"What is REAL?" asked the Rabbit one day. "Real isn't how you are made, " said the Skin Horse. "It's a thing that happens to you. It doesn't happen all at once. You become. It takes a long time. That's why it doesn't happen to people who break easily, or have sharp edges, or who have to be carefully kept. Generally, by the time you are Real, most of your hair has been loved off, and your eyes drop out and you get loose in the joints and very shabby. But these things don't matter at all, because once you are Real you can't be ugly, except to people who don't understand."
Conversation between the Rabbit and Skin Horse in The Velveteen Rabbit1
The wisdom portrayed in this conversation between two toys in the well-known children's book, The Velveteen Rabbit, goes beyond the magic often accepted as strange and wonderful by children. It can be open to many interpretations, one an excellent portrayal of aging.
The aging process itself should not be set aside as something unusual or undesirable. It is a very natural part of the life cycle. Psychological and sociological maturity is gained through events experienced throughout the lifetime. With the wisdom gained, the older person truly "becomes."
The aging process is also a paradox. While the aging person gains psychological and sociological maturity, he also experiences gradual physical deterioration and losses. The well-adjusted individual with adequate coping skills will probably be able to handle these changes and make the necessary lifestyle adjustments if the physical changes are not too great or debilitating.
One physical change considered by many to be very debilitating is osteoporosis - a degenerative condition prevalent in older people, particularly post- menopausal women. It is often thought to be an inevitable part of aging, and is not considered a separate disease entity that can be treated and/or possibly prevented. Resultant damage is very debilitating - physically, emotionally, and financially. It decreases functional status and can cause an overall decline in the quality of the affected person's life.
Is osteoporosis really an inevitable part of the aging process? If so, is it treatable? Are there preventive measures that can be instituted while the person is younger? Fortunately, physicians and researchers interested in this subject are conducting studies focused on both prevention and treatment of osteoporosis.
Nursing definitely has a role in both these areas. Nurses, whether they work in hospitals, outpatient clinics, or community health positions, have excellent opportunities to make ongoing assessments of their patients. They usually have more time to spend with the patient than the physician does. Having a good knowledge base of signs and symptoms of osteoporosis and applying this to assessment skills could make a difference to a patient who may be suffering from this condition. The overall goal is to improve the quality of the older person's life. This means assisting the person in maintaining optimum function, despite degenerative changes and losses associated with aging.
The human skeleton has three main functions: (1) provide a framework for locomotion, (2) provide protection for vital organs, and (3) act as a body reservoir for calcium and other minerals. The deposition and removal of minerals from bone is an active rather than a passive process, mediated by cells and controlled by a number of hormones. Osteoclasts are the bone-resorbing cells. Osteoblasts are the bone-forming cells. Simultaneous processes of bone resorption and bone formation go on constantly in the body. This constant state of change or renewal is called "bone remodeling."
In osteoporosis, new bone formation rates stay the same, but bone resorption rates increase. This results in a net loss of bone density and mass. Up until around age 40, the rates of resorption and formation remain normal. After that, the rates of resorption are greater, especially in women. By age 80, total bone mass may be reduced to one-half of what it was at age 40. 2 In osteoporosis, serum concentrations of calcium, phosphorus and alkaline phosphatase are normal. The bone cells, bone matrix, and bone crystals are also normal. However, the trabeculae and cortex are reduced, causing structural weakness of the bones and increasing the risk of fractures.
Epidemiological factors are important considerations in osteoporosis. Statistics indicate types of persons who are more prone to develop the condition. This is important for both prevention and treatment of osteoporosis. Although elderly men develop symptomatic osteoporosis between the ages of 50 and 70, it is predominantly a disease of women. The disease is rare among black men of any age. Black women of southern European ancestry are much less vulnerable than their Anglo-Saxon sisters.3 It has been estimated that 25% of all white women have undergone osteoporotic vertebral compression fractures by age 60. Up to 20% of all women will sustain one or more hip fractures sometime in their lives.4 These statistics alone indicate that osteoporosis is a significant health problem that deserves much attention.
Causes and Differential Diagnosis
Osteoporosis is divided into two groups: (1) primary osteoporosis, also called idiopathic or postmenopausal, and (2) secondary osteoporosis in which the osteoporosis is secondary to heritable or acquired abnormalities. Correct treatment is dependent upon accurate differential diagnosis and cause.
Some of the most prevalent causes of secondary osteoporosis are listed by Gruber and Baylink:
1. Marfan 's syndrome,
2. renal calcium leak,
3. renal tubular acidosis,
4. cirrhosis, and
6. multiple myeloma,
7. low serum phosphate,
8. selective deficiency of 1,25hydroxy-vitamin D,
9. treatment with anti-convulsant drugs,
10. female hypogonadism,
11. Cushing's syndrome,
13. chronic alcoholism,
15. chronic heparin treatment,
16. mild vitamin D deficiency, and
17. chronic obstructive pulmonary disease.5
A very complete history and physical exam can help elicit many of the causes of secondary osteoporosis. Chemical laboratory determinations can be done for many of them. If all secondary causes are ruled out, then the diagnosis of primary osteoporosis is made. Again, it is very important to find the cause of the osteoporosis, because some specific therapies can be very effective, especially in secondary osteoporosis.
One of the unfortunate aspects in both prevention and treatment is that patients usually don't present with symptoms until the condition is far advanced and they have vertebral or hip fractures. Conventional x-rays cannot be used to diagnose osteoporosis until 35% of the bone mass has been lost. Two newer methods now used to determine bone mass are computer tomography scanning and photodensitometry. These methods are utilized not only for diagnostic purposes, but also to record small changes in bone mass for the purpose of monitoring the effectiveness of a therapeutic regimen.
Loss of bone mass usually starts in the women around the age of 35. It increases greatly with the onset of menopause or with the decrease of naturally produced estrogens in the body. As mentioned before, most of the patients presenting with symptomatology of osteoporosis will be in this age group - the postmenopausal white women.
The patient usually has chronic back pain located between the shoulder blades or in the lower thoracic vertebrae. The pain tends to be non-radiating and is made more intense by bending forward or lifting heavy objects. Pain from osteoporosis is usually relieved by rest, unlike osteoarthritis or degenerative disc disease. The pain usually results from anterior wedge compression fractures of one or more of the lower thoracic or lumbar vertebrae, usually not related to trauma.
The progression of fractures eventually leads to kyphosis and loss of stature. Those affected have a typical physical appearance. Some may have such an extensive kyphosis from vertebral fractures that the lower thoracic cage actually rests upon the pelvic rim. In addition to the musculoskeletal discomfort, a variety of respiratory and gastrointestinal symptoms occur as a result of this compression. Loss of stature is generally two to three inches, but can be as great as 12 inches. Osteoporosis usually causes anterior wedge fractures of the vertebrae. Posterior wedge fractures are usually caused by Paget's disease, trauma, or metastatic malignancy - another important factor in making a differential diagnosis.
Other areas that have high fracture rates as a result of osteoporosis are the hip, wrist, and ulnar bone. More than 75% of all hip fractures are due to osteoporosis.
The degree of pain reported by the patient is not a good indicator of the amount of damage that has occurred. Some patients have extensive pain and slow healing with one fracture. Others may have a minimum of discomfort with seven or eight fractures. There are usually no abnormal neurological signs in osteoporotic fractures because the neural arch is not compressed by the fractures.
Some of the following characteristics have been associated with an increased risk of osteoporosis. They should be noted in any history and physical:
1. life-long small skeleton,
2. family history of vertebral or hip fracture,
3. history of oophorectomy prior to age 45,
4. history of hyperthyroidism,
6. symptoms of intestinal malabsorption,
7. past or present glucosteroid therapy,
9. rheumatoid arthritis, and
10. history of renal calculi.
The treatment of osteoporosis should be preventive and/or restorative. Chesnut defines two goals of treatment.6 In menopausal and post-menopausai women with relatively normal bone mass and no previous fractures, the goal of therapy is prevention of an osteopenic state sufficient to cause fracture. Attainment of the goal involves a slowing of the bone loss that normally occurs. In menopausal and post-menopausal women with a relatively low bone mass and previous fractures, treatment is directed at restoring bone mass to a level at which fracture risk is substantially reduced. This involves a slowing of age-related bone loss as well as replacement of bone previously lost. Up to now, most treatment has only been successful at decreasing bone resorption. Little can be done to successfully restore previously lost bone mass.
Several agents and combinations of agents have proven therapeutic in treating osteoporosis. However, most researchers are still unsatisfied with the results and feel that much more research needs to be done. It is thought that normal bone remodeling occurs over a long period of time, possibly in cycles. This necessitates long-range or longitudinal research studies to accurately assess the results of the specific regimens.
Estrogen is one of the most effective treatments for osteoporosis. It decreases the rate of bone turnover and reduces bone resorption. It is used both as a preventive agent and a therapeutic agent for the post-menopausal women who already have severe bone loss. However, it must be used with caution. Women who take the hormone run an increased risk of endometrial cancer.
Calcium intake also affects bone mass in women of this age group. Heaney's longitudinal study has shown that calcium will slow the loss of cortical bone with age in post-menopausal women.7·8 Calcium absorption often decreases with age. Dietary intake of calcium may also decrease with age. The combination of these two factors often creates a negative calcium balance in the elderly. If post-menopausal women do not ingest enough calcium in their regular diet, they are given calcium supplements. The recommended daily intake of calcium is 800 mg. It has been suggested that this should be increased to at least 1500 mg after the menopause.9 Supplemental calcium is usually used in any combination treatment for osteoporosis.
A form of vitamin D called 1,25dihydroxy vitamin D is also being used in experimental trials. This agent increases calcium absorption from the intestine. Dosages must be carefully regulated to avoid side effects. Hypercalcemia, one of the most deleterious side effects, often occurs when it is used alone in therapy rather than when it is used in combination with other drugs.
Anabolic steroids are new treatment agents. The major action of these is to increase the bone mass. However, the side effects of these drugs often outweigh the benefits, and dosages are still very experimental. Latest research shows that cyclic administration may reduce the side effects and retain the benefits. Some of the undesirable side effects are hepatic enzymes elevation, fluid retention, and androgenic effects.
Fluoride is the one agent that appears to directly increase bone formation. However, fluoridic bone has increased cystallinity and decreased elasticity, so it does not necessarily increase the bone strength. Riggs et al combined fluoride and calcium for good therapeutic results with increased bone mass and fewer fractures.10 Fluoride also has serious side effects, so the dosage must be carefully monitored. Major adverse reactions are synovitis, painful plantar fascial syndrome, recurrent vomiting, and anemia.
Most physicians find that a combination of agents is more successful in treating osteoporosis than any one of them alone. Another study by Riggs and his co-workers demonstrated the effectiveness of a combination of agents. " They used the rate of vertebral fractures as a measurement of efficacy of their treatment regimes and reported the following findings:
1 . Those treated with calcium reduced fracture rates by 50%.
2. Estrogen plus calcium lowered fracture rate to 25% of that in untreated women.
3. The combination of calcium, estrogen, and fluoride virtually abolished fractures after the first year of treatment.
Since fluoride is a potent stimulator of bone formation and estrogen is a potent inhibitor of bone resorption, the additive effects of these two are effective in making these changes.
Side effects of all these medications, some of them serious, must be considered. Dosages must be monitored closely. Future research should establish better methods of measuring changes in bone mass so that effectiveness of the therapeutic regimen can be determined. Research is also directed at determining indicators of persons who are most prone to developing osteoporosis, so that preventive measures can be instituted.
Last, but not least, continued exereise is important. Exercise increases the rate of bone formation. Immobilization is associated with a dramatic loss of bone mineral. As muscles are strengthened, bone density increases. Activity is also essential to good blood circulation. This increases absorption of all nutrients from the intestinal tract, including calcium.
Nurses have the opportunity and responsibility to effectively improve the quality of life of the older person with osteoporosis. Most nurses should also have a very personal interest in this subject. The majority of nurses are women who will some day have to cope with the prevention or treatment of this condition themselves.
As has been pointed out, diagnosis is usually not made until the bone mass loss is great and a fracture has already occurred. By being observant and making good assessments, you should be able to pick up on clues from the patient and possibly assist the physician in making an earlier diagnosis, subsequently initiating earlier treatment before extensive damage is done. A good assessment of ability to perform activities of daily living will give you clues to the patient's physical disabilities.
If the patient is already on a therapeutic regimen, monitor dosages and side effects of these various drugs. Stress the importance of medication compliance and follow-up visits to the physician. Encourage the patient to report any unusual side effects. If possible, include the family in any teaching to emphasize the importance of continued care.
Diet teaching should emphasize foods high in calcium. High-protein diets are contraindicated, since they have been shown to increase calcium losses. If a high-calcium diet cannot be tolerated, supplemental calcium will probably be necessary.
Emphasize the importance of continued exercise to the patient. There may be times, such as after a vertebral fracture, when bed rest will be indicated for a period of time. Generally, however, as much activity should be maintained as possible. Fracture prevention is a very important part of osteoporosis therapy. Attention should be given to accident prevention. Home furnishings may have to be rearranged to make a safer living environment. Patients should also be cautioned against heavy lifting and bending. Even minor trauma can cause vertebral fractures. Microtrauma to the spine can be decreased by wearing proper shoes with rubber heels. A cane provides the patient with better balance, reduces the possibility of falls, and decreases the low back pain resulting from weightbearing.12
So, is osteoporosis an inevitable condition in aging? It does seem to be a part of aging, particularly in the white postmenopausal woman. However, new methods of treatment yield good results in both prevention and treatment of existing osteoporosis. Increased knowledge about the tendency of some persons to develop osteoporosis may serve as an impetus for earlier recognition of symptoms and initiation of treatment.
The outstanding research finding at this time is that no definitive treatment has been established. However, increased interest and work in this field is encouraging. There is a promise of a better understanding of the physiology of skeletal system changes and the endocrine and other systems' influence on bone remodeling and calcium balance. A better understanding of this underlying physiology /pathophysiology should aid in the selection and institution of effective sequential and/or combination drug therapies.
Unless the patient is a participant of a formal research study sample, effectiveness of the therapeutic regime will be largely measured by subjective data (pain, mobility, and ability to perform daily activities) and objective data (observation of changes in these areas, changes in physical appearance, and actual fractures). Your observation and assessments in these areas will contribute to management of the treatment and guide its effectiveness. In the aging individual, other physical and emotional problems may compound the problem of osteoporosis. Each person must be considered an individual with unique needs. Plan your nursing care accordingly.
You, as a nurse, definitely have the opportunity to participate in assessment, nursing care and intervention planning, and evaluation of this condition. It is an opportunity to improve the quality of the older person's life and possibly increase his/her functional abilities. All efforts should be made to improve their physical condition. Don't just consider these degenerative, debilitating changes an "inevitable" part of aging.
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- 4. Quigley MM: Post-menopausal oestrogen replacement therapy: an appraisal of risks and benefits. Drugs 1981; 22:153-159.
- 5. Gruber HE, Bay link DJ: The diagnosis of osteoporosis. J Am Geriatr Soc 1981; 29:490-497.
- 6. Chesnut CH: Treatment of postmenopausal osteoporosis: some current concepts. Scott Med J 1981;26:72-80.
- 7. Heaney RP: Premenopausal prophylactic calcium supplementation. JAMA 1981; 245:1362.
- 8. Heaney RP. Recker RR, Saville PD: Calcium balance and calcium requirements in middleaged women. Am J Clin Nutr 1977; 30:1603-1611.
- 9. Dixon ASU: Non-hormonal treatment of osteoporosis. Br Med J 1983; 286(6370): 999-1000.
- 10. Riggs BL. Hodgson SF, Hoffman DL, et al: Treatment of primary osteoporosis with fluoride and calcium. JAMA 1980; 243:446449.
- 11. Riggs BL. Seeman E, Hodgson SF. et al: Effect of the fluoride/calcium regimen on vertebral fracture occurrences in postmenopausal osteoporosis. N Engl J Med 1982; 306(8):446-450.
- 12. Sinaki M: Postmenopausal spinal osteoporosis - physical therapy and rehabilitation principles. Mavo Clin Proc 1983; 57:699-703.