4Osteoporosis 2010 Definition: Osteoporosis is defined by the World Health Organization (WHO) in women as a bone mineral density 2.5 standard deviations below peak bone mass (20-year-old healthy female average) as measured by DXA.
5Audience Response Question So with all of these bad things in our futureHow are we doing in controlling HTN?4Not to wellWe have our work cut out for us
6Audience Response Question My current knowledge and understanding of osteoporosis is best described by which of the following:I should be giving this lecture.I recognize most risk factors and treatment protocols but could use a refresher or tune-up.I am a bit rusty but it will all come back to me.Osteo - what?Opinion, no correct answer.
7Osteoporosis 2010The link between age-related reductions in bone density and fracture risk goes back at least to Astley Cooper.
8Osteoporosis 2010The term "osteoporosis" and recognition of its pathological appearance is generally attributed to the French pathologist Jean Lobstein .
9Osteoporosis 2010The American endocrinologist Fuller Albright linked osteoporosis with the postmenopausal state.
10Osteoporosis 2010A major U.S. public health threat for 44 million men and women over age 50.Osteoporotic fractures responsible for:500,000 Hospitalizations800,000 ER visits2.6 million physician visits180,000 nursing home placements
11Osteoporosis Prevalence in U.S. Alabama = 2ndGeorgia = 11thFlorida = 22nd
12Osteoporosis 2010In 2005: > 2 million osteoporotic fractures reported.Treatment Costs = $17 Billion90% of all fractures due to underlying bone fragility.50% of women and 25% of men will have an osteoporosis- related fracture during their lifetime
15Osteoporosis: Complications Functionality Post-FractureHip: 22 hospital days/ 102 days of limited activity.Vertebral: 26 hospital days / 159 days of limited activity.Forearm: 1 hospital day / 56 days of limited activityFink, et al: Osteoporosis Intl, 2003
16Morbidity After Vertebral Fractures Loss of heightBack painDeformityPulmonary functionQuality of life
17Hip Fracture 1 yr. mortality= 20% Permanent disability= 30% Unable to walk independently = 40%Unable to carry out > 1 ADL = 80%Cooper, Am J. Med,1997
19Quality of Life Depression. Sleep Disorder. Opioid dependence. Distorted body image.Loss of independence.AACE Osteoporosis Guidelines, Endocr Practice, 2003
20Osteoporosis: Case Study Dan M.84 y. o.Fell out of bunk at deer campFx hipFatal Pneumonia
21Practice Barriers and Gaps Physicians do not discuss risk factors with patientsDiagnosis made most often after fractureFewer than 2/3 of women over 65 have had bone density test.Only 20.4% of women over age 67 had BMD or preventive Rx within 6 months of fracture.Non- adherenceNon-compliance
22Audience Response Question So with all of these bad things in our futureHow are we doing in controlling HTN?4Not to wellWe have our work cut out for us
23Audience Response Question Which of the following is NOT considered a risk factor for osteoporosis:Taking an anticoagulant such as warfarin.AgeGeneticsEducation level
24Risk Factors : Age Age trumps BMD Impact of age is at least 10x the risk of declining BMD.
25Risk Factors: Fracture Hx Prior forearm fracture = 2x riskWomen over 74 with vertebral fracture = 20% recur within a year.Risk ratio only lowered slightly by BMD
26Risk Factors: Genetics The greatest influence on a woman’s peak BMD is heredityHip fracture risks 50% higher with first degree relative127% higher if hip fracture occurred in a parent
27Risk Factors: Weight and BMI Weight under 127 lbs.BMI < 21Increases risk of low BMD and fracture, especially in older women
32Lifestyle Approaches: Nutrition Women over 60 do not consume the recommended servings of dairy products, fruits, vegetables or grains.Healthy Eating Index score of these women is Out of a possible 100.
33Nutrition: CalciumWHI: hip fractures significantly reduced in older women adherent to calcium/ vitamin D regimens.Calcium intake declines with age.Impaired absorption with age.Optimal intake: 1200 mg. daily
35Nutrition: CalciumDairy products supply 80% of calcium for women over 60.High elemental calcium content.High absorption rateCost- efficientSpinach and wheat bran may inhibit absorption.
36Audience Response Question So with all of these bad things in our futureHow are we doing in controlling HTN?4Not to wellWe have our work cut out for us
37Audience Response Question Vitamin D:Is not really a VitaminIs not affected by Sunscreens < 30 SPFIs abundant in most fresh foods.Has a narrow therapeutic window between efficacy and toxicity.
38Nutrition: Vitamin DIs actually a steroid pro-hormone rather than a vitamin.Essential for intestinal absorption of calcium.1000 IU daily.Only food sources are fortified dairy products and fatty fish.
39Nutrition: Vitamin D SPF > 8 blocks 97.5% of Vitamin D production. Low levels found in older, frail, chronically ill, housebound, or institutionalized women.Higher risk of Vitamin D deficiency in northern latitudes.
40Nutrition: Vitamin D 60% - 100% of patients will have a low level. Over age 90: 100% are deficient.Adequate Vitamin D levels associated with increased bone mass, decreased rates of falls, and significant reductions in fractures.
41Nutrition: MagnesiumMost people over 40 are deficient in magnesium intake.Intake falls severely after age 70.Found in green leafy vegetables, grains, and nuts.Severe deficiency can cause hypocalcemia and Vitamin D resistance.No evidence to support use in prevention or treatment of osteoporosis.
42Audience Response Question So with all of these bad things in our futureHow are we doing in controlling HTN?4Not to wellWe have our work cut out for us
43Audience Response Question For older women, protein supplement may:Help minimize bone lossShorten hospital stay for hip fracture and improve clinical outcomes.Significantly lower rates of complication and mortality up to 7 months post-fracture.All of the above4 – all of the above
44Nutrition: Protein For older women, protein supplement may: Help minimize bone lossShorten hospital stay for hip fracture and improve clinical outcomes.Significantly lower rates of complication and mortality up to 7 months post- fracture.
45Nutrition: Isoflavones Phytoestrogens found in soybeans, soy products and red clover.No evidence to support use in prevention or treatment of osteopenia or osteoporosis.
46ExerciseWeight –bearing and strength-training exercises are beneficial to bone development and maintenance.Mild to moderate exercise confers benefits.Exercise increased BMD 2% in PMP women.Exercise and strength training = 75% reduction in falls and injuries for women over 75
47ExerciseBMD in dominant arm of tennis players is greater than non-dominant arm.
50Exercise Target areas most involved in osteoporotic fractures: Large extensor muscles of the backThighUpper armsForearm
51Exercise Water aerobics for the physically impaired. Exercises to strengthen back extensor muscles reduce risk of spine fracture in women with and without prior fracture and improve quality of life.
52Osteoporosis: Case Study Lilly N.81 y.o.5ft, 4 in.122 poundsNon-smokerFell… hit shoulder..Fx humerus
53Audience Response Question So with all of these bad things in our futureHow are we doing in controlling HTN?4Not to wellWe have our work cut out for us
54Audience Response Question Concerning falls:They are a precipitating factor in 90% of fractures.A third of women over age 50 fall at least once a year.Over age 80, the fall rate declines for men, but not women.Elevated Mg++ levels are protective.1 – precipitating factor in 90% of fractures
55Falls Precipitating factor in 90% of fractures. One- third of women over age 60 fall at least once a year.Over age 80, fall rate is 80%
56Falls Risk Reduction: Exercises to improve balance and muscle strength Reducing fall hazards in the homeAdjusting medications (Tapering and discontinuing use of BZD’s, neuroleptics and anti-depressants found to reduce fall risk by 60%)
57Alcohol ConsumptionModerate alcohol intake possibly associated with BMD.Increased risk of falling and fracture with drinks a week.Two or more drinks in 6 hours = 20% of falls in working adults.
58Audience Response Question So with all of these bad things in our futureHow are we doing in controlling HTN?4Not to wellWe have our work cut out for us
59Audience Response Question Compared to non-smokers, women smokers:Tend to lose bone more rapidly.Have equivalent BMDReach menopause 2 years later.Have a similar fracture rate.1 – tend to lose bone more rapidly
60Smoking Cessation Compared to non-smokers, women smokers: Tend to lose bone more rapidly.Have lower BMDReach menopause 2 years earlier.Have a higher fracture rate.Second hand smoke also a risk factor.
61BMD TestingAll post-menopausal women with medical causes of bone loss.All women age 65 and over.Women age 50 and over with one of the following risk factors:Previous fracture after menopause.BMI <21Parental hip fractureCurrent smokerRheumatoid ArthritisExcessive ETOH
63Summary Osteoporosis is everywhere. Most women over 65 have not had screening.Most patients with osteoporosis go untreated.Adherence and compliance are suboptimal and lead top poor outcomes.We need to improve our communications with patients.
64Adherence and Compliance Compliance: follows instructions about dose and interval.Persistence: time from initiation to discontinuation.Adherence: Persistence + compliance. (Refills)
65Audience Response Question So with all of these bad things in our futureHow are we doing in controlling HTN?4Not to wellWe have our work cut out for us
66Audience Response Question Which of the following statements about health literacy is true?:Health literacy is a weak predictor of health statusThe mean reading level in America is 8th grade.Most illiteracy occurs in foreigners and ethnic groups.The majority of Americans can read and understand prescription instructions.2 - The mean reading level in America is 8th grade.
67Health LiteracyHealth literacy is believed to be a stronger predictor of health outcomes than social and economic status, education, gender, and age.American Medical Association, 1999.
68Health LiteracyRed and yellow are highest rates of low level literacy.
69Health Literacy Strongest predictor of health status. 30 million Americans have literacy skills defined as "below basic.”(difficulty comprehending directions for taking medicine or understanding an appointment slip.)
70Health Literacy“the cognitive and social skills which determine the motivation and ability of individuals to gain access to, understand, and use information in ways that promote and maintain good health.”WHO, 1998, p. 10
71Health Literacy“the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions"Nielsen-Bohlman, Panzer, & Kindig, 2004, p. 32).
72Health Literacy"a constellation of skills, including the ability to perform basic reading and numerical tasks required to function in the health care environment"American Medical Association Ad Hoc Committee on Health Literacy for the Council on Scientific Affairs, 1999,
74Health LiteracyOsborne (2005) reports that a 1992 survey of literacy in the United States found that:"nearly half of all adults...have at most, only marginal literacy skills. This means they are apt to have trouble understanding complex text, filling out bank statements and using maps and schedules"
75Health LiteracyAnother 63 million are at the "basic" level. These individuals find it difficult to calculate a dose of an over-the-counter medication for a child or comprehend a consent form.Most of the almost 50% of the US population in the below basic and basic literacy levels are native-born, white adults.
76Health Literacy 44% over age 65 scored at lowest level Other risk factors for literacy problems:PovertyHealth problemsIncarceration
78Health Literacy Readability Scales SMOG: To calculate SMOG Count a number of sentences (at least:10 from the start of a text, 10 from the middle, and 10 from the end).In those sentences, count the polysyllables (words of 3 or more syllables).Calculate usingA version is also given which is more easily used for mental math and is sometimes known as the SMOG Index:1. Count the number of polysyllabic words, excluding proper nouns, in a sample of thirty sentences.2. Take the square root of the nearest perfect square3. Add 3
80Health LiteracyMenopause__sometimes called the change of life__is a natural part of a woman's life. As you get older, your body produces less of the hormone estrogen. As you start making less estrogen, you may notice some physical changes like hot flashes or vaginal dryness. Having les natural estrogen may also be linked to certain serious health problems such as osteoporosis and heart disease. Inside, you will find comprehensive information about osteoporosis. The chart below describes some of the most common changes associated with menopause and ways in which you can manage the effects of these changes.
81SMOG Grade Educational Level 0-6= low literacySoap Opera DigestLadies Home JournalReader’s DigestNewsweekSports IllustratedTime MagazineNew York TimesAtlantic MonthlyHarvard Business ReviewIRS Tax Code7= junior high school 9= some high school 10= some high school 11= high school junior 12= high school graduate 13-15= some college 16 = college degree 17= post- grad level 19+= post grad degree
82Health LiteracyA majority of available health information is written at a 12th grade reading level. This exceeds the eighth grade reading level of the average American.Wilson, 2003
83Health Literacy Use short simple sentences Summarize key points at end of each section.Write in the active voice.Clarify with examples.Avoid technical terms and acronyms.Use simple relevant graphics.Use large font.Avoid blue, green, and lavender.