Continuing the Effort to Improve Outcomes||in Osteoporosis among Aging Adults

Since our last issue focusing on osteoporosis, much has changed and yet much stays the same. We have new Canadian guidelines on the detection and management of osteoporosis, several new treatment modalities, and a better understanding of osteoporosis in men. However, many people with osteoporotic fractures are not identified and managed, many people do not stay on effective treatment, and falls prevention programs are rarely available for appropriate older adults. In other words, we have a long way to go before we can say we are dramatically ameliorating the morbidity that osteoporosis causes. Hopefully, this edition of Geriatrics & Aging will do its part to promote the effective diagnosis and management of this important disorder.

Two articles tackle the important issue of diagnosing osteoporosis and determining who is at particular risk for complications. Dr. Angela Juby and Dr. David Hanley review “Diagnostic Tools for Osteoporosis in Older Adults” while Dr. Aliya Khan and Mohammed Rahman discuss one of the key issues in their article “Osteoporosis Screening and Assessment of Fracture Risk.” In our CME article, Dr. Savannah Cardew reviews “New Pharmacotherapy for Osteoporosis.” Our final focus article concentrates on a group at high risk of having osteoporosis and not being treated. Cathy Kessenich and Darlene Higgs review “Osteoporosis Fracture Prevention in Long Term Care.”

We also have our usual collection of key geriatric topics. My colleague, Dr. M. Bachir Tazkarji reviews the important area of “Blood Pressure and Cardiovascular Risk among Older Adults.” Dr. Ekaterina Rogaeva reviews an area of intense research scrutiny in her article on “The Genetic Profile of Alzheimer’s Disease: Updates and Considerations.” Dr. Sophie Robichaud and Dr. Joseph Blondeau address a common problem in their article “Urinary Tract Infections in Older Adults: Current Issues.” Educating students, residents, and even ourselves in proper medical care of the older adult has been a tremendous challenge so any improvements offered via technology are much appreciated. In their article, Drs. Anita Bagri, Bernard Roos, and Jorge Ruiz discuss “Simulation Technology in Geriatric Education.” And our Sexual Health column, written by Drs. Irwin Kuzmarov and Jerald Bain of our partner organization the Canadian Society for the Study of the Aging Male, looks at the important matter of "Sexuality and the Aging Couple, Part I: The Aging Woman."

Enjoy this issue,
Barry Goldlist

POWER in Osteoporosis: Descriptive Review of a Multidisciplinary Community-Based Prevention and Management Program

Michael Gordon, MD, MSc, FRCPC, FRCP Edin, Medical Program Director, Palliative Care Baycrest Geriatric Health Care System; Professor of Medicine, University of Toronto, Toronto, ON.
Kayi Li, BHSc, medical student, University of Toronto, Toronto, ON.

Osteoporosis is a systemic disease resulting in bone fragility and increased risk of fractures. For optimal prevention, the literature increasingly supports the combined use of education on nutrition, lifestyle, and exercise. Currently, multidisciplinary, multimodal initiatives are rarely implemented in the community. The POWER (Promoting Osteoporosis Wellness through Education, Exercise and Resources) program in Toronto, Ontario, strives to empower individuals with osteoporosis with diverse cultural backgrounds to sustain healthy behaviours for self-management of their condition. This article provides a description of the POWER program philosophy, as well as a preliminary evaluation to assess its benefits and potential for further expansion and adaptation.
Key words: osteoporosis, management program, cultural differences, education, health beliefs.

Use of Calcium or Calcium in Combination with Vitamin D Supplementation to Prevent Fractures and Bone Loss in People Aged 50 Years and Older

With osteoporosis fractures increasing in prevalence worldwide, the prevention of fractures has become a major economic and social burden. In addition, nations with poorer health care systems in Asia, Africa, and Latin America are facing aging populations, making the development of affordable preventative therapy especially important.

Supplemental calcium, either alone or in combination with Vitamin D, has been suggested as an inexpensive treatment for the prevention of osteoporotic bone loss and fractures. Data from clinical trials have resulted in inconsistent results regarding the efficacy of this treatment in preventing bone loss and fracture. Tang et al. have synthesized a meta-analysis of randomized trials in which calcium, or calcium in combination with vitamin D, was used to prevent osteoporotic fracture and bone loss in adults over 50 years of age in an effort to offer a comprehensive review of all the relevant evidence.¹

Their findings supported the use of calcium and vitamin D supplementation. When data were pooled, it was revealed that supplementation had resulted in a reduction of 12% in bone fractures of all types (risk ratio 0.88, 95% CI 0.83-0.95; p=0.0004), and a 0.54% decrease in bone mineral density loss (0.35-0.73; p<0.0001) at the hip and 1.19% (0.76-1.61%; p<0.0001) in the spine.

The authors conclude that the evidence supports the use of calcium, or calcium in combination with vitamin D supplementation, as preventative therapy for osteoporosis in adults over 50 years of age. In addition, they suggest a minimum dosage of 1200 mg for calcium and 800 IU of vitamin D for optimal therapeutic effect.

Reference

1. Tang BM, Eslick GD, Nowson C, et al. Use of calcium or calcium in combination with vitamin D supplementation to prevent fractures and bone loss in people aged 50 years and older: a meta-analysis. Lancet 2007;370:657-66.

Osteoporosis Screening and Diagnosis

Rowena Ridout, MD, FRCPC, Toronto Western Hospital, Toronto, ON.

Osteoporosis is a significant cause of morbidity and mortality in the older population. Bone density testing is recommended for all men and women 65 or older. In postmenopausal women, and in men over the age of 50, testing is recommended for those at high risk for osteoporosis. Effective therapy is available for those at risk for fracture. Bone density testing combined with clinical risk factors, including age and fracture history, can be used to assess fracture risk and identify those individuals most likely to benefit from drug therapy.
Key words: osteoporosis, bone density, fracture, diagnosis.

Physical Activity for the Prevention and Treatment of Osteoporosis

Panagiota (Nota) Klentrou, PhD, Associate Professor, Department of Physical Education and Kinesiology, Faculty of Applied Health Sciences, Brock University, St. Catherines, ON.

Physical activity/exercise can provide an important tool for both the prevention and treatment of osteoporosis. Physical stress transmits load to the bone and can improve or maintain its structural competence and strength. Participation in weight-bearing activities during adolescence is an effective method to achieve an ample peak bone mass and to reduce the risk for the later development of osteoporosis. Postmenopause, the ideal exercise to stimulate bone mineral density would involve progressive, resistive-type training involving overloading of some nature.
Key words: functional loading, weight-bearing activities, resistance training, peak bone mass, bone mineral density.

Nonpharmacologic Prevention and Management of Osteoporosis

Cathy R. Kessenich, DSN, ARNP, Professor, Department of Nursing, University of Tampa; Nurse Practitioner, Private Practice, Tampa, FL, USA.

Osteoporosis is a chronic, debilitating disease that is most distressing to patients and health care providers in the occurrence of fractures of the hip and spine. The lasting effects of vertebral and hip fractures can cause pain, deformity, and emotional distress. Various nonpharmacological modalities may be used adjunctively with prescribed agents to improve the quality of life of patients with fractures due to osteoporosis. Research evidence and clinical experience have determined that nutritional support, exercise and rehabilitation, pain management, orthopedic surgeries, fall prevention, alternative therapies, education, and social support may assist patients in coping with the pervasive effects of osteoporotic fractures. Clinicians need to be informed and encouraged about the use of nonpharmacological measures to assist patients at risk for experiencing the culminating event of this devastating disease.
Key words: osteoporosis, osteoporotic fracture, osteoporosis management.

New Drug Therapies for Osteoporosis

Angela M. Cheung, MD, PhD, FRCP(C), CCD, Director, Osteoporosis Program, University Health Network and Mount Sinai Hospital; Associate Director, Women’s Health Program, University Health Network; Associate Professor, University of Toronto, Toronto,ON.

Osteoporosis is common in postmenopausal women and older men. There are various efficacious therapies for the treatment of osteoporosis and the prevention of osteoporotic fractures in Canada. First-line therapies include alendronate, risedronate and raloxifene; all of these are oral antiresorptive therapies. In this article, we review new drug therapies currently or soon to be available in Canada, such as bone formation therapies (parathyroid hormone and strontium ranelate) and intravenous infusions (such as zoledronic acid), and compare them to existing therapies.
Key words: osteoporosis, osteoporotic fractures, parathyroid hormone, strontium, zoledronic acid.

Nutritional Interventions in Osteoporosis

The accredited CME learning activity based on this article is offered under the auspices of the CE department of the University of Toronto. Participating physicians are entitled to one (1) MAINPRO-M1 credit by completing this program, found online at www.geriatricsandaging.ca/cme

Susan J. Whiting, PhD, College of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon, SK.
Hassanali Vatanparast, MD, College of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon, SK.

This review describes the current state of knowledge in nutritional interventions in osteoporosis, using the Osteoporosis Society of Canada’s (OSC) 2002 clinical practice guidelines for the diagnosis and management of osteoporosis as a basis. Nutrients important for osteoporosis are calcium, vitamin D, protein, sodium, caffeine, and isoflavones. These recommendations are updated and other nutrients and food components, not covered in the OSC 2002 report, are described. As a single nutrient approach is no longer warranted, we discuss how the Dietary Approaches to Stop Hypertension (DASH) diet can be used to provide appropriate intakes of many key nutrients for persons with, or at risk of, osteoporosis.
Key words: DASH diet, calcium, vitamin D, protein, osteoporosis.

Fragile Bones

Enjoy this issue.
Barry Goldlist

Osteoporosis: Preventing the Deterioration of Bone

L. Giangregorio, PhD, Lyndhurst Centre, Toronto Rehabilitation Institute, Toronto, ON.
A. Papaioannou, MD, Department of Medicine, McMaster University, Hamilton, ON.
J.D. Adachi, MD, Department of Medicine, McMaster University, Hamilton, ON.

Osteoporosis is characterized by compromised bone strength, predisposing a person to an increased risk of fracture. The wrist, hip, and spine are the most common sites for fractures associated with osteoporosis. The economic and human costs of osteoporosis-related fractures are considerable. Although it is often considered a woman’s disease, osteoporosis is a significant source of morbidity and mortality in men. Available pharmacological treatments for osteoporosis include bisphosphonates, selective estrogen receptor modulators, calcitonin, parathyroid hormone, and hormone replacement therapy. Non-pharmacological interventions, such as nutritional counselling, exercise, and fall prevention, should also be considered in a fracture prevention plan.
Key words: osteoporosis, fragility fracture, bone, skeleton, bone density.