_______________________________________________________ Osteoporosis: Diagnosis and Management
Both smoking and heavy alcohol consumption have been associated with reduced bone mass and increased fracture risk. Smoking has been found to have a direct toxic effect on bone cells and may also harm bone indirectly by lowering the amount of calcium the intestine is able to absorb [23]. Heavy alcohol consumption has known negative effects on bone and bone remodeling [23]. Healthcare providers should review these preventive measures frequently with patients and be certain that language or cultural differences do not interfere with the patient’s ability to understand them.
PREVENTION Although the process of bone thinning is a natural part of aging and cannot be completely stopped, there are measures that can and should be taken early to prevent or delay osteoporosis. Ideally, it is best to start these measures during adolescence; however, adults who follow them also may benefit. An estimated 10% increase of peak bone mass in children reduces the risk of osteoporotic fracture during adult life by 50% [31].
Preventive measures include [20; 23; 31]: • A balanced, nutritious diet rich in calcium and vitamin D • Maintenance of a healthy body weight • Beneficial weight-bearing exercise for 30 to 60 minutes, five days a week • No use of tobacco products and only
DIAGNOSIS
CLINICAL SIGNS AND SYMPTOMS Osteoporosis is often a silent disease without obvious indications that it is present. However, there are some signs and symptoms that may accompany the development of the condition, including [23; 32]: • Decreasing height (patients may lose 10–15 cm in height due to collapsing vertebrae) • Back pain (typically in the lower thoracic and lumbar areas, T5–L5) • Development of a kyphosis or curvature of the upper back (Dowager hump)
moderate (if any) alcohol consumption, and avoid secondhand smoke, if possible
• Fall prevention • Careful medication usage, recognizing which agents increase risk for osteoporosis, and seeking alternatives, if possible
The American Association of Clinical Endocrinologists recommends counseling patients to maintain adequate dietary intake of calcium, to a total intake (including diet plus supplement, if needed) of 1,200 mg/ day for women 50 years of age or older.
• Fracture occurring with minimal trauma • Low body weight and weight loss of more than 1% per year in the elderly • Suspicion of vitamin D deficiency (e.g., due to low intake or little exposure to sunshine)
(https://www.sciencedirect.com/science/article/pii/ S1530891X20428277. Last accessed October 15, 2024.) Level of Evidence : Grade B (Evidence from at least one well-designed clinical trial, cohort- or case-controlled analytic study, or meta-analysis) Falls often precipitate fractures in individuals with low BMD. They occur for a variety of reasons and may involve multiple factors (e.g., problems with balance, mobility, vision, lower extremity weakness, and/or blood pressure circulation). Falls are a major contributor to hip fractures and have also been associated with an increased risk of spine, wrist, pelvis, and upper arm fractures. Preventive measures should include regular vision checks, elimination of medications that may cause dizziness, low blood pressure, or confusion, and elimination of environmental obstacles (e.g., removing throw rugs, installing night lights). Another important fall prevention measure is physical activity, which may help to improve muscle strength and balance. Physical activity, performed an average of three times each week for a duration of 30 to 45 minutes, should be encouraged in the elderly [23].
Any of these findings in a patient should lead to an evaluation for osteoporosis. A fracture in at-risk populations, especially one that is disproportionate to the amount of trauma, should prompt a work-up. Subtle vertebral fractures may be identified incidentally on chest radiographs or bone scans. A vertebral fracture assessment (VFA) may be needed if a vertebral fracture is suspected in certain populations [33]. Acute onset of low back pain with little or no trauma could represent a vertebral compression fracture. Wrist fractures (either Smith or Colles) should raise suspicion in a younger population; they often are an earlier manifestation of osteoporosis, with increasing incidence in women 40 years of age and older [34]. As noted, most often patients do not present with significant signs or symptoms of osteoporosis. In this example, Patient D does present with back pain in the lower lumbar area, which has been persistent for several months. The physical exam does not reveal any signs of radiculopathy, obvious fracture, nerve damage, or acute cause of the low back pain. In addition, the review of past records does demonstrate that Patient D is approximately 10 cm shorter in height than five years ago. She clearly needs a work-up for osteoporosis.
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MDFL2626
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