Welcome back! Hope all is well. I've decided to venture out on a bit of a branch- my previous posts have been focused mostly on what geriatrics is, house calls, goals of care, disposition issues...broader topics pertaining to older adults.
Today, I decided to do a high level review of osteoporosis & bone health. Why? Because, recently, several patients and acquaintances have had issues related to these items- specifically falls with significant fractures. Osteoporosis affects many more people than we think and it is quite often overlooked because it is "asymptomatic" (without symptoms) until it's too late- i.e. a fracture. At that point, it can result in severe pain, disability, and even death. So, it's kind of a shark waiting in the shadows to attack.
Osteoporosis is actually the most common metabolic disease of the bones that negatively impacts their strength, density & quality. Approximately 54 million Americans over the age of 50 either have it or are at risk for it. It's also the leading cause of fractures in older adults. And many of these fractures related to osteoporosis are the most common reasons for hospitalizing older adults- more common than heart attacks, strokes, & breast cancer COMBINED.
Unfortunately, the statistics for what happens after a fracture related to osteoporosis can also be difficult- an older adult's risk of mortality (dying) increases by 20% after a hip fracture; 60% of older adults will NOT regain their level of functioning after a hip fracture; and 20% of older adults will require LTC in a SNF after a hip fracture (LTC = long-term care; SNF = skilled nursing facility; see prior posts :)) Finally- osteoporosis and fractures related to osteoporosis can result in debilitating pain, loss of function, changes in posture (and hence balance & gait), loss of height, and challenges to other organ systems like the lungs or gastrointestinal. So...it's no joke.
Our bones are constantly undergoing change- the cells in the bone and body are continuously laying down new bone, resorbing (removing/destroying) old bone, & remodeling the matrix of the bone. Osteoporosis can occur when this cycle is thrown off balance and bone becomes less dense, carries less mass, and is laid down more erratically, something that happens as we age. See the picture below for a comparison of healthy bone vs. bone in someone who has osteoporosis. You can see how osteoporotic bone can be more susceptible to breaking or less able to support the forces needed for us to move around.
Women usually reach their peak bone mass when they are in the mid-20s or mid-30s. After that, there is a steady decline in bone mass which gets accelerated in the 1st 8-10 years after menopause. The decline in bone mass continues after that, but resumes a slower pace again. This is why osteoporosis can be especially common in older women. Men also lose their bone mass after their mid-30s or so, but it tends to be a slower process overall.
So- are you at risk for osteoporosis? If you have any of the following risk factors, consider the answer to be YES.
Older age?
Female sex?
Low Body Weight? (BMI < 20 kg/m2)
Physically Inactive?
Have taken courses of steroids temporarily or are taking them chronically?
Are White or Asian race?
Former or current smoker?
Excessive intake of alcohol (>/= 3 drinks per day; a drink is 12oz of beer; 5 oz of wine; or 1.5 oz of hard liquor)?
Poor diet that may be low in calcium and/or vitamin D?
There are some other conditions to be aware of that can increase your risk of osteoporosis- things like insulin-dependent diabetes, diseases of the thyroid/adrenal/parathyroid glands, celiac sprue, inflammatory bowel disease, gastric bypass or resection (removal), and certain medications.
Bottom line- if you have any of these risk factors, it may be time to speak to your doctor about getting evaluated and screened for osteoporosis. This would involve the following:
A thorough history & physical exam,
Reviewing your medications,
Reviewing your family history (regarding fractures especially)
Certain lab tests (if applicable)
A bone density evaluation (DEXA scan- Dual Energy X-ray Absorption).
DEXAs are non-invasive, meaning there are no needles/sedation/surgery/incision
Basically it's an x-ray; they assess your bone density at specific parts of your body (usually your hips/femurs, lumbar spine, & sometimes your forearm/heel).
Another important part of the evaluation of osteoporosis is to figure out your FRAX score (available for free at https://frax.shef.ac.uk/FRAX/tool.aspx?country=9). This tells us your risk of developing a hip fracture in the next 10 years and of developing any major osteoporosis related fracture in the next 10 years. Your risk will help determine how frequently you need your screening to be repeated as well as help guide treatment. Basically, remember that a 10-year hip fracture risk >/= 3% or a major osteoporosis related fracture of >/= 20% are critical numbers that determine treatment and screening frequencies.
How do we officially DIAGNOSE osteoporosis? Well, basically it's defined by your bone mineral density (BMD) which we get from your DEXA scan and/or clinically if you've had a fracture of the hip, proximal humerus (upper arm/near shoulder), forearm, or spine without any significant trauma.
The BMD will be reported as 2 "scores." The "Z-score" is less informative- it compares your BMD to those of other men/women in your age group. The one that we rely on for diagnosis and treatment guidance is the "T-score." This compares your BMD to those of other men/women who are younger- basically at the age when peak bone density has been reached. The T-score itself represents how many "standard deviations" you are above (+ number) or below (- number) the peak bone density. Osteoporosis is defined as having a T-score of </= -2.5. That means that your BMD is much less than the peak BMD & the more negative your number, the less dense are your bones. For example, severe osteoporosis is usually defined by a T-score of </= -3-3.5.
How frequently you should get screened with a DEXA scan is a conversation you should have with your doctor as there are many factors involved in that decision- what your baseline score is, what your FRAX score is, your risk factors, your baseline level of functioning, and your life expectancy. The US Preventive Services Task Force (USPSTF) & National Osteoporosis Foundation (NOF) each have their recommendations- they differ slightly, and these need to be considered for your individual profile also.
So, let's shift our focus to TREATING osteoporosis. In general, anyone with osteoporosis or a fracture should be on treatment. And in terms of age- anyone with > 1 year of life expectancy should be considered for treatment. The treatment of osteopenia (T-score between -1 & -2.5) is controversial. Some recommend treatment for osteopenia if your FRAX scores indicate a high 10-year risk of fractures.
Anyone with osteoporosis, risk factors for osteoporosis, or osteopenia should try to implement the following lifestyle changes if possible:
Weight-bearing exercise for 30 min/day at least 5 days/week.
Ensuring adequate calcium intake (see below)
Ensuring adequate vitamin D intake (see below)
Stop smoking
Modify alcohol intake if applicable
Review your medications regularly
In terms of calcium & vitamin D...A post-menopausal woman over the age of 50 is advised to take in 1200mg of calcium per day. For men, 1000mg per day is recommended between the ages of 51-70 & 1200mg after 70. NO ONE should be taking more than 2000mg of calcium per day.
Vitamin D3 is important to help the body absorb calcium and regulate its balance. It also is important to bone health and numerous other processes in the body. For men & women between 50-70, 600 International Units (IUs) of Vitamin D3 are recommended daily. After the age of 70, all men & women are recommended to have 800 IUs of Vitamin D3 daily.
Medications that are available to treat osteoporosis include:
Bisphosphonates
Alendronate (Fosamax); Risedronate (Actonel); Ibandronate (Boniva); Zoledronic Acid (Reclast)
Reduce the resorption (breaking down) & remodeling of bones
Improve bone density
Reduce fracture risk
Some are oral, some IV
For the oral ones- there are precautions as to how/when to take them
Generally well-tolerated, but can cause some GI side effects
Rare association with osteonecrosis of the jaw
Kidney function can impact the dose or ability to give these medications
Monoclonal Antibodies
Denosumab (Prolia)
Romosozumab (Evenity)
Usually for patients at high risk of fractures; those who haven't responded to other medications; those who can't tolerate other medications
Act with the immune system to modify cells influencing bone density
Can increase bone density
Can have rapid return to bone loss if discontinued; so, often need to transition to another medication at that time
Parathyroid Hormone Analogue
Teriparatide (Forteo)
Synthetic form of parathyroid hormone that helps your body form new bone & strengthen the existing bone's density
Taken subcutaneously (under the skin injection) daily
For severe osteoporosis
Usually not recommended to take for more than 2 years, at which point you would need to switch to another medication
Others
Not used as frequently
Selective Estrogen Receptor Modulators
Raloxifine (Evista)
Some protection against breast cancer
Maintains (not increases) bone density; reduces vertebral (spine) fracture risk only
An increased risk of blood clots
Estrogen (only for patients who cannot take any non-estrogen product above)
Calcitonin
The bottom lines (literally...hehehe):
Osteoporosis is more common than we think.
It is a silent disease until it erupts- often with fractures resulting in debility, pain, functional loss, & even mortality.
Talk to your doctor about screening for osteoporosis.
It is diagnosed based on a combination of your history, exam, & the DEXA scan results (T-score...remember that number!)
If you have osteoporosis or are at high risk for it, talk to your doctor about the treatment regimen that may be most appropriate for you.
The recommendations for the frequency of repeat screening tests are not the same for everyone. Talk to your doctor to figure out what makes the most sense for you.
The duration of treatment is also not the same for everyone and you should review whether you are eligible to get a "drug holiday" (period of time off the medication after being on it for some time) vs. a limited duration.
Weight bearing exercise is important- it has been shown to increase your BMD!
I hope you've found this helpful and if so, look out for the next blog..."I fell for a geriatrician...the basics of falls & gait issues in older adults, how to protect yourself in love and walking!"
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