November 2002

The Silent Disease

By Holly Franzen-Korzendorfer, MPT, CWS

As clinicians, most of us are aware of the risk factors for heart disease and know our own cholesterol levels. However, the same is not true for osteoporosis. In fact, according to the National Osteoporosis Foundation (NOF), bone density tests are underutilized despite being better predictors of fracture risk than cholesterol levels are for heart attacks. Since the general population is fairly unaware of the risks of osteoporosis, rehabilitation professionals must be aware of what to look for and recognize the risk factors in their patients.

Osteoporosis is “a metabolic bone disease characterized by low bone mass and microarchitectural deterioration of bone tissue leading to enhanced bone fragility and a consequent increase in fracture risk.”¹ Osteoporosis is often termed the silent disease, because many people do not know they have it until they suffer a fracture.¹ Bone mineral density (BMD) tests are the best way to diagnose osteoporosis and low bone mass. BMD test results for an osteoporotic patient is 2.5 standard deviations or more below the average for a young normal adult, whereas low bone mass is in the range of 1 to 2.5 SD below the average.¹ These definitions are based on the use of dual-energy x-ray absorptiometry (DXA) measurements, which are not currently used as a screening tool for all women.¹

It is estimated that in 2002, more than 10 million Americans have osteoporosis, of which approximately 80% are women.² Additionally, approximately 12 million men have low bone mass and an additional 2 million have osteoporosis.² This prevalence data for men with low bone mass and osteoporosis are much higher than the 1997 prevalence data because of newer research.²

The total number of Americans (age 50 or older) affected by osteoporosis is expected to increase to more than 61 million by 2020.² The estimated direct medical cost for osteoporotic fractures is $17 billion per year.³ The health care expenditures for osteoporosis will continue to rise with the expected increase in prevalence rates, unless bone health becomes a higher priority for all health care professionals. Since BMD tests are not regularly used for screening, health care professionals must become more astute with each patient’s history and ask questions about calcium intake, medications, fall history, and personal or family history of fractures.

RISK ASSESSMENT

Osteoporosis is believed to be largely preventable with lifestyle changes.^2,5 The risk factors for osteoporosis are generally categorized as nonmodifiable or modifiable. Commonly cited nonmodifiable risk factors include:^1,6-8,12-15

• Advanced age
• Female gender
• Personal or close family history of adult low impact fractures
• Small body frame
• Ethnicity (Caucasian or Asian has a higher prevalence)
• Age at menarche (later is higher risk) and menopause (earlier is higher risk)
• Impaired vision despite adequate correction
• Postmenopausal status

Modifiable risk factors include:^1,6-8,12-15

• Inactive lifestyle: prolonged bed rest results in a loss of bone mass.^8,13 There is an increased risk of hip fracture for women who spend less than 4 hours daily on their feet and walking has been found to decrease this risk.⁷
• Estrogen deficiency: estrogen replacement therapy has been shown to decrease the risk for osteoporotic fractures^7,8,13
• Low body weight (less than 127 pounds)
• Lifelong low calcium diet
• Eating disorders: anorexics most likely have poor dietary intake of calcium and may have amenorrhea.¹³ Bulimics may also have amenorrhea and take large doses of laxatives or diuretics, which interfere with calcium absorption.¹³ Compounding this is the age at which these disorders occur, usually during the time of building peak bone mass.
• Cigarette smoking, alcohol abuse, or caffeine use
• Previous falls: fall prevention programs to identify hazards and an exercise program can decrease the risk for falls.

Nutritional effects on bone health also need to be considered. For example, a high intake of phosphorus, as in cola drinks, compromises the bone uptake of calcium and, thus, may decrease bone mass.¹⁴ Excess protein and sodium in the diet can also interfere with the body’s utilization of calcium.13 Uptake of calcium may also be limited by ingestion of oxalates (spinach, rhubarb, beet greens, and almonds) or phyates (legumes and wheat bran).¹³ Therefore, these foods should be eaten 1 hour before or 2 hours after calcium-rich foods.¹³

Several diseases and drugs are also associated with an increased risk for osteoporosis, otherwise known as secondary osteoporosis. Conditions such as hyperthyroidism, hyperparathyroidism, multiple myeloma, organ transplants, inflammatory disorders, cancer, and chronic kidney, lung, or gastrointestinal disease may increase the risk for osteoporosis.¹ Medications such as glucocorticoids, thyroid hormone, phenytoin barbiturate anticonvulsants, gonadotropin releasing hormone, and aluminum-containing antacids and heparin may also increase the risk for osteoporosis.^1,13

FRACTURES

Spinal compression fractures account for 46% of osteoporotic fractures6 and cause pain, deformity, loss of height, kyphosis, and potential breathing difficulties for those experiencing them. This type of fracture often results from routine activities such as opening a window or carrying a bag of groceries.^1,6

A distal radius fracture, which frequently occurs after a minor fall, is the most common fracture of the upper extremity in those aged 65 years and older.⁴ Decreased bone density, recurrent falls, and a previous fracture after age 50 have been shown to increase one’s risk for a wrist fracture.⁴ Wrist fractures have been shown to increase the risk for hip fracture.⁷ In fact, any fracture after age 50 increases the risk for a hip fracture.⁷ Hip fracture is a serious sequela of osteoporosis. The lifetime risk for a hip fracture in women 50 years or older is 1:6, with a mortality rate in the range of 10% to 36% within the first year.^1,6,8,9 Hip fracture is also associated with higher morbidity as patients often need more assistance with activities of daily living and walking as well as experience more loss of mobility than that contributed to aging alone.¹¹

One study reviewed the treatment received by community-dwelling women after sustaining a hip fracture and found that 87% of them were receiving inadequate treatment for osteoporosis based on the NOF guidelines, of which 40% were receiving no treatment for osteoporosis after the hip fracture.¹⁰ Also, only 38% reported being treated with calcium plus multivitamin or vitamin D supplements, and 50% of those reporting past or current use of such supplementation did so by self-initiating treatment versus physician recommendation.¹⁰

Additionally, osteoporosis may often go undiagnosed as the physical changes associated with spinal compression fractures are often attributed to normal aging by the patient and the physician alike.⁶

CALL TO ACTION

These findings underscore the need for more prevention interventions by health care professionals. This information shows recurrent falls to be predictive of distal radius fractures, which may later result in hip fractures and death or significant loss in quality of life. Any nontraumatic fracture after age 50 should prompt a rehabilitation professional to consider other possible risk factors for osteoporosis and to provide the patient with information about preventative treatment. Consumer education can result in positive consumer health behavior as indicated above by the self-initiated calcium supplementation. Therefore, you should also consider providing information on fall prevention and suggest referral to other appropriate health care professionals for diagnosis or for treatments such as an exercise program.

Osteoporosis prevention should also be addressed with patients who are receiving treatment for diagnoses other than fractures, but who may have some of the other risk factors. For example, young women athletes, patients with eating disorders, and even mothers of preschoolers would benefit from information about nutrition, healthy exercise habits, and postural education to optimize bone health and minimize their risk for osteoporosis. In fact, just by sharing this information with mothers of young children, you may be improving the bone health of two generations.

Vertebral, Colles, and hip fractures are most commonly associated with osteoporosis.^9,13 The next time you treat someone with a fracture who is 50 years or older, ask further questions as a risk assessment for osteoporosis. Or in your middle-aged patients with poor nutritional status or other comorbidities, explain to them the impact of osteoporosis on our society. Health care professionals should be aware of osteoporosis and should suggest preventative measures for patients with multiple risk factors to minimize the impact on America’s health care consumption and to maintain our patients’ quality of life.

REFERENCES

1. Boning Up on Osteoporosis: A Guide to Prevention and Treatment. Washington, DC: National Osteoporosis Foundation; 2000.
2. National Osteoporosis Foundation. Advocacy: America’s bone health: the state of osteoporosis and low bone mass. Available at: www.nof.org/advocacy/prevalence/index.htm. Accessed February 24, 2002.
3. National Osteoporosis Foundation. Prevalence of low bone mass and osteoporosis affects significant percentage of men and women in US 50 and older. Available at: www.nof.org/news/pressreleases/prevreport_02.html. Accessed May 17, 2002.
4. Vogt MT, Cauley JA, Tomaino MM, Stone K, Williams JR, Herndon JH. Distal radius fractures in older women: a 10-year follow-up study of descriptive characteristics and risk factors, the study of osteoporotic fractures. J Am Geriatr Soc. 2001;50:97-103.
5. Donahue K. Osteoporosis: prevention is the best treatment. GeriNotes. 2002;9(1):39-41.
6. Brewer K. A bare bones look at a big problem. GeriNotes. 2002;9(1):7-9.
7. Cummings SR, Nevitt MC, Browner WS, et al. Risk factors for hip fracture in white women. N Engl J Med. 1995;332:767-73.
8. Messinger-Rapport BJ, Thacker HL. Prevention for the older woman, part 3: a practical guide to prevention and treatment of osteoporosis. Geriatrics. April 2002;57:16-27.
9. Cooper C. The crippling consequences of fractures and their impact on quality of life. Am J Med. 1997;103(2A):12S-19S.
10. Bellantonio S, Fortinsky R, Prestwood K. How well are community-living women teated for osteoporosis after hip fracture? J Am Geriatr Soc. 2001;49:1197-1204.
11. Johnell O. The socioeconomic burden of fractures: today and in the 21st century. Am J Med. 1997;103(2A):20S-26S.
12. National Osteoporosis Foundation. Physician’s Guide to Prevention and Treatment of Osteoporosis. Belle Mead, NJ: Excerpta Medica Inc; 1999.
13. Notelovitz M. Stand Tall: Every Women’s Guide to Preventing and Treating Osteoporosis. Gainesville, Fla: Triad Publishing; 1998.
14. South-Paul JE. Osteoporosis, part I: evaluation and assessment. Am Fam Physician. 2001;63:897-904,908.
15. National Osteoporosis Foundation. Osteoporosis Clinical Updates. 2002;III(1):3.

Holly Franzen-Korzendorfer, MPT, CWS, works in acute, skilled nursing facility, and home health settings in Fairfield County, Conn. She is currently pursing a doctoral degree from Nova Southeastern University.

Editor’s Note: The references that accompany this article appear with the Web version at: www.rehabpub.com

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