Untold Story of Osteoporosis: When minor fall breaks a major bone

Background

Osteoporosis (weak bones) is a disease wherein bones become weak and break easily resulting in fracture. People with osteoporosis are at high risk of fractures with minor events such as fall while standing or walking. The most commonly affected bones are the hips, wrists and spine. Osteoporosis can occur in people of any age, but it’s more common in older adults, especially women. According to global statistics from the International Osteoporosis Foundation, about one out of 10 women aged 60, two out of five women aged 80 have the disease. Osteoporosis can result in dependence on others, reduction or loss of mobility and death.

Normal bone cycle

During lifetime, the old bone is destroyed (bone resorption) and new bone is formed (bone formation) in a cyclical fashion. This process results in a net bone gain in youth in both men and women. As the age advances, bone loss exceeds bone formation resulting in net bone loss in postmenopausal women(>50 years) and older men(>70 years). Women who develop menopause at earlier age develop bone loss at younger age.

How common is osteoporosis?

Global scenario: According to global statistics from the International Osteoporosis Foundation, about 10% of women aged 60 and 40% of women aged 80 have the disease. Osteoporosis causes bones to become weak and fragile, so that they break easily – even as a result of a minor fall, a bump, a sneeze, or a sudden movement. Fractures caused by osteoporosis can be life-threatening and a major cause of pain and long-term disability.

Indian Scenario: It has been reported that 61 million people in India have osteoporosis and, out of these, 80 percent are women. The peak incidence of osteoporosis in India occurs 10–20 years earlier than in Western countries, which impinges harshly on the health and economic resources.

Symptoms

The early stages of osteoporosis don’t cause any symptoms or warning signs. In most cases, people with osteoporosis don’t know they have the condition until they have a fracture then pain may appear at the site of salient fracture. If symptoms do appear, some of the earlier ones may include: receding gums and dental issues, weakened grip strength, weak and brittle nails and some decrease in height.

Risk factors

Osteoporosis is common as age advances; it is more common in women than men and process of osteoporosis accelerate rapidly after menopause. Poor nutrition (diet less in calcium and low vitamin D status), low physical activity, smoking and alcohol consumption also predisposes to osteoporosis, also thin and small frame people are more predisposed to osteoporosis and fractures. Some of these risk factors such as poor nutrition and inactivity can be controlled with good nutrition and exercise, However, factors like age, gender and menopausal status will still continue to predispose a person to osteoporosis. Some medical conditions like thyroid, parathyroid disease, previous obesity surgery, gastrointestinal diseases like celiac and inflammatory bowel disease and blood dyscrasias like myeloma increase the risk of osteoporosis. Some medications cause side effects that may damage bone and lead to osteoporosis. These include steroids, medications for breast cancer and seizures.

Role of diet

The recommended amount of daily calcium intake is 1,000 mg to 1,200 mg daily. Getting an adequate supply of calcium and vitamin D is the mainstay of both prevention and treatment of osteoporosis. It is always better to get the calcium from food sources. The rich sources of calcium are milk and milk products like cheese and yogurt; beans; nuts like almonds, seeds like sesame seeds and dried fig, vegetables like collard, broccoli, kale and spinach, calcium-fortified juices and breads can be a source of calcium. Sometimes calcium supplements are required to meet the daily demand. If supplements are required, taking more than required amount may be associated with an increased risk of kidney stones, calcium buildup in the blood vessels and constipation. Vitamin D is also important because it enables the body to absorb calcium. The recommended daily allowances of vitamin D are around one to two thousand units per day. Vitamin D comes from sunlight exposure a few times a week or by drinking fortified milk. Many people who have vitamin D deficiency might need to take supplements.

What tests are required to diagnose osteoporosis?

Diagnosis of osteoporosis is based on measurement of bone density(thickness) on imaging. Routine X-rays will only detect osteoporosis if there is loss of more than 30% of bone density. It may also reveal an asymptomatic fracture. Many portable machines mostly used in camps can be used for screening of osteoporosis but the results based on the portable machines cannot be used for treatment of osteoporosis. Dual energy x-ray absorptiometry (DXA) scan is the most sensitive way of measurement of bone density. The machine tests for bone density at vertebral pelvic and fore arm bones. Modern DXA machines are efficient and have an extremely low radiation exposure and the test is complete in minutes. However, the DXA scan needs to be done by a trained person and the results interpreted by a trained clinician. Routine machine-made report may sometimes be misleading. All postmenopausal women should have a bone density test. The DEXA scan is required earlier for women who have risk factors for osteoporosis (such as early menopause). Men over age 70, or younger men with risk factors, should also consider getting a bone density test.

Treatment

The main purpose of treating osteoporosis is to prevent fractures. Two things are important in preventing fractures. These include low bone density and tendency to fall. So, in addition to improving bone density, prevention of fall is an important component of fracture prevention more so in elderly population, in other words just treating osteoporosis with out giving attention to fall prevention will not prevent fractures. In the present time treatment of osteoporosis is well established and there are clearcut guidelines in this regard.

Risk of fall and fracture and its prevention

Fall prevention is the most neglected part of fracture prevention. As per the reports, falls occur in 40 % of people aged 65 or more and 50% of people beyond the age of 75. Some of the risk factors for fall include advanced age, female gender, person living alone, medical factors like Parkinson’s disease, stroke, joint problems, problems with vision and muscle weakness. In addition, excessive use of sleeping pills, excessive hypertension medications, and pain killers also predispose to falls. In addition, there are many environmental factors both inside and outdoor home conditions which need an attention. Wet and slippery floor, poor lightning, rushing or hurrying, tripping on own clothes, loose or absent railings, loose cords and wires, uneven transitions such as level change between rooms, lack of grab bars in washroom. Outdoor risk factors include poor lighting, uneven sidewalks, irregular steps, unpredictable level change, uneven and broken sidewalks and wet surfaces.

Prevention of osteoporosis, falls and fractures

Lifestyle changes

Maintaining a healthy lifestyle can reduce the degree of bone loss. Begin a regular exercise program. Do not drink too much alcohol and do not have excessive amounts of caffeine. Do not use tobacco at all. Exercises that make your muscles work against gravity (such as walking, jogging, aerobics, and weightlifting) are best for strengthening bones.

Simple exercises to prevent falls

Individual simple home exercises should be taken three times a week. These include standing on with one foot Infront of other; walking on toes and walking on heels; walking backwards, sideways and turning around; stepping over an object, bending and picking up an object, stair climbing in the home, rising from a sitting position to a standing one; knee squats and moderate intensity strengthening exercises

Prevent falls inside your home

1. Use nightlamps in bedroom, bathroom and hallways leading to bathroom.
2. Keep a flashlight next to bed.
3. Prefer non-skid, nonglare flooring.
4. Avoid loose rugs.
5. Avoid uneven transitions between rooms.
6. Use sturdy handrails, if possible, on both sides of steps.

Prevention of fall in washroom

1. Use non- slippery chappals inside washroom.
2. Prefer an elevated toilet seat.
3. Use grab bars.
4. Keep a non-skid mat on the floor of shower.
5. Use shower chairs.
6. Walkways should be clear and straight as possible.
7. Increase width of walkways by removing obstacles and furniture.

Prevent falls outside your home

1. Make sure lighting is adequate in all areas outside your home.
2. Use a backpack or other type of bag that leaves your hands free.
3. Always keep your hands free and out while wearing a pheran
4. Keep areas outside in good repair and free of clutter.
5. Wear sensible shoes with non-slip bottoms.
6. Take your time. You might be less careful if you are in a hurry.
7. Don’t venture outside in snow and slippery conditions.

Summary

1. Osteoporosis is common especially in women after menopause.
2. Screen every woman for osteoporosis after the age of 50 years and men after 70 years.
3. Patients with osteoporosis are at high risk for fractures after routine activities.
4. Adequate intake of calcium is essential to prevent and treat osteoporosis.
5. Every effort should be made at home to prevent a fall and hence prevent a fracture.

Prof. ( Dr.) Bashir Ahmad Laway is a reputed Endocrinologist from Kashmir.