The indications and treatments options for complications from Osteoporosis in the case of 64-year-old woman
Keywords: Osteoporosis (porous bone), degenerative joint disease, asthma, type 2 diabetes, hypertension, DEXA, WHO, SERM, EU, IOF.
Information on the osteoporosis is a disease that produces spongy bones, as the density and quality of bones are diminished. This induces bone fracture as they are in a porous state, with the condition progressing quietly.
A woman of 64 years of age was taken to a medical clinic as she experienced an insistent lower back pain. She also has a history of type 2 diabetes, asthma, hypertension plus a degenerative joint disease. Her physical examination has indicated that she has experienced aching pain in the lower lumbar areas, as several hazardous peril’s such as old age, female gender, and a reduced weight of the body that indicates osteoporosis. Secondly the physical exam does not reveal any signs of radiculopathy, obvious fracture, nerve damage, or acute cause of the low back pain.
Diagnostic techniques such as a liver function test, calcium and phosphorus test, thyroid function and a complete blood count tests and a bone mineral density test were conducted. A dual energy X-ray absorptiometry (DEXA scan) was conducted since the patient was over 50 years of age with the risk of osteoporosis.
With a history of asthma, the patient was treated with steroids for exacerbation. Secondly a healthy diet was recommended immediately as supplementation of both vitamin D and calcium was recommended for her to build and maintain strong, dense bones. SERMs and bisphosphonates were the preferred medications.
Case study and diagnosis
Osteoporosis has been defined as a metabolic skeletal condition that has been attributed by fragility of bones, leading towards a high risk of developing spontaneous and traumatic ruptures. 64-year-old Clara jane was brought to the hospital by her daughter due to concerns about a pertinacious lower back pain. Clara’s daughter explained that over the last months her mother has been encoutering a throbbing pain on the lower lumbar area. Clara then says that with more strain it becomes even more detrimental as she struggles to carry out her day to day physical activities, e.g. gardening, but still tries to be active 3 to 4 days a week by walking. However, she does not experience any numbness or any tingling but is still worried about the pain she’s feeling as she is requesting an x-ray.
Clara also warily states whether she is exaggerating or not but feels as if she might be shrinking. Earlier on she had tried on a pair of jeans which she purchased a few years ago, as they are presently too long for her.
When asked about her family history, she remarked that her sister was diagnosed with brittle bones. Clara also has a history of high blood pressure (HBP), type 2 diabetes, degenerative joint disease and asthma.
With no cases of any physical trauma, the doctor began a physical examination, where her blood pressure, heart rate, temperature, respiratory rate, weight and height were recorded. Her heart rate was then measured by listening to her heart beats with a stethoscope. Secondly, he began to also record her body temperature and respiratory rate by measuring her rate of breathing. And then later moved on to her body weight and height, but discovered that her height is abnormal.
2781305334000Table 1: The table of the patients recorded results portray that her blood pressure, heart rate, respiratory rate, temperature and a body weight were all normal. But her height was abnormal which is a warning sign of a spine fracture (a broken bone in your back) caused by osteoporosis.
00Table 1: The table of the patients recorded results portray that her blood pressure, heart rate, respiratory rate, temperature and a body weight were all normal. But her height was abnormal which is a warning sign of a spine fracture (a broken bone in your back) caused by osteoporosis.
Vital signs Results Reference range Observation Units Citations
Blood pressure 135/75 120/80-140/90 Normal mm Hg Medscape, 2015
Heart rate 72 50-80 Normal bpm Medscape, 2015
Respiratory rate 18 16-20 Normal Bpm Medscape, 2015
Temperature 99 97-99 Normal 0F Medline, 2016
Height 4ft11in (150) 5ft 3in (161.6) Abnormal Inches (cm) ONS, 2010
weight 99 (45) 11 (70.2) Healthy weight lbs (kg) Nhs, 2015
Even though Clara has requested an x-ray, it would not be helpful unless the doctor is trying to eliminate the possibility of a structural fractures of the lower lumbar/back. Which is why a DEXA (DXA) scan was performed to measure the quantity of bone tissue in the area measured. The main premise of the scan is that the lower the density of the bone is, the greater the chance of having a fracture. The scan results are presented as SD (standard deviation) or T-score – the number of units above or below average. If the bone density is 2.5 SD then it is below average, which is identified as osteoporosis.
Region BMD (g/cm2) T-score Observation
Head 0.906 -1.9 Mildly normal
Arms 1.039 -1.3 Mildly normal
Legs 0.917 -2.1 Mildly normal
Trunks 0.952 -2.1 Mildly normal
Hip and spine 0.565 -2.5 Abnormal
left346075Table 2: The results of the patients DEXA scan show that from the regions starting at the head to the trunks, they are mildly normal indicating osteopenia. Whilst the hip and spine are shown to be abnormal indicating Osteoporosis.
00Table 2: The results of the patients DEXA scan show that from the regions starting at the head to the trunks, they are mildly normal indicating osteopenia. Whilst the hip and spine are shown to be abnormal indicating Osteoporosis.
left1524000The display of a negative score from the scans mean that the bone density is low, therefore a T-score of -2.5/lower qualifies as osteoporosis. A T-score of -1.0 to -2.5 qualifies as osteopenia, which refers to bone density that is lower than normal peak density but is not low adequately for the disease to be classified, as referred from figure 1 (CP advanced imaging, 2005).
Because the patients hip T-score is -2.5, she is attributed with the WHO (world health organization) formula for osteoporosis. Therefore, an intervention or treatment option is mandatory.
Treatment and outcomes
The treatment options for the patient were outlined to intervene the disease. Firstly, Clara’s diet was carefully reviewed, as it has been noted that she does not use any supplements because she eats a healthy diet. However, with a further assessment from a dietitian, it has been revealed that she has been below the recommended absorption of the necessary nutrients, vitamin D and calcium. Therefore, a supplementation of both the nutrients should begin immediately. Vitamin D is of great importance as it plays a substantial role with the regulation of calcium and conservation of phosphorus levels within the blood, two factors that are immensely valuable for maintaining bones in good health. Calcium helps to construct and conserve strong bones.
Medications were also strongly under careful consideration as given her T-score as well as her symptoms SERM’s (selective oestrogen receptor modulators) and bisphosphonates were the preferred medications. Raloxifene was the recommended SERM since they were developed to reap the benefits of oestrogen while avoiding the hormone’s potential aftereffects. Raloxifene, has been referred as a designer oestrogen, therefore it can act like oestrogen on protecting the bone’s density and decrease its risk of vertebral rupture. The SERM’s bind with high affinity to the oestrogen receptor and have oestrogen agonist and antagonist properties that vary depending upon the individual target organ (Cosman F, Lindsay R, 1999). The factors that determine the variable oestrogen receptor agonist and antagonist activity of SERMs are not fully defined but are still under active study.
Bisphosphonates such as alendronate (Binosto, Fosamax) would help to keep the body from tearing down bone structure. Bisphosphonates inhibit bone reabsorption by inducing apoptosis of bone cells (osteoclasts), thus preventing age related loss of bone and bone structure deterioration (Kenneth E Poole, 2012).
As aforementioned before, the patient tries to remain active by walking and gardening. Depending on the intensity these are of great benefit for aerobic activities. Which is why a heavy-weight exercise regimen should slowly be worked into her routine. As she has a degenerative joint disease, therefore a monitored exercise program should be initially pursued so that she focuses properly on form and does not cause any excess stress on her joints.
Bisphosphonates share a common chemical structure with side chain variations as they convey differences in their pharmacological properties, such as affinity for the minerals of the bone and inhibitory effect on osteoclastic bone reabsorption. The clinical profiles regarding bisphosphonates, such as time of onset and offset of effect, may differ according to their pharmacological properties. Bisphosphonates can be administered orally or intravenously with a wide range of doses and dosing intervals.
The side effects for raloxifene are hot flashes, because of its estrogenic effects, raloxifene increases the risk of blood clots, including deep vein thrombosis (DVT) and pulmonary embolism (blood clots in the lung).
Osteoporosis is a disease in where there is an imbalance of recent bone creation and previous bone reabsorption. This is because the body will fail to form brand new bone material, or there is too much old bone’s to be reabsorbed. Additional factors are able determine the strength bones besides BMD, factors such as size and shape of the bone are also discussed. Microarchitecture, turnover of bone, and bone mineralization are also other factors used to determine its strength. Symptoms for the disease include, back pain, a loss of height over time, a stooped posture and a more easily expected bone rupture. Women are more at risk of developing osteoporosis, due to hormone changes that occur during menopause as it directly affects density of the bone. This is because the female hormone oestrogen is essential for keeping bones in good health. After menopause has finished, oestrogen levels fall, as this can lead to a rapid decrease in bone density.
The bone is constantly remodelling itself in response to hormonal changes and mechanical stresses. Signals are transmitted onto the surface of the bone to osteoblasts and osteoclasts. The bone cell’s, osteocytes, play an important role in the activation and remodelling of bones. The osteoclasts form a reabsorption pit as they reabsorb bone matrix. Their function is halted with the apoptosis followed by coupling signals sent to osteoblasts. The bone matrix is synthesized by the Osteoblasts, as it will undergo a process that has been termed as mineralization.
With a towering prevalence worldwide, osteoporosis has been nominated to be a public health concern. It has been estimated that over 200,000,000 people across the globe suffer from this disease. In USA and Europe approximately 30% of all postmenopausal women have osteoporosis. It has been deduced that ageing populations globally will be responsible for a huge increase in the incidence of the disease, mainly in women are postmenopausal.
There are rare reports of vertebral ruptures that have been reported by physicians, but however in Europe, the prevalence that is defined by radiological criteria has been increasing in age and in both genders, since it is almost as high in men as it is in women. For example, in females it is 12% as it ranges from 6-21%. And in males it is also 12% ranging from 8-20% (IOF).
The prevalence of the porous bone condition within the EU has been estimated to be at 27.6 million in 2010. A report of 5 other major countries within the EU has also been conducted as it shows that there has been an increase of proportion of men and women with the disease by 35% (E Hernlund, 2013).
left464820Figure 2: The above image portrays the prevalence distribution of osteoporosis within the EU and 5 other major EU countries with the highest populations in 2010 (E Hernlund, 2013)
00Figure 2: The above image portrays the prevalence distribution of osteoporosis within the EU and 5 other major EU countries with the highest populations in 2010 (E Hernlund, 2013)
Blood Pressure: Blood pressure chart, Published: 2017, Available at:
Body norms, Body temperature norms: MedlinePlus Medical Encyclopaedia, published: 2017, Available at:
Cosman F, Lindsay R. Selective estrogen receptor modulators: clinical spectrum. Endocr Rev 1999; 20:418.
Riggs BL, Hartmann LC. Selective estrogen-receptor modulators — mechanisms of action and application to clinical practice. N Engl J Med 2003; 348:618.
Meunier PJ, Vignot E, Garnero P, et al. Treatment of postmenopausal women with osteoporosis or low bone density with raloxifene. Raloxifene Study Group. Osteoporos Int 1999; 10:330.
Ettinger B, Black DM, Mitlak BH, et al. Reduction of vertebral fracture risk in postmenopausal women with osteoporosis treated with raloxifene: results from a 3-year randomized clinical trial. Multiple Outcomes of Raloxifene Evaluation Investigators. JAMA 1999; 282:637.
Delmas PD, Ensrud KE, Adachi JD, et al. Efficacy of raloxifene on vertebral fracture risk reduction in postmenopausal women with osteoporosis: four-year results from a randomized clinical trial. J Clin Endocrinol Metab 2002; 87:3609.
Kenneth E Poole, Bisphosphonates in the treatment of osteoporosis. BMJ 22 May 2012, BMJ 2012;344: e3211.
Available online: <http://www.bmj.com/content/344/bmj.e3211 >