How to Make Your 80's Miserable, Part Two

The Bare Bones about Osteoporosis

Trudy* - whom I’ve written about before - is meeting with me to discuss her back pain.

I thought I blew out a disk or something. One minute I was fine and taking the tuna casserole out of the oven, then my back had a crunching feeling and started hurting. I dropped the tuna casserole and Tina had to pick it up and serve dinner.

I didn’t enjoy it at all, but it was the cousins’ dinner and they all like the tuna casserole their Grammy makes so I ate with them and after they left, I had Tina take me to the hospital. 

It got weirder there! They told me I had broken a vertebrae in my back and it sounded like something my husband would have gotten in the garage: a compressor fracture. I told him; I was in the kitchen! I wasn’t anywhere near a compressor.

They gave me ten vicodin and said you’d have to give me more if I needed it, but that maybe you could help me with something else, like get it fixed instead of just covering up the pain. It hurts a lot. I can’t lift my arms without it hurting, even to get a drink of water. Breathing hurts. Going to the bathroom hurts.

She started to laugh, then winced, 

Now you’ve got me laughing and that hurts worst of all. It’s like when I broke my rib except way, way worse. Can you do the thing they said you could and make it better?

Where to begin? I nodded and smiled at Trudy to let her know I’d heard her and was getting ready to respond. The points I wanted to communicate were:

1. Ouch! And yes, this is lousy.

2. I’m glad to hear she still has all her grandkids over monthly for a cousins’ dinner, even though they are all adults in college or working.

3. It’s a compression fracture.

4. It’s caused by compression of a bone that has osteoporosis.

5. How did she get osteoporosis without my noticing?

6. This is why I told her to take calcium. She hates how it makes her constipated.

7. I don’t do the procedure, but I can arrange for the procedure and the preliminaries that have to be done first.

8. There is something she can take in addition to the Vicodin that will help with the pain.

9. This is going to keep happening unless we can get her bones stronger. I have a pill for that.

First steps after an osteoporotic vertebral fracture

I think people understand things better if they have a scaffolding onto which to hang all of the details I’m going to tell them. It’s almost always best to start with an explanation of how things are supposed to work and what has gone wrong in the patient at whatever level I think the patient can hear given their attention span, level of pain, curiosity, etc.

Correcting her (adorable) misunderstanding of the name will provide a good way in for us and will prevent someone less nice from doing it later. 

It is probably going to be hard for her to hear anything I say until she feels I’m going to address her pain so I’ll start with that, and then move on to a quick medicine lecture. I tell her,

I don’t do the procedure, but I can get you to someone who can. It’s a bit of a process and we can go over that in a minute. First, I want to be sure you know what’s going on in that back of yours.  

It’s called a “compression fracture” because it’s caused by compression on the bone. The extra weight of the tuna casserole on your back, especially because it was way out here and your back was bent over like this (I pantomimed), caused you to break a vertebra. It’s not a single crack like you’d break an arm, but more like - sorry - an old mattress where you’ve sat on the side of it so many times it’s kind of scrunched down.

The author in the kitchen, demonstrating bad mechanics and the kind of position that leads to compression fractures in the susceptible. Photo by Doug Bates.

She started to laugh. I exclaimed,

Don’t laugh; it’ll hurt!

Then she started to laugh harder and winced. 

I’m sorry; that’s a horrible mean thing for it to do to hurt when you laugh, isn’t it? 

For pain control, I can give you something for the underlying problem of the crumbled bones. Keep taking the vicodin if you need it; meanwhile, take the acetaminophen as scheduled. I’ll tell you how to take it so you don’t take too much because there’s some in the vicodin. Acetaminophen is remarkably effective for most people. 

Also, we need to talk more about your osteoporosis – why your bones are so weak - but let’s talk about what the procedure would be for hopefully getting your back fixed.

I would go on here to tell Trudy about kyphoplasty which is a procedure that a radiologist or back surgeon does to put a little bag of cement in the vertebra where the bone crumbled. It usually works pretty well, and there is a particular set of steps that Trudy would have to go through to make sure she is eligible for the procedure. 

A fractured vertebra can be just as painful as a fractured arm, but unlike a fractured arm, you cannot put a cast on it to immobilize it. Vicodin or a similar pain medication works well for the pain, but of course, it has all kinds of issues because it is an opioid.

Additionally, there is an old, old treatment for osteoporosis that helps with the pain as well. It is an inhaled medication that the patient takes once daily, called calcitonin. It does not help the pain immediately like acetaminophen or Vicodin does. It simply lowers the overall level of pain. 

Treatment for osteoporosis

Before we go on, let me remind you that my articles are not personal medical advice. I don’t know anything about your personal medical situation. Your doctor does. Talk to them about your bones or treatment options for them if you have questions.

The usual medication to treat osteoporosis is a nuisance to take because it is not absorbed well in your stomach.

This means it has to be the only thing in your stomach when you take it. You cannot take other medications or food with it or for an hour after taking it. If it refluxes into your esophagus, it can be painful so you cannot lie down or turn upside down after you take it.

You have to keep your head above your stomach – sitting or standing or kneeling or walking – for an hour after you take it. 

The medication goes to your bones and is incorporated there so it can do its job. Infrequently, patients report that their bones hurt after the first dose or two, but not afterward. Acetaminophen is usually enough to take care of this short-lived side-effect.

Some patients cannot remember to take a weekly medication or to remain upright for an hour. Some cannot manage the empty stomach part. Some have esophageal issues that make further irritation more than they can tolerate.

For these patients, the medication comes in an IV formulation that needs to be taken once yearly. Patients go to the infusion center, an IV is placed, the medication is infused, the IV is removed and they are on their way. It takes longer for them to go through the check-in procedure than to get the medication.

Quite a few of these patients tell me that the IV treatment causes their bones to hurt for one or two days, but all of them tell me that acetaminophen works for the pain. 

I tell everyone with osteoporosis to take calcium and vitamin D. Comments on my pervious article encouraged me to look up the role of magnesium and I am going to start encouraging that, too. I encourage them to attend exercise classes specifically designed to help strengthen bones and I encourage them to do their exercises at home between classes.

How to tell if the treatment is working

As you might expect, it takes a while for bones to respond to the medication. I usually repeat the bone test after the person has been taking the medication for two years.

If their bone density is worse, I stop the medication and send them to a specialist who can pursue other treatment options.

If their bone density is improved, we continue for three more years.

If their bone density is the same, we talk about whether they would like to see a specialist or declare victory because their bone density is no longer worsening.

There is no free lunch

Most things come with trade-offs. That’s the case here. Taking osteoporosis medications for too long can cause the bones to become brittle, putting the patient at risk for other types of fractures. For this reason, after five years, we stop the medication, but the calcium and vitamin D continue.

Osteoporosis, left unchecked, is the usual cause of kyphosis and adult onset scoliosis. It is a major cause of loss of height in those over sixty. It causes untold misery in the form of hip, wrist, and vertebral fractures such as Trudy had. If you’ve seen tiny elderly people who have the rib cage resting on their hip bones, osteoporosis is usually the cause.

Early on in my medical career, I saw the tremendous suffering that these patients are subjected to, and I learned everything I could about osteoporosis to try to prevent this.

How did Trudy make out? 

Trudy did the MRI and lab preliminaries for the kyphoplasty.

I had to beg to get the MRI scheduled sooner than six weeks out and she had to arrive at seven am to get in for the special appointment they made for her. She was not happy to be up that early but was willing to do whatever it took to get relief.

The procedure was scheduled a week later. 

Trudy’s daughter Tina pushed her in a wheelchair to the procedure. After the kyphoplasty, Trudy felt so good that she insisted on walking out. She could not believe how good she felt with her pain relieved. 

Because of the severity of her condition, Trudy opted for the IV medication because it is faster-acting. 

She does her exercises faithfully now. Because the kyphoplasty put a block of hard material into her spine and is surrounded by weak vertebrae, she is at risk for cascading fractures around the kyphoplasty.

She has reluctantly accepted the idea that she should never lift anything heavy while bending over. Someone else will be putting the tuna casseroles into and out of the oven in the future.

In addition to her yearly infusions, Trudy will take her calcium and vitamin D faithfully, and do some physical therapy to decrease her risk of falling. 

Nothing focuses the attention like the experience of a compression fracture. Trudy is now motivated to avoid experiencing another. Doing absolutely everything exactly perfectly does not guarantee that she will avoid another fracture, but it does improve her chances.

How did Trudy get osteoporosis without her doctor (me) noticing?

Trudy’s first bone density test at 65 was normal. Her test at 75 showed osteopenia. She should have had another test within 2 or 3 years, but she was now 80 and hadn’t had one.

I usually use the patient’s annual wellness visit to discuss bone density, and when she was 78, I ordered a follow-up test for her. I had not noticed that she didn’t do it. 

Our office has a system for alerting doctors when patients don’t do the tests we’ve ordered. I either failed to notice or decided that it wasn’t crucial. I’d see her again next year.

But the next year Trudy - without consulting with anyone - canceled her wellness visit because she didn’t think she needed them anymore. “I’m so old! Why do I need a physical?”

By the time I was alerted that she was past due for her physical, my next available appointment was nine months out - three months after her injury.

Had Trudy not had her injury and shown up for her rescheduled annual wellness visit, I would have urged her to get her bone density tested again. That test would have taken three or four months to get scheduled. 

I considered whether or not to say anything to her about my missing that she hadn’t done her bone density.

Multiple things had gone wrong, multiple times, some of which were her decisions, and some of which were my failure - or at least the failure of my clinic and its systems.

All of these things work like the human spine works. If one vertebrae breaks, it can be a cascading catastrophe.

I decided to talk with her about our respective failures. Trudy responded. “Oh, honey, I know I shouldn’t have cancelled it or the physical and you don’t have to mind me like a child! I paid for it, too. I’m doing my exercises so faithfully now. Tina says she’s never seen me be so devoted to anything besides my grandbabies.”

Now, Trudy can laugh without pain. Her grandchildren are glad that she can still lift cookie trays in and out of the oven, even if they have to help with the tuna casserole.

* All patients are patient amalgams – organized from those who don’t cancel their appointments – and any resemblance to specific patients is accidental. None of this is personal medical advice.