Why brittle bones aren't just a woman's problem

Paula Spann

Ronald Klein was riding his bike in his neighborhood in North Wales, Pennsylvania, in 2006 and tried to hop a curb. “But I was going too slow, and I didn’t have enough momentum,” he recalls.

When the bike overturned, he extended his left arm to prevent the fall. He said it didn’t look like a serious accident, yet “I couldn’t get up.”

In the emergency room, X-rays showed he had broken his hip, which would require surgical repair, and his shoulder. Klein, the dentist, returned to work three weeks later using a cane. After about six months and a lot of physical therapy, he felt fine.

But he wondered about the damage caused by the fall. “A 52-year-old man isn’t supposed to break his hip and shoulder,” he said. At a follow-up visit with the orthopedist, “I said, ‘Maybe I should get a bone density scan.’”

As Klein suspected, the test showed that he had developed osteoporosis, a progressive condition that increases sharply with age, thins and weakens the bones and can lead to serious fractures. Klein immediately began a medication regimen that, now 70, he continues to follow.

Osteoporosis occurs more commonly in women, for whom medical guidelines recommend it Comprehensive examination after the age of 65that a man who was not a health care professional may not have thought about getting tested. The orthopedic doctor did not raise the possibility.

But about 1 in 5 men over the age of 50 will suffer an osteoporotic fracture in their remaining years, and among the elderly, approx A quarter of hip fractures occur in men.

When they do, “men have worse outcomes,” said Kathleen Colon Emerick, MD, a geriatrician at Durham VA Health Care System and Duke University and lead author of a recent study on treating osteoporosis in male veterans.

“Men don’t do as well in recovery as women,” she said. High death rates (25% to 30% within a year), disability and institutionalization. “A 50-year-old man is more likely to die from complications of a major osteoporosis fracture than from prostate cancer,” she said.

(What is “major”? Fractures of the wrist, hip, femur, humerus, pelvis, or vertebra.)

In it Study of 3,000 veterans Ages 65 to 85 years, conducted at Veterans Affairs health centers in North Carolina and Virginia, only 2% of those recruited into the control group underwent a bone density scan.

“This level is shockingly low,” said Douglas Bauer, a clinical epidemiologist and osteoporosis researcher at the University of California-San Francisco, who published the study. Accompanying comment In JAMA Internal Medicine. “Abyssal. And this is in Virginia, where the government pays for it.”

But the creation of the bone health service – overseen by a nurse who records orders, sends frequent appointment reminders and explains results – led to dramatic changes in the intervention group, which had at least one risk factor for the condition.

Forty-nine percent of them said yes to testing. Half of those tested had osteoporosis or a pre-existing condition, osteopenia. Where appropriate, most began taking medications to preserve or rebuild their bones.

“We were pleasantly surprised that so many agreed to be tested and were willing to begin treatment,” Colon-Emerick said.

After 18 months, bone density increased modestly for those in the intervention group, who were more likely to adhere to their medication regimen than osteoporosis patients of both sexes in real-world settings.

The study did not last long enough to determine whether bone density increased further or fractures decreased, but researchers plan to conduct a secondary analysis to track this.

The findings revive an old question: Given how life-threatening, even fatal, such fractures are, and the availability of effective medications to slow or reverse bone loss, should older men be screened for osteoporosis, as are women? If so, which men and when?

Such issues are less important when life spans are shorter, Bauer explained. Men have larger, thicker bones and tend to develop osteoporosis five to ten years later than women. “Until recently, these men were dying from heart disease and smoking,” he added, before osteoporosis took their toll.

“Now, men routinely live into their 70s and 80s, so they get fractures,” he added. By then, they also have other chronic conditions that impair their ability to recover.

By testing and treating osteoporosis, “a man can see a clear improvement in his mortality rate and, more importantly, in his quality of life,” Bauer said.

However, patients and many doctors still tend to consider osteoporosis as a female disease. “There’s a little bit of a Superman idea,” said Eric Orwell, an endocrinologist and osteoporosis researcher at Oregon Health & Science University.

“Men like to think they’re indestructible, so breaking doesn’t have the impact it should,” he added.

For example, one patient resisted for years the entreaties of his wife, a nurse, to “see someone” about his visibly rounded upper back.

Bob Grossman, 74, a retired public school teacher in Portland, blamed the bad situation instead and told himself to straighten up. “I thought: ‘It can’t be osteoporosis, I’m a man,'” he said. But it was.

There’s another hurdle to screening: “Clinical practice guidelines are all over the place,” Colon-Emeric said.

Professional societies such as the Endocrine Society and the American Society for Bone and Mineral Research recommend that men over age 50 who have a risk factor, and all men over age 70, You should seek examination.

but American College of Physicians and US Preventive Services Task Force They considered the evidence that the men had been examined to be “insufficient”. Clinical trials have found that osteoporosis Medications increase bone density in menAs is the case in women, but most studies in males were too small or lacked sufficient follow-up to show whether fractures also declined.

The task force’s position means that Medicare and many private insurance companies generally will not cover screening for men who have not had a fracture, although they will cover care for men diagnosed with osteoporosis.

“Things stopped decades ago,” Orwell said.

So it may fall to older men themselves to ask their doctors about a DXA (pronounced DECKS-ah) scan, which is widely available for $100 to $300. Otherwise, because osteoporosis is usually asymptomatic, men (and women, who are not adequately tested or treated) don’t know their bones have deteriorated until one of them breaks.

“If you have a fracture after the age of 50, you should have a bone scan — that’s one of the main indicators,” Orwell advised.

Other risk factors: falls, family history of hip fractures, and a fairly long list of other health conditions including rheumatoid arthritis, hyperthyroidism, and Parkinson’s disease. Smoking and excessive alcohol use also increase the risk of osteoporosis.

“A number of medications also affect your bone density,” Colon-Emeric added, particularly steroids and prostate cancer medications.

When screening reveals osteoporosis, depending on its severity, doctors may prescribe oral medications such as Fosamax or Actonel, intravenous formulations such as Reclast, daily self-injections of Forteo or Tymlos, or twice-yearly injections of Prolia.

Lifestyle changes such as exercising, taking calcium and vitamin D supplements, stopping smoking, and drinking alcohol only moderately will help but are not enough to stop or reverse bone loss, Colon-Emeric said.

Although the guidelines do not recommend it universally, at least not yet, she would like all men aged 70 and over to be screened, because the odds of disability after hip fractures are very high – two-thirds of older people will never regain their previous mobility – and she notes that the drugs that treat it are effective and often inexpensive.

but Inform patients and healthcare workers The fact that osteoporosis also threatens men has evolved “at the speed of a turtle,” Orwell said.

Klein remembers attending a seminar to instruct patients like him on how to use Forteo. “I was the only male there,” he said.

New Old Age is produced in partnership with New York Times.

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