The nursing home crack: even the best care will be challenged by osteoporosis. (Caregiving).

MANY 60-YEAR-OLD WOMEN SAY THEY FEAR FALLING, knowing how easily they can break a bone.

Their fear is well founded: The National Osteoporosis Foundation (NOF) attributes more than 1.5 million fractures annually to osteoporosis. (1)

Osteoporosis is often called a "silent disease," because many people don't know they have it until their bones become so weak that a sudden strain, bump, or fall causes a fracture. Ten million people in the U.S. already have osteoporosis while another 34 million are at risk for developing it because they have low bone mass, known as osteopenia.

Women are not alone in their susceptibility. Approximately 2 million men suffer from it and many more have low bone density as well, according to the osteoporosis foundation. One in four men over age 50 eventually will have an osteoporosis-related fracture. (1)

But it isn't just the statistics on fractures that are alarming--it's the morbidity and mortality associated with the fractures. Approximately one-fourth of patients age 50 and over who sustain a hip fracture die in the following year, according to the osteoporosis foundation. Long term care subsequently will be required by 25 percent of those who were ambulatory prior to the fracture.

Resorption, replacement, and risks

Bones are constantly undergoing remodeling, a complex process that balances two forces--resorption and replacement. During the resorption process, osteoclasts release acids and enzymes that remove minerals and collagen from old bone creating small pits on the bone surface. Now the replacement process begins. Osteoblasts move in and form a collagen matrix in the pits, which become mineralized, leading to new bone formation.

Replacement usually predominates over resorption until about age 35 when peak bone mass is achieved. Then, for a while, they are in balance so there is no net change in bone mass. At the onset of menopause, resorption becomes stronger than replacement and there is a gradual net loss of bone. Thus begins the road to osteopenia and osteoporosis. (2)

"Some risk factors are controllable and some are not," explains Stanley Wallach, MD, clinical professor of medicine at New York University School of Medicine and co-director of the Osteoporosis Center at the Hospital for Joint Diseases in New York. (3)

Smoking and drinking too much, inadequate intake of calcium and vitamin D, and too little physical activity are lifestyle practices that place an individual at risk. And certain medical conditions--early menopause, eating disorders, hormone deficiency, malabsorption, or chronic liver or kidney disease--will increase risk if not treated or managed appropriately.

"There are also things we do as physicians that predispose to bone loss," Wallach says. These include "excessive corticosteroid treatment, thyroid hormone replacement beyond the person's need, chronic heparin therapy, radiotherapy to the skeleton, and long-term use of anti-convulsants."

Recognizing who's at risk

Presence of osteoporosis and the risk for fracture can be assessed initially by medical history, presence of risk factors, and physical examination. "It isn't hard to detect osteoporosis with kyphosis by a good examination of the back," says Wallach.

Bone-mineral density (BMD) studies can be used to diagnose osteoporosis. One commonly used is the dual X-ray absorptiometry method (DEXA), which takes measurements at the spine, hip, or forearm and converts them to a T-score of standard deviations (SD) comparing the patient's reading with that of a young adult. A score of less than minus one SD is considered normal, while between minus one and minus two and a half SD is osteopenia. A deviation of minus two and a half is termed osteoporotic.

Medications for prevention and treatment of osteoporosis decrease bone resorption or promote bone formation, according to Manju Beier, PharmD, clinical assistant professor at the University of Michigan. (3) Antiresorptive medications reduce the rate of bone turnover by balancing resorption with bone formation, she says. (See "FDA-approved medications for osteoporosis," page 32.) But Beier cautions, "Patients with low bone density may still continue to have fractures because antiresorptive treatment results in either no change in bone mass or minimal increase."

Easing the bumps

Carlos Rojas-Fernandez, PharmD, of the Texas Tech University Health Science Center in Amarillo, believes that nursing home residents are not receiving adequate treatment for osteoporosis. Between 1992 and 1996 he and his colleagues studied nearly 30,000 residents with a diagnosis of osteoporosis and found that only one-fourth of those over the age of 65 were being treated with the anti-osteoporosis medications then on the market. Of those receiving treatment, only 11 percent were receiving calcium and 2 percent were receiving estrogen.

Rojas-Fernandez cites several possible reasons for this underuse of anti-osteoporotic drugs. Physicians may be concerned about drug-interaction effects in residents already taking numerous drugs, there may be concern about the higher costs of some of the newer drugs, or there may not even be awareness that the resident has the disease.

Every nursing home resident should receive therapeutic doses of calcium and vitamin D, says Rojas-Fernandez. Even if a resident does not have full-blown osteoporosis, the precursor condition is almost certainly there.

Calcium plus vitamin D

Ensuring that nursing home residents get adequate nutrients to prevent or treat osteoporosis can be a major challenge for dietary and nursing staff alike. The daily recommended intake of calcium is 1,200 mg for older adults but 1,500 mg if osteoporosis is present. Foods rich in calcium are dairy products, green vegetables, tofu, fish, and shellfish. A daily dose of 400 LU of vitamin D is recommended to absorb the calcium. Milk, fish, and eggs are sources of vitamin D, as is adequate exposure to sunlight. (2)

Individualizing the diet to meet resident needs is important, says Janet Johnson, RD, who consults with long term care facilities in Minneapolis. Likes and dislikes must be determined before developing the dietary plan, she says. Getting residents to eat enough to meet daily caloric and nutritional requirements may he a big challenge. Therefore supplements frequently are necessary, says Johnson.

Lactose intolerance, absorption abilities, and hydration all need to be factored in. Johnson emphasizes that the resident must get plenty of fluids, especially water, because hydration is so important.

Weight-bearing exercise

Maintaining an exercise program adapted to the person's abilities will help to maintain bone density and possibly reduce the chances of fracture. Walking or low-impact aerobics are good choices but need to be modified when movement becomes more difficult.

"Residents should be kept walking as long as possible," says Chris Radcliffe, director of senior care therapy for HealthEast Care System in St. Paul, Minn. 'But for the wheelchair-bound, standing during a transfer technique and wheelchair push-ups will provide some weight-bearing exercise." Pay special attention to the resident's posture and movement, continues Radcliffe. A resident with vertebral osteoporosis may sustain a fracture by moving too quickly or flexing the spine. She suggests using reachers and other adaptive equipment to avoid flexion.

Tai chi is highly recommended as an exercise for the person who is able to stand independently. It is a gentle, rhythmic weight-bearing exercise that promotes balance, coordination, and flexibility, Nicholson says.

Fall prevention

One of the biggest challenges facing staff in caring for the osteoporotic resident is that of minimizing falls and ultimately preventing fractures.

A number of strategies may be included in the fall-prevention program, including the exercises already mentioned. Other strategies include medication-regimen review to determine whether drugs used for other conditions may be causing confusion, lack of balance, or sedative effects. Environmental modifications include adequate lighting and clutter-free halls and rooms. Equally important are appropriate footwear and well-maintained walkers and wheelchairs.

References

(1.) National Osteoporosis Foundation (2002). Disease statistics; Patient Into. Available online at <www.nof.org>.

(2.) Phipps w, sands J, Marek J. Medical-Surgical Nursing: Concepts and Clinical Practice. 6th ed. St. Louis: Mosby; 1999. 2004-21.

(3.) Wallach S, Beier M, Lyles K, et al.. Innovative treatment of osteoporosis. Nursing Home Medicine: The Annals of Long-Term Care. Available online at <www.mmhc.com/nhm/articles/NE1M99O7/reporter.htmi>.

(4.) Wallace R. Bone health in nursing home residents. JAMA. 2000:284(5): 1018.

RELATED ARTICLE: FDA-approved medications for osteoporosis

BIPHOSPHONATES

Alendronate sodium. Prevention and treatment postmenopausal women, treatment in men. Reduces bone loss; increases bone density; reduces risk of spine, wrist, hip: fractures.

Risendronate sodium. Prevention and treatment postmenopausal. Slows bone loss increases bone density; reduces risk of spine and non-spine fractures.

CALCITONIN 

Naturally occurring hormone involved in calcium regulation and bone metabolism. Injection or nasal spray Cannot be given orally. Slows bone loss, increases spinal bone density Anecdotally may relieve fracture pain.

REPLACEMENT THERAPY

Estrogen replacement therapy (ERT). pill form or skin patch. Reduces bone loss; increases bone density in spine and hip; reduces risk of hip and spinal fractures postmenopausal National Cancer Institute recently reported increased ovarian cancer risk with long-term use.

Hormone replacement therapy (HRT). Combination of estrogen and progestin to reduce risk of uterine cancer in women with intact uterus. Women's Health Initiative study recently confirmed that while Prempro (one type of HRT) reduced risk of hip and other fractures, and colon cancer, it was associated with a modest increase in breast cancer, stroke, heart attack, and venous blood clot risk.

RALOXIFENE

Prevention and treatment postmenopausal. Type of Selective Estrogen Receptor Modulators (SERMs) developed to provide beneficial effects but not disadvantages of estrogen. Increases bone mass, reduces risk of spine fractures.

SOURCE: NATIONAL OSTEOPOROSIS FOUNDATION (2002). ONLINE At <www.NOF.ORG/PATIENTFO/MEDICATIONS.HTM>.

Woodbury, Minn.-based Janice K. Olson is a member of CLTCs advisory board, and former Director of Nursing with the Amherest H. Wilder Foundation in St. Paul.