osteoporosis osteoporosis osteoporosis is a systemic skeletal disorder characterized by low bone mass, micro-architectural deterioration of bone tissue leading to bone fragility, and consequent increase in fracture risk. it is the most common reason for a broken bone among the elderly. bones that commonly break include the vertebrae in the spine, the bones of the forearm, and the hip. until a broken bone occurs there are typically no symptoms. bones may weaken to such a degree that a break may occur with minor stress or spontaneously. after the broken bone heals, the person may have chronic pain and a decreased ability to carry out normal activities. not to be confused with osteosclerosis. osteoporosiselderly woman with osteoporosis showing a curved back from compression fractures of her back bones.pronunciation/ˌɒstioʊpəˈroʊsɪs/ specialtyrheumatology, endocrinology, orthopedicssymptomsincreased risk of a broken bonecomplicationschronic painusual onsetolder agerisk factorsalcoholism, anorexia, european or asian ethnicity, hyperthyroidism, gastrointestinal diseases, surgical removal of the ovaries, kidney disease, smoking, certain medicationsdiagnostic methoddexa scan( bone density scan)treatmentgood diet, exercise, fall prevention, stopping smokingmedicationbisphosphonatesfrequency15% (50 year olds), 70% (over 80 year olds) osteoporosis may be due to lower-than-normal maximum bone mass and greater-than-normal bone loss. bone loss increases after the menopause due to lower levels of estrogen, and after 'andropause' due to lower levels of testosterone. osteoporosis may also occur due to a number of diseases or treatments, including alcoholism, anorexia, hyperthyroidism, kidney disease, and surgical removal of the ovaries. certain medications increase the rate of bone loss, including some antiseizure medications, chemotherapy, proton pump inhibitors, selective serotonin reuptake inhibitors, and glucocorticosteroids. smoking, and too little exercise are also risk factors. osteoporosis is defined as a bone density of 2.5 standard deviations below that of a young adult. this is typically measured by dual-energy x-ray absorptiometry (dxa or dexa). prevention of osteoporosis includes a proper diet during childhood, hormone replacement therapy for menopausal women, and efforts to avoid medications that increase the rate of bone loss. efforts to prevent broken bones in those with osteoporosis include a good diet, exercise, and fall prevention. lifestyle changes such as stopping smoking and not drinking alcohol may help. bisphosphonate medications are useful to decrease future broken bones in those with previous broken bones due to osteoporosis. in those with osteoporosis but no previous broken bones, they are less effective. they do not appear to affect the risk of death. osteoporosis becomes more common with age. about 15% of caucasians in their 50s and 70% of those over 80 are affected. it is more common in women than men. in the developed world, depending on the method of diagnosis, 2% to 8% of males and 9% to 38% of females are affected. rates of disease in the developing world are unclear. about 22 million women and 5.5 million men in the european union had osteoporosis in 2010. in the united states in 2010, about 8 million women and between 1 and 2 million men had osteoporosis. white and asian people are at greater risk. the word "osteoporosis" is from the greek terms for "porous bones". signs and symptoms illustration depicting normal standing posture and osteoporosis osteoporosis has no symptoms and the person usually does not know that they have osteoporosis until a bone is broken. osteoporotic fractures occur in situations where healthy people would not normally break a bone; they are therefore regarded as fragility fractures. typical fragility fractures occur in the vertebral column, rib, hip and wrist. examples of situations where people would not normally break a bone include a fall from standing height, normal day-to-day activities such as lifting, bending, or coughing. fractures fractures are a common symptom of osteoporosis and can result in disability. acute and chronic pain in the elderly is often attributed to fractures from osteoporosis and can lead to further disability and early mortality. these fractures may also be asymptomatic. the most common osteoporotic fractures are of the wrist, spine, shoulder and hip. the symptoms of a vertebral collapse ("compression fracture") are sudden back pain, often with radicular pain (shooting pain due to nerve root compression) and rarely with spinal cord compression or cauda equina syndrome. multiple vertebral fractures lead to a stooped posture, loss of height, and chronic pain with resultant reduction in mobility. fractures of the long bones acutely impair mobility and may require surgery. hip fracture, in particular, usually requires prompt surgery, as serious risks are associated with it, such as deep vein thrombosis and pulmonary embolism. there is also an increased risk of mortality associated with hip surgery, with the mean average mortality rate for europe being 23.3%, for asia 17.9%, united states 21% and australia 24.9%. fracture risk calculators assess the risk of fracture based upon several criteria, including bone mineral density, age, smoking, alcohol usage, weight, and gender. recognized calculators include frax, the garvan frc calculator and qfracture as well as the open access frem tool. the frax tool can also be applied in a modification adapted to routinely collected health data. the term "established osteoporosis" is used when a broken bone due to osteoporosis has occurred. osteoporosis is a part of frailty syndrome. risk of falls progression of the shape of vertebral column with age in osteoporosis there is an increased risk of falls associated with aging. these falls can lead to skeletal damage at the wrist, spine, hip, knee, foot, and ankle. part of the fall risk is because of impaired eyesight due to many causes, (e.g. glaucoma, macular degeneration), balance disorder, movement disorders (e.g. parkinson's disease), dementia, and sarcopenia (age-related loss of skeletal muscle). collapse (transient loss of postural tone with or without loss of consciousness). causes of syncope are manifold, but may include cardiac arrhythmias (irregular heart beat), vasovagal syncope, orthostatic hypotension (abnormal drop in blood pressure on standing up), and seizures. removal of obstacles and loose carpets in the living environment may substantially reduce falls. those with previous falls, as well as those with gait or balance disorders, are most at risk. complication as well as susceptibility to breaks and fractures, osteoporosis can lead to other complications. bone fractures which are results from osteoporosis can lead to disability and even an increased chance of death after the injury. depression is considered to be a complication of osteoporosis. people with osteoporosis lose independence and risk being isolated due to less physical activity. this will further hinder the ability to manage health issues. osteoporosis is also linked to respiratory and cardiovascular health issues, such as loss of lung capacity. multiple fractures lead to a collapsed thoracic spine, which makes less air being able to move into the lungs. every thoracic vertebral body collapsed results in the loss of nearly 10% of lung volume. risk factors the risk of having osteoporosis includes age and sex. risk factors include both nonmodifiable (for example, age and some medications that may be necessary to treat a different condition) and modifiable (for example, alcohol use, smoking, vitamin deficiency). in addition, osteoporosis is a recognized complication of specific diseases and disorders. medication use is theoretically modifiable, although in many cases, the use of medication that increases osteoporosis risk may be unavoidable. caffeine is not a risk factor for osteoporosis. nonmodifiable bone density peaks at about 30 years of age. women lose bone mass more rapidly than men. the most important risk factors for osteoporosis are advanced age (in both men and women) and female sex; estrogen deficiency following menopause or surgical removal of the ovaries is correlated with a rapid reduction in bone mineral density, while in men, a decrease in testosterone levels has a comparable (but less pronounced) effect. ethnicity: while osteoporosis occurs in people from all ethnic groups, european or asian ancestry predisposes for osteoporosis. heredity: those with a family history of fracture or osteoporosis are at an increased risk; the heritability of the fracture, as well as low bone mineral density, is relatively high, ranging from 25 to 80%. at least 30 genes are associated with the development of osteoporosis. those who have already had a fracture are at least twice as likely to have another fracture compared to someone of the same age and sex. build: a small stature is also a nonmodifiable risk factor associated with the development of osteoporosis. potentially modifiable alcohol: alcohol intake greater than three units/day) may increase the risk of osteoporosis and people who consumed 0.5-1 drinks a day may have 1.38 times the risk compared to people who do not consume alcohol. vitamin d deficiency: low circulating vitamin d is common among the elderly worldwide. mild vitamin d insufficiency is associated with increased parathyroid hormone (pth) production. pth increases bone resorption, leading to bone loss. a positive association exists between serum 1,25-dihydroxycholecalciferol levels and bone mineral density, while pth is negatively associated with bone mineral density. tobacco smoking: many studies have associated smoking with decreased bone health, but the mechanisms are unclear. tobacco smoking has been proposed to inhibit the activity of osteoblasts, and is an independent risk factor for osteoporosis. smoking also results in increased breakdown of exogenous estrogen, lower body weight and earlier menopause, all of which contribute to lower bone mineral density. malnutrition: nutrition has an important and complex role in maintenance of good bone. identified risk factors include low dietary calcium and/or phosphorus, magnesium, zinc, boron, iron, fluoride, copper, vitamins a, k, e and c (and d where skin exposure to sunlight provides an inadequate supply). excess sodium is a risk factor. high blood acidity may be diet-related, and is a known antagonist of bone. some have identified low protein intake as associated with lower peak bone mass during adolescence and lower bone mineral density in elderly populations. conversely, some have identified low protein intake as a positive factor, protein is among the causes of dietary acidity. imbalance of omega-6 to omega-3 polyunsaturated fats is yet another identified risk factor. a diet high in protein may be optimal for bone health, as higher protein diets tend to increase absorption of calcium from the diet and are associated with higher bone density. no interventional trials have been performed on dietary protein in the prevention and treatment of osteoporosis a meta-analysis of published medical studies shows that higher protein diet helps slightly with lower spine density but does not show significant improvement with other bones. underweight/inactive: bone remodeling occurs in response to physical stress, so physical inactivity can lead to significant bone loss. weight bearing exercise can increase peak bone mass achieved in adolescence, and a highly significant correlation between bone strength and muscle strength has been determined. the incidence of osteoporosis is lower in overweight people. endurance training: in female endurance athletes, large volumes of training can lead to decreased bone density and an increased risk of osteoporosis. this effect might be caused by intense training suppressing menstruation, producing amenorrhea, and it is part of the female athlete triad. however, for male athletes, the situation is less clear, and although some studies have reported low bone density in elite male endurance athletes, others have instead seen increased leg bone density. heavy metals: a strong association between cadmium and lead with bone disease has been established. low-level exposure to cadmium is associated with an increased loss of bone mineral density readily in both genders, leading to pain and increased risk of fractures, especially in the elderly and in females. higher cadmium exposure results in osteomalacia (softening of the bone). soft drinks: some studies indicate soft drinks (many of which contain phosphoric acid) may increase risk of osteoporosis, at least in women. others suggest soft drinks may displace calcium-containing drinks from the diet rather than directly causing osteoporosis. proton pump inhibitors (such as lansoprazole, esomeprazole, and omeprazole), which decrease the production of stomach acid, are a risk factor for bone fractures if taken for two or more years, due to decreased absorption of calcium in the stomach. medical disorders the body regulates calcium homeostasis with two pathways; one is signaled to turn on when blood calcium levels drop below normal and one is the pathway that is signaled to turn on when blood calcium levels are elevated. many diseases and disorders have been associated with osteoporosis. for some, the underlying mechanism influencing the bone metabolism is straightforward, whereas for others the causes are multiple or unknown. in general, immobilization causes bone loss (following the 'use it or lose