Bone Deterioration & Fracture Risks among the Elderly

In Part 1 of our Elderly Joint and Bone Health article series, we covered common conditions related to inflammation and wear and tear of the joints, including

1. Rheumatoid arthritis (RA)
2. Osteoarthritis (OA) and Osteophytes (Bone Spurs)
3. Frozen Shoulders (Adhesive Capsulitis)
4. Sacroiliac Joint Pain

In this article, we focus on diseases that lead to bone deterioration, including osteoporosis, osteomalacia, and musculoskeletal tumours. We are also addressing two common consequences of bone deterioration: bone fractures and degenerative disc disease. 

Why is it important to pay attention to bone deterioration?

Bone deterioration and fractures are common causes for hospitalisation among elderlies. Bone deterioration aggravates the impact of falls among elderlies, in some cases causing serious consequences such as head injury, disability and even death. Recovery also takes longer and costs more for seniors. The mean medical cost for 3-month care, including hospitalisation and recovery for a case of osteoporotic fracture is estimated to be SGD 3,886.90, and up to SGD 11,438.70 in acute cases. 

According to the SAFE (Steps to Avoid Falls in the Elderly) study, 85% of emergency cases involving elderly patients with trauma in Singapore are due to falls. A study of patients with osteoporotic hip fractures revealed 26% of these patients could die in 1 year due to complications. Those who stay alive past 1 year are likely to need a walking aid, a wheelchair or remain bedridden for an extensive period. Whether you are entering senior years, or caring for an elderly at home, understanding bone deterioration and fall and fracture risk is critical. 

5. Osteoporosis

Overview

Osteoporosis features a progressive loss of bone strength, medically known as bone density. The bone becomes weak and brittle, increasing the risk of fractures, even after a minor fall. This is why elderly falls are so dangerous.

Young people can also develop osteoporosis, but it is more common in older adults. Bone tissues are renewed all the time in our body. Old bone tissues are broken down and replaced by new bone tissues. In children and teenagers, more new bone tissues are created than old bone tissues that need to be replaced, propelling them to grow. From the age of 40, however, it is common that new bone turnover rate is slower than old bone tissues breaking down, resulting in less ‘dense’ bone. When the imbalance between the two rates is too big, bones become ‘porous’ or spongy, and the person is diagnosed with osteoporosis. 

Causes & Risk Factors

In most cases, patients develop osteoporosis due to a number of factors rather than a single one. Some of the risk factors can be changed (modifiable risk factors) and some can not, for example age and gender (non-modifiable risk factors). Knowing the risk factors can help you prevent the condition from happening or worsening. 

• Age: New cell production in adults slows down with age. However it doesn’t mean that everyone will get osteoporosis in old age. Osteoporosis only happens when the gap between new bone tissue renewal and old bone tissue breaking down is too big.  
• Gender: Women are at higher risk than men, due to their smaller bones and lower bone mass.
• Body size: Smaller-sized, slender individuals are known to be at greater risk of developing osteoporosis.
• Hormonal changes: A number of hormones are important in bone formation in humans, most notably estrogen. Women after menopause experience a drop in estrogen levels, making them prone to osteoporosis. In other cases, individuals with hormonal disorders or ovariectomy resulting in low estrogen production could also be at increased risk.
• Diet: Of the various nutrients the body needs for bone production, calcium and vitamin D are most important. The body can not make calcium by itself, which is why sufficient calcium is critical throughout our lifetime to maintain bone health. People who have sustained a low intake of calcium and vitamin D are at higher risk of osteoporosis. 
• Lifestyle: Sedentary lifestyle with low levels of exercise and prolonged periods of inactivity can contribute to loss of bone strength and eventually osteoporosis. Smoking and heavy drinking are also identified as risk factors for osteoporosis. 
• Medication: Several drugs when used for long term are known to make it more likely for older adults to develop osteoporosis, include anti-clotting medications to prevent stroke, chemotherapy drugs to fight cancer, anticonvulsants, and steroid drugs to treat inflammation. 
• Other medical conditions: A number of diseases such as kidney disease or problems with the parathyroid gland can cause osteoporosis. In these cases, the body does not deal with calcium appropriately, resulting in considerable bone loss. 
• Family history: Your risk for osteoporosis could be higher when you have a close family member with the condition.

Symptoms

Osteoporosis is a silent disease. Most of the time, it doesn’t come with any obvious symptoms. Patients typically find out they have osteoporosis when they have a fall or a fracture and are recommended for a bone density check. In some cases, symptoms can be noticed such as intense back pain, loss of body height, or a hunched back that can’t be straightened due to spine malformation, or changes in the way a person walks. 

If you identify a few of the risk factors above, the best way is to do a bone density check even if you don’t have any symptoms. It is a quick, non-invasive process called Bone Mineral Density (BMD) test, typically done for the hip and spine area. The objective is to detect low bone density level before osteoporosis happens, or diagnose it early if it has happened, and intervene quickly. 

Complications

The most alarming complication of osteoporosis is elderly fractures, especially when it happens at the hip, due to the serious consequences associated with osteoporosis-related hip fractures such as high cost for treatment and recovery, the possibility of long-term disability, or even death.

Osteoporosis also causes chronic pain, usually located in the back. Activities the patient used to enjoy are now painful. Patients end up exercising less and exacerbating the condition and other health problems. They are more likely to experience anxiety and depression, too.

Treatment

In cases where the underlying causes of osteoporosis are treatable, the condition will improve when the causes are removed. For example, when a medication is causing the problem, we can take it away and replace it with another medication option. Lifestyle changes such as quitting tobacco smoke, controlling alcohol consumption may also improve this condition if these are the causes.

Doctors may also prescribe medications to help with bone renewal for certain individuals, or when medication that causes osteoporosis can’t be replaced, including medications to slow down bone loss, improves hormone production and 

In all cases, a nutritious diet with calcium and encouraging exercise will progressively strengthen the bones. Foods that are good sources of calcium include milk, cheese, yogurt and other dairy products, soya bean milk, green leafy vegetables such as kale and broccoli, and fish with bones such as canned sardine and canned salmon. Calcium supplements can be helpful, under doctor’s guidance. Be careful not to exceed a dose of 2,500 milligrams of calcium. Doing so could increase the risk of kidney stones. The recommended calcium intake by most health authorities is 1,200 milligrams a day. 

Prevention

The recommendations listed above work to prevent and treat osteoporosis at the same time. It is also important to check vitamin D levels in older adults, especially dark-skinned seniors and those who do not go out much. A healthy diet and exercise are fundamental to maintaining our calcium levels and strengthening our bones every day.

Preventing falls is also key for individuals suffering from osteoporosis. Making your home fall-safe, improving balance, eye sight, engaging in exercises to improve muscle strength and alertness all contribute to reducing fall risks and its consequences among osteoporosis seniors. 

6. Osteomalacia

Overview

Similar to osteoporosis, osteomalacia is a bone-softening problem. But this time, the cause is not a problem in calcium exchange by the bone tissue. Instead, there's a deficiency of vitamin D, which causes abnormal mineralization.

This problem is particularly relevant in older adults because they are at a higher risk of vitamin D deficiency. It is even more common in dark-skinned individuals who receive limited sunlight exposure or wear full-body clothing. It is an underestimated and silent disease affecting around 25% of older adults, according to post-mortem studies. 

Causes

The cause of osteomalacia is a reduction of vitamin D levels, which may come from:

• Insufficient production of vitamin D through sunlight exposure or as a part of the aging process
• Decreased absorption of vitamin D due to inflammatory bowel disease and other gastrointestinal problems
• Alterations in how the body uses vitamin D. For example, in liver and kidney disease.
• Medications such as steroids and antifungal agents used for a very prolonged period. They also change vitamin D metabolism, that is, how the body uses vitamin D.

Symptoms

Osteomalacia is another silent disease. As such, patients often remain asymptomatic until they fall and fracture a bone. Some older adults could experience symptoms of vitamin D deficiency before that. These symptoms are non-specific and often difficult to trace, including:

• Joint pain and muscle pain
• Muscle weakness and a reduction in muscle mass
• Painful muscle tightness, medically known as spasms
• Changes in how the patient walks

Patients with osteomalacia could experience bone pain, which is made worse by weight-bearing. If this condition is held for a very long time, they could also have bone deformities a doctor can see in X-rays.

Complications

Similar to osteoporosis, the most common complication is an increased risk of falling and enduring a bone fracture. Additionally, patients with osteomalacia could also experience seizures caused by an abnormal exchange of calcium in their organism. The muscle tissue can also endure very prolonged and severe spasms, known as tetany.

Treatment

The underlying cause of osteomalacia is vitamin D deficiency. Thus, vitamin D supplements can rapidly change this problem. However, the effect of vitamin D therapy will reflect on bone tissue after a long while. It takes weeks to normalize calcium levels and months to normalize bone chemistry changes.

The treatment is very long, and the patient should have a follow-up every six months to check their urine calcium levels and other parameters. The dose of vitamin D used to treat osteomalacia is adjusted in each patient, and they are usually recommended to consume 1,000 mg of calcium every day. 

Prevention

We can prevent osteomalacia by ensuring that seniors receive sunlight through an open window or in their daily walks. Dietary sources are required in patients with malabsorption problems and a dark skin tone. 

Keeping a healthy weight is also helpful, and exercise will contribute to strengthening their bones. Consuming fortified products with vitamin D, including milk, cheese, and yogurt, will help reach the recommended intake in winter and countries located in the northern hemispheres.

7. Musculoskeletal Tumours

Overview

This is a broad category of tumors located in the bone, cartilage, or muscle. According to the Manual of Orthopaedic Terminology, it comprises over 30 types of tumors which are sometimes broken down into different categories and sub-types. Some of them are benign, and others are malignant - or cancerous - tumors.

When the tumor is cancerous, you will hear the name sarcoma. They tend to spread to other tissues and sometimes come from cancer located elsewhere. On the other hand, benign tumors are more common. They do not spread to other tissues but cause a higher risk of fracture and significant pain.

Causes

As it happens with all types of cancer, musculoskeletal tumors do not have a single cause. They are multifactorial diseases, which means that many different factors join in the same patient causing this problem. Such risk factors include:

• Genetic predisposition
• Previous radiation treatment to destroy past cancer
• Recurrent bone fractures and metal implants in the bone
• Paget's disease, especially in older adults. This is a chronic disease in the bone tissue that affects bone tissue remodeling, creating new bone with an abnormal shape.

Symptoms

Musculoskeletal tumors are lumpy growths in bone tissue or soft tissues. As such, it can be felt through the skin in some cases. But when it is not near the surface, the only symptoms reported by patients are:

• Bone pain located in the site of the tumor
• Redness and swelling all around the tumor and tenderness to the touch
• Changes in bone mineralization that weakens the bone and increases the risk of fractures
• In malignant bone growths, the patient will also experience fatigue and weight loss.

Complications

The worst complication of this type of bone growth is metastasis. It is the spread of a malignant tumor and only happens in cancer. The consequences are far-reaching, affecting different organs and causing severe health problems. Luckily, bone cancer is not the most common type of musculoskeletal tumor.

In metastasis to the bone and benign bone tumors, crippling pain and functional limitation are common consequences. Bone chemistry often changes, and calcium exchange is affected, weakening the bone and increasing fracture risk.

Treatment

Some benign tumors resolve by themselves after some time, mainly if they occur as a part of the healing process of a fracture. Others do not keep growing and do not require surgery. But when the tumor keeps growing or causing severe symptoms, surgery will be necessary to remove the tumor. In most benign cases, the tumor won't grow back.

On the other hand, bone cancer is often found at an advanced stage when surgery is not enough to treat the problem. These patients often require radiotherapy, chemotherapy, and targeted therapy to control cancer growth.

Prevention

There is no current method to prevent bone tumors. However, it will be useful to check on patients with Paget's disease and those who underwent radiotherapy in the past to make sure they do not develop bone tumors.

8. Elderly Bone Fracture

Overview

Bone fracture happens when the bone has to endure greater force than it can take. Fractures include both total breakage (complete fracture) and crack in the bone (incomplete fracture). It happens most commonly in the hip, spine and wrist areas as a result of a fall. In addition to being more susceptible to falls and fractures, seniors take longer to heal and recover from bone fractures, due to age-related lower bone renewal rate, making fractures more devastating for older seniors than everyone else. 

Studies show that hip fractures caused by osteoporosis are on the rise. Since 1960, the number of seniors with this type of fracture has risen 5-fold in women and 1.5-fold in men. Researchers predict that by 2035 the incidence of osteoporotic fractures in Singapore will increase by 58%. This will have an economic burden of up to SGD 289.6 million a year if we don't do something about it.

Causes

Throughout this article, we have discussed elderly bone fracture as a complication of osteoporosis, osteomalacia, and bone tumors. Doctors refer to these cases as pathologic fracture, which means that fractures happen as a result of other medical conditions. We have also discussed falls as a cause for fracture. 

Another cause is simply bone fragility. Unlike younger individuals who require a severe blow to break a bone, older adults with a degenerative bone structure might experience a fracture after a minor fall, stress, trauma, or just a sneeze. In some cases, seniors experience unhealed microscopic bone tears caused by day-to-day activities without any other traceable cause. 

Symptoms

Elderly bone fractures have the same symptoms as a regular fracture:

• Deformity of the bone
• Limited mobility or a complete loss of function
• Pain and tenderness
• Redness and swelling

Complications

Serious fractures can cause debilitating consequences. Statistics about elderly bone fractures in Singapore are genuinely alarming. At one year, 26% of patients die from complications such as blood clot formation, pneumonia, and urinary tract infections due to long-term immobilization and complications after surgery to repair the affected bone.

Of those patients who stay alive after one year, 39% need a walking aid, 24% are left bound to a wheelchair, and 9% remain bedridden with a high risk of bedsores, infections, and other complications.

Treatment

The main goals of treatment for fracture are putting the bone back in place and controlling the pain. Thus, patients usually need painkillers and immobilization of the affected limb. In a complete fracture, pulling and stretching the limb could be required to align the bone ends. Surgery is also an option if the broken bone is unlikely to heal by itself.

Prevention

We wouldn't have as many cases of elderly fractures if older adults were carefully followed up. Many of them have a silent and undiagnosed bone condition that only manifests after they endure a fall. The best way to prevent fractures is to improve bone health and prevent falls. To learn more about fall risks among elderlies and making our homes safe for live-in seniors, read our earlier article here. 

9. Degenerative Disc Disease

Overview

There are two structures in the spine that contribute to its stability and flexibility. They are vertebrae and intervertebral discs. The bony part is the vertebra, and the intervertebral disc is a soft and very resistant cushion that absorbs the impact and pressure held by the vertebrae. Degenerative disc disease is the progressive weakening of the intervertebral disc, which happens as we age.

Patients with osteoporosis and osteomalacia who do not experience a fracture may suffer from degenerative disc disease. Recent studies show that this happens to both men and women due to changes in how the bone responds to pressure. It is a common cause of back pain among older adults, and most cases are not correctly diagnosed.

Causes

The intervertebral disc is affected every day due to wear and tear. It takes the impact when the spine receives a blow and helps to carry the weight in obese individuals. This day-to-day damage builds up as we age. It is widespread in older adults and could be accelerated by spinal injuries.

Osteoporosis may also contribute to the degeneration. First of all, weakened bone and its intervertebral disc do not receive the same quality of nutrients. Secondly, the weakened bone does not respond to pressure the same way as a healthy bone. Thus, the wear and tear damage to the intervertebral disc increases significantly.

Symptoms

The main symptom of degenerative disc disease is pain. It is located in the affected area, usually the lower back, and becomes aggravated when sitting, bending, twisting, and lifting heavy objects. 

In severe cases, the space between one vertebra and the other is reduced, leading to compression of the nerves that go through this reduced space. When this happens, the patient experiences symptoms such as tingling, numbness, and burning pain.

Complications

Degenerative disc disease does not usually cause life-threatening or very severe complications. Still, advanced cases could lead to loss of bowel and bladder control when the vertebrae compress the nerve that goes to the bladder or anal sphincters. Pain caused by a nerve compression can be disabling and very difficult to treat, affecting the patient's independence and quality of life.

Treatment

In most cases, degenerative disc disease improves with over-the-counter medications and physical therapy. In very severe cases, doctors may recommend steroid injections or surgical treatment to release the nerve or replace the intervertebral disc.

Prevention

The key to the prevention of degenerative disc disease is reducing the burden on your intervertebral discs. Thus, it is recommended to keep a healthy weight because obesity is a very common trigger. Exercise is also known to help, especially core training to strengthen the back muscles, correct your posture, and protect your spine.

Seniors should also avoid violent twisting movements and bending actions, especially if they already suffer from back pain. Studies show that tobacco smoke contributes to the problem. It is advisable for seniors with degenerative disc problem to quit smoking and avoid second-hand smoke.

Following these recommendations will reduce your risk but may not be enough to prevent degeneration. Thus, talking to your doctor is fundamental to assess your spinal health and make sure that you won't suffer from severe mobility or spinal stability issues in the future.