Osteoporosis Management (Home Health Care) - CE

ALERT

Osteoporosis may decrease functionality and quality of life. Aging is a risk factor for osteoporosis. Consider an osteoporosis risk factor assessment, screening, and treatments for all older adult patients.

Certain diseases, such as cancer, and their treatment may increase the risk of developing osteoporosis.

OVERVIEW

Osteoporosis is a common bone disease characterized by low bone mass, deterioration of bone tissue, and decreased bone strength, all of which can lead to an increased risk for fractures. The disease currently affects many people of both sexes and all races. It is becoming increasingly more prevalent as the population ages.^{undefined#ref1">1,5}

Osteoporosis is a condition in which a decrease in bone density results in porous, brittle, and fragile bones. Osteopenia is a reduction in bone density that precedes osteoporosis. Osteopenia and osteoporosis result in part from a decline in estrogen and testosterone levels that occur with aging in both sexes.

In addition to aging, a number of other characteristics and occurrences are risk factors for the development of osteoporosis (Box 1). Certain disease processes or the treatments prescribed for them can lead to osteoporosis. For example, cancer treatments involving androgen or estrogen deprivation therapy as well as other common medications used in oncology (Box 2) can lead to osteoporosis. The nurse should assess the patient for and document these risk factors.

Osteoporosis is considered a silent disease because many people are unaware that they have it until a fracture occurs. Once the fracture does occur, osteoporosis can place a significant burden on the afflicted individual. Osteoporosis can be prevented, detected, and treated before it progresses and leads to fractures.¹

Preventing osteoporosis and maintaining good bone health are key to decreasing mortality and morbidity. Nurses should be well versed in preventive measures (Box 3) and should educate patients about these interventions.

All postmenopausal women as well as men 50 years of age and older should be evaluated for osteoporosis risk to determine the need for further screening.^1,5 Advanced screening for osteoporosis (bone mineral density [BMD] testing or vertebral imaging) is recommended for women who are 65 years of age and older and for younger women who are at high risk for fractures.⁶ Currently, there are no specific recommendations for advanced screening for men without previously known fractures or secondary causes of osteoporosis.⁶

In many cases, osteoporosis is diagnosed after a hip or vertebral fracture in the absence of major trauma. The diagnosis is confirmed by measuring BMD with a dual-energy x-ray absorptiometry (DXA or DEXA) scan of the hip and lumbar spine.¹ Nurses should identify patients at high risk who may benefit from evaluation and screening to mitigate the risk of fractures.

Prevention and treatment of osteoporosis includes dietary evaluation and modification to ensure adequate intake of calcium and vitamin D, lifestyle and behavioral changes to include regular weight-bearing and muscle-strengthening exercises, cessation of tobacco use, limited alcohol consumption, and identification and mitigation of fall risk. Pharmacologic treatment, when indicated, may include bisphosphonates, calcitonin, parathyroid hormone, a selective estrogen receptor modulator (SERM), or monoclonal antibody therapy (Table 1).^1,5 Nurses play a key role in assisting patients with adhering to their prescribed regimen.

PATIENT AND CAREGIVER TEACHING

• Provide definitions and descriptions of osteopenia and osteoporosis.
• Discuss risk factors for osteoporosis (Box 1) (Box 2), including risks associated with treatments for cancer or other diseases.
• Teach the patient methods of preventing osteoporosis (Box 3).
• If indicated, explain the procedure for the DEXA scan.⁶
  • Procedure is noninvasive.
  • Patient remains fully dressed.
  • Procedure requires that the patient lie on a hard table with padding under his or her knees.
  • DEXA scan is different from a bone scan, which screens for metastatic disease in bone.
  • There is insufficient evidence supporting a specific frequency for repeat screening.⁶
• Reinforce the practitioner's explanation of the DEXA scan results.
• If warranted and prescribed, explain pharmacologic treatments, including drug dosing, route, and potential adverse effects (Table 1).
• Teach the patient about adequate calcium and vitamin D intake from food or supplements. Explain that food is the best source of calcium (Box 4).
• Teach fall prevention and home safety measures.
  • Remove or secure throw rugs.
  • Remove obstacles to ambulation.
  • Ensure that the patient has appropriate assistive devices and knows how to use them, if applicable.
  • Identify an emergency plan in case of a fall.
• Encourage questions and answer them as they arise.

PROCEDURE

1. Perform hand hygiene and don gloves.
2. Introduce yourself to the patient.
3. Verify the correct patient using two identifiers.
4. Explain the procedure to the patient and ensure that he or she agrees to treatment.
5. Verify the practitioner’s order and assess the patient for pain.
6. Prepare an area in a clean, convenient location and assemble the necessary supplies. Have the patient’s health record with orders for or results of diagnostic testing (e.g., DEXA scan), the care plan (practitioner’s orders), prescription or medication orders, dietary or supplement orders, and patient teaching and medication information sheets available.
7. Assess the patient's history and health record for risk factors for osteoporosis.
8. Interview the patient and caregiver to obtain a pertinent history and perform a physical assessment with the focus on osteoporosis risk factors.

   Rationale: Identifying risk factors (e.g., age, history of hip or vertebral fractures, insufficient calcium or vitamin D intake, lack of exercise, small bone frame) drives further diagnostic workup and treatment decisions. ⁶

9. Assess the patient's fall risk, including history of falls and fractures, impaired vision, sedating medication intake, dizziness, and environmental dangers.
10. Identify current and past medications, including over-the-counter medications, vitamin and mineral supplements, and herbal remedies that may increase the risk for osteoporosis.¹
11. Inquire about any drug allergies.
12. Assess the patient's current dietary habits, including calcium and vitamin D intake. Ensure that adequate daily intake is met.

    Rationale: Providing adequate daily calcium and vitamin D is a safe and inexpensive way to help reduce fracture risk. Daily requirements vary and should be prescribed and monitored by the patient's practitioner.

    1. Recommended daily calcium intake for men 50 to 70 years of age: 1000 mg/day¹
    2. Recommended daily calcium intake for women 51 years of age and older and men 71 years of age and older: 1200 mg/day¹
    3. Recommended daily vitamin D intake for adults 50 years of age and older: 800 to 1000 international units (IU)/day¹
13. If indicated, discuss the need for additional screening for osteoporosis with the patient's practitioner.
14. Explain the need for and the procedure of osteoporosis screening to the patient.
15. Obtain the results of the screening, reinforce the practitioner's explanation of the screening results, and answer the patient's questions.
16. If indicated, discuss the need for vitamin D testing (25[OH]D blood test) with the patient's practitioner.⁴
17. If vitamin D deficiency exists, obtain orders from the practitioner for the prescribed dose for supplementation to correct the deficiency.

    Rationale: Vitamin D deficiency in adults is generally treated with Vitamin D ₂ or D ₃ 50,000 IU/week for 8 to 12 weeks or until a 25(OH)D blood level of approximately 30 ng/ml is achieved. ¹

18. Recommend lifestyle and dietary changes as appropriate.
    1. Recommend weight-bearing exercises, such as walking. Ensure that the exercises are appropriate for the patient’s functional abilities.⁶

       Rationale: Physically active people are less likely to develop osteoporosis. ⁶

    2. Recommend dietary changes, such as calcium-rich foods, as appropriate.
    3. Assist the patient in smoking cessation if applicable.

       Rationale: The use of tobacco products is detrimental to the skeleton. ^1,5

    4. Discourage excessive alcohol consumption.^1,5

       Rationale: Moderate alcohol intake has no known negative effect on bone; however, an intake of more than two drinks per day for women or three drinks per day for men may impact bone health and increases the risk of falling. ¹

19. Review the adverse effects of the prescribed osteoporosis treatment and discuss self-care measures as appropriate.
20. Administer the prescribed treatment.
    1. Bisphosphonates^1,3

       Rationale: Bisphosphonates reduce the rate of bone turnover.

       Bisphosphonates have a small risk of causing osteonecrosis of the jaw (ONJ), especially if the patient has poor dentition or oral habits or has an invasive dental procedure performed during bisphosphonate therapy.

       1. Assess the oral cavity for signs of ONJ before bisphosphonate treatment.
       2. Ensure that oral bisphosphonates are taken on an empty stomach with a full glass of water and that the patient remains in an upright position and does not eat or drink for at least 30 minutes after administration.³

          Rationale: Oral bisphosphonates must be taken 30 minutes before eating or drinking to ensure full efficacy of the medication. ³ The patient also should remain in an upright position for 30 minutes to lessen the risk of gastrointestinal adverse effects. ³

          Oral bisphosphonates may cause gastrointestinal problems, such as esophagitis, heartburn, and ulcers.

       3. Monitor renal function to ensure it is adequate before administering an IV bisphosphonate. If renal impairment is present, obtain orders from the patient's practitioner to adjust or temporarily hold the dose.

          Use IV bisphosphonates with caution in patients with renal impairment because renal dysfunction may result.

    2. SERMs

       Rationale: SERMs bind to estrogen receptors and decrease bone remodeling. ⁵

       SERMs are contraindicated in women with blood clots or a history of blood clots.

    3. Monoclonal antibody (receptor activator of NF-KB ligand [RANKL] inhibitor; denosumab)

       Rationale: The RANKL antibody binds with RANKL, preventing osteoclast activation, reducing bone resorption. ²

       Monoclonal antibodies are contraindicated in patients with hypocalcemia; use caution with patients who have renal impairment.

21. Assess and monitor the patient for ONJ, renal deterioration, esophagitis, or other adverse reactions. Hold treatment and notify the practitioner as appropriate.
22. Monitor the patient's adherence and encourage compliance to the prescribed treatment.
23. Monitor the DEXA scan results and assess the effectiveness of therapy.
24. Discard supplies, remove gloves, and perform hand hygiene.
25. Document the procedure in the patient's record.

EXPECTED OUTCOMES

• Patient is compliant with care plan.
• Patient and caregiver accept teaching about osteoporosis management.
• Patient and caregiver can teach back recommendations for osteoporosis management.

UNEXPECTED OUTCOMES

• Patient not compliant with care plan
• Renal dysfunction
• ONJ
• Esophagitis
• Spontaneous fracture
• Falls

DOCUMENTATION

• Interventions and strategies implemented
• Patient's compliance
• Side effects experienced from prescribed treatment
• Efficacy of treatment
• Patient's response to treatment
• Patient's progress toward goals
• Assessment of pain, treatment if necessary, and reassessment
• Patient and caregiver teaching
• Complications and related interventions

SPECIAL CONSIDERATIONS

• Older adults are at higher risk for osteoporotic fractures. Hip fractures have significant morbidity and mortality in this group.⁶
• Many older adults take multiple medications; drug-drug reactions may occur.

REFERENCES

1. Cosman, F. and others. (2014). Clinician’s guide to prevention and treatment of osteoporosis. Osteoporosis International, 25(10), 2359-2381. doi:10.1007/s00198-014-2794-2 (Level VII)
2. Levis, S., Theodore, G. (2012). Summary of AHRQ’s comparative effectiveness review of treatment to prevent fractures in men and women with low bone density or osteoporosis: Update of the 2007 report. Journal of Managed Care Pharmacy, 18(4 Suppl. B), S1-S15. (classic reference)* (Level VII)
3. Lilly, L., Rainforth-Collins, S, Snyder, J. (2017). In Chapter 34, Women’s health drugs. Pharmacology and the Nursing Process. St. Louis, MO: Elsevier.
4. Rizzoli, R. and others. (2013). Vitamin D supplementation in elderly or postmenopausal women: A 2013 update of the 2008 recommendations from the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO). Current Medical Research and Opinion, 29(4), 305-313. doi:10.1185/03007995.2013.766162 (classic reference)* (Level VII)
5. Shanks, G., Sharma, D., Mishra, V. (2019). Prevention and treatment of osteoporosis in women. Obstetrics, Gynaecology and Reproductive Medicine, 29(7), 201-206. (Level VII)
6. U.S. Preventive Services Task Force (USPSTF). (2019). Final recommendation statement: Osteoporosis: Screening. Retrieved July 15, 2019, from https://www.uspreventiveservicestaskforce.org/Announcements/News/Item/us-preventive-services-task-force-issues-final-recommendation-statement-for-screening-for-osteoporosis (Level VII)

*In these skills, a “classic” reference is a widely cited, standard work of established excellence that significantly affects current practice and may also represent the foundational research for practice.

Elsevier Skills Levels of Evidence

• Level I - Systematic review of all relevant randomized controlled trials
• Level II - At least one well-designed randomized controlled trial
• Level III - Well-designed controlled trials without randomization
• Level IV - Well-designed case-controlled or cohort studies
• Level V - Descriptive or qualitative studies
• Level VI - Single descriptive or qualitative study
• Level VII - Authority opinion or expert committee reports