Managing patients with complications of osteoporosis

Experiences of postmenopausal osteoporosis: a narrative review

PURPOSE

A narrative review was conducted to identify, critically appraise, and synthesise primary research on the lived experiences of postmenopausal women with osteoporosis.

MATERIALS AND METHODS

A systematic search of qualitative studies published between January 1960 and August 2021 was conducted across seven databases. The selected qualitative studies reported the lived experiences of postmenopausal women with osteoporosis, both with and without a history of fragility fractures.

RESULTS

A total of 17 publications (n = 334) were identified. These results suggest that osteoporosis and fragility fractures significantly affected postmenopausal women's lives. They reported difficulties in carrying out daily activities due to pain and change in their routines to cope with health problems. Some women were satisfied with the information provided by healthcare professionals. Their medicine adherence was also determined by their belief in the importance of their scheduled treatment for osteoporosis.

CONCLUSION

Qualitative studies that explored the lived experiences of postmenopausal women with osteoporosis can provide important insights into the impact of the disease on women's lives and potential pathways for improving care and management.Implications for rehabilitationOsteoporosis and fragility fractures affect the quality of life of postmenopausal women worldwide.The provision of targeted and tailored health information for postmenopausal women with osteoporosis is paramount in improving their health literacy and aiding in the long-term management of their bone health.What is already knownOsteoporosis and related fragility fractures are common, affecting more than 200 million people worldwide, including three million people in the UK.Osteoporotic fractures have significant clinical and public health impacts.What this study addsOsteoporosis, particularly fragility fractures, has a significant impact on the lives of postmenopausal women, including pain and functional impairment.Women's belief in the importance of their scheduled treatment plays a significant role in their concordance with the prescribed medications for osteoporosis.Provision of targeted health information for postmenopausal women with osteoporosis is key to their involvement in decision-making and disease management.

Prevention of osteoporosis in menopausal women: A systematic review of nonpharmacological clinical trials

Osteoporosis is a systemic skeletal disease that is associated with negative physical and psychosocial consequences, so understanding the effective strategies that can be used in the prevention of osteoporosis is especially important. The aim of this study was to integrative review the published interventional of nonpharmacological studies regarding the prevention and treatment of osteoporosis among menopausal women. In this systematic review, databases such as PubMed, PsycInfo, Web of Science (ISI), Scopus, ScienceDirect, EmBase, Cochrane library, Google scholar, and Iranian databases, such as Scientific Information Database and Magiran, were searched. The latest search was performed between "November 2020 and December 2020" separately by two researchers and then double-checked by them. The quality of the included studies was assessed using the Jadad score calculation tool. Twenty eight randomized controlled trials and quasi-experimental studies were included in this current study. The quality assessment indicated that 19 studies had acceptable (good) methodological quality and also 9 studies had weak methodological quality. The main results of this study were classified in three main categories such as exercise or physical activity training (n = 15), educational sessions (n = 11), and other interventions (n = 2). The results of most included studies showed that nonpharmacological strategies such as physical activity and educational interventions are considered as the appropriate actions to prevention of osteoporosis among menopausal women so implementing these strategies can be a good alternative for women with contraindication of hormone therapy or therapeutic treatment.

Exercise and physical activity in individuals at risk of fracture

This is a review of evidence and practical tips on exercise for individuals with osteoporosis, including individuals with hip and vertebral fractures. Balance and functional training, with or without strength training, can prevent falls. Several types of exercise can improve outcomes that are important to patients, such as physical functioning or quality of life. Individuals with osteoporosis should prioritize balance, functional and resistance training ≥ twice weekly, where exercises, volume, intensity, and progression are aligned with the patient's goals and abilities. Patients who want to participate in other activities (e.g., walking, impact exercise, yoga, Pilates) can do them in addition to, but not instead of, balance and functional or strength training, if they can be done safely or modified. Avoid generic advice like "Don't bend or twist", which is difficult or impossible to operationalize, and may create fear and activity avoidance. Instead, be specific about the types of activities to avoid or modify, and provide tips on how to make daily activities safer, or signpost to resources from national osteoporosis societies. For example, not all bending or twisting is bad; it is activities that involve rapid, repetitive, sustained, weighted, or end range of motion twisting or flexion of the spine that may need to be modified, especially in individuals at high risk of fracture.

The "depressive" face of osteoporosis and the "osteoporotic" face of depression

Osteoporosis and depression are two chronic diseases that affect large population groups with great impact on morbidity, mortality and quality of life. An association between osteoporosis and depression has been described in the literature. Definitely, limited data suggest that osteoporosis may enhance depressive symptoms, while far more studies have shown that depression adversely affects bone density and increases fracture risk. However, neither causation nor a firm pathophysiological connection has been established. Thus the correlation of these diseases is still under research. This review comments on a plausible causative relationship and underlying mechanisms that might elucidate the link between two very common diseases. We describe the possible impact of osteoporosis on moods and the (better established) effect of depression on bone health. We also describe the effect of medication and review hormonal and cellular signals that may explain this effect.

Diagnosis and treatment of osteoporosis in older adults

Osteoporosis in the elderly is a serious problem that is increasing as the population ages. Diagnosis is established by measurement of bone mineral density or by the presence of a fragility fracture, especially a spine or hip fracture. Bone-active agents should be prescribed for older patients with osteoporosis to decrease fracture risk. Nonskeletal risk factors for fracture and psychosocial impairment must be identified and managed, and therapy must be individualized.

Evaluation of educational program on osteoporosis awareness and prevention among nurse students in China

This study assessed a targeted continuing osteoporosis educational program and investigated awareness and prevention of osteoporosis in Chinese female pre-internship nurse students. A quasi-experimental study was conducted. The program was presented to 256 nurse students. The baseline knowledge score of the nurse students was low (9.78 ± 3.13). They had inadequate osteoporosis health beliefs, self-efficacy and related behaviors. The educational program significantly augmented osteoporosis knowledge (Student's paired t = -13.42, P < 0.001), total osteoporosis health beliefs (Student's paired t = -4.46, P < 0.001), and the subscale (P < 0.001) except for the perceived barriers to exercising and calcium intake. Participants showed a significant increase in self-efficacy (Student's paired t = -6.45, P < 0.001) post intervention. Those who completed the program were better prepared to prevent and manage osteoporosis. Additionally, nurse students became more concerned about bone health of family members, subjects and themselves because of attending the program. Results of this study reinforce the need for osteoporosis-related continuing education in nurse students before clinical internship.

Association between generic and disease-specific quality of life questionnaires and mobility and balance among women with osteoporosis and vertebral fractures

BACKGROUND AND AIMS

The aims of this study were to assess correlations between two health-related quality of life (HRQOL) measurements, the Quality of Life Questionnaire issued by the European Foundation for Osteoporosis (QUALEFFO- 41) and the total score of The General Health Questionnaire (GHQ-20) in a population of women living at home with well-established osteoporosis and at least one vertebral fracture, as well as the internal consistency and floor and ceiling effects of these measurements. Also examined were the mean values of these measurements, to ascertain whether they were significantly different for the group consisting of 75% of the women with the best performance on mobility and balance, compared with the other participants.

METHODS

Across-sectional study of 89 women aged 60 years or more, evaluated by QUALEFFO-41 (consisting of one total score and five section scores), GHQ-20 (one total score), maximum speed and Functional Reach (FR).

RESULTS

Cronbach's alpha coefficient for measurements of HRQOL ranged from 0.61 to 0.92. Significant correlations between 'QUALEFFO- 41: total score' and 'GHQ-20: total score' were 0.49, and between 'GHQ-20: total score' and section scores of 'QUALEFFO-41' 0.28-0.63. Those in the 75% group with the highest maximum walking speed or longest distance on FR reported significantly better disease-specific HRQOL than the others, with poorer results on these tests.

CONCLUSIONS

Disease-specific and generic HRQOL instruments are not redundant when applied together, and the disease-specific 'QUALEFFO-41' and generic GHQ-20 measure different aspects of HRQOL.

Do estrogen or selective estrogen receptor modulators improve quality of life for women with postmenopausal osteoporosis?

Osteoporotic fractures result in significant deficits in health-related quality of life (HRQOL). The accumulation of deficits resulting from osteoporosis and fractures is now recognized as a major cause of reduced HRQOL in women after the menopause and in later life. Some of these same postmenopausal women may also have deficits in HRQOL related to vasomotor symptoms during the menopausal transition. Although estrogen therapy has not been shown to improve overall HRQOL in late postmenopausal women in randomized, controlled trials, it may improve menopausal symptoms. In contrast, selective estrogen receptor modulators (SERMs) such as raloxifene may increase vasomotor symptoms. Although estrogen is not indicated for the primary prevention of osteoporosis, estrogen therapy may be considered for the postmenopausal woman at risk of osteoporotic fracture who is symptomatic and who is not at high risk of breast cancer or cardiovascular events. Raloxifene decreases risk of invasive breast cancer and may be considered in women at high risk of breast cancer. Decision making about osteoporosis treatment should also consider the impact of the treatment on HRQOL.

Quality-of-life issues in osteoporosis

Osteoporosis is responsible for more than 1.5 million fractures per year in the United States including vertebral and nonvertebral fractures of the hip and wrist. Most of the impact of osteoporosis on quality of life relates to fracture. While the morbidity and mortality of hip fractures have long been recognized, only recently have we also recognized the significant burden of vertebral fractures. With the development of generic and disease targeted quality-of-life instruments we have now confirmed observational studies showing that clinical vertebral fractures have significant effects on quality of life. The economic burden of vertebral fractures, if we include direct and indirect costs, may be similar to hip fractures. The relative risk for mortality after clinical vertebral fracture is at least equivalent to that of hip fracture. The burden of vertebral fractures relates not only to pain but also to kyphosis. Because vertebral fractures are often under diagnosed and under treated, these findings are a call to action because the first vertebral fracture leads to significantly increased risk for subsequent vertebral and osteoporotic fracture with further loss of quality of life.

Self-reported prevalence and correlates of osteoporosis: results from a representative study in Israel

The aim of the present study was to determine self-reported prevalence of osteoporosis and its correlates in a representative sample of Jewish elderly persons aged 60 and older in Israel. Participants included 3022 Jewish community-dwelling men and women who provided information about themselves. Information was collected during home interviews regarding self-reported osteoporosis, health-related information, health behaviors and psychological measures. Osteoporosis self-reported prevalence rate was 7% for men and 25% for women. A history of fracture, joint pain and back pain, and psychological distress were the most important independent predictors in both men and women. Findings of the present study showed that also when based on self-reported measures, osteoporosis is a significant public health problem. Special attention should be paid to those who report themselves as suffering from the disease, but are not involved in health-related behaviors.

Osteoporosis health-related behaviors in secular and orthodox Israeli Jewish women

OBJECTIVE

To compare patterns of osteoporosis health-related behaviors in peri and postmenopausal ultra-orthodox and secular Jewish women.

METHODS

Interviews were conducted with 277 Israeli-Jewish women aged 45+. Health behaviors examined included: physical activity, smoking behavior, alcohol consumption, hormone replacement usage, screening behavior, calcium intake, pharmacological prevention, and help-seeking patterns. Correlates included demographic variables, health characteristics, knowledge, susceptibility beliefs, and familiarity with the disease.

RESULTS

Low proportions of women in both groups participated in physical activities, but differed in type. Calcium intake was deficient in both groups. Education was the only correlate of calcium intake among secular women, and previous experience with the disease was the main determinant among orthodox women. Compared with the secular group, a considerably lower proportion of orthodox women reported using HRT or having performed a bone density examination. Orthodox participants' level of knowledge about osteoporosis was significantly lower as well. Education was an important correlate of knowledge in both groups, as was having performed a bone density examination. Higher age and being menopausal were important correlates of knowledge only for secular women. Having a family member suffering from the disease was associated with higher levels of knowledge among orthodox women. Marked differences were found in the participants' sources of information across groups.

CONCLUSIONS

Findings emphasize the need to expand education in all areas of osteoporosis health-related behaviors among ultra-orthodox women, and in calcium intake and exercise for secular women as well. The transmission of the information should be adapted to the practices of each group.

Optimizing patient selection in percutaneous vertebroplasty

Percutaneous vertebroplasty has emerged as an effective technique for treatment of painful vertebral compression fractures (VCFs) caused by osteoporosis, malignancy, and some benign bone tumors. In selecting appropriate patients for vertebroplasty, it is important to distinguish the pain caused by VCF from other numerous causes of back pain. Careful adherence to clinical and imaging selection criteria is crucial to procedural success.

Osteoporosis and quality of life psychosocial outcomes and interventions for individual patients

Despite the substantial psychosocial impact of osteoporosis, little research has evolved in this area. Early reports conceptualized these nonskeletal problems as psychosocial in nature, but more recent investigations focus on health-related quality of life (HRQOL). Multiple HRQOL instruments have been designed to measure this construct in people with osteoporosis, and each has its strengths and weaknesses. Unfortunately, so much investigative energy has been spent on psychometric testing that these instruments have not been put to work efficiently to identify problem areas in HRQOL. It is from such results that interventions to improve HRQOL will occur.

The Impact of Osteoporosis Continuing Education on Nurses' Knowledge and Attitudes

BACKGROUND

Osteoporosis has rapidly evolved into a severe health threat to Americans and a major public health problem. The increasing incidence of this disease and related fractures mandates that continuing education include osteoporosis content to ensure nurses provide competent education and care. An osteoporosis educational program was presented to nurses as part of a continuing education symposium on women's health issues. The program was tested to determine its effectiveness in augmenting the osteoporosis-related knowledge and attitudes of nurses.

METHOD

Eighty-one RNs with educational levels varying from associate degrees to doctorates attended the continuing education program. Sixty-three of the program participants completed pretest and posttest measures.

FINDINGS

The educational program significantly increased osteoporosis knowledge in this cohort of nurses. Additionally, nurses indicated they were more likely to pay attention to their own bone health as a result of attending the program.

CONCLUSION

Results of this study reinforce the need for osteoporosis-related continuing education.

The impact of osteoporosis on quality-of-life: the OFELY cohort

Although the long-term outcomes of osteoporosis (Op) such as fracture, kyphosis, and pain are well known, the physical, psychological, and social consequences, beyond fracture and pain, are less clear. The Osteoporosis-targeted Quality-of-life (OPTQoL) questionnaire aimed at assessing the physical difficulty, fears, and adaptations to one's daily life was developed as a cross-sectional instrument to characterize the burden of Op within a community. The purpose of this study was to assess the impact of Op and related factors on community women participating in the OFELY study in France. Femoral neck bone mineral density (BMD) and OPTQoL questionnaire data were collected from women randomly selected from a large insurance company. Data were obtained for 756 women (mean age 59 years, range 36-92), most of whom were white. Women were classified into five groups based on the extent of physical manifestations and family history of Op. Women who had prior fractures, height loss, and/or kyphosis or both reported greater physical difficulty, more adaptations to their lives, and greater fears than women reporting no such changes. Scores on the Physical Difficulty domain, however, did not differ significantly based on BMD alone (BMD T score <or=2.5), after controlling for age and self-reported arthritis. The negative impact of Op on quality-of-life (QoL) seems to be more related to the physical manifestations of Op than to bone density levels. Recognition of the impact of Op-related factors on QoL may help health-care providers more fully appreciate the importance of prevention and treatment.

The nonskeletal consequences of osteoporotic fractures. Psychologic and social outcomes

The prevalence of osteoporosis is rising as the population of the United States and other developed countries ages. These increasing numbers of people have motivated pharmaceutical companies to develop and market several antiresorptive medications that can slow down the bone loss associated with osteoporosis. Although these are not cures for this disease, they are an important first step in a vital ongoing public health effort to prevent osteoporosis in the future and to manage osteoporosis now. We cannot expect to remediate the problems caused by this disease if we attend only to its skeletal implications. Like any other chronic disease, osteoporosis has significant psychologic and social consequences. From anxiety and depression to social withdrawal and isolation, if these problems are left unresolved, they can have a significant negative impact not only on health issues but also on overall quality of life. No quick fixes exist for the numerous ways in which osteoporosis can transform an autonomous person into a dependent and hopeless patient. In part, responsibility for helping this patient rests with the medical community. Referrals to appropriate providers can improve a patient's physical and emotional well-being. Physician specialists can help the patient manage comorbid conditions. Physical and occupational therapists can teach exercises, home safety, and safe movement. Social workers can provide a framework for coping that enables individuals to improve their interpersonal interactions and minimize stress in their lives. Nutritionists, pharmacists, nurses, and other health care professionals can make major contributions to the quality of life of people with osteoporosis and should be encouraged to do so. Unfortunately, managed care has set policies that deprive patients with osteoporosis of the kinds of care that would be most useful to them. As we have advocated for the last 15 years, a multidisciplinary approach offers patients the most positive overall way to manage osteoporosis. Therefore, new alternatives need to be examined, alternatives that provide both low-cost and high-quality care. In the long run, patients who practice self-management, that is, those who take responsibility for their own calcium and vitamin D intake, are compliant with medications, exercise, and practice home safety, and who have a healthy outlook, can control their osteoporosis. The most effective intervention for the future may be to teach individuals how to use self-management strategies so that they can take charge of their osteoporosis and positively influence their quality of life.

Instant vertebral assessment: a noninvasive dual X-ray absorptiometry technique to avoid misclassification and clinical mismanagement of osteoporosis

The presence of a vertebral fracture significantly increases the risk of future fracture, classifies a patient with "clinical" osteoporosis, and usually results in treatment for osteoporosis. However, the majority of vertebral fractures are silent, and lateral X-rays (the standard method for identification) are not routinely obtained. Instant vertebral assessment (IVA), a technology that utilizes dual X-ray absorptiometry (DXA), provides rapid assessment of vertebral fractures and is highly correlated with vertebral fractures, as assessed on standard lateral spine X-rays. To assess the role of IVA in patient management, we examined standard bone mineral density (BMD) of the spine, total hip, and femoral neck and spine IVA by DXA in 482 participants screened for an osteoporosis study, who had no previous knowledge of vertebral fractures. Using World Health Organization (WHO) guidelines, subjects were classified using BMD at the spine, total hip, femoral neck, or any combination of these central sites. In addition, we considered subjects as osteoporotic if they had vertebral fractures independent of low bone density. We found that vertebral fractures assessed by IVA were present in 18.3% of asymptomatic postmenopausal women recruited for this study. The sensitivity of BMD alone to diagnose osteoporosis based on either a vertebral fracture or low BMD using WHO criteria ranged from 40 to 74%. This means that between 26 and 60% of osteoporotic individuals could have potentially been missed. Furthermore, 11.0-18.7% of clinically osteoporotic individuals would have been classified as normal by BMD criteria alone. We conclude that IVA is a useful adjunct in the clinical identification of osteoporosis and may prevent mismanagement of osteoporotic patients.

Non-pharmacological interventions

The aim of non-pharmacological intervention for osteoporosis is to prevent, treat or alleviate the consequences of osteoporosis, the main one of which is fracture. Non-pharmacological interventions consist of a wide spectrum of treatment modalities to decrease pain, correct postural change, improve mobility, enable the patient to follow a normal social life and prevent (further) fracture. An exercise programme can increase bone mass in adolescents and adults, but in the elderly its main emphasis should be on improving muscle strength and balance in order to decrease the risk of falls. Physiotherapy is commonly prescribed to mobilize the patient after a fracture, to decrease muscle spasm and pain, and to improve balance and co-ordination. An orthesis or back support may be used to correct kyphosis and decrease pain. Medication for pain is often needed and should cover both acute severe pain following fracture and chronic pain caused by postural change. A hip fracture is the most severe consequence of osteoporosis. The risk of hip fracture can be decreased by pharmacological treatment to increase bone mass and bone strength. However, in the very elderly the occurrence of falling may be more important than the failure of bone strength. Hip protectors have recently become available and have been shown to decrease the risk of hip fracture after a fall. These shunt the energy from the trochanter away to the sides. Non-pharmacological approaches to treatment are often neglected in daily practice, the emphasis being instead on treatment with drugs that decrease bone resorption and thereby increase bone strength.

Estradiol repression of tumor necrosis factor-alpha transcription requires estrogen receptor activation function-2 and is enhanced by coactivators

The tumor necrosis factor-alpha (TNF-alpha) promoter was used to explore the molecular mechanisms of estradiol (E(2))-dependent repression of gene transcription. E(2) inhibited basal activity and abolished TNF-alpha activation of the TNF-alpha promoter. The E(2)-inhibitory element was mapped to the -125 to -82 region of the TNF-alpha promoter, known as the TNF-responsive element (TNF-RE). An AP-1-like site in the TNF-RE is essential for repression activity. Estrogen receptor (ER) beta is more potent than ERalpha at repressing the -1044 TNF-alpha promoter and the TNF-RE upstream of the herpes simplex virus thymidine kinase promoter, but weaker at activating transcription through an estrogen response element. The activation function-2 (AF-2) surface in the ligand-binding domain is required for repression, because anti-estrogens and AF-2 mutations impair repression. The requirement of the AF-2 surface for repression is probably due to its capacity to recruit p160 coactivators or related coregulators, because overexpressing the coactivator glucocorticoid receptor interacting protein-1 enhances repression, whereas a glucocorticoid receptor interacting protein-1 mutant unable to interact with the AF-2 surface is ineffective. Furthermore, receptor interacting protein 140 prevents repression by ERbeta, probably by interacting with the AF-2 surface and blocking the binding of endogenous coactivators. These studies demonstrate that E(2)-mediated repression requires the AF-2 surface and the participation of coactivators or other coregulatory proteins.