Alzheimer's Disease and Osteoporosis

By William K. Summers, MD
© 1999-William K. Summers, MD

People think of Alzheimer's disease as a brain disease. It is much more than this. Early work done by Dr. Robert Terry demonstrated that Alzheimer's disease (AD) is a total body disease. At autopsy, the brain of the Alzheimer's victim is about 15% smaller than age-matched control patients dying of other illnesses. Few people appreciate that the heart, liver and other organs are also about 15% smaller than age-matched control patients.

Osteoporosis is a major problem of Alzheimer's patients. Falling with hip and leg fractures is common. These dreaded $15-30,000 surgical events are considered part of the illness. The broken hip is often a one-way ticket to nursing home care.

Osteoporosis (bone thinning) has been the subject of recent publicity. Osteoporosis is an illness of elderly women. Worldwide, there are over two million hip fractures per year. A 50-year-old woman has a 40% risk of a broken bone. However, osteoporosis is a feature of many other circumstances. Alzheimer's disease, antiseizure medicines, and steroids medicines are examples.

Paul Harvey advertises that OSTEOPOROSIS IS VERY PREVENTABLE. There are three widely accepted current approaches:

1. Vitamin D3 with calcium supplements

2. Bisphosphonate medications and

3. Calcitonin-salmon.

Less well-known methods are:

4. Estrogen replacement (in women)

5. Exercise

6. Prescription strength Vitamin D2 and

7. Hiazide diuretics.

The over-the-counter vitamin D3 with calcium supplement is a fairly good solution for the average senior. Paul Harvey is right. Doctors who treat osteoporosis utilize either bisphosphates or calcitonin-salmon. There are five bisphosphonates. Of these, only three are commonly used by doctors to treat thinning of the bones. These are alendronate (Fosamax(r)), etidronate (Didronel(r)), tiludronate (Skelid(r)). All three work by inhibiting the bone cells (osteoclasts) responsible for breaking down and reshaping bone. Adverse effects start with the requirement to take these medicines up to two hours before eating or drinking any fluid. Gastrointestinal side effects are the most common. Abdominal pain, esophageal ulcers, diarrhea, nausea and/or vomiting occur in up to one in twenty patients. Of the three bisphosphonates, tiludronate is the best tolerated. The cost of these medications is substantial. Alendronate costs $1,600 per year. Etidronate costs $1,500 per year and tiludronate costs an astonishing $5,000 per year.

Calcitonin is a naturally secreted hormone made by the thyroid gland. It regulates bone and calcium metabolism. The pharmaceutical preparations of calcitonin (Calcimar(r) or Miacalcin (r)) are extracted from salmon (the fish). Like the bisphosphates, calcitonin inhibits the cells that reabsorb calcium from bone. Calcitonin is given by shot into the muscle or by nasal spray. The side effects include rhinitis, flu-like symptoms, nausea, vomiting, back and joint pains. Economically the cost is high at about $4,000 per year!

I rarely suggest the use of these "standard" medications because of the side effects and expense. I first recommend EXERCISE. Yes, exercise! The medical literature clearly demonstrates that simple walking 6-15 minutes per day greatly strengthens bones. Even better are exercises that improve balance. Tai Chi Chuan (Yang style, Wu Style, Chen Style, or Tibetan Style) is best because the focus is on balance and injury is rare.

My next recommendation is prescription strength Vitamin D2 (50,000 IU) given as a capsule once a week. Side effects are minimal to none. The cost is under $20 per year. Vitamin D has a much broader effect that the other drugs. It controls normal calcium and phosphate metabolisms. Vitamin D regulates the rate of calcium absorption by the small bowel. It regulates how calcium is handled by skeletal muscles. The rate of calcium excretion by the kidneys is controlled by vitamin D. Most important, it fine tunes the use of calcium by the bones. In humans, Vitamin D3 is about as active than D2. Because vitamin D2 is fat-soluble, the once a week dose is sufficient in most cases. Vitamin D2 has helped my mid- and late-stage Alzheimer's patients. They "bounce" and do not "break". The price and convenience cannot be beaten. The final insult is that the other osteoporosis treatments recommend concomitant use of vitamin D and calcium.

Finally, the use of female hormones (estrogens) and thiazide diuretics is best reserved where there are other indications for their use. To use these agents for no other reason than prevention of osteoporosis seems unwarranted.

So to review, my order of recommendation for osteoporosis in normal elderly is

1) Exercise and

2) Oral daily vitamin D3 and calcium.

For Alzheimer's patients, my recommendations are

1) Exercise and

2) Prescription strength vitamin D2 weekly.

The other agents are reserved for special circumstances.

If you have any questions regarding memory problems, Alzheimer's disease, or dementia, please drop a line to the editors of N.M. Senior Citizen News. This article written by Dr. Summers appeared in a summer 1999 issue of Prime Time - Albuquerque, NM. The NM Senior Citizen News publishes these articles monthly. You can pick up a copy of the paper at your closest New Mexico Senior Citizen Center.