VOL: 98, ISSUE: 48, PAGE NO: 52
Jacqueline Parrington, RGN, nurse manager, National Osteoporosis Society, BathIn 2001 the National Service Framework for Older People was launched and included a standard to reduce the number of falls and their impact through strategies encompassing the prevention and treatment of osteoporosis (Department of Health, 2001).
In 2001 the National Service Framework for Older People was launched and included a standard to reduce the number of falls and their impact through strategies encompassing the prevention and treatment of osteoporosis (Department of Health, 2001).
This key intervention, along with the development of falls services, emphasises the need for all health professionals involved in the care of older people to be aware of the management of osteoporosis.
Osteoporosis is defined 'as a skeletal disorder characterised by compromised bone strength predisposing to an increased risk of fracture. Bone strength reflects the integration of two main features: bone density and bone quality' (National Institute of Health Consensus Statement 2000). Add the risk of falling, which increases with age, into this equation and the consequence of osteoporosis - fracture - becomes a common feature of this disease.
The average age of sustaining the most common osteoporotic fractures is as follows: wrist - 65 years, vertebra - 67 years, and hip - 79 years (Dennison and Cooper 1996). One in three women and one in 12 men over the age of 50 will sustain a fracture due to osteoporosis.
Hip fractures alone cost the NHS £1.7bn per year (Torgerson et al, 2001), including both acute and social care costs. Of any type of fracture, hip fractures are also responsible for the greatest excess mortality among both men and women, particularly those aged over 75; around 20% of people die within a year as a result of their hip fracture (Cooper et al, 1993).
Loss of independence, limited mobility and social isolation are just some of the problems encountered by older people following a fracture. Vertebral fractures can lead to height loss, kyphosis and sometimes chronic back pain. After sustaining one vertebral fracture the risk of a subsequent vertebral fracture is as high as 20% (Lindsay et al, 2001).
Due to improved life expectancy and a doubling of the age-specific incidence of fractures in the past three decades the number of men and women presenting with osteoporotic fractures is increasing. Fracture risk is also associated with institutionalisation. Fractures are two to three times as common in elderly people in residential or nursing homes than in those living in the community (Sugarman et al, 2002).
Bone is a living tissue, its renewal, or turnover, due to osteoblast and osteoclast cellular activity. Growth and strength is influenced during childhood by a number of factors, including genetics, sex hormones, physical activity and nutrition. Bone mass is accrued during childhood and peaks in the mid-twenties, plateauing until the mid-thirties when age-related bone loss starts to occur. Men generally attain a higher peak bone mass than women and do not experience the rapid bone loss that women do, due to hormonal changes, around the time of the menopause.
General measures to reduce the risk of osteoporosis on a population-wide basis at any age include increasing physical activity, encouraging healthy eating, advise on alcohol intake and smoking cessation. However, there is not enough evidence to justify a 'screening for all' approach with the available technology to identify those who are at risk of the disease.
Identification Osteoporosis is characterised by a low bone density measured using dual energy X-ray absorptiometry (DXA) scanning. A low bone density gives an indication of risk of fracture much like blood pressure measurement and stroke (Box 1). Low bone density is symptomless, therefore those at high risk of osteoporosis are usually identified by assessment of the presence of clinical risk factors and referred for DXA, if necessary, to confirm the diagnosis. Older people with pre-existing fragility fractures may not need a DXA scan before treatment is recommended. If suspected, secondary causes of osteoporosis - for example, coeliac disease and hyperparathyroidism - will need to be investigated.
Case-finding Health professionals in both primary and secondary care are ideally placed to identify older people at high risk of or with osteoporosis. Case-finding can be opportunistic, fitting in with other clinics - for example, over-75 health checks - or by audit of specific risks groups.
Treatments for osteoporosis The Royal College of Physician guidelines (Royal College of Physicians and Bone and Tooth Society of Great Britain, 2000) provide an evidence-based approach to recommending treatment, ranging from bisphosphonates, calcium and vitamin D and a selective estrogen receptor modulator (SERM) to hormone replacement therapy (HRT) for men and women.
As well as providing general advice on bone health, nurses play a pivotal role in ensuring that people with osteoporosis understand their medication and are encouraged to adhere to it. Most osteoporosis treatments will not provide pain relief from fractures, and advice will be needed on measures to reduce pain.
The dosing instructions for the bisphosphonate therapies are specific, either being taken on an empty stomach on rising in the morning or between meals. Older people on a number of other medications may need more detailed recommendations on when to take these drugs.
Preventative advice on how to avoid constipation may be necessary for people taking calcium supplements.
Falls risk Older people will need an assessment of their risk of falling. Hip fractures usually occur after a fall from a standing height, with minimal trauma involved. Reasons for falling include a number of risk factors, such as polypharmacy, cognitive impairment, balance disorders, visual defects, lack of bathroom safety equipment and a previous history of falls.
Strategies to prevent falls are either population-based (increasing activity, reducing environmental hazards) or directed at those at greatest risk.
Any high-risk strategy will encompass assessment and implementation of a number of elements as appropriate, including specific exercise training to improve balance and gait, a review of medications and provision of hip protector pants to people in nursing homes to deflect force away from the hip in the event of a fall (Lauritzen et al, 1993).
A comprehensive service Osteoporosis results in high costs to both the NHS and to the individual following fractures. Interaction between multidisciplinary agencies in primary and secondary care is essential in order to meet the aims of the falls standard, including osteoporosis, of the National Service Framework for Older People.
Nurses working in a variety of health care areas can identify those at high risk of osteoporosis and falling as well as promoting bone health messages to the general population. Helping people to understand and manage a long-term condition requires nurses to provide information and support.
For further information on osteoporosis, including auditing women over the age of 75 in a primary care setting and audited protocols targeting people on long-term oral glucocorticosteroids, visit the National Osteoporosis Society's website at www.nos.org.uk