Osteoporosis patient assessment

For the physical assessment, the nurse generally appraises the patient s physical condition and limitations. If the patient has arthritis (any type), the nurse examines the affected joints in the extremities for appearance of the skin over the joint, evidence of joint deformity, and mobility of the affected joint. Fhtients with osteoporosis are assessed for pain particularly in the upper and lower back or hip. Vital signs and weight are taken to provide a baseline for comparison during therapy. If the patient has gout, the nurse examines the affected joints and notes the appearance of the skin over the joints and any joint enlargement. 

Patient assessment should begin with identifying risk factors for osteoporosis and fractures (see Table 88-1). Important points include age, history of nontraumatic adult fractures, family history of osteoporosis or fragility fractures, comorbid medical and mental illnesses, lifestyle habits (diet, physical activity, smoking, and alcohol use), menstrual history, fall risk, prior and current medications (especially... 

Some men with osteoporosis possess clearly identifiable risk factors. In others, further investigation for secondary canses is warranted (see above patient assessment section). Men 70 years and older should have DXA tests to screen for osteoporosis. DXA standards state T-scores shonld be compared with a white male normative reference database, regardless of ethnicity. BMD determination shonld also be considered for men with a low-tranma fracture, prevalent vertebral deformity, glucocorticoid use, hypogonadism, alcoholism, or poor overall health. Measmement of serum free or total testosterone can also determine if hypogonadism is contributing to bone loss. 

Evaluate patients for progression of osteoporosis, including signs and symptoms of new fragility fracture (e.g., localized pain), loss of height, and physical deformity (e.g., kyphosis). Patients should be assessed on an annual basis or more often if new symptoms present. 

Assess patient risk factors for osteoporosis, with special attention to age, menopausal status, previous history of osteoporotic fracture, smoking status, low body weight, family history of osteoporotic fracture in first-degree relatives, and presence of secondary causes of osteoporosis. 

Chavassieux PM, Arlot ME, Reda C, Wei L, Yates J, Meunier PJ (1997) Histomor-phometric assessement of the long term effects of alendronate on bone quality and remodelling in patients with osteoporosis. J Clin Invest 100 1475-1480... 

In the treatment of secondary adrenocortical insufficiency, lower doses of cortisol are generally effective, and fluid and electrolyte disturbances do not have to be considered, since patients with deficient corticotrophin secretion generally do not have abnormal function of the zona glomerulosa. Since cortisol replacement therapy is required for life, adequate assessment of patients is critical to avoid the serious long-term consequences of excessive or insufficient treatment. In many cases, the doses of glucocorticoid used in replacement therapy are probably too high. Patients should ideally be administered three or more doses daily. To limit the risk of osteoporosis, replacement therapy should be carefully assessed on an individual basis and overtreatment avoided. 

Optimal management of the postmenopausal patient requires careful assessment of her symptoms as well as consideration of her age and the presence of (or risks for) cardiovascular disease, osteoporosis, breast cancer, and endometrial cancer. Bearing in mind the effects of the gonadal hormones on each of these disorders, the goals of therapy can then be defined and the risks of therapy assessed and discussed with the patient. 

Ten patients who had taken lithium for less than 1 year and 13 who had taken it for more than 3 years were assessed for alterations in bone metabolism and parathyroid function (654). There were no differences in bone mineral density, serum calcium concentration, or PTH concentration, but both groups had increased bone turnover and the longterm group had nonsignificantly higher calcium and PTH concentrations (including one hyperparathyroid patient who had an adenoma excised). The authors conclusion that lithium therapy is not a risk factor for osteoporosis needs to be tempered by the small sample size, the case of adenoma, and the blood concentration trends. 

Before starting HRT patients should be assessed individually considering their risk of osteoporosis, the current status of their liver disease, and any other coexisting medical risks. They should also be assessed for any history, including family history, of jaundice. The risks and potential benefits of treatment should be carefully explained. 

Bone markers are used to assess bone turnover (resorption or formation) in patients with osteoporosis. This testing is useful for identifying osteoporotic individuals with elevated bone resorption and for predicting and assessing the response to therapy. Markers of bone resorption include collagen cross-finks (N telopeptide, deoxypyridinoline, or C-telopeptide). Because bone resorption and formation are coupled, markers of bone formation (BAP and serum osteo-... 

Since the first edition of this book developments have continued in this area, particularly in respect of computerised databases as a source of detailed and reliable data for use in the pharmacoeconomic assessment of new drugs. The creation of specialised databases, such as HIV Insight, which contains the detailed clinical records of about 2500 patients who are either HIV seropositive or have the disease AIDS, has been very successful and plans are being made to develop other specialised databases in diabetes, oncology, Alzheimer s, osteoporosis and other similar chronic diseases. 

Patients who are undergoing therapy for menstruation-related disorders should have a monthly examination by a clinician to assess efficacy and adverse effects and adjust dosing, if needed. If first-line treatment approaches are not effective after several months, then alternative or combination therapies should be considered. Perimenopausal women should be monitored every 1 to 2 months to determine the effectiveness of treatment. Once a patient is stable and responding to the treatmentplan, monitoring may be extended to every 3 to 6 months. Peri- and postmenopausal women should be monitored regularly because of the increased risk of osteoporosis, cardiovascular disease, and dementia. Throughout therapy, patients should be... 

Women and men over age 50 should be assessed for factors that increase the risk of developing osteoporosis and related fractures. Patients with premature or severe osteoporosis should be evaluated for secondary causes of bone loss. 

Numerous diseases and drugs can decrease bone mass (see Table 88-1). Secondary causes are suspected when osteoporosis occurs in premenopausal women, men younger than age 70, those with no risk factors, multiple low trauma fractures (especially at a young age), a Z-score less than -2.0 (see section below on quantification of BMD), or bone loss despite adequate drug treatment and calcium supplementation." Patients suspected of having secondary causes should undergo careful evaluation that includes a comprehensive physical exam and laboratory assessment. Both the osteoporosis and contributing disorders should be treated. 

In a retrospective audit of 105 patients (38 men and 67 women, over 18 years of age) in a tertiary care center in India, 56 % had at least one documented intervention related to osteoporosis prevention (calcium, vitamin D, bisphosphonates, or a bone mineral density study) [17. Only three patients received bisphosphonates for osteoporosis prophylaxis. There was poor pretherapeutic risk assessment, absence of instructions regarding preventive measures, inappropriate investigation for the presence of osteoporosis, and unacceptable failure to use bone protective agents. 

A 74-year-old woman, who was referred for evaluation of pain and persistently abnormal exposure of jaw bone after extraction of teeth, had been using weekly oral alendronate for osteoporosis for about 5 years. She had the clinical features of bisphosphonate-associated osteonecrosis of the mandible, which was precipitated by extraction of teeth 14 months before she was referred for assessment. She had multiple susceptibility factors for osteonecrosis of the jaw, including older age, type 2 diabetes mellitus, and a long duration of bisphosphonate therapy. The mandibular lesions did not improve despite repeated operations over 14 months. Bisphosphonate therapy was withdrawn and parathyroid hormone therapy was started after 2 months the oral mucosa had healed, after 4 months the pain had completely subsided, and after 6 months the patient s eating and drinking habits had returned. The serum concentration of osteocalcin, a marker of bone formation, which was initially suppressed, increased by 174% from baseline after 6 months of treatment with parathyroid hormone. 

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