A Fall from Grace

Grace was an eighty year old patient of mine. As she hobbled into her visit, she seemed to be in good spirits. Among other medical problems, Grace had an issue with anxiety. She was taking an antidepressant to try to help control it. The fact that she seemed to be in a good mood was a good start to the visit. She had an initial bone density test performed five years ago, which revealed that she had osteoporosis. Back then, Grace didn’t want to be on any medications that weren’t necessary. “I take enough medications,” she said. “I’ll take my vitamin D and drink my milk.”

When dealing with osteoporosis, it is beyond the point of simple vitamin supplementation. Something happens, particularly with women, where the balance between bone resorption and bone formation is tipped to favor bone resorption. This dysregulation causes the bones to become increasingly thin and fragile. Minor traumas, like bumping into a chair, can actually precipitate a fracture.  One way to understand this is to imagine a frozen lake. In the winter, the ice is rock solid. As the temperature starts to rise, the ice gets thinner and easier to break. Adding more water isn’t going to keep the ice frozen, much in the same way vitamin D and calcium isn’t going to strengthen the bones. Menopause is the summer.

When Grace fell two years ago, she shattered her hip. She didn’t fall from a height. She wasn’t involved in a crush injury. She simply slipped on a small puddle of water in her home and landed on her backside. It was an excruciating pain that she experienced, and fortunately for Grace, her daughter was home to notify EMS. Grace was not a fan of taking pain medication either, but after the fall, she couldn’t bear the pain. She willingly took whatever pain medication the EMT was willing to give her.

The signs of osteoporosis can be very subtle. A loss of height is one of the more common signs. My grandmother seems to have been constantly shrinking for the past twenty years. I remember growing up with her, my grandma having a ton of energy, chasing us kids around. Little did I know that while I was growing up, she was growing down. This is usually due to a vertebral fracture, which can also result in a scoliosis. Occult hip fractures can also result in a loss of height. A patient I had in an assisted living facility once presented with a slight limp. There was no history of trauma. Subsequently, she was diagnosed with an occult hip fracture. Gravity becomes a problem in osteoporosis. Other things can contribute, like chronic steroid use, cancer therapy, low body weight, sedentary lifestyle, smoking and early menopause.

After Grace had her hip replacement, she struggled with the rehabilitation. The pain was excruciating. She initially took oxycodone to try to alleviate her pain, but it made her drowsy and affected her balance. She struggled to do the therapy on just anti-inflammatories. Her rehab suffered as a result and she had a setback. As the pain slowly improved, she gradually gained her footing, but now she requires a walker, as she consistently feels unsteady on her feet.

Usually, physicians will recommend a bone density test to a woman at age 65. In patients with fragility-related fractures, screening should begin earlier. Treatment with medications are the usual treatment for the problem. Unfortunately, vitamins and calcium supplementation have a minor role in treatment, since the main issue with osteoporosis is the dysregulation or uncoupling of bony resorption to formation.

Grace has had a long way back to normalcy. During today’s visit, we addressed her worsening memory. With a serious event, like a hip fracture, problems such as dementia have a tendency to worsen at a much quicker pace. She was joined by her daughter, who told me that Grace may be ready for a long term care facility, as her care needs were becoming more than she could manage. The annual cost of osteoporosis related fractures in the US are estimated to be upwards of 16 billion dollars according to the NIH. The cost to a family can be devastating. This is now the new normal for Grace. The road hasn’t been easy, and with early treatment, it could’ve been different.

By: Dr. Juan Borja
Original post: https://yourdoctordad.com/a-fall-from-grace/

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