the precursor to osteoporosis.
● The consequences of osteoporosis is bone fracture.
● It is projected that one of every three women and one of every five men over the age of
50 will have an osteoporosis-related fracture at some point in their lives.
PREVENTION
● Peak adult bone mass is achieved between ages of 18 and 25 years in both women
and men is affected by genetic factors, nutrition, physical activity, medications, endocrine
status, and general health.
● Men typically develop larger, heavier bones than women; therefore, they manifest
osteoporosis at more advanced ages.
● Primary osteoporosis occurs in women after menopause (51) but it is not merely a
consequence of aging
● Secondary osteoporosis is the result of medications or diseases that affect bone
metabolism.
● Men are more likely than women to have secondary causes of osteoporosis
GERONTOLOGIC CONSIDERATIONS
● The prevalence of osteoporosis in women older than 80 years is 50%.
● The average 75 year old woman has lost 25% of her cortical bone and 40% of her
trabecular bone.
PATHOPHYSIOLOGY
● Osteoporosis is characterized by reduced bone mass, deterioration of bone matrix, and
diminished bone architectural strength.
● Normal homeostatic bone turnover is altered
● The bones become progressively porous, brittle and fragile
● This occurs most commonly as
-compression fractures of the thoracic and lumbar spine
-hip fractures, and
-Colles fracture of the wrist
● These fractures may be the first clinical manifestation of osteoporosis.
● Calcitonin which inhibits bone resorption and promotes bone formation, is
decreased
● Estrogen, which inhibits bone breakdown, also decreases with aging.
● Parathyroid hormone (PTH) increases with aging, thus increasing bone turn-over and
resorption.
● The withdrawal of estrogen at menopause or with oophorectomy causes an accelerated
bone resorption within the first 5 years after cessation of menses.
● Most women lose 10% of their bone mass.
● More than half of all women older than 50 years show evidence of osteopenia.
RISK FACTORS
● Small-framed women are at greatest risk for osteoporosis.
● In terms of ethnicity, Asian and Caucasian women are at highest risk.
● Men have a greater peak bone mass and do not experience a sudden midlife estrogen
reduction.
● Bone formation is enhanced by the stress of weight and muscle activity
-Alcohol intake of 3 or more drinks daily
-Corticosteroids prescription (prednisone) for longer than 3 months
-Current use of tobacco products
-Family history
-Hx of bone fracture during adulthood
-Hx of impaired glucose tolerance and diabetes
-Hx of rheumatoid disease
-Inadequate calcium and vitamin D intake
-Low BMI
-Malabsorption disorder (eating disorder, celiac disease, bariatric surgery)
-Men older than 60 years of age
-Women who are postmenopausal
Diet
● Adequate calories and nutrients needed to maintain bone
● Calcium and vitamin D must be consumed
ASSESSMENT AND DIAGNOSTIC FINDINGS
● Osteoporosis is diagnosed by dual-energy x-ray absorptiometry (DEXA), which
provides information about BMD at the spine and hip
● Baseline DEXA texting is recommended for all women older than 65 y/o, for women who
are postmenopausal older than 50 y/o with osteoporosis risk factors
● BMD studies are also useful in assessing response therapy and are recommended 3
months post any osteoporotic fracture.
● Female fracture risk can be estimated using the World Health Organization (WHO)
Fracture Risk Assessment Tool (FRAX)
● These FRAX tables typically underestimate the bone loss risk in men.
● The Male Osteoporosis Risk Estimation Score (MORES) generates a more gender
specific evaluation than the standard FRAX score in men.
MEDICAL MANAGEMENT
● A diet rich in calcium and vitamin D throughout life, with an increased calcium intake
during adolescence and the middle years, protects against skeletal demineralization.
● Such a diet includes;
-3 glasses of skimmed vitamin D- enriched milk or other foods high in calcium
(cheese, steamed broccoli, canned salmon with bones) daily
-A cup of milk or calcium fortified orange juice contains 300 mg of calcium.
-The recommended adequate intake level of calcium for men 50-70 years is 1000
mg daily and for women aged 51 and older
-And men aged 71 and older is 1200 mg daily
-The recommended Vitamin D intake of most adults, is between 400 and 1000 IU
daily
● Regular weight-bearing exercise promotes bone formation.
● Recommendations include 20-30 min of aerobic, bone stressing exercise daily (not
swimming)
● Weight training stimulates an increase in BMD
PHARMACOLOGIC THERAPY
● To ensure adequate calcium intake, a calcium supplement with vitamin D may be
prescribed and taken with meals or with a beverage high in Vitamin C to promote
absorption
● The recommended daily dose should be split and not taken as a single dose
● Common side effects of calcium supplements are abdominal distention and
constipation
FRACTURE MANAGEMENT
● Fracture of the hip that occur as a consequence of osteoporosis are managed surgically
by joint replacement or by closed or open reduction with internal fixation
Relieving Pain
● Supine or side lying position
OSTEOMALACIA
● Is a metabolic bone disease characterized by inadequate mineralization of bone.
● As a result, the skeleton softens and weakens, causing pain, tenderness to touch,
bowing of the bones, and pathologic fractures
PATHOPHYSIOLOGY
● The major defect in osteomalacia is a deficiency of activated vitamin D, which
promotes calcium absorption from the Gi tract and facilitates mineralization of bone
● Osteomalacia may result from failed calcium absorption or from excessive loss of
calcium from the body
● Hyperparathyroidism leads to skeletal decalcification and rhus to osteomalacia by
increasing phosphate excretion in the urine
GERONTOLOGIC CONSIDERATIONS
● A nutritious diet is particularly important in older adults
● Adequate intake of calcium and vitamin D is promoted
● Because sunlight is necessary for synthesizing vitamin D, pt should be encouraged to
spend 15-30 minutes each day in the sun
ASSESSMENT AND DIAGNOSTIC FINDINGS
● On x-ray studies, generalized demineralization of bone is evident.
● Bone biopsy demonstrates an increased amount of osteoid, a demineralized,
cartilaginous bone matrix that is sometimes referred to as prebone
MEDICAL MANAGEMENT
● Physical, psychological and pharmaceutical measures are used to reduce the patient’s
discomfort and pain
PAGET DISEASE OF THE BONE
● Paget disease (osteitis deformans) is a disorder of localized rapid bone turnover, most
commonly affecting the skull, femur, tibia, pelvic bones, and vertebrae
● The disease occurs in about 2% to 3% of the population older than 50 years
● The incidence slightly greater in aging men than in women
● The cause of Paget disease in not known
