Osteoporosis: Calcium and Vitamin D, Fall Prevention, and Safe Bisphosphonate Use

Who needs this teaching

Clients with osteoporosis or low bone mass (osteopenia), clients who take a bisphosphonate, and the caregiver. Osteoporosis is a loss of bone mass and deterioration of bone microarchitecture that increases fracture risk. A bone mineral density T-score of -2.5 or lower indicates osteoporosis; -1.0 to -2.5 indicates low bone mass; -1.0 or higher is normal. Risk factors include female sex, older age, menopause, low body weight, long-term corticosteroid therapy, smoking, and inactivity.

The priority teaching points

1. Calcium. Adults over 50 need 1,000 to 1,200 mg daily: 1,000 mg for men 51 to 70, and 1,200 mg for women over 50 and men over 70. Food comes first: dairy products, fortified juice and plant milks, canned salmon or sardines with bones, and kale. Use supplements only to fill the gap, no more than 500 mg at a time. Take calcium carbonate with food.
2. Vitamin D. Vitamin D increases intestinal calcium absorption. Adults 50 and older need 800 to 1,000 IU daily, or the dose the provider prescribes.
3. Exercise. Perform weight-bearing exercise (walking, dancing, stair climbing) on most days and muscle-strengthening exercise 2 to 3 days a week. Avoid spinal flexion and twisting, such as toe touches and sit-ups; these movements increase vertebral compression fracture risk.
4. Smoking and alcohol. Stop smoking. Limit alcohol to no more than 1 drink daily for women and 2 for men.
5. Fall prevention. Remove throw rugs, clutter, and cords. Install grab bars, night lights, and stair handrails. Wear nonslip shoes and rise slowly. Review medications that cause dizziness or sedation.
6. Alendronate administration. Alendronate inhibits osteoclast-mediated bone resorption. Take it first thing in the morning on an empty stomach, with a full glass (8 oz) of plain water only. Swallow the tablet whole. Remain upright, sitting or standing, for at least 30 minutes and until after the first food of the day. Wait at least 30 minutes before any food, other beverage, or other medication, including calcium and antacids. For a missed weekly dose, take 1 tablet the morning after remembering, then return to the usual day. Never take 2 tablets on the same day.
7. Adverse effects. Report heartburn, dysphagia, painful swallowing, or retrosternal pain. Complete a dental examination before therapy and tell the dentist about the bisphosphonate. Report jaw pain, loose teeth, or exposed bone (osteonecrosis of the jaw). Report new dull, aching thigh or groin pain, a warning sign of atypical femur fracture.

Red flags the client reports

Teach-back questions

• "How much calcium do you get from your food each day?"
• "Show me how you will take your alendronate tomorrow morning."
• "How long will you stay upright after your dose?"
• "Which changes will you make at home to prevent falls?"
• "Which symptoms will you report while you take alendronate?"

Teaching tips

• Total the calcium in the client's usual foods before recommending a supplement.
• Walk through a home safety checklist with the caregiver.
• Write the weekly dose day and the morning steps on the handout.

Read more on NCLEXPace

• Bones and Muscles Map: Fractures, Casts, Traction, and Joint Replacement
• Falls, Restraints, and Seclusion: The Rules

Sources

• LeBoff MS, et al. The Clinician's Guide to Prevention and Treatment of Osteoporosis. Osteoporos Int. 2022;33(10):2049-2102.
• Eastell R, et al. Pharmacological Management of Osteoporosis in Postmenopausal Women: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2019;104(5):1595-1622.
• Institute of Medicine. Dietary Reference Intakes for Calcium and Vitamin D. National Academies Press; 2011.
• Alendronate Sodium Tablets: FDA prescribing information and Patient Information (DailyMed).