World Osteoporosis Day – Time for a Check

With World Osteoporosis having taken place on 20th October, the Irish Osteoporosis Society are asking everyone to check to see if they have risk factors for bone loss.

Why prevention of Fractures is common sense as well as economical Worldwide, up to 37 million fragility fractures occur annually in people over 55, the equivalent of 70 fractures per minute. A fragility fracture is a broken bone from a trip and fall that if the persons bones were healthy, the fracture would not have occurred.

1 in 2 women over age 50 will experience osteoporosis fractures, and 1 in 4 men aged over 50, even though research shows that most fractures are preventable. A recent survey in Ireland showed that over one third of Irish adults over 40, had experienced a fragility fracture. The level of fractures in the survey would generally be expected/assumed by most people to be amongst the older age groups.

There are some in Ireland who believe that DXA scans should only be done on those 65 and older, as they are the highest risk group. Considering the rate of fragility fractures in this survey was highest amongst 40 to 54-year-olds shows that prevention of fractures not only is common sense, but financially for our health service and for the overall wellbeing of people living in Ireland. This is to help prevent people at high risk ending up disfigured, losing their independence and their care costing far more than the €120 to do a DXA scan on them.

The Irish Osteoporosis Society who are the National experts in Osteoporosis (IOS) find that a person who is high risk to fracture and especially those who have witnessed a family member who suffered from Osteoporosis, are usually the most proactive about their bone health. There was a person in Ireland who sadly committed suicide and in the note that was left, the person said that they could no longer live with the pain they were in. We are not a third world country and the fact that treatments are available this type of situation should never occur.

There is no other disease in the world that the IOS are aware off, where patients are discouraged from being proactive in preventing a disease. Recently a 33 year old male with T scores of -3.4, -3.6, -3.4 and -2.6 in his spine, with young children but due to back pain was unable to work, was refused a follow up DXA scan. He ended up paying privately for one and the DXA scan showed his results had declined, was sadly he told to “come back when you have fractured”.

Research shows that most fractures happen between a T score of -1. 5 to -2.49 which is the moderate to marked Osteopenia range. If a patient with bone loss is refused a DXA scan and/or a treatment and then fractures, who is responsible for them fracturing and possibly losing their independence?

A person knowing they are high risk for vertebral fractures which will leave them with skeletal damage that are not reversible, is at risk for high cortisol levels and anti-depressants, which many cause bone loss, which results in further bone loss, see figure 1 below.

The Irish Osteoporosis Society who are the leading experts in Osteoporosis recommend anyone who has one or more risk factors for bone loss, be referred for a DXA scan, as many will more than likely already have bone loss. Prevention is much cheaper for our health service and certainly less painful for patients then to treat them for fractures, which we all know in the first place can be life threatening. 20% of Irish people who fracture their hip will die within 6 to 12 months, 50% will lose the their independence, why would anyone not take preventing fractures more seriously.

Using the World Health Organization definition of osteoporosis, the disease affects approximately 6.3% of men over the age of 50 and 21.2% of women over the same age range globally. Based on the world population of men and women, this suggests that approximately 500 million men and women worldwide may be affected.

Across Europe in 2019 (European Union, plus Switzerland & the UK) 32 million individuals age 50+ are estimated to have osteoporosis, which is equivalent to 5.6% of the total European population age +50, or approximately 25.5 million women (22.1% of women aged +50) and 6.5 million men (6.6% of men aged +50).

These statistics are why prevention of bone loss and earlier diagnosis is crucial not only so that people in Ireland age gracefully but also in order that billions is not used to treat fractures, when a fraction of that cost could be used to prevent them in the first place.

By 2050, the worldwide incidence of hip fracture is projected to increase by 310% in men and 240% in women, compared to rates in 1990. The greatest number of hip fractures occur between 75 and 79 years of age for both sexes. For all other fractures, the highest number occur between 50-59 years which is why the IOS believe that not preventing fractures is not acceptable in this day and age.

Hip fractures cause chronic pain, reduced mobility, disability, loss of independence and in 20% of cases in Ireland premature death. The secondary effects of a hip fracture are a blood clot, pneumonia or infection. Less than half those who survive the hip fracture regain their previous level of function.

In Caucasian women worldwide, the lifetime risk of hip fracture is 1 in 6, compared with a 1 in 9 risk of a breast cancer diagnosis.

Vertebral fractures are the most common osteoporotic fractures that occur. A woman 65 years of age with one vertebral fracture has a one in four chance of another fracture over 5 years, which can be reduced to one in eight by them being investigated and placed on an Osteoporosis treatment. Prescribed Osteoporosis treatments have been shown to significantly reduce patients risk of fractures, which is why it is such a shame that the diagnosis rate is so poor not only in Ireland but worldwide.

Vertebral fractures can lead to back pain, loss of height, irreversible deformity of the skeleton, immobility, increased number of bed days, reduced pulmonary function and premature death. Their impact on quality of life can be profound as a result of loss of self-esteem, distorted body image and depression. Vertebral fractures significantly impact the person’s ability to be able to wash and dress themselves and even to be able to look up see where they are actually walking in order to prevent themselves from falling. Dowagers hump place them at higher risk of falling as their centre of gravity has altered and skeletal changes from vertebral fractures can cause the person to avoid socializing as they are embarrassed regarding how they now look.

Vertebral fractures are associated with an increased risk of further vertebral fractures but also nonvertebral fractures. Women who develop a vertebral fracture are at substantial risk for additional fracture within the following 1-2 years.

It is estimated that only one third of vertebral fractures are actually diagnosed and under diagnosis of vertebral fracture is not just in Ireland it is a worldwide issue. The proportion of vertebral fractures that go undiagnosed, during the assessment of a thoracolumbar lateral radiograph, is as high as 46% in Latin America, 45% in North America, and 29% in Europe/South Africa/Australia.

The incidence of vertebral fractures increases with age in males and females. Most studies indicate that the prevalence of vertebral fracture in men is similar to, or even greater than, that seen in women up to age 50 to 60. Research shows that over 55% of patients with hip fractures have evidence of a prior vertebral fracture, which is why screening of people for signs and symptoms of undiagnosed bone loss as well as for risk factors for bone loss is essential.

When a decline in bone loss occurs on a DXA scan it is crucial that the causes of why the decline has occurred is investigated and addressed, not assumed. Changing their treatment without investigating the cause/s is not the solution, as 10% loss of bone mass in the vertebrae can double the risk of vertebral fractures.

Why are women affected by bone loss more than men?

There are many reasons why women are more at risk, one of the main reasons is that women tend to have more hormonal issues, as they have ovaries and go through the menopause, when significant bone loss occurs.

So what about Men?

Bone loss is one disease that men are at a significant disadvantage as it is considered by most people to be “An old woman’s disease”. This is a myth as it is estimated that men’s lifetime risk of a fragility fracture is greater than developing prostate cancer. The overall number of fragility fractures is higher in women, but men generally have higher rates of fracture related mortality.

Research shows that more men die then women post hip fractures and that Men account for 25% of hip fractures occurring in the over 50 population. Similar to women, the mortality rate in men after hip fracture increases with age and is highest in the first year after a fracture. Over the first 6 months, the mortality rate in men approximately doubled that in similarly aged women.

A forearm fracture is an early indicator of male skeletal fragility. In aging men, wrist fractures carry a much higher risk for a hip fracture than spinal fractures in comparison to women. These statistics are why not only women in Ireland need to be proactive regarding their bone health, but men need to be more proactive and should be discouraged from doing so.

Personal and Economic affects of Osteoporosis

In Europe, the disability due to osteoporosis is greater than that caused by all cancers, except lung cancer. It is comparable or greater than that lost to a variety of chronic noncommunicable diseases, such as rheumatoid arthritis, asthma and high blood pressure related heart diseases.

Fragility fractures are the fourth leading cause of chronic disease morbidity in Europe. The only ones preceding are ischemic heart disease, dementia and lung cancer.

Finding causes of bone loss

The Irish Osteoporosis Society recommends that everyone fill in a risk factor boen loss questionnaire, which is available from the charity by emailing info@irishsoteporosis.ie causes of bone loss are found by

How is bone loss (Osteoporosis /Osteopenia) screened for or diagnosed?

• A DXA scan is the only test the Irish Osteoporosis Society recommend to screen or diagnosis Osteoporosis
• A DXA scan takes approximately 15 minutes
• A DXA scan is painless
• A DXA scan is not claustrophobic
• A DXA scan costs approximately ¤120

Repeat DXA scanning is important to monitor your bone health

• If you are losing bone, you will not feel bone loss
• A DXA scan does NOT contain excessive radiation
• A DXA scan contains 10% radiation of a regular Chest X-Ray
• A person flying from Dublin to New York is exposed to more radiation than a DXA scan

Did you know there are approximately 200 causes of bone loss?

The Irish Osteoporosis Society, the National experts in Osteoporosis, believe that every woman and man need to make their bone health a major priority. Research shows that fractures are preventable in most people, which is why the IOS believe people should not neglect their bone health, as you need healthy bones to sit up and walk.

Can senior citizens actually improve their bone health? YES

The woman below had become wheelchair bound due to vertebral fractures when her son phoned the Irish Osteoporosis Society. Sadly her son had been told that nothing could be done to help his mother.

To the Irish Osteoporosis Society Charity

I wanted to thank your organisation for the help and guidance I received from you regarding my mum’s Osteoporosis.

The improvement has been substantial and together with the practical steps we took to adapt her house, her quality of life has improved substantially to the point that she is mobile and active again. We recently took her to Bath, UK to celebrate her 90th birthday and she will go on a Mediterranean cruise with my sister next month!

My Mum and I are extremely grateful for your guidance that has truly given her a new lease of life.

Well done and keep up the great work.

Best Regards, Vincent C

What are the signs and symptoms of Bone Loss?

There are NO signs or symptoms (warning signs) prior to a person fracturing.

A person can look perfectly fine on the outside and have severe bone loss inside their bones

NOTE: A person can exercise daily and have a healthy diet, but still develop or have bone loss. Only 19% of people with bone loss are diagnosed, are you or a loved one or any of your customers in the 81% undiagnosed?

Are there Signs and Symptoms of Undiagnosed Osteoporosis?

Yes, if you or a loved one have one or more of the following signs/symptoms, you may have undiagnosed bone loss

• A broken bone/s (fracture) from a trip and fall or less, even if on ice or cement
• Upper, middle or low back pain, intermittent or constant back pain
• Postural changes – Your shoulders starting to become rounded
• Postural change – Your head starting to protrude forward from your body
• Postural change – A hump developing on your back.
• Your body shape changing – Example a pot belly developing
• You are losing height

The image above (figure 2) shows the irreversible changes that occur when a person develops bone loss and is not diagnosed or treated.

What type of exercise is recommended for bone health?

A person with bone loss should be individually assessed by a chartered physiotherapist with a special interest in bone health, to see what exercises are safe and appropriate for them to do. Please contact the Irish Osteoporosis Society as there appears to be many issues in this area.

What weight bearing exercises are safe for you should be based on the following:

If you have already broken bones or are high risk to break bones, your age, the results from your DXA scan report, your medical history and your fitness level. It is much safer to slowly build up your bone strength, then take the risk of breaking bones.

THOSE WHO HAVE BONE LOSS NEED TO BE VERY CAREFUL WHAT EXERCISES THEY DO AS THEIR MUSCLES MAY BE STRONG, BUT WHEN A STRONG MUSCLE PULLS ON A WEAK BONE, IT CAN FRACTURE.

As mentioned already, research shows that most broken bones occur in the Osteopenia range. This is why the Irish Osteoporosis Society recommend that senior citizens who have never lifted weights, start out actively without them and slowly build up to lifting

 

weights. This is to ensure that they do not end up really sore or with fractures. Those that prior to their diagnosis had lifted weights should start out with low weights and slowly build up, as it is not worth the risk of the person fracturing.

At the foot of the page are some of the many exercises the Irish Osteoporosis Society do not recommend for those with bone loss:

Touching your toes while in the sitting position or standing position, excessive weights, kettle bells, yoga, jumping off boxes, stopping your feet when walking, trampolines or swiss balls.

Did you know that all senior citizens need to ensure that they make their homes safe to reduce their risk of falling in their home?

It is very important that throw rugs are removed from floors, that people wear a good pair of walking shoes in their home versus slippers as many give no support. A handrail should be placed on steps into homes and handrails on both side of your stairs can make it much easier and safer for you. Clothes should be between hip and eye level in cupboards and any clothes that have not been worn in 5 years should be donated. The reason being that if you or a loved one has trouble finding clothes or when trying to pull an item out, you have difficulty, you have too many items. There are so many people who are not in this position and would be forever grateful to receive clothing. There have been multiple incidences where senior citizens with bone loss have actually fractured vertebrae while attempting to manoeuvre clothes out of a wardrobe.

More than one out of four older people fall each year, but less than half actually tell their doctor. The Irish Osteoporosis Society believe from feedback this is due to embarrassment and also many are concerned they may be sent to a nursing home. Research shows that falling once doubles the person’s risk of falling again and that more than 95% of hip fractures are caused by falling, usually by falling sideways.

What makes walking with a cane or rollator much more difficult?

One of the major issues with those who use canes or rollators is that they are adjusted to high. If either are too high, they can cause, neck, shoulder and back pain and make it more difficult for a person to walk.

How to check if your cane or rollator is too high – you will need someone to help you

A person needs to stand up as straight as they can, with their arms down by their sides, preferable with a chair behind them in case they need to sit down. It is important that the person looks straight ahead because if they look down to see what the person is doing their arm will lengthen. The handle of the cane or rollator should be level with the small bone on your wrist.

Did you know that there are major advances in the area of incontinence?

75% of people can completely recover and the other 25% can significantly improve the issue. This is so important because most people when they begin to have leakage of urine (or bowel), they start to reduce the amount of fluids they drink because they do not want to have an accident. Most people area not aware of the consequences of decreasing fluid intake.

Reducing the amount of fluids you drink can place you at risk of falls for several reasons.

• Slipping and falling from rushing to the bathroom or having an accident while trying to get there, can cause fractures.
• If you ever feel thirsty studies show that you only need to be 1% dehydrated to experience a 5% decrease in cognitive function, which can place a person at risk of falling. A 2% decrease in brain hydration can result in short term memory loss.
• You can develop kidney issues which can affect your overall health but also can affect the ability for a person to take some Osteoporosis treatments.

How much fluids should you drink?

8 regular glasses of fluids. Your body is made up of water, so it is essential for your overall health. By including fortified milk with Vitamin D, not only are you helping your bone health but also your overall health as Vitamin D is essential for your immune system. You should reduce caffeine intake to 2 a day.

Treatments for Bone Loss

The patient’s treatment plan should be based on

• The patient’s risk of fracture or re-fracture
• The results of their DXA scan of the spine and hips.
• The cause/s of why they developed low bone density
• Their age
• Their lifestyle
• Their medical history

Treatments available are the following

Bisphosphonates – Weekly or monthly tablets. A person should only take for maximum 5 years, not 5 years on different ones.

HRT – HRT is appropriate for menopausal symptoms but should not be taken just to protect bone, except in certain cases in pre-menopausal women.

Denosumab, brand name Prolia – Twice yearly injection. Should not be stopped without closing off the action of it with a bisphosphonate to prevent significant bone loss occurring.

Zoledronic Acid, brand name Aclasta – once a year IV bisphosphonate

Teriparatide – Daily injection for severe Osteoporosis.

Summary as to why everyone should be checking to see if they have risk factors for bone loss!

It is very important that everyone take their bone health seriously if they want to stay independent as they age, as a prior fracture is associated with an 86% increased risk of a further fracture occurring. The risk of a subsequent fracture is particularly increased in the first two years after an initial fracture. Research evidence suggests that many women who sustain a fragility fracture are not appropriately diagnosed and treated for osteoporosis. The great majority of individuals at high risk (possibly 80%), who have already had at least one osteoporosis fracture, are neither identified nor treated.

An IOF survey, conducted in 11 countries, showed denial of personal risk by postmenopausal women, lack of dialogue about osteoporosis with their doctor, and restricted access to diagnosis and treatment before the first fracture resulting in under diagnosis and under treatment of the disease.

A second hip fracture occurs in approximately one in four patients after any previous osteoporotic fracture, and in one in three patients who have sustained a hip fracture, on average within one and a half years.

For additional information, you can check our website at www.irishosteoporosis.ie Or Email info@irishosteoporosis.ie

Written by Michele O’Brien, CEO, Irish Osteoporosis Society

Read HPN November

Read our Clinical Features