Managing the Debilitating Effects of Osteoporosis

Osteoporosis is a major health problem in post-menopausal and elderly women. As many as 24 million Americans suffer from the condition, with more than 1.3 million osteoporosis-related fractures occurring annually. Hip and spinal fractures are the most debilitating outcomes of osteoporosis in the elderly. The consequences of these fractures include pain, surgery, loss of independence, and a reduced quality of life. The mortality of persons with a hip fracture is 15% to 20% higher than that of persons of the same age and gender without the fracture.

Osteoporosis can have a serious effect on the lives of those who suffer spinal fractures or other broken bones. Because simply bending over to pick up a newspaper or lifting a light package can cause a fracture, people with osteoporosis often become reluctant to participate in activities that they would otherwise consider routine. The physical changes which accompany osteoporosis can easily lead to rapid functional decline and decreased feelings of self-esteem.

While many people think that osteoporosis is simply a fact of life for elderly women, there are many treatment options available to help those who have the disorder. Hormone therapies such as estrogen replacement and calcitonin have proven to be effective forms of treatment, with calcium supplementation and therapeutic exercise also playing important roles. The following two-part Council Close-Up series is designed to shed light on the assessment and treatment of this misunderstood and debilitating disease.

Understanding Osteoporosis

Osteoporosis is a condition characterized by substantial bone loss. When the extent of bone loss reaches a critical point, fractures may occur as a result of minor stress. Osteoporosis affects the entire skeleton but fractures most often occur in the spine, wrists, and hips. The bones become so weak and brittle that normal workloads overcome their normal capacity. A simple fall can result in a broken hip. Fractures in the spine often cause a condition called "dowager's hump," which results in a loss in height and a stooped posture.

Because skeletons greatly outlast human life, many people get the impression that bones are hard and never change. However, bone is a very active tissue and changes constantly. Throughout life, bone is constantly renewed through a process in which old bone is removed and replaced with new bone. Early in life, more bone tissue is added than taken away. Maximum bone density and strength is reached between the ages of 25 and 35.

After that time, the body removes old bone faster than it can replace it with new bone, leading to a loss of bone density. With menopause, women experience increasing bone loss because the ovaries produce less estrogen, a female hormone which plays an important role in maintaining bone density.

When bone loss is excessive, bones become fragile and more likely to break. Once bone is lost, it cannot be replaced. Post-menopausal women can lose up to two to three percent or more bone mass each year. If this accelerated loss is not stopped, a susceptible woman can lose 50 percent of bone mass by the time she reaches 70 to 80 years of age.

Scientists do not know what exactly causes osteoporosis. The disease is a complex condition in which many factors influence the rate of bone loss. According to the National Osteoporosis Foundation, the following factors can increase an individual's chances of developing the disease:

• Advanced age
• A thin, small-boned frame
• Broken bones or stooped posture in older family members, especially women
• Early estrogen deficiency in women who experience menopause before the age of 45, either naturally or resulting from the surgical removal of ovaries
• A diet low in calcium
• An inactive lifestyle with little or no exercise
• Being of Caucasian or Asian descent
• Cigarette smoking
• Excessive use of alcohol
• Prolonged use of certain medications including glucocorticoids, which is a group of anti-inflammatory medications use to treat conditions such as ashthma, arthritis, and certain cancers; excessive thyroid hormone, and some anti-seizure medications.

Some men develop osteoporosis, but in far fewer numbers than women and at a much later age. Most men have more bone mass to begin with, consume more calcium, and are apt to exercise more. Unlike women, men do not have a sudden decline in the sex hormones that protect bone; their testosterone declines gradually with age and results in less bone loss.

Diagnosing Osteoporosis

Bone loss develops gradually over the span of many years and is largely symptomless, though some women may experience chronic pain along the spine or muscle spasms in the back. Making a diagnosis of osteoporosis is the first step in slowing down bone loss and reducing the likelihood of fractures.

After assessing an individual's lifestyle and medical history, doctors rely on bone density tests to accurately diagnose the disease. These tests use small amounts of radiation to determine the bone density of the spine, hip, wrist, or heel. Routinely used x-rays, while able to detect breaks in bone, are not sensitive enough to detect osteoporosis until 25 to 40 percent of bone mass has been lost. By this time, the disease is well-advanced. Bone density tests can help predict an individual's chances of having a fracture in the future, as well as monitor the effects of treatment if the test is conducted at multiple intervals.

Hormone Medications

Since the hormone estrogen is so important for maintaining bone in women, doctors often prescribe estrogen replacement therapy for women at menopause. Researchers have found that this therapy is also effective with older individuals and those who have established osteoporosis. For these individuals, the therapy helps to stabilize skeletal mass and reduce the risk of fracture.

Controversy has surrounded the use of estrogen replacement therapy, as studies have linked it to an increased risk of uterine and breast cancer. The risk of cancer in the uterus can be offset by the addition of another hormone, progesterone (which combined with estrogen is called hormone-replacement therapy). With the use of estrogen for more than 10 years, research has indicated that there is a slightly increased risk of developing breast cancer. Other possible side effects of this therapy include vaginal bleeding, breast tenderness, fluid retention, swelling, mood changes, and pelvic cramping.

For individuals already suffering from osteoporosis, doctors may prescribe calcitonin. The treatment is also used for women who cannot or will not take estrogen. Calcitonin is a naturally occurring hormone involved in calcium regulation and bone metabolism. Calcitonin safely prevents further bone loss and has been reported to provide relief from the pain associated with osteoporosis. As with all drugs, the decision to use estrogen or calcitonin should be made after discussing the benefits and risks with a knowledgeable physician.

Nutritional Considerations

Calcium plays an important role in maintaining bone. Calcium alone cannot prevent or cure osteoporosis, but it is an important part of an overall prevention or treatment program. Yet, national surveys reveal that American women consume less than half of the daily recommended amount of calcium. The National Osteoporosis Foundation recommends that individuals 65 years old or over should have a daily calcium intake of 1,500 milligrams a day, which roughly is the equivalent of five glasses of milk.

The best sources of calcium are dairy products, including whole or skim milk and cheese. Leafy green vegetables, including broccoli, collards, turnip greens, and spinach are also good sources of calcium. Salmon and raw oysters are high in calcium as well.

If a person in unable to get enough calcium through daily meals, a doctor can recommend an appropriate calcium supplement. While there are several types of calcium supplements available, experts generally recommend those which contain calcium carbonate, because this form delivers the highest amount of calcium per tablet.

Vitamin D plays an important role in calcium absorption and bone health. The relationship between calcium and Vitamin D is similar to that of a locked door and a key. Vitamin D is the key that unlocks and opens the door, allowing calcium to leave the intestine and enter the blood stream. A recent study in the Brown University Long Term Care Quality Letter indicates that elderly individuals who receive inadequate amounts of vitamin D in their diet can potentially have an increased risk of fractures and falls. The authors of the study recommend that these individuals consider using vitamin D supplements to help their bodies best utilize calcium and reduce the incidence of fractures.

Other vitamins and minerals have an important role in bone health. "Although calcium is a primary requirement for healthy bones, a growing body of evidence indicates that calcium is not the star of a one-man show," explains Stanley Wallach, M.D., of the Hospital for Joint Diseases in New York City. "Rather, calcium is a member of an ensemble cast that includes magnesium, vitamin D, vitamin K, and certain trace elements." This statement emphasizes the vital importance of a nutritious and well-balanced diet in the management of osteoporosis.