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

Paula Span, Tribune News Service

Ronald Klein was biking around his neighbourhood in North Wales, Pennsylvania, in 2006 and tried to jump a curb. “But I was going too slow — I didn’t have enough momentum,” he recalled. As the bike toppled, he thrust out his left arm to break the fall. It didn’t seem like a serious accident, yet “I couldn’t get up,” he said. At the emergency room, X-rays showed that he had fractured both his hip, which required surgical repair, and his shoulder. Klein, a dentist, went back to work in three weeks, using a cane. After about six months and plenty of physical therapy, he felt fine.

But he wondered about the damage the fall had caused. “A 52-year-old is not supposed to break a hip and a shoulder,” he said. At a follow-up visit with his orthopedist, “I said, ‘Maybe I should have a bone density scan.’” As Klein suspected, the test showed he had developed osteoporosis, a progressive condition, increasing sharply with age, that thins and weakens bones and can lead to serious fractures. Klein immediately began a drug regimen and, now 70, remains on one. Osteoporosis occurs so much more commonly in women, for whom medical guidelines recommend universal screening after age 65, that a man who was not a health care professional might not have thought about getting a scan. The orthopedist didn’t raise the prospect.

But about 1 in 5 men over age 50 will suffer an osteoporotic fracture in their remaining years, and among older adults, about a quarter of hip fractures occur in men. When they do, “men have worse outcomes,” said Cathleen Colón-Emeric, a geriatrician at the Durham VA Health Care System and Duke University and the lead author of a recent study of osteoporosis treatment in male veterans. “Men don’t do as well in recovery as women,” she said, with higher rates of death (25% to 30% within a year), disability and institutionalization. “A 50-year-old man is more likely to die from the complications of a major osteoporotic fracture than from prostate cancer,” she said.

(What’s “major”? Fractures of the wrist, hip, femur, humerus, pelvis or vertebra.) In her study of 3,000 veterans ages 65 to 85, conducted at Veterans Affairs health centers in North Carolina and Virginia, only 2% of those assigned to the control group had undergone bone-density screening. “Shockingly low,” said Douglas Bauer, a clinical epidemiologist and osteoporosis researcher at the University of California-San Francisco, who published an accompanying commentary in JAMA Internal Medicine. “Abysmal. And that’s at the VA, where it’s paid for by the government.” But establishing a bone health service — overseen by a nurse who entered orders, sent frequent appointment reminders and explained results — led to dramatic changes in the intervention group, who had at least one risk factor for the condition.

Forty-nine percent of them said yes to a scan. Half of those tested had osteoporosis or a forerunner condition, osteopenia. Where appropriate, most of them began medications to preserve or rebuild their bones. “We were pleasantly surprised that so many agreed to be screened and were willing to initiate treatment,” Colón-Emeric said. After 18 months, bone density had increased modestly for those in the intervention group, who were more likely to stick to their drug regimens than osteoporosis patients of either sex in real-world conditions. The study didn’t continue long enough to determine whether bone density increased further or fractures declined, but the researchers plan a secondary analysis to track that.

The results revive a longtime question: Given how life-altering, even deadly, such fractures can be, and the availability of effective drugs to slow or reverse bone loss, should older men be screened for osteoporosis, as women are? If so, which men and when? Such issues mattered less when life spans were shorter, Bauer explained. Men have bigger and thicker bones and tend to develop osteoporosis five to 10 years later than women do. “Until recently, those men died of heart disease and smoking” before osteoporosis could harm them, he said. “Now, men routinely live into their 70s and 80s, so they have fractures,” he added. By then, they have also accumulated other chronic conditions that impair their ability to recover.

With osteoporosis testing and treatment, “a man could see a clear-cut improvement in mortality and, more importantly, his quality of life,” Bauer said. Both patients and many doctors still tend to regard osteoporosis as a women’s disease, however.

“There’s a bit of a Superman idea,” said Eric Orwoll, an endocrinologist and osteoporosis researcher at Oregon Health & Science University.

“Men would like to believe they’re indestructible, so a fracture doesn’t have the implication that it should,” he added. One patient, for example, for years resisted entreaties from his wife, a nurse, to “see someone” about his visibly rounded upper back.

Bob Grossman, 74, a retired public school teacher in Portland, blamed poor posture instead and told himself to straighten up. “I thought, ‘It can’t be osteoporosis — I’m a guy,’” he said. But it was. Another obstacle to screening: “Clinical practice guidelines are all over the place,” Colón-Emeric said. Professional associations like the Endocrine Society and the American Society for Bone and Mineral Research recommend that men 50 and older who have a risk factor, and all men over 70, should seek screening. But the American College of Physicians and the US Preventive Services Task Force have deemed the evidence for screening of men “insufficient.” Clinical trials have found that osteoporosis drugs increase bone density in men, as in women, but most male studies have been too small or lacked enough follow-up to show whether fractures also declined.

The task force’s position means that Medicare and many private insurers generally won’t cover screening for men who haven’t had a fracture, though they will cover care for men diagnosed with osteoporosis. “Things have been stalled for decades,” Orwoll said. So it may fall to older men themselves to ask their doctors about a DXA (pronounced DECKS-ah) scan, widely available at $100 to $300 out-of-pocket.

Otherwise, because osteoporosis is typically asymptomatic, men (and women, who are also undertested and undertreated) don’t know their bones have deteriorated until one breaks. “If you had a fracture after age 50, you should have a bone scan — that’s one of the key indicators,” Orwoll advised.

Other risk factors: falls, a 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 increase the odds of osteoporosis as well. “A number of medications also do a number on your bone density,” Colón-Emeric added, notably steroids and prostate cancer drugs.