Charlie lived alone after breaking his arm. One morning he fell to the floor and broke his hip. He was brought to hospital in pain and dehydrated where he lay on a trolley for two days, unable to eat or walk to the bathroom. He went for surgery to repair his broken hip but sadly died a week later.
Ireland has one of the highest rates of osteoporotic fracture and death following hip fracture today. We spend a large sum of the healthcare budget treating patients who suffer a fracture, but have no national policy or programme for osteoporosis. This is at odds with most countries in the EU.
It is time we recognise that osteoporosis is not a silent disease. Ask anyone who has broken their hip and spent hours or days on a hospital trolley. I recall one patient telling me she would rather give birth to her five children all over again than go through the pain she experienced with her hip fracture.
We often hear the phrase “it’s just a fracture” when someone suffers a fracture. A fracture is the medical term for a broken bone. While breaking a bone is the clinical event, and most heal, it’s not “just a fracture”.
Fractures mean you have a disease of the skeleton, which needs treatment. Fractures mean pain and suffering. They also mean you are more likely to have another fracture. The fracture may mean you will not be able to function properly or return to your normal life.
It is startling to learn that 30-40 per cent of Irish people end up in nursing homes or long-term care following a hip fracture, if they survive. One in three men and one in five women will be dead within a year following a hip fracture, from complications related to their fracture or other illnesses. This outlook is worse than many cancers and other diseases today. Death rates following hip fractures remain very high in Ireland, almost twice that of other countries where national policies and programmes have reduced these numbers in the past decade.
A DXA test can be used to identify people with low bone density at risk of fracture before they break a bone and to monitor treatment or bone loss. But, like all medical tests, it is imperfect and comes with several caveats. Many people who break bones easily (ie, they have the disease osteoporosis) may have a DXA test which may not show it. This would be a “false negative test”, not “osteopenia”. Osteoporosis is not the only cause of low bone density.
Calcium and vitamin D are not enough to prevent fractures. Adequate calcium and vitamin D are essential for healthy bones, but there is little evidence that supplementation prevents fractures or slows bone loss in people with adequate intake. Supplements have a role in people who are deficient in calcium and vitamin D including those with poor diets, malabsorption problems, kidney or liver disease or frail elderly people with poor food and sunshine intake.
Medications are part of a treatment plan which should include fall prevention, diet, exercise and more. They are often avoided by patients but are generally safe, effective and well tolerated. Occasionally patients have side effects but osteoporosis is dangerous, and fractures lead to pain and suffering, loss of independence and death. Thinking that supplements alone can prevent fractures is a common misconception, as well as the following:
1 It was a really bad fall that did it
The human skeleton has evolved over millions of years to sustain a fall from a standing height without breaking. Hav
ing fallen on the ice several times while running in North America in winter months, I can attest to this, but despite being black and blue I never broke anything but my pride. People should not break their hip or spine with a simple fall, getting out of a chair, putting on their shoes, or ribs with coughing.
People over 50 years who break bones easily should be assessed for osteoporosis which includes a DXA scan, and if they have a spine or hip fracture, treated for osteoporosis.
2 Everyone who is worried about their bones should get a DXA
This is not true. The test was designed to test older people at risk of fracture before one occurred, mainly people 65 years and older. Younger people may require the test if they have certain diseases or conditions associated with bone loss or increased fracture risk, but healthy people do not.
3 My test showed I have osteopenia and I need treatment
This may not be true. It is much more important to treat the person than the test. As mentioned previously, like all tests DXA is imperfect.
4 It’s too late now, I’ve already broken bones
People with fractures and low bone density achieve the most benefit from treatment, so need to get tested and treated.
5 It’s not as important as high cholesterol so I avoid dairy products
The opposite is true. The annual risk of fracture for a postmenopausal women today is greater than her annual combined risk of stroke, heart attack, other cardiovascular illness and invasive breast cancer combined. A healthy balanced diet is important for all these conditions and the evidence that dairy or calcium-rich diets increase the risk of cardiovascular disease or breast cancer is non-existent.
6 I’m a big man, so I don’t need to worry
Sadly one in four osteoporotic fractures occurs in men. While men are less likely to fracture, they have a worse prognosis including higher death rates following fractures. You can’t tell by looking at them who will fracture, so if you are at risk, talk to your doctor. Be a real man and take responsibility for your health.
Guest columnist Prof John Carey is a consultant physician in rheumatology and medicine at University Hospital Galway, and specialist in osteoporosis and bone health. He is a personal professor at the National University of Ireland, Galway, and incoming president for the International Society for Clinical Densitometry for 2017.