Metabolic bone disorders in a
geriatric patient
MUDr. Kamila Greplová
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1. Osteoporosis
(a) Definitions
Osteoporosis is a systemic skeletal disorder characterised by low bone mass and microarchitectural
deterioration of bone tissue, resulting in increased bone fragility and susceptibility to fracture. Thus the
density and the quality of the bone are reduced.
Osteoporosis is the most common metabolic bone disease that typically develops in women after
transition; it also affects men at older ages, but can also occur in younger individuals with an
accumulation of risk factors. The clinical manifestation of osteoporosis is fracture. The typical
osteoporotic fracture is a compressive fracture of the vertebral body and a fracture of the proximal part
of the femur. Osteoporotic fractures include fractures of the distal part of the bones of the forearm, (most
typically Colles fracture), but these also affect women in early postmenopause, usually still in the
osteopenia zone. In a broader sense, except for fractures of the bones of the skull, ankle and the small
bones of the hands and feet, any fracture that has been caused by an inadequately small traumatic
event or even atraumatically can be considered osteoporotic. Another definition considers an
osteoporotic fracture to occur as a result of a fall from a standing height or from a lesser height. It is
clear from the above that the definition of a fracture as osteoporotic, in addition to the type of fracture,
is conditioned by the assessment of the mechanism of injury.
(b) Epidemiology
Currently, it is estimated that osteoporosis affects 7-10% of the population. In the Czech Republic,
the prevalence of osteoporosis may be as high as 1 000 000 inhabitants. Osteoporosis affects one in
three women and one in five men over the age of 50. At the age of 70 and over, it is already every
second woman.
Osteoporosis is an epidemiologically serious disease which, in addition to the suffering of patients,
has social and economic consequences. The costs of treating osteoporosis, both for the treatment of
the acute phase of clinical osteoporotic fractures and the subsequent costs of caring for patients with
proximal femur fractures, are considerable.
In the Czech Republic, an average of 65,000 fractures that meet the criteria of an osteoporotic
fracture have occurred in recent years. However, only a small percentage of patients are subsequently
diagnosed and treated. (Diagnostic gap 84% vertebrae to 94% proximal femur, Treatment gap 84%
vertebrae to 95 proximal femur). More education of physicians, the introduction of screening tests and
informing the general public could be the solution.
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(c) Characteristics
Osteoporosis can be divided into primary osteoporosis, which includes involutional osteoporosis,
idiopathic osteoporosis (e.g., osteogenesis imperfecta, Marfan's syndrome), juvenile osteoporosis and
postmenopausal osteoporosis, and secondary osteoporosis, which is slightly less common, results
from a specific clinical situation or disease, is often multifactorial and potentially reversible. However, it
should be kept in mind that up to 30% of postmenopausal and 50% of male OPs may have another
hidden cause.
The development of bone mass is 60-80% genetically determined, other important factors include
nutrition (sufficient Ca, P) and mechanical stimuli- sufficient physical activity. Peak bone mass is reached
around the age of 20-30 years, in the next period we lose bone mass, the more, the less optimal our
lifestyle is.
(d) Risk factors for fractures:
Uncontrollable risk factors
- Age
- Female gender
- History of proximal femur fracture in 1 parent
- History of vertebral body fracture
- Non-vertebral fracture after age 50
- History of repeated falls
Influenceable risk factors
- BMI less than 20
- Decreased mobility
- Smoking, COPD
- Vit D deficiency
- Low Ca intake (below 500 mg per day)
- Hyponatraemia
- Higher CRP
Diseases associated with the risk of osteoporosis and fractures
- Cushing's syndrome
- Hyperparathyroidism
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- Hyperthyroidism
- Diabetes mellitus
- Hypopituitarism
- Sexagen deficiency
- Celiac sprue
- Gastrectomy
- Rheumatoid arthritis
Drugs associated with increased fracture risk
- glucocorticoids
- aromatase inhibitors in women with breast cancer
- androgen deprivation therapy for prostate cancer in men
- benzodiazepines and antidepressants
- proton pump inhibitors
- antiepileptic drugs
- glitazones
(e) Clinical signs of osteoporosis
- initially inconspicuous - osteoporosis as the "silent bone thief"
- the first symptom may be a fracture
- chronic back pain
- decrease in height
- thoracic kyphosis, decrease in vital lung capacity,
- difficult venous return, compression of the upper GIT
(f) Diagnostics of osteoporosis
Medical history (fractures, diseases associated with OP, physical activity, diet, Ca+D intake,
pharmacological and gynaecological history)
Clinical examination (body height, hyperkyphosis TH p, symptoms of previously undiagnosed
diseases leading to OP)
Imaging methods
- X-ray - thoracic and lumbar spine - anteroposterior+ lateral view (vertebral compression
fractures)
- DXA- Dual Energy X-Ray Absorptiometry
Laboratory methods
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- FW, KO, Ca, P, ALP, ev. GMT, creatinin, GF, Alb, protein elfo, TSH, PTH, Vit D,
- a-tTG, calciuria
- marker of bone resorption (osteoclast activity) - CTx
- marker of bone formation (osteoblast activity) – PINP
Bone densitometry- DXA
- Determines BMD (Bone Mineral Density) g/cm2
- Low dose radiation 2-12 µS
- Areas measured: L1-L4, femoral neck, total proximal femur area, distal forearm
T-score – WHO basic dg criterion – comparison of measured BMD values
- with reference BMD value of young healthy women
- the difference expressed as the number of standard deviations (SD)
Z-score - number of SDs from the reference value (average BMD value of persons of the same age and
sex) - preferred in premenopausal women and men < 50 years
T-score> - 1 normal
T-score between - 1.0 and -2.5 osteopenia
T-score ≤ -2.5 osteoporosis
Indications for DXA:
- History of atraumatic or low-trauma fracture (except for fractures of the skull, ankle, small
bones of the extremities and fingers and toes)
- accumulation of fracture risk factors
- history of diseases with a negative effect on bone mass
- ongoing or planned treatment with glucocorticoids
- decrease in body height by ≥ 2 cm (compared with previous regular measurements) or by ≥ 6
cm (compared with maximum height attained in youth)
(g) Prevention of osteoporosis
- Creating sufficient peak bone mass
- Regular physical activity, walking
- A varied diet, Ca, vit D
- Achieve and maintain optimal BMI
- Prevention of falls
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- Detection of patients at risk of fracture
- Individual fracture risk estimation
FRAX- Fracture Risk Assessment Tool
The Czech version of the calculator is available at https://www.shef.ac.uk/FRAX/?lang=cz.
(h) Treatment of osteoporosis
Calcium
- recommended total daily intake of 1200-1500 mg
- diet 800 mg, supplementation 500-600 mg
Vitamin D
- recommended dose of supplementation 800-2000IU
- target serum 25OHD concentration 75-110 nmol/l
- vitamin D3 (cholecalciferol) preferred
- better shorter intervals, not bolus
Antiresorptive drugs
- Estrogens- HRT
- Bisphosphonates
Alendronate - p.o., once a week
Risedronate - p.o., once a week
Ibandronate - p.o., 1x per month, i.v. 1x /3 months
Zoledronic acid - i.v., 1x/year
- Denosumab inj., sc, á 6 months
CAVE rebound phenomenon on discontinuation: a rapid decline in BMD, a transient but
significant rise in bone remodelling markers above baseline
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2. Falls in geriatric patients
(a) Definitions
A fall can be characterised as a change in position that ends with the body making contact with
the ground and may be accompanied by a loss of consciousness and injury.
(b) Epidemiology
According to statistics, 30% of seniors over 65 years of age fall at least once a year, and in
half of the cases, the falls are repeated. In the 85+ age group, 50% of seniors fall at least once a
year. Approximately one in ten falls lead to serious consequences such as hip fractures, subdural
hematoma, other intracranial injuries or other serious injuries. Falls account for 10% of emergency
department visits and 6% of sudden hospital admissions in the elderly. Half to two-thirds of falls occur
in the patient's home and/or in the patient's immediate surroundings. 25% of seniors fall repeatedly
and half have a solvable cause of falls.
(c) Characteristics
Most falls have multiple underlying factors. Only 15% have specific unipathologies.
The causes can be categorised by the mnemonic DAME:
Drugs and alcohol
Ageing process
Medical causes
Environmental factors
Drugs and alcohol – e.g., chemically impaired concentration, balance, reaction times.
Ageing process – impaired reflexes and reduced muscle power to recover from a ‘trip’, decreased
visual acuity, impaired vestibular function and central processing
Medical causes – Remember the atypical presentation of common diseases such as:
- heart and circulation (abnormal heart rhythm, heart attack, orthostatic syndrome, heart failure)
- neurological (Parkinson’s disease, stroke, sensory impairment due to diabetes, epilepsy)
- metabolic (e.g., the low sugar level in a treated diabetic)
- musculoskeletal disorders (osteoarthritis, osteoporosis, conditions after orthopaedic surgery)
- psychiatric diseases (depression, cognitive disorders)
- visual disorders (cataract, retinopathy)
- atypical presentation of common infections such as chest infection and urinary tract infection
- visual disorders (cataract, retinopathy)
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Environmental causes – such as tripping over carpets or rugs; falling from chairs; poor lighting;
tripping over kerbs of irregular paving; poorly driven public transport; and cyclists on pavements.
(d) Diagnostics
Medical history – need to have information not only from the patient but also from the immediate
participant of the fall. Find out the circumstances of the fall, the symptoms that precede the fall (nausea,
vertigo, convulsions, palpitations, loss of consciousness), the disease the patient is being treated for
(cardiovascular, neurological, psychiatric and others) and the use of risky medications (e.g.,
benzodiazepines, diuretics, nitrates, opiates, hypnotics, antihistamines) are also important.
Physical examination – signs of trauma, measurement of BP in supine and standing position,
nystagmus, HR heart murmurs, gait examination, neurological deficit, lateralization
Functional geriatric assessment – evaluates self-sufficiency using the Barthel ADL test, gait and
balance assessment can be determined using the Tinetti test (sitting and standing balance, standing
with eyes closed, gait initiation, stride length and symmetry, trunk balance).
Laboratory methods – biochemical and haematological examination (ions, including Ca, Mg,
nitrogenous substances, glycaemia, liver enzymes, CRP, FW, vitamin D, KO +diff, basic coagulation)
ECG
Imaging – Doppler examination of carotid and vertebral arteries, EEG, CT or MRI of the brain
Other investigations – ECG Holter, ECHO, tilt-up test, neurological examination, ENT, psychiatric
examination
(e) Complications of falls
They can be divided into early (soft tissue injuries and fractures) and late (development of
immobilization syndrome and its complications).
Possible complications include:
- fractures (femoral neck fractures, Colles fracture of the forearm, compression fractures,
vertebral fractures and skull fractures)
- soft tissue contusion, development of crush syndrome
- hypothermia to possible rhabdomyolysis
- immobilization syndrome, development of decubitus, pneumonia and thromboembolic disease
- loss of self-sufficiency with subsequent institutionalization
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- psychiatric disorders (anxiety, depression)
- death (most common causes of pneumonia, decubitus sepsis, intracranial haemorrhage)
Causes of fall Physical signs associated with each cause
Cardiac arrhythmia:
Fast (tachycardia) and slow (bradycardia) rhythms
may cause dizziness or loss of consciousness.
Examine pulse – rate and rhythm.
Heart valve lesions:
Aortic stenosis is associated with syncope – sudden
loss of consciousness.
Mitral regurgitation and associated heart failure
Each lesion has a typical murmur(s) associated with
it.
Examination of pulse for abnormal signs (e.g. slow
rising pulse in aortic stenosis)
Blood pressure (narrow pulse pressure in aortic
stenosis, low BP in heart failure)
Auscultation of heart sounds for murmurs and
abnormal signs.
Mitral regurgitation: pan-systolic murmur
Aortic stenosis: ejection systolic murmur
Postural hypotension:
This describes a reduction in blood pressure on
positional change from lying (or sitting) to standing.
This is abnormal- normally the blood pressure will rise
when standing.
Measure blood pressure on lying and then after the
patient has been standing for at least 1 minute. A
reduction of more than 10 mmHg diastolic (lower
blood reading) or 20 mmHg systolic (higher reading)
is diagnostic of postural hypotension
Pneumonia Examination of the chest – inspection, palpation,
auscultation.
Neurological pathology
Common impairments predisposing to falls include
stroke, abnormal balance, Parkinson's disease,
diabetes, and alcohol.
Examination of the neurological system for relevant
findings
Musculoskeletal disease:
Osteoarthritis; gout or inflammatory arthropathies;
cervical spondylosis (osteoarthritis of the cervical
vertebrae disrupting proprioceptors (position sense
receptors) in the cervical joints).
Painful, swollen or unstable joints; reduced muscle
power; examine feet – toenails and footwear; neck
movements causing dizziness; watch the patient
walking.
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3. Geriatric testing
As the population ages, the number of patients with severe memory disorders, even
dementia, is increasing. Screening is an appropriate method for early diagnosis of cognitive impairment.
Therefore, an orientation examination of cognitive function should be part of the regular general
preventive check-up every two years for the population over 65 years of age.
The MiniCOG test, which is a combination of memorising three words and drawing a clock, is
considered to be an appropriate test for early detection. The MiniCOG test should be performed under
the guidance of a general practitioner as part of a preventive examination or at the time of examination
when the disease is suspected.
The Mini-Mental State Examination (MMSE) is a tool that can be used to systematically and thoroughly
assess mental status. It is an 11-question measure that tests five areas of cognitive function: orientation,
registration, attention and calculation, recall, and language. The maximum score is 30. A score of 25 or
lower is indicative of cognitive impairment. The MMSE takes only 10 minutes to administer and is
therefore practical to use repeatedly and routinely.
Barthel Index for Activities of Daily Living (ADL) is used to assess the degree of dependence on
basic activities of daily living and refers to activities oriented toward taking care of one's own body.
These activities are fundamental to living in a social world; they enable basic survival and well-being,
such as bathing, toileting, dressing and eating.
Instrumental Activities of Daily Living (IADL) refers to activities to support daily life within the home
and community that often require more complex interactions than those used in ADLs. Examples of
such activities include financial management, housekeeping, shopping for groceries, making telephone
calls, and taking medication.
The ADL and IADL functions are important to older adults, and IADL autonomy plays an important role
in "successful" ageing.
The Geriatric Depression Scale can be used to diagnose depressive disorder in geriatric patients.
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4. Depressive disorder
Depressive disorder is a complex condition characterised by a combination of emotional, cognitive, and
biological symptoms.
Emotional manifestations commonly include a persistently depressed mood, heightened irritability,
frequent tearfulness, difficulty concentrating, and an overall sense of fatigue or lack of energy.
Cognitive symptoms often involve negative and pessimistic thinking patterns, self-blame leading to
low self-esteem, pervasive anxious thoughts, and, in some cases, worries about real or imagined
physical symptoms (hypochondriasis). Severe cases might even experience suicidal ideation.
Alongside these psychological symptoms, the depressive disorder also presents with several biological
symptoms. Disturbed sleep patterns are common, often characterized by early morning awakenings
after just three or four hours of sleep. Affected individuals may also exhibit decreased appetite leading
to weight loss, a daily mood rhythm that typically worsens in the morning but improves slightly throughout
the day (diurnal variation), reduced sexual interest, and occasional constipation. Some individuals may
also experience an inability to cry.
Together, these diverse symptoms paint a comprehensive picture of the multifaceted impact of the
depressive disorder on an individual's life
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Annex 1.
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Annex 2.
MMSE rating
30- 28 points - standard
27- 25 points - mild cognitive impairment
24- 18 points - mild dementia
17- 13 points - moderate dementia
12 points or less - severe dementia
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Annex 3.
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