Osteoporosis: definition, symptoms, diagnosis and treatment

By Cristiano Antonino On Feb 5, 2023

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Osteoporosis causes bones to become weak and brittle, such that a fall or even slight stress, such as bending or coughing, can cause a fracture

What is osteoporosis?

Osteoporosis is classified as a metabolic bone disease.

Osteoporosis occurs when the creation of new bone does not keep pace with the removal of old bone.
Osteoporosis causes bones to become weak and brittle, such that they fracture after a fall or even minor stresses such as bending or coughing.

Osteoporosis can be classified into two types:

Primary osteoporosis. Primary osteoporosis occurs in women after menopause and in men later in life, but it is not simply a consequence of ageing, but rather of the failure to develop an optimal peak bone mass during childhood, adolescence and young adulthood.
Secondary osteoporosis. Secondary osteoporosis is the result of medication or other conditions and diseases that affect bone metabolism.

Pathophysiology

Osteoporosis is characterised by a reduction in bone mass, deterioration of the bone matrix and a decrease in the architectural strength of the bone.

Reduction in total bone mass. Normal homeostatic bone turnover is altered; the rate of bone resorption maintained by osteoclasts is greater than the rate of bone formation maintained by osteoblasts, resulting in a reduction in total bone mass.
Progression. Bones become porous, brittle and friable; they fracture easily under stresses that would not break normal bone.
Postural changes. Postural changes cause relaxation of the abdominal muscles and a protruding abdomen.
Age-related losses. Calcitonin and oestrogen decrease with age, while parathyroid hormone increases, increasing bone turnover and resorption.
Consequence. The consequence of these changes is a net loss of bone mass over time.

The causes of osteoporosis and their effects on bone include:

Genetics. Caucasian women of small build who are not obese are most at risk; Asian women of slight build are at risk of low peak bone mineral density; African American women are less susceptible to osteoporosis.
Age. Osteoporosis occurs in men at a lower rate and at a later age, as testosterone and oestrogen are thought to be important in achieving and maintaining bone mass, so the risk of osteoporosis increases with advancing age.
Nutrition. Low calcium intake, low vitamin D intake, high phosphate intake and inadequate calorie intake reduce the nutrients needed for bone remodelling.
Exercise. A sedentary lifestyle, lack of exercise, low weight and body mass index increase the risk of osteoporosis because bones need stress for their maintenance.
Lifestyle choices. Excessive consumption of caffeine and alcohol, smoking and poor exposure to sunlight reduce osteogenesis in bone remodelling.
Medications. Taking corticosteroids, anti-epileptic drugs, heparin and thyroid hormones affects calcium absorption and metabolism.

Common signs and symptoms seen in patients with osteoporosis include:

Fractures. The first clinical manifestation of osteoporosis may be fractures, most commonly occurring as compression fractures.
Kyphosis. The gradual collapse of a vertebra is asymptomatic and is called progressive kyphosis or ‘shepherd’s hump’, associated with loss of height.
Calcitonin decrease. Calcitonin, which inhibits bone resorption and promotes bone formation, is decreased.
Decreased oestrogen. Oestrogens, which inhibit bone disintegration, decrease with age.
Increase in parathyroid hormone. Parathyroid hormone increases with age, increasing bone turnover and resorption.

To prevent primary and secondary osteoporosis, measures such as the following must be implemented:

Identification. Early identification of adolescents and young adults at risk could prevent osteoporosis.
Diet. A diet with a higher calcium intake strengthens bones and prevents fractures.
Activity. Participation in regular weight-bearing exercise provides excellent bone maintenance.
Lifestyle. Lifestyle modifications, such as reducing the use of caffeine, cigarettes, fizzy drinks and alcohol, can improve osteogenesis for bone remodelling.

Assessment and diagnostic results

Osteoporosis may not be detected by routine X-rays until 25%-40% demineralisation occurs, resulting in radiolucency of the bones.

Dual Energy X-ray Absorption (DXA). Osteoporosis is diagnosed with DXA, which provides information on the BMD of the spine and hip.
BMD test. The BMD test is useful to identify osteopenic and osteoporotic bone and to assess the response to therapy.
Laboratory studies. Laboratory studies such as serum calcium, serum phosphate, serum alkaline phosphatase, urinary calcium excretion, haematocrit, erythrocyte sedimentation rate and radiographic studies are used to rule out other possible disorders contributing to bone loss.

Medical management of a patient with osteoporosis includes:

Diet. A diet rich in calcium and vitamin D throughout life, with increased calcium intake during adolescence, young adulthood and middle years, protects against skeletal demineralisation.
Exercise. Regular weight-bearing exercise promotes bone formation, e.g. aerobic exercise of 20-30 minutes, three times a week, is recommended.
Fracture management. Osteoporotic compression fractures of vertebrae are managed conservatively; pharmacological and dietary treatments aim to increase vertebral bone density and, for patients who do not respond to first-line approaches, are treated with percutaneous vertebroplasty or kyphoplasty (injection of polymethylmethacrylate bone cement into the fractured vertebra, followed by inflation of a pressurised balloon to restore the shape of the affected vertebra).

First-line and other drugs used to treat and prevent osteoporosis include:

Calcium supplements with vitamin D. To ensure adequate calcium intake, a calcium supplement with vitamin D may be prescribed to be taken with meals or with a drink high in vitamin C to promote absorption, but these supplements should not be taken on the same day as bisphosphonates.
Bisphosphonates. Bisphosphonates, which include daily or weekly oral preparations of alendronate or risedronate, monthly oral preparations of ibandronate or annual intravenous infusions of zoledronic acid, increase bone mass and reduce bone loss by inhibiting osteoclast function.
Calcitonin. Calcitonin directly inhibits osteoclasts, reducing bone loss and increasing bone mineral density; it is administered by nasal spray or subcutaneous or intramuscular injection.
Selective oestrogen receptor modulators (SERMs). SERMs, such as raloxifene, reduce the risk of osteoporosis by preserving bone mineral density without oestrogenic effects on the uterus.
Teriparatide. Teriparatide is an anabolic agent administered subcutaneously once a day; like recombinant PTH, it stimulates osteoblasts to build bone matrix and facilitates overall calcium absorption.

Surgical management

Hip fractures that occur as a result of osteoporosis are managed surgically through:

Joint replacement. Joint replacement is surgery to replace all or part of the joint with an artificial joint called a prosthesis.
Closed or open reduction with internal fixation. Open reduction with internal fixation involves the application of implants to guide the healing process of a bone and open reduction, or fixation, of the bone, while closed reduction is a procedure to fix or reduce a broken bone without surgery.

The management of a patient with osteoporosis consists of the nursing process

Nursing assessment

Health promotion, identification of persons at risk of osteoporosis and recognition of problems associated with osteoporosis form the basis of the nursing assessment.

Anamnesis. The anamnesis includes questions about the onset of osteopenia and osteoporosis and focuses on family history, previous fractures, dietary calcium consumption, exercise patterns, onset of menopause and use of corticosteroids, alcohol, caffeine and smoking.
Symptoms. Any symptoms that the patient experiences, such as back pain, constipation or altered body image are examined.
Physical test. The physical test may reveal a fracture, kyphosis of the thoracic spine or short stature.

Nursing diagnosis

Based on the assessment data, the main nursing diagnoses for a patient with osteoporosis may include:

Poor knowledge of the osteoporotic process and treatment regimen.
Acute pain related to the fracture and muscle spasm.
Risk of constipation related to immobility or development of ileus.
Risk of injury: further fractures related to osteoporosis.

Nursing care planning and goals

The main objectives for the patient may include

Knowledge of osteoporosis and the treatment regimen.
Relief of pain.
Improvement of bowel elimination.
Avoidance of further fractures.

Nursing interventions

Appropriate nursing interventions for a patient with osteoporosis are:

Promoting understanding of osteoporosis and the treatment regimen. Teaching the patient focuses on factors influencing the development of osteoporosis, interventions to stop or slow down the process and measures to relieve symptoms.
Relieve pain. Advise the patient to rest in bed in a supine or lateral position several times a day; the mattress should be firm and not saggy; bending the knees increases comfort; intermittent local heat and back massages promote muscle relaxation; the nurse should encourage good posture and teach body mechanics.
Improve bowel movement. Early introduction of a high-fibre diet, increased fluids and use of prescribed softeners help prevent or minimise constipation.
Injury prevention. The nurse encourages walking, good body mechanics and posture, and daily weight-bearing activity outdoors to increase vitamin D production.

Assessment

Expected patient outcomes may include

Acquisition of knowledge about osteoporosis and the treatment regimen.
Relief of pain.
Demonstration of normal bowel elimination.
No new fractures.

Discharge and home care guidelines

Upon completion of home care instructions, the patient or carer will be able to implement the following:

Diet. Identify foods rich in calcium and vitamin D and discuss calcium supplements.
Exercise. Carry out daily weight-bearing physical activity.
Lifestyle. Modify lifestyle choices: avoid smoking, alcohol, caffeine and fizzy drinks.
Posture. Demonstrate good body mechanics.
Early diagnosis. Participate in screening for osteoporosis.

Documentation guidelines

Documentation should focus on:

Individual outcomes, including learning style, identified needs, presence of learning blocks.
Learning plan, methods to be used and persons involved in planning.
Teaching plan.
Client/SO response to the learning plan and actions taken.
Description of client’s response to pain, specifics of pain inventory, expectations of pain management and acceptable level of pain.
Current bowel pattern, stool characteristics, drugs and herbs used.
Food intake.
Exercise and activity level.
Current physical results.
Client/caregiver understanding of individual risks and safety issues.
Availability and use of resources.
Achievement or progress towards desired outcomes.
Changes to the care plan.