Rajiv Gandhi University of Healthsciences

1GARDEN CITYCOLLEGEOF NURSING 2RAJIV GANDHI UNIVERSITY OF HEALTHSCIENCES, BANGALORE, KARNATAKA SYNOPSIS PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATIONMr. ABUBAKAR MUHAMMAD ISAH 1. NAME OF THE 1st YEAR M.Sc NURSING CANDIDATE AND GARDEN CITY COLLEGE OF NURSING ADDRESS 16th K.M. OLD MADRAS ROAD VIRGONAGAR POST-560 036 BANGALORE, KARNATAKA GARDEN CITY COLLEGE OF NURSING 2. NAME OF THE 16th K.M. OLD MADRAS ROAD INSTITUTION VIRGONAGAR POST-560 036 BANGALORE, KARNATAKA3. COURSE OF THE STUDY M.Sc NURSING FIRST YEAR AND SUBJECT MEDICAL-SURGICAL NURSING4. DATE OF ADMISSION 18th JUNE 2012 TO THE COURSEA RETROSPECTIVE STUDY TO 5. TITLE OF THE TOPIC IDENTIFY THE PREVALENCE AND CONTRIBUTING FACTORS OF OSTEOPOROSIS AMONG ADULTS IN SELECTED HOSPITALS AT BANGALORE 36 BRIEF RESUME OF THE INTENDED WORK"Given the serious public health burden of fractures associated with osteoporosis. It is important to learn as much as possible about way to prevent and treat bone loss"1 Joan Mc Gowan INTRODUCTION Osteoporosis is a disease of the skeletal system characterized by low bone mass and a continued loss of bone tissue with an associated rise in fracture risk . Osteoporosis is the most prevalent metabolic bone disease in developed countries.1Osteoporosis is a disease marked by reduced bone strength leading to an increased risk of fractuzis the major underlying cause of fractures in postmenopausal women and the elderly. Fractures occur most often in bones of the hip, spine, and wrist, but any bone can be affected. Some fractures can be permanently disabling, especially when they occur in the hip.2Osteoporosis is often called a “silent disease” because it usually progresses without any symptoms until a fracture occurs or one or more vertebrae collapse. Collapsed vertebrae may first be felt or seen when a person develops severe back pain, loss of height, or spine malformations such as a stooped or hunched posture. Bones affected by osteoporosis may become so fragile that fractures occur spontaneously or as the result of minor bumps, falls, or normal stresses and strains such as bending, lifting, or even coughing.2Osteoporosis affects women and men of all races and ethnic groups. It is most common in non-Hispanic white women and Asian women. African American and Hispanic women have a lower risk of developing osteoporosis, but they are still at significant risk. For Native American women the data aren’t clear. Among men, osteoporosis is more common in non-Hispanic whites and Asians than in men of other ethnic or racial groups.2The incidence of Osteoporotic hip fractures is 1 woman: 1 man in India, while in the Western world, it is 3 women: 1 man. And in most western countries, while the peak incidence of Osteoporosis occurs at about 70-80 years of age, in India it afflicts those at age 40-602Low bone mass plays an important role in determining a person’s risk of osteoporosis,. Fracture risk results from a combination of bone-dependent and bone-independent factors. 4Various aspects of “bone geometry,” such as tallness, hip structure, and thighbone (femur) length, can also affect chances of breaking a bone following fall. Increasing age, excessive weight loss, a history of fractures since age 50, having an existing spine fracture, hereditary influence , decreased muscle strength, poor balance, impaired eyesight, and impaired mental abilities. Use of certain medications, such as tranquilizers and muscle relaxants, and various medical conditions.3Another factor that may influence the strength bone mineralization is the amount of sun exposure. Skin produces vitamin D—the vitamin involved in calcium absorption by bones —in response to sunlight. Inadequate absorption due to use sunscreen, living in a northern latitude, cover skin with clothing that blocks the sun’s rays (especially in cultures in which women always wear body-concealing clothing outdoors) and spend little time in the sun during daylight hours.3 world Health organization in 1994 defined osteoporosis as by a bone mineral density measured as 2.5 standard deviation below average peak bone density achieved in young adults, matched by gender and race.4In a study of five Latin American countries (Argentina, Brazil, Colombia, Mexico and Puerto Rico), the prevalence of vertebral fractures in women over 50 years of age was about 15%, with 7% occuring within the 50-60 years old age group and increasing to 28% for those greater than 80 years old5Osteoporosis is a major health threat for more than 28 million Americans. In the United States, eight million women and two million men already have osteoporosis. More than 18 million Americans have low bone mass placing them at increased risk for osteoporosis.5Diagnosing osteoporosis involves several steps, physical exam and a careful medical history, blood and urine tests, and a bone mineral density assessment. History taking to find out factors for osteoporosis and fractures. lifestyle (including diet, exercise habits, smoke), current or past health problems and medications that could contribute to low bone mass and increased fracture risk. family history of osteoporosis and other diseases and menstrual history.5The most widely recognized test for measuring bone mineral density is a quick, painless, non-invasive technology known as dual-energy x-ray absorptiometry (DXA). This technique, which uses low levels of x rays, involves passing a scanner over the body while lying on a cushioned table. DXA can be used to determine BMD of the entire 5 skeleton and at various sites that are prone to fracture, such as the hip, spine, or wrist. (BMD) testing can be used to definitively diagnose osteoporosis, detect low bone mass before osteoporosis develops, and help predict risk of future fractures. The lower bone density, the higher risk for fracture.5BMD is compare with results of the average bone density of young, healthy people and to the average bone density of other people of same age, sex, and race. For both women and men, the diagnosis of osteoporosis using DXA measurements of BMD is currently based on a number called a T-score. T-score represents the extent to which bone density differs from the average bone density of young, healthy people.5The primary goal in treating people with osteoporosis is preventing fractures. A comprehensive treatment program includes a focus on proper nutrition, exercise, and prevention of falls that may result in fractures. several medications that have been shown to slow or stop bone loss or build new bone, increase bone density, and reduce fracture risk. For people with osteoporosis resulting from another condition, the best approach is to identify and treat the underlying cause. Staying as active as possible, eating a healthy diet that includes adequate calcium and vitamins, and avoiding smoking and excess alcohol.3With ongoing research, experts hope that osteoporosis will come to be considered a curable disease. Research has enhanced our knowledge about how to maintain a healthy skeleton throughout life and has led to progress in understanding the causes, prevention, diagnosis, and treatment of osteoporosis. Every research advance brings us closer to eliminating the pain and suffering caused by this disease.NEED FOR THE STUDYIn recognising the global problem posed by osteoporosis, WHO sees the need for a global strategy for prevention and control of osteoporosis focusing on three major functions: prevention, management and surveillance. Gro Harlem Braunland. The awareness of osteoporosis has grown worldwide in recent years. This silently 6.1 progressing metabolic bone disease is widely prevalent in India, and osteoporotic fractures are common cause of morbidity and mortality in adult Indian men and women. Rapid 6 bone loss occurs in postmenopausal women due to hormonal factors which lead to increased risk of fractures. Biochemical markers of bone metabolism are used to assess skeletal turnover.4Osteoporosis also takes a huge economic toll on both individuals and society. Approximately 1.6 million hip fractures occur worldwide each year, by 2050 this number could reach between 4.5 million and 6.3 million.2Fractures from osteoporosis cost the U.S. nearly $19 billion each year and that number is only going to rise as our population ages. Osteoporosis disproportionately affects older Americans with around 70% of fractures occurring in the 65 and older population. Without a significant change of course in the bone health of Americans, NOF projects as many as 61 million Americans could be affected by the disease by 20203In India precise figures on the prevalence of osteoporosis is not available at present, however it is estimated that more than 61 million Indians have osteoporosis, of these 80% patients are females. With the increase in life expectancy and already 10% of the population being above 65 years, osteoporosis has become a formidable public health problem. India is among the highest prevalence of osteoporosis and osteopaenia in the world followed by Japan and also that bone loss commences earlier in them. India seems to have the highest prevalence of osteoporosis. With growing awareness of osteoporosis and its impact on life span especially in India, special attention is being paid to early detection, management and treatment of postmenopausal osteoporosis in women.4Osteoporosis is greatly under diagnosed and undertreated in Asia, even in the most high risk patients who have already fractured. The problem is particularly acute in rural areas. In the most populous countries like China and India, the majority of the population lives in rural areas India: In a study among Indian women aged 30-60 years from low income groups, BMD at all the skeletal sites were much lower than values reported from developed countries, with a high prevalence of osteopaenia (52%) and osteoporosis (29%) thought to be due to inadequate nutrition.3Nearly all Asian countries fall far below the FAO/WHO recommendations for calcium intake of between 1000 and 1300 mg/day. The median dietary calcium intake for the adult 7Asian population is approximately 450 mg/day, with a potential detrimental impact on bone health in the region.3It was projected that more than about 50% of all osteoporotic hip fractures will occur in Asia by the year 2050. The number of osteoporosis patients at approximately 26 million (2003 figures) with the numbers projected to increase to 36 million by 2013.3 Most studies indicate that smoking is a risk factor for osteoporosis and fracture, although the exact reasons for the harmful effects of tobacco use on bone health are still unclear. Women who smoke have lower levels of estrogens compared to non-smokers and frequently go through menopause earlier.2A cross-sectional study of 150 pre- and post menopausal women was carried out at S.D.M College of Medical Sciences and Hospital, Dharwad, May 2005 to September 2005. The study group consisted of 75 Premenopausal women in the age group of 25-45 years and 75 Postmenopausal women in the age group of 46-65 years. Bone formation markers (Total Calcium,Phosphorus, Alkaline phosphatase), and bone resorption markers (Urinary Hydroxyproline) were analysed in pre and post menopausal women. Bone formation markers, Total and lonised calcium were significantly decreased and Alkaline phosphatase was significantly increased in postmenopausal women compared to premenopausal women. Bone resorption markers, Urinary hydroxyproline excretion was also significantly increased in postmenopausal women. The results from this study suggest that simple, easy, common biochemical markers can be used to assess the bone turnover in postmenopausal women and hence determined their risk of developing osteoporosis and fractures.6Osteoporosis, is expected to impact over 36 million patients in India by 2013, it is the single largest cause of spinal fractures. 20 per cent of women and 10 to 15 per cent of men aged above 50 suffer from Osteoporosis. there will be a marked rise in costs in decades to come. Osteoporosis is hugely under diagnosed and under-treated in India. The problem is particularly worse in rural and semi-urban areas. In urban regions, Osteoporosis is widely prevalent due to poor lifestyle pattern of the people. Widespread deficiency of Vitamin D and Calcium are also key factors. Hence, prevention of all Osteoporotic fractures, early diagnosis and treatment must be a key public health goal3Significant advances in preventing and treating osteoporosis continue to be made. This study will be aim to: determining the causes and consequences of bone loss, assessing risk 8 factors, developing new strategies to maintain and even enhance bone density and reduce fracture risk, exploring the roles of such factors as genetics, hormones, calcium, vitamin D, drugs, and exercise on bone mass.The aim of this retrospective study is to review the folders of adult patients in some selected hospitals at Bangalore and retrieve vital information that will enable the investigator to identify more information on the factors that increases the risk of osteoporosis, find more solutions to overcome the disease condition and provide preventive measures to reduce sufferance and future occurrence of osteoporosis.National osteoporosis awareness and prevention month is celebrated each May, and become a chance for Nation to become more familiar with the effect of this disease and about the preventable steps that we can take deal with it.7 REVIEW OF LITERATUREThis will give the comprehensive in depth ,systemic and critical review of scholarly publications and unpublished scholarly materials that provided relevant information about osteoporosis. a. Incidence and prevalence of osteoporosis b. Prevalence of osteoporosis in India. c. Review of literature related to osteoporosis d. Review of literature related to effect of osteoporosis e. Benefits of this retrospective studies 6.2A-INCIDENCE AND PREVALENCE OF OSTEOPOROSISOsteoporosis is a systemic skeletal disease responsible for the high incidence of fractures in older subjects, particularly in postmenopausal women. The increasing prevalence with population ageing and prolonged life expectancy raises the rates of 9 associated morbidity, loss of independence, and mortality. BMD and previous fracture history are two main risk factors associated with osteoporosis such that the presence of prior fractures can predict future fractures. 8A major contributor to bone loss in women during later life is the reduction in estrogens production that occurs with menopause. In men, sex hormone levels also decline after middle age, but the decline is more gradual. These declines probably also contribute to bone loss in men after around age 50. 8In the United States, more than 40 million people either already have osteoporosis or are at high risk due to low bone mass. Osteoporosis can strike at any age, although the risk for developing the disease increases with age. In the future, more people will be at risk for developing osteoporosis because people are living longer and the number of elderly people in the population is increasing.5From 1990 to projections in 2050 the number of hip fractures for women and men aged 50-64 in Latin America will increase by 400%. For age groups older than 65 the increase will be a staggering 700%]. Latin Americans will suffer an estimated 655,648 hip fractures in 2050, at an estimated direct cost of $13 billion. The mortality rates in the year following a hip fracture are 23-30% and are higher in men compared to women.2Osteoporosis is a contributing factor in as many as 1.5 million fractures each year, including: About 300,000 hip fractures, 700,000 vertebral (spine) fractures, 250,000 wrist fractures, and 300,000 fractures at other sites The risk of a serious fracture can double after a first fracture in certain high-risk groups. Additionally, many patients, particularly those who suffer hip fractures, are at high risk for premature death or loss of independence after the fracture.2Osteoporosis in men is undergoing major scrutiny in a seven-centre study funded by NIAMS in partnership with NIA and the National Cancer Institute. The study is following some 5,700 men age 65 years and older at the start of the study, and will determine the extent to which the risk of fracture in men is related to bone mass and structure, biochemistry, lifestyle, tendency to fall, and other factors.2In the prospective 12-year study in men and women 60 years of age and older, there was a 4-6% per year reduction in the incidence rate of overall osteoporotic fractures, but the study was unable to exclude any change in the hip fracture incidence rate. Approximately one-half of hip fractures occurred before 80 years in men and two-thirds 10 before 85 years in women. The age distribution of hip fractures underlines the need for earlier intervention in osteoporosis fractures, among the 1055 symptomatic a traumatic fractures (after excluding pathological fractures), there was a significant reduction in the overall fracture incidence rate in women (4% per year;) and men (6% per year;) over the 12 years. There were 229 hip fractures (175 in women and 54 in men) within 39,357 person-years of observation. The overall rate of hip fracture was 759 per 100,000 person- years in women and 329 45 per 100,000 person-years in men, with an exponential increase with age. With advancing age, the incidence rate of hip fractures in men approached that in women; the female : male ratio fell from 4.5 (95% CI: 1.3-15.7) to 1.5 (0.9-2.5) and 1.9 (1.2-2.8) in the 60-69, 70-79, and 80+ year age groups, respectively. In women, the absolute number of fractures and incidence rate continuously increased with age; however, in men, the absolute number of hip fractures peaked at 80-84 years of age and then decreased. Most importantly, despite the continuing increase with age, almost one-half (48%) of the hip fractures occurred before the age of 80 years in men, and 66% of hip fractures occurred before the age of 85 years in women. The overall hip fracture incidence is comparable with other white (except Sweden) and Asian groups as well as two other Australian studies. The study could not exclude a change in hip fracture incidence rate, even in those 80 years of age and over among whom the incidence of hip fractures was the highest. The incidence data highlight the fact that a large proportion of hip fractures occurs in those under 80 years of age, particularly in men. This age distribution underlines the need for earlier intervention in osteoporosis in women and particularly in men to achieve the most cost-effective outcomes.9B - PREVELENCE OF OSTEOPOROSIS IN INDIA.Peak bone mass, a major determinant of osteoporosis is influenced by genetic, nutritional, lifestyle and hormonal factors. The Physical activity, optimal nutrition and adequate sun exposure are vital for attaining peak bone mass. Syndromes of bone disease and deformities consequent to disorders of nutrition, bone and mineral metabolism constitute a serious national health problem. There is widespread prevalence of vitamin D deficiency from new-born to infancy, childhood and adult male and females (non- pregnant, pregnant and lactating). However, there is limited information of the vitamin D status in elderly Indians.9The clinical outcome of osteoporosis is bone fracture, attention is now increasingly focused on the identification of patients at high risk of fracture rather than the 11 identification of people with osteoporosis. Although osteoporosis is defined in terms of BMD and micro-architectural deterioration of bone tissue, BMD is just one component of fracture risk. Accurate assessment of fracture risk should ideally take into account other proven risk factors that add information to that provided by BMD. Osteoporosis has been shown in studies to have a large genetic component. Studies have provided evidence that weight in infancy is a determinant of bone mass in adulthood. Physical inactivity and a sedentary lifestyle as well as impaired neuromuscular function (e.g., reduced muscle strength, impaired gait and balance) are risk factors for developing fragility fractures. Smoking can lead to lower bone density and higher risk of fracture and this risk increases with age A high intake of alcohol confers a significant risk of future fracture. The risk of vertebral and hip fractures in men increases greatly with heavy alcohol intake, particularly with long term intake. Prolonged use of corticosteroids is the most common cause of secondary osteoporosis. It is estimated that 30-50% of patients on long term corticosteroid therapy will experience fractures Low body weight and weight loss is associated with greater bone loss and increased risk of fracture . Middle-aged and older men and women with annual height loss >0.5 cm are at increased risk of hip and any fracture . Some young females, particularly those training for elite athletic competition, exercise too much, eat too little, and consequently experience amenorrhea which makes them at risk for low bone mass and fractures.5The study survey of 337.68 million population residing in 0.39 million villages in 22 States of India during the period 1963 to 2005. Of the 4,11,744 patients identified with the disorders of bone and mineral metabolism, 2,13,760 (52%) had nutritional bone disease, 1,77,200 (43%) had endemic skeletal fluorosis and 20,784 (5%) had metabolic bone disease and in 41 patients (0.19%) the bone disease was rare, mixed or unidentified. Vitamin D deficiency osteomalacia and rickets caused by inadequate exposure to sunlight (290-315 nm), dietary calcium deficiency (<300 mg/day) and fluoride interaction syndromes, calcium deficiency induced osteoporosis and calcium and vitamin D deficiency induced osteoporosis in the elderly, Only mothers with severely depleted bone mineral and vitamin D stores gave birth to their babies with congenital rickets. Vitamin D deficiency rickets in children and osteomalacia in the mothers are the commonest disorders prevalent in the rural population of India. These disorders and the syndromes of calcium deficiency and fluoride interactions are largely responsible for the morbidity and mortality in the young and promising individuals, with economic consequences.10 12A cross-sectional survey on 110 women determine the preventive practice and assessing the risk status (KPR) on osteoporosis, find the association between selected variables and key variables, find the relationship between practice and risk status in each group of women; comparing the mean among the groups using Convenience sampling at Hiriadka, Karnataka. Demographic Performa, self reported practice scale and risk assessment tool were used. There was positive correlation between age and risk status in group1, whereas in group 2 it was negatively correlated. Preventive practices and risk status was negatively correlated in both groups12.The study has aimed to describe risk factors (RF) among women with osteoporosis (OP) treated in primary care (PC) and hospitals (HO). Cross-sectional, epidemiological and multicenter study, including 194 PC and 186 HO women with OP ware used. The result reveals that Patients in both groups had equivalent age .Some specific risk factors for falls such as prolonged use of benzodiazepines and heart rate higher than 80 pulses per minute were more frequent in the hospital setting . In contrast, intrinsically bone-related RFs for osteoporotic fracture were generally more prevalent in HO: surgical menopause previous vertebral fractures Sedentary lifestyle and tobacco consumption, however, were more prevalent in PC than in HO. The findings suggested that: Risk factors associated with the risk of falling (not bone-related factors) are more prevalent in OP patients, whilst factors associated with bone quality and density (bone-related factors) are more prevalent in HO patients.13In a study find out bone status of women over 40 years of age from two socioeconomic strata. 58 and 54 women from upper socioeconomic class (USC) and lower socioeconomic class (LSC), respectively, for their BMD at lumbar spine and total femur by Lunar DPX- PRO dual-energy X-ray absorptiometry. Socioeconomic, lifestyle and biochemical data were collected. The result shows prevalence of osteoporosis in USC women was 12% and 0% at lumbar spine and total femur, respectively, while it was 33% and 11%, respectively, in LSC women. When the mean BMD values were adjusted for the effect of body mass index, protein and calcium intake, physical activity, and sunlight exposure, only the total femoral BMD of USC premenopausal women was significantly greater. The research suggested that bone health of LSC women was poor possibly due to the influence of socioeconomic and lifestyle factors.14In A study to detect and compare the osteoporosis in symptomatic and asymptomatic adults by using the heel dexa technique total of 173 patients who attended a medical 13 health camp which was conducted in southern Karnataka, India. Their ages ranged from 20 to 80 years. They were asked for the presenting complaints before testing for their heel bone mineral density(BMD) by using the p-dexa technique. The WHO equivalent for the heel BMD was used to classify the patients, based on their T-score. Osteoporosis was considered when the T-score was less than - 1.6. Osteopaenia was considered when the T- score was between -0.6 to -1.6. The T-scores which were above -0.6 were considered as normal. The result reveals that: 94 out of the 173 patients presented with one or more complaints which were related to the skeletal system, like pain in the neck, back, shoulder, legs and hip, generalized body pain,. Among the 94 patients who were symptomatic, 54 (58.75%) had osteopaenia, 19(18.92%) had osteoporosis and 21(22.33%) had a normal T- score. Among the 79 remaining patients who were asymptomatic, 25 (31.6%) had a normal T-score, 46 (58.2%) had osteopaenia and 8(10.2%) had osteoporosis. The frequency of the osteoporosis was significantly higher in the symptomatic individuals than in the asymptomatic individuals The data suggests that P-dexa is a useful technique for detecting and comparing osteoporosis in both symptomatic as well as asymptomatic cases.15In a five-day programme to subject Bangalore’s traffic policemen to Bone Mineral Density Test (BMDT) has revealed on its first day, on Wednesday, that these men are prone to moderate or severe osteoporosis, 70 of the 160 traffic policemen tested scored the range between -1 downwards, indicating that they faced the threat of suffering from osteoporosis sometime or the other in the future. Projections on the number of traffic police men suffering from calcium deficiencies by the end of the five-day BMDT programme are likely to remain the same. most men over 35 tend to suffer from calcium deficiency and many among them suffer as they end up testing very late, leading to future complications. Among women, calcium deficiencies, and the threat of suffering from osteoporosis increases after childbirth and becomes more pronounce in advanced age.16C . REVIEW OF LITERATURE RELATED TO OSTEOPOROSISOsteoporosis is a disease in which the density and quality of bone are reduced, leading to weakness of the skeleton and increased risk of fracture, particularly of the spine, wrist and hip. Osteoporosis and associated fractures are an important cause of mortality and morbidity. Osteoporosis is a global problem which is increasing in significance as the population of the world both grows and ages. Of all fractures, hip fractures have the most 14 serious impact. Most hip fractures require hospitalization and surgery; Fifty percent of people who fracture a hip will be unable to walk without assistance. About one in five hip fracture patients over age 50 die in the year following their fracture as a result of associated medical complications. Vertebral fractures also can have serious consequences, including chronic back pain and disability. They have also been linked to increased mortality in older people.17In the study to assess the relationship between morbidity from hip fracture and that from other osteoporotic fractures by age and sex based on the population of Sweden. Osteoporotic fractures were designated as those associated with low bone mineral density (BMD) and those that increased in incidence with age after the age of 50 years. Severity of fractures was weighted according to their morbidity using utility values based on those derived by the National Osteoporosis Foundation. Morbidity from fractures other than hip fracture was converted to hip fracture equivalents according to their disutility weights. Excess morbidity was 3.34 and 4.75 in men and women at the age of 50 years, the morbidity associated with osteoporotic fractures was 3-5 times that accounted for by hip fracture. Excess morbidity decreased with age to approximately 1.25 between the ages of 85 and 89 years. The age- and sex-specific pattern of fractures due to osteoporosis is similar in different communities; the computation of excess morbidity can be utilized to determine the total morbidity from osteoporotic fractures from knowledge of hip fracture rates alone. Such data can be used to weight probabilities of hip fracture in different countries in order to take into account the morbidity from fractures other than hip fracture, and to modify intervention thresholds based on hip fracture risk alone., this would be exceeded in women with osteoporosis aged 65 years and more, but when weighted for other osteoporotic fractures would be exceeded in all women (and men) with osteoporosis.17A study was conducted to determine percentage of osteoporosis at femoral neck and lumbar spine (L1-L4) in women with different age group and various BMI ranges. 4528 women of > or =40 years who underwent first BMD measurement at King Chulalongkorn Memorial Hospital between 2000 and 2010. Bone mineral density (BMD) of femoral neck (non-dominant side) and lumbar spine (Li-L4) was measure by Dual-energy x-ray Absorptiometer (DXA). The percentage of osteoporosis was determined by WHO cut off value. The result reveals that : percentages of osteoporosis at femoral neck (FN) in age group of 40 to 49, 50 to 59, 60 to 69, and > or =70 years were 6.2%, 7.4%, 24.4%, and 1551.8% respectively. The corresponding figures for lumbar spine (LS) were 3.4%, 5.6%, 12.7%, and 20.9% respectively. The percentage of osteoporosis seems to increase strikingly after 60 years at both sites. The percentage of osteoporosis at FN in underweight, normal weight, overweight and obesity were 52.1%, 20.3%, 15.7%, and 9.4% respectively. The corresponding figures for LS were 22.8%, 12%, 4.8%, and 5.9% respectively. Over 30% of women of age > or =60 years with BMI of less than 23 kg/m2 had osteoporosis by the studied criteria. The percentage of osteoporosis seemed to be increasing with age and declining with BMI.18Retrospective pilot study was conducted to establish changes in 10-year fracture risk in postmenopausal women with respect to applied fracture management. A group of 191 postmenopausal women with a mean age of 68.76± 6.72 years was divided into subgroups. The subgroups were made up of untreated patients, patients treated with vitamin D plus calcium, and patients treated with bisphosphonates, vitamin D and calcium. Ten-year fracture risk was established, using FRAX. The mean follow-up period was 2.01±1.87 years. Results indicated, the mean fracture probability increased in the studied women over the observation period. Patients on bisphosphonates therapy demonstrated the smallest increase in fracture probability. The probability rate for either any fractures or hip fractures decreased when the T-score increased. A diminished number of falls non-significantly decreased the probability for hip fractures and any fractures. in conclusion, fracture risk increased irrespective of applied management, while a decreased risk was observed only in women with improved bone status.19In a study to evaluate Modifiable factors associated with low bone mineral content in underprivileged premenarchal Indian girls. Data on anthropometry, diet, lifestyle, total body bone mineral content (TBBMC), bone area, bone mineral density, and biochemical parameters [parathyroid hormone, vitamin D (25OH-D), calcium, and zinc] were assessed in 214 premenarchal girls (8-12 years). Compared with the Indian reference database, 15.6% girls had TBBMC for age Z-scores below -2 and 37.5% had Z-scores between -2 and -1. The TBBMC for total body bone area Z-scores were below -2 for 150 of girls, indicating under mineralized bones. Mean rate of increase in TBBMC with age and Tanner stage was lower in study population (11.6% and 20.7%, respectively) than reference database (14.2% and 33.4%, respectively). Low weight, 25OH-D, and intake of protein, calcium, and zinc adversely affected TBBMC. Many underprivileged premenarchal Indian girls are at risk of achieving low bone mass. Steps to improve 16 underweight, 25OH-D, intakes of protein, calcium, and zinc might improve bone health.20A prospective evaluation of the long-term effects of early menopause on mortality, risk of fragility fracture and osteoporosis conducted in Malmo, Sweden. 390 white north European women aged 48 years were studied. The prevalence of osteoporosis was determined using the DXA data. Mortality rate and the incidence of fractures were registered up until age 82. Data are presented as means with 95% confidence intervals (95% CI). Major findings were Incidence of fragility fractures, mortality, prevalence of osteoporosis at age 77. Women with early menopause had a risk ratio of 1.83 for osteoporosis at age 77, a risk ratio of 1.68 for fragility fracture and a mortality risk of 1.59.It was concluded that: Menopause before age 47 is associated with increased mortality risk and increased risk of sustaining fragility fractures and of osteoporosis at age 77.21In a study to assessed how different trajectories of women's smoking, covering the ages 40 to 48 years, relate to osteoporosis at age 65, 22.4% of the women reported having osteoporosis. Smoking contributes substantially to osteoporotic fractures.. analysis of tobacco use data reveals smoking patterns which may have differing relationships to osteoporosis. Logistic regression analyses revealed the varying relationships of different smoking patterns to osteoporosis., the chronic/heavy smokers were significantly more likely than the non-smokers to report having osteoporosis. Quitters and moderate smokers did not differ significantly from non-smokers on the osteoporosis measure. Chronic/heavy smokers should not be the only focus of public health efforts to reduce smoking and the associated risks of osteoporosis. The findings also highlight the efficacy of women smokers quitting in their 40s in order to reduce their likelihood of contracting osteoporosis.22 D- REVIEW OF LITERATURE RELATED TO EFFECT OF OSTEOPOROSISOsteoporosis is a major public health concern, resulting in increased fracture risk. Osteoporosis-related fractures impose a considerable economic burden on health care systems, and the disease has severe, debilitating consequences if left untreated. Measures for osteoporosis prevention should begin at childhood and include balanced nutrition, physical activity, and avoidance of risk factors such as smoking. In adulthood, early recognition of osteoporosis followed by timely and effective management can reduce fracture risk. However, the rates of screening and treatment for osteoporosis are low, even 17 in patients who have sustained a fragility fracture. Comprehensive fracture risk assessment should be part of routine patient care. Non pharmacologic strategies to improve or maintain bone health should always be implemented, but many patients also need pharmacologic intervention to achieve adequate fracture protection. Several pharmacologic therapies are currently available, and when choosing from the available options, clinicians should consider the efficacy and safety profiles of each therapy as well as the individual patient's needs and overall health. Ideally, therapy should satisfy multiple criteria: fracture protection across multiple skeletal sites; rapid onset of action to maximize the timing of fracture protection; and minimal side effects with proven long- term safety.23Many older adults living at home eat poorly. In one of four older people, protein- calorie malnutrition (PCM) develops. Sometimes, PCM occurs after a long hospital stay, or from loss of appetite due to a chronic disease or medication. Dental problems can also make it difficult to eat healthy foods. Poor nutrition adds to the risk of osteoporosis because it can cause a deficiency in calcium and other nutrients needed to build bones. Also, body will remove the calcium from bones to use it for other necessary functions if enough calcium.24Osteoporosis can cause vertebral (spinal) compression fractures and fractures of the ribs that shorten the torso, and cause kyphosis (also called Dowager’s hump). Along with poor posture and loss in height, kyphosis may lead to a squeezed ribcage and chest. In serious cases, lungs will no longer have enough space to expand normally with each breath. However, not all height loss is caused by osteoporosis. As age advanced, the disks lose their elasticity causing frame to shift downward. It is not uncommon to lose anywhere from one half to 1 inch in height between the ages 60 and 80.5Osteoporosis affects all the bones of the body. The jaw often suffers osteoporotic bone loss that is severe enough to impact the way the teeth are rooted in the jawbones. When the area of the jawbones where teeth are rooted lose bone mass, teeth become loose and may fall out. Research has found that women with osteoporosis are three times more likely to lose teeth than women who don’t have the disease. Osteoporosis causes other dental problems besides tooth loss. Treatments for osteoporosis, such as bisphosphonates medications, may build bone in the jaw and help keep teeth firm and healthy.24F- BENEFITS OF THIS RETROSPECTIVE STUDIES 18Osteoporosis is a serious health problem worldwide and leads to a significant burden on society. Unfortunately, efforts to control osteoporosis are largely unsuccessful. Lowering an individual's risk for osteoporosis must focus not only on treatment but also on modification of risk factors5 Bone health is determined by influences that accumulate over one's entire lifetime. Numerous factors including age, heredity, nutrition, physical activity, sex steroids and other medical problems all influence the possibility of an individual developing osteoporosis. Fractures due to minimal trauma are the important consequence of osteoporosis, but the risk of fractures is also determined by many non-skeletal risk factors such as body size and the frequency of injury. We now have effective therapeutic options to prevent bone loss and to reduce fracture risk. Assessing risk factors for both osteoporosis and for fractures24In a study to evaluate effects of sports training & nutrition on bone mineral density in young Indian healthy females. Healthy female college going students (N=186, sports women, 90; controls 96) in the age group of 18-21 yr, residing in New Delhi (India) were evaluated for anthropometry, biochemistry (serum total and ionic calcium, phosphorus, total alkaline phosphatase, 25-hydroxyvitamin D & parathyroid hormone), diet, physical activity and lifestyle. Bone mineral density (BMD) at hip, forearm and lumbar spine was studied using central DXA. Sports related physical activity and direct sunlight exposure were significantly higher in sportswomen than in controls with sedentary lifestyle. Significantly higher intake of all macronutrients (energy, protein, carbohydrates and fat) and dietary calcium was noted in the diets of sportswomen. Mean serum 25(OH)D levels were significantly were significantly lower in sportswomen when compared to controls. No significant difference was found in ionized calcium and inorganic phosphorus in the two groups. Significantly higher total BMD and BMD at all sites except femur neck were found in sportswomen than controls. The result reveals that Physical activity, optimal nutrition and adequate sun exposure are vital for attaining peak bone mass.25With ongoing research, osteoporosis will come to be considered a curable disease. Many researches have enhanced our knowledge about how to maintain a healthy skeleton throughout life and has led to progress in understanding the causes, prevention, diagnosis, and treatment of osteoporosis. Every research advance brings us closer to eliminating the pain and suffering caused by this disease.The findings from the study will provide students, health professionals, and the public 19 with important information on osteoporosis as metabolic bone diseases. It will hope to expand awareness, enhance knowledge and understanding of the prevention, early detection, and treatment of this diseases as well as strategies for coping with the associated risk factorsThe findings from the study will suggest the need for large community-based studies so that high-risk population can be picked up and early interventions.STATEMENT OF THE PROBLEMRetrospective study to identify the prevalence and contributing factors of osteoporosis among adults in selected hospitals Bangalore Karnataka.OBJECTIVES OF THE STUDY1. To identify the incidence of osteoporosis in the available document 201. 2. To compare the incidence of osteoporosis among male and female adults 2. 3. To identify the age occurrences of osteoporosis 3. 4. To identify the major complication of osteoporosis 4. 5. To compare the incidence between nutritional deficiency and other causes of osteoporosis 5. 6. To compare the occurrences of osteoporosis among smokers and non smokers. 6. 7. To compare the incidence of osteoporosis in women at early menopause and late menopause. 8. To identify the effect of medication on osteoporosis.OPERATIONAL DEFINITIONRetrospective study: In this study retrospective is refers to evaluation of patient’s file records who was diagnosed with osteoporosis or predisposed to risk factor from 2012 to 2008. Prevalence: In this study the prevalence refers to occurrence of reported cases of osteoporosis in selected hospitals at Bangalore from 2012-1008. 6.3Contributing factors: In this study contributing factors refers to age ,sex, nutritional deficiency, pathological diseases, cigarette smoking, side effects of certain drugs, dietary habits and menopause which are responsible for causing osteoporosis. Osteoporosis: In this study it refers to the adult patients who were diagnosed as having 6.4 osteoporosis between 2012 to 2008. Adult: Adult in this study refers to any patient’s document male or female that indicates age of 40 years and above.RESEARCH VARIABLES UNDER STUDY Dependant variable: refers to prevalence and Contributing factors of osteoporosis among adultsASSUMPTIONS 1. Bone demineralization during menopause is the main cause of osteoporosis This study 21 will identify the aetiology of the disease 1. 2. The study will identify the effects and impacts of Lifestyle, believes, nutrition environment and economic status on prevalence of osteoporosis. 6.5 2. 3. Osteoporosis has great effects on physical, social and physiological function of an individual. The study is intended to find out these factors and suggest appropriate modalities of preventive measure to general public. 3. 4. Many people have osteoporosis but they don’t know about it. The study will help in identifying people at high risk and those already affected, so that further complication could be prevented. 4. 5. Majority of people with osteoporosis are women .The study is intended to compare the incidence of osteoporosis among males and females.DELIMITATION OF THE STUDY a- This study will be limited to selected hospitals in Bangalore. b- The study will be limited patient’s file record, during the year 2012 to 2008 c- The study period is limited to 4 weeksPROJECTED OUTCOME 6.6 The statistical information of the study will help to evaluate the causes or risk factors, and effects of osteoporosis among adults as well as providing suggestive measures in early detection, treatments, preventions, and modification of lifestyles. The findings will be 6.7 communicated to the general public by using palm let.MATERIALS AND METHOD OF DATA COLLECTION.Retrospective evaluation of patient’s file records who were diagnosed with osteoporosis or shows the abnormalities in bone d from 2012 to 2008.SOURCE OF DATA COLLECTIONPatient’s folders records from2012 to 2008 in selected hospitals in Bangalore. 22RESEARCH DESIGN6.8 Retrospective design will be used in this study to collect necessary findings from patient’s previous records.SETTINGS The study will be conducted in selected hospitals in Bangalore through data analysis from hospital medical records. 6.9 POPULATION Available document/ folder from2012 to 2008.7.07.1 SAMPLE PROCEDURE Purposive sampling technique7.1.1 SAMPLE SIZE Patient’s folder which are available in selected hospitals Bangalore.SAMPLING TECHNIQUE7.1.2 The sampling technique to be use in this study is convenience sampling. 23INCLUSION CRITERIA All folders who were diagnosed as having osteoporosis from 2012-20087.1.3 EXCLUSION CRITERIA a- All folder that are not having /indicating osteoporosis. b- All patents folders that sustained traumatic fracture.INSTRUMENTS INTENDED TO BE USEDSurvey format will be use for analysing and collecting relevant data from the patients folders, using the followings I-Demographic information II-Complete medical history III-Available clinical findings8.0 METHOD OF DATA COLLECTION Formal permission will be obtained from the medical director or hospital management to get access to the patient’s folders. The medical record office will also be informed 8.1 formally and seek for their co-operation and providing basic information about the folders. Survey format will be used to collect the details from the available documents.8.1.2 METHOD OF DATA ANALYSISThe data will be analysed through descriptive statistical analysis8.1.3 ETHICAL CLEARANCEEthical clearance is obtained from the research committee of Garden City College of 8.1.4 Nursing. Permission will be obtained from the hospital management of selected hospitals in Bangalore. 248.28.2.18.2.28.3.0LIST OF REFERENCES1. McGowan J, William S, Barbara LM. 10-Year-Old Arthritis Institute Goes Beyond Aches And Pains Of Joints.Vol:10, #6, p. 13 & 18, March 18, 1996).Available from: http://www.the-scientist.com/?articles.view/articleNo/17835/title/10- Year-Old-Arthritis-Institute-Goes-Beyond-Aches-And-Pains-Of-Joints/2. Information Clearinghouse National Institutes of Health Osteoporosis Int. (NIAMS) 2010Jun; 21Suppl2:S425-9.Available from: http://www.niams.nih.gov/Health_Info/Bone/Osteoporosis/osteoporosis_hoh.asp#13. Aging & Health A to Z, Osteoporosis Unique to Older Adults. Updated: March 252012www.healthinaging.org › Aging & Health A to Z › Osteoporosis.4. Dana J, Kosmin MD. Attending Physician, Department of Medicine, Division of Rheumatology, Available from: http://emedicine.medscape.com/article/330598-overview5. international osteoporosis foundation Fact and statistics on osteoporosis© 2012. Indian JClin Biochem. 2007 Sep;22(2):96-100. www.iofbonehealth.org/facts-and-statistics. Available from: http://www.nlm.nih.gov/medlineplus/6. Indumati V, Patil VS, Jailkhani R.Hospital based preliminary study on osteoporosis in postmenopausal women. Department of Biochemistry, Belgaum Institute of Medical Sciences, Civil Hospital, Belgaum, Karnataka. Available from: http://www.ncbi.nlm.nih.gov/pubmed/231056929.0 7. Lois Capps. http://www.brainyquote.com/quotes/authors/l/lois_capps.html8. Cooper C. Osteoporosis: disease severity and consequent fracture management. Osteoporos Int. 2010 Jun; 21 Suppl Epub 2010 May 2:S425-9. 1 MRC Epidemiology Resource Centre, University of Southampton. Available from: http://www.ncbi.nlm.nih.gov/pubmed/2046437610. Chang KP, Center JR, Nguyen TV, Eisman JA. Incidence of hip and other osteoporotic fractures in elderly men and women: Dubbo Osteoporosis Epidemiology Study. J Bone Miner Res.2004 Apr;19 Epub 2004 Jan 5(4):532- 6. Available from: http://www.ncbi.nlm.nih.gov/pubmed/1500583811. Teotia SP, Teotia M. Nutritional bone disease in Indian population. Sri Sathya Sai General Hospital & Institute of Higher Medical Sciences, Bangalore, India. Indian J Med Res. 2008 Mar; 127(3):219-28.Available from: http://www.ncbi.nlm.nih.gov/pubmed/18497435 2612. Mondal J , Karkada S. Osteoporosis: Preventive practices and risk assessment among South Indian Women.IJ of Nursing Education.2011,[ 3],Print ISSN : 0974-9349. Online ISSN : 0974-9357. Available from: http://www.indianjournals.com/ijor.aspx? target=ijor:ijone&volume=3&issue=1&article=00613. González Macías J, Jodar E, Muñoz M, Díez Pérez A, Guañabens N, Fuster E. factors for osteoporosis in osteoporotic women followed in Primary Care and in Hospitals. OPINHO-PC study. Rev Clin Esp. 2009 Jul-Aug;209(7):319-24.Available from: http://www.ncbi.nlm.nih.gov/pubmed/1970953414. Vaidya SV, Ekbote VH, Khadilkar AV, Chiplonkar SA, Pillay D. Bone status of women over 40 years of age from two socioeconomic strata. 2011 Oct 11. Hirabai Cowasji Jehangir Medical Research Institute, Jehangir Hospital, Pune 411 004, Maharashtra, India. Endocr Res. 2012; 37(1):25-34Epub.Available from: http://www.ncbi.nlm.nih.gov/pubmed/2198824315. Suman Vb, Khalid Perwez, Subb Alaks Hmi Nk, Jeganathan Ps, Sheila Rp. A Comparative Study On Symptomatic And Asymptomatic Osteoporosis By Using The P-Dexa Technique. Journal Of Clinical And Diagnostic Research 2012 May [Cited: 2012 Nov 11 ]; 6:568-570. Available from http://www.jcdr.net/article_fulltext.asp?issn16. Dr Ajith Benedict. Traffic cops make no bones about it Published: Thursday, Aug 2, 2012, 12:13 IST Hosmat Hospital Bangalore By DNA Correspondent , Bangalore. DNA. Available from: http://www.dnaindia.com/bangalore/report_bangalore-traffic-cops-make-no- bones-about-it_172306117. Kanis JA, Oden A, Johnell O, de Laet C, Dawson A. The burden of osteoporotic fractures: a method for setting intervention thresholds. Osteoporos Int. 2001;12(5):417-27. Kanis JA, Oden A, Johnell O, de Laet C, Dawson A. The burden of osteoporotic fractures: a method for setting intervention thresholds. 27Osteoporos Int. Available from: http://www.ncbi.nlm.nih.gov/pubmed/1144409218. Rithirangsriroj K, Panyakhamlerd K, Chaikittisilpa S, Chaiwatanarat T, Taechakraichana N. Osteoporosis in different age-groups and various body mass indexes (BMI) ranges in women undergoing bone mass measurement at King Chulalongkorn Memorial Hospital. J Med Assoc Thai. 2012 May;95(5):644-9. Available from: http://www.ncbi.nlm.nih.gov/pubmed/2299402219. Pluskiewicz W, Drozdzowska B, Adamczyk P Ten-year fracture risk in the assessment of osteoporosis management efficacy in postmenopausal women: a pilot study. Climacteric. 2012 Feb 15. [Epub ahead of print]. Available from: http://www.ncbi.nlm.nih.gov/pubmed/2233535620. Kadam NS, Chiplonkar SA, Khadilkar AV, Fischer PR, Hanumante NM, Khadilkar VV. Modifiable factors associated with low bone mineral content in underprivileged premenarchal Indian girls. J Pediatr Endocrinol Metab. 2011;24(11-12):975-81. Available from: http://www.ncbi.nlm.nih.gov/pubmed/2230885121. Svejme O, Clinical and Molecular Osteoporosis Unit, Department of Clinical Sciences, An International Journal of Obstetrics and Gynaecology © 2012. Available from:http://www.mentalhelp.net/poc/view_doc.php? type=news&id=145962&cn=17622. Brook JS, Balka EB, Zhang C. The smoking patterns of women in their forties: their relationship to later osteoporosis. Department of Psychiatry, New York University School of Medicine, New York, Psychol Rep. 2012 Apr; 110(2):351-62. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22662390 23. Bonura F. Prevention, screening, and management of osteoporosis: an overview of the 28 current strategies.St. Catherine of Siena Medical Center, Smithtown, NY 11787, USA Postgrad Med. 2009 Jul; 121(4):5-17. Available from:http://www.ncbi.nlm.nih.gov/pubmed/1964126324. Marwaha RK, Tandon N, Garg MK, Kanwar R, Narang A, Sastry at -el Bone health in healthy Indian population aged 50 years and above. Indian J Clin Biochem. 2011 Jan;26(1):70-3 Available from : http://www.ncbi.nlm.nih.gov/pubmed/2127134125 Marwaha RK, Puri S, Tandon N, Dhir S, Agarwal N, Bhadra K et-al Effects of sports training & nutrition on bone mineral density in young Indian healthy females. Department of Food & Nutrition, Institute of Home Economics, University of Delhi, Indian JMed Res.2011Sep;134:307-13. Available from: http://europepmc.org/abstract/MED/21985813/reload=0;jsessionid=QMl1SZGD432S dPh1LSHQ.10 2910 SIGNATURE OF THE CANDIDATE11 REMARKS OF THE GUIDEPROF. SENTHIL KAVITHA 12 NAME AND DESIGNATION OF THE M.Sc(N) (Ph.D) GUIDE MEDICAL SURGICAL NURSING GARDEN CITY COLLEGE OF NURSING BANGALORE12.1 SIGNATURE12.2 CO-GUIDE12.3 SIGNATURE12.4 HEAD OF THE DEPARTMENT PROF. SENTHIL KAVITHA M.Sc(N) (PhD) 30MEDICAL SURGICAL NURSING 12.5 SIGNATURE13 REMARKS OF THE PRINCIPAL13.1 SIGNATURE

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