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The New Old Age Blog: Older Women and Bone Tests PDF Print E-mail

How often should older women be tested for thinning bones? Though it’s been nearly 15 years since Congress passed the Bone Mass Measurement Act mandating Medicare coverage for bone density tests to prevent osteoporosis, nobody really knew — until now.

Medicare will cover DXA testing (it stands for dual-energy X-ray absorptiometry, if you must know) of the hip and spine every two years, but that may be much more frequently than many women require, and not often enough for others.

So I was prepared to cheer this week when researchers at four medical centers around the country published the first large-scale investigation into how long it takes older women to reach the point of osteoporosis, which can lead to fractured hips and wrists and vertebrae. The study appeared Wednesday in The New England Journal of Medicine.

As The Times reported today, for women whose first DXA results showed normal or nearly normal bone mass, it turns out, that process takes considerable time: up to 15 years, an argument for a long interval between scans. Since researchers have been reconsidering the best regimen for preventing debilitating fractures, it was useful to learn that frequent testing for normal women appears unnecessary.

On the other hand, most older women still won’t know how often it makes sense to test bone density because of this unhappy fact: Unlike many of the other screening tests we’ve discussed in this blog that are often overused for older patients — – Pap smears and colonoscopies, for example — an initial bone mass measurement is seriously underused.

Despite the federal legislation, despite recommendations from the United States Preventive Services Task Force, the surgeon general and a range of other medical authorities, despite all those Sally Field ads, surprisingly few women over 65 get bone density tests at all.

How few? A 2008 study using a 5 percent sample of all Medicare beneficiaries revealed that from 1999 to 2005 only 30 percent of women turning 65 (and 4 percent of men) had bone density tests. About two-thirds, by contrast, had gotten recent mammograms, even though an older woman’s risk of osteoporosis is higher than her risk of breast cancer.

One reason that only a minority of older women get bone density testing is that osteoporosis is asymptomatic: People often don’t know they’re at risk until they break a bone, said Jeffrey Curtis, a rheumatologist at the University of Alabama at Birmingham, who was lead author of that study.

“Doctors don’t think about it,” he said. “Primary care physicians, who are responsible for most screenings in this country, have more to juggle than ever. And patients probably aren’t asking for it.”

Fractures from osteoporosis can mean lingering pain and disability, not to mention a 20 percent risk of dying within a year after breaking a hip. Yet even when older women do break bones, as half of those over age 50 eventually will (yes, half), the proportion who get tested for osteoporosis still remains very low despite the big red flag. That means few of those women will take advantage of medications with good track records of preventing additional fractures.

“It’s sad and depressing and very avoidable,” Dr. Curtis said. “If women assume this is a normal part of aging — ‘My mom broke her hip so I expect to break mine; this is what happens when you get old’ — that might have been true 20 years ago. Not today.”

Though the percentage of 65-year-old women getting screened rose during the seven years of his analysis, to nearly 13 percent from about 8 percent, it’s clear that most aren’t getting the message.

Back to the better news. Although Medicare will cover a bone test every other year, this new multisite study indicates that many women won’t need it nearly that often. In fact, one good reason to have that initial baseline screening is to learn whether you’re among those who may be able to forgo screening for a decade, maybe longer.

“We don’t want the mind-set of more screening for everyone,” said the study’s lead author, Dr. Margaret Gourlay, a family physician at the University of North Carolina, Chapel Hill. “We want to target it.”

Using data from a federally financed longitudinal study, she and her colleagues followed nearly 5,000 women age 67 and older who’d had their bone density measured and who did not have osteoporosis. They divided them into four groups: those with normal T scores (a measure of bone density), those with mild osteopenia (less severe bone loss that often progresses to osteoporosis), and those with moderate or severe osteopenia.

As the researchers tracked the women for 15 years, they wanted to see how long it took for 10 percent of each group to transition to actual osteoporosis. “As women age, we’ll all lose bone density and we’ll move from one category to another,” Dr. Gourlay explained. At the 10 percent threshold, the researchers reasoned, a significant number of women could be helped by medication and take other steps to ward off a fracture.

Among those with good bone density at the outset, it was 15 years before 10 percent developed osteoporosis. Less than 1 percent of women with normal bones and 4.6 percent of those with mild osteopenia developed osteoporosis over that period.

“These women look like they’re doing well,” Dr. Gourlay said. “Their bones are quite stable.”

For those with moderate osteopenia, the transition period shortened to 4.7 years — still a much longer interval than Medicare policy might suggest. Women with advanced osteopenia, however, crossed the line into osteoporosis within about a year.

Bottom line: A DXA test might be something you need quite rarely…or pretty often. Without the first screening to assess your bone density, there’s no way to tell. But if your first test brings happy results and you have no other risk factors, you can probably put off the second test for years.

“People can make different judgments, but without a baseline you have no information on which to make them,” Dr. Gourlay said. “We’d love to see more patients asking about this.”

Paula Span is the author of “When the Time Comes: Families With Aging Parents Share Their Struggles and Solutions.”

Read more http://feeds.nytimes.com/click.phdo?i=1c77c27a683f487ab0ec70b024fc723f