Osteoporosis

As well as the physical effects of Alzheimer’s disease, also follows emotional effects. The diagnosis of Alzheimer’s disease can have a huge impact on a persons life, causing a surge of various emotions, possibly disbelief, anger, shock, loss, fear and even relief. Following diagnosis it may take a patient a while to adjust and fall between emotions as they come to terms with the diagnosis.  Of course, family and friends will also react and have to cope with their loved ones fate. Some may be relieved to know they can plan ahead, and evaluate their relationships and be able to build upon them and make the affected as happy as possible to help them get through.  As Alzheimer’s progresses, the person may begin to lose control of their emotional responses or how they express their feelings. For example, the person may be prone to mood swings or overreact to things and even appear uninterested and distant. Alzheimer’s disease may also make people feel insecure about themselves and cause low self-esteem by reducing confidence. Feeling like you are no longer in control and not trusting your own judgements could cause fear and frustration. This could also stem from indirect effects Alzheimer’s may have on a person, it may affect relationships, financial circumstances or employment status.  As Alzheimer’s disease progresses and memory gets worse, more serious effects may occur. For instance, someone with Alzheimer’s disease may remember people who have passed away during their decline. As they become more confused they may be in positions where they have to often be reminded of the loss of a loved one and relive the grief over and over again, reliving the depression of the incident.  For instance, in the personal case study of who we will call BW, the emotional effects were considerably hard to deal with. Attending her sons funeral, she would obviously see many friends and family who had also attended, this led to confusion, asking people “what are you doing here?”, excited to see them as if they were just coming for a visit. Not truly understanding the situation and of course causing grief for herself when she had to listen to the explanation of why everyone was here, reliving the upset of when she was first told about the incident.  BW’s confusion often caused family grief when they had to explain to her why her husband was in prison and that he was not coming to get her or visit her whilst she was living in a care home, and in turn made her upset.  However, his confusion both caused and saved her from grief. Not being able to remember things like the passing of loved ones means the grief was short lived and possibly saved her from more depressive times.  Osteoporosis  Osteoporosis is a disease which affects the density and the quality of the bone, the work literally means porous bone. As the bones become fragile, the risk of fracture is increased which typically is the first sign of the disease, otherwise, the deterioration of the bone quality progresses silently.  Your bones are at their strongest and thickest in your early adult life as their density increases up until your late 20’s. Everyone will gradually start losing bone density, typically around the age of 35. However, those with osteoporosis will go through this process faster than normal increasing their risk of fracturing a bone.  The skeletal system in your body allows you to perform vital functions such as movement, support, protection, blood cell production and others that enable us to survive, the deterioration of this system makes simple thing like moving increasingly more difficult to do.    As you can see from the image above, the decreasing density from osteoporosis is extremely immense. This loss of bone structure makes things very difficult for the patient.  Causes  Osteoporosis is more common in older people however can affect anyone of any age. It is also more common in women, this is due to hormones that are related to menopause and directly affect bone density themselves. The female hormone, eostrogen, is plays a key role in keeping bones healthy, but during menopause oestrogen levels fall. This can potentially lead to a rapid decrease in bone density, leading to the possible development of osteoporosis.  Women are at peak risk of developing osteoporosis if they go through menopause early, which would be before the age of 45, or they have had a hysterectomy before the age of 45, or the have had absent periods for more than six months due to over exercising or too much dieting.  The cause of men developing osteoporosis is unknown in most cases. Although there is a link to the male hormone, testosterone, which helps keep bones healthy. Males will continue producing testosterone well into old age, but osteoporosis becomes more of a risk in men who have low levels of osteoporosis.  Half of the time testosterone levels decrease the cause is unknown, but the known reasons are to do with the use and side effects of certain medications such as oral corticosteroids. The misuse of alcohol is also a big cause of the decreased levels of testosterone.  There are also some conditions which can cause the hormone levels to decrease such as hypogonadism.  Risk Factors  Other than the before mentioned hormones, there are others that can affect the process of bone turnover, and some conditions may be directly linked to hormone producing glands, having these conditions creates a higher risk of developing osteoporosis.  These conditions include hyperthyroidism, hyperparathyroidism and disorders of the pituitary gland.  Other risk factors include eating disorders such as anorexia or bulimia, a family history of osteoporosis, a body mass index of 19 or less, long periods of inactivity (for example if one is on long-term bed rest), and some medications used to treat breast cancer and prostate cancer which can affect hormone levels. Lifestyle choices such as heavy drinking and smoking can also increase your risk of developing osteoporosis.  Symptoms  Typically symptoms are not present in the early stages of bone loss. However, as the condition develops, bones are increasingly weakened, this is when you may notice signs and symptoms such as back pain. This is caused by a fractured or collapsed vertebra. Your posture may become poor and stooped and bone fractured may occur more easily than expected. Another effect of the condition is you may notice a loss of weight over time.  Other than these, there are no tell tale signs of the development of osteoporosis. Knowing when to see a doctor is very important in getting a diagnosis as you may not notice the development yourself. Always seek advice if you are aware of any family history of osteoporosis or if you have gone through early menopause. Taking corticosteroids for several months at a time can affect hormone production so it is a good idea to get checkups if this is the case, in order to catch anything that isn’t right possibly caused by the medication. Diagnosing Osteoporosis  If a patients doctor suspects they have developed osteoporosis, they can make an assessment using an online programme, such as FRAX or Q-Fracture. These online tools help to predict the risk of a fracture between the ages of 40 and 90. The algorithms used give a 10-year probability of hip fracture and a 10-year probability of a major fracture in the spine, hip, shoulder or forearm. The doctor may also refer a person for a DEXA scan, used to measure bone mineral density. This will be compared to a healthy young adult, and a person who is the same age and sex as the person. The difference is calculated as a standard deviation and is called a T score. This standard deviation is a measure of variability based on an average or expected value. If a person’s T score is above -1 SD, this is considered normal. If their T score is between -1 and –2.5 SD, this shows a decreased bone mineral density compared with weak bone mass. When a persons T score is below –2.5 SD, it is defined as osteoporosis. When the bone density is shown to be decreased, but not enough to be diagnosed with osteoporosis, the patient may be instead diagnosed with osteopenia. This may still require treatments used to treat osteoporosis explained below. Treatment  The main aim for carers and health services across England is to try to prevent the falls that will cause fractures especially with people affected by osteoporosis and those with the risk factors that increase their chances of developing it.  The key message for these people, mainly the elderly, and their family and carers are: falls become a risk to all as you get older, but they are not inevitable and can be prevented so long as certain measures are taken in order to prevent or decrease the damage done by falls. This can be achieved by staying active and healthy through regular exercise and a healthy diet. Poor eyesight and certain medication as well as poor muscle strength can increase the risk of a fall, talking to a doctor and having these issues looked at and treated could help prevent an accident. Treatments for osteoporosis vary depending on age, sex, risk of fracture and previous injury history, even though it is the same diagnosis based on bone mineral density. Changing your diet to allow you to take in more calcium and vitamin D can help with the condition, especially if the patient does not need/want to take medication to treat it. The National Institute for Health and Care Excellence (NICE) recommends who should be treated with medication for osteoporosis and which medication to use based of individual factors mentioned before. These fall into two groups of people: postmenopausal women with osteoporosis who haven’t had a fracture (primary prevention) and postmenopausal women with osteoporosis who have had a fracture (secondary prevention).  Medication  There are several medications used to treat osteoporosis.  Bisphosphonates are used to slow down the deterioration of the bones in the body and also to maintain density which in turn reduces the risk of fractures. Zolendronic acid, alendronate and etidronate are all types of bisphosphonates. These can be given as injections or tablets. However these medications can often tale between 6 to 12 months to work and may need to be taken for several years after. Calcium and vitamin D supplements may also be prescribed.  Medication known as strontium ranelate can be used if bisphosphonates are seen as unsuitable. Strontium ranelate effects both the cells that break down the bone and the cells that create new bone (osteoblasts).  SERMs (Selective oestrogen receptor modulators) is a medication which has a similar effect on the bones as oestrogen, these too help to maintain bone density and reduce the risk of fractures, particularly in the spine. Raloxifene is the type of SERM used to treat osteoporosis and is taken in tablet form. Prevention  Regular exercise is a key part of preventing osteoporosis, adults aged 19-64 should be doing at least 2 and a half hours of moderate-intensity aerobic activity every week, this could include cycling or fast walking. As well as this they should also do muscle strengthening exercises that work all of the major muscle groups such as legs, arms, hips and abdomen, this will help to improve bone density. People diagnosed with osteoporosis should speak to a specialist about creating an exercise plan suited for themselves. Eating a healthy, balanced diet is always recommended to everyone as it can help prevent many serious health conditions like diabetes and heart disease. Calcium is known for its link to strengthening bones, foods like leafy green vegetable, dried fruit and yoghurt are rich with calcium and should always be part of your diet. Vitamin D is also very important for healthy bones because it helps the body absorb calcium. Vitamin D can be found in red meats, oily fish like salmon, egg yolk and liver. It can be difficult to ensure you’re taking in the right amount of vitamin D every day through food alone so adults, particularly those with higher risk factors of developing osteoporosis, should consider taking supplements of 10 micrograms of vitamin D a day. Other ways to help prevent osteoporosis are to eliminate any bad lifestyle choices like smoking and limiting your alcohol intake and avoid binge drinking. The NHS recommends not drinking any more than 14 units a week.  Affects on Emotional Health  Many patients with osteoporosis will experience a curving of the spine, preventing them from standing up straight. These changes in appearance can cause a great loss of confidence, losing height and seeing yourself stooped over could have an emotional impact. It may even cause a person to feel embarrassed. This could lead to a chain reaction of not wanting to be seen in public and staying away from friends and family, which will in turn lead to loneliness and then possibly depression.  The fear of falling may also keep a person from activities they would enjoy. Once you fracture a bone from osteoporosis, you are instantly at greater risk of doing it again. This fear can stop a person from even walking if they don’t need to. However this will do a person no favors, as the more weight-bearing exercises you do the more encouragement you are giving your body to regenerate the bones as it does naturally.  Case Study  In the case of a 68-year-old woman known as TC, osteoporosis was able to be diagnosed after she was sent to accident and emergency for pain in her right wrist along with swelling and displacement following a fall at home.  Her past medical history showed she had asthma since childhood which was treated with corticosteroids between the ages of 50-55. We know that the extended use of this medication can lead to a higher risk of developing osteoporosis. She also went through menopause at 59 and had had a left wrist fracture at age 67. Her family history showed her mother had had a hip fracture at age 78 and was diagnosed with osteoporosis, both parental fracture and family history of the condition can mean a higher risk. She smoked little (5 cigarettes a day), drinks little alcohol but did very little exercise however she was fully mobile and able to complete activities of daily living. She was then diagnosed with osteoporosis following a DEXA scan (dual energy X-ray absorptiometry, which looks at bone mineral density). 

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