Older persons, people who are at risk such as heavy drinkers and smokers, those with hormone-related disorders, eating disorders, malabsorption problems, certain diseases like arthritis, family history of osteoporosis, on certain types of medications, experiencing long periods of inactivity and caregivers should take osteoporosis very seriously as the disease can be debilitating and even life-threatening.
The key is to understand the disease, followed by taking preventive measures, good management of the disease, and knowing the appropriate surgical options, if required.
At the recent Media Briefing & Launch of the 3rd Clinical Practice Guidelines for the Management of Osteoporosis in Petaling Jaya, experts urged for greater awareness of the disease. The Malaysian Osteoporosis Society (MOS), Academy of Medicine Malaysia, and Kementerian Kesihatan Malaysia collaborated on the publication of the guideline.
Reducing the burden of osteoporosis
In his keynote address, Tan Sri Dato’ Seri Dr Noor Hisham Abdullah, Director General of Health Malaysia said: “Malaysians are now growing older and living longer. As a result of this, many more will be suffering from age related non-communicable diseases, including osteoporosis.
“Osteoporosis occurs when bone density is severely reduced. Osteoporosis results in bone fractures, which are associated with disability and premature death.”
He went on to elaborate on hip fractures- the most common fragility fracture in older people. A study in 2020 found that, upon discharge from the hospital, all needed walking aids. Six months later, only 24% or 1-in- 4 regained their mobility and independence.
“Sadly, another 26% or 1-in-4 died within one year after the fracture! This is especially relevant as hip fractures are projected to rise from 5880 in 2018 to 20893 in 2050, a 3.6-fold increase.”
He stressed, “Osteoporosis is a serious disease that requires early detection, intervention and management even at later stages.
For this reason, he urged healthcare professionals to utilise the CPG to make crucial and timely clinical decisions.
“Initiating best practices will improve the lives of their ageing patients and help reduce the burden of osteoporosis that is expected to rise in the not-too-distant future!”
In her opening speech, Dr Yeap, who is also the President of MOS, remarked that osteoporosis is a silent disease.
She said: “We usually only see osteoporosis at its late stages – after a fracture has occurred. By then, the patient would have incurred significant amounts of bone loss and treatment will not replace all the bone that has been lost, which is not ideal. Instead, treatment focuses on minimising the detrimental effects of a fracture experienced by the patient.
“Clearly, we should be giving more emphasis to screening and early detection, followed by suitable interventions so that we can protect the most vulnerable persons from this terrible illness.”
Dr Yeap, who is a Consultant Rheumatologist, went on to clarify that the CPG consists of evidence-based statements that are intended to assist healthcare providers in optimising patient care.
She remarked, “We must first recognise the fact that osteoporosis is a multifactorial condition. Nutrition, age, hormone, lifestyle and the presence of pre-existing disease are some of the aspects that can affect bone health. All these requires not only input from one profession but multiple of them in order to provide patients with proper and effective care.
“As such, the CPG had to be written by a panel of experts from all the related disciplines, such as nutrition, geriatrics, endocrinology, orthopaedic surgery, obstetrics & gynaecology, rheumatology, primary care and pharmacy.”
She added: “The wide variety of expertise involved in the writing of the CPG ensures extensive coverage so that the guidelines will be able to inform all types of healthcare professionals who would be involved in the screening, diagnosing and treatment of osteoporosis.”
Almost as common as diabetes
Dr Ong, a Consultant Geriatrician, remarked that the 3rd CPG is very timely as Malaysia is becoming an ageing society.
He revealed, “Osteoporosis usually happens in older people and is almost as common as diabetes. He said: “1-in-5 adult Malaysians have diabetes. Osteoporosis comes close because it affects 1-in-6 adult Malaysians aged 45-90 years old!
“Diabetes evokes fear and concern, yet most people wouldn’t give osteoporosis a second thought.”
According to Dr Ong, many people think losing bone density, falls and sustaining fractures is simply a natural part of the ageing process. However, there is nothing natural about this disease in fact it is actually a very complex condition that is influenced by many factors.
He explained: “Some things that we do not think too much about in our everyday lives have a huge impact on our bone health. These include physical inactivity, fad diets, cigarette smoking, and age-related hormonal changes (such as oestrogen in ageing women and testosterone in men). All these increase the rate of bone loss at a time when strong bones are most needed.”
Early detection, intervention prevent fractures
Professor Chan, a Consultant Endocrinologist, expressed that osteoporosis is an underdiagnosed and undertreated condition, despite its devastating effects.
She said: “This is mainly because you don’t even realise osteoporosis is there, until you suffer from a fracture. So, the only way to know if you have osteoporosis before a fracture occurs, is by going for a bone density scan, also called dual-energy x-ray absorptiometry, DEXA or DXA; this quick and painless X-ray procedure allows doctors to see whether osteoporosis is present and predict the risk of future fractures in order to provide timely and suitable treatment; this would save you so much trouble in the future.”
She proposes: “The CPG recommends that women aged 65 years or older, and men 70 years or older, should have a DXA scan done every two years.
“Younger individuals may also need to be screened, if they have certain conditions, such as diabetes, thyroid disorders, nutritional malabsorption, eating disorders, rheumatoid arthritis, or are dependent on certain medications (like steroids) that might make them more at risk of developing osteoporosis earlier.”
Professor Chan said that if the right steps are taken at the right time, osteoporosis can be effectively managed with prevention of low trauma fractures.
She added, “There are effective medicines that can be tailored to suit all sorts of patients based on their disease stage and lifestyle. Moreover, whenever pharmacological treatment is necessary, the medications that are available in Malaysia can reduce the risk of fractures from 15% up to 70%!”
She emphasised that anti-osteoporosis medicines are well-tolerated and effective.
Seek surgery, treatment
Professor Datuk Dr. Sabarul, Consultant Orthopaedic Surgeon, gave some insightful advice about the surgical treatment for those who have suffered from an osteoporotic fracture.
“Generally osteoporotic fractures would not require surgery especially for minor fractures. But sometimes early surgical intervention might be required- this is especially so among the elderly with hip fractures that affects their mobility. Surgical treatment goals in osteoporotic fractures are early weight bearing/ mobilisation and a return to normal activities.”
Professor Sabarul disclosed a worrying fact about surgical interventions for hip fractures in Malaysia: “Recommendations by the International Osteoporosis Federation (IOF) and our CPG 2022 suggest that when surgery for hip fracture is needed it should be carried out within 48 hours of the fall. However, in Malaysia it is reported that the average time was 5 to 7 days!
There are various causes for the delay including co-morbidities and financial reasons. Optimising co-morbid disease contributes to delay in performing surgery. Securing a slot to perform the surgery is also challenging due to overwhelming patient volume, traffic, and congestion especially in a public hospital setting. “
Professor Sabarul echoed the importance of a multidisciplinary approach to osteoporosis care stating, “Certain hospitals are privileged to have ‘fracture liaison service (FLS)’, a multidisciplinary team approach in managing fragility fractures. This service has proven to be a great tool that improves patient outcomes and we hope to see more FLS offered around Malaysia.”
He also stressed the importance of secondary prevention i.e., preventing a second or subsequent fracture.
He said: “You are 5 times more likely to experience another fracture in a year after fracturing once. So, it is vital to take your anti osteoporosis medication together with adequate calcium and vitamin D intake or supplements and doing proper weight bearing exercises. Our CPG 2022 also emphasized those at risk of falls should receive a multifactorial falls risk assessment and interventions.
Families Should Be Vigilant Against Osteoporosis
The event was rounded up with a patient testimony delivered by Dr Harshinderjeet Singh A/L Jeswant Singh on behalf of his mother Madam Jaswant Kaur, lovingly known by her family as Aunty Santa, who has osteoporosis as well as rheumatoid arthritis, breast cancer, hypertension and sepsis. Dr Hashinderjeet shared a very personal, intimate and moving account as he spoke about how he and his family came together to overcome the challenges faced when caring for his mother.
“There were a number of complications that resulted from the fracture which required a lot of emotional support, cost and resources from the society and my family. Words won’t suffice to describe the psychological impact the fall has caused my mother and the entire family. However, this situation has taught us to stay strong and try our very best to take care of our mother.
“Over the years, due to the complications that my mother has had from the osteoporotic fracture, our family did go through a huge emotional turmoil. Nevertheless, with our constant support and care, her condition has improved tremendously compared to how she was previously. Looking at how far she has come does put a smile on our faces. A bitter-sweet reminder that all the struggle my siblings and I went through was worth it,” said Dr Harshinderjeet on his families struggle as caretakers of their beloved mother.
Dr Harshinderjeet, Senior Principal Assistant Director of the Medical Practices Division of the Ministry of Health Malaysia, who shared a personal story regarding the impact of osteoporosis during the event advised everyone on the importance of taking initiative to be in charge of their own bone health. (Press release with minor edit)