Osteoporosis: The Silent Killer Joseph F. Scordino, MD

Osteoporosis: Osteoporosis: The Silent KillerThe Silent Killer

Joseph F. Scordino, MDJoseph F. Scordino, MD

Lincoln CountyLincoln County

Maine oldest state in the country Maine oldest state in the country Lincoln county oldest county in the Lincoln county oldest county in the

statestate

OsteoporosisOsteoporosis Osteoporosis is a disease that Osteoporosis is a disease that

causes the bones to become brittle causes the bones to become brittle and fragile and more likely to and fragile and more likely to break. break.

It is a silent disease in that it does It is a silent disease in that it does not cause pain until the bone not cause pain until the bone breaks.breaks.

Osteoporosis is most likely to cause Osteoporosis is most likely to cause fractures of the spine, hip or wrist fractures of the spine, hip or wrist which can lead to hospitalization or which can lead to hospitalization or loss of independent living. Spine loss of independent living. Spine fractures can cause spinal fractures can cause spinal deformity and severe pain in the deformity and severe pain in the backback

Osteoporosis Under the Osteoporosis Under the MicroscopeMicroscope

Build bone early in teens and twentyBuild bone early in teens and twenty Constantly remodelingConstantly remodeling

Normal Bone

PrevalencePrevalence Approximately one in two women and one in four men over age 50 Approximately one in two women and one in four men over age 50

will have an osteoporosis related fracture in their remaining lifetime.will have an osteoporosis related fracture in their remaining lifetime. Major threat for 44 million Americans or greater then 50% of Major threat for 44 million Americans or greater then 50% of

Americans over age 50Americans over age 50 Osteoporosis can affect any individual of any ageOsteoporosis can affect any individual of any age 80% of this pool of patients are women 80% of this pool of patients are women Osteoporosis is more predominant in White and Asian ethnic groups Osteoporosis is more predominant in White and Asian ethnic groups

then in other groupsthen in other groups

ConsequencesConsequences

Osteoporosis bone fractures are responsible Osteoporosis bone fractures are responsible for considerable pain, decreased quality of for considerable pain, decreased quality of life, lost workdays, and disability. life, lost workdays, and disability.

Some 20% of women with a hip fracture will Some 20% of women with a hip fracture will die in the subsequent year as an indirect die in the subsequent year as an indirect result of the fracture. result of the fracture.

In addition, once a person has experienced a In addition, once a person has experienced a spine fracture due to osteoporosis, he or she spine fracture due to osteoporosis, he or she is at very high risk of suffering another such is at very high risk of suffering another such fracture in the near future (next few years). fracture in the near future (next few years).

Effect on IndependenceEffect on Independence

At six months after a hip fracture, At six months after a hip fracture, only 15 percent of hip fracture only 15 percent of hip fracture patients can walk across a room patients can walk across a room unaided. unaided.

Up to 30% of patients suffering a hip Up to 30% of patients suffering a hip fracture will require long-term fracture will require long-term nursing-home care. nursing-home care.

SymptomsSymptoms People cannot feel their bones getting People cannot feel their bones getting

weaker. They may not know that they weaker. They may not know that they have osteoporosis until they break a have osteoporosis until they break a bone. A person with osteoporosis can bone. A person with osteoporosis can fracture a bone from a minor fall, or in fracture a bone from a minor fall, or in serious cases, from a simple action such serious cases, from a simple action such as a sneeze or even spontaneously. as a sneeze or even spontaneously.

Women can lose up to 20 percent of Women can lose up to 20 percent of their bone mass in the five to seven their bone mass in the five to seven years after menopause, making them years after menopause, making them more susceptible to osteoporosis. more susceptible to osteoporosis.

Peak Bone MassPeak Bone Mass

Peak bone mass is obtained at Peak bone mass is obtained at around age 20 healthy diet. Building around age 20 healthy diet. Building strong bones in childhood helps to strong bones in childhood helps to decrease fracture risk later in life.decrease fracture risk later in life.

Vertebral FracturesVertebral Fractures

Vertebral (spinal) fractures may Vertebral (spinal) fractures may initially be felt or seen in the form of initially be felt or seen in the form of severe back pain, loss of height, or severe back pain, loss of height, or spinal deformities such as kyphosis spinal deformities such as kyphosis or stooped posture. In many cases, a or stooped posture. In many cases, a vertebral fracture can even occur vertebral fracture can even occur with no pain.with no pain.

Postural DeformityPostural Deformity

Who Should be ScreenedWho Should be Screened NOF Screen > NOF Screen >

65.65. Less then 65 Less then 65

based on risk based on risk factors 1) , 100 factors 1) , 100 lbs 2) FH of lbs 2) FH of fracture 3) fracture 3) incidence of incidence of previous previous fracture fracture

Risk FactorsRisk Factors

AgeAge Female SexFemale Sex RaceRace Low weight or BMILow weight or BMI Previous FracturePrevious Fracture Parental history of Parental history of

hip fracturehip fracture Steroid useSteroid use

Current smokingCurrent smoking Alcohol > 3 drinks a Alcohol > 3 drinks a

dayday Rheumatoid ArthritisRheumatoid Arthritis Inflammatory Bowel Inflammatory Bowel

diseasedisease Prolonged Prolonged

ImmobilizationImmobilization Type 1 DiabetesType 1 Diabetes Thyroid DisorderThyroid Disorder

FracturesFractures

1 in 2 women after age 50 will have a 1 in 2 women after age 50 will have a osteoporotic fracture in their lifetime osteoporotic fracture in their lifetime while for men this 1 in 4.while for men this 1 in 4.

Fractures due to osteoporosis lower an Fractures due to osteoporosis lower an individuals quality of lifeindividuals quality of life

25% of individuals die within 1 year of an 25% of individuals die within 1 year of an osteoporotic fractureosteoporotic fracture

1 in 6 individuals previously independent 1 in 6 individuals previously independent individuals require long term care individuals require long term care following a fracturefollowing a fracture

DiagnosisDiagnosis A specialized machine A specialized machine

called a bone mineral called a bone mineral density test can be used to density test can be used to measure the extent of measure the extent of osteoporosis at various osteoporosis at various sitessites

BMD is safe and painlessBMD is safe and painless Bone density testing helps Bone density testing helps

to monitor response to to monitor response to treatment as well as treatment as well as predict the chance of predict the chance of future fracturesfuture fractures

Medicare reimburses for Medicare reimburses for BMD testing every 2 yearsBMD testing every 2 years

How to make sense of BMD How to make sense of BMD testingtesting

BMD compares your BMD to a healthy BMD compares your BMD to a healthy 30 year old this is the T score which 30 year old this is the T score which stands for standard deviationsstands for standard deviations

Lower score is worseLower score is worse -1 to 1 is a normal bone density test-1 to 1 is a normal bone density test -1 to -2.5 is termed osteopenia -1 to -2.5 is termed osteopenia -2.5 or less is termed osteoporosis-2.5 or less is termed osteoporosis Z score is comparison to similar age Z score is comparison to similar age

adults and is less helpful then the T adults and is less helpful then the T scorescore

When to TreatWhen to Treat

Individuals with T Individuals with T score less then -score less then -2.52.5

Individuals with T Individuals with T score from -1 to -score from -1 to -2.5 with risk 2.5 with risk factorsfactors

FRAX scoreFRAX score

Easy to use program Easy to use program to give score for to give score for probability of hip probability of hip fracture in 10 years fracture in 10 years timetime

Requires a DEXA Requires a DEXA scanscan

http://http://www.sheffield.ac.uk/www.sheffield.ac.uk/FRAX/FRAX/

Preventative StepsPreventative Steps Remove all obstacles like throw rugs and Remove all obstacles like throw rugs and

long phone cordslong phone cords Install handles next to toilets and showersInstall handles next to toilets and showers Do not wear sandals or slippers without Do not wear sandals or slippers without

backsbacks Use 100 watt light bulbs instead of low Use 100 watt light bulbs instead of low

lightlight Install night lights to help to see when Install night lights to help to see when

getting up to go the bathroomgetting up to go the bathroom Review all medications with the doctor Review all medications with the doctor

which may cause dizzinesswhich may cause dizziness

Treatment of Treatment of OsteoporosisOsteoporosis

Fall preventionFall prevention Proper NutritionProper Nutrition Exercise and weight bearing Exercise and weight bearing

activities regularlyactivities regularly MedicationMedication

Measures to Decrease Measures to Decrease RiskRisk

Stop excessive alcohol useStop excessive alcohol use Stop smoking – ask for help if Stop smoking – ask for help if

neededneeded

ExercisesExercises

Hold onto the back of a sturdy chair Hold onto the back of a sturdy chair and stand on one foot for 1 minuteand stand on one foot for 1 minute

Hold onto the back of a sturdy chair Hold onto the back of a sturdy chair and rock onto your toes and your and rock onto your toes and your heels 10 timesheels 10 times

Perform with 2 hands, then as you Perform with 2 hands, then as you get stronger go to one hand, then get stronger go to one hand, then one fingertip, then no hands and one fingertip, then no hands and finally with your eyes closed.finally with your eyes closed.

Medication - Medication - AntiresportiveAntiresportive

Bisphosphonates orally (Actonel, Bisphosphonates orally (Actonel, Fosamax)Fosamax)

Bisphosponates IV once a year Bisphosponates IV once a year (Zolendronic Acid or Reclast)(Zolendronic Acid or Reclast)

Calcitonin (Miacalcin)Calcitonin (Miacalcin) Estrogen TherapyEstrogen Therapy

MedicationMedication

Calcium 1200 mg to 1500 mg by Calcium 1200 mg to 1500 mg by mouth every day for postmenopausal mouth every day for postmenopausal womenwomen

Vitamin D 800 mg by mouth every Vitamin D 800 mg by mouth every day day

Vitamin D3 has been shown to be Vitamin D3 has been shown to be equivalent to vitamin D2.equivalent to vitamin D2.

Foods high in CalciumFoods high in Calcium

Foods high in Vitamin DFoods high in Vitamin D

Patient Non adherencePatient Non adherence

Greater then 50% of patients stop Greater then 50% of patients stop taking within 1 year associated with taking within 1 year associated with cost, concern for to many cost, concern for to many medications, dosing regimen, side medications, dosing regimen, side effects.effects.

SummarySummary Osteoporosis is a disease where bone Osteoporosis is a disease where bone

becomes more fragile with increase risk of becomes more fragile with increase risk of fracturefracture

Peak bone mass develops in 20’s then dropsPeak bone mass develops in 20’s then drops Key risk factors for osteoporosis include Key risk factors for osteoporosis include

genetic factors, lack of exercise, lack of genetic factors, lack of exercise, lack of calcium and vitamin D, personal history of calcium and vitamin D, personal history of fracture as an adult, rheumatoid arthritis, fracture as an adult, rheumatoid arthritis, cigarette smoking, excessive alcohol cigarette smoking, excessive alcohol consumption, low body weight, and family consumption, low body weight, and family history of osteoporosis. history of osteoporosis.

Summary Summary

Patients with osteoporosis have no Patients with osteoporosis have no symptoms until bone fractures occur. symptoms until bone fractures occur.

Diagnosis can be suggested by X-rays and Diagnosis can be suggested by X-rays and confirmed by using tests to measure bone confirmed by using tests to measure bone density. density.

Treatments for osteoporosis, in addition Treatments for osteoporosis, in addition to prescription osteoporosis medications, to prescription osteoporosis medications, include stopping use of alcohol and include stopping use of alcohol and cigarettes, and assuring adequate cigarettes, and assuring adequate exercise, calcium, and vitamin D. exercise, calcium, and vitamin D.

Miles InitiativesMiles Initiatives Beginning a new Beginning a new

osteoporosis treatment osteoporosis treatment protocol to increase protocol to increase treatment for osteoporosis treatment for osteoporosis and cut down on future and cut down on future fracturesfractures

Increase screening for Increase screening for osteoporosis through osteoporosis through reinforcement of education reinforcement of education with health care providerswith health care providers

Educate community and Educate community and increase awareness about increase awareness about osteoporosis through talks, osteoporosis through talks, press releasespress releases

Questions?Questions?