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Woods up with an exercise group close to her house, or a support group
who could help her with adjusting to her new diagnosis and give her
support. The social worker and the nursing staff would also be able to
educate Mrs. Woods' family on the condition and what needs to be done to
maximize her bone health.
5. Should Mrs. Woods have a history of renal calculi; care will be
taken for the administration of calcium supplements. Any supplement she
would take would need co-administration of Vitamin D for proper absorption.
Hormone replacement therapy is no longer considered to be a stable of
treatment due to concerns about heart disease. Additionally, there was no
significant evidence of fracture reduction of the HERS study, so the risk
of thrombosis and breast cancer probably outweighs the need for HRT.
Selective estrogen receptor modifiers are other alternatives which preserve
bone density but do not affect the endometrium or the breast tissue. These
medications two years show a modest increase in bone mineral density but
there has been evidence of an increased incidence of thromoembolic disease.

Bisphosphonates inhibit bone resporption and generally have minimal
side effects, and can be used for treatment and prevention of osteoporosis.
There is a rather high incidence of gastro esophageal side effects in
these medications. They can cause esophagitis and ulcers, and may
sometimes be associated with esophageal stricture. The pharmacist should
instruct the patient to stay upright for 30 minutes after she takes the
pill, and also not to eat anything which could impair absorption of the
drug or cause reflux of the medication back into the esophagus. Some of
the medications can be taken monthly which some must be taken once per
week. Some combination therapies of these drugs have been shown to be
effective as well. Most recently there has been intranasal calcitonin
which can treat steroid induced osteoporosis nicely, and has replaced the
previously used injected medication. Calcitonin may also be more helpful
in the patient who experiences severe bone pain, although the mechanism of
action is not clear (Sambrook and Birmingham, .1993)
At the time of admission, Mrs. Woods' fund of knowledge regarding the
disease process must be assessed. Should she appear to be relatively
unclear regarding the disease, then a significant amount of education
should be given, to include the provision of pamphlets. She should be
given a good amount of time to formulate her questions and be able to have
them answered before discharge and not on the way out the door. Also, at
admission it will be necessary to assess what kind of intervention she
desires. She may be entirely happy with simply taking analgesia for her
fracture and not desire any treatment to reverse the process. Conversely,
she may desire every intervention and assessment possible. Only by
sitting down and discussing her wishes will any of this information be
known.
It will also be important to know what kind of help she has at home,
and who will be willing to help her get to exercise or therapy
appointments, or ongoing medical appointments. Her full medical history
will also be enlightening, so that any medical co morbidities (Osterweil,
Brummeis-Smith & Beck, 2000) or contraindications to treatment will be
known. Does she have any kind of personal or religious belief which would
prevent her from having treatment or evaluation? Is she allergic to any
medications, or any type of contrast media? All of these issues will make
it necessary to modify her treatment plan.
Where does the patient live? If she lives in a flat with no high
stairs or areas which put her at risk of falls this may be best for her.
If she lives in an older house which requires her to walk up many flights
of stairs, or puts her at higher risk of falls, then perhaps she may want
to consider moving, or even going to a nursing home for a period of time to
feel more stable before she must care for herself. Are there other issues
in her life which may make her more likely to fall, such as a cat that gets
under her feet? Does she have poor eyesight? When was the last time she
had her glasses checked? All of these elements must be evaluated and
addressed before she leaves the hospital (Miller, 2000).
On discharge, it must be clear that she understands the medication she
is taking, why she is taking it, when she must take it and what kind of
side effects she would look for. It is also important that she understand
what to do if she misses a dose, or accidentally takes an extra dose.
Would it be helpful for her medication to be placed into a medi-set or some
other type of pre-arranged holder? If she is to take on of the once per
week or once per month formulations, how will she remember which day she is
to take the medication?
What kind of follow-up or specialty referral is needed for this
patient? If she has very severe osteoporosis, a history of transplant or
appears to be unable to tolerate the treatment, then referral to a
specialist in osteoporosis may be in order and this appointment should be
arranged before the patient leaves the hospital. If she has no
complicating factors, then it should be made clear how she should follow
up. She will need re-evaluation at least yearly to look at her compliance
to the medication regimen as well as evaluation for any new fractures or
complications from the medications. She should have her bone mineral
density evaluated at least once per year until her density appears stable,
and then every two years after that. Periodic blood test for calcium
levels and liver/kidney function should be done and can be arranged via her
primary care provider. Mrs. Woods should be given an appointment for
follow-up with her general practitioner after her hospitalization in any
case, just to review the changes in her medication regimen and to re-
enforce all that she has learned while she was in the hospital.

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Reference
1. Libanati CR, Baylink DJ. (1997) Prevention and treatment of
glucocorticoid-induced osteoporosis. A pathogenetic
perspective. Chest. 102:1426-35.
. 2. Sambrook P, Birmingham J, Kelly P, et al. Prevention of
corticosteroid osteoporosis: A comparison of calcium,
calcitriol and calcitonin. N Engl J Med. 1993;328:1747-1752
2. Heaney RP. (1998) Pathophysiology of osteoporosis. Endocrin
Metabol Clin North Am.;27:255-65.

3. Kanis JA, Melton LJ III, Christiansen C, Johnston CC, Khaltaev
N. (1994) The diagnosis of osteoporosis. J Bone Miner Res.
1994;9:1137-41.

4. Wasnich R. Bone mass measurement: prediction of risk. (1993)
Am J Med. 1993;95:65-103
5. Gray, L et al. 2000, 'Geriatric medicine', A pocket guide for
doctors, health professionals and students, 2nd edn, Ausmed;
Melbourne.
6. Nolan, M, Davies, S & Grant, G, (eds) 2001, Working with older
people and their families, Open University Press,
Philadelphia.
7. Osterweil, D, Brummeis-Smith & Beck, JC 2000, Comprehensive
geriatric assessment, McGraw-Hill.
8. Staunton, P & Chiarella, M 2002, Nursing and the law, 5th edn,
Churchill Livingstone, Marrickville.
9. Stockslager, J & Schaeffer, L, (eds) 2003, Handbook of
geriatric nursing care, 2nd edn, Lippincott Williams & Wilkins
10. Theobald, M 2003, Delirium risk management program resource
kit, Ballarat Health Services, Ballarat, Victoria.
11. Miller, C 2004, Nursing for wellness in older adults, 4th edn,
Lippincott, Sydney.

12. Cauley JA, Black DM, Barrett-Connor E, et al. Effects of
hormone replacement therapy on clinical fractures and height
loss: The Heart and Estrogen/Progestin Replacement Study
(HERS). Am J Med. 2001;110:442-450.

13. Khovidhunkit W, Shoback DM. Clinical effects…[continue]

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