Osteoporosis: An under diagnosed disease

Background

Bone is continuously formed and broken down in a cyclical fashion in such a way that there is a net bone gain in youth and bone loss in old age. Bone continues to grow up to the age of 35 years, remains stable for few years followed by net loss of bones. In women, there is a rapid bone loss after menopause (after 50 years) and in men, bone loss occurs after the age of 70 years. Osteoporosis (weak and brittle bones) is a disease of bones wherein bones become weak (due to loss of bone density and strength) and are prone to break resulting in fracture. Consequently, people with osteoporosis are at a high risk of fractures with trivial trauma or while doing routine activities like standing or walking. The most commonly affected bones are the hip, wrist and spine. Osteoporosis can occur in people of any age, but it is more common in older adults, especially women. According to global statistics from the International Osteoporosis Foundation, about one-tenth of women aged 60 have osteoporosis; while two-fifths of women aged 80 have the disease. The reduced quality of life for those with osteoporosis is enormous. Osteoporosis can result in disfigurement, lowered self-esteem, reduction or loss of mobility, and decreased independence.

How common is osteoporosis?

In India, osteoporosis is seen in 25-62% of women of postmenopausal age. With ageing population one out of four (even one out of two) women after the age of menopause will have osteoporosis.

Why should we worry about osteoporosis?

Osteoporosis leads to low trauma fractures and makes a person bed ridden with its subsequent issues. Fractures commonly occur in vertebrae, hipbone and forearm. With one fracture, the chances of fracture at second site are quite common. Femur neck fracture makes a person bed ridden and one in four women above the age of 60 years (with hip fracture) has high chances of death in the subsequent one year.

What are the symptoms of osteoporosis?

The early stages of osteoporosis do not cause any symptoms or warning signs. In most cases, people with osteoporosis do not know they have the disease until they have a fracture. If symptoms do appear, some of the earlier ones may include receding gums, weakened grip strength, weak and brittle nails, and decrease in standing height. If a particular bone gets a fracture, pain and limitation of motion may be apparent at the site of fracture. The fracture may be give rise to minor symptoms in the form of pain at ribs and back, however fracture at neck of femur results in severe disability and inability to move.

What are the risk factors for osteoporosis?

Some of the irreversible risk factors are old age, female gender, low body weight, family history of osteoporosis and some of the reversible risk factors include poor nutrition, smoking, and physical inactivity. In addition to these, some of the commonly used drugs (such as glucocorticoids) can cause osteoporosis. Some of these risk factors for osteoporosis, such as poor nutrition and inactivity can be controlled. For instance, improving one’s diet and starting an exercise program can benefit bone health. However, other risk factors, such as age or gender are irreversible.

How to diagnose osteoporosis, role of DXA scan?

Osteoporosis in our setting is diagnosed quite late when a person develops a fracture after a trivial trauma. Best time to diagnose osteoporosis ideally is before fracture occurs. Awareness about osteoporosis in doctors and people is minimal. Any woman above 60 years and any man above 70 years should be screened for osteoporosis. As of now, gold standard for diagnosis of osteoporosis is DXA (dual energy X-Ray absorptiometry). DXA scan measures the bone density (thickness of bones) and compares either with the density of the same age and gender or else (in people with age > 50 years) with the bones of a young person. A score is calculated based on density of bone (compared with either a young person or same age and gender). A low score means that bones are weak, more negative the score, weaker the bones.

Proper interpretation of DXA scans

A DXA scan done at a clinic or hospital comes with a 4-5-page report consisting of pictures, and interpretation of data. The DXA report should be properly reviewed by a specialist trained in interpretation of DXA scan. This review by a trained person is important to identify the common errors of performing the test by the technician and interpretation of results by the machine and consequently avoid errors of diagnosis and treatment. A DXA scan may need to be repeated after a year or two to look for the progress of disease or response of treatment. The interpretation of DXA report at the repeated measurement is technically more demanding to decide whether treatment has worked.

Treatment of osteoporosis

Main aim of treatment of osteoporosis is to prevent fracture. Fracture usually occurs when a person with weak bones has a fall. Therefore, fracture prevention is incomplete without proper measures taken to prevent fall. An adequate intake of calcium and vitamin D are important to prevent and treat osteoporosis. Depending upon the severity of osteoporosis, drugs may be given in addition to calcium and vitamin D to increase bone strength and subsequently decrease the chances of fracture.

Prevention of osteoporosis

Prevention of osteoporosis rests on giving attention at young age during the years of attainment of bone mass (up to 30 years) and subsequent prevention of loss after that age. Diet rich in calcium and adequate supplies of vitamin D along with adequate exercise help in attainment of a good bone mass. After the attainment of peak bone mass, adequate calcium, vitamin D, exercise and avoidance of factors causing osteoporosis like smoking, alcohol use and steroids can help in prevention of bone loss.

Prevention of falls and fractures

Fractures usually result from fall; common causes of fall include aging, poor eyesight and hearing coupled with poor lighting at home. In addition, elderly people are on multiple drugs. If the number of drugs exceeds four, chances of fall are very high.

Following measures can reduce the chances of fall:

1. Have a diet rich in fruits, vegetables and adequate calcium and vitamin D, strengthen your muscles by doing regular weight bearing exercises.

2. Keep your eye glasses clean and glare free; be careful on stairs while wearing a bifocal lens.

3. Wear non-slip shoes and socks to prevent a fall.

4. Avoid getting up during night when the chances of fall are more.

5. Remove objects from the way of walking that could result in loss of balance.

6. Keep your washrooms clean, and dry. Use anti-skid mats and walking support in the form of handrails along the walls of washroom and replace washroom chapels at regular intervals.

7. Put handrails on both sides of stairs.

8. Get sidewalks and walkways repaired to have a smooth and uneven surface.

9. Use torch while moving in and around house during darkness.

Summary

1. Osteoporosis is a common disease especially in women after the age of menopause.

2. Screening for osteoporosis is required after 60 years of age in women and 70 years in men.

3. Some drugs like steroids cause osteoporosis.

4. Adequate vitamin D and calcium intake during youth builds bones and prevents bone loss in old age.

5. Prevention of fall in elderly prevents fractures and its adverse effects.

6. Every effort should be made to make your home fall proof.

7. A proper diagnosis and treatment of osteoporosis will certainly prevention disability because of fractures.

Author is Prof & Head Department of Endocrinology, SKIMS, Srinagar