October 20, 2011

October 20 is observed as ‘World Osteoporosis Day’. Osteoporosis is a common problem of the elderly, with the rise in aging population, osteoporosis is also on the rise. Although early detection and treatment can substantially decrease the risk of fractures, none of the available treatments for osteoporosis are complete cures. In other words, it is difficult to completely rebuild bone that has been weakened by osteoporosis. Therefore, prevention of osteoporosis is more important than treatment.

What is Osteoporosis?

Osteoporosis, which means "porous bones", is a disorder of the skeleton commonly seen in the elderly that leads to abnormally weak and porous bones that are compressible, like a sponge. It causes bones to become weak and brittle — so brittle that a minor fall or even mild stresses like bending over or coughing can cause a fracture. These fractures are also known as fragility fractures.

Normal bone is made up of bone mass which is composed of protein, collagen, and calcium, all of which give bone its strength. In osteoporosis the bone mass is decreased as a result the normal strength of the bone is reduced.

I have pain in the lower back, in the knee joints. I can not bend for long. Is this due to osteoporosis?

The symptoms expressed by you are unlikely due to osteoporosis; osteoporosis presents without any symptoms for decades. Osteoporosis doesn't cause any symptoms until the bone fractures. Moreover, some osteoporotic fractures may escape detection for years when they do not cause symptoms. Therefore, patients may not be aware of their osteoporosis until they suffer a painful fracture. The bones silently lose the bone mass and become weak. That’s why osteoporosis is known as ‘silent thief’.

You mean, most of the fractures that you get are due to osteoporosis?

Osteoporosis is seen commonly in elderly people and osteoporotic fractures are seen in them; they sustain the fractures even with minor trauma like a simple twisting strain or minor fall. The fractures that are seen in young individuals with normal bones are commonly due to major trauma like road traffic accidents, fall from heights. In some elderly people the osteoporotic hip may break first and then the person may fall, rather than them falling and sustaining a fracture. The spine, hips, ribs, and wrists are common areas of bone fractures from osteoporosis although osteoporosis-related fractures can occur in almost any skeletal bone.

Why there is so much awareness about osteoporosis these days which was not there earlier?

Osteoporosis is now considered as a public health issue. All over the world, that too in developed countries, the number of elderly population is on the rise and as a result the number of people with osteoporosis is increasing.

In the U.S., 44 million people have low bone density. This amounts to 55% of the U.S. population aged 50 years and older. In the U.S., direct health-care costs from osteoporosis fractures amount to a billion dollars, without even taking into account the indirect costs, such as lost days at work and productivity.

Almost one in three urban Indian women past the age of 45 has osteoporosis. India, after China sees the most cases of osteoporosis in Asia. By 2050, half of the world's fractures will occur in India according to a survey by the Arthritis Foundation of India.

Approximately 20% of those who experience a hip fracture will die in the year following the fracture. One-third of hip-fracture patients are discharged to a nursing home within the year after fracture. Only one-third of hip-fracture patients regain their pre-fracture level of function. With the aging of population, the number of people with osteoporosis-related fractures will increase exponentially. The pain, suffering, and overall impact on health and economic costs will be enormous.

Why is osteoporosis common in women?

Osteoporosis or the problem of decreased bone mass is common in women. Bone mass (bone density) is determined by the amount of bone present in the skeletal structure. Generally men have a higher bone mass than women.

Normally, bone mass accumulates during childhood and reaches a peak by around age 25. Bone mass then is maintained for about 10 years. After age 35, both men and women normally lose 0.3%-0.5% of their bone mass per year as part of the aging process.

Estrogen is important in maintaining bone density in women. When estrogen levels drop after menopause, loss of bone mass accelerates. During the first five to ten years after menopause, women can suffer up to 2%-4% loss of bone density per year. This can result in the loss of up to 25%-30% of their bone density during that time period. The accelerated bone loss after menopause is a major cause of osteoporosis in women, known as postmenopausal osteoporosis.

Is osteoporosis a common problem in all elderly women?

No. Those women who have accumulated good stock of bone mass when they are young may not get affected by normal aging process and hormone depletion. Those who exercise regularly, eat well balanced diets right from childhood and adolescence are unlikely to suffer from osteoporosis.

Other than poor nutrition and lack of exercises during growth period, there are certain risk factors for osteoporosis such as cigarette smoking, excessive alcohol consumption, sedentary life style-without exercises, early removal of both ovaries for some other conditions, some other hormone problems like hyperthyroidism, hyperparathyroidism etc.

Is osteoporosis also seen in men?

Osteoporosis is often considered to be a woman's disease. Although it is more common in women, osteoporosis is also a serious health issue for elderly men. Men lose bone mass with aging, but because men begin with a higher bone density, they reach osteoporotic levels at an older age than women. However, osteoporosis is less common in men than in women for a number of reasons. Men have greater peak bone mass and do not experience the accelerated bone loss women do at menopause. As well, they generally do not live as long and are less likely to fall than elderly women.

With age, men experience multiple vertebral fractures. Elderly men with osteoporosis account for almost 30 per cent of hip fractures. Men are more likely to die after a hip fracture than women.

How is osteoporosis diagnosed? Can the doctor diagnose it with an X-ray?

A routine X-ray can reveal osteoporosis of the bone as the bones appear much thinner and lighter than normal bones. Unfortunately, by the time X-rays can detect osteoporosis, at least 30% of the bone mass has already been lost. In addition, X-ray often is affected by variations in the degree of exposure of the X-ray film and therefore X-rays are not accurate indicators of bone density. At present a test known as dual-energy X-ray absorptiometry scan (DXA, formerly known as DEXA) is recommended for diagnosing osteoporosis. DXA measures bone density in the hip and the spine. The test takes only 5 to 15 minutes to perform, exposes patients to very little radiation (less than one-tenth to one-hundredth of the amount used on a standard chest X-ray), and is quite precise. However the test is not cheap and may cost 200% of the routine X-rays. The facility for this test is now available at major centers in India.

There are frequent free camps conducted in many of the hospitals to detect osteoporosis...

In these camps the ultra-sound technique is used and the camps are sponsored by the pharmaceutical companies. This test is not accepted as the standard method for testing osteoporosis.  This appears to be a more cost-effective method of screening bone mass. Ultrasound measurements are usually performed at the calcaneous and it is not possible to measure sites of osteoporotic fracture such as the hip or spine.

Why is osteoporosis prevention better than cure?

The goal of treatment of osteoporosis is the prevention of bone fractures by increasing bone mass and strength. Although early detection and timely treatment of osteoporosis can substantially decrease the risk of fractures, none of the available treatments for osteoporosis are complete cures. In other words, it is difficult to completely rebuild bone that has been weakened by osteoporosis. Therefore, prevention of osteoporosis is more important than treatment. However once osteoporosis has set in, there are treatments available which may prevent further worsening of the condition rather than reversing it.

Can you tell how osteoporosis is treated?

I want to stress again that there are no treatments that can cure the problem completely. There are three important aspects in the management of osteoporosis- lifestyle changes, medicines that prevent further bone loss and the medicines that increase the bone formation. Of these the third aspect, that is medicines to increase the bone formation are very expensive and are not commonly in use. Of the remaining two the medicines that stop the bone loss are in use, but their real benefits are not well established. However, the life style changes are easy, but are to be practiced much before the disease sets in. Life style changes include quitting smoking, curtailing excessive alcohol intake, exercising regularly, and consuming a balanced diet with adequate calcium and vitamin D.

What about calcium supplements? Do they help in prevention or in the treatment of osteoporosis?

It is a myth that consuming calcium tablets at or after middle age prevents osteoporosis. The calcium is only one part of the bone mass and there are other substances like proteins and collagen. Moreover osteoporosis is not a calcium deficiency disorder. Mere swallowing calcium does not help to build up bone mass.

The calcium absorption from the intestine and ultimate assimilation in the bone is controlled by several factors like age, health of the intestine, the other food items in the diet, certain hormones etc.

There is no doubt in the fact that, building strong and healthy bones requires an adequate dietary intake of calcium beginning in childhood and adolescence for both sexes. Most importantly, however, a high dietary calcium intake or taking calcium supplements alone is not sufficient in treating osteoporosis and should not be viewed as an alternative to or substituted for more potent prescription medications for osteoporosis. In the first several years after menopause, rapid bone loss may occur even if calcium supplements are taken.

There is no use in taking calcium tablets for osteoporosis?

Adequate amount of calcium intake is required for general health. The surveys have shown that the average woman is consuming less than the recommended amounts of calcium in their diet. Additional calcium can be obtained by drinking more milk and eating more yogurts or by taking calcium supplement tablets as well from calcium-fortified foods, such as orange juice. This has to be started when people are young. There is no point in swallowing calcium tablets alone once the osteoporosis has set in. There are medicines that may prevent further bone mass loss. These can be used as per the advice of the physician.

I want to stress that an adequate intake of calcium and vitamin D are important foundations for maintaining bone mass and strength. However, calcium and vitamin D alone are not sufficient to treat osteoporosis and should be given in conjunction with other treatments.

Then what are the medications that prevent bone loss?

At present the most effective medications for osteoporosis that are approved are antiresorptive agents, which decrease the removal of calcium from bones. The bone is a living dynamic structure; it is constantly being built and removed (resorbed). Osteoporosis results when the rate of bone resorption exceeds the rate of bone rebuilding. Antiresorptive medications inhibit removal of bone (resorption), thus maintaining the balance in favour of bone rebuilding and increasing bone density. The medicines commonly used are grouped as bisphosphonates. These are to be taken carefully under the guidance of the physician as they have potential side effects.

If calcium doesn’t help, and if the medicines that are in use are of doubtful value, how can osteoporosis be managed?

Osteoporosis is one of those medical conditions that are better prevented than treated. Getting older, onset of menopause thereby depletion of estrogen can not be avoided so the osteoporosis is. It is therefore better to build up strong bone mass when women are young. They have to consume good food rich proteins, vitamins, calcium and other minerals and do regular exercises.

Regular exercises like walking can help a lot to increase the bone mass. If you develop good bone mass when young, osteoporosis is not seen when you grow old.

If we have elderly at home with osteoporosis, what precautions do we have to take?

Most of the elderly have weak bones and they are likely to suffer fractures if they fall. The fall prevention is one of the important measures in care of the elderly.

• If the elderly has problems like dizziness, joint pain, numbness in the limbs, it is better to consult the doctor to have a proper evaluation of the problem. If the medicines are causing the problems like drowsiness, giddiness, the doctor can prescribe alternate medications.
  
• Physical activity can go a long way toward fall prevention. The activities such as walking can greatly improve the physical endurance. If there are problems like loss of balance or apprehension of fall the help from a physical therapist may be sought. The physical therapist can create a custom exercise program aimed at improving the balance, flexibility, muscle strength and gait.
  
• High heels, floppy slippers and shoes with slick soles can make one to slip, stumble and fall.  The properly fitting, sturdy shoes with non-skid soles are better.
  
• The living room, kitchen, bedroom, bathroom, hallways and stairways may be filled with hazards. The home should be made safer:

- Remove boxes, newspapers, electrical cords and phone cords from walkways.
- Move furniture from the areas where the elderly commonly move around.
- Secure loose rugs or remove loose rugs from the home. Repair loose carpeting right away.
- Store clothing, dishes, food and other necessities within easy reach.
- Immediately clean spilled liquids, grease or food.
- Use non-skid floor wax.
- Use Nonslip mats in the bathtub or shower.

• Keep the home brightly lit to avoid tripping on objects that are hard to see. Place night lights in the bedroom, bathroom and hallways. Place a lamp within reach of the bed for middle-of-the-night needs.