Clinical review
Detection and treatment of osteoporosis K ate C ustis, U niversity C ollege and M iddlesex School o f M edicine, L ondon Osteoporosis is a condition that affects bone. It occurs most commonly in postmenopausal women and costs the health service many millions of pounds each year. This article describes how osteoporosis can be detected and the treatments that are available. Kate Custis is Senior 1 Radiographer in the Osteoporosis Clinic of the Institute of Nuclear Medicine at University College and Middlesex School of Medicine, London
^ ^ ^ ^ ^ te o p o ro sis is a disease that affects bone particularly in women, causing loss of bone density which leads to pain, dis comfort and disability. It is a silent disease which can develop over many years and usually becomes apparent in the over-60 age group. The bones affected by osteoporosis retain their original dimen sions but lose their minerals so that the skeleton becomes brittle and weak and therefore more susceptible to fracture. Al though osteoporosis occurs in both men and women, the accelerated postmeno pausal bone loss causes fractures to occur much more frequently in women. Age-related osteoporosis affects both sexes and is the result of a relatively slow but long-lasting and consistent bone loss which takes place after peak bone mass has been reached. Postmenopausal osteoporosis occurs in women 10-15 years after the menopause and is the result of significant accelerated bone loss in the early menopau sal years. During the menopause, bone can be lost at a rate of up to 5% per year and by the age of 70 the bone density can be reduced to 50% of premenopausal levels (Geusens et al, 1986). In contrast, men lose only 25% of their bone density
T a b le 1. T h e tw o typ e s o f o ste o p o ro sis P rim ary
This causes loss of trabecular and cortical bone in women following the menopause, and in both men and women at a later stage. A fairly rare type of idiopathic osteoporosis can also affect young people.
Secondary
This is produced by a number of disorders, such as corticosteroid therapy (e.g. in pa tients with asthma or systemic lupus erythematosus), thyrotoxicosis, malnutrition, rheumatoid arthritis, prolonged amenor rhoea and other conditions such as Turner's syndrome (gonadal dysgenesis) and Sheehan’s syndrome (pituitary infarction).
British Journal of Nursing, 1992,Voi I.No 14
by the age of 90 (Francis et al, 1989). Normal nutrition and growth lead to a peak bone mass by the mid-30s. After that the bone density of men decreases steadily at a rate of 1% per year whereas in women this rate is accelerated after the menopause, when 3-5% of bone can be lost each year as a result of oestrogen deficiency. This de cline continues for at least 10-15 years. The danger point is reached when the bone den sity falls below the fracture threshold, at which stage even minor trauma can cause fractures. Osteoporosis is most commonly mani fest as bony pain and fractures of the verte bral bodies (particularly thoracic), hip and wrist. Crush fractures of the vertebrae can lead to a loss of height of up to 25 cm, shortness of breath, reduced rib-cage vol ume and therefore exercise intolerance, and reduced spinal mobility. Vertebral body fractures tend to become apparent during the 50s as do wrist frac tures, whereas femoral neck fractures are more common in the 60-70 age group. The two types of osteoporosis are shown in Table 1.
Nursing management Recent publicity about osteoporosis has led to increased public awareness of the disease, and more and more women attending wellwoman and gynaecological clinics are seek ing information on the subject. Nurses working within these departments should be well versed on the causes of osteoporosis and the various treatments available, as well as the methods of detection and prevention. Patients admitted for investigation of in creased or decreased calcium or sex hor mone levels (e.g. due to hypogonadism or hyperparathyroidism) will be encountered by nurses on the wards, as will patients who have sustained fractures due to osteoporosis. Nurses should recognize that such patients may be in extreme pain be cause of vertebral fractures and may be
711
Downloaded from magonlinelibrary.com by 130.237.122.245 on January 13, 2019.
Detection and treatment of osteoporosis
worried about their condition. It is import ant to be able to give correct advice and reassurance. Staff must be fully aware of the difficulties encountered by these pa tients, which are secondary to their disease, e.g. breathing difficulties and the everyday worry of finding clothes that fit properly, both of which can be frightening and de pressing.
Detection Dual energy X-ray absorptiometry At present the most accurate method of measuring bone density is with a dual en ergy X-ray densitometer (Gênant, 1990). This equipment consists primarily of a scanning table, a radiation source and de tection arm, a computer, a visual display unit and a keyboard (Fig. 1). The detection arm moves over the part being scanned in contiguous steps until the entire area has
Fig. 1. Bone density measurement scanning equipment.
Fig. 2. Patient positioning for a lumbar spine scan.
712
been covered. The dose for each scan is minimal and the radiation received is equiv alent to one tenth of that received from a chest X-ray. However, it is preferable not to scan patients who have a confirmed or suspected pregnancy. Currently both hip and lumbar spine scans are performed for each patient. The scans are then analysed and the results are plotted against a database of normal refer ence values. All metallic objects in the area being scanned, such as belts and zips, are removed and the patient lies supine on the scanning table (Fig. 2). The scanning arm is positioned according to the part being scanned and the patient is instructed to lay still for the duration of the scans. A spine scan takes approximately 10 minutes and a hip scan 6-7 minutes. The data are analys ed at the end of each scan and the results are presented as a picture with a list of the bone mineral content and bone mineral density for each area (Figs 3 and 4). The results can be compared with those obtained from a group of women of the same age as the patient who are considered to have a normal bone mineral density. The comparison indicates whether the patient’s bone density is within the normal range but towards the lower end (suggesting that the patient may be in danger of developing osteoporosis in later life), or below the nor mal range (suggesting that the patient is de veloping osteoporosis or has a high prob ability of doing so in the future). Subse quent scans on the same patient can be plot ted against the same normal values (Compston et al, 1988) so that the rate of bone loss or increase can be quantitatively assessed (Fig. 3). Scan data are stored per manently on either floppy or optical discs and thermal paper print-outs of the scans are kept in the patient’s notes. Although dual energy X-ray absorp tiometry is probably the most accurate and widely used method, several other tech niques can also be used to calculate bone density. However, for reasons of cost, ac curacy or availability, they are less popular. Single photon absorptiometry: In single photon absorptiometry, bone mineral den sity is measured by its ability to absorb photons produced by a radioactive source such as iodine-125. Because soft tissue in the path of the beam affects the results, this method is not used for axial skeleton measurements. Dual photon absorptiometry: A radiation source such as gadolinium-153, which natu rally emits photons of two energies, is used
British Journal of Nursing, 1992,Voi l.N o 14 Downloaded from magonlinelibrary.com by 130.237.122.245 on January 13, 2019.
Detection and treatment of osteoporosis
(To date, the most widely accepted and available treatment for women with osteoporosis is hormone replacement therapy (HRT). 5
for dual photon absorptiometry. Because bone differs from soft tissue in absorbing a greater proportion of higher energy photons, the machine can calculate the amount of bone mineral density. This method is widely used and provides fairly accurate results for hip and spine bone den sities. However, the output of the source must be closely monitored to ensure con sistency of results. Quantitative computed tomography. Metabolically active trabecular bone can be
k = 1.190
d0 = 114.3d.000H)
studied independently of the less active cor tical bone by quantitative computed tomography, which is thus a highly sensi tive method of detecting bone mineral changes. However, the high cost and radi ation dose make this option impractical for widespread scanning or long-term monitor ing (Reinbold et al, 1986). The emergence of these new techniques, which have the necessary sensitivity to measure bone mineral density very accu rately, has made it possible to diagnose osteoporosis in its earliest stages. This has FI1049203 Nane : Connent:
Ued 04.Nov.1992 10:35
I.D. : Sex: F S.S.tt : Ethnic: E Height: 170.00 cn ZIPCode: Ueight: 60.70 kg Scan Code : Age: 36 BirthDate: 02.Sep.56 Physician: TOTAL BHD CO FOR LI - L4 C.F.
0.997
Region
Area (cn2)
LI L2 L3 L4 TOTAL
13.30 14.44 16.26 15.13 59.13
1.073
1.0x 1.000
BNC BND (grams) (gns/cm2) 13.27 15.36 18.44 17.77 64.84
0.997 1.064 1.134 1.175 1.097
Hologic QDR-1000/U (S/N 1026 P) Lunbar Spine U4.45P
Fig. 3. Normal spine scan.
k = 1.199
d0 = 116.1C1.000H)
•04.Nov.1992 10:59 [90 x B9] Hologic QDR-1000/U (S/N 1026 P) Left Hip 04.45P
Ued 04.Nov.1992 10:45 F11049204 Nane : Connent: Sex: F l.D. : Ethnic: E S.S.tt: Height : 170.00 cn ZIPCode: Ueight: 60.70 kg Scan Code: Age : 36 BirthDate : 02.Sep.56 Physician : C.F.
0.997
Region
Area (cn2)
1.073
1.000
BHD BMC (grans) (gns/cn2
4.89 0.921 5.31 Neck 0.767 11.09 8.51 Troch 1.241 12.24 15.19 Inter 0.998 28.59 28.64 TOTAL 0.800 1.13 0.91 Uard's Nidi ine ( 90, 98)-(160, 52) Neck -45 x 16 at [ 22, 10) 1 X 43 at [ 0, 0) Troch Uard's -11 X 11 at I 3, 41
Fig. 4. Normal left hip scan. British Journal of Nursing, 1992, Vol I, No 14
713
Downloaded from magonlinelibrary.com by 130.237.122.245 on January 13, 2019.
Detection and treatment of osteoporosis
‘Bone density scanning can not only be useful in one-off pretreatment cases but also, if repeated regularly, be used to assess changes in bone density and the efficiency of various drug regimens. 5
Lumbar Spine Reference Database • ------1------1---- - 1
1.4 1.3 1.2 1.1 - r ■-[ t 1.0 0.9 W .H — 0.7 0.6 0.5 0.4 i ______i ---0.3 0.3'-----1 ----- 1 ----- 1 1 -----34 3S 36 37 38 Age Region L1-L4
Rate of Change ±SD** -0.0096 0.0101
X
Change
±X
SD
FI1049203 Ued 04.Nou.,1992 10:35 Name! Comment: Sex : F I .D.: Ethnic: E S.S.#: Height : 170.00 cm ZIPCode: Weight : 60.70 kg Scan Code Age : 36 BirthDate: 02 .Sep.56 Physician: Date of Scan
Age
27 17 12 04
35.0 35.4 35.8 36.2
Aug Jan Jun Nou
91 92 92 92
BMDÎL1-L4 1.108 1.096 1.093 1.097
-0.87 0.91
**1.96xSD = 95x Confidence Interval ♦ Age and sex matched T = peak bone mass Z = age matched TK 04 Nov 91
Fig. 5. Normals graph showing bone mineral density on 4 visits to the bone density clinic.
enabled the introduction of preventive ther apy before microstructural failure makes the disease virtually irreversible. Bone density scanning can not only be useful in one-off pretreatment cases but also, if repeated regularly, be used to assess changes in bone density and the efficiency of various drug regimens. Long- and short term bone loss during and following the menopause can be monitored and abnormal growth patterns in children, caused by radiotherapy to the brain (thus inhibiting the secretion of growth hormone from the pituitary) or by idiopathic pituitary disord ers or other disorders affecting growth, can be studied. Children are usually scanned at 3-6 month intervals; the first scan is per formed before the commencement of treat ment and follow-up scans are performed regularly until bone density reaches a nor mal level for the age of the child.
Treatment Once detected or suspected, osteoporosis can be monitored and treated successfully. To date, the most widely accepted and available treatment for women with osteoporosis is hormone replacement ther apy (HRT). This uses a combination of oes trogen and progestogen or oestrogen only (for posthysterectomy patients) to replace the natural hormones that are reduced fol lowing the menopause or lacking as a result of conditions such as gonadal dysgenesis or pituitary imbalance (Kiel et al, 1987). HRT comes in a variety of forms includ ing creams, patches, tablets and subcu
714
taneous implants, all of which contain oes trogen. This may be supplemented with several days of progestogen tablets every month to induce a withdrawal bleed and prevent endometrial hyperplasia. HRT, given in the correct dose, should arrest bone loss. In some cases an increase in bone density has been seen after several years of treatment. A cream containing oestradiol which is rubbed directly onto the skin is a useful form of HRT for children (e.g. those with Turner’s syndrome), with the oestrogen be ing absorbed directly into the bloodstream. HRT patches changed twice weekly also employ this method of administration, al though occasionally local reactions occur at the site of the patch. In women who have not had a hysterectomy, patches should be supplemented with progestogen tablets. Hormone implants consisting of small pel lets containing oestrogen can be inserted subcutaneously under local anaesthetic; a Steristrip is used to seal the puncture site. Implants release their oestrogen slowly over approximately 6 months and doses of varying strengths can be prescribed in 25 mg steps. Again, progestogen supple ments may be necessary (Savvas et al, 1988). Calcitonin, which regulates the amount of calcium in the blood and prevents cal cium loss from the bones, can be adminis tered by injection. This is an effective but expensive treatment for osteoporosis. Nasal sprays have recently been introduced and these may prove easier to use and cheaper. This form of treatment may be of consider-
Downloaded from magonlinelibrary.com by 130.237.122.245 on January 13, 2019. British Journal of Nursing, 1992, Voi l,N o 14
Detection and treatment of osteoporosis
able value in the prevention of osteoporosis, particularly in older women who will not tolerate uterine bleeding. Bisphosphonates bind to bone and pre vent it being broken down while allowing new bone to form. This strengthens the bones and thus leads to a reduced incidence of fractures. Clinical trials involving an oestrogen re placement that does not cause a monthly bleed have just been started and this may well be the treatment of preference for many women in the future. It is hoped that these trials will demonstrate that oestrogens can be effective in maintaining bone density
KEY POINTS • Osteoporosis is a silent disease that affects one in four women. Bone loss increases rapidly following the menopause. • Osteoporosis can be easily detected and successfully monitored and treated. • Prevention of osteoporosis is better than cure. • Osteoporosis can be counteracted by developing a strong, healthy skeleton in early life. • Bone density scanning provides a quick and accurate measurement of bone mineral density.
without the necessity for a monthly bleed (Heaney and Saville, 1976). Appropriate weight-bearing exercise, a balanced diet and reduction of smoking and drinking levels can have a beneficial effect bn bone density, particularly during child hood and adolescence. The peak bone den sity, reached at about the age of 30, is af fected by all of these factors. In the long term, attention to these factors could bring about a reduction in the number of cases of osteoporosis-related fractures, thus sav ing both patient discomfort and valuable National Health Service resources.
Compston JE, Evans WD, Crawley E, Evans C (1988) Bone mineral content in normal UK subjects. Br ] Radiol 61: 631-6 Francis RM, Peacock M, Marshal DH, Horsman A, Aaron JE (1989) Spinal osteoporosis in men. Bone Mineral 5: 347-7 Genant HK (1990) Methods of bone densitometry. In: Ring EFJ, ed. Current Research in Osteoporosis and Bone Mineral Measurement. British Institute of Radiology, London Geusens P, Dequeker T, Verstraten A (1986) Age-sex and menopause related changes of vertebral and peripheral Done. A population study using DEXA. J Nucl Med 27: 1540-9 Heaney RP, Saville PD (1976) Etidronate disodium in post-menopausal osteoporosis. Clin Pharmacol Ther 20: 293-604 Kiel DP, Felson DT, Anderson JJ, Welson PWF (1987) Hip fracture and the value of oestrogens in post menopausal women. N Engl J Med 317: 1169-74 Reinbold WD, Genant HK, Reise UJ, Harris ST, Ellinger B (1986) Bone mineral content in early post-menopausal and post-menopausal osteoporotic women. A comparison of measure ment methods. Radiology 160: 469-78 Sawas M, Studd J, Fogelman I, Dooley M, Mont gomery J, Murby B (1988) The skeletal effects of oral oestrogen compared with subcutaneous oestradiol and testosterone in post-menopausal women Br Med ] 297: 331-3
MAKE SURE OF YOUR COPIES OF BJN If you are having tro u b le obtaining a copy o f British Jo u rn al o f N u rsin g from y o u r local new sagent then please get in to u ch w ith us im m ediately and w e will ensure th at y o u r copy of BJN keeps on com ing. N o w p o st this form to: T he P u b lish er B JN , C roxted M ews, 288 C ro x ted R oad, L ondon SE24 9D A . (Tel: 081-671 7521). NAME............................................................................................................................................................................... ADDRESS..........................................................................................
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Detection and treatment of osteoporosis K ate C ustis, U niversity C ollege and M iddlesex School o f M edicine, L ondon Osteoporosis is a condition that affects bone. It occurs most commonly in postmenopausal women and costs the health service many millions of pounds each year. This article describes how osteoporosis can be detected and the treatments that are available. Kate Custis is Senior 1 Radiographer in the Osteoporosis Clinic of the Institute of Nuclear Medicine at University College and Middlesex School of Medicine, London
^ ^ ^ ^ ^ te o p o ro sis is a disease that affects bone particularly in women, causing loss of bone density which leads to pain, dis comfort and disability. It is a silent disease which can develop over many years and usually becomes apparent in the over-60 age group. The bones affected by osteoporosis retain their original dimen sions but lose their minerals so that the skeleton becomes brittle and weak and therefore more susceptible to fracture. Al though osteoporosis occurs in both men and women, the accelerated postmeno pausal bone loss causes fractures to occur much more frequently in women. Age-related osteoporosis affects both sexes and is the result of a relatively slow but long-lasting and consistent bone loss which takes place after peak bone mass has been reached. Postmenopausal osteoporosis occurs in women 10-15 years after the menopause and is the result of significant accelerated bone loss in the early menopau sal years. During the menopause, bone can be lost at a rate of up to 5% per year and by the age of 70 the bone density can be reduced to 50% of premenopausal levels (Geusens et al, 1986). In contrast, men lose only 25% of their bone density
T a b le 1. T h e tw o typ e s o f o ste o p o ro sis P rim ary
This causes loss of trabecular and cortical bone in women following the menopause, and in both men and women at a later stage. A fairly rare type of idiopathic osteoporosis can also affect young people.
Secondary
This is produced by a number of disorders, such as corticosteroid therapy (e.g. in pa tients with asthma or systemic lupus erythematosus), thyrotoxicosis, malnutrition, rheumatoid arthritis, prolonged amenor rhoea and other conditions such as Turner's syndrome (gonadal dysgenesis) and Sheehan’s syndrome (pituitary infarction).
British Journal of Nursing, 1992,Voi I.No 14
by the age of 90 (Francis et al, 1989). Normal nutrition and growth lead to a peak bone mass by the mid-30s. After that the bone density of men decreases steadily at a rate of 1% per year whereas in women this rate is accelerated after the menopause, when 3-5% of bone can be lost each year as a result of oestrogen deficiency. This de cline continues for at least 10-15 years. The danger point is reached when the bone den sity falls below the fracture threshold, at which stage even minor trauma can cause fractures. Osteoporosis is most commonly mani fest as bony pain and fractures of the verte bral bodies (particularly thoracic), hip and wrist. Crush fractures of the vertebrae can lead to a loss of height of up to 25 cm, shortness of breath, reduced rib-cage vol ume and therefore exercise intolerance, and reduced spinal mobility. Vertebral body fractures tend to become apparent during the 50s as do wrist frac tures, whereas femoral neck fractures are more common in the 60-70 age group. The two types of osteoporosis are shown in Table 1.
Nursing management Recent publicity about osteoporosis has led to increased public awareness of the disease, and more and more women attending wellwoman and gynaecological clinics are seek ing information on the subject. Nurses working within these departments should be well versed on the causes of osteoporosis and the various treatments available, as well as the methods of detection and prevention. Patients admitted for investigation of in creased or decreased calcium or sex hor mone levels (e.g. due to hypogonadism or hyperparathyroidism) will be encountered by nurses on the wards, as will patients who have sustained fractures due to osteoporosis. Nurses should recognize that such patients may be in extreme pain be cause of vertebral fractures and may be
711
Downloaded from magonlinelibrary.com by 130.237.122.245 on January 13, 2019.
Detection and treatment of osteoporosis
worried about their condition. It is import ant to be able to give correct advice and reassurance. Staff must be fully aware of the difficulties encountered by these pa tients, which are secondary to their disease, e.g. breathing difficulties and the everyday worry of finding clothes that fit properly, both of which can be frightening and de pressing.
Detection Dual energy X-ray absorptiometry At present the most accurate method of measuring bone density is with a dual en ergy X-ray densitometer (Gênant, 1990). This equipment consists primarily of a scanning table, a radiation source and de tection arm, a computer, a visual display unit and a keyboard (Fig. 1). The detection arm moves over the part being scanned in contiguous steps until the entire area has
Fig. 1. Bone density measurement scanning equipment.
Fig. 2. Patient positioning for a lumbar spine scan.
712
been covered. The dose for each scan is minimal and the radiation received is equiv alent to one tenth of that received from a chest X-ray. However, it is preferable not to scan patients who have a confirmed or suspected pregnancy. Currently both hip and lumbar spine scans are performed for each patient. The scans are then analysed and the results are plotted against a database of normal refer ence values. All metallic objects in the area being scanned, such as belts and zips, are removed and the patient lies supine on the scanning table (Fig. 2). The scanning arm is positioned according to the part being scanned and the patient is instructed to lay still for the duration of the scans. A spine scan takes approximately 10 minutes and a hip scan 6-7 minutes. The data are analys ed at the end of each scan and the results are presented as a picture with a list of the bone mineral content and bone mineral density for each area (Figs 3 and 4). The results can be compared with those obtained from a group of women of the same age as the patient who are considered to have a normal bone mineral density. The comparison indicates whether the patient’s bone density is within the normal range but towards the lower end (suggesting that the patient may be in danger of developing osteoporosis in later life), or below the nor mal range (suggesting that the patient is de veloping osteoporosis or has a high prob ability of doing so in the future). Subse quent scans on the same patient can be plot ted against the same normal values (Compston et al, 1988) so that the rate of bone loss or increase can be quantitatively assessed (Fig. 3). Scan data are stored per manently on either floppy or optical discs and thermal paper print-outs of the scans are kept in the patient’s notes. Although dual energy X-ray absorp tiometry is probably the most accurate and widely used method, several other tech niques can also be used to calculate bone density. However, for reasons of cost, ac curacy or availability, they are less popular. Single photon absorptiometry: In single photon absorptiometry, bone mineral den sity is measured by its ability to absorb photons produced by a radioactive source such as iodine-125. Because soft tissue in the path of the beam affects the results, this method is not used for axial skeleton measurements. Dual photon absorptiometry: A radiation source such as gadolinium-153, which natu rally emits photons of two energies, is used
British Journal of Nursing, 1992,Voi l.N o 14 Downloaded from magonlinelibrary.com by 130.237.122.245 on January 13, 2019.
Detection and treatment of osteoporosis
(To date, the most widely accepted and available treatment for women with osteoporosis is hormone replacement therapy (HRT). 5
for dual photon absorptiometry. Because bone differs from soft tissue in absorbing a greater proportion of higher energy photons, the machine can calculate the amount of bone mineral density. This method is widely used and provides fairly accurate results for hip and spine bone den sities. However, the output of the source must be closely monitored to ensure con sistency of results. Quantitative computed tomography. Metabolically active trabecular bone can be
k = 1.190
d0 = 114.3d.000H)
studied independently of the less active cor tical bone by quantitative computed tomography, which is thus a highly sensi tive method of detecting bone mineral changes. However, the high cost and radi ation dose make this option impractical for widespread scanning or long-term monitor ing (Reinbold et al, 1986). The emergence of these new techniques, which have the necessary sensitivity to measure bone mineral density very accu rately, has made it possible to diagnose osteoporosis in its earliest stages. This has FI1049203 Nane : Connent:
Ued 04.Nov.1992 10:35
I.D. : Sex: F S.S.tt : Ethnic: E Height: 170.00 cn ZIPCode: Ueight: 60.70 kg Scan Code : Age: 36 BirthDate: 02.Sep.56 Physician: TOTAL BHD CO FOR LI - L4 C.F.
0.997
Region
Area (cn2)
LI L2 L3 L4 TOTAL
13.30 14.44 16.26 15.13 59.13
1.073
1.0x 1.000
BNC BND (grams) (gns/cm2) 13.27 15.36 18.44 17.77 64.84
0.997 1.064 1.134 1.175 1.097
Hologic QDR-1000/U (S/N 1026 P) Lunbar Spine U4.45P
Fig. 3. Normal spine scan.
k = 1.199
d0 = 116.1C1.000H)
•04.Nov.1992 10:59 [90 x B9] Hologic QDR-1000/U (S/N 1026 P) Left Hip 04.45P
Ued 04.Nov.1992 10:45 F11049204 Nane : Connent: Sex: F l.D. : Ethnic: E S.S.tt: Height : 170.00 cn ZIPCode: Ueight: 60.70 kg Scan Code: Age : 36 BirthDate : 02.Sep.56 Physician : C.F.
0.997
Region
Area (cn2)
1.073
1.000
BHD BMC (grans) (gns/cn2
4.89 0.921 5.31 Neck 0.767 11.09 8.51 Troch 1.241 12.24 15.19 Inter 0.998 28.59 28.64 TOTAL 0.800 1.13 0.91 Uard's Nidi ine ( 90, 98)-(160, 52) Neck -45 x 16 at [ 22, 10) 1 X 43 at [ 0, 0) Troch Uard's -11 X 11 at I 3, 41
Fig. 4. Normal left hip scan. British Journal of Nursing, 1992, Vol I, No 14
713
Downloaded from magonlinelibrary.com by 130.237.122.245 on January 13, 2019.
Detection and treatment of osteoporosis
‘Bone density scanning can not only be useful in one-off pretreatment cases but also, if repeated regularly, be used to assess changes in bone density and the efficiency of various drug regimens. 5
Lumbar Spine Reference Database • ------1------1---- - 1
1.4 1.3 1.2 1.1 - r ■-[ t 1.0 0.9 W .H — 0.7 0.6 0.5 0.4 i ______i ---0.3 0.3'-----1 ----- 1 ----- 1 1 -----34 3S 36 37 38 Age Region L1-L4
Rate of Change ±SD** -0.0096 0.0101
X
Change
±X
SD
FI1049203 Ued 04.Nou.,1992 10:35 Name! Comment: Sex : F I .D.: Ethnic: E S.S.#: Height : 170.00 cm ZIPCode: Weight : 60.70 kg Scan Code Age : 36 BirthDate: 02 .Sep.56 Physician: Date of Scan
Age
27 17 12 04
35.0 35.4 35.8 36.2
Aug Jan Jun Nou
91 92 92 92
BMDÎL1-L4 1.108 1.096 1.093 1.097
-0.87 0.91
**1.96xSD = 95x Confidence Interval ♦ Age and sex matched T = peak bone mass Z = age matched TK 04 Nov 91
Fig. 5. Normals graph showing bone mineral density on 4 visits to the bone density clinic.
enabled the introduction of preventive ther apy before microstructural failure makes the disease virtually irreversible. Bone density scanning can not only be useful in one-off pretreatment cases but also, if repeated regularly, be used to assess changes in bone density and the efficiency of various drug regimens. Long- and short term bone loss during and following the menopause can be monitored and abnormal growth patterns in children, caused by radiotherapy to the brain (thus inhibiting the secretion of growth hormone from the pituitary) or by idiopathic pituitary disord ers or other disorders affecting growth, can be studied. Children are usually scanned at 3-6 month intervals; the first scan is per formed before the commencement of treat ment and follow-up scans are performed regularly until bone density reaches a nor mal level for the age of the child.
Treatment Once detected or suspected, osteoporosis can be monitored and treated successfully. To date, the most widely accepted and available treatment for women with osteoporosis is hormone replacement ther apy (HRT). This uses a combination of oes trogen and progestogen or oestrogen only (for posthysterectomy patients) to replace the natural hormones that are reduced fol lowing the menopause or lacking as a result of conditions such as gonadal dysgenesis or pituitary imbalance (Kiel et al, 1987). HRT comes in a variety of forms includ ing creams, patches, tablets and subcu
714
taneous implants, all of which contain oes trogen. This may be supplemented with several days of progestogen tablets every month to induce a withdrawal bleed and prevent endometrial hyperplasia. HRT, given in the correct dose, should arrest bone loss. In some cases an increase in bone density has been seen after several years of treatment. A cream containing oestradiol which is rubbed directly onto the skin is a useful form of HRT for children (e.g. those with Turner’s syndrome), with the oestrogen be ing absorbed directly into the bloodstream. HRT patches changed twice weekly also employ this method of administration, al though occasionally local reactions occur at the site of the patch. In women who have not had a hysterectomy, patches should be supplemented with progestogen tablets. Hormone implants consisting of small pel lets containing oestrogen can be inserted subcutaneously under local anaesthetic; a Steristrip is used to seal the puncture site. Implants release their oestrogen slowly over approximately 6 months and doses of varying strengths can be prescribed in 25 mg steps. Again, progestogen supple ments may be necessary (Savvas et al, 1988). Calcitonin, which regulates the amount of calcium in the blood and prevents cal cium loss from the bones, can be adminis tered by injection. This is an effective but expensive treatment for osteoporosis. Nasal sprays have recently been introduced and these may prove easier to use and cheaper. This form of treatment may be of consider-
Downloaded from magonlinelibrary.com by 130.237.122.245 on January 13, 2019. British Journal of Nursing, 1992, Voi l,N o 14
Detection and treatment of osteoporosis
able value in the prevention of osteoporosis, particularly in older women who will not tolerate uterine bleeding. Bisphosphonates bind to bone and pre vent it being broken down while allowing new bone to form. This strengthens the bones and thus leads to a reduced incidence of fractures. Clinical trials involving an oestrogen re placement that does not cause a monthly bleed have just been started and this may well be the treatment of preference for many women in the future. It is hoped that these trials will demonstrate that oestrogens can be effective in maintaining bone density
KEY POINTS • Osteoporosis is a silent disease that affects one in four women. Bone loss increases rapidly following the menopause. • Osteoporosis can be easily detected and successfully monitored and treated. • Prevention of osteoporosis is better than cure. • Osteoporosis can be counteracted by developing a strong, healthy skeleton in early life. • Bone density scanning provides a quick and accurate measurement of bone mineral density.
without the necessity for a monthly bleed (Heaney and Saville, 1976). Appropriate weight-bearing exercise, a balanced diet and reduction of smoking and drinking levels can have a beneficial effect bn bone density, particularly during child hood and adolescence. The peak bone den sity, reached at about the age of 30, is af fected by all of these factors. In the long term, attention to these factors could bring about a reduction in the number of cases of osteoporosis-related fractures, thus sav ing both patient discomfort and valuable National Health Service resources.
Compston JE, Evans WD, Crawley E, Evans C (1988) Bone mineral content in normal UK subjects. Br ] Radiol 61: 631-6 Francis RM, Peacock M, Marshal DH, Horsman A, Aaron JE (1989) Spinal osteoporosis in men. Bone Mineral 5: 347-7 Genant HK (1990) Methods of bone densitometry. In: Ring EFJ, ed. Current Research in Osteoporosis and Bone Mineral Measurement. British Institute of Radiology, London Geusens P, Dequeker T, Verstraten A (1986) Age-sex and menopause related changes of vertebral and peripheral Done. A population study using DEXA. J Nucl Med 27: 1540-9 Heaney RP, Saville PD (1976) Etidronate disodium in post-menopausal osteoporosis. Clin Pharmacol Ther 20: 293-604 Kiel DP, Felson DT, Anderson JJ, Welson PWF (1987) Hip fracture and the value of oestrogens in post menopausal women. N Engl J Med 317: 1169-74 Reinbold WD, Genant HK, Reise UJ, Harris ST, Ellinger B (1986) Bone mineral content in early post-menopausal and post-menopausal osteoporotic women. A comparison of measure ment methods. Radiology 160: 469-78 Sawas M, Studd J, Fogelman I, Dooley M, Mont gomery J, Murby B (1988) The skeletal effects of oral oestrogen compared with subcutaneous oestradiol and testosterone in post-menopausal women Br Med ] 297: 331-3
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