Your questions about bone health and aging answered, with Dr. Carol Lin

Bone health is a concern for many seniors, but it’s often overlooked. Osteoporosis, or the loss of bone mass, affects over 10 million Americans. Often referred to as the ‘silent disease’ since it doesn’t show any obvious symptoms, so many seniors don’t realize they have it until after a break occurs. Leading efforts to treat fracture patients and raise awareness is Dr. Carol Lin, Director of the Geriatric Fracture and Bone Health Programs and orthopaedic surgeon at Cedars Sinai Hospital in Los Angeles, CA. 

I sat down with Dr. Lin to talk about recovering after a fracture, why early prevention matters, and practical steps to keep your bones strong.

Tell us about your background.

I’m a Southern California native and an orthopedic trauma surgeon specializing in trauma care. At Cedars, we have a large geriatric population, so I treat many fragility fractures. Bones can be very soft and unreliable, requiring creativity in fixation. I chose orthopedics in medical school after seeing how grateful hip and knee replacement patients were, and I ultimately chose trauma as a subspecialty because I love being able to help people when they critically need it. Soon after I started at Cedars, I started the Geriatric Fracture Program, which has grown into a Bone Health Program. We start with ER patients who’ve had a fracture, test bone density, and treat to prevent the next break. We plan to expand to preoperative patients and eventually the whole healthcare system.

What makes a geriatric fracture different from a fracture in younger people?

The term geriatric fracture is a little loaded because it doesn’t just happen when you’re old. It happens when you have a problem with bone density. We also refer to them as fragility fractures, which people don’t like to hear, but fundamentally, it’s where your bone density is compromised for a number of reasons. Most commonly, it is caused by hormonal changes that occur when you age, especially for women around menopause when you lose the normal estrogen-progesterone cycle. Your bones become less dense, and at a certain point they become soft enough that even a simple trip and fall results in a serious fracture of the pelvis, hip, or spine, where normally they shouldn’t break. If you just tripped over the curb, even if you landed on concrete, you shouldn’t be breaking a bone with that.

Bone density itself is a challenge because people don’t feel it. It’s not like a heart attack, and there isn’t as much press or glamor around it the way breast cancer, ALS, and heart disease have movements to generate public interest. Fragility fractures are more challenging than typical car accident fractures, and geriatric fractures in particular, when the patients are older, are harder because geriatric patients tend to have less reserve, and the soft bone or presence of prior implants from a joint replacement or earlier fracture adds some technical complexity. So you have a technically complex fracture in a more frail patient. In general, you fell because you lost your balance, and maybe you didn’t have great balance to begin with. Your reflexes were slower, so you weren’t able to catch yourself and turn it into a stumble. You fell, and then your bone is broken, usually a critical weight bearing bone. For example with hip fractures, you can barely move in bed with a bad hip fracture. People with hip fractures need surgery almost all of the time to recover. It’s rare that they don’t.

Now you have two stressors: you fell and you broke your hip. That’s stressful to your body and takes away nutrients and resources. Then you have surgery, which is also stressful, and now you have to heal the bone, which takes a lot of energy and resources. During that time, you’re not mobile. Your appetite isn’t great because you’re on medications, you don’t feel good, your hip still hurts. All the normal functions you need to recover are delayed — how much you can exercise, how much protein you’re eating. You need to eat and exercise to get muscles to grow, and when you are older and already de-conditioned, putting in that effort early is difficult, and you get more de-conditioned.

A 25-year-old who gets hit by a car will usually bounce back in 6 months, and be back on the soccer field. For the older patient, it’s usually at least 9 months to a year before they fully recover. In general, only about a third of patients will return to their previous level of activity with hip fractures. A third lose one level of independence — now they need a cane, or if they had a cane, now they need a walker. A third are the frailest patients who pass away. It’s a combination of normal aging and the fact that unless you’re intentional about exercise and nutrition, it’s normal for our bodies to become less strong and to have less muscle and bone density. The only way to really counteract that is to be as strong and healthy as you can in your early 40s before menopause, and then continue the effort so that you lose as little as possible as you age.

What does healthy recovery look like after hip fracture surgery?

Everybody’s a little different, and it depends on where you started from. In orthopedics, the stronger and healthier you are before any surgery, the better your outcomes. For the average patient who walks for exercise, doesn’t do weight lifting, is not an athlete, has a normal diet, maybe some high blood pressure, maybe prediabetes or moderate diabetes, maybe a thyroid problem, it will typically be at least 2-3 months to be back to walking and starting to get off the cane.

They start with a walker for 4-8 weeks, and by 3 months they’re usually on a cane, trying to get off the cane, starting to go for longer walks, maybe back to the gym for low-impact activity with physical therapy. If they were fully independent before, it takes another 3-4 months to get back to their baseline activity. It’s rare to recover faster than 6-9 months. The typical recovery arc is 50% of total recovery in the first 6 months, then slower gains. By one year, you’re about 80% recovered, with slow improvements beyond that.

What should men know about bone health?

Men also lose bone and muscle mass as testosterone declines. They’re an underrecognized group for osteoporosis. Principles are the same: healthy diet, resistance exercise, screening at 70 or earlier if risk factors exist. Avoid your first break being a hip fracture, it’s truly disabling.

As a surgeon, what do you wish more seniors knew about bone health?

Hip fractures are my bread and butter to fix, but it’s hard to see patients suffer. Only about 30% of hip fracture patients get the right osteoporosis treatment to prevent another fracture. I’ve seen patients return 9 months later with a fracture in the other hip and it’s devastating. They were just starting to feel more independent again. Get your bone density checked, it’s not invasive and easier than a mammogram or colonoscopy.

Why don’t people hear more about osteoporosis?

Partly reimbursement and testing, partly lack of attention because it’s “silent”. Heart attacks and cancer are dramatic. Osteoporosis leads to death indirectly, through loss of mobility and frailty. My grandmother fell, broke her hip, never walked again, lived in a nursing home, and declined. People understandably focus more immediate conditions like diabetes or heart disease. There’s also little direct-to-consumer marketing for osteoporosis drugs compared to other conditions.

What can seniors do to prevent bone loss and avoid fractures?

Number one, get your bone density tested with a DEXA scan. Medicare covers it. If you’re minus 2.5 standard deviations below a young person’s normal bone density, your risk of a hip fracture is very high, and you should be started on a medication that helps bone density.

If you’re in between, which we call osteopenia, more than one but not more than 2 or 2.5 standard deviations, you usually don’t qualify for the medications because, like any other drug or intervention, there could be side effects. At that point, there are lifestyle interventions: optimal nutrition, weight bearing exercises, paying attention to protein intake (needed for both muscle and bone), making sure vitamin D intake is appropriate. Many people are vitamin D deficient. You cannot absorb calcium without vitamin D.

Newer understanding of bone metabolism includes vitamin K2, typically made by gut bacteria fermenting meat and dairy. Vitamin K2 takes calcium from the blood and puts it in the bones. If you have vitamin D, you get calcium into the blood, but without K2 it’s not utilized well. The best way to get K2 is a healthy, balanced diet, though supplements exist for those who are vegan or have absorption problems.

Beyond nutrients, bones and muscles don’t respond unless they’re used. You have to load the skeletal system, with weight-bearing exercises, resistance bands, body weight, or weight lifting. Even lifting with the upper body helps.

You have to feel challenged. If you do 10 reps but aren’t struggling at the end, you’re not changing your body. The goal is to force your body to respond to new stimuli. I counsel people to do what they can, then add 5-10% next time. Resistance exercise and a healthy diet can, in some cases, reverse osteoporosis, but it takes organization, discipline and resources. Prevention and starting early is best.