Good Medicine: Osteoporosis and the Dangers of Falling

More than 10 million Americans aged 50 and older have osteoporosis, a skeletal disease marked by weak and brittle bones that can easily fracture with a fall. In extreme cases, bumping into furniture or having a coughing fit is all it takes to break a hip or rib. One in two women and one in five men will have an osteoporotic fracture in their lifetime.

Bone is living, mineralized tissue, constantly growing and breaking down in a process called remodeling. By age 30, the skeleton has reached its peak mass and strength. But by 40, remodeling becomes imbalanced, and bone resorption outpaces bone replacement. Skeletal mass diminishes with time; in some, bone loss becomes severe resulting in osteoporosis,  which means “porous bone.” Most people have no symptoms, unaware they have the condition until a fall and fracture.

The most common osteoporotic “fragility fracture” — 1.5 million yearly in the United States — is vertebral compression. Typically caused by falling from a standing height, the force of the landing partially collapses one or more vertebrae, pinching surrounding nerves and causing back pain, which can then become chronic. Compression fractures can impact posture and lead to spinal curvature, interfering with the victim’s ability to drive a car or even gaze straight ahead.

There are 350,000 osteoporosis-related hip fractures annually in the U.S.; a majority occur in people over age 65. One in three die within the first year of their injury, and another third become dependent on an ambulatory aid like a cane or walker. Up to 20% must enter a permanent care facility.

Dual-energy X-ray absorptiometry — the DEXA scan — is the gold standard for osteoporosis (and low bone mass) screening and treatment. Commonly called bone mineral density testing (BMD), the painless test assesses the thickness and strength of bones, using less radiation than a chest X-ray. A result of minus-1 or higher is normal; minus-1 to minus-2.5 indicates low bone density (osteopenia); minus-2.5 or lower is consistent with osteoporosis.

The U.S. Preventive Services Task Force recommends BMD screening begin at age 65 in women and age 70 in men, and earlier in postmenopausal women and men over 50 who have fracture risk due to autoimmune disease, thyroid conditions or regular use of steroid medication. Scanning frequency is determined by the medical provider.

Most clinicians take a multi-pronged approach to osteoporosis treatment and prevention, with a goal of strengthening the skeleton and slowing further bone loss. Recommendations often include weight-bearing exercises, like walking or using light weights for at least 30 minutes daily, and eating a calcium-rich diet — foods like deep green leafy vegetables (such as spinach and kale) and dairy products (yogurt and cheese). If you need calcium and Vitamin D supplements (over-the-counter or prescription-strength), your provider will tailor the doses to fit your health needs.

Your clinician may also prescribe osteoporosis medication — safe for men and women — selected from one of two broad categories, Antiresorptive drugs stop bone from breaking down: They include Fosamax or Actonel pills, intravenous Boniva or Reclast, and Prolia (injected under the skin). Anabolic medication, like injectable Forteo, stimulates bone regrowth. Evista, a daily antiresorptive pill for women, has not been studied in men.

Sometimes those with osteopenia are treated with medication, too. You may be asked to complete a FRAX questionnaire to assess your fracture risk and help inform your clinician’s decision. Your response to treatment will be followed by annual BMDs; medication is frequently discontinued after five to 10 years. In the meantime, protect yourself from fractures by avoiding falls. Declutter your house, use ladders properly and wear appropriate protective equipment for all sports.

Dr. Mary Jenkins, a contributor to the Herald and member of its board of directors, retired after nearly 40 years as a family practice physician in New York state.