Pathophysiology week 3b

Caution: Fragile!

When we are young and sprite, we believe we are invincible. When we become older, we are programmed to think young regardless of the physical wear and tear changes that occur, it just takes a little longer (life cycle). In the following scenario, Bill is enjoying his retiring life style in ways he enjoys; however back pain may involve some changes.
Bill is a 70 y.o. male who held a desk job until his retirement 5 years ago. Since then, he has spent most of his time working on his stamp collection. Bill has never been very active due to his asthma. He also is a picky eater and does not like dairy products. Bill and his wife do take a daily walk around the neighborhood. One day while on their walk, Bill begins to complain of back pain. The next day, the pain is worse and Bill's wife insists that he see the doctor.
Bill suffers from asthma. Asthma is an chronic allergic lung disorder that inflames, creates swelling and narrows the airways. Because the airways are already inflamed, certain factors promote episodes of breathing difficulties called asthmatic attacks. The factors that can trigger an asthmatic attack include allergens, environmental agents, exercise, or infection. When asthmatic attack occurs narrowing of the airway occurs the same way regardless of the stimuli factor as the following: The inflamed mucosa causes edema (swelling), broncho constriction of the smooth muscle occurs, and increase thick stick mucus. According to the National Heart Lung and Blood Institute inhaled corticosteroids are the preferred medicines for long-term control for asthma. It helps reduced inflammation and helps prevents symptoms caused by asthma. Corticosteroid pills and liquids are only used short term in order to control severe cases of asthma. Prolong use of pill/liquid corticosteroid can raise the risk of cataracts and osteoporosis. (nih, 2012)
The doctor does an x-ray which shows a compression fracture in Bill's L1 vertebrae. As a follow-up, the doctor also orders a Bone Mineral Density Test. This test comes back with a T score of -2.8. The doctor prescribes a pain reliever for Bill's back pain and a course of treatment for the diagnosed disease.
Our skeletal system has many primary functions such as body's structural support, storage for calcium, contributes to blood cell production, protection of the soft tissues in the body, and gives our body leverage in order to assist our muscles in movement. When we are younger, our bones are in a frequent manufacturing mode throughout the year building bone mass ( bone density) by absorbing calcium and removing protein and mineral components. After 30s the body starts to reabsorb calcium faster than the bones can rebuild leading to a net loss in bone mass as we age. This net loss of bone mass (bone density) cause the bones to become more fragile and a candidate for fractures especially in the spine, hip and wrist.
Osteoporosis occurs when there is a marked loss of bone density and a increase in bone porosity. This condition is frequently seen the aging. There is usually no symptoms until the damage has already occurred such as back pain, loss of height and fractures of vertebrae, hips, wrist and other bones. Unlike hip fractures, fractures in the spine do not need an incident like a fall to occur. The spine may have become so weakened that it just starts to compress. There is many risk factors that can make a person prone to osteoporosis. Some of these factors are the following: You are an older person; You are a woman; Decrease estrogen levels especially after menopause; For men, low testosterone levels; Have a sedentary life style; Decreased intake of vitamin D, C, and calcium; Heredity; and Take corticosteroid drugs. (NIH.gov)
Men have more bone mass than women; whereas men in their 50s are loosing bone mass at a very slow rate compared to women after menopause. By the time men reach their mid sixties – 70, men and women lose bone density at the same rate. This is a possible reason why men are not diagnose with osteoporosis until a fracture actually happens because women are having bone density tests earlier in life. (about, 2012)

Diagnosis of osteoporosis can be done by simply having a bone mineral density test called DXA or DEXA ( Dual-energy X-ray absorptiometry) that measures bone loss. DXA is the standard for measuring bone mineral density. A Lateral Vertebral Assessment (LVA) is a low -dose x-ray examination of the spine to screen for vertebral fractures is also performed on the DXA, especially if a person has lost in height, or have an unexplained back pain, or if the DXA scan gives a borderline reading. Radiation from the DXA is lower than a chest x-ray. The DXA works by sending out a low-dose x-rays with two distinct energy peaks through the bones being examine. One peak is absorbed by soft tissue and other is absorbed by bone. The bone density measurement results is by subtracting the soft tissue amount from the total. The test results are in two forms. The 'T' score is the amount of a person's bone compared to a young adult of the same gender, which are the following: A score above
[ -1 ] is considered normal. A score between [ -1 ] and [ -2.5 ] is classified as low bone mass (osteopenia). A score below [ -2.5 ] is defined as osteoporosis. T score estimates your risk of developing fractures. A 'Z' score reflects the amount of bone a person's has compared others in the same age group. Score is usually high or low, indicating a need for further testing. Bills T score was
[-2.8]. Bill T score is classified as osteoporosis accordingly to the DXA test results. (radiologyinfo, 2012)
Bills history, supports his risks for osteoporosis. His use of asthma medications which could be either glucocorticoids or corticosteroid puts him at risk for bone loss. The gluccorticoid is an anti-infla mmatory drug decreases calcium absorption from food, decreases bone formation, and increases calcium excretion in the kidneys. The corticosteroid drug can interfere with sex hormone production, promote muscle and bone loss. Most of Bills activity is mostly sedentary due to his asthma, although he does take daily walks which is a plus. He also does not eat well and does not take in dairy products. Lastly his age makes him an obvious risk. His increasing back pain after a walk was the only symptom that made him go to a physician. The x-ray report showing a compressed (collapse) fracture the L1of the vertebrae which probably cause his pain. The vertebrae (lumbar region) is a region that bears most of the body weight. The Bone Mineral Density Test (DXA) T results was scored [-2.8]. Both x-ray and DXA medical findings support Bill's diagnosis.
Bill's treatment management will possibly require a increase calcium and vitamin D diet intake, with the emphasis in a calcium supplement of 1200-1500 mg daily and a vitamin D of 600 -800 units a day. Continue to encourage a more active life style along with his daily weight bearing exercise to prevent bone loss, which he already does by walking. Bill's physician will probably manage both asthma and osteoporosis by balancing medication that will benefit Bill with least side effects. For his asthma, the physician may put Bill on a glucocorticoid ( hydrocortisone or prednisone) inhaler instead of oral, at a lower dose and encourage shorter time of use. For osteoporosis, treatment would consist of anti-resorptive agents which inhibit bone reabsorption. Bisphosphonates is a class of drugs that inhibits breaking down of bone, decreasing the risk for hip, wrist, and spinal fracture. One example of this drug would be Fosamax ( bisphosphonate anti-resorptive medication) which has shown to increase bone density in men. Another example, Actonel (bisphosphonate anti-resorptive ) is a better medication for those people who have osteoporosis caused by cortisone related medication, which may be indicated in Bill's case. This medication is more potent in resorption of bone than Fosamax and is less irritating to the esophagus.




References
Anonymous. (2012). How Is Asthma Treated and Controlled?
Retrieved January 20, 2012, from Nhlbi.nih.gov website
http://www.nhlbi.nih.gov/health/health-topics/topics/asthma/treatment.html
Anonymous. (2012). What is Asthma?
Retrieved January 20, 2012, from Nhlbi.nih.gov website
http://www.nhlbi.nih.gov/health/health-topics/topics/asthma/
Anonymous. (2011, January). What People With Asthma Need to Know About Osteoporosis
Retrieved January 20, 2012, from Nhlbi.nih.gov website
http://www.niams.nih.gov/Health_Info/Bone/Osteoporosis/Conditions_Behaviors/asthma.asp
Anonymous. (2012). Bone Density Scan
Retrieved January 20, 2012, from Radiologyinfo website
http://www.radiologyinfo.org/en/info.cfm?pg=dexa
Bihari, M. MD. (2008, November 25). Osteoporos for men
Retrieved January 20, 2012, from About website
http://drugs.about.com/od/osteoporosismedications/a/osteoporos_men.htm
Anonymous. (2012). Osteoporosis medications
Retrieved January 20, 2012, from ACAAI website
http://www.acaai.org/allergist/asthma/conditions/osteoporosis-and-asthma/Pages/osteoporosis-medications.aspx


Gould, B. E.. (2011) Chapter 10
(pp. 180), Path physiology for the Health Professions, 4th Edition. Saunders Learning, printed in United States.