Diagnosis and Treatment of Osteoporosis in Older Men

Osteoporosis, a well-known condition in women following menopause, also affects nearly 1.5 million men in the US age 65 and older. An additional 3.5 million are at risk. Osteoporosis is characterized by thinning bone mass and deterioration of bone tissue at the microscopic level. This makes bones more fragile and susceptible to fracture.

In elderly individuals, broken bones -- hip fractures from falling are particularly common -- are slow to heal and can actually lead to death. While osteoporosis is less frequent in men than women, almost one-third of all hip fractures in the world occur in men. The death rate of men over age 75 from hip fractures is 30%, compared to 9% in women of the same age. After age 80, one in every six men will have a hip fracture, and osteoporosis may be a key factor.

Bone is a living tissue that continually "remodels" itself throughout life. The rate of bone reformation slows after peak bone mass is reached, usually in a person's 20s. The rate of bone remodeling in elderly people is not great enough to maintain bone mass. In elderly men, certain steroidal treatments (i.e., glucocorticoids), medications to prevent convulsions, lowered testosterone levels and excessive alcohol consumption may increase the rate of bone loss.

Genetic, environmental and nutritional factors are also important. African-American men are less likely to develop osteoporosis than Caucasian men. Declining kidney function and vitamin D deficiency may play a role in osteoporosis. A lack of calcium in the diet, or a limited ability of the intestines to absorb calcium, can lead to bone loss, too. Smoking and consuming excessive amounts of sodium, caffeine and anti-acids containing aluminum are also risk factors. Medications given to patients with kidney, heart or liver transplants can cause severe osteoporosis.

A study of 820 men in Australia aged 60 and older found certain risk factors for osteoporosis-related fractures. These risk factors included a lower bone mineral density at the top of the thigh bone (where it enters the hip), weakness of the quadriceps muscles above the knee, low body weight, a shorter height than earlier in life, falls in the preceding year and a history of fractures in the previous five years. The study found that the following factors protected against osteoporosis fractures: higher rates of physical activity, moderate intake of alcohol, and the use of thiazide diuretics (typically to treat high blood pressure).

Diagnosis and Treatment

Bone mass is usually measured in terms of bone mineral density (BMD). The World Health Organization defines osteoporosis in terms of a patient's BMD as compared to a normal, healthy, young adult's. However, the criteria were developed based on studies of Caucasian women, which may lead to inaccuracies when diagnosing men.

Osteoporosis may be suspected in men with a history of bone fractures from falls or other "low-trauma" causes, bone loss or abnormality present on a standard X-ray, or who have a significant risk factor, such as long-term use of corticosteroids. If osteoporosis is suspected, a BMD measurement should be conducted using a dual energy X-ray absorptiometry (DEXA) scan, preferably of the hip and spine. A complete survey of drug history, lifestyle habits and dietary intake should be conducted. Laboratory tests that measure such things as testosterone, calcium and thyroid function should also be performed.

In some cases, the presence of osteoporosis may not yet be evident, but lifestyle changes and another BMD measurement two or three years later may be recommended. For men diagnosed with osteoporosis, medication and lifestyle changes may be prescribed.

Quitting smoking, ensuring adequate calcium and vitamin D intake, limiting alcohol to four cans of beer or two ounces of liquor per day and receiving regular exercise are recommended for men with osteoporosis. Men over 65 should receive 1,500 mg per day of calcium, preferably through diet, rather than supplements. For adults over age 70, 600 IU (international units) of vitamin D is recommended. Measures may be taken to avoid falling, such as changing room layouts, correcting visual impairment and taking precautions with medications that may cause dizziness. Hip padding may also be worn for protection.

There is not a great deal of research data on the effectiveness of medications to treat men with osteoporosis. However, bisphosphonates and calcitonin are prescribed for men with osteoporosis because, in theory, they should have the same positive effects as in women. Alendronate sodium (Fosamax) has been approved for use in certain men with osteoporosis. Some men with osteoporosis may also benefit from testosterone replacement.

However, before diagnosis and treatment can occur, elderly men must understand that, like women their age, they also may be at risk for osteoporosis.

Edmund H. Duthie, MD
Professor and Chief of Medicine (Geriatrics)
Medical College of Wisconsin

Geriatrician
Zablocki VA Medical Center and the
Froedtert & Medical College Geriatrics Program

Dr. Duthie and Kaup R. Shetty, MD, Professor of Medicine (Geriatrics), were co-authors of a September, 1999, article on this topic with Nadeem A. Siddiqui, MD, then a fellow in Geriatrics at the Medical College. The article appeared in Geriatrics (Vol. 54, No. 9).

Each year, Medical College of Wisconsin physicians care for more than 180,000 patients, representing nearly 500,000 patient visits. Medical College physicians practice at Children's Hospital of Wisconsin, Froedtert Memorial Lutheran Hospital, the Milwaukee VA Medical Center, and many other hospitals and clinics in Milwaukee and southeastern Wisconsin.