Fragile Bone Health A Treatable Health Risk in the Aging Population

As the Canadian population of baby boomers ages, a plethora of health-related challenges is emerging. These challenges require preventive, cost-effective treatment options to properly manage this growing concern.

Osteoporosis “porous bones” is a disease in which the quality and density of bone is reduced. The risk of fracture increases as the bones become more porous and fragile. Loss of bone occurs silently and progressively, usually with no symptoms until the first fracture occurs. (International Osteoporosis Foundation, 2009). Bone is continuously broken down through the action of osteoclasts and reformed through the action of osteoblasts (Mahan & Escott-Stump, 2008). In those over age 50, there may be an imbalance of the rate of bone breakdown over the rate of new bone formation leading to decreased bone strength. Further information about osteoporosis is available on Dietitians of Canada website (Dietitians of Canada/Osteoporosis).

According to Brown and Josse (2002) a paradigm shift from the traditional medical model of prevention and treatment of osteoporosis and bone fractures is occurring. This traditional model focused primarily on treating low bone mineral density, but this is only one of several risk factors for fracture.

Attention is now centered on the prevention of fragility fractures and on reducing their negative consequences, including: increased mortality, morbidity, chronic pain, admission rates in long term care facilities, and high treatment cost, in addition to a reduction in overall quality of life (Papaioannou et al., 2010).

In a 2010 clinical practice guideline proposed by Papaioannou and colleagues, recommendations for the assessment of fragility fracture risk for osteoporosis are made for women and men over the age of 50. One tool widely used to measure the 10-year percentage probability for development of major osteoporotic fracture and fracture risk for the hip, vertebra, forearm or proximal humerus is the Fracture Risk Assessment tool (FRAX). This tool is available from the World Health Organization (WHO) and contains risk assessment algorithms specifically for the Canadian population.

The FRAX tool also includes questions regarding: sex, age, body mass index (BMI), previous fracture history (including vertebral fracture as an especially strong risk factor), parental hip fracture, prolonged glucocorticoid use, rheumatoid arthritis, current smoking habits, alcohol consumption, and bone mineral density (BMD) of the femoral neck (optional since that data is not always available). When BMD is not available, BMI can be used combined with a number of other clinical risk factors.

Answers to these questions are then computed by the FRAX program to predict risk of major osteoporosis and hip fracture over a 10 year period (FRAX, 2010). Probability of major osteoporotic risk of fracture is established as follows: high (>20%), moderate (10-20%), and low (<10%). The completed assessment is a valuable aid as an adjunct in planning a treatment regime (Papaioannou et al., 2010).

Therapeutic treatment options for maintaining and improving bone health

It is of utmost importance to encourage basic bone health for all individuals over the age of 50. Regular active weight bearing exercise improves quality of life, muscle strength, and balance; these factors are important for those at risk of falls. Use of hip protectors should also be considered for older adults at risk for falls and possible fractures (Papaioannou et al., 2010).

Consultation with a Registered Dietitian on how to best achieve a nutritionally complete diet with increased intakes of calcium and Vitamin D using food as a best practice is an excellent starting point. The recommended daily intake of elemental calcium (through diet and supplements) for those over age 50 is 1200 mg. Vitamin D recommended intakes are 800 – 1000 IU/day and up to 2000 IU/day as prescribed to achieve optimal vitamin D status for healthy bones (Papaioannou et al., 2010). To a lesser extent, magnesium, phosphorus, vitamin K and other vitamins and minerals also play a role in bone health.

Use “Eating Well with Canada’s Food Guide” as the basis for healthy choices every day to promote optimum nutrition. Canada’s Food Guide specifically states that everyone over the age of 50 should take a daily vitamin D supplement of 400 IU/day.

Vitamin D assists the body in absorbing and using calcium ingested daily from diet and supplements, increases bone and muscle strength, and reduces the potential risk of fracture. Vitamin D can be obtained by eating fish at least 2 times a week, drinking Vitamin D-fortified milk or a soy/rice beverage several times a day-and from moderate sun exposure for 10-15 minutes a day. Moderate sun exposure (as seasonally available in Canada) is necessary for the absorption of ultraviolet B (UVB), which is needed for the body to make Vitamin D (Papaioannou et al., 2010).

The required daily calcium intake from foods can be achieved through ingestion of milk or calcium fortified soy /rice beverage, dairy products, salmon canned with bones, nuts, seeds, and selected beans.

Intake of sufficient amounts of required daily nutrients may not be achievable due to loss of appetite, co-morbid health conditions contributing to insufficient oral intake, or inadequate exposure to the sun.

When taken concurrently with Vitamin D and calcium there are several drug therapies available to relieve symptoms and prevent fractures due to osteoporosis. These therapies help to slow bone loss and increase bone density. Medications may be taken orally on a weekly or monthly schedule or intravenously on an annual schedule. These time frames may be more conducive to suit lifestyle preferences, especially for the aging population who may be resistant to taking several medications on a daily basis.

Biphosphonates are a class of non-hormonal drugs that work by binding to the surface of bones, thus slowing bone loss, increasing bone density, and reducing the risk of fracture. Some commonly prescribed biphosphonates include zoledronic acid, risedronate, alendronate which need to be taken as prescribed. There are other prescribed pharmacologic treatments which may also be used to fight osteoporosis. Selective Estrogen Receptor Modulators (SERMS) act by binding to estrogen receptors and help to build and maintain bone density. Calcitonin is a hormone produced by the thyroid gland that works to regulate calcium metabolism. Both synthetic and natural calcitonin can act to slow down the rate of bone breakdown, allowing an increased rate of bone rebuilding. In addition, parathyroid hormone is an anabolic hormone that may be used to stimulate bone production. It may be selected as the treatment of choice and given daily as a subcutaneous injection for women who are at high risk of fracture and who have been unsuccessful or are intolerant to other osteoporosis therapies. At present, some of these prescription medications are covered by the Government formulary plans. The charge associated with several of the other medications may be covered by private benefit plans. If not, the cost must be paid by the patient or their family (Fight Osteoporosis, 2010).

The choice of treatment modality must be individualized based on the patient’s particular health status and circumstances. Biochemical testing and a thorough health assessment must be completed and carefully evaluated by the physician. Decisions must be made based on the benefits of treatment in improving quality of life.

All individuals should be encouraged to consume adequate amounts of foods to meet daily nutrition requirements, including foods rich in calcium and Vitamin D to promote bone health. In addition, supplements of calcium and vitamin D can be prescribed and taken daily at little additional cost.

As the Canadian baby boomer population continues to age, the numbers of health-related challenges increases. Health care providers can no longer afford to ignore the implementation of these cost efficient and effective treatment options in the management of fragile bone health and osteoporosis, the “silent, progressive disease.”