Page 1 of 3

Bone Matters with Dr. Marla Shapiro

This is the second in a series of columns, exclusive to healthandbone.ca that will focus on issues that are important to you, as a person concerned about their own bone health, or of that of a family member or friend. Dr. Marla Shapiro will draw upon her expertise and that of other expert colleagues to keep you up-to-date on the latest thinking in osteoporosis.

Emotional health: Staying strong with osteoporosis

Osteoporosis is a chronic illness with potentially life-altering consequences when not managed properly. It is currently a major health concern in Canada and the world over and will continue to be so as the population ages.

Osteoporosis is a disease characterized by low bone mass and the deterioration of bone tissue. The bones weaken, putting those affected at greater risk of suffering a broken bone or fragility fracture. Fragility fractures are those that occur following a minor trauma, such as a fall from standing height, a sitting position or having missed 1-3 steps in a staircase.

Broken bones or “fragility” fractures that occur as a result of osteoporosis tend to happen most commonly in three areas— the wrist, the spine, and the hip. Research has shown that osteoporotic fractures result in longer hospital stays and lead to chronic disability. They can also impair mobility and decrease your ability to perform normal daily tasks independently. These effects can have a negative impact on a patient’s outlook on life and their quality of life.

Osteoporosis affects people in many different ways. Some of the potential effects it can have on quality of life include:

Poor self-image.
Limitations in the ability to work and to enjoy leisure activities.
Changes in relationships with family and friends.
Feelings of anxiety or depression.

In my practice I not only see the physical effects of osteoporosis but also the toll it can take emotionally. I asked Dr. Keri-Leigh Cassidy, Associate Professor in the Department of Psychiatry at Dalhousie University, about the impact of osteoporosis on mental health.

Dr. Cassidy says, "When faced with any chronic condition, people commonly have some negative thoughts and feelings, and worry about the implications. They might wonder what they can do about the condition, whether they will be able to cope with the consequences of a chronic disease, if there will be limitations to their functioning, or if they will have pain as a result. Sometimes these negative thoughts can compound feelings of loss and powerlessness related to the aging process."

Women with osteoporosis have often reported feelings of fear, anxiety and depression. One phrase that I hear often is “I’m afraid.” Time and time again patients tell me they are afraid to even get out of their car when faced with an icy parking lot. They are scared of falling and breaking a bone. They become extremely anxious when faced with situations where a potential fall could occur.

I have patients who routinely turn down invitations from friends and family to participate in activities such as skiing, curling, and golfing. Going for walks outdoors in the winter is not something they would consider because they are so afraid they may come across a patch of ice and slip, fall and break a bone. As a result they begin to cut themselves off from friends and withdraw from family members. This change in the friendship and family dynamics seem to be all too common in patients with osteoporosis.

These changes may lead to feelings of isolation. I’ve heard patients say they feel they are “on the sidelines,” watching life go by. Feelings of depression often follow.

Some patients isolate themselves for other reasons. Fragility fractures can lead to physical deformity which can progress over time. One such deformity is a pronounced curve in the upper spine, known as kyphosis.

Patients affected physically by osteoporosis often become uncomfortable with their appearance and develop a poor self-image. As a result they may not want to go out in public.

What can you do to help yourself or someone you care about?

It has been clearly established that women with osteoporosis frequently report feelings of fear, anxiety and depression. If you are experiencing these feelings, there are others out there just like you.

There may be a support group in your area with women who are going through the same thing (Osteoporosis Canada has local chapters across the country and you can access their Canadian Osteoporosis Patient Network on the Osteoporosis Canada website for additional resources). It may do you a world of good to join a group and discuss your fears and apprehensions.

Dr. Cassidy adds, “To improve one's mental health and outlook when faced with a chronic condition such as osteoporosis, one of the most useful steps to take is to find out as much about the natural course of the condition as possible. Ask your doctor what you should expect over time, and about any steps you can take to slow the progression such as medication, vitamin supplements and physical activity. By arming yourself with accurate information, you can develop an action plan to manage the condition, which might stop or even reverse bone loss. You will then benefit psychologically from the knowledge that you, and your doctors, are doing everything possible to slow disease progression.”

If you find that negative thoughts or emotions are interfering with your ability to carry out the action plan needed to manage the condition, such as participating in regular exercise, you should discuss this with your family physician.

Other tips to consider:

Dr. Cassidy says, "Your overall outlook on aging cannot be underestimated in terms of its impact on your life. In one interesting study out of Yale University, seniors with positive self-perceptions on aging were found to live 7.5 years longer than those with negative self-perceptions of aging, controlling for health conditions."
If you are afraid or anxious about breaking a bone when you go out to crowded places such as malls, movie theaters, or museums, try going at less crowded times. Take breaks and sit down when you feel tired.
You may be able to find ways to change the way you perform sporting or leisure activities that you enjoy in such a way as to protect your bones. As an alternative to this, look for new types of physical activity that are less risky and can help you build strong bones.
Friends, family members and the support groups mentioned can help you manage the difficult life changes and the associated emotional turmoil that can accompany being diagnosed with osteoporosis. For example, ask a family member, friend, or neighbour to help you bring groceries into your house or apartment. A caregiver or family member can encourage their loved one to become as educated about the disease as possible, and encourage them to follow up with any treatments. Joining an appropriate exercise program together is one way to offer direct support to your loved one. A family member/caregiver is also in a good position to watch for signs of depression and anxiety in their loved one, as described below.
Don't be afraid to ask others for help to deal with any physical limitations you may have as a result of osteoporosis and/or fragility fractures.
- You may want to find ways to give back to those who help you so that you do not feel as though you are asking too much without providing something in return. This may also make you feel less hesitant about asking them for help in the future.
If you are feeling self-conscious about your appearance, try to find styles of clothing that minimize figure changes. Examples include wearing a bright scarf to draw the eye away from what you feel is a problem area or choosing loose-fitting clothing.

What are the signs of depression?

Depression is a real illness and something that can and should be treated. Suffering from depression does not mean you are just feeling sad.

As physicians, Dr. Cassidy and I look for a number of different symptoms that may indicate a patient is depressed. Symptoms include:

Depressed mood
Marked loss of interest or pleasure in activities which used to give you pleasure
Significant weight loss or gain
Insomnia or difficulty sleeping (usually waking up in the early morning rather than having difficulty falling asleep) or sleeping too much
Lack of interest or concern about what’s going on around you
Feelings of agitation
Lack of energy
Feelings of worthlessness and/or guilt
Inability to concentrate or make decisions

If you have at least five of the symptoms from this list, and these symptoms have been present most days, all day, for at least two weeks, you should talk to your doctor.

Dr. Cassidy adds that anxiety might be playing a role if you have intrusive and repetitive thoughts or worries especially if they interfere with sleep, or are expressed in your body physically as panic attacks.

Medications and counseling can help treat depression. Your doctor can help determine the right treatment for you.

Can depression cause osteoporosis?

There has been considerable debate in the medical community as to whether or not depression can actually cause osteoporosis or vice versa.

I asked Dr. Cassidy to comment on the association between psychiatric illness, in particular depression, and osteoporosis. She agrees this has been the subject of a growing body of research but that the findings are variable.

According to Dr. Cassidy, some research suggests depression can be a consequence of bone loss and fractures, due to a reactive depression to the diagnosis. Also, women with osteoporosis have been found to have significantly higher levels of depressive symptoms than those without osteoporosis.

Dr. Cassidy's opinion is that scientific research suggests that major depressive disorder, which is the medical or clinical name given to those diagnosed with depression, may be a risk factor for low bone mineral density (BMD) and fractures. Some in the medical community have even suggested that those with depression be considered for osteoporosis screening and, alternatively, those with low BMD should be considered for depression screening.

In women with osteoporosis some of the side effects associated with antidepressant treatments, particularly light-headedness and lowered blood pressure, may place these women at risk of falling and thus fracturing.

It is important to discuss your treatment options with your doctor. Together you can determine the treatment that is best for you. Drug therapy has been shown to be effective and can help lift the burden of depression for those suffering. The risks should be discussed with your doctor and make sure you understand the risks and weigh them accordingly.

In closing - Take care of yourself, body and mind

Fortunately, there are many ways to combat the emotional distress you may feel at times. Aside from cultivating a strong social support network and getting appropriate exercise, one very effective option is meditation. Meditation can give you a sense of calm, peace and balance that benefits both your emotional well-being and your overall health.

Scientific evidence of the health benefits of meditation is growing but not yet conclusive; however, practicing meditation has been shown to stimulate some changes in the body. Some types of meditation might work by affecting the "fight-or-flight response", slowing heart rate and breathing.

Secondly, make sure you are getting enough sleep. Unfortunately, the ability to sleep for six to eight hours at one time may be reduced with age.

Being in good health means more than feeling physically well; it also means feeling psychologically well. Life is full of change, risks and challenges. Achieving good psychological or emotional health helps us find our balance and stay in control, even during turbulent times.

Today, we are more aware of how our psychological and physical health affect each other. Setting aside time to focus on psychological health is important – to you and those who care about you. By practicing mind and body fitness, you can nurture your mind, body and spirit in a positive and enjoyable way.