Osteoporosis in late life: does health locus of control affect psychosocial adaptation?

Depression, Quality of Life, and Self-Esteem of Moroccan Postmenopausal Women with Osteoporosis before the Occurrence of Fractures

Objectives

Previous researches have investigated depression in postmenopausal women (PMW) with osteoporosis and fractures, but little is known regarding Moroccan PMW without fractures. We investigated depression prevalence and severity in Moroccan PMW with osteoporosis without fractures and its relationship with quality of life (QoL) and physical and psychological state.

Methods

This cross-sectional study enrolled 100 PMW with osteoporosis without fractures. Depressive symptoms, QoL, self-esteem, and fatigue were evaluated using the Patient Health Questionnaire-9 (PHQ-9), Arabic version of ECOS-16 questionnaire, Rosenberg self-esteem scale, and Arabic version of the Multidimensional Assessment of Fatigue scale, respectively. A questionnaire including sociodemographic factors, bone density features, pain intensity, and sleep disturbance was completed.

Results

Overall, 58% patients suffered from depression and 55% from pain (63.8% depressed women vs. 42.9% nondepressed patients; P = 0.03). Bone mineral density, lumbar spine T-score, ECOS-16, and self-esteem in depressed and nondepressed women were 0.791 (0.738–0.840) vs. 0.835 (0.790–0.866); −3.25 (−3.8 to −2.875) vs. −2.9 (−3.425 to −2.700), P = 0.02; 2.338 ± 0.605 vs. 1.638 ± 0.455; and 13.517 ± 5.487 vs. 18.404 ± 5.771, P < 0.0001, respectively. Depression severity correlated with pain, QoL, self-esteem, and fatigue (r = 0.367, r = −0.390, r = −0.390, and r = 0.369, respectively; P < 0.0001) as well as lumbar spine bone mineral density and T-score (r = −0.258 and r = −0.255, respectively; P = 0.01). Multiple linear regression analysis revealed impaired QoL (β = 0.526; P < 0.0001), fatigue (β = 0.177; P = 0.02), and lower self-esteem (β = −2.170; P = 0.005) as the strongest risk factors of depression.

Conclusions

Our study shows that even without fractures, Moroccan PMW with osteoporosis suffered from depression, pain, impaired QoL, and lower self-esteem.

Osteoporosis and depression: a historical perspective

In the early 1980s, researchers studying osteoporosis noted that depression was one of the major negative consequences of bone loss and fractures. These researchers believed that osteoporosis and fractures occurred first, causing a reactive depression. Meanwhile, a similar but distinct psychiatry literature noted that osteoporosis or bone loss appeared to be an undesirable consequence of major depression. Here, depression was seen as the causal factor, and osteoporosis was the outcome. The psychiatric perspective is more biological, based on the presence of hypercorticoidism in depressed individuals. Those who believe that osteoporosis leads to depression point out that depression is a consequence of many chronic illnesses. Regardless of the correct causal order, the strong positive relationship between osteoporosis and depression merits further clinical and research attention in the future.

Health locus of control and depression in chronic kidney disease: a dynamic perspective

Participants in the present study were 207 patients with chronic kidney disease (CKD) who completed internal HLOC and depression measures at baseline and at an approximately 16-month follow-up period. Regression results indicated that after controlling for baseline level of depression, baseline internal HLOC was not a significant predictor of depression at follow-up. However, increases in internal HLOC over the 16-month follow-up were predictive of depression at follow-up. Furthermore, this relationship was qualified by an interaction between change in internal HLOC and disease progression. These results suggest that changes in internal HLOC over time may be a particularly important determinant of adjustment for individuals whose chronic illness progresses or becomes life threatening.

Association of severe vertebral fractures with reduced quality of life: reduction in the incidence of severe vertebral fractures by teriparatide

OBJECTIVE

The association between vertebral fracture severity and health-related quality of life (HRQOL) was investigated in a subset of patients in the Fracture Prevention Trial. We sought to determine whether vertebral fracture severity was associated with HRQOL scores, and if so, to determine the effects of teriparatide (recombinant human parathyroid hormone 1-34) on vertebral fracture grades that most strongly impact HRQOL in postmenopausal women with osteoporosis.

METHODS

Vertebral fracture severity was assessed by the visual semiquantitative (SQ) method. A subset of 444 patients with a baseline radiograph completed the Osteoporosis Assessment Questionnaire. Baseline HRQOL scores were modeled as a function of maximum baseline vertebral fracture grade, while controlling for age, bone mineral density, body mass index, and back pain.

RESULTS

The effect of baseline vertebral fracture grade on baseline HRQOL was statistically significant, while interactions between vertebral fracture grade and the other variables were not statistically significant. SQ grade 3 (SQ3) vertebral fractures were associated with a significantly lower overall HRQOL score and with significantly lower physical function, symptoms, and emotional status dimension scores. After a median of 19 months of therapy, new or worsening SQ3 vertebral fractures occurred in 21 of 448 patients (4.7%) in the placebo group compared with 3 of 444 patients (0.7%) in the 20 mug/day teriparatide group. The risk of developing a new or worsened SQ3 vertebral fracture was reduced by 86% (P < 0.001) in patients treated with 20 mug/day teriparatide.

CONCLUSION

Compared with prevalent fractures of lesser severity, SQ3 vertebral fractures were associated with reduced HRQOL. Teriparatide treatment significantly reduced the risk of new or worsening SQ3 vertebral fractures. These findings suggest, but do not directly demonstrate, a benefit of teriparatide on HRQOL.

Life satisfaction and its correlates in older women with osteoarthritis

PURPOSE

To identify the relationships among functional disability, chronic daily stress, coping strategies, beliefs about personal control, social support, and life satisfaction in older women with osteoarthritis.

DESIGN

A descriptive, correlational design was used.

SAMPLE

The study participants were 107 women aged 60 years or older.

METHOD

Study participants completed six survey questionnaires and a demographic form.

FINDINGS

Bivariate correlational analyses showed that older women with poorer functional ability experienced greater chronic daily stress, reported more frequent use of emotion-focused coping strategies, and had a higher chance health locus of control. A hierarchic regression analysis revealed that the perceived social support and internal health locus of control significantly contributed to the prediction of life satisfaction after demographic, illness-related, and stress-related variables were controlled.

IMPLICATIONS

Stress management strategies matched to the participants' style of coping process can increase their sense of control over their health and enhance their social networks and activities.

Osteoporosis and quality of life psychosocial outcomes and interventions for individual patients

Despite the substantial psychosocial impact of osteoporosis, little research has evolved in this area. Early reports conceptualized these nonskeletal problems as psychosocial in nature, but more recent investigations focus on health-related quality of life (HRQOL). Multiple HRQOL instruments have been designed to measure this construct in people with osteoporosis, and each has its strengths and weaknesses. Unfortunately, so much investigative energy has been spent on psychometric testing that these instruments have not been put to work efficiently to identify problem areas in HRQOL. It is from such results that interventions to improve HRQOL will occur.

Women with osteoporosis: strategies for managing aging and chronic illness

This study focused on how self-concept and the meanings of aging and chronic illness provide an understanding of the diversity of strategies older women with osteoporosis use to manage their aging and chronic illness on a day-to-day basis. Twenty-eight women participated in this qualitative study through in-depth interviews and a self-administered questionnaire. While there was a range of strategies used across three groups of women, there was a predominant strategy which emerged as useful for each group: acceptance was used by women with confident selves, denial by women with contradictory selves and resignation by women with disparaged selves. An awareness of these strategies may be useful in understanding how women with osteoporosis make decisions to seek care from health and social service providers.

Aging, chronic illness and self-concept: a study of women with osteoporosis

The coalescence of aging and chronic illness may alter the relationships between the meanings of aging and chronic illness and the self-concept. Using Rosenberg's conceptualization of self-concept (1979), a qualitative study was designed and data collected from twenty-eight women with osteoporosis. Three types of self-concepts emerged from the data: the confident self, the contradictory self and the disparaged self. A description of these types is presented highlighting the reciprocal relationship among meanings of aging and chronic illness and self-concept and including discussion of the strategies used to enhance, protect and maintain self-concept despite changes brought on by aging and chronic illness.

Correlates and consequences of chronic pain in older adults

Chronic pain is a frequent challenge to older adults' coping skills. Despite the widespread occurrence of chronic geriatric pain, no comprehensive body of literature on this topic exists. Instead, research on chronic pain is scattered across disciplines and is perceived as inaccessible by scientists. We completed a comprehensive review and qualitative analysis of the geriatric chronic pain literature since 1990 and found 314 articles on this topic that reported. North American research. Physical, social, and psychologic variables associated with chronic pain and the elderly were mentioned in just over half (53%) of the articles. However, both psychosocial causes and consequences of chronic pain were understudied. Only 16% of the articles had social variables (gender, race, and age) as their primary interest; 27% focused on psychologic or psychiatric issues, with half including depression as the variable of interest. An analysis of the articles' content suggests that research on chronic pain in later life would be substantially improved if a more structured and comprehensive approach were used that combined the study of psychosocial issues with that of physical pain. Researchers and clinicians with a global understanding of chronic pain might help improve quality of life for older adults.

Consequences of vertebral deformities in older men and women

The objectives of this study were to ascertain the prevalence of the number and severity of vertebral deformities in elderly people and determine the extent to which these are associated with several aspects of functioning. The study was conducted in a subsample of the Longitudinal Aging Study Amsterdam (LASA) consisting of 527 participants (260 men and 267 women), aged 65 years or over. Lateral radiographs of the spine (T4-L5) were made of each participant and a semiquantitative method was used to assess the number and degree of vertebral deformities. The prevalence of having at least one vertebral deformity was 39% in both men and women. Six percent of the men and 5% of the women had at least three vertebral deformities. For severe deformities, the prevalence was 8% in men and 12% in women. The number of vertebral deformities was significantly associated with a height loss of more than 5 cm, difficulties in activities of daily living, poor performance, more than 3 days in bed and more than 3 days with limited activities because of health problems in the past month, and poor self-perceived health. For most of these outcome measures, associations were strongest when three or more deformities were present. The presence of a severe deformity was associated with a height loss of more than 5 cm, poor performance, more than 3 days with limited activities in the past month, and poor self-perceived health. None of the associations between number and severity of vertebral deformities and the level of functioning was modified by sex. We can conclude that vertebral deformities are very common in both older men and older women and that vertebral deformities, even if they are not clinically manifest, have a substantial impact on the level of functioning and well-being of older people.

The Canadian Model of Occupational Performance applied to females with osteoporosis

Osteoporosis is a prevalent disease among older women. It results not only in physical limitations, but may raise spiritual and affective issues that can interfere with a person's ability to perform routine occupations. In addition, the social, cultural, physical, and institutional elements of the environment play a vital role in influencing the choices individuals make and how they manage symptomatic osteoporosis. The purpose of this paper is to examine the occupational impact of osteoporosis on post-menopausal women by applying the Canadian Model of Occupational performance (Canadian Association of Occupational Therapists, 1997) as an organizational framework to existing knowledge of this disease.

Bone mineral density and depression: a community study in women

In a community sample of 102 Portuguese white women we evaluated the relationship between osteoporosis and indexes of psychopathology and well-being. Depressive symptoms were assessed by the Beck Depression Inventory (BDI), psychopathology by the Hopkins Symptom Checklist-90 Revised (SCL-90-R), and quality of life using the Psychological General Well-Being Index. A questionnaire comprising social, demographic, clinical, and behavioral characteristics was also used. The sample prevalence of osteoporosis was 47.1%. Women with osteoporosis presented significantly higher scores on the total BDI (16+/-9 vs. 13+/-10, p=0.045) and lower scores in the hostility (0.8+/-0.6 vs. 1.2+/-0.7, p=0.012) and phobic anxiety (1.1+/-0.8 vs. 1.5+/-0.9, p=0.041) subscales of the SCL-90-R. No differences were found regarding mean general well-being scores (62+/-17 vs. 64+/-19, p=0.665). This study showed that women with osteoporosis have significantly higher levels of depressive symptoms and a corresponding higher prevalence of depression, independent of other factors strongly associated with osteoporosis, such as age or body mass index.

Reliability of an Osteoporosis-Targeted Quality of Life Survey Instrument for use in the community: OPTQoL

A brief Osteoporosis-Targeted Quality of Life (OPTQoL) questionnaire was previously developed as a cross-sectional survey instrument to assess the community impact of osteoporosis on quality of life in women. The initial development process involving item generation through focus groups, item reduction, and content and construct validation yielded a 36-item questionnaire with three domains (physical difficulty, adaptations and fears) and 10 health-related questions. In the present study, test-retest reliability and internal consistency of the questionnaire were assessed in a mail-based study with two clinical sites. Two hundred women (50 with severe osteoporosis, 50 with osteopenia, 50 with normal bone mineral density (BMD) and 50 with osteoarthritis and normal BMD), aged 43-84 years, completed the self-administered questionnaire initially and again about 2 weeks later. Using weighted kappas, agreement between questionnaire administrations ranged from 0.60 to 0.80 for most of the individual items. Intraclass correlation coefficients to assess reliability for the domain scores were 0.93 (physical difficulty), 0.82 (adaptations) and 0.88 (fears). Internal consistency of each of the domains was also high, with Cronbach's alpha coefficients ranging from 0.89 to 0.91. Four items were dropped from the 36-item questionnaire due to high percentage of 'not applicable' responses. Results of the analyses support the validity and reliability of this instrument as a cross-sectional survey tool for assessing the impact of osteoporosis on quality of life in women living in the community. The questionnaire has been translated and culturally adapted into seven languages to allow cross-cultural studies of the community impact of osteoporosis.

Paget's disease of bone and quality of life

Little is known about how Paget's disease of bone affects quality of life. To better understand the relative impact of factors on quality of life, we mailed a brief survey to 2000 people randomly selected from the Paget's Foundation mailing list. The sample was geographically stratified to examine the effects of specialist availability. Nine hundred and fifty-eight persons responded to the questionnaire (53% response rate after adjustment for death, incorrect addresses, and nondeliverable mailings). The sample had equal proportions of males and females, with a mean age of 74 years (SD = 9.0). Most (97%) were white, with high levels of education (mean 13 years; SD 3.7) and income (60% earned more than $20,000 annually). They reported pagetic bone in the skull (34%), spine (35%), pelvis (49%), and leg (48%). The most frequently mentioned complications were hearing loss (37%) and bowed limbs (31%). Comorbidity included arthritis (64%), hypertension (32%), and heart problems (28%). Nearly half (47%) reported feelings of depression, and 42% said that their health was fair or poor. Only 21% reported that quality of life was very good or excellent. In multiple partial F-test regression analyses, variables were divided into four domains (social, psychological, care, and biomedical). The psychological domain explained 19% of the variance beyond that explained by all other variables; the social domain explained 3%, the biomedical domain explained 3% and the care domain explained 1%. The importance of the psychological aspects of Paget's disease suggests that treatment protocols should include psychological intervention to improve quality of life.

The clinical impact of vertebral fractures: quality of life in women with osteoporosis

Osteoporosis has obvious physical and functional consequences such as kyphosis, restricted range of motion, and pain. What are not so obvious are the psychosocial sequelae that result from this metabolic bone disease. Many patients in the initial phases of the disease express substantial anxiety, especially about the possibility of future fractures and physical deformity. As the disease progresses, depression can become profound for those who experience hip or multiple vertebral fractures. The effects of the chronicity of osteoporosis, its disabling and disfiguring aspects, and the chronic postural pain that develops as time passes challenge even the most stable individuals. In addition, osteoporosis has substantial impact on interpersonal relationships and social roles. The dependency created by this disease affects close relationships, because the patient with osteoporosis cannot reciprocate in social support. Today's older women find the restrictions of the disease socially devastating. These women, unlikely to work in the labor force, took pride in their roles of housekeeper and cook. Unfortunately, severe osteoporosis can force women to relinquish even these social roles, leaving them with no source of self-esteem or accomplishment. In all, osteoporosis is devastating both psychologically and socially.

Functional and mobility impairments associated with Paget's disease of bone

OBJECTIVE

To determine if patients with Paget's disease of bone involving the tibia, femur, and/or acetabular portion of the ilium had more impairments in function and mobility than age- and sex-matched control subjects.

PATIENTS AND METHODS

A case control study with Paget's disease patients selected from a center for bone disease at a tertiary medical center; control subjects were volunteers from the Duke University Aging Center subject registry. Demographic characteristics, physical examination and serum alkaline phosphatase levels were obtained. Radiographs of the pelvis and lower extremities were evaluated by a radiologist. All participants completed a Functional Status Questionnaire (FSQ). Mobility measures included mobility skills protocol, 10-foot walk time, 360-degree turn left (number of steps), and 6-minute walk distance.

RESULTS

The 12 Paget's disease patients were no different in age (70.7 +/- 6.2 years) than the 12 control subjects (69.5 +/- 6.2 years). Serum alkaline phosphatase levels were elevated in Paget's patients (539 +/- 530 IU/L), and normal in control subjects (85 +/- 17 IU/L). In addition to Paget's disease, radiographs showed joint space loss in joints proximate to the diseased bone. On the FSQ scales Paget's disease patients had significantly lower scores in basic activities of daily living (P < .05), instrumental activities of daily living (P < .001), and social activity than control subjects (P < .05). There was no difference between the groups on scales measuring mental health and quality of social interaction. On mobility measurements, Paget's disease patients showed significant impairments when compared with control subjects: mobility skills protocol score (22.5 +/- 2.5 vs 25.6 +/- 0.7, P < .001); 10-foot walk (3.96 +/- 1.3 vs 2.55 +/- 0.5 seconds, P < .001); 360 degree turn left (8.0 +/- 1.0 vs 5.9 +/- 0.6 steps, P < .001); and 6-minute walk (342.0 +/- 108.5 vs 519.4 +/- 100 meters, P < .001).

CONCLUSION

When compared with control subjects, patients who have Paget's disease of bone involving the tibia, femur, or acetabular portion of the ilium have clinically and statistically significant functional and mobility impairments compared to age- and gender-matched controls.

Health locus of control and psychological distress in cancer patients: interactive effects of context

Delineation of the relationship between health locus of control (HLOC) and psychological adjustment in chronic disease has been hampered by the failure to consider the moderating effect of contextual factors. The extent to which HLOC beliefs match the control realities in a situation (Reality Matching hypothesis) as well as the degree of threat (Threat hypothesis) posed by the situation were hypothesized to moderate the HLOC-distress relationship. Distress, disease severity (i.e., threat), and HLOC were assessed in 69 individuals with malignant disease undergoing evaluation for bone marrow transplantation. Hierarchical regression analyses indicated that the HLOC-distress relationship was moderated by disease severity and treatment history (i.e., whether an individual had failed prior cancer therapy). However, in some instances, the specific interaction relationships obtained differed from those evident in previous research with ESRD patients. It was concluded that there is no simple main effect relationship between HLOC beliefs and psychological adjustment. Rather, this relationship is best described by joint consideration of factors descriptive of the context in which the individual is embedded.

Sociodemographic correlates of health beliefs among black and white community dwelling elderly individuals

This study examined the hypothesis that sociodemographic characteristics such as age, education, race, and gender would be predictive of Multidimensional Health Locus of Control Subscale scores in a population-based sample of 342 community dwelling elderly individuals. Bivariate analysis revealed associations between black race, lower socioeconomic status, and lower education on the Chance and Powerful Others Subscales. While the multivariate analysis revealed no predictors for the Internal Subscale, a higher socioeconomic status, white race, and a higher level of education continued to predict low scores on the Chance Subscale when controlling for all other variables. Scores on the Powerful Others Subscale appeared to be a function of socioeconomic status and gender. Of note, the higher the education level for both men and women, the lower the scores on the Chance and Powerful Others Subscales. This sex by education interaction term reached statistical significance for the Chance Subscale. The results demonstrate the measurable influence of sociodemographic variables on the health beliefs of community dwelling elderly individuals.

Association of osteoporotic vertebral compression fractures with impaired functional status

PURPOSE

To determine if vertebral compression fractures in elderly women were associated with impairments in physical, functional, and psychosocial performance.

SUBJECTS AND METHODS

Ten white women with confirmed vertebral compression fractures were age- and race-matched with 10 control subjects without fractures in a case-control design. All subjects invited to participate in this study were patients of the Geriatrics Division of the Department of Medicine at Duke University Medical Center. All study participants lived either in the community or in the independent-living sections of local retirement communities in and around Durham, NC. Subjects with fractures (mean age = 81.9 years, SD = 5.9 years) had two or more vertebral compression fractures in their medical records, whereas control subjects (mean age = 79.6 years, SD = 6.5 years) had no history of vertebral fractures. Spinal radiographs of all women confirmed group assignment. Physical, functional, and psychosocial performances were evaluated. Physical performance was assessed by measurements of maximal trunk extension torque and thoracic and lumbar spinal motion in the sagittal plane, functional reach, mobility skills, 10-ft timed walk, and 6-minute walk test. Thoracic and lumbar spinal configurations were also determined. Functional performance was assessed using the Functional Status Index. Psychosocial performance was assessed with the following scales: Hopkins Symptom Checklist 90 Revised, Rosenberg Self-Esteem Scale, West Haven-Yale Pain Inventory, Beck Depression Inventory, and single-item health-belief questions.

RESULTS

Control subjects were not significantly different from patients with fractures in age, weight, number of current illnesses, number of prescribed medications, number of pain medications, ratings of lumbar spine degenerative disc disease, or lumbar spine facet joint arthritis. Activity levels and exercise participation were similar in both groups. Control subjects had no vertebral fractures, whereas fracture subjects had 4.2 +/- 2.6 fractures (range: 2 to 10). Thoracic kyphosis was increased and lumbar lordosis was reduced in fracture subjects. Fracture subjects had reduced maximal trunk extension torque, thoracic and lumbar spine sagittal plane motion, functional reach, mobility skills, and 6-minute walk test. The Functional Status Index showed reduced levels of functional performance in fracture subjects compared with controls with increased levels of assistance, pain with activity, and difficulty in activities. Psychosocial performance was limited in fracture subjects with increased psychiatric symptoms, increased pain, and greater perception of problems caused by health.

CONCLUSION

Vertebral compression fractures are associated with significant performance impairments in physical, functional, and psychosocial domains in older women.