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Osteoporosis in Elderly Men

Authors:

Neil Baum, MD

Case Presentation

A 66-year-old male had a routine physical examination. He had a moderately enlarged benign

prostate gland. The prostate-specific antigen (PSA) was 7.7, and the ratio of free/total PSA

was 9% (normal > 25%). A prostate biopsy revealed multiple cores of adenocarcinoma of the

prostate, Gleason score 3 + 4. He was treated with I-125 brachytherapy plus 20 Gy of

external beam therapy to the periprostatic tissue, and the PSA nadir was 0.7 ng/mL 6 months

after the radiation therapy. However, 6 months later the PSA increased to2.7, and repeat PSA

testing demonstrated progressive increase in the PSA. A ProstaScint scan demonstrated

recurrence in the prostate. He was offered salvage radical prostatectomy, cryotherapy, or total

androgen ablation consisting of luteinizing hormone-releasing hormone (LHRH) agonist and

anti-androgen therapy. He opted for the latter, and the PSA decreased to < 0.1 ng/mL. He

noted loss of height, lethargy, and falling asleep after meals. A bone mineral density (BMD)

dual energy x-ray absorptiometry (DEXA) scan was obtained, which revealed that the

patients T -scores were: spine = -2.2 and hip = -2.5 (Figure). Radiographic studies revealed a

compression fracture at T-10, which confirmed the diagnosis of osteoporosis.

Discussion

The definition of osteoporosis for women is centered on the level of bone mass, measured as

BMD for diagnostic purposes. Two thresholds of BMD have been defined by the World

Health Organization on the basis of the relationship of fracture risk to BMD. The first

threshold defines the majority of individuals who will sustain a fracture in the future(osteoporosis), and the second is a higher threshold more appropriate for the prevention of

bone loss (low bone mass or osteopenia). Osteoporosis denotes a value for BMD that is -2.5

standard deviations or more below the young adult mean value (T-score less than

-2.2). Low bone mass means a T-score that lies between -1 and -2. The risk of bone fracture

increasees twofold for each standard deviation decrease in BMD. Suitable diagnostic cut-off

values for men are not as well defined. A similar cut-off for BMD that is used in women can

also be used for the diagnosis of osteoporosis and osteopenia in men.

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The patient described represents a case of secondary osteoporosis, which is commonly seen

in men treated with androgen ablation for prostate cancer. Secondary osteoporosis can be

caused by medical conditions (inflammatory bowel disease, malabsorbtion), prescription

medication (corticosteroids, thyroxine, anticonvulsants), or an unhealthy lifestyle (inactivity,

tobacco, and excessive alcohol consumption). Nearly half of all men with osteoporosis have

no known cause for their disease. Osteoporosis in men can be a major health problem. In

2004, there were 10 million Americans with osteoporosis (8 million women and 2 million

men) and 18 million with low bone mass. 1 Because of the predicted growth in the number of

elderly persons in this country, the number of men with osteoporosis is expected to increase

dramatically. 2 Yet, despite the large number of men affected, osteoporosis in men remains

underdiagnosed, underreported, and inadequately treated.

Although osteoporosis is less common in men than in women, it is estimated that one-fifth to

one-third of all hip fractures occur in men. Symptomatic vertebral fractures occur about half

as often in men as they do in women. Seventeen percent of men who reach age 90 have had a

hip fracture in their lifetime, and hip fractures can be catastrophic in older men who are at

increased risk of chronic physical disability and even death. In fact, men are much more

likely than women to die or experience chronic disability after a hip fracture. Twenty-four

percent of people die in the year following a hip fracture.

This disease causes nearly 1.5 million fractures annually and costs this country nearly $18

billion each year. 3

Osteoporosis is less common in men than in women for several reasons: men have larger

skeletons, their bone loss starts later in life and progresses more slowly, and they do not

experience the rapid bone loss that affects women when their estrogen production quickly

drops as a result of menopause. Despite these differences, men can be at high risk for this

disease. The best long-term information available suggests that at age 60, Caucasian men

have a 25% chance of sustaining an osteoporotic fracture.

Men can experience a marked loss of bone as they age, and this decline in bone mass is an

important contributor to the development of osteoporosis. There are several reasons for this

loss of bone. Declining testosterone levels may cause bone loss that is similar to the bone lossthat occurs in women at the time of menopause and estrogen deficiency. In addition, estrogen

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Blood and urine tests such as an increase in N-telopeptide of type I collagen (NTx), a marker

of bone resorption seen in men after receiving gonadotropin-releasing hormone (GnRH)

agonist therapy, may identify many of the secondary causes of osteoporosis. Additionally, a

thorough medical evaluation may identify additional med ical conditions or medications that

may play a role in poor balance and an increased risk of falling.

The treatment of osteoporosis in men consists of identifying and treating specific causes of

bone loss and maintaining a balanced diet with an adequate intake of calcium (1000 mg/day

in younger men and 1200-1500 mg/day in men over age 65 years) and vitamin D (400-800

IU/day). An exercise program that includes weight-bearing activities should be insti tuted. An

integral part of osteoporosis prevention and treatment should also include a recommendation

for an appropriate exercise or physical therapy program. Weight-bearing exercise andresistance training are especially helpful. If testosterone deficiency is found by a blood test

documenting hypoandrogenism, testosterone replacement therapy should be consid ered. This

can be administered by either an injection of testosterone enanthate, transdermal patches, or

topical gels. Of course, testosterone replacement ther apy is contraindicated in patients with

prostate cancer. Other treatments for use in men include calci tonin, bisphosphonates (eg,

alendronate 10 mg/day or one 70-mg tablet/week, risedronate 5 mg/day or one 35-mg

tablet/week, human parathyroid hor mone, teriparatide (one injection, 20 mcg/day for 24 mo),and others such as ibandronate sodium.

Preventing bone loss and fractures is of primary importance. Where possible, risk factors

such as smoking and excessive alcohol intake should be avoided, a balanced diet replete in

calcium and vitamin D should be a priority, and proper exercise, particularly weight-bearing

exercises, should be a regular part of weekly activities. Finally, the prevention of falls is very

important, and common household hazards (such as slippery floors and unlit stairways) and

medications or drugs that dull the senses and produce drowsiness should be avoided.

As we learn more from research concerning the biology of bone, we will be able to develop

new means to diagnose, prevent, and treat osteoporosis. Finally, we need to educate men that

osteoporosis is not an inevitable consequence of aging. They need to know that it can be

prevented by proper diet, exercise, and use of medication when necessary.

Outcome of the Case Patient

The patient was started on an exercise program that included weight-bearing exercise,

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