Osteoporosis and prevention of fractures in the elderly.

A walk on the beach in Maui. (Dr. Noorali Bharwani)
A walk on the beach in Maui. (Dr. Noorali Bharwani)

Recently, I came across a good article on osteoporosis and prevention of fractures in the elderly written by Dr. Erika Dempsey, clinical assistant professor with the University of Calgary (MD Scope, March 7, 2019).

Osteoporosis is a condition in which there is loss of calcium and a gradual softening of the bones that make them fragile.

Osteoporosis leads to an increased incidence of fractures resulting from low impact injury. Sometimes no injury is involved in case of spontaneous fractures of vertebrae. Believe it or not, 80 per cent of all fractures in patients over the age of 50 are thought to be related to osteoporosis. Osteoporosis affects more women than men because of hormonal (estrogen) changes at menopause. This causes bone loss and softening.

There are several reasons why we should control osteoporosis. Osteoporosis is exceedingly costly, both for the patient and the health care system. Osteoporosis Canada estimates that acute care for patients with hip fractures alone will cost Alberta over $62 million in 2020. 

This does not include increased costs of care after discharge. Roughly a quarter of the patients with hip fractures will require institutional care on a long-term basis. A person with hip and spinal fracture may die from medical and/or surgical complications. One-year post-operative death for hip fracture patients is 25 to 30 per cent.

Should individuals over 50 be on vitamin D and calcium supplements?

Both calcium and physical activity are important to build and maintain strong bones. Ingesting the recommended daily amounts of calcium primarily through dietary sources and staying physically active appear to be the best approaches to limit your fracture risk.

Sometimes we forget how regular exercise builds strong bones.

We need vitamin D to absorb calcium. Vitamin D enhances absorption of calcium.

Vitamin D is necessary for building and maintaining healthy bones. That’s because calcium, the primary component of bone, can only be absorbed by your body when vitamin D is present. Your body makes vitamin D when direct sunlight converts a chemical in your skin into an active form of the vitamin.

Vitamin D isn’t found in many foods, but you can get it from fortified milk, fortified cereal, and fatty fish such as salmon, mackerel and sardines.

Dr. Dempsey suggests treatment of osteoporosis should be accompanied by vitamin D supplementation (800-2000 IU daily) and 1200 mg/day of (preferably dietary) calcium. Do not start these pills without consulting your family doctor.

If the osteoporosis begins before menopause then estrogen loss alone cannot account for the changes. Other causes of osteoporosis for men and women are: long-term use of cortisone, smoking, heavy drinking, sedentary lifestyle, low body weight and medical conditions that affect absorption, such as celiac disease. Diagnosis of osteoporosis is made by measuring bone mineral density.

The current national guidelines recommend the test for osteoporosis (measuring bone mineral density) should be done every two to three years.

How to prevent hip fractures?

All individuals over the age of 50 should consult their doctors and seek advice. General recommendations are: get enough calcium and vitamin D, do regular exercise to strengthen bones and improve balance. Do weight-bearing exercises, and do walking that helps you maintain peak bone density for more years. Avoid smoking or excessive drinking.

Walking has other advantages. “All truly great thoughts are conceived while walking,” says Friedrich Nietzsche. Let us walk and change the world!

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The Mental and Cardiac Toll of Being Angry

A good way to relax - a boat in Maui. (Dr. Noorali Bharwani)
A good way to relax - a boat in Maui. (Dr. Noorali Bharwani)

In one of the online medical journals (Figure1) there was a clinical case presentation. It went like this:

“A 73-year-old male is brought to the emergency department by his daughter with vomiting, confusion, and tinnitus (ringing in the ears). She reports that his symptoms began a few hours earlier, following a heated argument with his son. He has a history of stable angina, and takes aspirin daily. On examination, he has a temperature of 38.6 degrees Celsius and is mildly confused. His breathing rate is 30. Which is very high.”

Obviously, he was in emotional and medical distress. Did the heated argument trigger the life-threatening symptoms?

This is an example of how your emotions can affect your heart. What are the other things bad for your heart? Loneliness and depression.

Whether you are young or old, whether you exhibit your anger or not, studies have shown some of the quieter emotions can be just as toxic and damaging. If you have a sense of connection and love you will feel happy and healthy. You won’t have chest pain or shortness of breath.

Dr. Srini Pillay, MD, writes in the Harvard Health Blog (May 09, 2016), “We often think of the heart and brain as being completely separate from each other. After all, your heart and brain are located in different regions of your body, and cardiology and neurology are separate disciplines. Yet these organs are intimately connected, and when your emotions adversely affect your brain, your heart is affected as well.”

His message is simple, managing your emotions saves lives.

Besides anger, three brain-based conditions – stress, anxiety and depression – can affect your heart as well. Even in people with no prior heart disease, major depression doubles the risk of dying from heart-related causes, says Dr. Pillay.

Many famous people have had some form of mood disorder. On the Internet I found a list of famous names who have publicly gone on to say they have bipolar mood disorder (formerly known as manic depression) and are seeking help. The famous names are: Carrie Fisher, actress, Russell Brand, comedian, Catherine Zeta-Jones, actress – just to name a few.

If you are having problems controlling your anger, if it is affecting your life at home or at work, if you are having trouble maintaining relationship then you should seek professional advice. You can change your brain and get a healthier heart in the process.

Cardiac Psychology

For all the reasons outlined earlier, a new emotion-based approach to heart health, called cardiac psychology, is receiving increasing interest.

The link between heart and mind has been studied over the centuries in many fields, such as medicine and psychology. It is important to treat the mind to improve the heart. There are several articles in the medical journals on this subject. So, talk to your doctor if you care about your health and how it affects your family and friends.

There are many things you can do at home: stress management, relaxation techniques like yoga and meditation. Physical exercise like aerobics can help you be more mentally nimble by helping you think faster and make you more flexibly. As somebody has said, “Exercise is brain food.”

Various types of aerobic exercises, including jogging, swimming, cycling, walking, gardening, and dancing, have all been proven to reduce anxiety and depression and to improve self-esteem. This is thought to be due to increased blood circulation in the brain, and the fact that exercise can improve the brain’s ability to react to stress. When you feel angry, shut your eyes and meditate for a few minutes or go for a walk. It works for me!

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New breast cancer screening guidelines empower women.

The Westin Dawn Beach Resort & Spa, St. Maarten. (Dr. Noorali Bharwani)
The Westin Dawn Beach Resort & Spa, St. Maarten. (Dr. Noorali Bharwani)

Recently, Canadian Medical Association Journal (CMAJ December 10, 2018) published new recommendations on screening for breast cancer in women aged 40-74 years who are not at increased risk for breast cancer.

These guidelines apply to women with no previous history of breast cancer, no history of the disease in a first-degree relative like a mother or sister, no known BRCA genetic mutation and no previous exposure to therapeutic radiation of the chest wall.

The recommendations come from the Canadian Task Force on Preventive Health Care. The new recommendations update guidelines first published in 2011. The guidelines are summarized below:

1. There should be no routine mammography for most women aged 40 to 49 because the risk of cancer is low in this group while the risk of false-positive results and overdiagnosis and overtreatment is higher.

2. Routine screening mammography should be done every two to three years for women aged 50 to 69.

3. For women aged 70 to 74, routine screening mammography should be done every two to three years.

4. MRI and ultrasound should not be used for screening purposes.

5. Routine clinical breast examinations or breast self-examinations to screen for breast cancer is discouraged.

Although we rely on mammography for screening the fact remains it is not a perfect screening tool. Screening may lead to overdiagnosis, resulting in unnecessary treatment of cancer that would not have caused harm in a woman’s lifetime and false-positive results that can lead to both physical and psychological consequences. Overdiagnosis and false-positives with subsequent biopsies are more common in younger women.

Other risks and limitations of mammograms include: exposure to low-dose radiation, having a mammogram may lead to additional testing in about 10 per cent of cases. Mammograms can miss one in five cancers in women.

On the other hand, mammography is the only technique proven to be safe and effective in screening for breast cancer, and mammography equipment is the only imaging technique licensed by Health Canada for breast cancer screening. It is good at finding breast cancer, especially in women ages 50 and older. Overall, the sensitivity of mammography is about 87 per cent. Screening may identify breast cancer earlier and lead to more effective and less invasive treatment.

What about women aged 40 to 49 years? Research shows balance of benefits and harms from screening is less favourable for women in this age group than for older women. If a woman in this category requests a mammogram then the guidelines suggest she should not be denied.

Death rates from female breast cancer dropped 40 per cent from 1989 to 2016. Since 2007, breast cancer death rates have been steady in women younger than 50, but have continued to decrease in older women (www.cancer.org).

You may ask, if none of the screening tests are perfect then why is there a decline in the death rate from breast cancer?

A review article in the Lancet Oncology (Why is breast-cancer mortality declining? April 2003), the authors argue that although some of the decline in breast-cancer mortality is due to a reduction in breast-cancer risk, most of it can probably be attributed to adjuvant systemic therapy and the earlier detection of palpable tumours. The authors also explain in the article why advances in the treatment of breast cancer might be outpacing the value of mammography screening.

Important thing to remember is new guidelines empower women to be in charge of their own screening protocol. The final decision on whether to be screened should fall to the patient as long as that patient understands the risks. Patients should be left ultimately to decide what is best for them.

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Early Colorectal Cancer Screening Saves Lives

Nile Cruise Dancer (Dr. Noorali Bharwani)
Nile Cruise Dancer (Dr. Noorali Bharwani)

Colorectal cancer is the second most commonly diagnosed cancer in Canada and the second leading cause of cancer death. First being lung cancer.

It is estimated about one in 13 men and one in 16 women will be diagnosed with colorectal cancer during their lifetime. Seventy per cent of cancers are in the colon and 30 per cent are in the rectum.

Over the years we have been diagnosing colorectal cancer at an earlier stage thanks to public awareness and the variety of screening tests available to the public. Cancer diagnosed early has about 90 per cent survival rate. Cancer diagnosed in advanced stage has about 10 per cent survival rate.

There are many ways to get the general public involved in the screening programs. The programs can be adjusted to an individual’s needs and fears. Screening tests are purely for people who have no bowel symptoms or family history of colorectal cancer or polyps. For them screening should begin at age 50 and we have a variety of tests to choose from.

Colonoscopy is the most accurate test for detecting colorectal cancer, proven to detect the disease early and save lives. But even a very good test can be done too often, according to experts at Choosing Wisely Canada (CWC). CWC is the national voice for reducing unnecessary tests and treatments in health care. Having a colonoscopy more than once every five or ten years usually isn’t necessary unless there are clear indications. Routine checks usually aren’t needed after age 75.

If a screening colonoscopy does not find adenomas (pre-malignant benign tumours) or cancer and you don’t have risk factors, the next test should be in ten years. If one or two small low-risk adenomas (polyps) are removed, the exam should be repeated in five to ten years.

Some individuals, who are at a low or average risk of colorectal cancer would prefer to go for an alternative test. For whatever reasons, some people do not like the idea of getting a screening colonoscopy. Here are some other choices, though not as good as colonoscopy.

Virtual colonoscopy (CT colonography): During a virtual colonoscopy, a CT scan produces cross-sectional images of the abdominal organs, allowing the doctor to detect changes or abnormalities in the colon and rectum. To help create clear images, a small tube (catheter) is placed inside your rectum to fill your colon with air or carbon dioxide. Virtual colonoscopy takes about 10 minutes and is generally repeated every five years.

Fecal occult blood test or fecal immunochemical test: These are lab tests used to check stool samples for hidden (occult) blood. The tests usually are repeated annually.

Flexible sigmoidoscopy: During flexible sigmoidoscopy, a thin, flexible tube is inserted into the rectum. A tiny video camera at the tip of the tube allows the doctor to view the inside of the rectum and most of the lower part of the colon (sigmoid colon). A flexible sigmoidoscopy test takes about 20 minutes and is generally repeated every 5 years.

Stool DNA test: The stool DNA test uses a sample of your stool to look for DNA changes in cells that might indicate the presence of colon cancer or precancerous conditions. The stool DNA test also looks for signs of blood in your stool.

If any of the above test is positive then you must have a colonoscopy to confirm the findings and manage the problem.

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