Screening for Osteoporosis in Rural Areas: "Must do" or "Why Bother"

James E. Rohrer, Ph.D., Professor and Chair, Department of Health Services, Research and Management, Texas Tech University Health Sciences Center, Lubbock, Texas

Osteoporosis is a disease that is growing in importance on the national and international stage. Any of us can remember elderly relatives who"broke a hip" when we were children. The seriousness of that event no doubt escaped our attention at the time. Nevertheless, a broken hip is serious indeed, because it may signify the presence of advanced osteoporosis in the patient. If so, more broken bones are likely to lie in the future for that person, who may become afraid to go anywhere or move around, for fear of becoming bedridden.

The prevalence of this problem is increasing, partly because the population is aging; the longer you live, the more chance you have to experience a variety of diseases, including osteoporosis. Also, the risk factors for osteoporosis are more prevalent in the newer generations of elderly persons. These include lack of exercise, consumption of large quantities of soft drinks, not drinking enough milk, and excessive dieting. Back in the days when many girls were working on ranches and farms, they built up bones strong enough to last most of their lives. Later generations spent more time watching television, eating chips and drinking soda, then starving themselves to emulate the bizarre body shapes of supermodels. Such behaviors did not build up bones.

As a result, many elderly people, especially women but also men, have fragile bones and may not be aware of the risks they face. Treatment is available, though by now most will have heard of the potential risks associated with hormone replacement therapy. Well-meaning health care professionals, especially those who treat patients with advanced osteoporosis, have argued that mass screenings are needed to identify people with low bone density and refer them for treatment. Projects such as these have been attempted in several places around the nation. The purpose of this effort is to prevent further deterioration in bones, prevent fractures, assure longer life, and assure higher quality of life at the end of life.

What could be more logical or more humane? Well, ask elderly women in rural areas who have osteoporosis, and this is what some of them will tell you:

• I can't afford to go to the hospital and pay for an x-ray scan of my bones;
• I expect to have osteoporosis-after all, I am an old woman;
• Even if my doctor gave me a prescription, I could not afford to get it filled;
• I have lived a long and full life and it is neither sensible nor desirable to try too hard to extend it much further.

Screening programs targeted at the rural elderly have failed to trigger the levels of treatment health professionals recommend, because many in the targeted population think it is pointless, under the circumstances.

On the other hand, if Medicare covered the x-ray and the medications, many of them might take advantage. Whether their lives would be longer or better as a result, is a question that researchers will have to address in the future.

Some of us might be outraged that the rural elderly forgo testing and treatment for a serious disease because of cost. Perhaps that situation will change, perhaps not. Meanwhile, community health advocates should give serious consideration to a change in strategy: target younger women. With a younger target population, insurance is less likely to be a problem. Furthermore, the disease can be caught in its earlier stages, when lifestyle changes can be more effective and there is less need for medications.

Maybe this is what we should have been doing in the first place. Maybe we should have asked those little old ladies in rural communities, before we initiated our screening programs.