If you are reading this blog, you probably have some concerns about your health, but the problem of osteoporosis may not be high on that list of concerns. As a consequence of having osteoporosis, you have an increased chance of breaking a bone. We tend to think of broken bones as more of an inconvenience and something that heals with few consequences. But in older adults, fractured bones can lead to major problems.
THE DANGER OF BROKEN BONES
If you are a woman over age 50, you have about a one in six chance of breaking a hip over your lifetime. If you are one of the unfortunate to break a hip, your chance of dying in the next year is about 1 in 4, and you are about equally as likely to spend time in a nursing home. Although the group of women developing breast cancer is younger, if you were to compare the likelihood of dying in 5 years after a hip fracture or breast cancer, your chance of dying is twice as much from the hip fracture.
Although hip fractures are probably the most serious consequence of osteoporosis, other factures also can cause serious problems. For example, spine or back fractures can cause severe pain, loss of height, loss of self-esteem, and carry a mortality rate over five years of about 25 percent.
Of the women and men who should fall and break a wrist, about 1 in 4 will still have pain and lack of full use of that arm a year after the fall. Other bone breaks such as shoulder, ribs, pelvis and lower leg all can lead to long-term consequences and serve as a sign of a high risk of having a subsequent fracture.
WHO IS AT RISK?
Given the seriousness of the problem, there is a real need to try to prevent these fractures. We have the real possibility of reducing fracture risk, but only if we improve our strategies for identifying those who are most at risk and using proven ways to prevent fractures from occurring.
There are two groups of people for whom we can focus our efforts of identification: the first are those who have had a previous fracture and the second are those who are shown from a test called bone densitometry to have a higher chance of breaking a bone because of weaker bones identified on the test.
In the United States, most bone density tests are done on equipment called a dual-energy absorptiometer, commonly referred to as DXA (pronounced “decksa”). Who, then, should have a bone density study?
- There appears to be general agreement that bone density testing should be done as a screening test for any healthy woman age 65 and older.
- For men, the recommendations are not as clear, but the National Osteoporosis Foundation and other organizations, recommend screening for men at age 70 or more.
- There is also agreement that women who have gone through menopause and who have risk factors for developing osteoporosis should be tested.
- Although there is not total agreement, most bone disease experts agree that men over age 50 with risk factors would benefit from testing.
WHAT ARE THE RISK FACTORS?
A partial list of the risk factors include:
- Previous fracture
- Use of glucocorticoids (steroids like prednisone) and other medications that could reduce bone strength.
Other risks include low body weight, a family history of a parent having a hip fracture, excess alcohol consumption, or rheumatoid arthritis.
HOW DO YOU MEASURE BONE DENSITY?
The procedure for measuring bone density is quite simple. You lie on a table and a scanner using a very low dose of x-ray passes over you. The entire process generally takes 10 minutes unless additional studies are needed. The amount of radiation is less than what you would receive in a plane ride from Vermont to California.
After we have the results, we compare the density or amount of bone you have at specific areas of your skeleton, such as the spine and hip, to a population of normal young people either men or women. We report this as a T-score which is a number that gives us an idea of how low or high your density is. Since an average bone density for the young population is 0, most measurements as you get older tend to be less than 0 and are reported in negative numbers such as -1 or -2. The lower the density, the greater is the likelihood of breaking a bone.
We consider any density down to -1 as being normal, between -1 and -2.5 is called osteopenia and for -2.5 or lower, we label this as osteoporosis. Osteoporosis indicates an increased risk of breaking a bone and osteopenia as a potential risk. From the information we obtain from the bone density study can say whether you have osteoporosis or not.
Next, we take your T-score and combine it with the risk factors that you have and from that we predict the likelihood of fracturing over a period of time. We have chosen 10 years as the length of prediction and derive a likelihood of breaking a bone over 10 years and report that as a percentage. For example, you may have a 20 percent chance of breaking a bone over the next 10 years. .
We now have two categories to work with. We have your T-score, from which we derive a diagnostic category of osteoporosis, osteopenia, or normal. We also have a prediction of your chance of breaking a bone in the next 10 years which is called your Fracture Risk Assessment or FRAX.
WHAT ARE THE TREATMENT OPTIONS?
Here we’re not talking about calcium, vitamin D, and weight bearing exercise, which everyone should be doing to help their bones, but therapy with prescribed medication. For that we look to the guidelines from the National Osteoporosis Foundation who recommends treatment on for people who have osteopenia or osteoporosis and
- Have had a previous fracture of the spine or hip other than from a major accident.
- Have a bone density T-score at either the spine or hip of -2.5 or less, the osteoporotic range.
- or, have a bone density in the osteopenic range (less than -1 to greater than -2.5) and have additional FRAX score of 20% percent, 10 year risk for “major” fractures or 3% for hip fractures.
If you meet those criteria, we would recommend starting medication to reduce significantly your risk of breaking a bone.
In a future blog, I’ll discuss the medications available for treatment and how we can reduce the chance of side effects from these medications.
Edward Leib, MD, a rheumatologist, is medical director of the Osteoporosis Center at the University of Vermont Medical Center, where he is also a emeritus professor in the Larner College of Medicine at UVM.