OSTEOPROSIS

IN OLDER ADULTS

Osteoporosis in Older Adults Dean M. Seidman Syracuse University

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The public health concern that I will be exploring is the older adult population that is suffering from osteoporosis. More specifically, I will be investigating the population as it pertains to the rural community with moderate to low income. Osteoproisis is a disease that generally affects older adults and can lead to an increased risk of fractures. The increased risk of fractures is due to a low bone mineral density. There are many concerns with the older adults that have osteoporosis, one of them being that they have limited mobility and they have difficulty doing daily tasks. Simple household tasks become difficult such as washing the dishes, cleaning the floors, and doing gardening. The reason that these types of tasks are difficult is because the low bone mineral density makes the bones very brittle and can fracture very easily. Another concern that older adults with osteoporosis have is that they are usually limited in the amount of social contact. They often remain in their homes and do not have the ability and energy to get outside. Having adequate social interaction improves quality of life and ables the older adults to converse with others. Social interaction is sometimes overlooked but it is very crucial in improving the daily lives of older adults with osteoporosis. An important aspect in improving the condition of osteoporosis among older adults is to decrease sedentary activity and increase physical activity. By doing this, the bones are being stimulated and bone mineral density can improve. A combination of a proper diet and physical activity will improve the condition of the older adults with osteoporosis. Formulating an intervention that will address these two issues is crucial to the improvement in the older adults. Osteoporosis is a condition that will most likely affect women after menopause.

Men can develop osteoporosis as well but it is not as prevalent. Worldwide, there are 200 million women that are affected by this disease and one tenth of women aged 60 are

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affected. After women reach age 80, two fifths of the female population are affected. In the year 2000, there were about 9 million osteoporotic fractures and the most commonly fractured sits include the hip, forearm, and vertebrae. 9 million fractures annually equates to an osteoporotic fracture every three seconds. This high amount of fractures suggests that there is more time spent in the hospital than many other diseases including diabetes, cardiovascular disease, and breast cancer (Facts and statistics). Also, following a fracture, one in five people will die within a year of that fracture (Facts about osteoporosis). All of these facts can be startling, but this shows that osteoporosis is a major disease that should not be ignored. The amount of people it affects and its effect on health is profound and everything should be done to reverse the effects. The broad risk factors for osteoporosis include being female, old age, being Caucasian/Asian, family history of osteoporosis, and a small body frame. Menopause is another serious risk factor that is associated with osteoporosis. There is a reduction in estrogen levels after menopause and this leads to a lower bone mineral density. Low testosterone in men is also another hormone that is associated with a lower bone mineral density. Sex hormones may have the greatest affect on bone mineral density but thyroid hormones can also cause bone loss. An overactive thyroid would be a risk factor for osteoporosis. One of the most important risk factors for osteoporosis is the diet that the individual is consuming A low intake of calcium is highly associated with osteoporotic fractures. Although a low intake of calcium is associated with a greater risk of fractures, the effects of adding calcium to the diet is not immediate. A lifelong intake of calcium is best for preventing osteoporosis in the later years. Vitamin D is also a key nutrient in the prevention of osteoporosis. Along with a low intake of calcium and vitamin D, eating disorders can also pose a large risk for osteoporosis in older adults.

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Anorexia can reduce the amount of food being taken in and it can also seize menstruation which lowers the amount of estrogen being produced. A low intake of calcium and vitamin D is correlated with eating disorders. A weight-loss surgery can also be a risk factor for developing osteoporosis. The smaller stomach limits the amount of surface area available to absorb nutrients, two of which being calcium and vitamin D. Medications can interfere with the bodys ability to rebuild bone. These types of medications include corticosteroids such as prednisone and cortisone. Also, medications used to prevent seizures, depression, gastric reflux, cancer, and transplant rejection can increase the likelihood of developing osteoporosis. Lifestyle choices can also highly influence the risk for getting osteoporosis. A sedentary lifestyle limits the amount of weight-bearing exercise that is needed to stimulate the bone. The more sedentary activity that is present, the greater the risk for developing osteoporosis. Excessive alcohol and tobacco consumption can also be a indicator for developing osteoporosis. Two or more alcoholic drinks per day can increase the risk of osteoporosis because alcohol intake interferes with the bodys ability to absorb calcium. Although the physiological processes behind tobacco use as it relates to osteoporosis is not clearly understood, there is an increased risk for developing osteoporosis if tobacco is used. Preventing osteoporosis is easily done by avoiding the risk factors that were explained above. Many people try their best to avoid these risk factors, however, most people do not even know if they have osteoporosis and it goes undiagnosed. The symptoms for osteoporosis include back pain, loss of height, stooped posture, bone fracture. These symptoms are very general which is why many people go undiagnosed. An individual should see their doctor if they have gone through early menopause, experienced a loss of height, taken corticosteroids for a long period of time, and have had a family

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history of osteoporosis. The only way to know if an individual has osteoporosis is to complete a dual energy x-ray absorptiometry to measure bone mineral density (Clinic staff). There are many treatments available to attempt to reverse the effects of

osteoporosis. Medications can be either bisphosphonates or revolve around a hormone therapy. Bisphosphonates are the most common medications that are used for osteoporosis and work by slowing the rate of bone thinning and prevent the development of osteoporosis. Hormone therapy involves the administration of estrogen and this is thought to increase bone mineral density and reduce bone loss. Calcitonin is another hormone that is commonly given to individuals suffering from osteoporosis. Calcitonin works by regulating calcium levels in the body and directing it to the bone. There is also a class of drugs that are called selective estrogen receptor modulators, which deals with regulating the amount of estrogen in the body (Clinic staff). These medications do work and are widely used in the clinical field to reverse the effects of osteoporosis. Although these medications have their place in the health industry, lifestyle changes are the best method to combat osteoporosis. An increase in physical activity along with a diet high in calcium and vitamin D is the best intervention for any individual that has osteoporosis. The environment that an individual is apart of is a big influence for developing

osteoporosis. Environmental factors can include availability of parks, proximity to grocery stores, sunlight exposure, neighborhood safety, peer interactions, and economic status. The availability of parks is important in promoting physical activity for all ages. Not only are parks and walking trails beneficial to the older adults with osteoporosis, but also it can be looked at as a preventative measure for younger individuals in delaying the onset of

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osteoporosis later in life. Rural communities generally have more parks and walking trails than city areas but that is not always the case. Some communities are less developed and do not have the money to afford building a park. The location of grocery stores is another environmental factor that plays a role in the condition of osteoporosis. If grocery stores can not be easily accessed easily, it would limit the amount of available food to the individual. Older adults, and especially those with osteoporosis have a hard time getting out of the house and to the grocery store to buy food. A low-intake of food is correlated to an increased risk for osteoporosis. Sunlight exposure is important to general health as well as stimulating bone health. Some areas of the United States get more sunlight than others such as Alaska that gets limited sunlight and New Mexico that gets daily sunlight. It is recommended that older adults aged 51-70 should get 400-600 IU of vitamin D per day. Long exposure to sunlight might increase the risk of getting skin cancer so it is recommended that older adults make short trips outside throughout their daily routine. 100-200IU of vitamin D should be provided through the skin (Fujiwara, 2005). Neighborhood safety is important to all individuals of the community and especially older adults because they may be more susceptible to robberies. The safety of the neighborhood is crucial to the amount of physical activity that can be done in the community. Neighborhood walks can become scary for older adults if there is high crime. Older adults will tend to stay inside than rather deal with the unsafe neighborhood, which can seriously limit the amount of physical activity. Peer interaction does not directly affect the condition of osteoporosis however it is important in improving quality of life. Social isolation can lead to increased sedentary activity and depression, which has negative mental health consequences. Having a good network of friends and a close-knit family can help decrease

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the amount of social isolation. Having peer interaction and increased social contact will also help the individual in the case of an emergency. The economic status of an individual is usually correlated to their health status. Lower-income individuals will typically be in poorer health and middle-high income individuals will most likely be in better health. Individuals with low-income do not have the funds to buy healthy foods, go for doctors visits, buy osteoporotic medications, and buy gym memberships. The combination of all of these environmental factors can highly influence the negative consequences of osteoporosis. Although some of these environmental factors cannot be adjusted, individuals should do everything in their power to prevent osteoporosis. There are not many programs that exist that deal with improving the condition of

older adults as it relates to osteoporosis. Most of the programs are ran out of hospitals and older adults do not like the feeling of going to a hospital. There is a lack of community driven programs that deal with improving the condition of osteoporosis. Osteoporosis is one of the few diseases that can be reversed quite easily with lifestyle changes. For an intervention, I would like to include both a physical and educational component. For the physical component, I would like to implement a neighborhood walking program. For the educational component I will provide bi-weekly brochures with information pertaining to the important aspects of osteoporosis. The intervention will be community driven and upon success, the program will branch out to other local communities. The idea for this intervention is to improve social contact and at the same time promoting healthy lifestyle changes. The walking program is available to all individuals, even those without osteoporosis. The goals for my intervention are: 1. Promote healthy bone changes through physical activity that will lead to an increase in bone mineral density.

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2. Minimize social isolation by conversing with peers and learning about osteoporosis. The objectives for my intervention are: 1. Increase bone mineral density by 10% in one year in older adults with osteoporosis 2. Decrease number of fractures by 30% in six months in older adults with osteoporosis

The bone mineral density will be reported from the individuals involved with the walking program. They will get the bone mineral density value from their respective doctor when

they go in for a bone scan. Everybody that is involved in the program will not have access to a bone scan so only the individuals that have access to a bone scan will report their values. Fractures will be reported to the staff and recorded. These values will be looked at over time and hopefully the amount of fractures will decrease after the start of the intervention. Once an individual has reported a fracture the staff will pay close attention to that individual to ensure safety. The goals and objectives for my intervention are critical and the intervention will revolve around focusing on these specific aspects. The walking program will consist of daily-guided walks Monday through Friday.

The daily walks will take place at 3PM and again at 6PM. The reason for having two different times is to optimize the amount of participants by avoiding scheduling conflicts among the participants. There will be one group leader that will lead the walks to ensure safety as well as provide educational material that I will discuss later. The group leader will stimulate conversation to promote social interaction among the walkers. The topics that will be discussed during the walking trial will include helpful tips for living with osteoporosis as well as general health tips to improve the participants health status. The conversations that will take place during the walking trail will require the participation of the older adults in the intervention to promote social interaction. The individuals that are

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new to the program might be quiet during the intital sessions, however, over time the group leader will attempt to include these people in the conversation to promote social interaction. This is a crucial component to the intervention because peer interaction is essential to improving overall quality of life. The mobility limits that osteoporosis poses on the individual can limit the amount of time that they get to socialize with their peers so this is something that my intervention will focus highly on. The walking trail will be through the community and the route will change every week. The community sidewalk will serve as the walking trail. Removable signs will be placed throughout the community to serve as a map for the current route. The signs will have mile markers on them as well as helpful one-sentence tips for living with osteoporosis. Every week the intervention supervisor will relocate the signs throughout the community to designate the current weeks route. The signs will have large lettering so the older adults will be able to read them without a problem. Since vision declines with aging, it is essential to fabricate the signs with large lettering. The group leader will be in charge of the safety of the older adults in case of emergency and will be wearing a bright neon shirt to clearly designate him/her. A walkie- talkie will be provided to the group leader so there is adequate communication between the group leader and the intervention supervisor in case of an emergency. The older adults participating in the program may have trouble walking due to their condition so it is pertinent that safety is a number one priority. High-impact weight-bearing exercises are recommended for stimulating bone

growth because these exercises load the bone directly and promote bone remodeling. If a fracture has already occurred, low-impact weight-bearing exercises would be recommended. Walking would be considered a low-impact weight-bearing exercise,

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however our intervention chose this to ensure safety among our participants. High-impact weight-bearing exercises would provide the most benefit but this does not go without risk. 30 minutes per day of general weight-bearing exercises are recommended for older adults and this is the approximate length of my interventions walking trail (Exercise for strong bones). A study completed in 1991 examined a one-year walking program and increased dietary calcium in postmenopausal women. Participants participated in a supervised walk four times per week for one year and the results found that women maintained trabecular bone mineral density. Individuals who did not complete the walking program and engaged in sedentary activity lost bone mineral density in the same sites where it was maintained for the walking group. This study suggested that women should be encouraged to adopt a calcium-rich diet and weight-bearing exercise to maintain skeleton health (Nelson, 1991). A similar study completed in 2004 used a similar study design and found that moderate walking exercise sustained lumbar bone mineral density. This study also reported that four hours per week of walking compared to one hour per week was associated with a 41% lower risk of hip fractures (Yamazaki, 2004). The findings from both of these studies suggest that efficacy for my intervention program is valid and would result in positive outcomes. Alongside the physical component of my intervention, there will also be an

educational component. The educational component will consist of bi-weekly brochures developed by the intervention supervisor and volunteers. These brochures will consist of helpful information and tips for older adults living with osteoporosis. Since calcium supplementation is correlated to decreased bone loss, this will be a major topic that will be discussed. There will be recipes that have high amounts of calcium will be easy to make for

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the older adults. Easy at-home weight-bearing exercises will be suggested and encouraged for the older adults to complete. Every other week there will be new helpful information in these brochures and the current issue will always be available form the group leader. A book club will also be started to stimulate conversation during the walks. These books will be related to living with osteoporosis and general health for older adults. A study done in 2004 explored the effectiveness of brochures containing health information. The results revealed that the implementation of a single behavior change in a brochure could have substantial health benefits as long as the information is suitably formulated (Jamison, 2004). The brochures that are going to be provided by my intervention will be a crucial component in making behavior changes because it is something the participants can take home and study. The staff that will be working for my intervention will consist of one supervisor and

10-15 volunteers from the community to serve as group leaders. The supervisor will be in charge of creating routes, ensuring participant satisfaction, participant safety, collecting data, formulating brochures, and formulating tips and information on osteoporosis for use by the group leaders. Group leaders will need to have proficient knowledge of osteoporosis and have a sincere desire to help out the community. Upon being a volunteer, a crash course by the supervisor on osteoporosis will be provided to ensure that the volunteers have adequate knowledge of the disease. The group leaders will be responsible for stimulating conversation, ensuring safety, providing tips & information, providing assistance to supervisor on developing brochures, and developing cohesion among participants.

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One of the benefits of my intervention is that there is a minimal cost associated with

implementation. Although there will be initial costs for developing materials, overall, this is a low-cost intervention. A petition for funding will be sent to the local township to acquire a grant to begin the intervention. The initial costs will include the removable signs, office space, t-shirts, insurance, waklie-talkies, and office supplies. Having a low-cost intervention will be beneficial because the local township will be more likely to approve it. The combination of being a low-cost intervention alongside an intervention with substantial health benefits for the community will significantly increase the chances of success in funding. In the beginning stages of the intervention process, it will be difficult to accumulate

enough participants to join the program. To help get my intervention started, we will collaborate with the local hospital outpatient services. Upon diagnosis of osteoporosis in the hospital setting, the physician or assigned doctor will recommend our walking program. It is something that is easy to suggest for the clinical staff and will provide health benefits for the older individual. The clinical staff will also report bone mineral density values to the intervention supervisor for the participants that are enrolled in our program. By obtaining these values, we are able to see if our objective of increasing bone mineral density by 10% among participants is being reached. I believe that the local hospital will be more than willing to collaborate with our program. The benefit for the hospital is that they will see improvements or a maintence of bone mineral density among their patients. The benefits for my intervention will be an increased number of participants being referred as well as useful data to confirm the success of the intervention over time.

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My intervention strives to be as successful as possible in improving the health status

of older adults with osteoporosis. Evaluating the intervention by using a survey will ensure that what we are doing is keeping the participants satisfied. A survey will be available from the group leader and will be available for all participants to fill out at any time. Some of the topics and questions the survey will include will be concerning the intensity of the program, current health status, length of the program, effectiveness of the educational materials, helpfulness of the staff, degree of social interaction, overall desire to participate, improvements in health, and additional comments and suggestions. The intervention supervisor will read all surveys and make changes if there is a strong desire for a certain adjustment. These surveys will be taken seriously because we want to make sure that all participants are happy. A potential barrier for the intervention will be the safety of participants. Some individuals living with osteoporosis are not able to walk flawlessly and may have trouble keeping up with the group while others may spring ahead. If there are enough participants that want to walk at a slower pace, one of the daily walks will be a slower group while the other will be at a moderate pace. Another potential barrier would be getting enough participants to join the program. While some individuals are highly motivated, depending on the community there might be varying levels of motivation, which could affect adherence and participation. Collaboration with the local hospital will hopefully alleviate this problem. Upon success of this intervention in a single community, we would look to branch out to other local communities following a needs assessment of that community. If success continues in subsequent communities, we would look to become a state-run agency. With additional funding by the state, there would be a substantial expansion of funding, qualified staff, and educational materials. The overall

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goal for the future is to become the most well known intervention for osteoporosis and establishing a first-class reputation. Overall, the intervention that I have designed will help maintain and improve bone

mineral density in older adults that are suffering from osteoporosis in rural communities. The combined physical and educational components is implemented to improve the health condition of the participants. Studies in the past have reavaled positive outcomes associated with my intervention elements so there is a high chance of success. Peer interaction is a big emphasis for my intervention because some individuals living with osteoporosis have limited mobility leading to limited social contact. By decreasing sedentary activity and increasing the amount of weight-bearing exercise there will be improvements in participants conditions. With an improvement in the participants condition, simple household tasks will become easier which will help improve quality of life. Osteoporosis affects millions of people worldwide and starting an intervention at a community level is the first step to help alleviate the effects of the disease.

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References

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Exercise for Strong Bones. (n.d.). National Osteoporosis Foundation. Retrieved May 5, 2013, from http://www.nof.org/articles/238 Facts about osteoporosis. (n.d.). World Osteoporosis Day. Retrieved May 4, 2013, from http://www.worldosteoporosisday.org/facts-statistics Facts and Statistics . (n.d.). International Osteoporosis Foundation . Retrieved May 4, 2013, from http://www.iofbonehealth.org/facts-statistics Fujiwara. (2005). Osteoporosis and sunlight. Radiation Effects Research Foundation, 15(8), 1410-2. Retrieved May 4, 2013, from http://www.ncbi.nlm.nih.gov/pubmed/16062013 Jamison, J. R. (2004). Prescribing Wellness: A Case Study Exploring The Use Of Health Information Brochures. Journal of Manipulative and Physiological Therapeutics, 27(4), 262-266. Clinic staff. (n.d.). Risk factors. Mayo Clinic. Retrieved May 4, 2013, from http://www.mayoclinic.com/health/osteoporosis/DS00128 Nelson., Fisher., Dilmanian., Dallal., & Evans. (1991). 91178245 A 1-y Walking Program And Increased Dietary Calcium In Postmenopausal Women: Effects On Bone. Maturitas, 14(1), 84. Yamazaki, S., Ichimura, S., Iwamoto, J., Takeda, T., & Toyama, Y. (2004). Effect Of Walking Exercise On Bone Metabolism In Postmenopausal Women With Osteopenia/osteoporosis. Journal of Bone and Mineral Metabolism, 22(5), 500-8.