Archives of Community Medicine and Public Health Women with osteoporosis present their quality of life: Three cases from Vlore, Albania

Aim : Osteoporosis is a disease characterized by low bone mass and micro-architectural deterioration of bone tissue, with a consequent increase in bone fragility and increase to fracture risk. Around the world, up to one in three women and one in ﬁ ve men are at risk of an osteoporotic fracture. Osteoporosis can be prevented and managed with healthy and balanced diet, rich in calcium and vitamin D, an exercise plan, a healthy lifestyle and regular medications. Our aim was to show what patients with osteoporosis, based in their experience with the disease suggest to do for better quality of life. Methods : In this study we are reporting two cases with osteoporosis and one with osteopenia. Based on qualitative research methods face-to-face semi-structured interviews were conducted. Patients included in the study were patients diagnosed with osteoporosis and randomly selected from medical records in the Primary Health Care Center, No 2 in the city of Vlora. We contact them by phone and once the overall purpose has been explained, they express eligibility to be part of the study. Results : This study shows how the disease history was, what where the factors and barriers for success in the self-management of osteoporosis and the preventive measures for osteoporosis in case of osteopenia. These cases report how osteoporosis progresses silently and can have a severe impact on the health and well-being of those who suffer from it, especially if it is not diagnosed and treated in a timely manner. Conclusion : People with osteoporosis can have a better quality of life if the disease is managed as recommended, including dietary and physical activity recommendations, well the information about any medications that they need. Case Report


Introduction
Osteoporosis has been operationally defi ned on the basis of bone mineral density (BMD) assessment. According to the World Health Organization criteria, osteoporosis is defi ned as a BMD that lies 2.5 standard deviations or more below the average value for young healthy women (a T-score of <-2.5 SD) [1]. A disease characterized by low bone mass and microarchitectural deterioration of bone tissue, with a consequent increase in bone fragility and increase to fracture risk [2].
Osteoporosis is a disease that reduces the BMD of bones to the point where they break easily even as a result of a minor fall, a bump, a sneeze, or a sudden movement. Osteopenia is a disease related to osteoporosis and is defi ned when the T-score is in the range 1-2.5. A person with osteopenia is at risk for getting osteoporosis if it is not controlled [1][2][3].
Fractures caused by osteoporosis can be life-threatening and a major cause of pain and long-term disability, and in many countries, up to one in three women and one in fi ve men aged 50 years or over will suffer an osteoporotic fracture [3,4].
Osteoporosis can be prevented with a healthy diet with enough calcium and vitamin D, exercise, not drink in excess or smoke [5]. In addition, osteoporosis can be managed with a balanced diet rich in calcium and vitamin D [6], an exercise plan, a healthy lifestyle and regular medications [7]. Because of the morbid consequences of osteoporosis, the prevention of this disease and its associated fractures is considered essential to the maintenance of health, quality of life, and independence in the elderly population. The number of osteoporotic fractures is certain to increase in both men and women as a result of the ageing population and two thirds of all incident fractures occurred in women [8]. The major increases will occur outside of Europe and the United States, particularly in Asia and Latin America [5]. through ongoing assessment, teaching and counseling [11]. The aim of presenting these case studies is to demonstrate the process by which osteoporosis is detected, and the patient's quality of life is improved through lifestyle counseling and health knowledge improvement regarding the disease.

Methods
The aim was to conduct face-to-face semi-structured

Background of fi rst case
The fi rst case is an 83 years old woman. She lives in Vlore, Albania. She was a potential candidate to develop osteoporosis due to early menopause at age 30 and giving birth to seven children. The patient was diagnosed with osteoporosis using bone mineral density (BMD) testing at the age of 80 years old.
"I did not have any visible signs of osteoporosis, I had pain, tiredness in walking, and I was aff ected by rheumatoid arthritis. I was very fortunate that I did not make a fracture after I fell down several times. I am always very careful when moving" she explained.
Following her interview she said "I was a very active person. Now, I didn't really move too much because of constant fatigue. I always consumed milk, yogurt less. In addition, the concerns suff ering from osteoporosis bother me a lot because makes me anxious and depressed. Also, being optimistic and thinking positively is of great importance".
She cited that medical staffs (doctor, nurse) have not given her preventive consulting for osteoporosis even if she was affected of rheumatoid arthritis, which is associated with an increased risk of osteoporotic fractures [13]. In addition, her emphases that the support and care of her children and family members is her success factor in osteoporosis self-management as well in hear well-being. Also, based on her experience with osteoporosis she recommended all older women to take care of their bone and screening for osteoporosis.

Background of second case
The second case is a 60-year-old woman. Even if she was diagnosed with rheumatoid arthritis at age 47 and with no other risk factors for osteoporosis as the early installation of menopause [14,15], or family history with fractures [16], in her case there were no visible signs of osteoporosis. She gave birth to two children and her menopause was onset at age 51. She was diagnosed with osteoporosis, after a small accidental fall which resulted in a deep thrombosis in one leg and a knee fracture. She attributes the good self-management of her osteoporosis to early detection, economic standpoint, healthy lifestyle and regular drug treatment. Doctors have advised her to get more sun exposure and exercise by swimming usually in early morning and late afternoon.

She emphasizes the importance of prevention "Now, every year based on my doctor recommendations', I get bone mineral density (BMD) testing".
She cited that the fi nancial costs of treatment and rehabilitation have often been unaffordable.
Following her experience, she said "I suggest all women and girls to be active, to care for the health of their bone, to consume as much dairy products, fi sh, fruits and vegetables as possible because the calcium present in these products is very important for bone health. These are informed choices that I have adopted after the health counseling I have taken from my physician". Today she is defi ned general well-being as before being diagnosed with osteoporosis. She also stresses that regular medication in doses and care are very important in the good self-management of disease. "At fi rst I tried to reduce the doses of medications, and for that I had constantly pain. I think a caution for patients trying to reduce the doses of prescribed medications is that they should talk to their doctor fi rst, before making any changes", she says.

Background of third case
The third case is a 50-year-old woman diagnosed with osteopenia following gastric resection.
Her menopause was onset at age 47 and she has given birth once. Osteopenia is a disease related to osteoporosis and is defi ned when the T-score is in the range 1-2.5. Osteopenia is the term used for bones that have become somewhat less dense than normal, but not as severe as in osteoporosis. Bone mineral density estimates the chances of bone breakage without any major strain. Osteopenia can cause fractures, distorts the posture and is accompanied by a lot of pain. A person with osteopenia is at risk for getting osteoporosis if it is not controlled [1][2][3]. But an individual can prevent osteoporosis cutting down alcohol intake, quitting smoking, exercising regularly, getting enough calcium and vitamin D and eating healthy foods, including fruits and vegetables [5][6][7]. The patient states that there was no sign or symptoms. After the gastric resection surgery, the patient reports that doctors recommended her to get BMD testing, which revels presence T-score in the range classifi ed as osteopenia. Also, she states that blood electrolytes were low, while calcium levels have decreased considerably. It is treated for one year with intravenous medications, 1/3 months. Based on her experience she also advises women to: "Eat enough calcium rich foods, get enough sun exposure and be active, keep walking comfortably".

Discussion and Conclusion
This case reports show how osteoporosis progresses silently and, especially if not diagnosed early, can lead to painful and debilitating fractures. Living with osteoporosis will be better with regular medication treatment and healthy lifestyle changes. In addition, screening and health education from health care practitioners is an important infl uencing factor in the prevention of osteoporosis. It is aimed at two groups, postmenopausal women as the high risk group and the other one, ordinary people. The age at which natural menopause occurs is between the ages of 45 and 55 for women worldwide [17]. In Albania, there is no evidence related to the onset of menopause in women. Except for the fi rst case, the other two cases presented were within the natural menopausal interval, respectively onset of menopause at age 30, 51 and 47.
In addition, early menopause has been associated with higher risk ratio for osteoporosis [18], higher risk for fracture as women age [19]. It is an essential for lifelong bone health for people at every life stage adopting a healthy eating with plenty of calcium rich foods, fruits, vegetable and regular exercise.
These case reports also show that people with osteoporosis can have better quality of life if the disease is diagnosed early and managed well.