Osteoporosis and fractures in older people: What are the possible complications?

Although a decline in the density of our bones is inevitable as we age, there are many lifestyle changes patients can make to help promote strong and healthy bones.

In this detailed guide to osteoporosis, leading consultant in rheumatology and general internal medicine Dr Ziad Farah explains how the natural ageing process affects our bone health and the importance of effective management of the condition in older people to avoid further complications.

How is osteoporosis defined?

Osteoporosis is a condition of weakening bones that tends to develop slowly over years and is associated with fragile bones that are likely to break and fracture. It is often diagnosed after a fall or sudden impact that leads to a broken bone – a fracture.

The World Health Organisation defines osteoporosis based on the bone mineral density and how this compares to average values of young healthy adults. This refers to the T-score. Osteoporosis is defined as a T-score of less than -2.5. A T-score of -1 and above is normal. Between -1 and -2.5 is called osteopenia.

It is important to recognise that osteoporosis, however, is not only an issue of bone density but also bone architecture. By analogy, a high-quality bridge is not one with just a lot of steel. Both the steel and the way in which it is structured combine to make a bridge strong. The same could be said about bone mineral density and bone architecture.

What are the signs and symptoms of osteoporosis?

Osteoporosis itself does not produce signs or symptoms on its own. Most symptoms relate to fracture and change in bone architecture. Often patients can have osteoporosis for years without realising. It is the fractures that are associated with osteoporosis that result in pain and disability.

Depending on the site of the fracture, there can be other symptoms too. Fractures within the vertebral column may cause compression of the vertebrae and can lead to a stooped posture and mechanical lower back pain. Hip and spinal fractures can also lead to a decline in mobility, imbalance and further falls.

What are the most common causes of osteoporosis?

A decline in bone density is a normal part of bone physiology over time. We reach a peak bone density in the mid to late 20s, and after the age of 40 this density begins to decline steadily. Women around the time of the menopause, due to the changes in hormones, experience a more rapid decline in bone density at that time.

Therefore, osteoporosis is dependent on two factors. The first is peak bone mass which is largely dependent on genetic factors, dietary intake of vitamin D and level of physical activity in the second and third decades of life.

The second is the rate of decline in bone density, which is influenced by hormone levels, certain medical conditions like hyperthyroidism or rheumatoid arthritis, medications including steroids, anti-epileptics and blood thinners like heparins, as well as lifestyle factors like smoking, alcohol intake, diet, body mass index (especially people who are very thin), and level of physical activity where immobility is most associated with rapid loss of bone density.

What lifestyle modifications should people make to help improve their osteoporosis symptoms and what should people avoid?

Lifestyle modification to reduce the risk factors for osteoporosis and fractures is the cornerstone of management strategies. Ensuring adequate vitamin D and calcium in the diet is a simple way to improve bone health. Foods such as dairy, egg, salmon, pulses, broccoli and mushroom are rich in vitamin D and calcium.

Regular weightbearing exercise also improves bone density. The recommendation is for about 150 minutes per week of moderate to vigorous intensity exercise including brisk walking, dancing, jogging, strength training or aerobics class.

As smoking and alcohol intake both negatively impact bone density, it is important to stop smoking and limit alcohol intake to the recommended allowance. The recommended maximum alcohol intake in the UK is no more than 14 units a week for both men and women, with two or more drink-free days in the week.1

How is osteoporosis treated?

In patients with a high risk of fracture and in whom lifestyle modification alone is unlikely to be sufficient, certain medications are used to treat osteoporosis. The most used medications are drugs that prevent further bone loss, known as anti-resorptive drugs such as Bisphosphonates. These can be taken orally as a tablet, or intravenously by a drip. More advanced anti-resorptive medications include a biologic therapy called Denosumab which is taken as an injection twice a year.

The second group of medications used in treating osteoporosis are drugs that promote new bone formation, or anabolic drugs such as Teriparatide or Romosozumab. These target the pathway associated with the parathyroid hormone which is responsible for regulating bone formation.

There are set criteria and considerations that need to be assessed before using these treatments. Finally, hormone replacement therapy (HRT) also plays an important role in managing osteoporosis. HRT has been shown to reduce vertebral, non-vertebral and hip fractures in postmenopausal women. The recommendation is to consider HRT in younger postmenopausal women with osteoporosis, often under the age of 60, as in older women, there is an unfavourable risk/benefit balance.

The management of osteoporosis requires regular assessment of risk factors and fracture risk. Care is tailored to the individual patient bearing in mind their unique circumstances. Over time, these may change and that is why regular review is needed.

How important is it that osteoporosis is managed in order to avoid the complications it can bring?

Osteoporotic fractures are associated with significant complications especially in older patients. Evidence suggests that one year after hip fracture, 60 per cent of patients had difficulty with at least one essential activity of daily living, 40 per cent were unable to walk independently and 30 per cent had permanent disability. In addition, there was a 20 per cent mortality one year post hip fracture.

Osteoporosis is also a rapidly progressive disease: one in four women with osteoporosis who sustain a vertebral fracture will have another fracture within one year, and one in three patients with subsequent non-vertebral fracture (such as hip or wrist) will have another non-vertebral fracture within one year.

A study which examined the impact of all clinical fractures on mortality rate using data from the Fracture Intervention Trial (FIT) found that women who sustained any clinical fracture had a six to nine times higher mortality rate, with the highest risk associated with hip and vertebral fractures.

Arguably therefore, treatments that have been shown to reduce fracture risk within the short term should be started as soon as possible in patients with higher fracture risk.

Not only is the impact of osteoporosis on the individual patient, but on a population scale, it is estimated that there are 8.9 million osteoporotic fractures every year world-wide, which is equivalent to a fracture every three seconds. In the UK, the cost of these fractures on the NHS is estimated at around £1.73 billion every year, and 1.3 million bed-days in English hospitals.

Dr Farah recommends accessing further information from The Royal Osteoporosis Society, Health Talk Online and The NHS encyclopaedia.

Dr Ziad Farah is one of the UK’s leading specialists in the management of osteoporosis. If you are concerned about osteoporosis or wish to discuss how your treatment plan could be improved, you can schedule a consultation with Dr Farah by visiting his Top Doctors profile.

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• Lindsay R, Silverman SL, Cooper C, et al. Risk of new vertebral fracture in the year following a fracture. JAMA 2001; 285(3):320-3
• Cauley JA, Thompson DE, Ensrud KC, Scott JC, Black D. Risk of mortality following clinical fractures. Arthritis & Rheumatism 1998; 41(9):S129