By Eduardo Grunvald, M.D.
“Her chest had dropped, so that she stooped . . .”
Dickens describes Miss Havisham in his classic novel, “Great Expectations”, like authors of mythology and fairy tales throughout the times have depicted older women, as bent over and hunch-backed, a result of untreated brittle bones and small fractures of the vertebral column. But in our modern times, women need not face similar skeletal deformities. A healthy diet and appropriate medications can reduce the risk of osteoporosis, a condition where bones lose their minerals and strength and are more prone to breaking.
In older folks, just a minor fall can make an outstretched wrist snap or a hip crumble.
In fact, fractures of the hip or the vertebrae (spine bones) are a major cause of death and disability, not to mention the economic burden on the medical system. It is estimated that every year over 300,000 wo-men are hospitalized for broken hips, 25 percent of which will end up in a long term nursing home, and only 40 percent will regain the same level of function and independence they had before the injury. These people also have a 10 to 20 percent increased likelihood of dying in the year following their fracture. The most recent statistics reveal that hip fractures in the United States account for over $17 billion in healthcare costs.
Most people think of their bones as structures that serve merely as a support framework or a protective casing. In truth, human bones are dynamic tissues in a continuous state of demolition and reconstruction, a process that is dependent on estrogen levels in women.
As women go through menopause however, their estrogen levels drop, creating an imbalance whereby bone cells remove minerals faster than they can replace them, leading to decreased bone strength, also known as bone density. Low bone density, or osteoporosis, puts one at higher risk of suffering fragility fractures, broken bones that occur with falls that would not normally cause a problem in a younger person with strong bones.
Fortunately, there is a simple test called a DEXA scan that can detect this problem. Like an x-ray, this test is painless and readily available. It measures the density of bones, usually at the hips and spine. By using a statistical comparison, called a T-score, the relative risk of future fractures can be predicted.
To simplify the rating, one’s bone density can be categorized as normal, osteopenia (“pre-osteoporosis”), or osteoporosis.
Although there are women with certain conditions that increase the risk of low bone density, the vast majority of cases occur in post-menopausal women due to waning estrogen levels. Some men can also develop osteoporosis, but the vast burden is from women with the disease.
Although Hispanic women are at decreased risk of osteoporosis compared to white or Asian women, they are still greatly impacted because they tend to have inferior access to preventive medical care and education on ways to reduce the risk.
Certain risk factors for osteoporosis cannot be modified, such as family history, thin body type, and white or Asian race. Others can be changed: not smoking, increasing regular weight bearing exercise, avoiding excessive alcohol consumption and maintaining necessary levels of calcium and vitamin D in the diet.
Adequate calcium consumption maintains this important mineral in the tissues so that cells called osteoblasts can utilize it to build bone strength. It is recommended most women take 1,000 to 1,200 milligrams of calcium per day, and those with osteopenia or osteoporosis get 1,500 milligrams daily, with a combination of dietary intake and supplements. Foods high in calcium content include dairy products, green leafy vegetables, and some fish.
Vitamin D is vital for facilitating absorption of calcium from the intestinal tract. It is produced in the skin under the influence of sunlight. This is easily achieved just by living in southern California, but the recommended daily allowance is 400 to 600 units daily usually combined in the calcium pills - and up to 800 units daily for patients who have limited exposure to sunlight.
Many medications are available to treat osteoporosis, or prevent its development in women with osteopenia or those at high risk for the condition. The most common ones are known as bisphosphonates, three of them currently available in pill form: alendronate (Fosamax), risedronate (Actonel), and ibandronate (Boniva). The first two can be taken once a week, and the third can be taken once a month. Calcium and vitamin D should be taken in conjunction, and not in lieu of these drugs. Each has potential side effects. Consult a doctor to determine which medication is most appropriate.
For elderly women who have osteoporosis and are at high risk of falls and fractures because of frailty, decreased muscle strength, poor vision, or poor equilibrium, measures should be taken to minimize injuries. These fall precautions include getting rid of loose rugs and clutter in the home, making sure there is adequate lighting, including nightlights, and using appropriate assistive devices for walking (e.g. rails, canes, or walkers).
Osteoporosis, and its long-term consequences, especially in light of the growing aging population, deserves widespread attention. Women now have the knowledge and medical support to thrive in their golden years, leaving the image of the decrepit, crooked old woman to stories and fairy tales.
For more information on osteoporosis, visit the website for the National Osteoporosis Foundation at www.nof.org, or call (202) 223-2226 for publications in Spanish.
Dr. Grunvald is Associate Clinical Professor, Department of Medicine at the Perlman Internal Medicine Group, UCSD Medical Center.