KUALA LUMPUR, Oct 25 — Experts have revealed that the Covid-19 pandemic led to osteoporosis patients skipping medical appointments and defaulting on their medications, worsening their condition over the past two and a half years.
In a virtual media event held last October 11 in conjunction with World Osteoporosis Day on October 20, the Bone Health Alliance Malaysia (BHAM), represented by the Osteoporosis Awareness Society of Kuala Lumpur, hosted a panel discussing the importance of awareness, prevention, and the effects of the Covid pandemic on people suffering from osteoporosis.
Fragility Fracture Network Malaysia president Dr Lee Joon Kiong, a member of the panel, touched on two key issues that he saw to be plaguing the treatment of osteoporosis amidst the pandemic.
The first issue he found, across the board, was that patients did not come forward to get themselves examined, and the second issue was that they defaulted on their medication.
“I think the last two and a half years, most of us actually stay home – young to the old, and particularly the old ones, our senior citizens. They actually do not come forward to the doctors. Even to the family doctors to actually assess not only bone health issues, even including other diseases.
“And those who have osteoporosis, in fact, actually stopped their medicine. So, the compliance adherence is really a big issue during the last two and a half years because they do not come for refill.
“They go back to the hospital to get assessed, how the bone status is like, they do not continue medicine that they’re supposed to have, but clear some medicine that they’re not supposed to stop. But it stopped for the last two and a half years, and then bone density suddenly drops very fast,” said Dr Lee.
The lack of treatment adherence is extremely concerning for a country like Malaysia which has an aging population.
In a press statement released by the BHAM, Malaysian Osteoporosis Society president Dr Chan Siew Pheng stated that Malaysia is expected to spend over RM530 million, or in excess of half a billion ringgit, on health-related services by the year 2050, as Malaysia is projected to have the highest number of hip fractures in Asia.
Dr Chan told the panel discussion that the lack of medication compliance cannot solely be blamed on the pandemic. She pointed out that patients themselves contribute to their osteoporosis by not going for therapy and not taking their medication a year or two after the initial fracture is cured.
“We’ve identified in the last 10 to 15 years is that patients who’ve had fractures have been discharged, effective, of orthopedic surgical procedures all done, but within a year, many of them are not taking appropriate therapies that will prevent them from having a subsequent fracture. What I mean is taking medications that will prevent them from fracturing again.
“Patients, [whose] fracture has been healed – they’re no longer in pain, and they forget all about it. And that is really a huge potential opportunity for us to interrupt the osteoporosis progression and cascade,” said Dr Chan, seeing non-compliance as an area whereby a fracture liaison service can step in and provide treatment, education and awareness.
The cascade that Dr Chan is referring to is the 86 per cent refracture chance within the next two years of the first fracture.
This cascade effect stems from the nature of osteoporosis itself. Osteoporosis is a disease that weakens the bones to the point that it breaks easily. This is caused by a loss of bone density.
To keep bones strong, the body naturally breaks down old bones and replaces them with new bone tissue. This process stops at around the age of 30, and people in their 40s and 50s may experience more bone breakdown than replacement, leading to osteoporosis.
Slipping and falling, however, are not the only ways that one can fracture their bones. Fragility fractures are fractures that happen as a result of low-energy trauma, such as a fall from standing height or less, and they occur following an event that, in normal circumstances, would not have resulted in a fracture.
“For example, for a granny which actually sneezes, coughs, or even bends down to carry a grandchild, the granny can actually feel a sudden snap, a sudden sound — crack — and severe pain in the back.
“That kind of movement, even bending forward without any trauma, they can fracture the spine,” said Dr Lee.
The most common places where an osteoporotic fracture may occur is the wrist, spine and hip, and according to Dr Lee, hip fractures are the worst fractures a patient could receive, as hip fractures happen in “those groups who actually carry other medical problems”, such as hypertension and diabetes.
Drawing upon data published in the World Journal of Orthopedics, Dr Lee stated that 20 to 25 per cent of patients who undergo surgery following a hip fracture do not live past the first year due to underlying complications.
“They’re bed-bound, they’re wheelchair-bound, they present sores, pneumonia, all the signs for sepsis, and only 20 per cent of them actually back to normal function without any support, or in between the 50 per cent of them they are either wheelchair-bound, or home-bound. So you can imagine 75 per cent of hip fracture patients do not do well,” said Dr Lee.
According to the statement released by BHAM, only 12 per cent of patients were on bone health optimising medications and fewer than one in five patients received surgery within the recommended 48-hour timeframe from hospital admission. BHAM attributed this neglect to a lack of awareness on bone health management.
The above domino effect does not only affect the patients’ physical state, but it also has a great impact on their mental health.
Recovering from a fracture is not a quick process for many osteoporotic patients, with one out of four patients being discharged only after having stayed in the hospital for over 30 days. And according to Choo Yem Kuen, president of the Osteoporosis Awareness Society of Kuala Lumpur and Selangor, after having suffered a long hospital stay, only one-third of patients do not need assistance post-discharge.
“Definitely a loss of quality of life. And when you are in that stage, you know, as you grow older, you become dependent and many diseases will also follow, like depression, you know. It can cause a lot of other things.”
Dr Lee, in the BHAM press statement, further stressed upon the fragile mental state of these older patients, who, as a result of “increased social isolation”, may experience cognitive impairment. This in turn may lead “to lack of adherence to proper treatment or dietary care and engaging in activities that pose a greater risk for falling and fractures.”
Medication To Improve Bone Density Is Available
Once a patient has suffered a fracture, secondary prevention becomes a crucial factor, and for that, Dr Chan stressed that there are many types of effective medication that can be prescribed to improve “bone density”.
“By taking these medications, you improve the amount of calcium that comes, goes into the bone, and therefore the reason why you need to have adequate calcium and vitamin D in order to help you absorb that calcium.
“But really, seek appropriate medical consultation so that you can start getting medications that will improve bone strength and reduce your fracture by up to 50 per cent or more. So there are effective medications. The problem is, again, that gap that we are talking about,” said Dr Chan.
A curious thing to note about people living in Malaysia is that despite the country’s tropical climate, many suffer from a lack of vitamin D. A study titled “An Update on Vitamin D Deficiency Status in Malaysia” published in the Nutrients journal found that 67.4 per cent of teachers in Kuala Lumpur had vitamin D deficiency, while 78.9 per cent of adolescents aged 12 to 13 living in Perak, Selangor, and Kuala Lumpur were found to be vitamin D deficient.
The pandemic exacerbated the issue, as more people were forced to stay home and have their routines disrupted during Covid-19 lockdowns, experts said.
“They’re (patients) hiding at home most of the time. They don’t get exposed to adequate sunlight and they don’t get adequate vitamin D. In fact, vitamin D deficiency or insufficiency in Malaysia, the prevalence very high, and on top of that, the two and a half years of inactivity and inadequate exposure of sunlight that bring the vitamin deficiency retention to even a bigger problem today,” said Dr Lee.
Vitamin D is crucial for the optimisation of bone health as it helps the body absorb calcium and phosphorus, key minerals for bone health, and a good way to get vitamin D is by standing in the sun without sunscreen for about 10 to 15 minutes a couple of times a week.
Although medication is available for patients, the panel agreed that prevention is definitely better than any cure.
Dr Chan, in particular, was vehement in her statement that osteoporosis is not a “normal phenomena.” Likening it to diabetes, Dr Chan stated that the disease is not a “part and parcel of aging” and that people can prevent or delay osteoporosis.
“A lot of people think, ‘Oh, I’ve got a very strong family history of diabetes. I can’t run away from it.’
“But yes, you can. You can prevent it. You can delay the onset of diabetes. And so for osteoporosis, a similar scenario where you can improve your bone health. Improve your bone health by having an active lifestyle, exercising to keep yourself sort of steady, good balance, as well as having an adequate diet where you consume adequate amounts of calcium, have enough vitamin D. All these things work towards improving your bone health and perhaps preventing an osteoporotic fracture.
“It may not be a hundred percent preventable, but certainly you can delay or perhaps not even have the fracture if you keep, if you perhaps follow that healthy lifestyle.”
Women More Likely To Get Osteoporosis
This need for prevention is more important for women than it is for men due to the hormonal changes that take place throughout a woman’s life.
Women who go through menopause will experience a drop in estrogen. This drop in estrogen, according to Dr Chan, is what causes the bone to lose its ability to retain calcium which protects and strengthens the bones.
“There is a faster rate of loss of calcium from the bone at the time of menopause, and that’s when probably these women are most vulnerable. So, female hormones having menopause are one of the key risk factors for individuals.”
Thus, Dr Chan strongly recommended that women older than 60 years and men older than 70 with a positive history of hip fractures consult their doctors and get a DEXA scan.
“You do a DEXA and you’ll be able to assess what is the quality of the bones that you have. Using that, the doctor who’s treating the patient will be able to quantify and calculate the risk of fracture in these people.”
A DEXA scan is a bone density scan that uses low dose X-rays to see how dense (or strong) a person’s bones are.
Members of the panel agreed that for bone health to be adequately addressed, the disease should be made a priority in Malaysia’s health care system and ought to be one of the “primary services provided by national health care.”
BHAM, in their press statement, summed up key points of prevention:
- A healthy and balanced diet with sufficient intake of calcium, protein, and vitamin D.
- Regular exercise that improves balance, posture, coordination, and muscle strength.
- Be proactive about preventing falls, inside the home and out by fall-proofing your environment.
- Discuss with your doctor if you need to assess your osteoporosis risk through a DEXA scan and what the appropriate bone health management should be.
- Maintain continuity on bone care and treatment.
