It’s almost cliche. An elderly woman’s ‘hip fracture’ precipitates the beginning of the end of her life. Being incapacitated, and often requiring surgery, she is at increased risk because she already has advanced age-related cardiovascular disease and atherosclerosis. There may be discussions about quality of life if various procedures are performed versus avoided. If surgery is not performed, she may not walk. She may have pain. Being sedentary, with a fracture, thromboembolic events are considerably more likely. Surgery to repair the fracture is performed, and under general anesthesia, the patient suffers ischemic events to the brain. Cerebrovascular transient ischemic attacks may not be seen on imaging of the head. However, large cerebrovascular accidents would. The woman is confused post-operatively and never fully cognitively recovers. Her vascular dementia progresses until her demise within weeks to years. 

Could this all too common vignette have been avoided? One simple fall could have a huge impact on the future of an individual. Osteoporosis is a progressive disease in which bone density is reduced, leading to increased bony fragility. Osteoporosis increases risk of low-trauma fracture (fracture sustained from standing height or less). Because postmenopause, older age, and female gender are all factors associated with a greater risk for osteoporosis or osteopenia it is recommended to screen all women 65 years or older. X-ray or CT specialized for bone density evaluation is used. Women younger than 65 may be screened if they have risk factors such as previous fractures, low body weight, cigarette smoking, excessive alcohol use, hypogonadism, premature menopause, gastrointestinal absorption disorders, or liver disease. For men screening may be prompted by history of loss of body height, history of endocrine or metabolic disorders, and long term steroid use. 

Because most individuals reach their peak bone mass in their 20’s, it is important that children have healthy bone-forming years. This means that they should take in enough vitamin D and calcium. They should maintain body weight in the healthy range for their age and height. They should exercise as much as possible. It is a healthy choice to avoid smoking and alcohol consumption in the adolescent years for many reasons, but healthy bone growth is an important one. Use of glucocorticoids or anticonvulsants could also adversely affect bone growth. Chronic inflammatory disease and diseases affecting gastrointestinal absorption of nutrients can adversely affect bone formation during youth. Healthy children 9-18 years old, without known deficiency, are recommended 1300mg total daily calcium and at least 600 U vitamin D.  Vitamin D3 is also better absorbed than D2.   Calcium should be mostly dietary, however, and more than 500mg of elemental calcium supplementation per dose is likely not to be utilizable in the body. 

Unfortunately, age related bone loss in both men and women may begin shortly after peak bone mass occurs. For women, the rate of bone loss seems to be highest during perimenopause. Decreased estrogen production is strongly associated with decreasing bone mineral density. The severity of bone loss may be mitigated by similar lifestyle factors as were needed to achieve peak bone mass in adolescence – high impact exercise most days of the week along with a healthful and varied diet. Supplementation with calcium and vitamin D may be more necessary at this age. Fall prevention becomes very important if osteopenia and osteoporosis do develop (an inevitability for many of us). It is recommended that adults quit smoking and take in only moderate alcohol, if any.

Most people are aware that dairy products are good sources of calcium. To estimate the amount of elemental calcium per serving, multiply by 300mg. Calcium citrate is better absorbed than calcium carbonate on an empty stomach. Excess calcium intake may be associated with kidney stones. Calcium may be found in dark green vegetables, some nuts. It may be in breads, cereals, soy products and fruit juices as fortification. For supplementation, up to 1500mg elemental calcium can be taken daily in divided doses of 500mg or less. A daily dose of at least 1000mg should be taken for healthy adults and 1200mg for postmenopausal women. Vitamin D is produced in the skin during exposure to sunlight. It is generally not found in the diet, but is found in fortified milk and infant formula. It is not excreted in breast milk so 400U of vitamin D daily is recommended for breastfed infants. The number of cups of milk x 100U may approximate the daily dietary D intake. 

Lack of sun exposure is a frequent cause of D deficiency. Vitamin D deficiency has been associated with poorer prognosis in infectious and chronic disease states, and can increase risk of fractures. Muscle weakness, depression and fatigue may be signs of D deficiency. Low D increases parathyroid hormone production and leads to bone resorption. For healthy Alaskan adults, up to 5000U daily vitamin D3 supplementation may be considered. More may be required for those already deficient. 

In addition to calcium and vitamin D supplementation various medications are available for those at risk, or already suffering from, osteoporosis.  These all have potential adverse side effects so are available by prescription, after a discussion with a healthcare provider.  Hormone replacement therapy, bisphosphonates, or raloxifene may be recommended; if not otherwise contraindicated.