Progress isn’t everything it’s cracked up to be. Take increased life expectancy, for instance: Thanks to advances in nutrition, hygiene, housing and the health sciences, vast numbers of people are living good, long lives – which, in most respects, is a wonderful thing. As a percentage, twice as many Canadians now live into their retirement years, 65 and over, as compared to a century ago. In fact, the average Canadian man can expect to live 15 years longer than the average man did as recently as 1931 – the average woman almost 20 years longer.
Even if we accept that a good deal of that temporal abundance is the result of a steep drop in infant mortality, the fact remains that people are living longer – long enough (and here’s the rub) to develop all the age related illnesses our forebears knew so little about. Of course they too suffered heart disease and diabetes and cancer, but it’s only been in recent generations that such medical conundrums as arthritis and Alzheimer’s and osteoporosis have exacted a heavy toll across a broad population — again, because a greater percentage of us are living into the years when such conditions typically develop.
If there’s an upside to e downside, it’s that doctors – armed with increasingly sophisticated diagnostic techniques – now have a chance to study such diseases through every stage of their progression, which has led in almost every case to significant advances in understanding, treatment and care. Osteoporosis, which typically develops with increasing prevalence after the age of 50 in women and after age 75 in men, is a prime example.
The word comes from osteo, meaning bone, and porosis, meaning porous, which accurately sums up the condition. Osteoporosis is an excessive loss of bone mass that leaves bone thin and brittle and extremely susceptible to fractures – the defining feature of the disease. Dr. Robert Josse, chief of the Division of Endrocrinology and Metabolism at St. Michael’s Hospital and a professor of medicine at the University of Toronto, describes osteoporosis as merely the risk for the disease. The real disease, he says, is fracture: “That’s the major problem.”
Theoretically, you could live with bones “thinned” by osteoporosis your entire adult life without experiencing any symptoms at all. That’s because osteoporosis (it’s often called “the silent thief”) doesn’t involve any other major health issues, Josse says. “The major health issue that occurs with osteoporosis is fracture.”
Estimates of just how big a problem the condition is vary according to whether it’s defined as reduced bone mass (osteopenia) or as fracture incidence (established osteoporosis), but the standard estimate puts the number of Canadians with the disease at 1.4 million – about one in four women and one in eight men over 50. However, it would be reasonable to assume that with the greying of society those numbers will continue to climb. And accompanying that rise will be more fractures due to osteoporosis and increased dependence on healthcare resources and healthcare dollars, says
Dr. David A. Hanley, professor of medicine and head of the Division of Endrocrinology and Metabolism at the University of Calgary and Foothills Hospital. “Unless, of course, we can do something to prevent these fractures from happening in the first place.”
That’s the goal of current research, but at present, says Hanley, a former chairperson of the Osteoporosis Society of Canada (OSC) and a current member of its Scientific Advisory Board, osteoporosis is rarely diagnosed before the patient suffers her first fracture, and by that time, the disease is usually quite advanced. The subsequent impact of the fracture on the patient is often significant – and sometimes deadly.
Take hip fractures, for example (90 per cent of which are due to osteoporosis), the second most common fracture, after spinal compression fractures, due to osteoporosis: Only about half of those who suffer a hip fracture return to their pre fracture level of mobility and function; a quarter will continue to live with very limited mobility and a reduced quality of life; the fourth quarter will never walk again independently.
According to some studies, as many as 20 per cent of people who have a hip fracture die within a year of the event because of complications directly attributable to the fracture. It’s been estimated that, in 1992, hip fractures contributed to the death of 1,400 Canadians.
That’s not the only toll. “The personal and emotional effects of patients suffering a fracture and receiving a diagnosis of osteoporosis often can be devastating,” Hanley points out. “People who’ve suffered a fracture often live in fear of future fractures and the future implications of osteoporosis. The victim’s life becomes a cycle of pain, fear and inactivity. The person’s afraid to leave home and often becomes housebound.”
Some fractures – particularly vertebral or spinal compression fractures – cause physical disfigurement, such as the spinal curvature variously known as hunchback or “dowager’s hump,” which can play havoc with a person’s self esteem. Tally the effects of reduced mobility, limited activity and increased dependence on family or friends, and you’ve got a sure fire recipe for emotional turmoil.
And that would be a lot of emotional turmoil: In 1993, the last year for which there are solid figures, osteoporosis related fractures among Canadians over the age of 45 resulted in some 29,000 hospitalizations, representing approximately 643,000 days in hospital. “By the best estimate we can make,” Hanley says, “there were probably an additional 47,000 fractures that required out patient care. Close to 23,000 Canadians were either in long term or chronic care facilities due to osteoporotic fractures in 1993.”
Needless to say, all of that medical attention (plus lost wages, medications, assistive devices, home care, and other direct and indirect expenses) costs us all a considerable amount of money – a steady pay out that’s only going to grow as the population continues to age.
How much? Using 1993 figures, a group of physicians at McMaster University in Hamilton, Ont., estimated that it costs the Canadian healthcare system about $1.3 billion a year just to treat osteoporotic fractures. Project those figures forward 25 years or so, and the cost of treating osteoporotic fractures – and osteoporosis in general (it’s been estimated that osteoporosis accounts for 76,000 hospital visits a year) – will have increased exponentially. If, that is, prevention and treatment strategies for people at risk for the disease are not followed through.
“The truth is,” Hanley says, “without change in the current practice of the diagnosis and treatment of osteoporosis, the disease has the potential to become an epidemic in Canada as the population ages, and an increasing burden on our shrinking healthcare budget. Preventing fractures is really the key to limiting the impact of osteoporosis on health and lifestyle.
Early intervention through prevention, diagnosis and treatment is the key to reducing the incidence of fractures.”
Hanley points to the recently released results of the clinical fracture arm of the ongoing multicentre Fracture Intervention Trial (which includes 6,457 patients in all phases of the study) as proof that “fractures can be prevented in patients with the early stages of osteoporosis. As Canadian physicians, we now have the information, and the tools needed, to effectively diagnose osteoporosis early, and I think we have treatments that now can be used to prevent fractures from occurring. By using these tools and information, we can limit the impact of osteoporosis now and in the future.”
The job of lessening the impact of osteoporosis, of course, doesn’t fall entirely to doctors; a good deal of that responsibility rests on the shoulders of ordinary people, who need to understand the importance and means of prevention, be aware of and recognize the warning signs of the disease, and know what steps to take to reduce their own risks.