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Osteoporosis- Vitamin D and Calcium
Drug specific content
The Older Adult
Use in Practice
References
1/4 Canadian women and 1/8 Canadian men are affected by osteoporosis

An additional 60% experience osteopenia (decreased bone mineral density)

Prevalence: 6% at 50 years of age, increases to over 50% at 80 years of age

Cost of treating osteoporotic fractures in Canada is just under 2 billion dollars per year currently, which is expected to increase by more that 15x by 2018 with the aging population
Bone Development
and the Older Adult
Four Factors affecting bone development are:

1. Nutrition- Cost and availability, transportation, ability to cook

2. Exposure to Sunlight- spend more time indoors, delicate skin (more likely to cover up)

3. Hormonal Secretions- menopause causes BMD to decrease

4. Physical Exercise- decreased mobility, less weight bearing exercise


Lilley, Ch 38
Older Adult Risks: Osteoporosis
Lilley, Ch 38
Use in Practice (Con't)
Use in Practice (Con't)
-One of the biggest risks for an older adult with osteoporosis is falls.
- The most common fracture seen in this population is?

"In high-income countries, osteoporotic fractures account for more hospital bed days that those for myocardial infarction, breast cancer or prostate cancer. The burden of hip fracture alone accounts for 1.4 % of disability- adjusted life years in the established market economies"
-WHO (2004)

"Fractures at the hip incur the greatest morbidity and mortality . . . Their incidence increases exponentially with age"
-WHO (2004)

Prevention strategies: get adequate vitamin D and calcium intake, perform physical exercise and weight bearing exercise, as well as implementation of fall prevention
strategies. -Kenny et. al, 2009

Challenges of administering calcium supplements:
Esophageal dysfunction (dysphagia)
Need to be sitting upright
Drug allergy
Over supplementation
Drug interactions
Thicken fluids for patient with dyspagia
Language barrier (Lilly et al.,2011)
Chronic kidney disease
Liver problems (Lewis et al., 2014)
Challenges of administering vitamin D:
Dysphagia
Need to be sitting upright
Thicken fluids
Drug interactions
Language barrier
Over supplementation
Liver complications
Chronic kidney disease
Challenges with Drug therapy for Osteoporosis:
Drug allergy
Hypercalcemia
Esophageal dysfunction (dysphagia)
Inability to sit or stand upright for at least 30 minutes after taking the medication
Severe kidney dysfunction as a result, some individuals cannot take zoledronic acid (Lilly et al., 2011)
Malnourished
Decreased exposure to sunlight
Hormonal secretions
Insufficient physical exercise (Lewis et al., 2014)
Lack of staffing
Therapeutic effects of Calcium
Replacement of calcium in deficiency states
Decrease the signs and symptoms of hypocalcemia
Resolution of indigestion
Significant interactions of Calcium with other drugs
Prior to administration:
-Ensure correct preparation and dosage prior to administration
-Observe for symptoms of Hypocalcemia

Can be administered orally, intramusculary, or subcutaneotusly

Monitor BP, Pulse and ECG

When used as antacid, assess for:
-Heart burn
-Indigestion
-Abdominal pain

Assess toxicity/ Overdose

Concurrent use of other calcium supplements
The risk of Digoxin toxicity.
Chronic use with antacids in renal insufficiency
Decreases the absorption of tetracyclines, fluoroquinolones, phenytoin, and iron salts.
Calcium channel blockers
Etidronate and Risedronate
Diuretics
Calcium: How To Administer Accurately
How do RNs administer Vitamin D accurately?
Adverse effects and toxicity are not very common

Symptoms of Hypercalcemia:
-anorexia, nausea, vomiting and constipation

Adverse effects of intramuscular or subcutaneous injection:
-burning, necrosis and sloughing of tissue, cellulitis and
soft tissue calcification

Side effects for oral use:
1) Cardiovascular: 2) Metabolic:
-Hemorrhage - Hypercalcemia
-Rebound hypertension - Meatbolic Alkalosis

3) Gastrointestinal: 4) Genitourinary:
- Constipation - Renal Dysfunction
- Obstruction - Renal Stones
- Nausea - Renal Failure
- Vomitting
- Flatulence


Check seven rights and perform three-time check
Assess for symptoms and signs of vitamin D deficiency.
During therapy, assess the patient periodically.
Observe patient for signs and symptoms of hypocalcemia
Assess for toxicity and overdose.
Adverse effects of vitamin D
Prolonged intake of vitamin D
1) Cardiovascular: hypertension and dysrhythmias
2) Central Nervous System: fatigue, weakness, drowsiness and headache
3) Gastrointestinal: Nausea, vomiting, anorexia, cramps, metallic taste, dry mouth, constipation
4) Genitourinary: polyuria, albuminuria, increased blood urea nitrogen
5) Musculoskeletal : decreased bone growth, bone pain, muscle pain


Calcium: Adverse Effects
Health teaching related to vitamin D
Educate patient to take vitamin D as directed.
how to take missed dose
do not exceed RDA
Encourage patient to consume vitamin D-sufficient foods.
Advise patient with adverse effects.
Advise patient to avoid concurrent use of antacids containing magnesium
follow-up exams

Do not to take:
-Enteric-coated tablets within one hour of calcium carbonate
-With other calcium-containing supplements
-With foods containing oxalic acid, phytic acid or phosphorus
-within one to two hour of other medication

Take missed doses ASAP

Adverse effects

Avoid excessive tobacco, alcohol, and caffeine use

Take adequate vitamin D

Exercise!

Calcium: Health Teaching
Fulfill daily vitamin D intake level
Treat conditions caused by deficiency of Vitamin D levels
Promote absorption of calcium and phosphorus

Vitamin D: Therapeutic Effect
Interacts with:
Lubricant laxatives and cholestyramine
Digitalis preparation
Calcium-containing drugs

Vitamin D: Drug Interaction
Calcium
Class:

Therapeutic: Mineral and electrolyte replacement/supplement

Common uses:
Osteoporosis
Calcium deficiency related disorders: Infantile Rickets, Osteomalacia, muscle cramps, hypothyroidism, Renal Dysfunction
Vitamin D
Class:

Therapeutic: Vitamins
Pharmacologic: Fat-soluble vitamins

Two types of Vitamin D:
Vitamin D2 (
ergocalciferol
) - obtained through dietary plant sources
Vitamin D3 (
cholecalciferol
) – obtained via the sun


Common uses:
Vitamin D deficiencies
Osteoporosis
Homeostasis of phosphorus levels with chronic kidney disease
Basic Functions
Calcium:
Transmission of nerve impulses
Contraction of the heart, smooth and skeletal muscles
Renal function
Catalyst for coagulation pathways of blood
Regulator of neurotransmitters and hormones in WBC and hormone activity
Regulates binding of amino acids
Regulates intestinal absorption of Vit. B12
Regulates Gastrin secretion

Vitamin D:
Regulates the absorption and utilization of calcium and phosphorus
Regulates the rate of bone resorption and breakdown, in conjunction with hormones
Lewis, Dirksen, Heitkemper, Bucher & Camera, 2014)
Osteoporosis: Vitamin D & Calcium Therapy
Lilly, Harrington, & Snyder, 2011)
Bone Homeostasis- dynamic process, maintained through a balanced coordination between bone reabsorption by osteoclast, and bone building by osteoblast
Osteoporosis- progressive loss of bone density and thinning of bone tissue
Supplementation of Vitamin D and Calcium are recommended most regularly for the treatment and prevention of Osteoporosis
Vitamin D facilitates the uptake of Calcium into bone
Calcium adds mineral to the bone, building and strengthening it
Common Assessment:

Observe for signs of hypocalcemia
Monitor for signs of toxicity and deficiency
Monitor pulse, ECG and BP throughout parenteral therapy
Assess for bone pain and weakness prior to as well as during therapy
Bone density is measured to determine diagnosis of Osteoporosis
For Calcium and Vitamin D Therapy
Common Nursing Diagnoses:
For Calcium and Vitamin D
Hypocalcemia/Hypercalcemia
Vitamin D toxicity/deficiency
Osteomalacia
Osteoporosis
Hypothyroidism
Nursing Interventions
Weight bearing exercises
Nutrition, fortified dairy products
Increased time in sunlight
Administration of calcium supplements in conjunction with Vitamin D supplements
Careful positioning of client
Monitoring of bone density
Expected outcomes of drug therapy:
Best possible result= bone homeostasis
Increased bone strength
Decrease risk of fracture
Increased independence of client
Kenny, A., Smith, J., Noteroglu, E., Waynik, I., Ellis, C., Kleppinger, A., & ... Walsh, S. (2009). Osteoporosis risk in frail older adults in assisted living
. Journal Of The American Geriatrics Society, 57(1), 76-81 6p. doi:10.1111/j.1532-5415.2008.02072.x

Lewis, S. L., Dirksen S. R., Heitkemper M. M., Bucher, L., & Camera, I. M. Medical-surgical nursing in canada: assessment and management of clinical problems. (3rd E). Toronto, ON: Elsevier.


Lilly, L. L., Harrington, S., & Snyder, J. S. (2011). Pharmacology for canadian health care practice. (2nd Ed.). Toronto, ON: Elsevier.






Valerand, A. H., Sanoski, C. A., & Deglin J.H. (2013). Davis’s drug guide for nurses (14th ed.). Philadelphia, PA: FA Davis Company.


WHO. (2004). Who scientific group on the assessment of osteoporosis at primary health care level. Retrieved from http://www.who.int/chp/topics/Osteoporosis.pdf
Office of the Surgeon General. (2004). Bone health and osteoporosis: A report of the surgeon general. Retrieved from http://www.ncbi.nlm.nih.gov/books/NBK45504/
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