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Table of Contents
Osteoporosis is loss of bone mass and density which can lead to bone fragility and increased risk for bone fractures [1]. Bone fractures can occur anywhere in the body with the most common fractures occurring in the wrist, hip, and vertebra.
In the United States, during 2017-2018, there were 18.8% of women and 4.2% of men 50 years and older with osteoporosis in their lumbar spine or femur neck [2]. Worldwide, there are about 500 million women and men who have osteoporosis, and there are 8.9 million osteoporotic fractures that occur yearly [3].
Types of Osteoporosis:
Primary osteoporosis. Primary osteoporosis is classified as deterioration of bones that leads to increased risk of fracture, which mostly occurs in postmenopausal women and men over 75 years old [4].
Secondary Osteoporosis. Secondary osteoporosis is bone loss caused by certain medications or medical conditions [5].
PathophysiologyThere are two types of cells that are essential in bone structure; this comprises of osteoclasts (bone resorption cells) and osteoblasts (bone forming cells) 4. Every year, about 10% of bone is remodeled with this process 4. The remodeling process is regulated by several hormones, such as calcitriol produced by vitamin D3, calcitonin, parathyroid hormone, testosterone, and estrogen 4 [6]. If the amount of the bone resorbed is greater than the amount formed, then it can lead to osteoporosis 4.
Causes and Risk FactorsOsteoporosis has more likelihood of developing in those with certain risk factors including 1:
Signs and SymptomsTypically, osteoporosis does not have any symptoms and is known as the "silent" disease until a fracture occurs 1.
Screening and Diagnostic AssessmentDual-energy X-ray Absorptiometry (DXA) measures bone mineral density (BMD) and should be performed for women 65 years and older and men 70 years and older 7. A DXA T-score of -2.5 or higher is a diagnosis of osteoporosis 4. A person who presents with a fracture in their adulthood should be evaluated for osteoporosis. Assessing fall risk status is critical to prevent morbidity and mortality.
Treatment and ManagementTreatment of osteoporosis should be considered depending on the patient's history and score from the Fracture Risk Assessment Tool (FRAX) 7. The FRAX score is used to calculate the probability of a major osteoporotic fracture within 10 years.
Pharmacologic treatment options include:
Lifestyle management includes:
Education to PatientsPatients need education on osteoporosis prevention, causes and potential risk factors, as well as treatment options to improve their self-care at home. There should be an emphasis on lifestyle changes including physical exercise, dietary recommendations, fall prevention, smoking cessation, limiting alcohol intake, and taking prescribed medications [8].
Poor medication compliance is common, and educating patients on how to take medications will help them adhere to their regime. For example, alendronate (Fosamax) is a commonly prescribed treatment, and this needs to be taken in the morning, prior to any food or drinks, with a full 8 oz glass of water and they need to remain upright for at least 30 minutes after taking the pill [9].
Recent Treatment BreakthroughIn 2019, the U.S. Food and Drug Administration approved Evenity (romosozumab-aqqg) to treat high-risk postmenopausal women [10]. Evenity is an injectable monoclonal antibody that improves new bone growth by blocking the protein sclerostin, which is responsible for stopping bone growth production. It is given as two subcutaneous injections on the same day and then monthly for a maximum of 12 months. The new drug has the warning of increased risk for stroke, heart attacks and cardiovascular death and should be avoided in those at high risk for these conditions.
Recently, a newly developed technology called the deep learning model was created to improve accuracy of osteoporosis risk screening [11]. It uses explainable artificial intelligence (XAI) techniques to evaluate additional variables not identified by conventional methods, and studies suggest it is more accurate than clinical assessment tools and machine-learning models[11]. Since the quality of a DXA scan depends on manual validation, AI-based algorithms have been used and have shown to perform better in trabecular bone score and evaluating bone mineral density[12]. Accurate osteoporosis screening is needed to consider initiating treatment.
On February 23rd this year, the World Health Organization (WHO) and the European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO) signed a five-year agreement for an action plan that will help older adults improve their bone health. The objectives will involve applying evidence-based interventions and policies to reduce bone fractures[13].
Clinical ExperienceIn my years of experience as both a registered nurse and a nurse practitioner, I have found that many adults are unaware of the significance of morbidity and mortality surrounding osteoporosis. Many do not realize that their bone health starts in their youth and prevention of bone loss at a young age will determine their BMD in the future.
There have been several incidences where a patient presents to the office with an acute fracture and is unaware of their osteoporosis due to not meeting the age requirements for screening. Therefore, individualizing care based on someone's history and presentation can improve their outcomes.
Key TakeawaysReferences
About Michelle Flanagan, MSN, NP
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