By now, we’re all aware that Malaysia is an ageing society.
Seven percent of our population is aged 65 and above, and many of them are suffering from poor bone health, but don’t know it.
They only find out they have osteoporosis when they fall and sustain a fracture, most likely in the hip, spine or wrist.
Osteoporosis is a disease that causes bones to become weak and brittle.
It occurs when the creation of new bone doesn’t keep up with the loss of old bone.
It can affect both men and women.
Those who are frail, underweight and small in built, as well as post-menopausal women, are at a higher risk of this condition.
Consultant geriatrician Dr Terence Ong Ing Wei said: “Although osteoporosis happens in older people, it is almost as common as diabetes.
“One in five adult Malaysians has diabetes – osteoporosis comes close because it affects one in six adult Malaysians aged 45-90 years old!
“Diabetes evokes fear and concern, yet most people wouldn’t give osteoporosis a second thought.”
Many people think losing bone density, falls and sustaining fractures are simply a natural part of the ageing process, but this is a myth.
Osteoporosis is actually a very complex condition that is influenced by many factors.
He said: “Some things that we do not think too much about in our everyday lives have a huge impact on our bone health.
“These include physical inactivity, fad diets, cigarette-smoking and age-related hormonal changes (such as oestrogen in ageing women and testosterone in men).
“All these increase the rate of bone loss at a time when strong bones are most needed.”
On average, one in three elderly have osteopenia, i.e. the bones are already fragile, but perhaps not fragile enough to make a diagnosis as there are no signs or symptoms.
“Statistics show that one in four who fall and sustain a hip fracture will not survive beyond 12 months – this is worse than some cancer diagnoses!
“If you are the three in four who survives after a year, chances are you will still require some sort of aid,” added Dr Ong.
The consultant was speaking at the launch of the 3rd Clinical Practice Guidelines (CPG) for the Management of Osteoporosis last month (January 2023).
The CPG, which was jointly published by the Malaysian Osteoporosis Society (MOS), Academy of Medicine Malaysia and the Health Ministry (MOH), contains key vital sections, including on prevention of osteoporosis/bone loss; assessment of falls risk; calcium and vitamin D; and exercise and avoiding smoking and alcohol to help in preventing bone loss and falls.
Early detection
According to consultant rheumatologist Dr Yeap Swan Sim, when doctors pick up osteoporosis after a fracture, the patient would have already incurred significant amounts of bone loss and treatment cannot replace all the bone that has been lost.
“Instead, treatment focuses on minimising the detrimental effects of a fracture.
“We should be giving more emphasis to screening and early detection, followed by suitable interventions, so that we can protect the most vulnerable persons from this terrible illness.”
Dr Yeap, who is also the president of MOS, said the disease is a multifactorial one and requires the input of multiple specialists for optimum patient care.
“Nutrition, age, hormones, lifestyle and the presence of pre-existing disease are some of the aspects that can affect bone health.
“As such, the CPG is written by a panel of experts from all the related disciplines, such as nutrition, geriatrics, endocrinology, orthopaedic surgery, obstetrics and gynaecology, rheumatology, primary care, and pharmacy,” she said.
Earlier in his keynote address, Health director-general Tan Sri Dr Noor Hisham Abdullah said all osteoporotic fractures are associated with disability and premature death.
This is especially so with hip fractures, which are projected to increase from 5,880 in 2018 to 20,893 in 2050 – a 3.6-fold increase.
A 2020 study found that, upon discharge from hospital, all hip fracture patients needed walking aids.
Six months later, only 24%, or about one in four, had regained their mobility and independence.
“Investing in primary healthcare systems has demonstrated overall improvements in the healthcare delivery across the globe.
“Thus, it is commendable that the CPG recommends how one’s risk level can be assessed at government health clinics and general practitioners’ (GPs’) clinics.
“If patients are at risk, the CPG provides further assessment, diagnosis and intervention, and information.
“If osteoporosis is present, there is guidance on the course of action to be taken, including when to initiate treatment, what medications are available in Malaysia, and which medications to prescribe under different situations.
“These are encouraged to prevent even the first fracture.
“This is crucial because once you have had one fragility fracture, you are likely to experience another,” pointed out Dr Noor Hisham.
He urged healthcare professionals to utilise the CPG to make crucial and timely clinical decisions.
Hidden and deadly
Consultant endocrinologist Professor Emeritus Dr Chan Siew Pheng lamented that despite its devastating effects, osteoporosis remains underdiagnosed, undertreated and silent.
“So, the only way to know if you have osteoporosis before a fracture occurs is by going for a bone density scan, also called dual-energy X-ray absorptiometry – DEXA or DXA.
“This quick and painless X-ray procedure allows doctors to see whether or not osteoporosis is present and predict the risk of future fractures in order to provide timely and suitable treatment – this would save you so much trouble in the future,” she said.
The CPG recommends that women aged 65 years or older, and men 70 years or older, get a DXA scan done every two years.
Prof Chan elaborated: “Younger individuals may also need to be screened if they have certain conditions, such as diabetes, thyroid disorders, nutritional malabsorption, eating disorders, rheumatoid arthritis, or are dependent on certain medications (like steroids) that might make them more at risk of developing osteoporosis earlier.
“There are effective medicines that can be tailored to suit all sorts of patients based on their disease stage and lifestyle.
“Moreover, whenever pharmacological treatment is necessary, the medications that are available in Malaysia can reduce the risk of fractures from 15% up to 70%.”
In general, she said anti-osteoporosis medicines are well-tolerated and effective.
Chipped in Dr Ong: “Every time we see older patients, they are usually accompanied by a family member – this is the time we try to ‘catch’ them to change their perception about osteoporosis – that it is not natural – and encourage them to go for a scan.”
Prof Chan said older people tend to underestimate the value of nutrition as they get (even) older.
“They lose teeth, don’t bite well, don’t take solid food and they don’t exercise, so they get sarcopenia, i.e. loss of muscle mass.
“If you’re also diabetic, you have a higher chance of fracturing a bone – the bone may look strong in the scan, but it can still fracture because the quality is poor.”
As a senior consultant orthopaedic surgeon, Prof Datuk Sabarul Afian Mokhtar sees tons of broken bones daily, though not all require surgical intervention.
He disclosed a worrying fact about surgical interventions for hip fractures in Malaysia.
“Recommendations by the International Osteoporosis Federation and our CPG 2022 suggest that when surgery for hip fracture is needed, it should be carried out within 48 hours of the fall.
“However, in Malaysia, it is reported that the average time was five to seven days,” he said.
There are various causes for the delay, including the patient having other health conditions and financial reasons.
Securing a slot to perform the surgery is also challenging due to overwhelming patient volume and congestion, especially in public hospitals.
Prof Sabarul stated: “Certain hospitals are privileged to have ‘fracture liaison service (FLS)’, a multidisciplinary team approach in managing fragility fractures.
“This service has proven to be a great tool that improves patient outcomes and we hope to see more FLS offered around Malaysia.”
Back pain a sign
Data shows that the main reason Malaysians visit the GP is for colds, cough and influenza.
The second reason: back pain.
Prof Sabarul shared the story of his 65-year-old retired patient who didn’t drink milk and previously led a sedentary life, doing desk-bound work at the office.
One day she was driving and went over a small speed bump.
Thereafter, she developed back pain, but every time she rested in bed, the pain disappeared.
“The problem was there for a few days and she consulted a GP, who prescribed painkillers.
“She still didn’t get better and was referred to the hospital.
“We did an X-ray and discovered one of her backbones had fractured.
“Imagine, her osteoporosis was so bad that going over a hump could break a bone!
“The screening is simple.
“In osteoporosis, you lose more than 2% bone a year and it is usually from the spine – that’s why you get backaches or get shorter or your blouses/shirts hang loose.
“(But) people ignore these symptoms,” he said.
Prof Chan added: “In osteoporosis, you can fracture the spine without having to fall, so if a woman bends over to pick up a pot of flowers or her grandchild, she may get back pain and this could be a sign of a broken back.”
Never give up
Jaswant Kaur, affectionately called Aunty Santa, was once a chirpy, active, independent lady who loved cooking delicious meals for her family and friends.
As age advanced, she developed high blood pressure, diabetes, rheumatoid arthritis and breast cancer.
Her health, along with her social engagements, gradually went downhill.
“She was living with my sister and what we were afraid of most was that she would fall,” shared her son Dr Harshinderjeet Singh, MOH’s Medical Practices Division senior principal assistant director.
“And she did in 2021, while going from the bathroom to her bed.
“It wasn’t a hard fall, but she fractured her hip and was operated on at a government hospital on the third day – her whole personality changed afterwards.
“When she came home, she was bedridden, developed fear and refused to move for fear of falling again.
“It was a challenging time – she developed bed sores and sepsis due to being on diapers and not mobilising, had to be readmitted, then she developed deep vein thrombosis.”
Sometimes, Aunty Santa would wake up in the middle of the night screaming.
She was determined not to walk again.
She would constantly cry, but the family, especially her grandkids, never gave up and tried to make her laugh.
“We couldn’t just leave her like that.
“Elderly patients need a lot of patience and care.
“We hired two physiotherapists and a carer to help rehabilitate her.
“Words won’t suffice to describe the psychological impact the fall has caused my mother and the entire family,” said Dr Harshinderjeet.
The additional expenses incurred on food, supplements, diapers, medications, etc, soared to almost RM5,000 monthly.
Slowly, Aunty Santa got better, and today, can sit up, take a few steps with the help of a walker, and watch television.
She celebrated her 83rd birthday recently.
Dr Harshinderjeet said: “My sister and I are still working and it was a crazy time.
“Still, it’s all worth it and looking at how far she has come puts a smile on our faces.”
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