Integrating Osteoporosis Prevention and Treatment into Clinical Practice

Integrating Osteoporosis Prevention and Treatment into Clinical Practice Barbara M. Thorpe, MSN, RNC, CNP ABSTRACT Bone health is an important factor in an individual’s overall health. The promotion of bone health must begin before birth and continue throughout life into old age. The high prevalence of osteoporosis and the significant burden associated with osteoporotic fractures highlights the importance of effective screening and detection. Educational and medical interventions to address unique bone health requirements at each stage of life must be recognized and optimized. The nurse practitioner (NP) is uniquely positioned to identify patients who are at increased risk for osteoporosis and related fractures. We should provide education about bone health and can give practical suggestions for preventing falls and fractures. We often identify patients for whom pharmacologic treatment options, including bisphosphonate therapy, might be beneficial. Although some of the most effective interventions for reducing risk of fractures are simple and inexpensive, it is important to offer patients the most effective interventions appropriate given their level of risk. Osteoporosis is a multifactorial condition, and by employing a combination of strategies, the risk for developing the disease and for experiencing related fractures can be decreased.

INTRODUCTION Promotion of optimal bone health and prevention of osteoporosis is a life-long process that begins during the prenatal period and extends throughout the entire life span. The importance of good bone health at every stage of life is highlighted by the significant burden imposed by osteoporosis. Osteoporotic fractures will affect approximately 1 of every 2 white women and 1 of every 5 men in the United States during their lifetime. The incidence is greater than the risk of heart attack, stroke, and breast cancer combined.1-4 The epidemiology and economic impact of osteoporosis are reviewed elsewhere in this supplement (see Osteoporosis: Background and Overview on page S4). Osteoporotic fractures greatly impact patients’ lives, reducing their quality of life and increasing morbidity (eg, pain, depression) and mortality. During the first year following a hip fracture, mortality increases by 10% to 20%. Additionally, 1 in 10 patients who experience a hip fracture will have another osteoporosis-related fracture S21

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within a year, and a quarter of patients will require longterm nursing home care.4 Osteoporotic fractures may also place a significant burden on caregivers and family members, who may need to take time off from work and their own activities to care for the affected individual.5 WHICH PATIENTS ARE AT RISK FOR OSTEOPOROSIS? A variety of factors, several of which are presented in Table 1, have been associated with increased risk of osteoporosis. These risk factors are key targets in efforts to promote bone health and prevent osteoporosis. Socioeconomic factors such as poverty also have an influence on bone health, as is evident in many clinical practices where pockets of poverty tend to have distinct ethnic, urban, and rural boundaries and tend to be associated with increased incidence of osteoporosis and related fractures. Because osteoporosis is a silent disease, it often goes undiagnosed and untreated, especially in patients with secondary risk factors (eg, medication use, disorders associated with bone loss, inadequate protein intake). Osteoporosis screening June 2009

Table 1. Other Key Risk Factors for Osteoporosis FOR MORE INFORMATION… Your patients can get information on bone health from the following websites: The National Osteoporosis Foundation at http://www.nof.org

• Female gender • Thin and small frame • Family history of osteoporosis • Amenorrhea

“Powerful Bones, Powerful Girls.The National Bone Health Campaign” at http://www.cdc.gov/powerfulbones

• Eating disorders, such as anorexia nervosa and bulimia

“Bone Health and Osteoporosis: A Report of the Surgeon General” at http://www.surgeongeneral.gov/library/bonehealth

• High intake of carbonated beverages

“Bone Health” on the website of the National Institute of Arthritis and Musculoskeletal and Skin Diseases at http://www.niams.nih.gov/Health_Info/Bone/Bone_Health “Consumer Corner: Osteoporosis and Bone Health” on the website of the U.S. Department of Agriculture National Agricultural Library at http://fnic.nal.usda.gov/nal “Boning Up on Osteoporosis” from the AARP at http://www.aarp.org/health/staying_healthy/prevention/ a2004-12-21-osteoporosis.html “Bone Biology for Kids” at http://depts.washington.edu/bonebio “The Incredible Adventures of the Amazing Food Detective” at http://members.kaiserpermanente.org/redirects/ landingpages/afd/ “Eat Smart. Play Hard” at http://www.fns.usda.gov/ eatsmartplayhard/ “MyPyramid.gov: For Kids” from the U.S. Department of Agriculture at http://www.mypyramid.gov/kids/index.html “Smallsteps Kids” from the US Department of Health and Human Services at http://www.smallstep.gov/kids/flash/ index.html “Media-Smart Youth: Eat,Think, and Be Active!” from the National Institute of Health at http://www.nichd.nih.gov/msy “Kids Health” from the Nemours Foundation's Center for Children's Health Media at http://kidshealth.org/kid “Nutrition for Everyone: Bone Health” from the Centers for Disease Control and Prevention at http://www.cdc.gov/nccdphp/dnpa/nutrition/nutrition_for_ everyone/bonehealth “Dietary Supplement Fact Sheet: Calcium” from the Office of Dietary Supplements at http://ods.od.nih.gov/ factsheets/Calcium “Dietary Supplement Fact Sheet:Vitamin D” from the Office of Dietary Supplements at http://ods.od.nih.gov/ factsheets/VitaminD

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• Low calcium intake

• Excessive use of caffeine • Sedentary lifestyle • Use of anticonvulsant medications • Caucasian and Asian ethnicity Source: NIH Consensus Development Panel on Osteoporosis Prevention, Diagnosis, and Therapy. JAMA. 2001;285:785-795.

and prevention efforts are also hindered by time constraints imposed by managed health care mandates, as well as the high volume of competing health information offered to patients in the primary care setting. Despite these obstacles, to reduce the significant economic and social costs associated with osteoporosis, it is vital that bone health education and osteoporosis prevention and treatment be integrated into clinical practice. General prevention measures include patient education in good bone health, regular bone health assessments, and minimizing risk for falls in high-risk patients. A variety of medications are currently available to help prevent and treat osteoporosis. Even after an initial fracture has occurred, medical treatments can decrease the likelihood of a subsequent fracture. The most effective patient education and treatment will not prevent initial and recurrent osteoporotic fractures unless patients are compliant with the recommended interventions. Programs for promoting bone health must also stress to patients the importance of adherence to prevention measures and to the prescribed treatments. The nurse practitioner (NP) model of care promotes patient education and complements the efforts of the physician community. This article will guide the NP through the different stages of the patient’s life and will provide information on how to navigate the health care system to appropriately counsel, treat, or refer patients with osteoporosis or those at risk for the disease. Many effective interventions are available at no cost or low cost and can be structured effectively without additional time burdens. In the case of osteoporosis, what may seem to be The Journal for Nurse Practitioners - JNP

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a simple intervention has the real potential to prevent a fracture and with it, associated financial, physical, and emotional costs. BONE HEALTH BEGINS BEFORE BIRTH Human skeletal formation begins during the development of the embryo. Inadequate maternal nutrition during pregnancy can have a negative impact on later bone growth and development.6 Studies have shown that levels of vitamin D and calcium intake by the pregnant mother predict childhood bone mineral density and content, both of which later determine the risk for fracture.6-8 Vitamin D is naturally present in very few foods and is added to others. It is also produced when ultraviolet (UV) rays from sunlight strike the skin and trigger vitamin D synthesis. The currently recommended daily intake for calcium and vitamin D is presented elsewhere in this supplement, in the article Preventing and Treating Osteoporosis: Pharmacologic and Nonpharmacologic Approaches, on page S13).9 Prenatal calcium and lactation requirements of 1200 mg per day are needed to make quality fetal bone. Unfortunately, this requirement is often not met due to personal food preference and/or poor food choices, lactose intolerance, and poverty. Although no specific requirements or recommendations have been made on vitamin D dosing during pregnancy, results from a recent longitudinal study conducted in 17,000 prenatal women in Korea suggest that maternal vitamin D levels should be maximized, especially during the third trimester, either by diet, supplementation, or by safe UV exposure. This study concluded that most fetal calcium accumulation occurs in the third trimester of pregnancy and that placental transport is influenced by maternal vitamin D. In light of this finding, to ensure optimal fetal bone development and future bone health, it is important to make sure that our pregnant patients are not deficient in vitamin D. In addition to the calcium requirements of the fetus, pregnancy and lactation may also place the mother at risk for bone loss. Although absorption of calcium in the intestine increases during pregnancy to satisfy the calcium needs of the fetus, there is potential for maternal bone loss during the final months of pregnancy.10 Milk and dairy products are the best sources of calcium but other sources such as fish with bones (sardines and salmon), or greens (collard, kale, mustard, and turnip) are also good. Table 2 provides a list of selected food sources of calcium, and Table 3 provides a simple method S23

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for determining calcium intake for patients. It is imperative that all prenatal patients understand the role of nutrition, calcium, and phosphorus to bone health for themselves and their fetus.9 While mothers may want to do what is best for their babies, they don’t always have all the information they need to make the right choices and decisions. As NPs, we are uniquely positioned to educate expectant mothers on the importance of maternal nutrition during pregnancy on the short- and long-term bone health of their children. BONE DEVELOPMENT IN NEWBORNS Evidence that birth weight is related to bone mass later in life suggests that the intrauterine environment programs the trajectory of subsequent bone development. While further research is needed to clarify the relationship between birth weight and later bone health, what is relevant for the NP in clinical practice is the need for early bone health assessment in newborns during routine office visits. It is important to evaluate bone development, assess whether a child is receiving adequate caloric intake to avoid undernutrition, and to document that the primary food source for the newborn is milk or formula and that these essentials are not being substituted with non-nutritious fillers. The recommended calcium requirements for infants from birth through 6 months is 210 mg/day and from 7 months through 1 year is 270 mg/day.9 As discussed above, prenatal vitamin D exposure appears to contribute to later bone health.6-8 There is also evidence that vitamin D supplementation during the first year of life is associated with higher bone mineral density measured in pre-pubertal children. FACTORS AFFECTING BONE HEALTH IN EARLY CHILDHOOD The role of undernutrition in disease is well documented, and nutritional interventions are commonly used to prevent and treat many disease processes (eg, vitamin D deficiency, which can lead to rickets). The NP caring for young children should routinely assess nutritional status, including calcium and vitamin D intake, and correlate patterns of growth with age-appropriate norms. Because the NP in a pediatric or family practice often has close and frequent contact with a patient throughout early childhood, s/he can easily detect changes or shifts in patterns of growth and make early recommendations or referrals. In cases where undernutrition is suspected, s/he can intervene with patient education targeted to the parent or caregiver, stressing the importance of proper nutriJune 2009

Table 2. Selected Food Sources of Calcium Food

Calcium (mg)

% DV*

Sardines canned in oil, with bones, 3 oz

324

32

Cheddar cheese, 1 1/2 oz shredded

306

31

Milk, nonfat, 8 fl oz

302

30

Yogurt, plain, low fat, 8 oz

300

30

Milk, reduced fat (2% milk fat), no solids, 8 fl oz

297

30

Milk, whole (3.25% milk fat), 8 fl oz

291

29

Milk, buttermilk, 8 fl oz

285

29

285-302

29-30

Cottage cheese, 1% milk fat, 2 cups unpacked

276

28

Mozzarella, part skim, 1 1/2 oz

275

28

Tofu, firm, w/calcium, 1/2 cup†

204

20

Milk, lactose reduced, 8 fl oz

Orange juice, calcium fortified, 6 fl oz

200-260

20-26

Salmon, pink, canned, solids with bones, 3 oz

181

18

Pudding, chocolate, instant, made with 2% milk, 1/2 cup

153

15

Tofu, soft w/calcium, 1/2 cup†

138

14

Breakfast drink, orange flavor, powder prepared with water, 8 fl oz

133

13

Frozen yogurt, vanilla, soft serve, 1/2 cup

103

10

100-1000

10-100

Turnip greens, boiled, 1/2 cup

99

10

Kale, raw, 1 cup

90

9

Kale, cooked, 1 cup

94

9

Ice cream, vanilla, 1/2 cup

85

8.5

Ready-to-eat cereal, calcium fortified, 1 cup

Soy beverage, calcium fortified, 8 fl oz

80-500

8-50

Chinese cabbage, raw, 1 cup

74

7

Tortilla, corn, ready to bake/fry, 1 medium

42

4

Tortilla, flour, ready to bake/fry, one 6” diameter

37

4

Sour cream, reduced fat, cultured, 2 Tbsp

32

3

Bread, white, 1 oz

31

3

Broccoli, raw, 1/2 cup

21

2

Bread, whole wheat, 1 slice

20

2

Cheese, cream, regular, 1 Tbsp

12

1

*DV = daily value. †Calcium values are only for tofu processed with a calcium salt. Tofu processed with a non-calcium salt will not contain significant amounts of calcium. Source: U.S. Department of Health and Human Services. Bone Health and Osteoporosis: A Report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, Office of the Surgeon General; 2004.

tion to bone health. This kind of simple educational intervention can lead to important behavioral changes. Recommended adequate calcium intake for children 1 to 3 years of age is 500 mg/day, for children 4 to 8 years of age, 800 mg/day, and for children 9 to 13 years of age, 1300 mg/day.9 In climate zones where there is little seawww.npjournal.org

sonal sunlight and where children are indoors, daily supplemental vitamin D should be considered. When assessing the nutritional status of a child, it is important to consider the food they receive in the school setting. Parents who rely on school cafeteria services for dispensing meals throughout the week may not be aware The Journal for Nurse Practitioners - JNP

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Table 3. Estimating Daily Dietary Calcium Intake Product

Servings/Day

Calcium/ Serving, mg

Calcium, mg

Step 1: Estimate calcium intake from calcium-rich foods* Milk (8 oz)

x

300

=

Yogurt (6 oz)

x

300

=

Cheese (1 oz, or 1 cubic inch)

x

200

=

Fortified foods or juices

x

80-1000**

=

Step 2: Total from above + 250 mg for nondairy sources = total dietary calcium *About 75% to 80% of the calcium consumed in American diets is from dairy products. **Calcium content of fortified foods varies. Reprinted, with permission, from the National Osteoporosis Foundation, Clinician’s guide to prevention and treatment of osteoporosis. Washington, DC: National Osteoporosis Foundation; 2008.

of the kinds of foods their children are receiving and the nutritional value of those foods. This is especially true in the case of children who depend on school food services for 2 regular meals. With cutbacks in funding for school breakfast and lunch programs, school cafeterias are less likely to provide milk, an important source of calcium, so it is important to work with parents and caregivers to ensure that children receive enough calcium and other nutrients. On a positive note, the recent movement to replace soft drink machines in some schools with juice machines is an important improvement from a nutritional perspective. Children who have severe asthma may require long-term treatment with glucocorticoids for control of symptoms. NPs who care for asthmatic children should coordinate their care with subspecialists. Because glucocorticoid medications are associated with bone loss, it is especially important to ensure that children with asthma who depend on these medications for asthma control receive adequate calcium and vitamin D.9 Diagnosis of pediatric osteoporosis should not be made based on bone density alone. If a young patient has an inherited disorder that negatively influences bone maturation and health, that patient is best referred to the subspecialist for careful diagnosis and treatment. NUTRITIONAL AND EXERCISE-RELATED FACTORS IN SCHOOL-AGED CHILDREN In many schools, mandatory recess has gone the way of the mid-morning snack of milk and graham crackers. With the advent of the computer-driven classroom, there has been a shift away from recognition of the importance of physical education in the growth of the child. Given the fact that the school-age years are a critical period for S25

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bone mineralization and formation, both of which depend on regular exercise, the trend away from physical activity during the school day is not a positive development. It is well established that exercise and proper nutrition are responsible for up to 50% of bone mass and structure. One study demonstrated that high-intensity jumping improved bone mass in the hip and lumbar spine of pre-pubertal children.11 Today’s students, especially those in the early grades, may not be getting the necessary weight-bearing exercise, sunlight, and vitamin D required for bone health. NPs can often identify children who may not be getting adequate physical exercise. Early interventions to promote regular exercise among schoolage children can create life-long patterns of physical activity with many long-term benefits, including bone health. Exercise can also stimulate group socialization and promote a sense of confidence and general well-being. BONE HEALTH IS STILL IMPORTANT DURING ADOLESCENCE Adolescence is a challenging developmental stage in many respects, and bone health may take a back seat to reproductive and other more pressing issues. It is clear, though, that diet, physical activity or inactivity, and social patterns during adolescence clearly correlate with measures of future bone health.12 It is well documented that bone mass is laid down during the first 3 decades of life and that the bone-building years before age 18 are especially important in this process.13-15 Figure 1 compares the bone mass lifeline for individuals who reach their peak skeletal mass potential and those who do not and identifies factors that contribute to skeletal growth.16 The majority of skeletal mass is achieved well before an individual reaches the age of 20 years.16 The NP should assess the adolescent patient’s knowledge of bone health and June 2009

Figure 1. Bone mass lifeline. This graph presents a

Figure 2. Percent of U.S. adults aged 18 years and over

comparison of individuals who achieve their full

who engaged in regular leisure time physical

genetic potential for skeletal mass (upper line)

activity, by age group and sex, January-

and those who do not (lower line). It also lists the

September 2003. Reprinted from U.S. Department

factors that affect skeletal mass at different points

of Health and Human Services. Bone health and

throughout the course of life. Reprinted with

osteoporosis: a report of the surgeon general.

permission from Heaney RP, Abrams S, Dawson-

Rockville, MD: U.S. Department of Health and

Hughes B, et al. Peak bone mass. Osteoporos Int.

Human Services, Office of the Surgeon General;

2000;11(12):985-1009.

2004.

determine whether the patient is getting the adequate nutrients and exercise for bone health. Figure 2 shows results from a study of leisure-time physical activity in adults aged 18 years and older.9 The graph shows a steady decline in the percentage of physically active adults from 18 years of age through 75 years of age and older.9 Considering the importance of regular physical activity to bone health, establishing a pattern of physical activity in childhood and adolescence can pay dividends in good bone health later in life. In addition to assessing levels of physical activity and nutrition, the patient’s contraceptive history should be noted, where applicable. Adequate calcium intake for adolescent children ages 14 to 18 years should be 1300 mg/day. Studies have consistently demonstrated that the majority of adolescents in the United States receive less than the recommended daily allowance (RDA) (1300 mg) of dietary calcium.17-19 Among those 9 to 17 years of age, only an estimated 25% of boys and 10% of girls met their recommended daily intake.20 Analysis of data from the National Health and Nutrition Examination Survey 1999-2002 has also demonstrated that U.S. children 9 to 18 years of age consumed significantly less calcium than the RDA and less www.npjournal.org

than all other age groups.18 There is evidence that a lack of effective health education may play a role in the failure of adolescents to meet RDA of calcium. In a survey conducted by the National Osteoporosis Foundation (NOF), only 38% of the participants stated that they had received information about calcium and bone health. In addition to inadequate calcium intake, other factors such as carbonated beverage consumption have been associated with compromised bone health and increased risk of fracture in adolescents. Adolescents who consume cola beverages—drinks that are processed with phosphoric acid, which has a negative effect on calcium metabolism and bone mass—appear to be exposed to the greatest risk of fracture.19 A cross-sectional retrospective study of 9th- and 10th-grade female adolescents found that consumption of carbonated beverages was associated with a 3-fold greater risk of fracture among physically active and less active subjects.21 These findings emphasize the importance of educating adolescents in bone health as a means of raising awareness concerning negative risk factors and changing key behaviors during this important stage in skeletal development.You may find that some adolescents simply do not like milk. Others are lactose intolerant and still others are vegan and do not consume dairy products. For The Journal for Nurse Practitioners - JNP

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these patients, it is particularly important to provide alternative options for obtaining RDA of calcium. Even in the presence of adequate calcium, several lifestyle factors can offset adequate calcium absorption and should be addressed. Cigarette smoking and consumption of alcohol or carbonated beverages can decrease available calcium and deplete calcium absorption and should be discouraged. Regular measurement of height and weight correlated to norms for age can provide clues to undernutrition in teenage patients. Therefore, height and weight should be measured at each clinical visit. While the importance of such regular measurements in growing children may seem obvious, some data suggest that as many as 60% of primary care practices do not routinely measure height. Use of the contraceptive Depo-Provera for adolescent girls has been widely studied and concerns have been raised related to the risk of ongoing amenorrhea which may contribute to later osteopenia and osteoporosis.16 Prescribing information for the drug contains a “blackbox warning” regarding the use of the agent in adolescents and young adults because of uncertainty regarding whether such use might lead to reduced peak bone mass and an increased risk for osteoporotic fracture later in life.22 Studies show that once Depo-Provera is discontinued, low bone mass trends are quickly reversed with what appears to be minimal long-term negative consequences.23,24 Nurse practitioners, and all health providers, should use their clinical judgment and assess the individual risks vs benefits of Depo-Provera use. One must be reminded that as the circumstances of life change, so may contraceptive choices change. Even the risk of multi-year use with compliance may be more beneficial than the consequences of an unplanned or unwanted pregnancy. Patients taking Depo-Provera should be individually assessed and counseled about its risks and benefits, the importance of adequate calcium and vitamin D intake and weight-bearing exercise, and the need to avoid other bone health risk factors (eg, smoking, alcohol consumption). The addition of estrogen to Depo-Provera is controversial and may be unnecessary. Parents, teachers, coaches, and health care providers all need to be attentive to the bone health needs of adolescents. Different stressors may trigger an eating disorder in the adolescent, with negative consequences on general nutrition and bone health. Red flags that signal a potential eating disorder include domestic stress, intersocial problems, or pressures to excel athletically or academiS27

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cally. As health providers, we may be the first to hear about exercise-induced amenorrhea or anorexia in an adolescent female patient. Some issues can be addressed simply with education and understanding, others take more time and effort. Adolescents with repeated stress fractures require greater attention and may need behavioral and/or dietary interventions. Provide such patients with educational handouts and other information resources (eg, websites, books) to support your advice concerning bone health. BONE HEALTH IN ADULTS Low bone density and/or fragility fractures in women are an indication for further evaluation to determine whether the patient has osteoporosis. Low bone mass may be related either to inadequate peak bone mass acquisition and/or ongoing bone loss. Bone loss and/or fractures can often be attributed to estrogen deficiency, glucocorticoid exposure, or hyperparathyroidism. While most discussion and research concerning osteoporosis focuses on post menopausal female patients, osteoporosis is as serious a problem in men as it is in women.25 Although the time course and some of the causes of bone loss in men may differ from those in women, clinical evaluation is similar. Many men with osteoporosis have a contributing disease or condition that causes low bone mass. Men lose bone because of poor calcium intake, lack of exercise, falling testosterone levels, and age-related bone metabolism.9,25 Treatment for osteoporosis in both adult females and males includes weight-bearing exercise, calcium and vitamin D supplementation, hormone replacement therapy, and approved medications. Aggressive treatment should be considered if rapid bone loss is evident. All adults should get at least 30 minutes or more of moderate weight-bearing physical activity on most, if not all, days of the week. In addition to this basic requirement, strength and balance training should also be added as a part of a regular exercise program. Ordinary activities such as walking, yard care, or gardening contribute importantly to our daily requirements for physical activity. Geriatric Patients Geriatric patients are clearly the group at greatest risk of osteoporosis and related fractures and require the closest attention. In addition to the fact that bone mass and quality declines with advancing age, the geriatric patient faces increased risk of bone loss and fracture due to comJune 2009

Figure 3. Use of hip protectors to prevent fractures. With

pounding medical conditions and other factors, including forgetfulness, loss of visual acuity, and declining physical strength and balance.

this type of protector, 2 padded shields are worn in pockets of the undergarment. The rationale behind the design is that during a fall, the padded insert will absorb the shock of the impact, and the

Persons with Disabilities The prevalence of osteoporosis in persons with disabilities is not well documented. Results from a recent study of institutionalized developmental disabled adults found a very high prevalence of bone mineral density (BMD) measurements in the osteoporotic range.26 Persons with disabilities are recognized as having multiple risk factors for osteoporosis and related fractures, including malnutrition, immobility, susceptibility for falls, and use of medications associated with bone loss (eg, anticonvulsants, glucocorticoids).26 Such patients are at increased risk of falling because their muscle tone can be presumed to be weaker than normal and they may have poor balance and slower reaction times. Patients with disabilities should be evaluated carefully for any risk factors not related to their disability. Fall Prevention Falling is a common and serious problem in the elderly. Elderly patients cling to their independence and are often too proud to use a cane or just do not want to “look old.” Falls often occur when the elderly patient becomes distracted while going about ordinary tasks such as collecting the mail or taking out the trash. Common causes of falls include failure to use canes or walkers when traveling short distances in the home or elsewhere, obstructions in pathways, and slippery stairs or floors. When assessing elderly patients in the office, inquire whether they have recently fallen and whether they have taken steps to prevent falls in the future. Consider undergarment hip protectors for patients who are at significant risk for falling, particularly those who have had a previous fracture (Figure 3).27 Although hip protectors tend to be warm in the summer, they are very effective in preventing fractures resulting from falls. They come in several sizes and are available at a reasonable cost. At-risk patients should purchase hip protectors and use them whenever they engage in behaviors where the risk of falling is increased. For instance, a thin postmenopausal osteoporotic woman who engages in hiking in mountainous terrain should probably make use of a hip protector. If your elderly patient is still driving a car, www.npjournal.org

firm external shield will diffuse the energy away from the greater trochanter.27 Reprinted with permission from HRA Pharma, Paris, France,

http://www.kph-hip-protector.com.

inquire whether they have easy and safe access to their car and whether they have a handicapped-parking pass. Improving access to a car by use of handicapped parking spaces or by keeping the car in a place that is adequately lighted and where access is safe and clear can help prevent falls and fractures. There are many prevention measures that can be taken to decrease the risk of falling in the home. Figure 4 shows key fall risks in the home for the elderly patient. Home safety measures can be carried out by patients or their family or caregivers and will pay substantial dividends in preventing fractures resulting from falls. Have patients or their caregivers remove raised doorsills and consider replacement of stairs with easy access ramps. Stairs should be equipped with handrails on both sides of the stairwell and loose steps should be repaired. Scatter rugs and runners should be removed or secured with tape. Make sure adequate lighting is installed in dark rooms or spaces. Nightlights should also be installed and functional. This is especially important for patients with impaired vision. Such patients should take steps to obtain vision correction where impairments are correctable. For patients who wear glasses, The Journal for Nurse Practitioners - JNP

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Figure 4. Fall risks to elderly in the home. Reprinted from U.S. Department of Health and Human Services. Bone health and

osteoporosis: a report of the surgeon general. Rockville, MD: U.S. Department of Health and Human Services, Office of the Surgeon General; 2004.

stress the importance of making sure glasses are clean and easy to locate. If your patient is prone to losing their glasses, suggest that they keep them on a tie around their neck. Suggest that the patient organize their home in such a manner that frequently used items are easily within reach. General home organization steps should be taken, such as removing clutter and extra furniture. Keep in mind that many of our elderly patients may have grown up during the depression and may have difficulty discarding items around the home, such as newspapers, magazines, and mementos. Such items may create a hazard, especially if they block frequently navigated pathways. Work with patients and their caregivers to ensure that clutter is minimized and that access to all essential rooms is clear. Make sure that your patient’s bed height is adjusted optimally and suggest installing grab bars and non-skid decals in the tub and shower. S29

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Also make sure that the commode is at a safe level. If your elderly patient is living independently, make sure that they have an alarm system that alerts 911 or caregivers or family in the event of a fall. During office visits, take note of patients who are receiving multiple medications, those who are frail, or those who have experienced recent falls without injury. These are patients who may be at very high risk of falls and fractures and may benefit from immediate fall prevention measures. Evaluate any neurological deficits that might contribute to an unexpected fall. Low physical activity may be a sign of poor muscle tone. IDENTIFICATION OF PATIENTS AT HIGH RISK FOR OSTEOPOROSIS Because osteoporosis is a silent disease and fractures may occur without warning signs, assessing risk is an imporJune 2009

tant first step in identifying patients who might benefit from various preventative interventions and treatments. The first article in this supplement, Osteoporosis: Background and Overview, discusses risk factor assessment in greater detail, starting on page S4. You should take special note of these major risk factors in evaluating your patients for risk of osteoporosis. The greater number of major risk factors a patient has, the greater the risk they face for osteoporosis and related falls. All postmenopausal women and older men should be evaluated to determine whether there is a need for BMD testing. The U.S. Preventive Service Task Force and the NOF recommend BMD testing for all women age 65 years and older. In addition, the NOF recommends BMD testing for all men age 70 years and older.4 Other important factors that are useful in identifying patients at increased risk for osteoporosis are discussed in detail in Osteoporosis: Background and Overview, the first article in the supplement (see page S4). Unique Risk Factors In addition to the risk factors presented above, other unique factors have received less systematic study in relation to bone health but may have value in identifying patients at risk for osteoporosis. Most notable among these are poverty and lactose intolerance. Because good nutrition is fundamental to bone health and disease prevention, in general, poverty should be viewed as conferring increased risk for osteoporosis. Research is emerging on the negative health consequences, particularly for children, of a lack of adequate food and nutrition in households that fall below the threshold for poverty. Much of this research relates to household hunger and/or obesity, poor school performance, destructive behaviors, depression, and other health issues.There is at present a small body of literature on undernutrition and poverty and its long-term effects on bone health. One study that evaluated the dietary intake of calcium and knowledge needs relating to calcium intake among 90 low-income African American women found that the mean dietary calcium intake for the entire sample was below the RDA, with 80% of the women reporting dietary calcium intake 75% below the RDA. Only 20% of respondents who thought they consumed enough calcium had intake of calcium above 800 mg/day.8 Another study evaluating diet quality and weight status in 248 low-income urban children found that more than 75% of participants failed to meet recommended servings for grains, vegwww.npjournal.org

etables, dairy, and fruit groups, and that mean intake of calcium was below the adequate intake for calcium. More than three-quarters of children 8 years old and younger and over 90% of children 9 years old and older did not meet the adequate intake for calcium.28 Hippocrates first described lactose intolerance in 400 BC, but clinical symptoms have become recognized only in the last 50 years.29 About 70% of the world population has some undiagnosed hypolactasia, but not all of these individuals have lactose intolerance. It is noted in clinical practice that some individuals with hypolactasia can consume some milk and dairy without debilitating symptoms, whereas others require extreme restriction. Patients may instinctively avoid milk and dairy products to avoid symptoms without making a direct correlation to causation. Ethnic origin affects the severity of lactose intolerance with the lowest rates among white Europeans and North Americans, while lactose intolerance is extremely high among Native Americans. Interestingly, persons from mixed ethnicity have lower rates of lactose intolerance.30 NPs should be aware of lactose intolerance among all patients and its effect on dietary intake of calcium. Suggestions should be made regarding alternative sources of calcium (eg, calcium supplements, non-mammalian milk) to ensure adequate calcium intake. CLINICAL EVALUATION FOR OSTEOPOROSIS Clinical evaluation should include a thorough medical history and physical examination including serial measurements of height, as well as targeted laboratory, radiographic, and diagnostic studies. Medical history should seek to identify risk factors for osteoporosis, with focus on major risk factors. The patient should be asked about bone pain, including the nature and location of such pain. Localized severe pain may be a sign of fracture, infection, Paget’s disease, or a bony metastasis. A careful review of constitutional systems should be made, noting weight loss and gain and systemic complaints. Osteoporosis may be secondary to a variety of conditions and differential diagnosis should be made to identify conditions associated with bone loss. Common secondary causes of osteoporosis include31: In women • Glucocorticoid use • Hypogonadism • Excess thyroid hormone • Anticonvulsants • Hypercalciuria The Journal for Nurse Practitioners - JNP

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• Hyperparathyroidism • Malabsorption In men • Glucocorticoid treatment • Hypogonadism • Alcoholism Physical examination should also seek to identify a secondary cause of osteoporosis. Relevant blood and urine studies should be obtained in patients in whom a secondary cause of osteoporosis is being considered (Table 4).31 For example, a serum 25(OH)-vitamin D level should be obtained when considering vitamin D insufficiency and osteomalacia. As a general rule, biochemical testing (eg, serum calcium, creatinine) should be performed for patients with documented osteoporosis before starting treatment.4 PHARMACOLOGIC THERAPY There are a variety of pharmacologic agents indicated for the prevention and/or treatment of postmenopausal osteoporosis. The benefits of these drugs in decreasing risk for fractures have been demonstrated in many large clinical trials. Data from several drugs demonstrate that they increase bone mass in men with osteoporosis, but there are limited data on reducing fracture risk in men, because osteoporosis fracture trials have primarily included only women. Data also exist on preventing and treating bone loss in patients on chronic glucocorticoid therapy, but with limited fracture data. Table 5 shows indications for pharmacologic treatment.You should counsel your patients who are candidates for drug treatment concerning measures for reducing risk and on the importance of adequate calcium and vitamin D intake and regular exercise as part of any treatment program for osteoporosis. Laboratory tests that are commonly used in the evaluation of patients at risk for osteoporosis are presented in Table 4. FDA-approved drugs for menopausal osteoporosis include bisphosphonates, calcitonin, estrogens, estrogen agonist/antagonist, and parathyroid hormone. See the second article in this supplement, Preventing and Treating Osteoporosis: Pharmacologic and Nonpharmacologic Approaches, for a detailed discussion of the pharmacologic treatments for osteoporosis, including dosing and efficacy information. Many factors influence choice of treatment. The most important include dosing and administration, efficacy, and tolerability. Compliance is another factor that S31

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Table 4. Routine Laboratory Evaluation for Osteoporosis • Chemistry profile (electrolytes, renal function, glucose, liver enzymes, alkaline phosphatase, phosphorus) • Complete blood count • Erythrocyte sedimentation rate (in patients with back pain or vertebral fractures) • Thyroid-stimulating hormone ± free T4 (in patients on thyroid hormone or with any symptoms of hyperthyroidism) • 24-hour urine for calcium and creatinine • Optional: 25(OH)-vitamin D and intact parathyroid hormone • Optional: biochemical markers of bone turnover Reprinted, with permission, from the National Osteoporosis Foundation, Clinician’s guide to prevention and treatment of osteoporosis. Washington, DC: National Osteoporosis Foundation; 2008.

affects choice of agent. Issues of treatment compliance among patients with osteoporosis should be a key concern for the NP because noncompliance is associated with serious health consequences. Estimates of rates of non-compliance with osteoporosis treatment are high. In a retrospective study of almost 40,000 postmenopausal women who were receiving osteoporosis treatment, 75% of patients were found to have low compliance. Poor compliance with prescribed treatments was associated with a 31% increase in risk of fracture and a 47% increase in risk of hospitalization.32 Bisphosphonate therapy has become an important treatment option for preventing osteoporotic fractures in postmenopausal female patients, although the complexity of administering many bisphosphonates represents a barrier to compliance.33 Data on compliance with bisphosphonate therapy suggest that weekly dosing regimens result in superior compliance compared with daily dosing regimens; however, compliance remains suboptimal with both weekly and daily dosing regimens.34 Currently, only one approved bisphosphonate therapy, zoledronic acid (Reclast), provides a dosing schedule (5-mg IV infusion over 15 minutes once yearly) that guarantees compliance over the one-year dosing interval, while providing robust rates of fracture risk reduction. Results from the HORIZON pivotal fracture study in over 7700 women with postmenopausal osteoporosis determined that an annual infusion of zoledronic acid resulted in reduction of risk of vertebral and hip fractures by 70% and 41%, respectively, over a 3-year period.35 June 2009

Table 5. Indications for Pharmacologic Treatment4 Postmenopausal women and men age 50 and older presenting with the following should be treated: • A hip or vertebral (clinical or morphometric) fracture • Other prior fractures and low bone mass (T-score between –1.0 and –2.5 at the femoral neck, total hip, or spine) • T-score less or equal to –2.5 at the femoral neck, total hip, or spine after appropriate evaluation to exclude secondary causes • Low bone mass (T-score between –1.0 and –2.5 at the femoral neck, total hip, or spine) and secondary causes associated with high risk of fracture (such as glucocorticoid use or total immobilization) • Low bone mass (T-score between –1.0 and –2.5 at the femoral neck, total hip, or spine) and 10-year probability of hip fracture ⱖ 3% or a 10-year probability of any major osteoporosis-related fracture ⱖ 20% based on the U.S.-adapted WHO algorithm Reprinted, with permission, from the National Osteoporosis Foundation, Clinician’s guide to prevention and treatment of osteoporosis. Washington, DC: National Osteoporosis Foundation; 2008.

NAVIGATING THE HEALTH CARE SYSTEM Osteoporosis is a disease associated with significant costs, both to the patient and society. Osteoporotic fractures disrupt the lives of those they affect, causing loss of independence and autonomy, as well as unexpected financial burdens. The myriad costs associated with this disease are not all covered by insurance carriers and there may be time limits to Medicare funding. Despite these issues, you can make a difference in outcomes for your patients by using the resources that you do have in your practice. Navigating the health care system can be tedious not only for the patient but for the practitioner, as well. Time constraints in many busy practices limit the amount of time that can be spent counseling patients adequately concerning bone health. We all know that other conditions such as heart disease and diabetes often monopolize clinic time and resources. Some practices and health plans provide the luxury of specific sessions to monitor bone status and outline bone health strategies. All practitioners should make sure that bone health is on the radar for each and every patient and identify individual risk factors throughout the lifespan for future disease and fracture. Practitioners should counsel patients of all ages to maintain a diet with adequate calwww.npjournal.org

cium and vitamin D intake, maintain regular weightbearing exercise, and to avoid cigarette smoking and excessive alcohol consumption. Most insurance plans now accommodate patients who are at risk for osteoporosis with baseline BMD testing. Some plans require prior authorization for such testing. If your office system is complex, a simple tickler file may be helpful to ensure referral and follow-up for patients who are at high risk of osteoporosis. Often communities have specialists with specific interest and expertise in bone health to whom referrals can be made. These experts are able to make time for detailed intervention and treatment. Know the resources in your own community. Not all practices offer non-oral therapies onsite. Become familiar with the local practices or outpatient infusion centers that do. Knowing which patients in your practice are at risk for osteoporosis and performing basic patient education in risk prevention, as well as becoming aware of local resources for referral can have an enormous impact in preventing negative outcomes. CONCLUSION The NOF estimates that over 10 million Americans have osteoporosis and an additional 34 million have low bone mass, placing them at risk for fractures and the hardship, morbidity, and increased mortality that accompany them. 4 The economic burden of osteoporosis and osteoporotic fractures is staggering and, with an increasing population of the elderly, that burden is estimated to double or triple by the year 2040. 5,9 Integrating osteoporosis prevention and bone health promotion into clinical practice is essential to address the growing public health problem posed by osteoporosis. Doing so requires awareness of the unique requirements that bone health poses at each stage of life. From the developing fetus to newborn child to the teenager and elderly patient, the NP is in a unique position to identify patterns of risk that may affect future bone health as well as the signs and symptoms of osteoporosis. Identifying risk in patients at each stage of life provides the opportunity to intervene with education in nutrition, exercise, and fall prevention and to offer effective medical treatments where indicated. These interventions, many of them simple and inexpensive, can help prevent osteoporosis and related fractures and improve outcomes for our patients. The Journal for Nurse Practitioners - JNP

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References 1. American Heart Association. Heart Disease and Stroke Statistics — 2007 Update. Dallas, TX: American Heart Association; 2007. 2. American Cancer Society. Cancer Facts and Figures 2005. Atlanta, GA: American Cancer Society; 2005. 3. Burge R, Dawson-Hughes B, Solomon DH, et al. Incidence and economic burden of osteoporosis-related fractures in the United States, 2005-2025 J Bone Miner Res. Mar 2007;22(3):465-475. 4. Clinician's guide to prevention and treatment of osteoporosis. National Osteoporosis Foundation. 2008. 5. Braithwaite RS, Col NF, Wong JB. Estimating hip fracture morbidity, mortality and costs. J Am Geriatr Soc. Mar 2003;51(3):364-370. 6. Prentice A, Schoenmakers I, Ann Laskey M, et al. Symposium on nutrition and health in children and adolescents. Session 1: Nutrition in growth and development. Nutrition and bone growth and development. Proceedings of the Nutrition Society. 2007;65(4):348-360. 7. Ganpule A, Yajnik CS, Fall CHD, et al. Bone mass in indian children— relationships to maternal nutritional status and diet during pregnancy: the Pune Maternal Nutrition Study. J Clin Endocrinol Metab. 2006;91(8):29943001. 8. Javaid MK, Crozier SR, Harvey NC, et al. Maternal vitamin D status during pregnancy and childhood bone mass at age 9 years: a longitudinal study. Lancet. 367(9504):36-43. 9. U.S. Department of Health and Human Services. Bone Health and Osteoporosis: A Report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, Office of the Surgeon General; 2004. 10. Reed SD, Scholes D, LaCroix AZ, et al. Longitudinal changes in bone density in relation to oral contraceptive use. Contraception. 2003;68(3):177-182. 11. Fuchs RK, Bauer JJ, Snow CM. Jumping improves hip and lumbar spine bone mass in prepubescent children: a randomized controlled trial. J Bone Miner Res. 2001;16(1):148-156. 12. Kalkwarf HJ, Khoury JC, Lanphear BP. Milk intake during childhood and adolescence, adult bone density, and osteoporotic fractures in US women. Am J Clin Nutr. 2003;77(1):257-265. 13. Bonjour JP, Theintz G, Buchs B, Slosman D, Rizzoli R. Critical years and stages of puberty for spinal and femoral bone mass accumulation during adolescence. J Clin Endocrinol Metab. 1991;73(3):555-563. 14. Katzman DK, Bachrach LK, Carter DR, Marcus R. Clinical and anthropometric correlates of bone mineral acquisition in healthy adolescent girls. J Clin Endocrinol Metab. 1991;73(6):1332-1339. 15. McKay HA, Bailey DA, Mirwald RL, Davison KS, Faulkner RA. Peak bone mineral accrual and age at menarche in adolescent girls: a 6-year longitudinal study. J Pediatr. 1998;133(5):682-687. 16. Heaney RP, Abrams S, Dawson-Hughes B, et al. Peak bone mass. Osteoporos Int. 2000;11(12):985-1009. 17. Albertson AM, Tobelmann RC, Marquart L. Estimated dietary calcium intake and food sources for adolescent females: 1980-92. J Adolesc Health. 1997;20(1):20-26. 18. Kranz S, Lin P-J, Wagstaff DA. Children's dairy intake in the United States: too little, too fat? J Pediatr. 2007;151(6):642-646.e1–2. 19. Golden NH. Osteoporosis prevention: a pediatric challenge. Arch Pediatr Adolesc Med. 2000;154(6):542-543. 20. NIH Consensus Development Panel on Osteoporosis Prevention, Diagnosis, and Therapy. Osteoporosis prevention, diagnosis, and therapy. JAMA. 2001;285(6):785-795. 21. Wyshak G. Teenaged girls, carbonated beverage consumption, and bone fractures. Arch Pediatr Adolesc Med. 2000;154(6):610-613. 22. Physician information. Depo-subQ provera 104. Pharmacia and Upjohn Co. March 2005. 23. Kaunitz AM, Arias R, McClung M. Bone density recovery after depot medroxyprogesterone acetate injectable contraception use. Contraception. 2008;77(2):67-76. 24. Rosenberg L, Zhang Y, Constant D, et al. Bone status after cessation of use of injectable progestin contraceptives. Contraception. 2007;76(6):425-431. 25. Khosla S, Riggs BL. Pathophysiology of age-related bone loss and osteoporosis. Endocrinol Metab Clin North Am. 2005;34(4):1015-1030, xi. 26. Leslie W, for the Manitoba Bone Density Program Committee. Absolute fracture risk reporting in clinical practice: a physician-centered survey. Osteoporos Int. 2008;19(4):459-463. 27. Kannus P, Parkkari J. Prevention of hip fracture with hip protectors. Age Ageing 2006;35-S2:ii51–ii54. 28. Langevin DD, Kwiatkowski C, McKay MG, et al. Evaluation of diet quality and weight status of children from a low socioeconomic urban environment supports “at risk” classification. J Am Diet Assoc. 2007;107(11):1973-1977. 29. Matthews SB, Waud JP, Roberts AG, Campbell AK. Systemic lactose intolerance: a new perspective on an old problem. Postgrad Med J. 2005;81(953):167-173.

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30. Lomer MC, Parkes GC, Sanderson JD. Review article: lactose intolerance in clinical practice—myths and realities. Aliment Pharmacol Ther. 2008;27(2):93-103. 31. Melton LJ 3rd, Kan SH, Wahner HW, Riggs BL. Lifetime fracture risk: an approach to hip fracture risk assessment based on bone mineral density and age. J Clin Epidemiol. 1988;41(10):985-994. 32. Huybrechts KF, Ishak KJ, Caro JJ. Assessment of compliance with osteoporosis treatment and its consequences in a managed care population. Bone. 2006;38(6):922-928. 33. Compston J. Treatments for osteoporosis - looking beyond the HORIZON. N Engl J Med. 2007;356(18):1878-1880. 34. Cramer JA, Amonkar MM, Hebborn A, Altman R. Compliance and persistence with bisphosphonate dosing regimens among women with postmenopausal osteoporosis. Curr Med Res Opin. 2005;21(9):1453-1460. 35. Black DM, Delmas PD, Eastell R, et al. Once-yearly zoledronic acid for treatment of postmenopausal osteoporosis. N Engl J Med. 2007;356(18):1809-1822.

Barbara M.Thorpe, MSN, RNC, CNP, is a certified menopause practitioner for New Mexico Gynecology Consultants, Southwest Clinical Research, in Albuquerque, NM. She is also on the speaker’s bureau of Novartis Pharmaceuticals, Procter & Gamble, Sanofi-Aventis, and Merck.

Acknowledgments—The author thanks Eileen O’Connor of BioScience Communications, New York, NY, for her editorial assistance in the preparation of this manuscript. 1555-4155/09/$ see front matter © 2009 American College of Nurse Practitioners doi:10.1016/j.nurpra.2009.03.016

June 2009