Eldercare at Home: Bone Weakness
Caregiving How Tos
Understanding the Problem
As people age, their bones begin to thin and lose strength. Bone thinning is called osteopenia. Severe bone thinning to the point where a person is at a high risk for broken bones (fractures) is called osteoporosis. Warning signs of osteoporosis include loss of height or a stooped posture. However, most people are not aware of their bone loss until a bone is broken.
Up to the age 75, osteoporosis is more common in women than in men. At that point, men "catch up." Women who develop osteoporosis usually do so after menopause. After menopause a woman's body stops producing estrogen, one of the hormones that keep bones strong. Without estrogen, bones may become softer, weaker, and more likely to break. Women who are most at risk for osteoporosis have a family history of the disease, are thin, smoke, and did not take hormones after menopause. Other risk factors include a diet low in calcium and Vitamin D, lack of exercise and lack of exposure to the sun, smoking and excessive alcohol or caffeine use, history of an overactive thyroid gland, and taking certain medicines such as corticosteroids and medicines used to treat seizures. For reasons that are unclear, Caucasians and Asian-Americans are more likely to develop osteoporosis than African-Americans. Older men are also at risk for osteoporosis, particularly after prolonged inactivity.
For people with osteoporosis, any little bump, trip, or fall may be all that is necessary to cause a broken wrist, hip, or back bone. Sometimes a bone can break first, and then the person falls. Also, an older person's bones may take longer to heal after a break.
Once a person has broken a bone, inactivity must be avoided at all costs, because an older person who is laid up for months healing is unlikely to resume previous levels of activity. After that experience he or she may be afraid to go out or walk. For this reason, orthopedists recommend fixing most hip fractures by operating on them. The person can get up and start walking with the help of a physical therapist almost immediately. Unfortunately, some older people who have fallen cut back on exercise for fear of falling again. Lack of exercise will further weaken bones and muscles and actually make falls more likely. So it is important for older people to be as active as possible, even after a fall.
Your goals are to:
- Call the doctor if the older person has a serious fall
- Encourage proper diet and exercise to strengthen bones
- Prevent falls
Call the doctor or nurse immediately or go to the emergency room if any of the following symptoms occur:
- The older person has experienced a major fall.
If he or she is able to get up quickly and is not feeling pain, it might not be necessary to see a doctor, even if they say they are feeling okay. However, if the older person experiences a hard fall (for example, if the legs suddenly move out from under and he or she lands on the back or side), it is important to see a doctor as soon as possible. A frail older person can suffer a broken bone from a seemingly minor injury.
- Pain in the hip or in the groin after a fall.
This could mean a broken hip or pelvis.
- Difficulty or pain when standing or trying to walk after a fall.
- Limping or other unsteadiness in gait after a fall.
- Serious back pain
Pain after lifting a heavy object, reaching overhead, or taking a wrong step off the curb.
- Pain or swelling after a fall or if a bone has an unusual shape.
Call the doctor or nurse during office hours to discuss the following problems:
- Feeling lightheaded or dizzy
Fluid loss from diarrhea or vomiting can cause lightheadedness. Also, medicines used to treat high blood pressure, depression, chronic pain, and insomnia can make persons dizzy, less alert, or lightheaded when they stand, especially at night. This can increase the risk of falling and fracturing a bone. Keep track of what prescription, over-the-counter medicines, herbal and other remedies the older person is taking and report any side effects to the doctor.
- Recurring pain after hip surgery or a fracture
If there is recurring pain after hip surgery, contact the doctor, as this could be a new problem. Pain can be controlled with medicines, or, in some instances, with physical appliances such as braces. Exercising in a swimming pool can help to restore flexibility and strength and reduce pain without stressing the body like other types of exercise. If the older person continues to have pain or remains unable to participate in his or her normal activities, you may wish to ask the doctor about referral to a rehabilitation specialist.
Know the answers to the following questions before calling the doctor
If the person has fallen, have ready the SPLAT information: Symptoms, Previous falls, Location, Activity, and Time. (See Eldercare at Home: Mobility Problems) In addition, be prepared to answer how old is the person? Is he or she frail? What other conditions does the person have?
Here is an example of what you might say when calling:
"I am Susan Smith. My mother, Sara Smith, a patient of Dr. Turner, fell around 9:00 a.m. (Time) while standing at the kitchen sink (Activity and Location). She is complaining of pain in her right hip (Symptoms). She is having difficulties moving because of the pain. (Mention the person's size if extra help will be needed to lift her.) She has not had any serious falls in the past.She did not hit her head when she fell.”
- Make the older person's environment risk-free by doing the following:
- Have proper railings on all stairs and provide good lighting
- Do not use throw rugs on hardwood floors
- Route electrical and telephone cords near walls and out of the walking path of the older person
- Make the older person's room and pathway to the bathroom clutter free
- Use night lights
- Install grab bars in the bathroom or shower walls, on the tub, or in the wall
- You may want to consider talking to the older person about using hip protectors
See Eldercare at Home: Mobility Problems for tips on safe-proofing your home.
- Encourage the use of stabilizing devices if the older person has walking problems or is unsteady on his or her feet
Many older people are, at times, unsteady when they walk. If the older person uses a cane, he or she should be encouraged to carry it at all times. A cane can be used to provide "emergency" support when the person feels unsteady. The cane or other stabilizing device, like a walker, should be fitted properly. A physical or occupational therapist can help to get a good fit and can show the older person how to use the cane properly.
- Drink fluids.
Encourage drinking four to six glasses of water a day. When people become dehydrated they often feel dizzy and can fall. Fluid loss from diarrhea and vomiting needs to be replaced by drinking liquids. If the older person is taking a diuretic medicine to get rid of fluid or treat high blood pressure, check with his or her doctor about how much liquid he or she should drink each day.
Older people should take in 1200-1500 milligrams of calcium a day. The best sources of dietary calcium are milk and other dairy products such as yogurt and cheese. You can also buy calcium supplements with Vitamin D that help the body absorb calcium. Inexpensive calcium tablets are widely available, but some store brands may not be as effective. Check with your doctor. Calcium tablets may need to be broken up to be easier to swallow. Calcium citrate tablets are digested easily and absorbed better than calcium carbonate. If the older person has trouble digesting milk, try products such as Lactaid(TM), which contains an enzyme that aids in digesting milk. There are also lactose-free milk products. For those watching their fat intake, many delicious low or non-fat dairy products are available that supply an adequate amount of calcium.
Older people should usually take calcium and vitamin D supplements if they are taking drugs to control seizures or if they are taking steroids. These medications can be damaging to bones. However, this needs to be balanced against other possible health risks from extra calcium such as heart disease or kidney stones. Be sure to ask your healthcare professional about taking calcium supplements before you start.
- Smoking and alcohol.
If possible, the older person should give up smoking which weakens bones. An occasional glass of wine or a beer with dinner is fine for most people. However, too much alcohol both weakens bones and contributes to falls and other accidents.
One of the worst things the older person can do is to stay seated on the family couch and avoid exercise. Exercise strengthens the bones and muscles, improves steadiness when walking, and helps prevent fractures. Activity helps people carry their bodies better and makes them less clumsy or unsteady. Depending on the older person's condition, there are many good exercises: walking, running, swimming, lifting weights, or riding a stationary bike. Housework and gardening are also beneficial and should be encouraged if the older person enjoys these activities. Bones actually get stronger and muscles become strengthened with exercise. Let the older person work at his or her own pace and slowly develop an exercise routine.
- Estrogen replacement for women.
Estrogen use has been shown to prevent bone loss and reduce the rate of fractures in post-menopausal women. The greatest bone loss occurs in women after menopause, when the body stops producing estrogen. Estrogen replacement improves menopausal symptoms, reduces the risk of osteoporosis and the incidence of colon cancer. It is unclear at this time whether estrogen reduces the risk of dementia.
Since taking estrogen alone puts some women at slightly greater risk for developing cancer of the lining of the womb, every woman who still has her womb should take progesterone (another hormone) as well as estrogen to protect against this. However, recent studies have shown that this combined therapy (estrogen plus progesterone) can increase the risk of coronary artery disease, stroke, venous thrombosis (a blood clot in a major vein that can be life-threatening if a portion of it breaks off and travels to the lungs), breast cancer, and cholecystitis (inflammation of the gallbladder). It is not yet clear whether taking estrogen alone carries these same risks. This question is still being studied.
Therefore, a decision to take estrogen or combined estrogen-progestogen therapy should be discussed with a doctor and the risks and benefits to the individual woman carefully considered.
- Other bone strengthening medicines.
There are several other medicines which slow bone loss, including bisphosphonates, parathyroid hormone, calcitonin, a group of medicines called synthetic estrogen receptor modulators (SERMs), and denosumab. As with all medicines, risks and benefits of each should be discussed with your healthcare professional.
Actonel(tm) and Fosamax(tm) are bisphosphonates that can be taken orally on a daily or weekly basis but may cause upper gastrointestinal side effects such as esophageal ulcers. They must be taken on an empty stomach.
Parathyroid hormone is a recently licensed medication which shows promise but which must be taken by daily injections at this time.
Calcitonin can be taken through a nasal spray or by injection.
SERMs, taken orally, reduce bone loss in postmenopausal women. Raloxifene (Evista(TM)) is one of them. They do not affect the breast or the womb, and so far have not been found to have bad effects on the heart. There is an increased risk of venous thrombosis (see above) in some women. Postmenopausal symptoms, such as hot flashes, are not helped, and, in fact, may be worsened by them.
Calcium and vitamin D are usually prescribed with these medicines.
Denosumab is a recently approved medication that may be an alternative for those who are intolerant of bisphosphonates.
- Testosterone replacement for men.
Men who have very low levels of testosterone are also at risk for osteoporosis and can often benefit from testosterone replacement treatment. The benefits and risks of this should be discussed with their doctor.
"I don't need bone strengthening medicines"
Taking one of the above medicines can significantly strengthen your bones and avoid fracture. Your doctor can help you choose one that is right for you.
"I'm afraid of exercising; I might fall and break another bone.
There is evidence that balance and strength training has helped reduce injurious. Ask your doctor for a referral to a physical therapist who will show you some safe exercises, or check for programs at your local senior center. Walking is one of the best exercises and can be done outdoors when the weather is good, or indoors if the weather is bad. Many shopping malls open early so that groups can get together to exercise and socialize. This can make exercising fun. If you don't exercise, your bones and muscles will become weak and your chances of falling will increase. Let’s exercise together. I will pick you up and we will go to the mall and walk for a little while. We will start by going as far as you are comfortable and over time walk farther.
"I've been smoking since I was 15 and I don't need to stop now."
It is hard to change things you have done for a long time. But your body has changed and so stopping smoking is more important now. A fracture now could mean an end to your independence or even the end of your life. Let’s look at some smoking cessation programs and see which one you think you could do.
"I can walk fine without a cane."
A cane will make you more independent because it can prevent falls from happening. If a cane prevents just one serious fall, it will be well worth it.
"I don't have time to be Mother's exercise coach."
A complicated exercise routine for your mother is not necessary. But it is very important that activity becomes part of her everyday routine. Even simple activities will do much to improve her physical, mental, emotional, and social health. If supervision is required, get help from other family members or friends. They should understand that helping with exercise on a regular basis is a key part of caring and support for an older person, as well as improving his or her health. Exercising can be as simple as going to the grocery store together or sharing in another activity. Many senior centers have exercise classes increasing the benefit of socialization for your mother. Exercising is more fun when done with others.
"It hurts to exercise."
Your doctor should find out why you hurt and treat the cause if this is possible. There are many medicines now available to control pain, once the reason for it is known. A physical therapist can develop an exercise program to minimize pain and help you gain more control over your pain. A gentle warm-up routine can avoid aches, and strains.
Think of other obstacles that could interfere with carrying out your plan
What additional roadblocks could get in the way of doing the things suggested in this home care plan? For example, will the older person cooperate? Will other people help? How will you explain your needs to other people? Do you have the time and energy to carry out this plan?
The key to avoiding bone problems is to review the suggestions outlined in this section. Ask yourself the following questions. Some of these questions will need to be discussed with the older person's doctor:
- Is the older person taking too many medicines (remember to include non-prescription medicines and alternative and herbal remedies)? Is he or she experiencing any unpleasant side effects of medications such as dizziness or drowsiness which can lead to falls? If corticosteroids are being taken, can the dose be reduced or tapered off completely? If not, ask about the benefits and risks of taking calcium and vitamin D supplements.
- Should the older person be taking one of the bone strengthening medicines described above? Have the risks and benefits of each medicine been thoroughly considered?
- Does the older person have a well-balanced diet that gives the proper amount of calcium?
- Have you taken measures to reduce the risk of falling?
- Is the older person continuing to smoke? Would your encouragement help him or her to quit?
- Is the older person drinking excessive amounts of alcohol? If so, can you help reduce alcohol intake (or use)?
- Is the older person less active? If so, is this because of persistent pain, general social withdrawal, or some other problem? Start with low levels of regular activity and work up towards greater activity - it's never too late to start, benefits can be gained at any age.
What to Do If Your Plan Isn't Working
Many of the causes of bone problems are hard to change quickly. Be persistent and set reasonable goals. Small changes will eventually add up to larger ones.