Pain Management Options Based on the category of illness and their stage level of sickness
by Vladimire Herard
A proper diet, physical exercise, avoidance of tobacco and alcohol, use of medical devices such as hip padding and medical testing preserve bone health in senior patients, various units of the National Institutes of Health (NIH), the Centers for Disease Control and Prevention (CDC), the U.S. Department of Health and Human Services’ (HHS) Surgeon General and researchers say.
The federal agencies, NIH and CDC, the U.S. Surgeon General and researchers released guides, a report and findings of research studies about maintaining bone health among senior citizens, advising for proper nutrition, regular exercise, shunning of smoking and drinking, the use of protective devices and therapies and undergoing medical exams to test bone strength and density.
Particularly, the NIH’s Osteoporosis and Related Bone Diseases National Resource Center, a national health care provider and patient informational and policy clearinghouse about bone health, works to secure its educational material with:
–the National Institute of Arthritis and Musculoskletal and Skin Diseases;
–the National Institute on Aging;
–the Eunice Kennedy Shriver National Institute of Child Health and Human Development;
–the National Institute of Dental and Craniofacial Research;
–the National Institute of Diabetes and Digestive and Kidney Diseases;
–the NIH Office of Research on Women’s Health and the HHS Office on Women’s Health, and;
–university and medical researchers.
The guides and report are titled Exercise for Your Bone Health, Once Is Enough: A Guide to Preventing Future Fractures, Information for Patients About Paget’s Disease of Bone, Bone Mass Measurement: What the Numbers Mean and the Surgeon General’s Report on Bone Health and Osteoporosis: What It Means To You.
This body of literature is aimed at instructing seniors, their families and the primary care, internal medicine and family practice physicians, endocrinologists, rheumatologists, orthopedic surgeons, neurologists, ear, nose and throat physicians treating them.
Bone Health and Factors
Human bone is ever-evolving and living tissue, composed of collagen, a soft, structured protein, and calcium phosphate, a strengthening and hardening mineral. Both collagen and calcium strengthen bone but also allow it to be flexible.
In the course of a person’s lifetime, old bone is disposed of (resorption) and new bone replaces it (formation). During his or her youth, a person’s new bone grows faster than the rate at which old bone is discarded.
Bone formation proceeds at a speed faster than resorption until a person’s skeleton reaches peak bone mass, which translates into “maximum bone density and strength” at age 30.
After that age, bone resorption starts to surpass bone formation. The loss of bone material is quickest in the earliest years of menopause but continues past this period.
After menopause in women and, to a lesser extent, in men, bone becomes more fragile or brittle and vulnerable to breakage or injury. Among the most common bone problems are bone fractures, osteoporosis, Paget’s disease and chronic illnesses with complications that impact bone health.
Osteoporosis, Fractures, Bone Deformities, Menopause
Osteoporosis, also known as porous bone, is a form of bone illness featuring low bone mass and structural decline of tissue, leading to more brittleness and a greater risk of fractures of the hip, spine and wrist. Called the “silent disease,” it is characterized as effecting bone loss without any symptoms.
In fact, despite a series of policy changes and laws affecting health care delivery to senior patients, some individuals may still not be aware that they have osteoporosis until their bones weaken severely to the point that any strain, bump or fall leads to a hip fracture or to the collapse of a vertebra and sometimes it is not even acknowledged then.
Such were the findings of a June 16, 2002 study by the University of California’s San Francisco School of Nursing Institute for Health and Aging that appeared in a journal Medical Week.
Additionally, researchers with Osteoporosis International found that, aside from osteoporosis affecting primarily women, of all osteoporosis patients in the hospital, 80 percent were white and 75 percent were over the age of 65 years.
The organization also found that osteoporosis costs billions of dollars nationally with the majority of the expense connected to hip fracture. The U.S. Surgeon General reports that it may cost $18 billion a year to treat fractures from osteoporosis. Most treatment for osteoporosis was covered by Medicare and the greatest cost borne was for nursing home cost, amounting to 59 percent of all dollars spent.
The National Osteoporosis Foundation and Harris Interactive, too, found that, while most senior participants in a survey meant to honor National Osteoporosis Awareness and Prevention Month in 2011 knew about osteoporosis, its risks and prevention efforts, about 34 percent did not know about the disease.
Still, 70 percent of women survey participants stated they thought the onset of osteoporosis could be avoided, though only 50 percent recognized physical exercise as a means of prevention and only 27 percent realized diet had an influence.
A collapsed vertebra can present as severe back pain, a loss of a person’s height or deformities of the spine such as kyphosis or a extremely stooped posture.
The onset of osteoporosis takes place when bone resorption begins too rapidly or the formation of bone happens too gradually. Osteoporosis is more likely to take place if a person did not peak in optimal bone mass during youth and young adulthood.
Nationwide, about 10 million persons suffer from osteoporosis and an additional 34 million have low bone mass, making it a public health threat for 44 million individuals total and increasing the chances of those with low bone mass of developing the disease. Half of all women and one in eight men over the age of 50 stand to experience an osteoporosis-related fracture at least once.
Unless they change their diet and lifestyle, the U.S. Surgeon General predicts that half of all individuals nationwide over the age 50 may suffer from fragile bones.
Every year, osteoporosis causes nearly two million fractures, the U.S. Surgeon General and the National Osteoporosis Foundation reported, including 2.6 million visits to the doctor’s office, 500,000 hospitalizations, 800,000 emergency room trips, 180,000 nursing home placements, 300,000 hip fractures, nearly 700,000 vertebral fractures, 250,000 wrist fractures and over 300,000 fractures in other parts in the human body, causing disability, pain and other health issues.
NIH and CDC researchers have identified several risk factors for developing osteoporosis. Some individuals hold many of these risk factors but others have none. They include gender, age, body size, ethnicity, family history, sex hormones, anorexia, drug use, a lack of physical exercise, smoking and drinking.
With respect to gender, a woman is more likely to develop osteoporosis than a man. Women have less bone mass and are more likely to lose bone material than men because they are more likely to undergo menopause, which causes changes in their bodies leading to this loss.
By contrast, men with osteoporosis make up one out of every five patients with osteoporosis. However, their level of ill health and risk of death are higher than that of chronically ill individuals without this disease.
When testing men for the risk of bone fracture and osteoporosis, researchers say physicians should evaluate the mineral density and strength of their senior patients’ bones. The most method is to use central dual energy X-ray absorptiometry.
Doctors must also factor in secondary causes for bone fracture or osteoporosis in men such as a reproductive health and hormonal condition known as hypogonadism. Drugs should be administered to senior male patients with a background of low-trauma fracture or severe bone loss.
Because of the links among proper nourishment, including daily intake of bone-building calcium and vitamin D, smoking, alcohol use, an exercise regimen and fall prevention and optimal bone health, researchers recommend that male senior patients and their physicians take these factors into consideration when treating men with osteoporosis or at risk for cultivating this illness.
They also urge male patients and doctors alike to administer appropriate drug therapy for all men in danger of bone fracture, including the use of the medication alendronate, deemed “first-line therapy” because of its effectiveness and mildness, and the “second-line therapy” drug teriparatide for managing osteoporosis in “high-risk men.”
Teriparatide is considered “second-line” because of its high cost, difficult administration routine and safety risks. Moreover, calcitonin and testosterone are also included in a doctor’s arsenal of solutions for managing the risk or onset for bone fracture and osteoporosis in men.
The second factor for bone fractures and osteoporosis is age. In both men and women, bones become less thick and weaker as they age. As a result, physicians must be mindful of the risks and the advantages of detecting and addressing osteoporosis in seniors.
Federal research finds that senior patients are not frequently tested enough for bone mineral density and strength and medications or other therapies are not prescribed often enough for them when they do present with bone disorders or the risks for them.
More data is needed on the safety and effectiveness of drugs and therapies in seniors for osteoporosis and bone fractures otherwise, making managing bone-related illness difficult.
Researchers say not enough is known about the effectiveness and safety risk of drugs, various bone-related diseases and costs so as to bridge the gap between the number of seniors at risk for such illness and the number actually being addressed.
As with elderly male bone disorder sufferers, researchers urge testing with central dual energy X-ray absorptiometry, which is for all seniors.
Researchers ask doctors to teach their senior patients to lead lives that encompass bone health, including a program of a proper diet, especially one rich in calcium and vitamin D, physical exercise and private home safety and security but free from smoking and drinking.
Facts and figures from the National Health and Nutrition Examination Survey (NHANES) demonstrate that the incidence of osteoporosis based on hip bone density was calculated at 4 percent for women aged 50 to 59 versus 44 percent for women aged 80 or older.
The NHANES survey finds that the number of seniors aged 65 and older will rise from the 36.8 million it was in 2004 to 54.6 million by the year 2020. In that time period, the number of senior aged 85 and older will jump from 5.1 million to 7.3 million. The incidence of hip fractures and their costs could increase by two to three times by the year 2040. Similar findings are made for seniors worldwide.
The danger of bone fractures rises with age. Hip fracture risk increases after age 70. Research shows that hip fractures were 1.6 per 1,000 years for female seniors aged 65 compared to 35.4 per 1,000 years for women aged 95 or older.
In 2004, there were about 329,000 hospital discharges for hip fractures with 125,000 taking place in patients aged 85 years and older — compared with 116,000 in patients aged 75 to 84 and 48,000 in patients between aged 65 and 74.
Researchers say bone fractures in general boost health care expenses and lead to an increased risk of illness and death for older seniors. After an event of hip fracture, half of all patients fully recover. Additionally, about 3 to 5 percent of patients die during their first hospital stay for hip fracture and about 20 percent to 40 percent in a year.
Data demonstrates that seniors with osteoporosis are not administered medications. A study of nursing home residents, aged 80 and older, with diagnosed osteoporosis or hip fracture showed that 69 percent of them were given calcium and 63 percent vitamin D but only 19 percent received a bisphosphonate. In total, about 36 percent were prescribed drugs or hip protectors for osteoporosis.
For the third factor of body size, small or petite women with thin bones are most endanger of developing bone disorders.
With the fourth factor of race and ethnicity, white and Asian women are most likely to develop bone fractures and osteoporosis than African-American and Hispanic women. The latter two racial groups have a lower but still relatively substantial risk of cultivating such diseases.
The fifth factor involves family history. Part of the risk for developing bone disorders is genetic. Senior patients whose parents suffered from bone fractures and osteoporosis, too, may share their fate with declining bone mass and a great risk of injury.
Six more factors are recognized as responsible for bone fractures and the development of osteoporosis, however, researchers say, with these, the odds can be reversed.
They include sex hormones with the unusual absence of menstrual periods, also known as amenorrhea, the low estrogen levels commonly known as menopause and low levels of the hormone testosterone in men; a high incidence of the eating disorder known as anoxeria because its resulting loss of calcium and vitamin D in the afflicted person’s diet; use of such drugs to treat chronic conditions such as glucocorticoids and some classes of anticonvulsants; a lack of physical exercise; cigarette smoking, and; abuse of alcohol.
Drugs and Other Therapies
A series of studies published in Medical Week in 2002 point to a number of medications and other therapies that treat osteoporosis and bone fractures, including a special class of drugs known as bisphosphonates such as Actonel, Fosamax, Actone, Boniva and Zometa, a commercial form of calcitonin known as Oratonin, a hormone known as Forteo, another treatment by the drug parathyroid hormone (PTH), and a therapy known as vertebroplasty.
Additionally, the Food and Drug Administration (FDA) has long approved the hormone estrogen and the medications alendronate, raloxifene, and risedronate to both prevent osteoporosis and to treat the disease. Alendronate is meant to treat osteoporosis in men. Both alendronate and risedronate are to be used for men and women with glucocorticoid-induced osteoporosis.
A separate set of research that appeared in Medical Week in 2002 finds that the structural network in bones can disintegrate in a year in early postmenopausal women.
Research discovered that the network, known as the trabecular architecture, can deteriorate even with a small amount of loss in bone mineral density, leading to skeletal fragility. The findings were brought before a meeting of the Endocrine Society in San Francisco.
The bisphosphonate drug Actonel, taken once a week, is meant to protect the trabecular architecture in early postmenopausal women, boost bone mineral density and to prevent and treat postmenopausal osteoporosis. Fosamax, too, is taken once a week to prevent and treat the disease in postmenopausal women and to stimulate bone mass in men with osteoporosis.
Bisphosphonates are the nonhormonal class of drugs that stem bone loss, increase bone mineral density and decrease the danger of fractures.
Research involved women within six months to five years after menopause who were administered with Actonel, a total of 12 participants, or a substitute, a total of 14 such participants, for a year. The women who took part in the study did not receive calcium supplements throughout that time period.
A review of hip bone biopsy samples demonstrated that, after one year, the 12 women taking the placebo were already found to have the deteriorated microarchitecture of trabecular bone even with only a small loss in the lumbar spine bone mineral density.
At the same time, the 14 women who received Actonel were able to restore trabecular bone microarchitecture and experienced greater lumbar spine bone mineral density.
The drug parathyroid hormone (PTH) is anabolic and triggers bone formation. This medication is more potent than some anti-resorptive therapies, which are meant to halt bone resorption.
The boost in bone density in two to three years amounts to 15 percent with PTH instead of 6 percent with its rival therapies. The results of research and clinical trials of PTH were reviewed by the American Association of Clinical Endocrinologists.
Yet another drug, Oratonin, is an oral form of calcitonin to treat osteoporosis, which was once only available by injection or in nasal spray form. Calcitonin is a hormone generated in the thyroid gland that decreases the amount of calcium and phosphate in the blood and blocks the resorption of bone, lowering the risk of fracture in an individual suffering from osteoporosis.
Additionally, patients with the disease and who are enduring spinal fractures are relieved from their pain with a procedure known as vertebroplasty. This procedure stabilizes a fractured bone, relieving a patient from pain and averting further damage if the procedure is conducted early enough. The results of research and clinical trials of vertebroplasty were examined by the Society of Cardiovascular and Interventional Radiology.
Lastly, the hormone Forteo, a natural bone-forming substance, is administered to men with osteoporosis through daily injections. Forteo works by triggering new bone-building activity by boosting the number and activity of bone-creating cells known as osteoblasts. The result is a reduced risk of bone fractures and an increase in bone mineral density and strength. A study of the hormone was published in the New England Journal of Medicine.
Paget’s disease, a chronic disorder that results in bone pain, swollen and deformed bones, fractures and arthritis near the joints, involves “excessive breakdown and formation” of bone tissues leading to weakened bones. Compared with osteoporosis, which affects all of the bones, Paget’s disease is localized and affects one or more bones.
The condition is caused by environmental factors and family medical history, particularly a slow-acting virus. Most especially, the disease afflicts seniors and individuals of northern European descent.
Symptoms include pain in any bone impacted by the disease or arthritis; headaches and hearing loss when the illness strikes the skull; pressure on nerves; increased head size; the bowing of a limb; curving of the spine; hip pain, and; damage to the cartilage of joints.
The illness is diagnosed using X-rays but can also be detected with an alkaline phosphatase blood test and bone scans. Complications include osteogenic sarcoma that is known as a rare form of bone cancer, arthritis, hearing loss, heart disease, kidney stones, nervous system problems, sarcoma, loose teeth and vision loss.
Paget’s disease is treated with calcium and vitamin D supplementation, physical exercise, the class of drugs known as bisphosphonates, calcitonin from the thyroid gland and surgery to correct bleeding, fractures, severe degenerative arthritis and bone deformity.
However, other chronic illnesses can cause bone disorders. Vitamin D deficiency causes a number of diseases such as rickets and osteomalacia, which can lead to bone deformities and fractures. Renal osteodystrophy, a form of kidney disease, can cause fractures. Illnesses such as osteogenesis imperfecta leads to abnormal bone growth and easy breakage. Overactive glands can cause endocrine disorders.
Prevention and Bone Health Enhancement
In order to prevent osteoporosis and bone fractures and to promote bone health, the NIH, CDC and the U.S. Surgeon General recommend a proper diet; regular physical exercise; avoidance of tobacco and alcohol; a review of medications to treat chronic ailments that compromise bone wellness; medical testing, and; the use of medical devices and therapies such as hip padding or protectors to avert injury or recover from bone disorders.
The agencies ask seniors and their doctors to lower the risks of falls that hamper bone health. Preventing falls is a prime consideration for men and women with osteoporosis as accidents can cause bone fractures in the hip, wrist, spine or other parts of the human skeleton.
Osteoporosis patients are urged to pay attention to any alterations in their physical balance or gait and they must be ready to speak with their primary care, internal medicine and family practice physicians, endocrinologists, rheumatologists, orthopedic surgeons, neurologists, ear, nose and throat physicians about these changes.
After consulting with their doctors, senior patients and their families may be called upon to protect their bones through a variety of activities:
–private home safety and security efforts such as removing loose rugs or extension cords, fixing unstable staircases, installing grab bars in the bathroom and enhancing lighting;
–examining and, if need be, correcting their vision;
–determining whether they need canes, walkers and assistive devices;
–treating heart conditions that lead to falls such as orthostatic hypotension or arrhythmias, and;
–properly managing drugs that boost the danger of falls such as antipsychotic agents, benzodiazepines, anti-depressants, anti-hypertensives and diuretics.
Senior patients are to consume a diet high in calcium, protein and vitamin D as these nutrients are proven to improve bone mineral density and strength, according to research by the federal agencies and Tufts University in Boston that has appeared in the American Journal of Clinical Nutrition.
If calcium and the other minerals and vitamins are lacking in the diet, their absence is linked to low bone mass, quick bone loss, high rates of fracture and the development of osteoporosis. National nutrition research finds that individuals of any age take in less than their recommended daily amount of calcium.
Aside from mineral supplements, the U.S. Surgeon General reports that seniors can increase their intake of calcium in certain foods such as almonds, baked beans, broccoli, ready-to-eat cereal, cheese, cheese pizza, cottage cheese, ice cream, lasagna, milk, fortified oatmeal, fortified orange juice, pudding, salmon, sardines, soy or rice milk, soybeans, spaghetti, tofu, turnip greens, fortified waffles and yogurt.
If possible, seniors may also increase their intake of other bone-building vitamins and minerals such as boron, collagen, dried plum, magnesium, especially magnesium citrate, manganese, silica, silicon, vitamin K2 and zinc.
And doctors are requested to play their role in convincing their patients to adopt sound nutritional habits for healthy bones. A 2002 study in the journal Menopause found that mere minutes of osteoporosis prevention education in the physician’s office prior to an appointment can encourage more women to take calcium or supplements.
For the study, a group of patients with the Women’s Health at the University of Medicine and Dentistry of New Jersey were subject to viewing a 10-minute osteoporosis education video before seeing their doctors. After watching the video, over 25 percent started their calcium supplements while only 4.9 percent of those who visited their physicians without watching the video did so.
Additionally, researchers ask patients to combine calcium and vitamin D to avoid the development of osteoporosis.
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