1st Place Diversity Essay
Public Health: Preventative Care for Osteoporosis in Men
By: Stacey Steer Mercer PA-S, Duquense University
Osteoporosis is traditionally associated with post-menopausal women; however, it is also becoming recognized as a cause of morbidity and mortality in men. By 2010 it is predicted that more than 17 million men will have osteoporosis or osteopenia, known as low bone mass.1 Men account for approximately 30% of all hip fractures2 and are twice as likely as women to die in the hospital after a hip fracture.1 It is estimated that direct medical costs of osteoporosis are between $13.7-20.3 billion in the United States alone.2 Due to this we should place a stronger public health focus on proper calcium intake for young men, screening, early treatment and fall prevention to decrease the morbidity and mortality and also decrease the health care cost in men with osteoporosis.
Osteoporosis is a skeletal disorder distinguished by low bone mass and micro architectural deterioration.1 This leads to bone fragility and an increased risk of fracture.1 Everyone reaches their peak bone mass by 20 years of age, however, men achieve a peak bone mass which is at least 8-10% higher bone mineral density than women.1 Once a person reaches the age of 30, bone mineral density is maintained through resorption and remodeling.1 In osteoporosis, there is a high rate of bone turnover which leads to bone frailty, and finally fracture.1
Often the development of osteoporosis in men is multifactorial.1 There are two categories of osteoporosis: primary and secondary.1 Primary osteoporosis usually occurs in men older than 70 years and is idiopathic in origin.1 Secondary osteoporosis is due to risk factors.1 These risk factors include chronic diseases that alter hormone levels, regular use of glucocorticoids, undiagnosed low levels of testosterone, smoking, excessive alcohol use, low calcium intake, and inadequate physical exercise, age, and race.3 The most common secondary causes are hypogonadism, glucocorticoid use, and alcoholism.1
By age 65 or 70, men and women are losing bone mass at the same rate.3 6% of men will suffer a hip fracture and 5% will endure a vertebral fracture caused by osteoporosis after the age of 50.3 Hip fractures are the most important osteoporotic fracture, because they are very costly and have a high morbidity and mortality rate.4,5 In 1995 hip fractures accounted for 63% of the total medical costs for all osteoporotic fractures.4 Hip fractures carry a high risk of morbidity and mortality.5 In one study, at 12 months after discharge, 32% of men had died.5 In women in the same study, the mortality rate at 12 months was only 17%.5
Early detection of osteoporosis can be difficult because the disease is often asymptomatic in men.1 Frequently it is diagnosed in men as an incidental finding on radiography or after a low-trauma fracture.1 Low trauma fractures are most often seen in the middle and lower thoracic and upper lumbar regions of the vertebral column; they are also seen in the wrists, hips, ribs, pelvis and humerus.1 Patients may attribute back pain to aging and may not seek treatment.1 Patients should be educated about vertebral compression fractures so they can help health care professionals identify this important symptom early on. Vertebral compression fractures may cause a loss in height and spinal deformities, for instance “Dowager’s Hump”, which is a dorsal kyphosis accompanied by a cervical lordosis.1
During the history it is very important to focus on nontraumatic fractures, osteopenia seen on radiography, and any family history of osteoporosis or osteopenia.1 The health care professional should also assess for risk factors of osteoporosis.1 In the course of the physical exam it is important to take height measurements.1 Height loss is caused by vertebral fractures; consequently hip-to-heel length remains the same.1 The most accurate clinical assessment is the crown-to-rump height.1 This is taken with the patient seated on a firm stool.1 In men fifty years or older osteoporosis should be screened for at each office visit. This will help to reduce fracture incidents from osteoporosis.
Bone mineral density measurement is the gold standard for diagnosing osteoporosis.1 Bone mineral density is measured using dual-energy x-ray absorptiometry (DEXA).1 Unfortunately, there is no normative data to use to assess the occurrence of osteoporosis in men.4 Currently men’s results are being compared to those of post-menopausal women for diagnosis.1 The International Society for Clinical Densitometry recommends DEXA for men over 70 years old who have risk factors and for potential candidates for pharmacologic therapy.1 The International Society for Clinical Densitometry currently also recommends using separate guidelines to assess men’s DEXA results.5
If DEXA testing is to be an effective diagnostic tool of osteoporosis in men, then there needs to be guidelines established for what are normal DEXA results of a 20 year old male as well as an older male. There also needs to be diagnostic criteria for the determination of osteoporosis in a man. In addition, there should also be criteria for what findings in the history and physical exam maybe indicative of the need for DEXA to determine if osteoporosis or osteopenia is present.
Once there has been a diagnosis of osteoporosis, there are multiple nonpharmacologic and pharmalogic options for management of osteoporosis. Nonpharmacologic options include smoking cessation, decreasing alcohol consumption, weight-bearing exercises and maintaining adequate calcium and Vitamin D intake.1 Support and assistance should be offered for lifestyle changes that may be difficult. Maintaining adequate calcium and Vitamin D intake is essential in osteoporosis prevention and treatment. Men 50-65 years old should take 1,200 mg of calcium per day, men older than 65 years should take 1,500 mg per day, Vitamin D should also be taken at 800 IU per day for any age.1
Common pharmacologic treatments for men with osteoporosis include testosterone replacement therapy, bisphosphonates and parathyroid hormone (PTH).1 These work to decrease bone resorption, increase bone remodeling, or a both.1 Osteoporosis is often undertreated in men. One study found that on discharge from the hospital following a hip fracture, less than 5% of men were being treated for osteoporosis.5 In men whom had had a previous hip fracture, only 13% were being treated before their second hip fracture.5
Health care professionals should be treating these patients early. If a patient does come in with an osteoporotic fracture though, they should not be released without receiving some form of osteoporosis treatment. Patients will often require more than one form of treatment. Patient education and discussion will result in the patient having a better understanding and better compliance with therapies. Patients should also be followed to ensure any medications they are taking are interacting with their body effectively to stop or possibly even partially reverse the course of osteoporosis.
Nearly all fractures are caused by a fall.1 There are many factors which can lead to a fall, both environmental and medical.1 If a fall has occurred patients should undergo a medical and home risk assessment to establish if there should be changes made.1 In their homes patients may need to minimize clutter, install handrails, anchor rugs, and increase lighting in halls and stairwells.1 To minimize the impact of medical problems, patient’s eyesight and balance should be assessed and treated after a fall and at each office visit.1 Also, there should be a focus on arthritis, which causes many falls, and medications that have sedative effects.1Public health education for elderly men should include a focus on fall prevention. By educating men before they have even experienced a fall, there would hopefully be a decrease in the number of falls and associated fractures
It is important for young boys prior to the age of 20, which is when peak bone mass is reached, to get proper amounts of calcium.1 A greater public health focus should be placed on encouraging parents to insist on their male children taking proper amounts of calcium and vitamin D. This will lead to a higher peak bone mass and a reduced likelihood of getting osteoporosis and having osteoporosis related fractures as they age. This could be achieved through a public health campaign which focuses on the reasons for giving calcium and Vitamin D and which shows how much should be administered.
Osteoporosis is a serious problem in men and should be addressed as such. As this comes to be more acknowledged it is important to educate the public about osteoporosis in men and what they can do to prevent it, ensure early detection, and treat osteoporosis if they are diagnosed. As a result, there will be a decline in the number of incident fractures, men diagnosed and also the severity of osteoporosis in men as they are detected earlier.
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