Upon completion of this case study, the researcher should be better able to:
* Assess patients who have a history of a fragility fracture
* Formulate long-term management plans for patients with osteoporosis-related fragility fractures
* Outline strategies for treatment and adherence in accordance with evidence-based guidelines on the management of osteoporosis
* Recommend a multidisciplinary approach for the patient at high risk of fragility fracture
Case History and Presentation
Mrs. X, is a 78 year old women. She had worked heavily for fifty years. She does not exercise, seldom goes to a doctor for check-up, has a poor diet, and is slightly underweight. While in her work, she was unable to stand because of severe back pain, so was rush to the hospital were a radiograph revealed a fraction in her vertebrae and that she has osteoporosis
. Following discharge orders suggesting follow-up with an orthopedic surgeon, Mrs. X presents to her family orthopedist, who does an initial history and physical examination. There is no family history of cancer or heart disease. She was also play on a diet and exercise program designed to improve the strength of her bones. In addition, she was prescribe to increase dietary calcium and vitamin D uptake to promote bone formation.
* Height: 5 ft
* Weight: 92 lbs
* BMI: 18 kg/m2
* BP: 170/80 mm Hg
* Lungs: normal breath sounds
* Heart: regular heart rate
Calcium, the most abundant mineral in the body, is found in some foods, added to others, available as a dietary supplement, and present in some medicines (such as antacids). Calcium is required for vascular contraction and vasodilation, muscle function, nerve transmission, intracellular signaling and hormonal secretion, though less than 1% of total body calcium is needed to support these critical metabolic functions . Serum calcium is very tightly regulated and does not fluctuate with changes in dietary intakes; the body uses bone tissue as a reservoir for, and source of calcium, to maintain constant concentrations of calcium in blood, muscle, and intercellular fluids .
The remaining 99% of the body’s calcium supply is stored in the bones and teeth where it supports their structure and function . Bone itself undergoes continuous remodeling, with constant resorption and deposition of calcium into new bone. The balance between bone resorption and deposition changes with age. Bone formation exceeds resorption in periods of growth in children and adolescents, whereas in early and middle adulthood both processes are relatively equal. In aging adults, particularly among postmenopausal women, bone breakdown exceeds formation, resulting in bone loss that increases the risk of osteoporosis over time .
Bone health is largely an unrecognized health issue in the Philippines. In a landmark report made by International Osteoporosis Foundation in 2009, awareness of osteoporosis in the country was one of the lowest compared to other countries in the mid 1990s. Although, awareness moved a higher level a decade later, it was still recognized as a consequence of old age.
One out of every three Filipino women, as well as one in five Pinoy men, is likely to suffer from osteoporosis. These are higher than the number of people succumbing to cancer of the breast or prostate-and should be given the attention they deserve. In the Philippines, institutional data show that the leading osteoporosis-related fractures are hip fractures, since they are easily recognized due to associated pain and minimal trauma, unlike the vertebral or spine fractures, which usually go unrecognized.
Based on the 2010 Philippine Census of Population and Housing, the total population of the country is 92 million. Also in 2010, approximately 6.4 million are senior citizens. Moreover, the share of seniors to total population has been increasing over time, from 5.3 percent in 1980 to 6.0 percent in 2000 to 6.9 percent in 2011 to 13.8 percent in 2040.
Specifically in the Philippines, based on IOF’s report, the prevalence of hip fractures in individuals over 70 years and above was estimated to be 160 per 10,000. Based on this prevalence rate, it is estimated that there were about 28,000 hip fractures in 2003 and 34,000 in 2005. The numbers are expected to reach 65,000 by 2020 and almost 175,000 by 2050.
In 2003, the National Nutrition and Health Survey revealed that fracture incidence among patients 50 years and above is 11.23 percent in women and 8.97 percent in men. Among the 50-and-above group, the overall prevalence is 0.2 percent. Using the Osteoporosis Assessment Tool for Asians (OSTA), it also suggested that 11.23 percent of women and 8.7 percent of men over 50 are at high risk for osteoporosis. It is predicted that about 4 million people will be at high risk by 2020, and figures may surpass 10 million mark by 2050.
Given these figures and estimates, calcium intake levels in the Philippines are generally inadequate. According to the 2008 nutrition survey conducted by the Food and Nutrition Research Institute of the Department of Science and Technology (FNRI-DOST), nearly 90 percent of Filipino households do not meet the average requirements for calcium. Only one in every ten Filipino households meets the average requirement for calcium.
Calcium requirements also differ based on population groups and gender. Male and female Filipino adults aged 19 to 64 years old need 750 milligrams of calcium per day, while those aged 65 years old and above need 800 milligrams per day, based on the Recommended Energy and Nutrient Intakes (RENI) for Filipinos developed by FNRI.
Recent research has revealed that osteoporosis symptoms are more common in women with early menopause. Women who go through menopause are almost twice as likely to be diagnosed with symptoms of osteoporosis at some point later in life.Osteoporosis is a bone disease where bone mineral density is reduced, leading to an increased risk of fracture due to the deterioration of bone microarchitecture and the alteration of a variety of proteins in the bone.
According to Ola Svejme of Skane University Hospital in Malmo, Sweden, “the results of this study suggest that early menopause is a significant risk factor for osteoporosis, fragility fracture and mortality in a long-term perspective. To our knowledge, this is the first prospective study with a follow-up period of more than three decades.”
Additional findings of the 29-year study were that these early-menopause women are at greater risk for fracture and have an increased death rate. The study started in 1977 and is composed of 390 white women from Northern Europe, who were 48 years old at the time. The women were divided into two groups: those who went through menopause before the age of 47 and those who started menopause at age 47 or later. For roughly three decades, their bone mineral density was measured on a regulatory basis.
By the time that the researchers concluded their study, the women were already 77 years old and only 198 women remained due to deaths, relocation, or lack of participation. The study concluded that 56 percent of the women with early menopause had osteoporosis, compared with just 30% of those who menopause later. Those with early menopause had a higher risk of fragility fracture and mortality.
Unfortunately, osteoporosis has no cure but it can be prevented with a healthy lifestyle and a well-balanced diet. According to the Mayo Clinic, adequate amounts of calcium, Vitamin D, and regular exercise are necessary to keep our bones healthy.
Between the ages of 18 and 50, 1,000 milligrams of calcium a day is needed. And the daily amount increases to 1,200 milligrams when women turn 50 when and men turn 70. Good sources of calcium include leafy vegetables, soy products, low-fat dairy products, and orange juice.
Vitamin D is necessary to absorb calcium. According to scientists, adults may start to take 600 to 800 international units (IU) a day through food supplements. Teens and adults can safely take up to 4,000 international units a day.
Exercise can also build strong bones and slow bone loss. Walking, jogging and even stair climbing can strengthen muscles and bones.