Osteoporosis: The Silent Thief

There is no doubt that osteoporosis is yet another syndrome that can be characterized as 'silent.' The long period of bone loss is characteristically asymptomatic until the first clinical fracture occurs. However, even when the diagnosis is being shouted aloud (via a fracture requiring hospitalization), only a small minority of patients actually has the diagnosis of osteoporosis recorded on the hospital chart. Furthermore, it is likely that an even smaller proportion receives effective treatment, sometimes despite hospitalization for an osteoporotic fracture. Surveys of apparently healthy women in primary care practices reveal a prevalence of osteopenia and osteoporosis that approaches 50%; yet most of these women are not diagnosed as having bone disease.

What are the reasons for this? Clearly, the lack of symptoms prior to the first fracture is very important. In other disorders, the best example being hypertension, the medical community and the public at large understand the importance of diagnosis before the first clinical disaster occurs. In addition, screening for that disorder (by using a blood pressure cuff) is relatively easy and inexpensive. Hopefully, new techniques for determining bone density (particularly ultrasound) will be cost effective for primary care in the future. Another contributing factor may be that, until recently, there was a paucity of proven effective treatments for osteoporosis. We now have several excellent medications, with the prospect of more to come in the near future.

One cannot help but wonder if the fact that osteoporosis is a 'woman's disease' has also contributed to its relative neglect in the past. Certainly, many of the best young clinicians and investigators in the field are now women, and this should keep the focus on the problem of 'bone health' in the future. It is also interesting to note that the problem of male osteoporosis is finally coming to light. It is surprising that we have been blind to this fact for so long, considering that up to one quarter of hip fractures occur in elderly men.

This edition of G&A has several articles on the topic of osteoporosis. We can learn about the standard pharmacological management of osteoporosis in Sophie Jamal's article, while Jan Bruder's piece outlines new possibilities for the prevention and treatment of osteoporosis. I am particularly pleased that D'Arcy Little has written about osteoporosis in men (possibly my male bias showing). Frances Simone and Gabriel Chan tackle one of my favourite topics, the interface between osteoporosis and the classic geriatric syndrome of falls. Simone and Chan present a new type of program designed to tackle both sides of the fracture problem: bone density and the propensity for falls. We also have the first of our case studies series, which discusses the management of osteoporosis in an elderly woman (Chui Kin Yuen).

In addition, we have our usual collection of geriatric articles. Ann-Sophie Rigaud and Bernard Forette discuss the treatment of hypertension; despite the fact that it is now over 15 years since the first randomized trial on the efficacy of treatment of hypertension in the elderly was published, we do a very poor job of diagnosing and effectively treating hypertension in the elderly. There is an article on aphasia by Farcnik, Persyko and Bassel, and one by Ozdal and Tanguay on a new treatment for benign prostatic hyperplasia. Miller and Lemmons discuss the ethical (and legal) issues when clinicians are paid finder's fees for finding subjects for research studies. Jerilynn Prior reviews estrogen and progesterone therapy in older menopausal women and Kathryn Yorkston and her colleagues give advice on managing dysarthria in patients with ALS.

Enjoy this issue.