Men's Osteoporosis Prevention and Screening Neglected

By Jamie Santa Cruz

Physicians must become proactive in recommending screening for and treatment of osteoporosis in older men.

New research presented in May at the American Geriatrics Society's annual meeting has found that men are far less likely than women to take preventive measures against osteoporosis or to be screened for the disease.

Osteoporosis is typically thought of as a women's issue, says Irina Dashkova, MD, geriatric fellow at North Shore-LIJ Health System and lead author of the study, but that perception is not strictly accurate. Although the disease is more common in women, about 20% of cases occur in men.1 Currently up to 2 million men have osteoporosis, and millions more have low bone density and are at risk of developing the disease.2

Dashkova's research, however, found little awareness among men about their risk and the striking differences in behaviors surrounding osteoporosis. In the study, an anonymous cross-sectional survey of 146 patients in New York and Florida (average age of 72), less than 10% of the men reported a family history of osteoporosis, compared with more than 90% of women. Few had been offered screening; only 11.4% of men reported having been offered screening compared with 88.6% of women. And women were four times more likely to engage in preventive measures, such as taking calcium and vitamin D supplements to protect bone health.

A number of medical organizations, including the National Osteoporosis Foundation,3 the American College of Physicians,4 and the Endocrine Society,5 recommend regular risk assessments and screening for older men. According to Andrea Singer, MD, clinical director of the National Osteoporosis Foundation, however, screening for men "is not a standard offering" among clinicians, and screening rates lag behind the recommendations.

Dashkova's research, however, suggests that it's not only clinicians who neglect screening; patient attitudes also play a role. When asked whether they would accept screening if it were offered, less than 25% of the men said yes. "Even when it's offered, men aren't willing to take it," says Dashkova.

It's not entirely clear why men are reticent to accept screening, but the hesitancy may reflect a lack of understanding about how screening is performed or concerns about payment, according to Dashkova. Other factors may be at work as well—namely, a general perception among men that osteoporosis is harmless for both genders. (In the study, 78% of women believed screening was necessary for women over 65, but only 21% of men agreed.) "We found that men not only don't think [of osteoporosis] as their problem; they don't think of osteoporosis as a problem at all," Dashkova says.

Despite the lack of concern prevalent among men in the survey, the medical consequences of osteoporosis tend to be more severe for men than for women. Mortality in particular is substantially higher in men than in women following osteoporotic fractures.6,7 "I don't want to minimize the consequences in either gender; both [experience] serious consequences, [but] men often do even worse," says Singer, who is also director of women's primary care and director of bone densitometry in the department of obstetrics and gynecology at MedStar Georgetown University Hospital.

According to Dashkova, the worse outcomes for men may be due in part to the fact that the condition frequently goes unrecognized and untreated in men, who are often not diagnosed until an older age, after they have already suffered a severe fracture. She compares the problem to the issue of heart disease: because heart attacks occur more frequently in men, she explains, they came to be considered a men's issue, even though women are also susceptible. Thus neither patients nor clinicians are attuned to the possibility of heart attacks and osteoporosis in the less common gender.

According to Singer, the lack of concern about osteoporosis in men is part of a broader problem of insufficient attention among physicians to osteoporosis in bothgenders. "We have an issue with osteoporosis in general in terms of being underdiagnosed and undertreated," she says. "There needs to be greater awareness when it comes to the clinical community."

She acknowledges, however, that even when clinicians are aware of the risks for osteoporosis and even when they encourage patients to be screened, the lack of Medicare coverage for bone density tests is a roadblock for male patients. For men, the test is covered only in certain instances, specifically, when a patient has suffered a spine fracture, has a history of hyperparathyroidism, has been treated with steroids for three months or more, or is already on treatment for osteoporosis and is being monitored. For women, by contrast, coverage of bone density testing is much broader: they can receive the test based strictly on age, for example, or in the case of a wider variety of fractures, including hip, shoulder, or wrist fractures.

Although low screening rates pose a problem, the good news, Singer says, is that when men are screened and diagnosed appropriately, the disease is treatable. Many currently available treatments are exclusive to women, but a number have been approved for men. And the therapies, according to Singer, are effective, assuming they are given "in the right setting to the right patient."

When to Screen
Both the National Osteoporosis Foundation and the Endocrine Society recommend dual-energy X-ray absorptiometry (DEXA) screening for osteoporosis for all men aged 70 or older, as well as for men between the ages of 50 and 69 who have additional risk factors.3,5

The biggest risk factor is history of low trauma or fragility fractures. Whenever patients suffer fractures, Singer says, "a red flag should go up that there may be something wrong with the bones, and that [the patient] should be investigated, diagnosed if appropriate, and treated if appropriate."

Even if patients haven't yet suffered a fracture, a history of falls should also be considered a warning sign, Dashkova says. "The highest risk for falls is having a prior history of falling," she explains. "If somebody has fallen, it has to be highlighted in clinicians' minds that we have to investigate bone health in this person."

According to Singer, other risk factors that should prompt screening include the following:

• underlying medical problems such as hypergonadism, low testosterone levels, or parathyroid disease;

• use of high-risk medications such as steroids, proton pump inhibitors, or androgen deprivation therapy for prostate cancer; or

• history of smoking.

For evaluating risk, Dashkova recommends use of FRAX, a tool developed by the World Health Organization to calculate the ten-year probability of fracture (available at www.shef.ac.uk/FRAX/tool.jsp?locationValue=9). While the tool is already commonly used by endocrinologists, it would be beneficial for primary care physicians to incorporate it into their practices more frequently as well, Dashkova says.

When recommending screening via a DEXA scan, physicians should be sure to explain why testing is important, stressing the risks osteoporosis carries for men and the potential loss of independence that can result from the disease. Clinicians should also explain how screening is performed, Dashkova says. It's possible that lack of understanding of the procedure plays a role in why men frequently refuse screening when offered, she explains, so stressing that the procedure is both quick and painless may be valuable.

Steps to Prevention
In addition to recommending screening, physicians should also be diligent about discussing osteoporosis prevention with men and women alike. "In an ideal world, we should be talking about prevention with children and teens and young adults before they reach peak bone density," Singer argues. "But it's never too late to intervene."

Singer's key points to stress with regard to prevention are the following:

• A healthful well-balanced diet with adequate calcium intake. Dietary sources of calcium are preferable, but supplements are acceptable if a patient is not getting sufficient calcium from diet alone.

• Adequate vitamin D, which typically requires supplementation.

• Adequate weight-bearing exercise. Care should be taken with patients who have already had a fracture, Singer says; advise these patients to choose weight-bearing exercises that are lower impact and have a low fall risk.

• Fall risk reduction. Singer recommends a standard evaluation of fall risk as well as a gait/balance assessment.

As the US population ages, Dashkova says, the need for prevention and screening will only become more acute. "We're going to encounter more and more of this problem [of osteoporosis in men]," she claims. With better education about the outcomes of osteoporosis in men, however, she hopes to stem the tide. "We want everybody to reach their milestones [as they are] growing older with good quality of life."

— Jamie Santa Cruz is a freelance writer based in Englewood, Colorado.

References
1. Lane JM, Serota AC, Raphael B. Osteoporosis: differences and similarities in male and female patients. Orthop Clin North Am. 2006;37(4)601-609.

2. Cauley JA. Osteoporosis in men: prevalence and investigation. Clin Cornerstone. 2006;8 Suppl 3:S20-S25.

3. Cosman F, de Beur SJ, LeBoff MS, et al. Clinician's guide to prevention and treatment of osteoporosis. Osteoporos Int. 2014;25(10):2359-2381.

4. Qaseem A, Snow V, Shekelle P, et al. Screening for osteoporosis in men: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2008;148(9):680-684.

5. Watts NB, Adler RA, Bilezikian JP, et al. Osteoporosis in men: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2012;97(6):1802-1822.

6. Center JR, Nguyen TV, Schneider D, Sambrook PN, Eisman JA. Mortality after all major types of osteoporotic fracture in men and women: an observational study. Lancet. 1999;353(9156):878-882.

7. Bliuc D, Nguyen ND, Nguyen TV, Eisman JA, Center JR. Compound risk of high mortality following osteoporotic fracture and refracture in elderly women and men. J Bone Miner Res. 2013;28(11):2317-2324.