Impact of Myeloma Disease,
Tr
T eatments
r
, Long-Te
Term
rm Effects, and
and
Patient-Specific Characteristics on:
Bone Disease and Bone Health
Functional Mobility and Safety
Teresa Miceli, RN, BSN, OCN®
Mayo Clinic Rochester
Rochester, MN
74
Bone Disease in Multiple Myeloma
Bone destruction is a hallmark of multiple myeloma.
Caused by defects in the
balance between bone
formation and resorption
· Osteoblast inhibition and
Osteolysis often present
activation of osteoclasts
in multiple myeloma
bone marrow biopsy
· 80% to 90% of patients will have
ostt
teoporo itic
d
an
t
os
l
eo ytitic bone
lesions at some time during the
course of their disease
disease
75
http://www.wheelessonline.com/ortho/multiple_myeloma; http://www.uams.edu/radiology/info/clinical/pet/images.asp
Bone Disease in Multiple Myeloma (cont
(cont'd)
· Bone disease is the major cause of morbidity
and mortality, leading
leading to
Pathological fractures
Spinal cord compression and neurological changes
changes
Severe pain (~60%)
Hypercalcemia (30%)
· Prognostic implications
Increased number of lesions correlates with poorer
prognosis
Co-morbid sequelae
Sk l
e
l
eta events may progress d
i
esp te
i
cont nued treatment
76
http://www.wheelessonline.com/ortho/multiple_myeloma
Consequences of Bone Disease
Functional mobility
Pain
Limits normal activities of daily living
Impact on employability
Neurological changes due to vertebral
compression fractures
· Paralysis
· Chronic paresthesia
Psychological impact
Depression, sexual dysfunction,
body image
Quality of life
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IMF NLB Long-Term Care Survivorship Plan, manuscript in preparation
Bone Health and Bone Disease:
Summary of Treatments
Management of multiple myeloma-related bone disease
involves treatment of the underlying disease!
Therapy
Comments
Bortezomib
Affects osteoclast functions, reduces resorption. May
increase osteoblast activity and induce bone formation.
Thalidomide
Immunomodulators
Decrease osteoclast formation, may positively affect
Lenalidomide
bone formation and prevent resorption.
Pomalidomide
Dexamethasone
Steroids
Induces apoptosis.
Prednisone
Radiation Therapy
Component of general therapy and palliation. Alleviation
Therapy
ofi
f pain and
l
neuro
i
og
l
ca probl
blems.
Surgery
Prevention of impending fracture. Vertebroplasty and
balloon kyphoplasty for vertebral compression fractures.
Bisphosphonates
Standard of care for myeloma-related hypercalcemia,
bone pain, and skeletal lesions.
78
Roodman, Am S Hem Ed Prog 2008; Yeh & Berenson, Clin Cancer Res 2006; Fitch & Maxwell, Oncol Nurs Forum 2008; Berenson et al, JCO
2002; Pennisi et al, Am J Hematol 2009; Cady et al, J Am Coll Surg 2005; Faiman et al, Clin J Onc Nurs 2008
Bone Health and Bone Disease:
Position Statement
· Improvement in OS makes effective skeletal care critically
it
import t
an in MM
MM
t
pa iti t
en s
· Oncology healthcare providers play a key role.
Monitoring for bone disease and related sequelae
sequelae
Maintaining adequate bone health
· Nurses need to provide interventions that promote
pp
bone
health maintenance to improve mobility and enhance
quality of life
· NLB to enact a plan of care that encompasses the needs
of MM survivors along their care spectrum
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IMF NLB Long-Term Care Survivorship Plan, manuscript in preparation
Strategic Recommendations
Osteoporosis and osteolytic bone lesions have clinical
implications and impact
pp
qualit
q
y of life.
· Assess and treat bone disease and bone-related sequelae
· Monitor regularly for bone pain and bone-related complications
· Assess impact f
o MM therapeutics on bone h lth
ea
· Include risk factors present due to co-morbid conditions to optimize
treatment plan
· Institute interventions and management strategies based on the
patients disease state
Active disease
Remission
80
IMF NLB Long-Term Care Survivorship Plan, manuscript in preparation
Eviden
de ce-B
ce ased Recomm
eco
en
e dation
o s
· Mobility and exercise
· Dietary recommendations and supplements
· Regular assessment of bone disease and bone health
(lab and imaging)
· Radiation treatment
· Surgical interventions and post-
post surgery care
care
· Use of bisphosphonates
· Effective pain manag
pgement
· Healthcare Provider Tool
· Pt
Pa iti t
en Ed
Ed
t
uca ition T l
oo
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IMF NLB Long-Term Care Survivorship Plan, manuscript in preparation
Functional Mobility and Safety
in Multiple Myeloma
· Multiple
ltiple myeloma occ
occurs more commonly
in the elderly population
· Bone disease is a major comp
jponent of
multiple myeloma
· Inherent to this and other risk factors are
issues of mobility and safety.
Up to 1/3 of
of older
older adul
adu ts fall every year
year
In myeloma, falls often lead to fractures
82
Roodman, Leukemia 2008; Roodman, Hem Am Soc Hematol Educ Program 2008; Melton et al, J Bone Miner Res 2004
Risk Factors Affecting Functional
Mobility in
in Multiple
Multiple Myeloma
Myeloma Patients
Patients
Factors Contributing to High Risk of Falls (ROF):
Sensory Issues
· Vision
· Hearing
· Cardiovascular
· Diabetes
· Osteoporosis
Age-Related
· Hormonal status
Pki
' di
Co-Morbidities
· Parkinson's disease
· Dementia
· Urinary incontinence
· Arthritis
Nutrition
· Muscle weakness
· Weight loss
Ph
Psych l
o
i
og cal Issues
d
an Lif
Lif t
es l
y e
83
Gantz et al, J Am Med Assoc 2007
Side Effects' Impact on Functional
Mobility and
and Safety
Common SE
Effects on Functional Mobility
Peripheral neuropathy
· Discomfort or prescribed limitations by the
Sensory and motor symptoms
health practitioner
Ataxia
· Pain and/or discomfort
Muscle wasting
· Lack of desire to participate in activity and
Tone and mass
· Inability to
to mobilize
mobilize safely
Strength and motor function
Myelosuppression
· Lack of ability to withstand extended activity
Thrombocytopenia
· May require oxygen
Neutropenia
Anemia
Gastrointestinal symptoms
Inability to participate in activities due to
Nausea, vomiting, constipation, diarrhea
organ-function restrictions as prescribed by
Dehydration, anorexia, weight loss
healthcare provider
Hypercalcemia, hypokalemia, hyponatremia
Fatigue and somnolence
· Mobility limitations due to these symptoms
· Cognitive changes related to pain medication
Cardiovascular issues
· Difficulty in desire or ability to participate in
Deep vein thrombosis
activities of daily living, including exercise,
diet, etc, and impact on overall quality of life
84
CJON June 2008, 12(3) suppl.
Functional Mobility and Safety:
Position Statement
Statement
· Mobility issues and ROF pose serious challenges to
MM patients
· Oncology healthcare providers need to help patients to
achieve improvements in functional ability, strength, and
balance to reduce ROF and fall-related injuries
· NLB to enact a plan of care that includes assessment,
evaluation, intervention
intervention, and education for
for reducing
symptoms and enhancing functional capacity
· NLB recommendations to advocate health maintenance as
an integral part in preserving mobility
85
IMF NLB Long-Term Care Survivorship Plan, manuscript in preparation
Strategic Recommendations
Functional mobility and ROF have clinical implications,
and impact
impact quality of
of life and
and safety.
· Assess level of activity and factors affecting mobility
· Routinely assess
assess for factors
factors that increase ROF
ROF
· Institute interventions and management strategies:
Safe mobility and physical activity programs tailored to the needs
of each patient
Incorporate nutrition
86
IMF NLB Long-Term Care Survivorship Plan, manuscript in preparation
Evidence-Based
Recommendations
· Overall assessment (medications, lab, and
diagnostic tests)
· Risk factor and falls risk assessment
· Planned physical activity
Type of physical activity guidelines
Regular exercise regimen/program
· Dietary recommendations and nutrition
· Healthcare Provider Tool
· Patient Education Tool
87
IMF NLB Long-Term Care Survivorship Plan, manuscript in preparation