Prevention and treatment of osteoporosis in postmenopausal women - Clinical Update

Journal of Family Practice, Oct, 2002 by Linda French, Mindy Smith, Leslie Shimp

Calculations based on risk factors. In a comparison of strategies using risk factors to predict low BMD in postmenopausal women, 2 decision rules performed well: the Osteoporosis Risk Assessment Instrument, which is based on age and weight (Table 1), (17) and the Simple Calculated Osteoporosis Risk Estimation (SCORE). (17) Research to test these instruments with fracture rather than BMD as outcome is needed. (18)

Biochemical markers. Levels of markers in serum and/or urine reflect bone turnover and have potential use in diagnosing and monitoring therapy of osteoporosis. They are not yet widely available and have not been consistently associated with identifying patients at risk for fracture. (10) They are not recommended at this time.

IMPORTANCE OF PRIMARY PREVENTION

At least half of bone strength is attributable to genetic factors (12); modifiable factors may contribute almost equally as a group, and therefore warrant attention. Genetic risk factors include age, family history, female sex, low weight, small frame, and white or Asian race. Primary prevention efforts should begin in childhood and continue throughout the life span to maximize bone mass. (3)

Prevention efforts that target the modifiable factors described below should be a routine part of the health-maintenance visit.

Fall reduction

Falls are the direct cause of more than 90% of osteoporotic hip fractures, (19) and the tendency to tall increases with age. Some studies have shown that, for women over age 70, the most important predictors of hip fractures are fall-related factors (20,21) such as poor cognitive function, slow gait and otherwise impaired mobility, poor vision, drugs that impair alertness or balance, and history of falls. In women over 75, age and slow gait are equal to low BMD of the femoral neck as predictors of hip fracture. (22) Unfortunately, labeling women as osteopenic or osteoporotic can cause fear of falling and lack of activity, leading to further acceleration of bone loss. (10)

Medications that interfere with balance or alertness should be avoided if possible. Environmental hazards such as loose rugs and uneven or slippery surfaces are also well-recognized modifiable risks for falls (23,24) that should be eliminated. Hip protectors effectively reduce fractures in the frail elderly (25) and can boost confidence for beneficial increases in physical activity levels, (26) but they are often poorly accepted by patients. (25,27) Other options include referral for gait training, home visits by a physician or nurse to identify problems in the home that increase the risk of falls, or providing information on home modification (such as installing bathtub rails, removing throw rugs, etc.).

Improvement of nutritional intake

Adequate consumption of calcium is essential for bone health. Calcium balance also can be adversely affected by dietary habits, including high intake of protein, phosphorus, and sodium, although these effects appear to be less important when dietary calcium is sufficient. (3) The recommended calcium intake for postmenopausal women (1200-1500 mg/day) (28) can be met with food sources, but supplements should be added if needed. Most postmenopausal women in the United States consume only about 600 mg/day. (28) High-calcium foods include milk (290-300 mg/cup), sardines in oil, with bones (370 mg/3 oz), yogurt (300-500 mg depending on container size) cheese (165-270 mg/slice) canned salmon, with bones (170-210 mg/3 oz), broccoli (160-180 mg/cup), and tofu (144-155 mg/4 oz). (15)