What familiar disorder affects at least 10 million seniors yet goes unrecognized in two-thirds of its victims and untreated more than 85% of the time? It is osteoporosis, and it is a major cause of pain, disability or even death in the elderly.

Osteoporosis causes bone to become fragile and more easily breakable. Bone is a living tissue that is continually being dissolved and replaced. Bone mass reaches its peak in all of us at around age 30. After that the dissolving process predominates and gradual bone loss begins, progressing throughout life. Osteoporosis occurs when enough bone mass has been lost to significantly increase the likelihood of breakage due to a fall or injury.

Who Gets Osteoporosis?
Women are much more vulnerable than men for two major reasons. The peak bone mass reached in women is less than in men; and, women experience an acceleration of bone loss following the menopause. In fact, most osteoporosis is categorized as postmenopausal osteoporosis and more is known about this type than other types, including osteoporosis in men.

Besides advanced age and postmenopausal status, a number of factors make osteoporosis and fractures more likely. The most important is a prior fracture occurring after age 40, unless severe trauma (such as a car accident) was the cause. A history of adult fractures in a parent or sibling is another risk factor. Being thin and of low body weight can also contribute, as can poor calcium intake, cigarette smoking, excess alcohol use and a sedentary lifestyle. Caucasians are at higher risk than other ethnic groups.

Many medical disorders and drugs can contribute to osteoporosis. Such so-called secondary causes are commonly present in younger adults or males with osteoporosis, but they also often coexist with postmenopausal osteoporosis. Examples include thyroid disease or other hormonal disorders, nutritional deficiencies, rheumatoid arthritis, some chronic kidney diseases, long-term steroid usage and treatment with certain anti-seizure drugs.

How is Osteoporosis Recognized?
The symptoms of osteoporosis entirely relate to the resulting bone fractures. Although any bone can be affected, the commonest are the spine, hip and wrist. Hip fracture is the most serious, with a mortality of as much as 25% at one year and impaired independence in 50% of survivors. Spinal fractures may range from being painless to life-threatening. Often multiple spinal bones fracture over time, causing chronic pain, loss of height, curvature of the spine (the so-called "dowager's hump") and crowding of internal organs.

No test directly measures bone strength, but a common test called a DEXA scan does measure bone density, which correlates closely with the extent of osteoporosis. Bone density by this technique is usually measured at the hip and spine. It is safe, painless and does even not require disrobing.

Authorities disagree on just who should undergo bone density testing and how often. A common recommendation is to perform the test in all women who sustain a fracture after age 40, in all women 65 or older, and periodically in any person being monitored for bone loss progression or undergoing treatment. Many experts also recommend bone density measurement in people who have one or more of the risk factors or secondary contributors mentioned earlier.

Anyone whose bone density is found to be low must undergo additional evaluation, including a complete medical history and examination, as well as laboratory testing and traditional skeletal x-rays.

What Can be Done?
Both the onset and severity of osteoporosis can be reduced by lifestyle and nutritional measures, which should be followed lifelong but are beneficial at any age. Adequate calcium and vitamin D intake are among the most important. Recommendations vary with age and sex, but women over 50 should ingest 400-800 IU of vitamin D and 1200 milligrams of elemental calcium daily. A typical multivitamin contains 400 IU of vitamin D.

The main dietary calcium sources are milk products. Some fortified cereals and juices, and certain fish and vegetables also contain significant calcium. Read nutritional labels or consult a nutritional table to determine actual calcium content. Milk contains about 300 milligrams of calcium per cup. Since most people don't get enough calcium in their diets, experts advise making up the difference with a calcium supplement. Be sure to check the label for the amount of elemental calcium per pill. It would also be prudent to confer with your doctor before starting a calcium supplement.

Lifestyle measures that help prevent osteoporosis include regular weight-bearing exercise, smoking cessation and avoidance of excess alcohol. Measures to reduce the risk of falling can prevent osteoporosis-related fractures (see the January 2003 issue of the Golden Gazette for more on this topic). For postmenopausal women or those who have had their ovaries removed, hormonal replacement therapy (HRT) can slow down osteoporosis. However, HRT is a complicated issue requiring a careful weighing of multiple considerations.

As distinct from preventive measures, the treatment of osteoporosis has the potential to arrest or partially reverse bone loss. Treatment currently consists of the regular use of one or more medications such as alendronate (Fosamax), risendronate, calcitonin or raloxifene (Evista). These drugs all have individual strengths and weaknesses and should be taken only after careful discussion of the benefits and risks with one's physician.

Osteoporosis has been called "the silent disease" because it can progress unrecognized for decades until a fracture occurs. However, with greater awareness of the risk factors, earlier diagnosis and better prevention and treatment, many osteoporosis-related fractures can be avoided.

August, 2003