“Unfortunately, you have sustained a fracture of your hip and will need surgical repair.”
Yikes. If I had a quarter for every patient I have met at skilled rehab who has heard that statement, I would be a rich woman. It’s actually a fairly common story and it generally plays out in one of two ways. Scenario one involves an elder that has sustained a fracture through a “trip and fall” event. They will tell you that it was “so dumb” and they were doing something they “do everyday.” Scenario two is generally a little more vague–”I’m not sure what happened…one moment I was standing next to my kitchen counter, and then all of a sudden I was on the floor.” In the first scenario the fall caused the fracture. In the second scenario, the individual’s bones are so brittle that the leg fractured spontaneously while standing, therefore causing the fall. If you dig a little deeper into their history, you will undoubtedly find that both of these individuals have a history of either osteopenia or osteoporosis. And the unfortunate truth is that these conditions can directly impact an elder’s ability to age in place (with or without grace).
Geez. I came in a little hot on that one. But truly, it’s hard to find anything remotely humorous or positive about declining bone health. But, we can be inspired to make a positive impact on our bodies by having the knowledge and tools to either prevent this decline in bone health or put in place support systems to help manage it. So today…we focus on bone health.
So what are osteoporosis and osteopenia? Well, they are both conditions characterized by a decrease in bone density. Bone density is a measure of the amount of mineralized bone tissue in a certain volume of bone–and can tell us something about bone strength. These conditions increase the risk of fractures (your bones become a little “crumbly”) and can significantly impact a person’s quality of life. The only difference between the two conditions is that osteoporosis is a more severe version of bone loss. Osteopenia signifies “less than normal” bone density (ok, slap on the wrist, but we can deal with this). Osteoporosis, on the other hand (or hip), is indicative of severe loss of bone density leading to very brittle and weak bones.
So who does this typically affect? Older individuals for sure–age is the greatest risk factor for this disease process. Gender is also a risk factor and it is more predominant in postmenopausal females secondary to all the hormone changes that occur (like hot flashes aren’t enough to deal with, now our bones are crumbling 🙄) That’s not to say that men don’t suffer from this, and the true incidence in men is likely higher than we have data to represent. Additionally, sedentary lifestyles, certain medications, smoking, excessive alcohol intake, and inadequate intake of calcium and vitamin D can significantly impact bone density.
How are these conditions diagnosed? Well, your primary care provider at some point will order what is called a DEXA scan to study your bone density. In women, this is usually done at age 65 and at 70 for men. A DEXA scan (Dual Energy Xray Absorptiometry) is the most accurate test for measuring bone density and is essentially a special x-ray of your hip, spine or wrist–or a combination of two or more sites, the hip being the most reflective of current bone density and the most predictive of your fracture risk. From these results, a score is determined (called a T-score). The basis for the T score is as follows: we look at the average bone mineral density of a healthy young adult reference population and compare that to your bone mineral density. If your bone density is more than one “standard deviation” (expected variance) below the average bone mineral density for a young adult (T-Score of -1.0 or below) then you are considered to have osteopenia or osteoporosis. Osteopenia (or low bone mass) is diagnosed with a T-score between -1.0 and -2.5. Osteoporosis is characterized by any T-score at or below -2.5. Treatment for these conditions is based on this score and a variety of other factors and considerations.
Wow, that was boring! However, I do feel it’s important that you have at least a basic understanding of the diagnostic process. That way, when your PCP spits T-scores at you, you have some familiarity with what that actually means. So what happens if and when this DEXA scan result is positive? Well, panic is not allowed. Taking a proactive stance, however, is encouraged because the only bones that should be crumbly are the ones that have spent a good 8-10 hours slow cooking in a crock pot!.
So let’s backtrack and start from the beginning. Much of your bone health later in life depends on calcium consumption early on, genetics, and lifestyle habits. At this point we can do nothing about how much calcium was consumed in childhood–that’s in the past so don’t spend another moment lamenting what did or did not occur. Same thing with age and genetics, though it is good to be aware of whether or not your aging loved ones had any degree of bony demineralization. Our focus is on moving forward and next steps. So here goes….
Early detection and management of osteopenia and osteoporosis are crucial in reducing the risk of fractures. (First step is complete! You’ve had your DEXA scan. Good job! And if you haven’t , I know you will talk to your PCP about it at your next visit)
Lifestyle modifications (this is big) including a diet rich in calcium and vitamin D, weight-bearing exercises, and fall prevention strategies, can help minimize fracture risk. There will most certainly be discussion about calcium and vitamin D supplementation. I would say that if you are actively consuming a diet rich in these vitamins, you may be able to forego supplementation. If you are not confident that your diet is sufficient, I would recommend choosing a calcium citrate supplement rather than calcium carbonate. Calcium citrate is better absorbed, does not have to be timed with food, and causes LESS constipation and gas than calcium carbonate. (Stay tuned for follow-up blog posts on dietary sources of crucial vitamins and minerals as well as fall prevention strategies!)
Start engaging in weight bearing exercise as mentioned above as this can strengthen both muscles and bones to give your skeletal system adequate support and help to prevent fractures. Using resistance bands or small 2-5 lb free weights with a guided exercise program can work wonders! Also, walking, swimming and other aerobic fitness programs are helpful as well. Get out and move!
Get rid of harmful habits (smoking and over-consumption of alcohol). I know, I sound like I am trying to strip you of all pleasures in life. Think of it this way though–if you smoke cigarettes regularly the nicotine and other additives can inhibit calcium absorption. In females, smoking has been linked to earlier menopause and thus decreased estrogen levels. Estrogen is a crucial hormone in maintaining bone density, and earlier menopause can often accelerate bone loss. Significant bone loss leads to the potential for significant fractures, and if you smoke, you will not heal well, leading to decreased mobility and an inability to age in place (at home). And just an FYI—there is NO smoking in the nursing home, so you would have to quit anyway! 😬 Essentially the same goes for alcohol consumption–hindering calcium and vitamin D absorption, lowering estrogen levels, and when the liver starts to malfunction it can affect the metabolism of vitamin D which is an important regulator of calcium absorption. So now that I have ruined your weekend, let’s move on!
Lastly, the treatment. Depending on your T-score, certain medications such as bisphosphonates, denosumab (Prolia) injections, and others may be prescribed to improve bone density and reduce fracture risk. This is a discussion that will take place with your primary care provider and may also involve a visit to an endocrinologist.
So if you do, by chance (or consequence) end up with crumbly bones despite best efforts (or no efforts), the natural next question would be, “which ones will I bust first?!?” When it comes to fracture risk, the most commonly seen fractures in individuals with decreased bone density are hip fractures, vertebral fractures and wrist fractures. All fractures in the setting of osteoporosis are impactful and can really dictate the course of someone’s future. What I have seen most common in practice is that the fractures that change lives most dramatically are hip and vertebral fractures. They directly impact mobility, independence and, vertebral fractures especially, can lead to height loss, spinal deformities and chronic back pain.
Well that was a lot! I do not love any of this for my audience, followers, online family, etc. So let this serve as a call to action. Get out there, get moving, ditch some bad habits, visit your primary care provider, take a calcium supplement, have a DEXA, change your diet, start dancing. Do what you can so that when or if I ever meet you in person, it is not within the walls of my skilled rehab and long term care facility! Stay healthy and stay home!
