Osteoporosis is becoming an increasingly significant health problem in our society as the percentage of elderly persons in our population expands. Post-menopausal and elderly women are especially at risk for developing osteoporosis and the fractures that often occur as a result of this common bone disorder. The most common sites of fracture in osteoporosis include the proximal femur (hip), distal radius (wrist), and vertebral body.1
Osteoporosis and its associated fractures exact a tremendously high toll not only in economic terms, but also in terms of physical and psychological morbidity, and even mortality.
Gerontological nurses, as health care providers, need to understand the problem of osteoporosis and the disabilities that it typically evokes. Armed with knowledge, nurses can be instrumental in providing competent care for individuals with established osteoporosis and in providing counseling and education in order to, hopefully, prevent the disorder in persons at risk for developing it.
This article provides an overview of osteoporosis and its frequent result, vertebral fractures. Whereas, an adequate number of resources are available to guide nurses in providing care for clients with hip fractures, there is minimal information available to direct nurses in providing care for clients with osteoporotic vertebral fractures.
Osteoporosis is defined as a condition in which there is a decrease in total bone mass. The chemical composition of the bone remains normal. However, there is simply less bone.2·3 The loss of bone substance causes the bone to become mechanically weakened and prone to either spontaneous fractures or fractures due to minimal trauma.
Since these fractures are such a frequent end result of bone loss, some authorities believe that a person can be said to have osteoporosis only when a fracture due to bone loss has occurred. Other authorities, however, believe that "the term osteoporosis should be applied when bone mass is below that expected for age and sex, irrespective of whether fracture has occurred."4
Osteoporosis is classified as being either primary or secondary. Primary osteoporosis includes postmenopausal, senile, and idiopathic osteoporosis. Secondary osteoporosis refers to bone loss that is secondary to inherited or acquired abnormalities.5
There are various opinions as to the precise differentiation between "postmenopausal osteoporosis" and "senile osteoporosis." While some authorities make specific distinctions, other authorities use the terms almost interchangeably. Since the focus of this article is osteoporosis and its effects in older women, it is very clear that not only the estrogen deficiency that characterizes the postmenopausal state, but also the usual loss of bone that occurs with aging will be influencing the bone mass of this particular group.
Osteoporosis is estimated to be present in one out of every four postmenopausal women in North America and northern Europe.6 Recent studies indicate that at least 10% of women over age 50 in the United States have severe enough bone loss to result in fractures.7
In particular, one in four women (nine million) will experience a compression fracture of the spine by age 60. One out of every two women (18 million) will have had a compression fracture of the spine by the age of 75 years.8
An understanding of osteoporosis is facilitated by knowledge of bone physiology. It is particularly helpful to understand the process of "bone remodeling." Bone remodeling refers to the continuous and cyclical process by which bone is being broken down and rebuilt. "What actually happens is that small quantities of bone are lost through breakdown (resorption) on the inner surface (the surface lining the marrow cavity), while at the same time new bone is formed on the outer surface."9 A person's bone mass is maintained by the two processes of bone formation and bone resorption. When an imbalance between these two processes occurs, then bone mass can be lost. For example, if either bone formation is decreased, or bone resorption is increased, or if both occur, then bone mass will be decreased.
It is also important to recognize the differences between the two basic types of bone tissue. One type is called cortical bone - this type appears solid and dense. The other type is called trabecular bone - this type appears more porous and resembles a honeycomb. "Every bone is composed of both types, with trabecular inside, surrounded by the cortical. The relative proportions of each differ from one bone to another and even within parts of an individual bone. "9 The long bones of the arms and legs are composed mainly of cortical tissue with areas of trabecular tissue at both ends. Bones of this type are referred to as tubular bones. The vertebrae are composed primarily of trabecular tissue surrounded by a thin layer of cortical tissue. Bones of this type are called cancellous bones. The bones or parts of bones that have a high proportion of trabecular tissue are the most susceptible to the effects of osteoporotic changes. "Three excellent examples of cancellous bone are the vertebral body, proximal femur, and distal radius, ie, the three major sites of fracture in osteoporosis."1
Factors Associated with the Development of Osteoporosis
Aging - Maximal bone density is attained at maturity. Thereafter, there is a gradual, but continuous, loss of bone tissue on both sexes. For women, loss of trabecular bone starts in young adulthood and continues throughout life. Loss of cortical bone, in women, usually starts at menopause and accelerates until about age 65, at which time the loss decelerates.10 By age 80, a woman will have lost nearly 50% of her trabecular bone.9
Estrogen Deficiency - The association between the declining estrogen levels that accompany menopause and the acceleration of osteoporosis has been well supported by research. The mechanisms responsible for the protective effects of estrogens on bone have not been identified. However, some research has indicated that the loss of bone mass associated with decreased estrogen levels may be caused by the sensitization of the skeleton to the effects of parathyroid hormone (PTH) which leads to increased bone resorption.1
As a general rule, women experiencing an early menopause have a greater risk of developing osteoporosis than do women experiencing a later menopause. Women who have an artificial menopause due to removal of the ovaries experience an abrupt and nearly complete loss of estrogens and are especially at risk for osteoporosis.9
Diet - It is probable that nutritional factors play an important role in the development of osteoporosis. Specifically, a calcium deficiency in the diet has been demonstrated to be associated with osteoporosis. Indeed, low calcium intakes have been associated with higher fracture rates in all age groups. Older persons often have a chronically low calcium intake. Also, many older persons do not absorb calcium efficiently. In addition, there is a significant proportion of the adult population that have a lactose intolerance and can not tolerate milk or milk products - a major dietary source of calcium.11·12·13,14
Some research has suggested that the ratio of calcium to phosphorous in the diet is more important than the absolute intake of either mineral. It is suggested by some authorities that the ratio should be 1:1. This ratio is difficult to attain, however, because few foods contain large amounts of calcium and small amounts of phosphorous. On the other hand, many common foods are high in phosphorous and low in calcium.8
Vitamin D deficiency has also been implicated as a dietary factor in the development of osteoporosis. This vitamin is the primary factor responsible for the active transport of calcium via the intestine.15
While an adequate amount of protein is necessary for skeletal health, it has been shown that an excessively high protein intake can enhance bone loss.12
Genetic Background and Body Characteristics - There is a much higher incidence of osteoporosis in white women than in black women. Specifically, white women with a northwestern European background are at especially high risk, while women of Mediterranean descent have a lower incidence of osteoporosis.16
It has been found that small, slender women are more likely to develop osteoporosis than are tall, heavy women. Although the reason for this is not known, it has been suggested that the reason may be that androgens can be chemically converted to estrogens in fat tissue. Thus, the obese woman has a greater ability to produce estrogens after menopause than do slender women.9
Activity Level - It has been well established that persons of all ages experience bone loss with prolonged periods of immobility. Regular exercise is essential for the maintenance of bone mass. Indeed, exercise seems to not only stop bone loss, but to stimulate the formation of new bone.9
Diseases and Drugs - Some diseases are associated with a higher risk of developing osteoporosis. These diseases include the following: hyperparathyroidism, hyperthyroidism, Cushing's syndrome, kidney disease, rheumatoid arthritis, advanced alcoholism, cirrhosis of the liver, and diabetes mellitus.8·9
Certain drugs may be associated with bone loss. These drugs include the following: corticosteroids, isoniazid, tetracycline, some anticonvulsants, aluminum-containing antacids, thyroid supplements, furosemide, and heparin.9·15
Making the Diagnosis
Problem of Early Diagnosis - One of the biggest problems associated with osteoporosis is that early detection is extremely difficult. Osteoporosis can be called a silent disease because there are no early symptoms to alert a woman or her physician to bone loss until substantial damage has already occurred. While there are sophisticated tests available, such as dual photon absorptiometry and computed tomography, to detect early loss of bone, these tests are, for the most part, reserved for use in clinical research.17
In most cases, osteoporosis is discovered either when a women suffers a vertebral compression fracture or when a radiologist notes decreased bone density on x-rays taken for an unrelated problem. Unfortunately, osteoporosis can be noted by standard x-ray only when 30-40% of the mineral content of the bone has been lost.1·18
Clinical Manifestations - Since the development of a vertebral compression fracture is often the earliest evidence of osteoporosis, this event deserves attention. The most typical clinical picture of a vertebral compression fracture is the onset of sudden, severe pain in the affected area with associated paravertebral muscle spasms and localized tenderness. The pain may radiate to the abdomen or chest. The pain is usually most severe when the woman sits or stands.19
A vertebral compression fracture typically occurs after minimal trauma. For example, activities such as opening a window, lifting a child, making a bed, stepping from a curb, coughing, stooping, getting up out of a chair, or even receiving a hug can be precipitating factors. In some cases, there is no specific precipitating factor. The weakened vertebral body simply collapses due to the weight of the body. The lower thoracic or upper lumbar vertebrae are those most often affected.
In describing osteoporotic changes of the vertebral bodies, several terms are used. The term "wedge fracture," or wedging, is used to describe the condition present when the anterior side of the vertabra collapses. Thus, the anterior height of the vertebra is less than the posterior height. As the condition progresses , the posterior side of the vertebra may collapse as well. This condition is referred to as a compression fracture, a crush fracture, or a totally collapsed vertebra. Thus, in a compression fracture, both the posterior and the anterior heights of the vertebra are reduced.2
FOODS HIGH IN CALCIUM
The pain experienced due to a vertebral fracture can be differentiated into two phases. The acute phase is due to the actual fracture and damage of the surrounding tissue, as well as muscle spasms. This pain usually subsides in from one to three months, when the bone has healed into a new, collapsed form. The chronic phase is due primarily to muscle spasm and ligament strain that can occur as a result of the increased lumbar lordosis that occurs from the increased anteroposterior curvature at the fracture site. This pain can last from three to six months. If a person has multiple compression fractures, there may be long-term continuing back pain as a result of mechanical stress on ligaments, muscles, and joints.10 Some persons with compression fractures may simply complain of a chronic backache or state that they have a "tiredness in the back. " This discomfort is usually relieved by rest.5 Interestingly, there is no correlation between the degree of damage present and the degree of pain perceived by the client. Some clients with totally collapsed vertebrae can be completely asymptomatic . 15
The occurrence of multiple vertebral fractures over time can lead to a progressive loss of height, an increased lumbar lordosis (inward curvature of the lower spine), thoracic kyphosis (outward curvature of the upper spine which is commonly referred to as dowager's hump), and a protruding abdomen.9 It is not uncommon for a person to lose two to three inches of height. It is possible for a person to lose from eight to 12 inches of height. The deformity may become so pronounced that eventually the ribs actually come to rest on the anterior iliac crest. Problems associated with this include decreases in both thoracic and abdominal volumes. A decrease in exercise tolerance occurs due to decreased lung expansion; whereas, a feeling of early satiety occurs because of changes in the abdomen. Needless to say, the obvious physical changes that result from vertebral fractures can pose significant body image problems.19
Prevention of Osteoporosis
During childhood and adolescence a diet that is nutritionaly balanced and includes generous amounts of calciumcontaining foods is imperative. See Table 1 for a list of good sources of calcium. The habit of regular exercise should also be established at this time.
The woman in young adulthood should continue sensible diet patterns and be aware that an adequate calcium intake is as important for her as it is for the growing child. Of particular note is the fact that calcium requirements are increased during pregnancy and lactation. It is during young adulthood when bone mass is at its greatest. Every effort should be made to insure that the bone mass is in its most optimal condition to protect against the inevitable (to some extent) future losses. Regular exercise should continue during the young adult years.
During the perimenopausal and postmenopausal years the preventive regimen should become more vigorous. Specifically, an increase in calcium intake is recommended at this time. While the United States recommended daily allowance (RDA) of calcium is set at 800 mg./day, it is likely that this quantity is inadequate to maintain bone mass in perimenopausal and postmenopausal women. It is suggested by some authorities that women in these groups ingest from 1.0 to 1.5 grams of elemental calcium per day.20 Since it may be difficult for some women to take in this amount of calcium via dietary intake alone, calcium supplementation is often advised. A wide variety of calcium supplements are available. They vary greatly in the amount of elemental calcium that they provide (see Table 2).
Postmenopausal women at high risk for the development of osteoporosis may be treated with estrogens. While estrogen therapy has been controversial, it is now generally recongized as being effective in maintaining bone mass, as well as being relatively safe.21,22 "If estrogens are given to postmenopausal women, the consensus is that they should be given in small dose, in interrupted cyclical sequence with progestin and there be withdrawal of both hormones to allow periodic bleeding. Regular examinations should be made for early detection of endometrial neoplasm."3 An unanswered question is for how many years estrogen therapy should be continued.
In the postmenopausal years, exercise continues to be important in maintaining bone mass.23·24
One authority states that "osteoporosis is an example of a disease that may be preventable in many women if physicians and the public became better informed."20
AMOUNTS OF ELEMENTAL CALCIUM PROVIDED BY 1000mg. OF VARIOUS CALCIUM PREPARATIONS
Treatment of Vertebral Fractures
The treatment of vertebral fractures parallels the phases of pain described earlier. Specifically, there is treatment directed toward the acute fracture phase and treatment directed toward the postural back pain phase.25
Acute Fracture Phase - The major treatment during the immediate postfracture phase "consists simply of putting the patient at complete horizontal bedrest but otherwise in any position of comfort, that is, on either side or supine, until the pain subsides sufficiently to allow turning over freely with minimal discomfort. This should take about 7 to 10 days."25 During this phase, analgesics, muscle relaxants, stool softeners and/or laxatives are often prescribed.
After this period, the client is usually fitted with a back support. A variety of supportive devices are available varying from being fully supporting and rigid to being flexible in nature.25·26
Once fitted with an appropriate back support that is acceptable to the client, periods of being out of bed are instituted. At first, the client is permitted to sit up for short but increasingly frequent periods of time. For example, for the first day or two, perhaps the client would sit up for 15 minutes four times daily. This woufd then be increased to 15 minutes eight times daily. After sitting becomes comfortable, walking is begun. As with sitting, it is most helpful and comfortable if periods of walking are frequent but short. For example, walking for ten times daily but for only ten minutes at a time should be tolerable to start with. In a week or so this could be increased to walking ten times daily for 20 minutes at a time. What is excessive activity for a given individual can best be determined by how much discomfort (back pain) the particular activity provokes.25
Hospitalization is not necessarily required during the above period of time, providing that the client understands and is willing to adhere to the treatment plan and has sufficient assistance in the home setting.
In situations where the person has been hospitalized for treatment of a vertebral fracture, discharge would usually occur within several weeks. The client would return home being ambulatory for a large part of the day. However, it is recommended that an intermittent rest regimen be followed until complete healing of the fracture has occurred. Specifically, the client should lie down in a horizontal position for 15 to 20 minutes every two to three hours throughout the day. This regimen should be followed for at least two to three months following the fracture. This routine seems to greatly decrease back pain.25
The primary elements of treatment during the acute postfracture phase are initial bedrest, analgesia, progressive activity, mechanical support, and time.25
Postural Back Pain Phase - Within from one to three months after fracture when the individual is ambulatory for most of the day, there is usually a new development. While the pain of the acute fracture was located in the area of the fracture, the pain now shifts. The site of the new pain is usually in the lumbosacral region. The pain is intensified by activity and improves during horizontal rest. As previously mentioned, the cause of this pain is increased lumbar lordosis, a compensatory mechanism that occurs as a result of the loss of height in the^Bollapsed vertebra. It is encouraging to recognize that this pain is nearly always self-limiting and dissipates within from three to six months when local structural adaptations have occurred. 10 This pain may last for as long as six to nine months.25
The treatment during this' phase consists of continuing use of a lumbosacral support and the continuation of the above described intermittent rest regimen. It is desirable that analgesics not be given in this phase. When a person experiences pain, it is a signal that a rest period is needed.25
General Measures to Treat Osteoporosis
The previously described measures (calcium, exercise, and estrogen) for preventing osteoporosis may also be . useful in treating osteoporosis.
For example, nutrition is an important item to consider. Adequate calcium and vitamin D intake (either through diet alone or through diet and supplementation) may aid in the prevention of future fractures. Specifically, calcium has been shown in some studies to halt bone loss.27
Exercise is also important in the treatment of osteoporosis. However, "it is essential to state that the exercises of the axial-loaded skeleton that may be predicted to be most successful in the prevention of osteoporosis would be hazardous in its treatment because of the risk of fracture. "28 Walking at least one mile per day on a flat surface, with an eventual goal of walking three miles per day should be encouraged.28 Extension exercises of the spine are permitted, but flexion exercises of the spine are not recommended because they can increase the vertical compression forces on the vertebrae and may increase the chance of further compression fractures.26 In general, heavy lifting, stooping, and bending movements should be avoided.
The use of estrogen therapy in the treatment of osteoporosis, as in the prevention of osteoporosis in high risk individuals has been shown to be effective in slowing bone resorption. If used as treatment, the same precautions previously described should be followed.
While the use of fluoride in the treatment of osteoporosis is still experimental, early results of clinical trials are encouraging.29
The avoidance of situations in which fractures would be highly likely to occur is also important. Modifications in the home environment can greatly improve safety.
This article has presented an integrated approach to describing both postmenopausal osteoporosis and vertebral fractures. It is hoped that the foregoing information has provided a solid base for understanding the nursing diagnoses that such clients are likely to have. Nursing diagnoses in the acute fracture phase may include the following: alteration in comfort (back pain), alteration in bowel elimination (constipation), sleep pattern disturbance, impaired physical mobility, selfbathing/hygiene deficit, self-toileting deficit, and anxiety. Nursing diagnoses in the postural back pain phase may include the following: alteration in comfort (back pain), potential for injury, knowledge deficit, impaired physical mobility, and body image disturbance.
- 1. Mallette LE: Osteoporosis: Approaching treatment with optimism. Postgrad Med 1982; 72(5):27 1-278.
- 2. Nordin BEC: Osteoporosis with particular reference to the menopause, in Avioli LV (ed): The Osteoporotic Syndrome: Detection, Prevention, and Treatment. New York, Grune and Stratton Ine, 1983, pp 13-43.
- 3. Whedon GD: Recent advances in management of osteoporosis. Adv Exp Med Biol 1980; 128:597-613.
- 4. Stevenson JC, Whitehead MI: Postmenopausal osteoporosis. Br Med J 1982; 285(634 1):585-588.
- 5. Gruber HE, Bay link DJ: The diagnosis of osteoporosis. J Am Geriatr Soc 1981; 29(ll):490-497.
- 6. Heaney RP: Foreward, in Proceedings of the international Symposium on Osteoporosis (New York City, Oct. 25-27, 1978), sponsored by Marion Laboratories, New York, Biomedical Information Corporation, 1979.
- 7. Avioli LV: Postmenopausal osteoporosis: Prevention versus cure. Fed P roc 1981; 40(9):24 18-2422.
- 8. Gorrie TM: Postmenopausal osteoporosis. JOGN Nurs 1982; 11(4):214-219.
- 9. Notelovitz M, Ware M: Stand Tall! The Informed Woman's Guide to Preventing Osteoporosis. Gainesville, Florida, Triad Publishing Co, 1982.
- 10. Lukert BP: Osteoporosis - A review and update. Arch Phys Med Rehabil 1982; 63(10):480-487.
- 11. Draper HH, Scythes CA: Calcium, phosphorus, and osteoporosis. Fed Proc 1981; 40(9):2434-2438.
- 12. Raisz LG: Osteoporosis. J Am Geriatr Soc 1982;30(2):127-138.
- 13. Seeman E, Riggs BL: Dietary prevention of bone loss in the elderly. Geriatrics 1981; 36(9):71-79.
- 14. Yen PK: Fractures and diet - What's the relationship? Geriatric Nursing 1981; 2(5):327 and 378.
- 15. Spencer H: Osteoporosis: Goals of therapy. HospPract 1982; 17(3): 13 1-148.
- 16. Lane JM: Vlgorita VJ, Falls M: Osteoporosis: Current diagnosis and treatment. Geriatrics 1984; 39(4):40-47.
- 17. Heath H: Progress against osteoporosis. Ann Intern Med 1983; 98(6):101 1-1012.
- 18. Lane JM, Vigorita VJ: Osteoporosis. J Bone Joint Surg 1983; 65-A(2):274-278.
- 19. Jackson TK, Ullrich IH: Understanding osteoporosis: Cornerstone of prevention and treatment. Postgrad Med 1984; 75(2):118-125.
- 20. Whedon GD: Osteoporosis. New Engl J Med 1981; 305(7):397-399.
- 21. Saville PD: Post-menopausal osteoporosis and estrogens: Who should be treated and why. Postgrad Med 1984; 75(2): 135-143.
- 22. Sedlacek TV: Postmenopausal estrogen therapy. Am Fam Physician 1983; 28(l):207-208.
- 23 . Aloia JF: Exercise and skeletal health. J GeriatrSoc 1981; 29(3): 104-107.
- 24. Yeater RA, Martin RB: Senile osteoporosis: The effects of exercise. Postgrad Med 1984; 75(2): 147-163.
- 25. Frost HM: Clinical management of the symptomatic osteoporotic patient. Orthop Clin North Am 1 98 1 ; 1 2(3):67 1 -68 1 .
- 26. Sinaki M: Postmenopausal spinal osteoporosis: Physical therapy and rehabilitation principles. Mavo Clinic Proc 1982; 57:699-703.
- 27. Lee CJ, Lawler GS, Johnson GH: Effects of supplementation of the diets with calcium and calcium-rich foods on bone density of elderly females with osteoporosis. AmJ Clin Nutr 1981; 34(5):8 19-823.
- 28. Aloia JF: Estrogen and exercise in prevention and treatment of osteoporosis. Geriatrics 1982; 37(6):81-85.
- 29. Riggs BL, et al: Effect of fluoride/calcium regimen on vertebral fracture occurrence in postmenopausal osteoporosis. New Engl J Med 1982; 306(8):446-450.
FOODS HIGH IN CALCIUM
AMOUNTS OF ELEMENTAL CALCIUM PROVIDED BY 1000mg. OF VARIOUS CALCIUM PREPARATIONS