In March 2022, the Parkinson Society British Columbia hosted a webinar on bone health in Parkinson’s disease (PD) with geriatrician Dr. Naaz Parmar. Dr. Parmar discussed how osteoporosis is diagnosed and treatment options. For treatment, there is a focus in reducing the risk of falls. In Parkinson’s specifically, there is a higher risk of having osteoporosis due to PD itself and treatment with dopaminergic medications.
Osteoporosis is a history of a fragility fracture or a bone density less than -2.5 standard deviations below normal. In comparison, osteopenia is one standard deviation below normal and shows someone is at risk for osteoporosis. Osteoporosis is a common disease and everyone over the age of 65 years or younger with other medical concerns should be screened with a bone density, according to the speaker.
Osteoporotic fractures have a greater negative effect on quality of life than parkinsonism when assessed individually. As such, all those with PD should be screened for osteoporosis. Dr. Parmar stressed that the increased risk of osteoporosis in itself is NOT a reason to avoid Sinemet treatment.
The speaker also discussed treatment options for osteoporosis in PD. Estimates show that 90% of fractures are due to a fall and 68% of those with PD will have at least one fall per year. This could be due to Lewy body development in the brain, or due to decreased physical activity. To combat this, lifestyle changes such as resistance exercises, weight bearing exercises, and minimizing environmental causes of falls are also recommended.
Next, the speaker recommends ensuring Vitamin D and calcium levels are at the level they should be. Vitamin D and calcium deficiency is caused by lifestyle changes and decreased time spent outdoors, as well as dietary changes. It is important to remember that it is possible to take too much calcium.
Finally, the speaker presented three medication classes that may help those with PD and osteoporosis. These include:
- Antiresorptive agents
- Anabolic agents
For information on fall prevention classes for those living in Northern California, please see this Stanford Parkinson’s Community Outreach webpage:
For more information on fall prevention, please see this Stanford Parkinson’s Community Outreach webpage:
For a recording of this webinar, please see this Parkinson Society of British Columbia YouTube webpage
My notes of the March 14 webinar are below.
“Bone health and Parkinson’s disease” – Webinar Notes
Speaker: Naaz Parmar, MD, geriatrician, Pacific geriatricians group
Webinar Host: Parkinson Society BC
Webinar Date: March 14, 2022
Summary by: Joëlle Kuehn, Stanford Parkinson’s Community Outreach
What is osteoporosis:
- Metabolic bone disease characterized by low bone density and an increased risk of fracture:
- Means the disease is managed by hormones
- Certain hormones tell our bones to break down or build up again
- Bones break down faster than they build up
- It leads to increased fracture risk in all bones, but particular fractures that greatly alter health and quality of life include hip, femur (thigh), humerus (arm) and vertebrae (back)
- Canadian census data shows that over 2.2 million people, or 12% of the population over the age of 40 suffers from osteoporosis
How is osteoporosis diagnosed:
- History of a fragility fracture:
- Fracture that occurs after non-traumatic movement such as bending, lifting, or tuning or falling from standard height
- When we fall, the weight of our body should not be able to break bones
- If you do suffer a fracture, your bones are too thin and considered fragile
- Some people have severe enough osteoporosis that lifting something of a moderate weight (10 pounds) will cause bones to fracture
- Bone density of less than 2.5 standard deviations below normal:
- Radiology test:
- Injection of markers that adhere to the bone nad shows up how dense your bones are
- Compared to average to see how far from normal you are
- Osteoporosis is 2.5 standard deviations below normal
- Osteopenia is 1 standard deviation below normal, shows at risk for osteoporosis
- Nuclear medicine
- Most major hospitals and radiology labs will have a nuclear medicine test
- Radiology test:
Risk factors for osteoporotic fractures – who should we screen?:
- Age greater than 65
- History of previous fragility fracture
- Prolonged use of glucocorticoids (steroids) or other high-risk medication
- Family history or parental hip fracture
- Vertebral fracture or osteopenia identified on radiography
- Excessive alcohol intake, it has a negative effect on hormonal balance and bones
- Low body weight (less than 60 kilo) or major weight loss (more than 10% of body weight at age 25 lost)
- Rheumatoid arthritis – steroids used to treat and disease itself
- Other disorders strongly associated with osteoporosis
Effect of osteoporosis on health and quality of life:
- Osteoporotic fractures have a greater negative effect on quality of life than parkinsonism when assessed individually
- Effect is additive when you have both
- Disability life adjusted years (DALY): disability-adjusted life year is a measure of overall disease burden, expressed as the number of years lost due to ill-health, disability, or early death
- Osteoporotic fracture has a high score, higher than parkinsonism
- Can use those years through disability and passing away earlier due to the disease
- Immediate consequence of any fracture is pain and debility
- Long term effects of fractures include: long term disability, need for a gait aide, chronic pain, altered posture and decreased exercise ability
- Mortality rate also increases with osteoporosis:
- You can pass away with osteoporosis
- With hip fractures the one year mortality rate is 25% :
- 1 in 4 people with a hip fracture will pass away in that year
- Once hip fracture has happened, here is little that can be done to help that, so the focus is on prevention and diagnosing it as early as possible
PD and osteoporosis:
- PD itself and common treatments are both risk factors for osteoporosis. Can increase incidence
- In a review, it was found that 91% of women and 61% of men with PD also had osteoporosis
- Other studies have shown that those with PD have a 2.66 times higher risk of a fracture than those without PD
- The increased risk of fracture with PD is not tied to course of disease with those diagnosed with PD within the last 5 years having a similar risk of PD to those diagnosed greater than 5 years. Connection to the disease right from day 1.
- Risk factors that increase fracture risk: Increased risk of falls
- Estimates show that 90% of fractures are due to a fall and 68% of those with PD will have at least one fall per year
- Lewy Body development in the brain is theorized to affect hormonal release including estrogen and growth hormone
- Vitamin D deficiency increases due to lifestyle changes and dietary changes
- Decreased physical activity, especially decreased resistance exercises
- Changes in nutrition and weight loss
Sinemet and osteoporosis:
- Sinemet has a connection with low bone mass
- Use of dopaminergic medications such as Sinemet can increase homocysteine levels and lower bone formation
- This should be considered and steps taken to protect bone
- It is crucial to realize that Sinemet is also very helpful and the risk to bone health should not be a reason to not take Sinemet. Ongoing FDA trials have shown that of 23,795 who have reported side effects to Sinemet, only 112 have reported osteoporosis as a side effect. This is less than 0.5%
How to treat osteoporosis:
- Osteoporosis treatment is a two-pronged approach: lifestyle changes and medications
- Lifestyle changes:
- Lifestyle changes focus on minimizing risk of falls and include incorporating resistance exercises into daily life
- Weight bearing exercises such as walking, using resistance bands, Tai Chi and classes such as OsteoFit are suggested
- Minimizing environmental causes of falls is also suggested including walking in well lit areas, avoiding the use of bifocals or progressive lenses, and using gait aides if suggested by a professional (physio or OT)
- Medications are also suggested for all with osteoporosis
- Vitamin D:
- Vitamin D supplements should be started for everyone with low bone density or a fragility fracture
- Common starting dose is 1,000 units a day
- Vitamin D can be taken in different forms such as tablets, pills, gummies or drops
- Should be taken all year round
- Calcium supplements are suggested for those with less than 1500mg of calcium intake from their diet
- It is possible to take too much calcium
- It is not recommended to take extra calcium as there can be increased risk of heart disease and kidney stones with excess calcium
- Don’t need fancy or expensive brands, just plain 500mg of calcium
- Trick: can also use Tums because that is calcium carbonate and can give you enough
Medication options for osteoporosis:
- Target bone turnover and balance towards bone deposition rather than break down
- Suggested for all with osteoporosis
- Your physician will discuss with you what your best options are for treatment
- Classes of medications include:
- Bisphosphonates: Alendronate, Risedronate:
- Oldest ones, best researched and cheapest
- Usually covered so usually first line of treatment
- Slow release, tell enzymes to stop breaking down bones, let body naturally build them back up
- Once a week, so it is a large pill, which is difficult for some people because they can get stuck
- Are specific guidelines for when to take them
- Concern online about the medications, but from a scientific point of view, it has all been debunked
- Antiresorptive agents: Prolia (Denosumab):
- Slightly more effective than bisphosphonates
- Show increased strength of the bones over the years
- Injection into the arm (small needle)
- Every 6 months
- Downside: not always covered by insurance
- Anabolic agents: Forteo (Teriparatide), Tymlos (Abaloparatide), Evenity (Romosozumab):
- Steroids targeted specifically for your bones
- Forteo is a daily injection
- Evenity is newest
- Reserved for rare patients who have failed treatment for pills and Prolia injection. Difficult to take (daily injections), need to be controlled, and very expensive
- Bisphosphonates: Alendronate, Risedronate:
Where do you find a specialist:
- Specialized osteoporosis clinics
- It is strongly recommended that anyone with concerns be reviewed by an osteoporosis specialist who may be a:
- General internist with extra training
- Can get a bone density test done at your normal doctor
- If you are looking at treatment it is recommended to get a specialist involved in your care
Question and Answer:
Question: What are the risks for Prolia and dental work?
Answer: There isn’t really a big concern. Usually your dentist will be fine with it for day to day work. If you’re having major work done, such as major dental surgery, your dentist may want you to not be on anything affecting your bones at that time. Talk to your dentist to see what their concerns are.
Question: What about bioidentical hormones for women for prevention?
Answer: Hormones or lack of hormones can put you at risk of osteoporosis. Estrogen is a driving force of that. We strongly suggest against any treatment of estrogen, whether that is medical grade estrogen or bioidentical hormone for treatment of osteoporosis because of an increased risk of cancers. Estrogen will help your bone strength but will also increase your risk of breast cancer, ovarian cancer, and uterine cancer. The risk of increased cancers is not worth the benefit of the estrogen on your bones. Men shouldn’t take testosterone because that can increase prostate cancer.
Question: How should Risedronate be taken?
Answer: It shouldn’t be taken on an empty stomach. It absorbs better on a full stomach. It does have a bit of an increased risk of reflux because of the coating of the medication.
Question: How does having a family history of osteoporosis impact your potential to develop osteoporosis?
Answer: A family history on your mothers side does cause an increased risk for osteoporosis. Family history is quantified as a hip fracture, if your parents had bad osteoporosis you are considered a high risk for that.
Question: What food and drink should I avoid if I have PD and osteoporosis?
Answer: With osteoporosis there aren’t any foods that we specifically avoid. We do encourage calcium rich foods and vitamin D. But coffee and other carbonated things haven’t been proven in large studies to have a negative effect. But we do encourage you to take in more dairy as best as you can.
Question: Do you suggest taking magnesium as well?
Answer: No, not just for osteoporosis. Magnesium can have some downsides if you take too much.
Question: I was put on hormone suppressants for my cancer, and took a lot of calcium to prevent osteoporosis. I’ve also had a heart event, I have two stents put in. What are the conflicts there with calcium?
Answer: It depends on how much calcium you are getting from your diet. If you’re getting enough from your diet and taking extra, that is where we worry about your heart given your personal history.
Question: What is your opinion on zoledronic acid injections?
Answer: Zoledronic acid injections are bisphosphonates and are equivalent to the other bisphosphonates pills. It’s nice because it is an IV infusion once a year. People aren’t getting it because of the difficulty of getting it arranged, especially during COVID. It’s not always covered.
Question: What about omega and turmeric?
Answer: Unfortunately they have no effect on your bone strength.