RA is a Risk Factor for Osteoporosis

Osteoporosis is silent. People’s bones can gradually become weaker and weaker with no outward hints that there is a problem — until suddenly bones break.  Spontaneous compression fractures of the spine can be quite painful and lead to deformity, chronic pain, and premature death.  Broken hips are another risk factor for early death — approximately 20% of people with a broken hip die within one year of the fracture.

In an ideal world, osteoporosis would not occur.  In theory, osteoporosis is entirely preventable.  Since we don’t live in an ideal world, it is crucial that osteoporosis be identified early and treated aggressively.

DEXA is the gold-standard in osteoporosis testing.  DEXA scanners (Dual-Energy X-ray Absorptiometry) (also called DXA) use two separate very low-radiation x-ray beams – about 1/10th the radiation of standard x-rays — to image the hips and spine to measure bone mineral density.  As we would expect from the “dual energy” portion of the name, these two x-ray beams have different energy levels.  Bone mineral density is calculated by measuring the difference between what is absorbed from the first beam and the second.

Test results will provide a variety of numbers.

  • Bone Mineral Density
  • T-Score
  • Z-Score

Bone Mineral Density (BMD) is a raw number indicating the average concentration of minerals in your bones. The higher the number, the higher the bone mineral density and the stronger the bones.  Lower numbers indicate weaker bones.

T-score and Z-score are based on statistics.  Compiling the results from many people has allowed scientists to determine what is normal bone mineral density, and what constitutes strong or weak bones.  Graphing the data forms a picture shaped somewhat like a bell.

A brief aside about statistics:  in statistics, the mean is the average — it tells us what is normal. The standard deviation tells us how far away something is from what is normal. 68% of all data will only deviate slightly from the average (will be within one standard deviation of the mean) — this makes sense because obviously most things should be close to what is normal. On a bell curve (pictured below), the mean does not deviate at all from what is normal, thus the center of the curve deviates zero (labeled 0), and most of the data clusters close to the middle — one standard deviation is labeled +1 (above zero) and -1 (below zero).  95% of the data will be within two standard deviations of the mean (labeled +2 and -2), and 99.7% of the data will be within three standard deviations of the mean. It is very rare for something to deviate significantly from what is normal.

T-score and Z-score numbers indicate standard deviations from the mean on a bell curve.  A T-score compares your BMD with healthy young adults who have good bone mineral density.  A Z-score compares your BMD with others of your age and ethnicity.  Doctors are most concerned with the T-score.

DEXATscores

A bone mineral density scan T-score that is more than one standard deviation below the mean is bad. Between one and 2.4 standard deviations below normal is osteopenia, while a T-score of 2.5 or more standard deviations below the mean is osteoporosis.

Who should get a bone density scan? The general rule is women at age 65 or men at age 70.  Before age 65, the test is only considered if you have risk factors, and if treatment would occur based on test results.  If you wouldn’t be treated, there’s no point in having the test done.  Bone density scans are rarely done on premenopausal women; until menopause, high estrogen levels seem to provide protection against broken bones even in people with low bone mineral density.  The question is, what are the risk factors?

Rheumatoid arthritis is just one of many risk factors for development of osteoporosis.  Other risk factors include:

  • history of taking 5mg or more of corticosteroids for more than three months
  • taking methotrexate (other meds, too)
  • family history of osteoporosis
  • history of an immediate family member with a fragility fracture
  • history of bone fracture as an adult
  • loss of height
  • weight of less than 127 pounds
  • being a smoker
  • menopause
  • eating a diet low in calcium
  • avoiding sunlight (indicative of low vitamin D production)

Given these risk factors, it is no surprise than rheumatologists refer patients for bone density scans.

Everything published about DEXA says that it is painless.  This information is obviously prepared by people who have never had the test.  Although it is technically true that the x-rays themselves do not inflict pain, before the scan is taken you’re strapped to a table in an uncomfortable position and required to stay tied down for the duration of the 15-20 minutes of the test. Although the average person might not be physically injured by the scan, it is inaccurate to say that the test is painless.  More accurately, the test is uncomfortable, but not unbearable.

After the test is complete, the referring doctor will receive a report showing your Bone Mineral Density, your T-score, and your Z-score.  Your report might also include use of the World Health Organization’s Fracture Risk Assessment Tool (FRAX) . This attempts to calculate a person’s probability of fracture within the next ten years with the goal of frightening patients into taking osteoporosis seriously.  A 28% risk of fracture within ten years is about 2.8% per year.  2.8 doesn’t sound nearly as scary as 28%, though, thus the use of ten-year risk estimates.  If you click on the link, select “calculation tool” and then select your continent/country and complete the questionnaire.  The calculation can be made either with or without results of a bone density scan.

Avoiding Holiday Flare

Flare — dramatic worsening of RA symptoms — seems to occur at the worst possible times. That’s because triggers include stress and overwork.  We have two weeks until Thanksgiving, so unless our goal is to flare badly and miss out on all the festivities, a bit of advance planning is needed. Don’t wait until the last minute; start the work now.

Menu Planning

Write out your menu.  A few years ago, I realized that our menu was way more food than what we really needed.  I have no idea why it took me so long to recognize that we were serving two full feasts. My pared-down menu requires about half the work. Nobody feels deprived (that’s why there are still rolls on the menu) and it’s way less work to clean up.  Do whatever works for your situation.

ThanksgivingMenu

Next list all the ingredients that will be needed to prepare your menu.  This should eliminate running out of ingredients and needing to make an emergency run to the store.  Here is my list; you’ll generate your own based on your specific menu.

Click to enlarge

Click to enlarge

Make things easy for next year!  Type your list and save it in your computer; you’ll be able to find it next year. You can even slip a holiday notebook onto your cookbook shelves so that the same menu and grocery list can be used every Thanksgiving (and Christmas, if you’re like me).

Check this required-ingredient list against your pantry to determine what you need to get at the grocery store. Don’t wait until next week.  Now is a good time to take care of getting your menu planned and your grocery list made.  Obviously you won’t want to buy vegetables this soon, but everything else can be done now.  Spreading out the work a little-bit-at-a-time helps to minimize RA flares.

Menu Prep

Delegate!  Just because you’re hosting an event does not mean you have to provide all the food and do all the work.  My mom is diabetic, so she is in charge of bringing the cranberry relish that she loves and wants instead of my cranberry sauce.  The person who’s celiac is in charge of the GF dinner rolls so that she knows they are safe for her to eat.  Another person is asked to bring drinks.  Green salad is another thing that’s easy to delegate.

Copy your menu, then work out a schedule of when those things should be prepared.  Mine is provided below as an example.  How much can be done in advance? The turkey needs to be roasted on Thanksgiving day, but almost everything else can be done ahead.

ThanksgivingMealPrep

Cleaning

Everyone’s standards of cleanliness are different. Mine are generally, “clean enough to be healthy; messy enough to be happy,” so I do a little extra right before the holidays. No matter what your personal standards are, if you try to clean your entire house the day before company comes, you’re going to flare and miss out on the fun of having people over.  Spread the work out over the next two weeks so that everything gets done without you wearing yourself out. I do a scaled-down spring-cleaning in the fall to get ready for holiday company.

ThanksgivingCleaning

Getting it All Done

Choosing a couple jobs a day makes all the cleaning and meal prep realistic instead of flare-inducing.  Make yourself a little calendar and spread the jobs out over the weeks leading up to Thanksgiving.  Here’s my plan:

ThanksgivingPrepCalendar

Click to enlarge

This lets me do just a few jobs each day so that I’m not too tired, and it gets things done Thursday morning with minimal effort. I’m able to sit and visit with family and friends instead of rushing around, stressed about getting everything done.

Serving the Meal

Gone are the days of multiple serving dishes so that both tables are set completely.  Gone are the days of taking forever to fill everyone’s glasses.  Gone are the days of taking two hours to clean up after dinner.  Life is so much easier now!  I serve Thanksgiving dinner buffet-style.  The plates go in a pile on the counter. People get their own drinks. The food is arranged so that everyone can walk through the kitchen to fill their plates, then head to a table to sit and eat.  The table isn’t too crowded; there isn’t a side-board set up to hold the salad and dressings that won’t fit on the table.  Cleanup goes much faster with half the serving dishes.  It’s much less work this way and everyone still enjoys a nice meal together.

Thanksgiving, like the rest of life with RA, goes much more smoothly when we learn to pace ourselves.

When the Doctor is Running Late

Recently I’ve seen a number of complaints about doctors running late.  There’s even a cartoon showing the (im)patient handing the receptionist a bill for excess time spent in the waiting room.  I have to admit that I used to feel that way. If I made an appointment for a specific time, I expected the doctor to see me at that time.  No excuses.

The more experience I have as a patient, though, I believe that’s the wrong approach. I don’t want a doctor who schedules patients in carefully allocated appointment slots and watches the clock, kicking people out when their time is up.  Sometimes things happen.

When one of my children was an infant, we went in for a routine check-up and the doctor noticed a strange lump.  A clock watcher could have said, “Your time is up. You need to make a new appointment — preferably soon — about that lump.”  He didn’t.  He called in a colleague to take a look and they consulted some of their medical reference books.  The consulting doctor then resumed her schedule (running behind), while my daughter’s doctor made some phone calls, then ushered me into his office to use his phone and make an urgent appointment to see a specialist at Children’s Hospital.  It seemed like a whirlwind to me, but took about an hour.  That hour he spent on my child was an hour that he was scheduled to see someone else’s child.  He spent the rest of the day behind schedule, but not due to lack of respect for people’s time. Rather, due to caring about the health of a patient.

I think we need to adjust our thinking.  What if we viewed medical appointments like airline flights?  We would show up early without complaining.  The airline industry has to check everyone in just like the doctor’s office does.  While doctor’s offices don’t need to x-rayed our luggage, they do need to verify insurance coverage and document receipt of copays.  The airline wants people there at least an hour before the flight; we should be happy that medical appointments only need us there 15 minutes early!

Last week’s newscast showed footage at a jam-packed airport where flights had been delayed.  Nobody was ranting and raving about having their schedule thrown off. It was inconvenient, but nobody was demanding a refund or billing the airlines for their time lost.  Everyone knows when we buy our tickets that the airline will try to depart the airport on time, but that things sometimes come up to cause delays.  People just make the best of the situation.  We need the same mindset when we need medical care.  Doctors try to keep to the schedule, but sometimes there are delays.  We just need to make the best of it.

What are our options?

  • Asking for the first appointment in the morning can help.  In theory, there have been fewer chances for things to go wrong with the schedule if you’re the first patient of the day.  Note, however, that if your doctor rounds on patients in the hospital before opening the clinic, that the first appointment in the clinic is not the first patient of the day, so the doctor could still be late.
  • Asking for the first appointment after lunch allows for catch-up time to counteract any delays in the morning’s schedule.
  • Taking the last appointment of the day almost guarantees that the doctor will be running behind.
  • Doctors are swamped in December, with people trying to fit in everything they can before the end of the year.
  • Doctors tend to have much more space in their schedules in January (because charges are applied to your insurance deductible, which means that appointments in January are out-of-pocket).
  • Leave yourself a cushion.  If your appointment is for 10:00, don’t have somewhere else you must be by 11:00.  Expect that the doctor might be running late and allow time.
  • If you’ve allowed a cushion, but not enough, be polite. Once I was scheduled to teach a class at 1:00. I couldn’t be late.  My doctor’s appointment was at 11:00 and I knew the office closed for lunch, so I thought I had plenty of time.  Unfortunately, the doctor was so far behind that he worked through lunch.  I explained that I would need to reschedule since at that point I couldn’t get a sub to teach my class. I wasn’t mad, but couldn’t stay. Rescheduling might not be ideal, but getting one patient out the door helps the doctor be a little less behind, and gets patients where they need to be next.  When you reschedule, take a first-appointment of the day to reduce the odds having a repeat experience.
  • Friday after Thanksgiving is a shopping day and nobody wants to be at the doctor’s office.  I can’t speak for every doctor in every year in every city, but my limited experience shows the years that I’ve checked my doctors, this is a great day to get an appointment. The doctor will be running on time, and even has extra time.
  • Avoid Mondays.  Everyone who has issues arise over the weekend phones the doctor and tries to get in on Monday. It’s a zoo. Avoid the pharmacy on Mondays, too (same reason).  Likewise, on Fridays people try to squeeze in to see the doctor before the weekend.  Specific offices might have variances in their schedules, but in general, people claim that Wednesdays are best.  If this matters to you, ask the staff in your doctor’s office to see which days they believe run most smoothly.

Scheduling a medical appointment isn’t the same as taking a class at a specific time, nor is it like meeting someone for lunch.  It’s more like scheduling an airline flight — the appointment time is a hopeful estimate of when the doctor will be able to see you.  We can make our lives a lot easier if we recognize that delays are inevitable and plan accordingly.

Edit to add: Mondays.