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Tribune News Service

Ronald Klein was biking around his neighbourhood in the US state of Pennsylvania in 2006 and tried to jump a curb. “But I was going too slow – I didn’t have enough momentum,” he said.
As the bike toppled, he thrust out his left arm to break the fall. It did not seem like a serious accident, yet he “couldn’t get up”.
At the accident and emergency, X-rays showed that he had fractured both his hip, which required surgical repair, and his shoulder. Klein, a dentist, went back to work three weeks later, using a cane. After about six months and plenty of physiotherapy, he felt fine.
But he wondered about the damage the fall had caused.
“A 52-year-old is not supposed to break a hip and a shoulder,” he said.

At a follow-up visit with his orthopaedist, he suggested that he have a bone density (Dexa) scan.
As he suspected, the test showed he had developed osteoporosis, a progressive condition, increasing sharply with age, that thins and weakens bones and can lead to serious fractures. Klein immediately began a drug regimen and, now at age 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 is not a healthcare professional might not think about getting a scan. Klein’s orthopaedist did not raise the prospect.
But about one in five men over age 50 will suffer an osteoporotic fracture in their remaining years, and among older adults, about a quarter of hip fractures occur in men.
When they do, “men have worse outcomes”, said Cathleen Colón-Emeric, a geriatrician at the Durham VA Health Care System and Duke University in the US state of North Carolina, 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 added.

What is “major”? Fractures of the wrist, hip, femur, humerus, pelvis or vertebra.
In her study of 3,000 veterans aged 65 to 85, conducted at Veterans Affairs health centres in the states of North Carolina and Virginia, only 2 per cent of those assigned to the control group had undergone bone density screening.
Establishing a bone health service – overseen by a nurse who entered orders, sent frequent 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 the forerunner condition, osteopenia. Where appropriate, most of them began taking medication to preserve or rebuild their bones.
“We were pleasantly surprised that so many agreed to be screened and were willing to initiate treatment,” Colón-Emeric said.
After 18 months, bone density had increased modestly for those in the intervention group, who were more likely to stick to their drug regimens than osteoporosis patients of either sex in real-world conditions.
The study did not 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 long-standing 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? If so, which men and when?
Douglas Bauer, a clinical epidemiologist and osteoporosis researcher at the University of California, San Francisco, said such issues mattered less when lifespans were shorter. 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 seventies and eighties, so they have fractures,” he added. By then, they have also accumulated other chronic conditions that impair their ability to recover.
With osteoporosis testing and treatment, “a man could see a clear-cut improvement in mortality [prevention] and, more importantly, his quality of life”, Bauer said.
Both patients and many doctors still tend to regard osteoporosis as a women’s disease, however.
“There’s a bit of a Superman idea,” said Eric Orwoll, an endocrinologist and osteoporosis researcher at Oregon Health & Science University. “Men would like to believe they’re indestructible, so a fracture doesn’t have the implication that it should.”

Bob Grossman, a 74-year-old retired teacher in Portland, in the US state of Oregon, for example, resisted entreaties from his wife, a nurse, to “see someone” about his visibly rounded upper back for years.
He blamed poor posture instead and told himself to straighten up. “I thought, ‘It can’t be osteoporosis – I’m a guy,’” he said. But it was.
Another obstacle to screening: “Clinical practice guidelines are all over the place,” Colón-Emeric said.
Professional associations such as the Endocrine Society and the American Society for Bone and Mineral Research recommend that men 50 and older who have a risk factor, and all men over 70, should seek screening.
But 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.
The task force’s position means that the United States’ federal health insurance programme, Medicare, and many private insurers, generally will not cover screening for men who have not had a fracture, though they will cover care for men diagnosed with osteoporosis.
So it may fall to older men themselves to ask their doctors about a Dexa scan, widely available at US$100 to US$300 out of pocket.

Otherwise, because osteoporosis is typically asymptomatic, men – and women, who are also undertested and undertreated – who do not get screened will not 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,” Orwoll said.
Other risk factors: falls, a family history of hip fractures and a fairly long list of other health conditions, including rheumatoid arthritis, hyperthyroidism and Parkinson’s disease.
Smoking and excessive alcohol use also increase the odds of osteoporosis.
Colón-Emeric said that “a number of medications also do a number on your bone density” – notably steroids and prostate cancer drugs.
When a scan reveals osteoporosis, depending on its severity, doctors may prescribe oral medications such as Fosamax or Actonel, intravenous formulations such as Reclast, daily self-injections of Forteo or Tymlos, or twice-annual injections of Prolia.
Lifestyle changes such as exercising, taking calcium and vitamin D supplements, stopping smoking and drinking only moderately will help, but are not sufficient to stop or reverse bone loss, Colón-Emeric said.

Although guidelines do not universally recommend it, at least not yet, she would like to see all men aged 70 and over be screened, because the odds of disability after hip fractures are so high – two-thirds of older people will not regain their prior mobility, she said – and the medications that treat it are effective and often inexpensive.
But informing patients and healthcare professionals that osteoporosis threatens men, too, has progressed “at a snail’s pace”, Orwoll said.
Klein remembers attending a seminar to instruct patients like him in using the drug Forteo. “I was the only male there,” he said.
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About one in five men over the age of 50 will suffer an osteoporotic fracture in their remaining years, and men do not do as well in recovery as women, according to an expert. Photo: Shutterstock

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Cathleen Colón-Emeric is a geriatrician at Duke University. Photo: Duke University

The odds of disability after hip fractures are high: two-thirds of older people will not regain their prior mobility. Photo: Shutterstock

Bone density, or Dexa, scans can help diagnose osteoporosis in patients who would otherwise have no idea until they break a bone. Photo: Shutterstock

Lifestyle factors such as excessive alcohol use increase the odds of getting osteoporosis. Photo: Shutterstock

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Men who break bones weakened by osteoporosis are at higher risk of death and disability. Experts share why awareness and screening are key


Men who break bones weakened by osteoporosis are at higher risk of death and disability. Experts share why awareness and screening are key.


Disease

How to age well

Ageing society

Medicine

Osteoporosis in men is less common. But with worse outcomes, is it time they got tested?

.css-1c6uqr6{color:inherit;font-weight:inherit;font-size:inherit;font-family:inherit;line-height:inherit;overflow-wrap:break-word;}Men who break bones weakened by osteoporosis are at higher risk of death and disability. Experts share why awareness and screening are key

Men who break bones weakened by osteoporosis are at higher risk of death and disability. Experts share why awareness and screening are key