The occurrence of pain in the elderly, especially the appearance of generalized wandering pain seems to be very common, and their family members or even the elderly themselves, if the pain is not unbearable, simply do not think that it is caused by the disease. In fact, it is likely caused by the invisible killer osteoporosis.
Osteoporosis is a degenerative disease that increases the risk of developing as we age. Osteoporosis can occur in different genders and ages, but is most often seen in postmenopausal women and older men over the age of 70. With the increase of human life expectancy and the advent of an aging society, osteoporosis has become one of the major diseases that endanger human health. However, patients often have no obvious symptoms in the early stage, and often discover that they have osteoporosis only after the fracture occurs by X-ray or bone density examination. This silent quality makes osteoporosis the name of invisible killer.
Do all people get shorter as they age?
Osteoporosis has many manifestations, among which pain, spinal deformation and the occurrence of fragility fractures are the most common and typical.
Pain: Low back pain is the most common
Pain caused by osteoporosis can be manifested as low back pain or pain in the peripheral bones, and the pain is aggravated when the load increases or the activity is limited, and in severe cases, it is difficult to turn over, get up and sit and walk.
Low back pain is the most common symptom of osteoporosis. In China, low back pain caused by osteoporosis accounts for 67% of the prevalence, and some patients also suffer from numbness of the limbs, general weakness or nerve radiating burning pain. The spine is the pillar of gravity for the whole body, and its own activities are dorsiflexion, pronation and rotation, which are mostly extension and flexion activities in daily life. Therefore, the muscles of low back extension and flexion activities are easily fatigued, especially the back extensor muscles are more easily fatigued. Normal people can quickly self-regulate, the muscles are completely relaxed at rest, blood flow and metabolism return to normal, and can quickly recover from fatigue. However, patients with osteoporosis are different, as the weight-bearing capacity of the spine gradually decreases, so that the back muscles at rest are still contracting and in a constant state of tension, making it easy to experience low back pain.
Initially, low back pain only occurs during activity and can be relieved with a little rest. As time passes, the degree of osteoporosis increases, and continuous low back pain occurs, sometimes accompanied by multiple bone and joint pain, soft tissue jerking pain or nerve radiating pain. The pain can be aggravated if a certain posture is maintained unchanged for a long time (e.g., prolonged standing, sitting, etc.). The pain can be induced to worsen when exerting force or holding heavy objects.
Spinal deformation: hunchback deformity is the most common
Severe osteoporosis can lead to height shortening, hunchback, spinal deformity and limited extension. Compression fractures of the thoracic spine can lead to thoracic deformity, affecting cardiopulmonary function and causing symptoms such as chest tightness, shortness of breath and dyspnea; fractures of the lumbar spine may change the abdominal anatomy, leading to constipation, abdominal pain, bloating and loss of appetite.
The vertebrae of the human spine are cancellous bones that can easily change shape due to osteoporosis. Patients with osteoporosis suffer from massive calcium loss, atrophy of bone trabeculae, and reduced bone mass, resulting in loose bone structure and weakened bone strength, which reduces the weight-bearing capacity of the spine. This can cause gradual deformation of the vertebral body even when subjected to the gravity of its own weight. If the compression in the front of the vertebral body, that is, wedge-shaped change. After multiple vertebral wedge changes, the spine then tilts forward and the physiological anterior convexity of the lumbar spine disappears, resulting in a hunchback deformity.
Due to factors such as increasing age and decreasing activity, degenerative changes occur in various tissues and organs of the human body. The degenerative changes in the soft tissues between the vertebrae narrow the vertebral space, loosen the bone structure due to osteoporosis, weaken the strength, and compress and flatten the original columnar vertebrae (about 2cm in height), reducing each vertebra by 1~3mm. The compression and flattening of the 24 vertebrae and narrowing of the vertebral space can shorten the height by several centimeters (3~6cm on average). It is easy to understand that people often say “people get shorter as they get older”.
As the degree of osteoporosis increases, the curvature of the hunchback increases, increasing the weight of the joints of the lower limbs, resulting in pain in several joints, especially in the soft tissue around the knee joint, which is tense and spasmodic, and the knee joint cannot be fully extended, making the pain more severe.
Fragility fracture: most common in women over 50 years old
A fragility fracture, or osteoporotic fracture, is a low-energy or non-violent fracture. A fracture can be caused by a fall while standing tall or less than standing tall or by other daily activities, or by minor movements and injuries.
Features of fragility fractures: history of trauma is not obvious; fractures occur at relatively fixed sites, such as compression fractures of the thoracolumbar spine, femoral neck fractures or intertrochanteric fractures of the hip, and fractures of the lower end of the ulnar radius; compression fractures of the thoracolumbar spine, some of which are asymptomatic and do not feel pain, and some of which can be significantly painful. The lifetime risk of fragility fracture in women is about 40%, which is higher than the combined prevalence of breast cancer, endometrial cancer and ovarian cancer; the lifetime risk of fragility fracture in men is about 13%, which is higher than the prevalence of prostate cancer. The occurrence of fragility fractures is mostly seen above the age of 50, with an increased incidence in women 7-10 years after menopause, and men are prone to fragility fractures at an age 7-10 years later than women.
The evolutionary pattern of bone mass over a person’s lifetime: ≥90% of bone mass is obtained by age 20; peak bone mass is reached by age 30; wrist fractures are a problem for women at age 50-70; hip and spine fractures are a major problem at age 70-80; and pelvic and rib fractures are a problem throughout all postmenopausal years.
Fragility fractures are very dangerous and can lead to increased disability and mortality. Hip fractures have the most serious impact on quality of life, such as death from various comorbidities up to 20% within 1 year after hip fracture, while about 50% of survivors are disabled, unable to take care of themselves and have a significantly reduced quality of life.
Who does osteoporosis love?
Osteoporosis can be divided into two categories, primary and secondary, according to the cause of the disease. In the former, blood calcium, phosphorus, alkaline phosphatase, and parathyroid hormone are in the normal range, while in the latter, the above indicators are abnormal. Primary osteoporosis is further divided into three categories: postmenopausal osteoporosis (type I), senile osteoporosis (type II), and idiopathic osteoporosis (including adolescent type). The table below compares the first two common types of primary osteoporosis.
Osteoporosis induced by pathological impairment of bone metabolism due to certain diseases or drugs is classified as secondary osteoporosis, such as osteoporosis caused by metabolic endocrine diseases (hyperthyroidism, diabetes mellitus, chronic kidney disease, chronic liver disease, etc.), bone marrow diseases (leukemia, lymphoma, etc.), connective tissue diseases (systemic lupus erythematosus, rheumatoid arthritis, etc.) and drug factors.
Diagnostic indicators of osteoporosis, i.e. the occurrence of fragility fractures or low bone density, can be tested to know the status of our bone density. Bone density refers to the amount of bone per unit volume or unit area. Dual-energy X-ray absorptiometry (DXA) is recognized as the gold standard for the diagnosis of osteoporosis. It is based on the principle that a certain dose of X-rays is blocked and attenuated through the bone to measure and evaluate bone density. Bone densitometry is often reported as a T value, which means that the difference between the measured BMD value and the mean value of peak BMD in a young population is equivalent to several standard deviations. The diagnostic criteria for osteoporosis based on T-value are as follows.
Vertebrae and hips are generally selected for BMD measurement because the common fracture sites are the spine, femoral neck and forearm. These sites are rich in cancellous bone that can more quickly reflect changes in bone density in osteoporosis. Studies of bone density at different sites have shown that the prediction of fractures can be improved by performing bone density measurements at sites where fractures are likely to occur.
Unlike MRI and CT, dual-energy x-ray absorptiometry is a convenient test that does not require the patient to remove clothing or enter a tunnel-like scanner or some confined space, and only requires the patient to lie still for about ten minutes for the relevant scans of his or her hip and spine. In some cases, the patient’s forearm or heel can even be examined.
With the Osteoporosis Self-Assessment Scale for Asians (OSTA), one can simply determine for oneself whether one has osteoporosis and can tell whether one is at risk for osteoporosis.
Calculation method: (weight – age) × 0.2, results are rounded to the nearest whole number.
The result < -4 is for people with high risk of osteoporosis, -4 to -1 is for people with medium risk, and > -1 is for people with low risk.
High risk: Bone density testing was performed and drug treatment was considered.
Medium risk: Bone density test is performed and medication is considered if the test value is low.
Low risk: Bone density testing is generally not required unless accompanied by other risk factors for osteoporosis, such as long-term glucocorticoid use, bed rest or wheelchair use.
Can osteoporosis be prevented and treated?
The goal of preventing and treating osteoporosis is to avoid initial fractures and re-fractures. That is, to intervene when there is a decrease in bone density but no fracture to prevent a first fracture; and to prevent a second fracture after a first fracture. The prevention and treatment approach consists of three components, which can also be referred to as the “three-step ladder”, namely basic measures, pharmacological interventions and rehabilitation.
Basic measures: Reduce the risk factors of osteoporosis
The basic measures of osteoporosis prevention and treatment include lifestyle modification and the administration of basic bone health supplements. Controllable risk factors for osteoporosis include lack of exercise, application of drugs that affect bone metabolism, low gonadal function, smoking, excessive alcohol or coffee consumption, low body weight, inadequate calcium intake, vitamin D deficiency (low light or intake), nutritional imbalance in the diet, and too high or too low protein intake. Risk factors for osteoporosis can be minimized through lifestyle modifications such as a balanced diet, avoidance of tobacco and alcohol, careful use of medications, physical activity, and increased protection from falls. Please refer to Table 1.
Calcium and bone metabolism can be influenced by dietary habits and foods. Inadequate calcium intake is caused by insufficient intake of dairy products such as milk, yogurt, and cheese. Soy products, vegetables, fruits and seaweed have preventive effects on osteoporosis and menopausal syndrome. Milk, dairy products, tofu and yellow green vegetables are indispensable daily, and fish and shellfish are also consumed as much as possible to ensure a daily calcium intake of 800mg or more. On top of this, take care to maintain a balance of protein, vitamins and minerals.
Basic bone health supplements include calcium and vitamin D. Calcium is recommended to slow down bone loss and improve bone mineralization, with a daily intake of 800-1000 mg. Elderly people in China get about 400 mg of calcium from their diet daily, and should take 500-600 mg of calcium supplements, but avoid taking extra large doses of calcium supplements. Currently, various calcium supplements on the market contain different amounts of elemental calcium, and calcium preparations with high content should be chosen.
Calcium that can dissolve naturally in the gastrointestinal tract (without the condition of stomach acid), including calcium in milk and calcium citrate, is suitable for people with low stomach acid such as the elderly. Calcium citrate can be taken when the stomach is emptying. Calcium carbonate requires stomach acid to dissolve and is restricted to people with low stomach acid, such as the elderly, and is best taken with a meal, as stomach acid and the acid in food can help it dissolve. Please refer to Table 2.
Vitamin D can promote calcium absorption and reduce the risk of fracture. The recommended dose is 200IU (5mg)/day for adults, 400~800IU (10~20mg)/day for the elderly, and 800~1200IU/day for the treatment of osteoporosis. Blood and urine calcium should be monitored regularly with vitamin D supplementation. Please refer to Table 3.
Pharmacological intervention: “triple drug combination” is effective
Medication should be considered if one of the following conditions is present.
1. Patients with diagnosed osteoporosis (BMD T-value ≤ -2.5), whether or not they have had a fracture.
2.Patients with low bone mass (BMD T value of -2.5~-1.0) and more than one osteoporosis risk factor, with or without previous fracture.
3.When there is no bone densitometry condition, if there has been a fragility fracture, drug treatment also needs to be considered.
There are three types of drugs commonly used in osteoporosis treatment. Drugs that inhibit bone resorption include calcitonin, bisphosphonates, estrogens, selective estrogen receptor modulators, etc. Drugs that promote bone formation include calcium, vitamin D, parathyroid hormone, etc. Other drugs include strontium salts, vitamin K, phytoestrogens, herbs, etc.
Osteoporosis treatment emphasizes the combination of drugs with different mechanisms of action. The combination has a synergistic effect and can reduce or even reverse bone loss in the elderly. The currently accepted drug combination is a “triple drug combination” of calcium, vitamin D, and a bone resorption inhibitor, called the “land, sea, and air” combination. This combination can increase bone density and reduce the risk of fracture, but the side effects are not elevated. Since the mechanism of action of the drugs differs depending on the patient’s condition, it is recommended that patients use the drugs according to their specific condition under the guidance of a physician.
Rehabilitation: Exercise can prevent fragility fractures
Exercise is one of the successful measures to ensure bone health. Exercise has different effects on bone at different times, increasing bone mass in childhood, gaining bone mass and preserving it in adulthood, and preserving bone mass and reducing bone loss in old age. Exercise can prevent fragility fractures in two ways: by increasing bone density and by preventing falls.
The main forms of exercise include weight-bearing exercises and resistance exercises, such as brisk walking, dumbbell exercises, weight lifting, rowing exercises, and pedaling exercises. The frequency and intensity of exercise varies from person to person. It is recommended that weight-bearing exercise be performed 4-5 times a week and resistance exercise 2-3 times a week; the intensity should be such that the muscles feel sore and tired after each exercise and the feeling disappears the next day after rest.