My grandmother Esther found out she had osteoporosis in 1977 the way too many people still do today – in the hospital. She took a bad spill on tiles being installed in her apartment and broke her hip. X-rays confirmed not only the fracture, but also thinning of the bones so severe that diagnostic tests were done to rule out cancer and other causes.
Not yet 65 at the time of the fall – the age now recommended for most women to begin regular bone density tests – there would have been no practical way of knowing about her condition or its seriousness beforehand. But armed with the new knowledge, she was able to modify her lifestyle to live with the disease and avoid serious falls. She went on to live another 30 vibrant years and died in May from conditions unrelated to her osteoporosis. During that time, she watched her four grandchildren grow up and even saw her great-grandson learn to walk.
Despite the many advances in osteoporosis treatment in the last 30 years, however, studies have shown that awareness and management of this disease, characterized by compromised bone strength, still lags behind for too many patients – especially for those who discover their osteoporosis by sustaining a fracture. Orthopedic surgeons and other medical personnel concentrate on repairing the fracture, as well they should, but too often a discussion and intervention upon the patient’s brittle bones is neglected. And a patient who is in pain and possibly confronting a temporary loss of independence may be unprepared to start the conversation.
Nevertheless, it is vital to start thinking about osteoporosis within the first 48 hours after a fracture and diagnosis.
“You have to make sure the patient doesn’t get lost,” says Dr. Carlos Lozada, associate professor of rheumatology and immunology at the University of Miami Miami Miller School of Medicine and director of its Rheumatology Fellowship Program. And he cited an important reason why those who have already broken bones are especially in need of an osteoporosis consultation: “If you have a hip or vertebral fracture, you’re at much higher risk of more fractures,” he said.
In fact, at a seminar he led in May at Cedars Medical Center in Miami, Fla. on the diagnosis and treatment of osteoporosis, Dr. Lozada discussed research that demonstrated that sustaining a fracture indicates a significantly higher risk for another one within a year. The risk goes up with each subsequent fracture, he said. In other words, those patients who suffer a fragility fracture have the most to gain from treating their osteoporosis.
Dr. Lozada said that in the past, such patients were sometimes overlooked for treatment, perhaps because after a fracture was considered too late to help those with osteoporosis. “These patients are not lost causes,” he said. However, “most fracture patients receive no treatment for the underlying disease.”
Dr. Lozada noted that a tiny minority of patients treated at a hospital for a fragility fracture receive osteoporosis follow-up such as a bone density scan, a test that can diagnose low bone mass in an individual. Some studies have pegged the figure receiving such care at three to five percent, depending on the type of fracture. “It’s obvious there’s a problem, but it’s not being picked up,” Dr. Lozada said.
While still concentrating on their role of treating fractures and alleviating the resulting pain and other symptoms, medical experts around the world are taking notice of the problem and doing more to recognize and care for the osteoporosis patient’s condition in the days after a fracture. In response to its own studies indicating that 90 percent of patients with such fractures leave the hospital without an osteoporosis work-up, the International Osteoporosis Foundation has just launched a new initiative to educate orthopedic surgeons about the disease and present them with clear clinical guidelines for dealing with it.
While a similar trend has been developing in the United States, it is frequently the patient who must take the lead to ensure adequate care for their osteoporosis. One of the first steps, interestingly enough, is too rule out – or if necessary, confirm – other conditions that may compromise the patient’s health besides osteoporosis. This is particularly true if the fracture was the result of a fall, as most osteoporosis fractures are.
According to the National Institutes of Health, falls are the number one cause of fractures, hospital admissions for trauma, loss of independence and injury deaths for older adults. While a fall can occasionally be attributed to a specific cause, such as an icy sidewalk or a loose rug, it is possible, especially for an older person, that another ailment contributed to the spill, perhaps by causing a brief loss of consciousness.
After a fall that results in a fracture, it is imperative to receive a complete medical check-up, including evaluation for medical conditions such as a mild stroke or a heart arrhythmia. “The fall warns you that something new may have occurred to cause the fall that needs medical attention," says Dr. Susan Nayfield, chief of the Geriatrics Branch at the National Institute on Aging in Bethesda, Md. and an expert on falls in older people.
Even if some tests were performed in the hospital, patients may want to make a point to see their primary physician as soon as practical after a fracture. In addition to a comprehensive health screening, outside the context of a hospital the patient and physician may have more time and a comfort level to discuss treatment possibilities for the osteoporosis itself. One crucial priority, if it has not already been accomplished, is obtaining a current bone density scan to help determine the amount of bone loss and assess a risk of further fracture. The results can be taken into account with other negative factors – such as family history of fracture, slight frame, smoking, or low lifetime calcium intake – to devise a plan to combat the condition.
Part of facing a fracture combined with an osteoporosis diagnosis is to make an immediate, permanent commitment to taking adequate levels of calcium and Vitamin D. The National Osteoporosis Foundation recommends that those 50 and older take 1200 mg of calcium per day, along with 800-1000 I.U. (international units) of Vitamin D – a recent increase over the previous level suggested.
“Many physicians may not be aware of exactly how much vitamin D,” an older person needs, says Dr. Denise Houston, a nutrition epidemiologist at the Wake Forest University Baptist Medical Center. “We’re probably not taking it at these levels. It does need to be pushed in this group.”
Dr. Houston was the lead researcher on a recent study in the medical journal Gerontology demonstrating the connection between Vitamin D deficiency and insufficiency and poor physical performance. Her team conducted a battery of tests on older individuals, such as walking briskly for a short distance and getting in and out of a chair. Grip strength and balance were also measured. The results indicated that Vitamin D deficiency was correlated with poor balance and lower muscle strength. Even a more subtle “insufficiency” was correlated with lower handgrip strength.
While medications may be ultimately become part of a multifaceted reaction to an osteoporosis diagnosis, a patient probably shouldn’t expect the doctor to prescribe such treatment, such as bisphosphonates, in the days after a fracture. Most physicians will usually wait for a patient to stabilize before introducing a new drug.
Granted, finding the energy and motivation to confront osteoporosis can be no easy task for someone dealing with a painful fracture such as that of the hip, wrist or vertebrae. If the fracture has rendered the person temporarily bedridden, the patient is also at risk of complications, including pneumonia and blood clots, which would need to be treated immediately. Yet facing such health challenges should be no reason to neglect one’s condition of osteoporosis, since being weakened by bed rest may be one of the factors that contribute to a subsequent fall, which in the worst case could result in further fracture.
A study in the April 25, 2007 issue of the Journal of the American Medical Association found that even previously healthy older people, when confined to bed rest for two weeks (as might well be the case for someone suffering from a hip fracture, for example), lost a large amount of skeletal muscle, particularly from the lower extremities. In fact, they lost more lean tissue in 10 days than young individuals after 28 days. This is a good reason to get up and around again as soon as the doctor gives the go-ahead, but can also be a reason to be extra careful.
Sometime after a fracture, a physician may prescribe physical therapy to restore the previous function of the body part. Those who suffered wrist fractures, for example, might need help practicing normal hand movements in order to do chores at home. This is due both to the fracture itself and the resulting muscle atrophy while the limb was immobilized. While it is essential to follow the doctor’s instructions in this regard, the effects of other bone-strengthening exercise regimens after a fracture have been debated. According to a July 2006 study in the Archives of Physical and Medical Rehabilitation, healthier individuals with a single fracture may benefit, while more frail individuals with a history of fracture may actually put themselves at risk of further injury. One should consult with a physician before beginning any exercise program and always proceed with caution.
The most important thing to remember following an osteoporosis diagnosis, especially after a fracture, is that the disease entails a lifetime of managing low bone mass and devotion to round-the-clock fall prevention. Unlike an infection that clears up after a couple of days on antibiotics, the battle against osteoporosis will require constant vigilance and dedication to be controlled. And as Dr. Nayfield points out, following the treatment prescribed by one’s physician won’t produce change overnight.
“Your bones are not going to be back to normal the day after you begin therapy. It takes time to strengthen the bones again,” she said. During the period following a fall, Dr. Nayfield advises, “is an important time to look carefully at the things you can do to prevent other falls in the future, while the bones are getting stronger.”
Published On: June 04, 2007