Ronald Klein was biking around his neighbourhood in Pennsylvania, US, in 2006 and tried to jump a curb. “But I was going too slow — I didn’t have enough momentum,” he recalled. As the bike toppled, he thrust out his left arm to break the fall. It didn’t seem like a serious accident, yet “I couldn’t get up”. At the emergency room, X-rays showed that he had fractured both his hip and his shoulder.
Klein, a dentist, went back to work in three weeks, using a cane. But he wondered about the damage the fall had caused. At a follow-up visit with his orthopaedist, he asked for a bone density scan.
As he suspected, the test showed that he had developed osteoporosis, a progressive condition that weakens bones and can lead to serious fractures. Klein immediately began a drug regimen and, now 70, remains on one.
Osteoporosis occurs so much more commonly in women, for whom medical guidelines recommend universal screening after age 65, that a man who was not a healthcare professional might not have thought about a scan. But about one in five men older than 50 will suffer an osteoporotic fracture and among older adults, about a quarter of hip fractures occurs in men.
When the fractures occur, “men have worse outcomes”, said Dr Cathleen Colon-Emeric, a geriatrician at the Durham VA Health Care System and Duke University, US, and the lead author of a recent study of osteoporosis treatment in male veterans.
“Men don’t do as well in recovery as women,” she said, with higher rates of death
(25 per cent to 30 per cent within a year), disability and institutionalisation. “A 50-year-old man is more likely to die from the complications of a major osteoporotic fracture than from prostate cancer,” she said.
In her study of 3,000 veterans aged 65 to 85, conducted at Veterans Affairs health centres, only 2 per cent of those assigned to the control group had undergone bone-density screening.
“Shockingly low,” said Dr Douglas Bauer, a clinical epidemiologist and osteoporosis researcher at the University of California, San Francisco, US, who published an accompanying commentary in JAMA Internal Medicine. “And that’s at the VA, where it’s paid for by the government.”
But establishing a bone health service — overseen by a nurse who entered orders, sent appointment reminders and explained results — led to dramatic changes in the intervention group, who had at least one risk factor for the condition.
Forty-nine per cent of them said yes to a scan. Half of those tested had osteoporosis or a forerunner condition, osteopenia. Where appropriate, most of them began medications to preserve or rebuild their bones.
After 18 months, bone density had increased modestly for the intervention group members, who were more likely to stick to their drug regimens than patients of either sex in real-world conditions.
The study didn’t continue long enough to determine whether bone density increased further or fractures declined, but the researchers plan a secondary analysis to track that.
The results revive a longtime question: given how life-altering, even deadly, such fractures can be, and the availability of effective drugs to slow or reverse bone loss, should older men be screened for osteoporosis, as women are?
Such issues mattered less when lifespans were shorter, Dr Bauer explained. Men have bigger and thicker bones and tend to develop osteoporosis five to 10 years later than women do. “Until recently, those men died of heart disease and smoking” before osteoporosis could harm them, he said.
“Now, men routinely live into their 70s and 80s, so they have fractures,” he added. With osteoporosis testing and treatment, “a man could see a clear-cut improvement in mortality and, more importantly, his quality of life,” Dr Bauer said.
However, many still tend to regard osteoporosis as a women’s disease, however. “There’s a bit of a Superman idea,” said Dr Eric Orwoll, an endocrinologist and osteoporosis researcher at Oregon Health and Science University in the US. “Men would like to believe they’re indestructible, so a fracture doesn’t have the implication it should,” he added.
The American College of Physicians and the US Preventive Services Task Force have deemed the evidence for screening of men “insufficient”. Clinical trials have found that osteoporosis drugs increase bone density in men, as in women, but most male studies have been too small or lacked enough follow-up to show whether fractures also declined.
So it may fall to older male patients themselves to ask their doctors about a DXA (pronounced DECKS-ah) scan. Otherwise, because osteoporosis is typically asymptomatic, men (and women, who are also undertested and undertreated) don’t know their bones have deteriorated until one breaks.
“If you had a fracture after age 50, you should have a bone scan — that’s one of the key indicators,” Dr Orwoll advised.
Other risk factors: falls, a family history of hip fractures, and a long list of other health conditions including rheumatoid arthritis, hyperthyroidism and Parkinson’s disease. Smoking and excessive alcohol use increase the odds as well.
“A number of medications also do a number on your bone density,” Dr Colon-Emeric added, notably steroids and prostate cancer drugs.
She would like to see all men over 70 screened, because the odds of disability after hip fractures are so high — two-thirds will not regain their prior mobility — and the medications that treat it are effective and often inexpensive.
NYTNS