Screening for Osteoporosis

Osteoporosis is a condition of decreased bone mineral density associated with an increased risk of fracture. Half of all postmenopausal women will have an osteoporosis related fracture in their lifetime. These include hip fractures. which are associated with higher risks of loss of independence, institutionalization and death. The risk of osteoporosis is increased with advancing age, tobacco use. low body weight. Caucasian or Asian ancestry, family history of osteoporosis, low calcium intake and sedentary lifestyle.

Osteoporosis may also occur in men, although with a lower incidence than it does in women. Along with the risk factors noted above, the prolonged use of corticosteroids, presence of diseases that alter hormone levels (such as chronic kidney or lung disease) and undiagnosed low testosterone levels increase the risk of osteoporosis in men.

Screening for osteoporosis is done by measurement of bone density. Measurement of the hip bone density by Dual energy X-ray Absorptiometry (DXA) is the best predictor of hip fracture. Measurement of bone density is compared to the bone density of young adults and the result is reported as standard deviation from the mean bone density of the young adult (T-score). Osteoporosis is present if the patient's T-score is at or below -2.5 (i.e., measurement of the patient's bone density is more than 2.5 standard deviations below the young adult mean): osteopenia is present if the T-score is between -1.0 and -2.5. Other modalities, such as measurement of wrist or heel density, single energy x-ray aborptiometry and ultrasound are being evaluated and may have some short term predictive value. The USPSTF recommends screening for osteoporosis via DXA in women after the age of 65 and considering screening in women over age 60 with higher risk of osteoporosis related fractures (Level B recommendation).

Calcium and vitamin D intake have a role in the prevention and treatment of osteoporosis. The National Osteoporosis Foundation (NOF) recommends at least 1200 mg of calcium and 400-800 IU of vitamin D per day for all women over the age of 50. If dietary intake is not sufficient, supplements may be used. Weight-bearing and muscle strengthening exercise is also recommended both for its direct effects on increasing bone density and for its benefits in strength, agility and balance, which may reduce the risk of falls.

When osteoporosis is diagnosed, patients should be treated with calcium, vitamin D. exercise and strategies should be implemented to reduce the risk of falls. These strategies include evaluation and treatment, if needed, of vision and hearing deficits, management of medical disorders that can promote falls (movement disorders, neurological disorders, etc) and periodic evaluation of medications taken that may affect balance or movement. Hip protectors may be beneficial in those at high risk for falls.

Medications used for the prevention and treatment of osteoporosis are included in Table 11.1.

Table 11-1

MEDICATIONS FOR THE PREVENTION AND TREATMENT OF OSTEOPOROSIS

Table 11-1

MEDICATIONS FOR THE PREVENTION AND TREATMENT OF OSTEOPOROSIS

CLASS/ MEDICATION

RELATED

INDICATIONS

DOSAGE

SIDE EFFECTS

Bisphosphonates

Esophagitis, gastritis, swallowing difficulty: all bisphosphonates should be taken on an empty stomach with a full glass of water and the patient should stay upright for at least 30 minutes after taking the pill

Alendronate

Fosamax

Prevention and treatment

Prev: 5 mg daily or 35 mg weekly Tx: 10 mg daily or 70 mg weekly

Risedronate

Actonel

Prevention and treatment

Prev:

Ibandronate

Boniva

Prevention and treatment

Prev and Tx: 150 mg monthly

(inj or nasal spray)

Treatment

IM/SC: 100 units daily Nasal: 1 spray (200 units) daily

Inj: flushing, injection site reaction NS: nosebleeds, nasal irritation

Estrogen

Numerous

Prevention

Varies

Potential increased risk of DVT, MI. stroke. PE

Parathyroid Hormone

Tcriparatide

Forteo

Treatment

20 (.1 SC daily

Leg cramps, dizziness, transient hypercalcemia

Selective Estrogen Receptor Modulator

Raloxifene

Evista

Prevention and treatment

60 mg daily

Hot flashes, weight gain. DVT/PE

Abbreviations: DVT. deep venous thrombosis: Inj, injection: Ml. myocardial infarction: NS. nasal spray: PE. pulmanary embolism; Prev. prevention. Tx. treatment.

Abbreviations: DVT. deep venous thrombosis: Inj, injection: Ml. myocardial infarction: NS. nasal spray: PE. pulmanary embolism; Prev. prevention. Tx. treatment.

Screening for Domestic Violence

Estimates indicate that between 1 and 4 million women are sexually, physically, or emotionally abused by an intimate partner each year. Women are also much more likely to be abused by an intimate partner than men. Multiple factors are associated with intimate partner violence and include young age, low income status, pregnancy, mental illness, alcohol or substance use by victims or partner, separated or divorced status, and a history of childhood sexual/physical abuse. Multiple rating scales are available to assess for presence of domestic violence which are of variable quality. The USPSTF found insufficient evidence to recommend for or against routine screening for intimate partner abuse, or that screening affects outcomes (Level I recommendation). Other groups, including the American Academy of Family Physicians and American Medical Association, recommend awareness and advocate asking about domestic violence. Documentation and treatment of injuries, counseling and information regarding protective services are part of the evaluation when domestic violence is suspected. Reporting of domestic violence is mandatory in several states; be aware of the requirements of your state.

Comprehension Questions

[11.1 J Which of the following screening tests would be recommended in a 50-year-old woman with hypertension and who had a total abdominal hysterectomy at the age of 35 for endometriosis?

A. Exercise stress test

B. Pap smear

C. DXA scan

D. Stool occult blood

111.2] Which of the following situations is associated with an increased risk of intimate partner violence?

A. Pregnancy

B. Older age

C. Higher income

D. Married status

[ 11.3] Which of the following statements regarding osteoporosis is true?

A. Fewer than 25% of women will have an osteoporosis related fracture in their lifetime.

B. Long-term therapy with a combination of estrogen and progesterone is recommended for the treatment of postmenopausal osteoporosis.

C. Asian and African-American women have an increased risk of osteoporosis.

D. 1200 mg of calcium and 400-800 IU vitamin D. through diet or supplement, is recommended for all women over the age of 50.

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