Any nurse who measures patients’ heights and weights is likely to hear “I can’t believe I have shrunk that much.” Loss of height as we age is normal, and occurs in both men and women. However, too much loss might be a sign of osteoporosis, which is not a physiologic norm, and can result in a myriad of problems for patients.
There are two major changes that result in loss of height as we age. In the first, the discs that cushion and separate the vertebrae of the spine compress, and over time, shrink. This results in what we think of as normal age-related loss in height, which is not likely to be preventable. The second cause of loss of height is the compression and deterioration of the vertebrae as a result of bone loss. This affects the normal curvature of the spine (kyphosis or “dowager’s hump”), and there is an accompanying loss of height. The bone loss that contributes to this loss of height is osteoporosis (National Osteoporosis Society, 2003; Spine University, n.d). This latter condition can be treated and prevented.
The Baltimore Longitudinal Study of Aging examined the change in height of men and women as it related to interpreting the Body Mass Index (BMI). While this study did not control for osteoporosis, it does give some data on loss of height over time. The study observed 2,084 men and women aged 17 to 94 between the years of 1958 to 1993. In both sexes, height loss began at about the age of 30 and accelerated with age. The cumulative height loss from age 30 to 70 years averaged about 3 cm (1.18 inches) for men and 5 cm (1.97 inches) for women (Sorkin, Muller, & Andres, 1999). This study demonstrates that not only women lose height, but men do as well. Furthermore, it supports observations that women lose height at a greater rate then men.
Various researchers differ on their definition of what is considered “normal” height loss related to aging (Kantor, 2004; Ohio Health, 2003; Shmerling, 2003), but in general, it is agreed that a height loss of 2 or more inches may indicate osteoporosis and a need for further evaluation. Because there is a link between estrogen loss and osteoporosis, and women lose estrogen during menopause, more progress has been made in the identification of osteoporosis in women. But less has been done to identify it as a problem in men. Since osteoporosis can be prevented and treated, it is important to raise awareness of the need to evaluate for osteoporosis in both sexes and to educate patients on prevention strategies.
Although osteoporosis is less common in men than in women, when it does occur in men, it can have more devastating outcomes. One in five men over the age of 50 will experience an osteoporotic fracture (seeman, n.d.), and men account for 30% of all hip fractures (American Medical Association [AMA], 2004). Hip fractures in men result in a 31% mortality rate at one-year post fracture, whereas the mortality rate for women at the same time after fracture is 17% (Campion & Maricic, 2003). Because of their greater peak bone mass, men experience hip, vertebral, or distal wrist fractures about 10 years later than women (Campion & Maricic, 2003). However, by age 65 to 70, men and women lose bone mass at the same rate (National Institutes of Health Osteoporosis and Related Bone Diseases-National Resource Center, 2003). Seeman (n.d.) states that osteoporosis is an equal opportunity disease. Therefore, routine screening for osteoporosis in men is essential.
Osteoporosis is under treated in men in spite of their higher mortality rate from hip and vertebral fractures (AMA, 2004; Campion & Mericic, 2003). Many authors report that osteoporosis is ignored, inadequately researched, under diagnosed, and under reported in men (AMA, 2004; Seeman, n.d.). This is most likely the primary reason osteoporosis in men is under treated. Lack of data also complicates early diagnosis of osteoporosis. For example, the International Society for Clinical Densitometry recommends bone mineral density (BMD) studies for a variety of populations including men 70 years of age and older, adults with a fragility fracture, and anyone not receiving osteoporosis therapy in whom evidence of bone loss would lead to treatment (AMA, 2004).
Currently, Medicare only approves studies for men with vertebral abnormalities, those receiving or planning to receive long-term glucocorticoid therapy, primary hyperparathyroidism, and assessment of the response to osteoporosis therapy (AMA, 2004). Additionally, exact diagnostic criteria for osteoporosis in men are controversial (AMA, 2004). Not only is osteoporosis under recognized as a disease in men, it is difficult to get testing reimbursed, and experts do not agree on what constitutes the diagnosis of osteoporosis in men.
What can nurses in a primary care clinic do to address this problem? There are several simple approaches that can be integrated into a routine primary care appointment that can help raise awareness of the problem of osteoporosis in men, teach prevention strategies, and identify patients who are especially at risk and need further evaluation for the diagnosis.