Last Updated July 2015
Understanding the Problem
As people age, their bones begin to thin and lose strength. Bone thinning is called osteopenia. Severe bone thinning to the point where a person is at a high risk for broken bones is called osteoporosis.
Up to age 75, osteoporosis is more common in women than in men. At that point, men “catch up.” Women who develop osteoporosis usually do so after menopause. After menopause a woman's body stops producing estrogen, one of the hormones that keeps bones strong. Without estrogen, bones may become softer, weaker, and more likely to break. Women who have a family history of the disease, are thin, smoke, or did not take hormones after menopause are most at risk for osteoporosis.Warning signs of osteoporosis include loss of height or a stooped posture. However, most people are not aware of their bone loss until a bone is broken.
Other risk factors include a diet low in calcium and Vitamin D, lack of exercise, lack of exposure to the sun, smoking, excessive alcohol or caffeine use, a history of an overactive thyroid gland, and taking certain medicines such as corticosteroids and medicines used to treat seizures.
For reasons that are unclear, white people and Asian Americans are more likely to develop osteoporosis than African Americans. Older men are also at risk for osteoporosis, particularly after prolonged inactivity.
For people with osteoporosis, any little bump, trip, or fall may be all that is necessary to cause a broken wrist, hip, vertebra, or backbone.
Sometimes a bone can break first, and then the person falls. Also, an older person's bones may take longer to heal.
Once a person has broken a bone, inactivity must be avoided at all costs. Older people who are laid up for months healing a broken hip are unlikely to get back to their previous levels of activity. After that experience, they may be afraid to go out or walk.
For this reason, orthopedists recommend fixing most hip fractures by operating on them. The person can get up and start walking with the help of a physical therapist almost immediately.
Unfortunately, some older people who have fallen cut back on exercise for fear of falling again. Lack of exercise will further weaken bones and muscles and actually make falls more likely. So it is important for older people to be as active as possible, even after a fall.
Your goals are to:
- Call the healthcare provider if the older person has a serious fall
- Encourage proper diet and exercise
- Strengthen bones
- Prevent falls
Click on each of the topics below to read more.
Call a healthcare provider or go to the emergency room immediately if any of the following occur
The older person has experienced a major fall
If the older person has experienced a major fall and is able to get up quickly and is not feeling pain, it might not be necessary to see a healthcare provider. However, if the older person experiences a hard fall, it is important to see a healthcare provider as soon as possible. (An example of a hard fall is when someone’s legs suddenly move out from under them and they land on their back or side.) A frail older person can suffer a broken bone from a seemingly minor injury.
Pain in the hip or in the groin after a fall
This could mean a broken hip or pelvis.
- Difficulty or pain when standing or trying to walk after a fall.
- Limping or other unsteadiness in gait after a fall.
- Serious back pain
- Pain such as after lifting a heavy object, reaching overhead, or taking a wrong step off the curb.
- Pain or swelling after a fall or if a bone has an unusual shape.
Call a healthcare provider during office hours to discuss the following problems
Feeling lightheaded or dizzy
Lightheadedness or dizziness can increase the risk of an older person falling and fracturing a bone. Fluid loss from diarrhea or vomiting can cause lightheadedness. Also, drugs used to treat high blood pressure, depression, chronic pain, and insomnia can make people dizzy, less alert, or lightheaded when they stand, especially at night. Keep track of what prescription and over-the-counter medicines the older person is taking and report any side effects to the healthcare provider.
Recurring pain after hip surgery or a fracture
If there is recurring pain after hip surgery or a fracture, contact the healthcare provider, as this could be a new problem. Pain can be controlled with medicines, or, in some instances, with physical devices such as braces. Exercising in a swimming pool can help to restore flexibility and strength and reduce pain without stressing the body like other types of exercise. If the older person continues to have pain or remains unable to participate in normal activities, you may wish to ask for a referral to a rehabilitation specialist.
Know the answers to the following questions before calling a healthcare provider
If the person has fallen, have the SPLAT information ready:
- Symptoms
- Previous falls
- Location
- Activity
- Time
In addition, be prepared to answer questions such as, how old is the person? Are they frail? What other conditions does the person have?
Prevent falls
Make the older person's environment risk-free
- Have proper railings on all stairs and provide good lighting
- Do not use throw rugs on hardwood floors
- Keep electrical and telephone cords near walls and out of walking paths
- Make the older person's room and pathway to the bathroom free of clutter
- Use night lights
- Install grab bars in the bathroom or shower walls, on the tub, or in the wall
- Encourage the use of stabilizing devices if the older person has walking problems or is unsteady on their feet
Many older people are, at times, unsteady when they walk. If the older person uses a cane, they should be encouraged to carry it at all times. A cane can be used to provide “emergency” support when the person feels unsteady. The cane or other stabilizing device, like a walker, should be fit properly. A physical or occupational therapist can help to get a good fit and can show the older person how to use the cane properly.
Encourage drinking fluids
Encourage the older person to drink four to six glasses of water a day. When people become dehydrated they often feel dizzy and can fall. Fluid loss from diarrhea and vomiting needs to be replaced by drinking liquids. If the older person is taking a diuretic medicine to get rid of fluid or treat high blood pressure, check with the healthcare provider about how much liquid should be taken in each day
Strengthen bones
Encourage taking calcium
Older people should take in 1200-1500 milligrams of calcium a day. The best sources of dietary calcium are milk and other dairy products such as yogurt and cheese. You can also buy calcium supplements with vitamin D that help the body absorb calcium. Inexpensive calcium tablets are widely available, but some store brands may not be as effective. Check with the healthcare provider.
Calcium tablets may need to be broken up to be easier to swallow. Calcium citrate tablets are digested easily and absorbed better than calcium carbonate. If the older person has trouble digesting milk, try products such as Lactaid™,which contains an enzyme that aids in digesting milk. There are also lactose-free milk products. For those watching their fat intake, many delicious low or non-fat dairy products are available that supply an adequate amount of calcium.
Older people should take calcium and vitamin D supplements if they are taking drugs to control seizures or are taking steroids, as these medicines are damaging to bones.
Discourage smoking and limit alcohol
If possible, the older person should give up smoking, since it weakens bones. As for drinking, an occasional glass of wine or a beer with dinner is fine for most people. However, too much alcohol both weakens bones and contributes to falls.
Encourage exercise
One of the worst things the older person can do is to stay seated on the couch and avoid exercise. Exercise strengthens the bones and muscles, improves steadiness when walking, and helps prevent fractures. Activity helps people carry their bodies better and makes them less clumsy or unsteady.
Depending on the older person's condition, there are many good exercises: walking, running, swimming, lifting weights, or riding a stationary bike. Housework and gardening are also beneficial and should be encouraged if the older person enjoys these activities.
Bones actually get stronger and muscles become strengthened with exercise. Let the older person work at their own pace and slowly develop an exercise routine.
Ask about bone-strengthening medicines for women
There are several medicines that can slow bone loss in women, including estrogen replacement and bisphosphonates.
Estrogen
Estrogen use has been shown to prevent bone loss and reduce the rate of fractures in post-menopausal women. The greatest bone loss occurs in women after menopause, when the body stops producing estrogen. Estrogen replacement improves menopausal symptoms, and can reduce the risk of osteoporosis and the incidence of colon cancer.
Taking estrogen alone puts some women at slightly greater risk for developing cancer of the lining of the uterus, so estrogen is often taken along with progesterone (another hormone) to protect against this. However, recent studies have shown that this combined therapy can increase the risk of certain diseases, so a decision to take estrogen or combined estrogen-progestogen therapy should be discussed with a healthcare provider and the risks and benefits to the individual woman carefully considered.
Biphosphonates
Biphosphonates are another medicine that can be taken to slow bone loss in women. Actonel™ and Fosamax™ are bisphosphonates that can be taken orally on a daily or weekly basis but may cause upper gastrointestinal side effects such as esophageal ulcers. They must be taken on an empty stomach.
Other Medications
Parathyroid hormone is a recently licensed medicine that shows promise but which must be taken by daily injections at this time.
Calcitonin can be taken through a nasal spray or by injection.
Synthetic estrogen receptor modulators (SERMs), taken orally, reduce bone loss in postmenopausal women. Raloxifene (Evista™) is one of them. They do not affect the breast or the uterus, and so far have not been found to have bad effects on the heart. There is an increased risk of venous thrombosis in some women. Postmenopausal symptoms, such as hot flashes, are not helped, and, in fact, may be worsened by them. Calcium and vitamin D are usually prescribed with these medicines.
Ask about testosterone replacement for men
Men who have very low levels of testosterone are also at risk for osteoporosis and can often benefit from testosterone replacement treatment. The benefits and risks of this should be discussed with their healthcare provider.
Even when you have excellent plans, there can be obstacles or problems that prevent you from carrying out your plans. You or the older person may have some beliefs that might get in the way of carrying out your plan. Here are some responses that can challenge those beliefs.
"I don't need bone strengthening medicines"
"Taking one of the above medicines can significantly strengthen your bones and avoid fractures. Your healthcare provider can help you choose one that is right for you."
"I'm afraid of exercising. I might fall and break another bone."
"Ask your healthcare provider for a referral to a physical therapist who will show you some safe exercises. Walking is one of the best exercises and can be done outdoors when the weather is good or indoors if the weather is bad. Many shopping malls open early so that groups can get together to exercise and socialize. This can make exercising fun. If you don't exercise, your bones and muscles will become weak and your chances of falling will increase."
"I've been smoking since I was 15 and I don't need to stop now."
"It is hard to change things you have done for a long time. But your body has changed and so stopping smoking is more important now, especially for your bones. A fracture now could mean an end to your independence or even the end of your life. You should think hard whether the satisfaction from smoking is worth these risks."
"I can walk fine without a cane."
"A cane will make you more independent because it can prevent falls from happening. If a cane prevents just one serious fall, it will be well worth using it."
"I don't have time to be Mother's exercise coach."
"A complicated exercise routine for your mother is not necessary. But it is very important that activity becomes part of her everyday routine. Even simple activities will do much to improve her physical, mental, emotional, and social health. If supervision is required, get help from other family members or friends. They should understand that helping with exercise on a regular basis is a key part of caring and support for an older person, as well as for improving health."
“It hurts to exercise.”
"Your healthcare provider should find out why you hurt and treat the cause if this is possible. There are many medicines now available to control pain once the reason for it is known. A physical therapist can develop an exercise program to minimize pain and help you gain more control over your pain. A gentle warm-up routine can help prevent aches and strains."
Think of other problems that could interfere with carrying out your plan
What other problems could get in the way of doing the things suggested in this presentation? For example, will the older person cooperate? Will other people help? How will you explain your needs to other people? Do you have the time and energy to carry out this plan?
You need to make plans for solving these problems.
The key to avoiding bone problems is to review the suggestions outlined in this guide. Ask yourself the following questions. Some of these questions will need to be discussed with the older person's healthcare provider:
- Is the older person taking too many medicines? Are there any unpleasant side effects of medicines such as dizziness or drowsiness, which can lead to falls? If corticosteroids are being taken, can the dose be reduced or tapered off completely? If not, ask about taking calcium and vitamin D supplements.
- Does the older person have a well-balanced diet that provides the proper amount of calcium? Should the older person be taking one of the bone strengthening medicines described earlier? Have the risks and benefits of each medicine been thoroughly considered?
- Does the older person have a well-balanced diet that gives the proper amount of calcium?
- Have you taken measures to reduce the risk of the older person falling?
- Is the older person continuing to smoke? Would your encouragement help in quitting?
- Is the older person drinking excessive amounts of alcohol? If so, can you help reduce the use of alcohol?
- Is the older person less active? If so, is this because of persistent pain, general social withdrawal, or some other problem? Start with low levels of regular activity and work up towards greater activity. It’s never too late to start, as benefits can be gained at any age.
What to do if your plan isn't working
Many of the causes of bone problems are hard to change quickly. Be persistent and set reasonable goals. Small changes will eventually add up to larger ones.