**[Evidence Based Periodic Exam in the Elderly Native
American]{.underline}** 4/10/04njm

by Bruce Finke, MD

Indian Health Elder Care Initiative

For Dr. Finke's initial comments please go here

<http://www.ihs.gov/MedicalPrograms/MCH/M/PCForum_docs/ElderExamPrimer11604.doc>

For the overall Summary go here

<http://www.ihs.gov/MedicalPrograms/MCH/M/PCdiscForum.asp>

and scroll down to the word 'Summary' under **Evidence Based Periodic
Exam in the Elderly Native American**

**[Discussion]{.underline}**

**Murphy, Neil**

**Tue 2/17/2004 6:17 PM**

Bruce

These are some great guidelines to work from. Thanks

One area I think we, in Indian County, are not performing adequately is
osteoporosis screening. There is a benchmark recommendation from ACOG to
perform as you said....

"Osteoporosis Screen

*Dexa test or peripheral screening for all women 65 years and older or
55-64 with risk factors."*

We now have data from the National Women's Resource Center that there
are significant untreated occult rates of osteoporosis in Native women.

But even at ANMC, e.g., a tertiary care center in an urban area of
reasonable size, we don't have a DEXA machine on site and we have to
deal with Contract Health issues every time to send the patients to the
private sector.

I bet it is even harder for providers in smaller facilities.

Does anyone have better luck at getting the following done at their
facility?

*Dexa test or peripheral screening for all women 65 years and older or
55-64 with risk factors."*

**N. Burton Attico, MD \[nbattico@POL.NET\]**

**Tue 2/17/2004 11:26 PM**

Thanks for that. pDXA is ideal for screening, with DEXA for the
definitive testing (recognized standard). Some facilities are using CT
scans for testing, which give far more radiation, combined with the
claustrophobic feeling that some patients feel in the CT scanner.

ADA has recently had an article on diabetes as a high risk factor for
unrecognized osteoporosis, in both type 1 and type 2 diabetes. With the
high rates of diabetes that we see in AI/AN, this should be a major
emphasis in the diabetic patient. Most providers are probably unaware
that there are not standard charts for BMD in AI/AN, and thus the BMD
values for whites are usually being used. Is this a correct usage? As
many western tribes have relationship to Asian peoples
anthropologically, should we be using Asian standards? Much effort needs
to be expended on getting enough data so that we can derive AI/AN
standards for appropriate use, as well as rates of osteoporosis.

**Murphy, Neil**

**Wed 2/18/2004 7:05 AM**

Perhaps a better question is\....

Which of your locations are NOT able to perform Osteoporosis screening
regularly onsite at your facility\...

\....or have very access to a local contractor who performs Osteoporosis
screening?

Please let us know if you are not actively screening for osteoporosis at
this time

Any thoughts on how to improve that situation?

**North, Charles \[CNorth@ABQ.IHS.GOV\]**

**Wed 2/18/2004 8:41 AM**

We at the Albuquerque Service Unit consider anything recommended by the
USPSTF to be a core clinical service and will pay with CHS if the
service is not available directly. This seems prudent financially since
we may save money as well as improve quality of life if we can avoid a
hospitalization.

For non-CHS eligible patients we refer to the county/university hospital
which has programs for medically indigent (25% of NM population). The
enthusiasm for DEXA screening varies widely in our population of doctors
and patients. There is much more concern about breast cancer and
diabetes screening. I agree with Dr. Attico that we do not have adequate
data to develop tribal specific norms. However this is true with most
continuous variables that we use as guides for clinical care in American
Indians and Alaska Natives and we still follow the national
recommendations, albeit with some skepticism at times. For example we
use national LDL and BMI standards.

In general, it would be prudent to address osteoporosis screening with
our patients at highest risk, then the general population of women. We
can also advocate for calcium, vitamin D, walking, resistance training
and other preventive measures from childhood to geriatric ages. After
screening, we should not overlook the cost of treatment and follow up
DEXA exams which are necessary to assess effectiveness of our treatment.

**McGuiggin, Mary (FDIH) \[Mary.McGuiggin@FDIH.IHS.GOV\]**

**Wed 2/18/2004 10:09 AM**

Would anyone have information or experience using heel ultrasound for
diagnosis and f/u post treatment of osteoporosis? I\'ve been able to
find one article.

**Birnbaum, Bernard \[Bernard.Birnbaum@CHINLE.IHS.GOV\]**

**Wed 2/18/2004 11:58 AM**

In Chinle we have dexa scanning available on site only twice per year
for only approx 25 patients - this is provided by our rheum
consultants\... I have not had trouble sending people for screening off
the reservation, but I do have trouble getting them to actually go. The
closest scanner is 95 miles away. I think this is an excellent topic for
discussion as we see many fractures that are likely preventable! I also
think the question of ultrasound screening would be interesting to
investigate more fully.

**Saari, John \[John.Saari@NA.IHS.GOV\]**

**Wed 2/18/2004 12:12 PM**

On an unrelated geriatrics screening matter, I relay the following that
may influence our decision about prostate cancer screening:

[Prostate-Specific Antigen Screening in Elderly Men]{.underline} \--
Journal of the National Cancer Institute

<http://www.mdlinx.com/InternalMDLinx/thearts.cfm?artid=792192&specid=3>

" Although the efficacy of prostate-specific antigen (PSA) screening for
prostate cancer has not been established, it is widely used. However,
despite the overall controversy regarding PSA screening, there has been
general agreement that elderly men (i.e., those aged 75 years or older)
should not be screened\..."

**Hays, Howard \[ghhays@ANMC.ORG\]**

**Wed 2/18/2004 12:26 PM**

Thanks, John. I\'m still waiting for the evidence that says we\'re
actually reducing morbidity or saving lives with PSA screening at any
age. I do it when requested or when symptomatic, but don\'t offer it.

**Phillips \[tjphillips@CITLINK.NET\]**

**Thu 2/19/2004 5:19 AM**

I completely agree with not routinely screening. Even if a man has
hypertrophy-like symptoms, I do not check it without at least making an
attempt to inform them about the test and ask if they would like it
checked. (I try to explain the possible implications with regard to
further testing should the test be abnormal!) Most people default to
going ahead and getting it checked but I try at least to get informed
consent.

**Kitson, Nancy E. \[nkitson@ABQ.IHS.GOV\]**

**Wed 2/18/2004 2:24 PM**

At Jicarilla Service Unit we purchased a portable heel ultrasound last
year.

So far we have screened 96 of 131 Jicarilla elders (age over 65).
Results are as follows: 13-osteoporosis \[T-score \</= to -2.5\];
51-osteopenia \[T-score (-1.0)-(-2.4)\]; 25-normal; 9-refused. Treatment
with actonel and calcium has been offered to all elders with
osteopenia/osteoporosis.

The heel ultrasound testing has been well accepted by our elders.

**N. Burton Attico, MD \[nbattico@pol.net\]**

**Wed 2/18/2004 7:36 PM**

I will have to look for references. There is more coming out on the
subject almost monthly. Heel (calcaneus) is believed to be superior to
wrist, since the calcaneus is weight bearing.

Chuck Rhodes (Area Diabetes) and I had researched this specific item
when we were in our \"battle\" with the folks in Procurement, as well as
with PIMC (and their desire to use CT rather than central DEXA, the
\"gold standard\" in BMD testing). Chuck might have his data more
readily available. Both heel & wrist pDXA equipment are portable.
Incidentally, I believe that PIMC \"excessed\" its DEXA table to Gallup.

**Diane Pratt \[Diane.Pratt@GRANDRONDE.ORG\]**

**Wed 2/18/2004 6:40 PM**

Sounds like you are doing some good work in New Mexico

**N. Burton Attico, MD \[nbattico@pol.net\]**

**Wed 2/18/2004 7:53 PM**

I was not on the \'net for most of the day, but Neil asked if I could
respond to you. Chuck Rhodes & I researched this last year, and the
differences between pDXA and US. pDXA is superior (literature, NOF
site), but would be OK for screening. In some way, a positive screen
should have a formal \"test\" using DEXA, so that you could also
determine hip and the spine, and complete the diagnostic w/u. With the
recent articles\* in Diabetes Care, diabetes should be an automatic
\"trigger\" to screen.

GIMC has the DEXA table that was at PIMC, which PIMC never installed.
The radiation in DEXA is so low that they are used in OBG practices,
with the same tech performing the tests day after day.

\*Brown, SA, Sharpless JL. Osteoporosis: An under-appreciated
complication of diabetes mellitus. Clinical Diabetes 2004 22(1):10-20

**Finke, Bruce \[bruce.finke@MAIL.IHS.GOV\]**

# Wed 2/18/2004 8:44 PM

The reference below is for the article that published the results of the
NORA study, a study of almost 200,000 women (including about 1700 self
identified Native American women) with peripheral screening, including
heel ultrasound. The results of the study make a compelling argument for
the use of peripheral devices (including heel ultrasound) as a way of
identifying those women at highest risk for fracture in the near term.

Siris ES, et al. Identification and fracture outcomes of undiagnosed low
bone mineral density in postmenopausal women; results from the National
Osteoporosis Risk Assessment. JAMA 2001. 286(22): 2815-2822.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11735756>

**Finke, Bruce \[bruce.finke@MAIL.IHS.GOV\]**

**Wed 2/18/2004 9:15 PM**

I agree with Chuck that the USPSTF recommendations are conservative in
nature and should represent the floor for our screening efforts.
Although we do not have good data on AIAN risk for osteoporosis, the
NORA study suggests that in a large primary care based cohort of women
self identified as Native American, the risk of fracture is the same as
for Caucasian women. This is not the final word by a long shot, but for
me it suggests that, until we have further data, we should assume that
the risk of osteoporosis in AIAN women is not significantly different
than the risk in caucasian women.

On the issue of screening only the highest risk\...I think the USPSTF
guidelines address this when they begin screening at 65 with the
exception of women with strong, known risk fractures. Low bone density
(whether measured by DEXA or peripheral devices) remains the most potent
single risk factor for fracture.

**Riley, Sheila (OKCMIA) \[Sheila.Riley@MAIL.IHS.GOV\]**

**Thu 2/19/2004 5:09 AM**

At the Miami Indian Clinic here in Oklahoma we are not screening
patients well at all. When I ask about sending patients for DEXA I am
stopped at contract health. Of course we are a small clinic and run only
on federal funds, but I worry about the impact of Osteoporosis in the
next few years for several reasons.

We are living longer

Many Indians are not truly Indian but mostly white

Our dietary habits in America

**Phillips \[tjphillips@CITLINK.NET\]**

**Thu 2/19/2004 5:03 AM**

I am a geriatrician working with the Navajo tribe in Chinle, Arizona. We
are very remotely located and have to send people more than an hour and
a half away to Gallup, NM in order to get a DEXA in the private sector.
We often run into difficulty with transportation despite our "Safe Ride"
service. Another issue, interestingly, is that even in Gallup, the scan
is located in a trailer and the person needs to be able to climb several
stairs. We also have a very limited number of scans that can be done
on-site. Dr. Jeff Lisse, a rheumatologist from Tucson's Univ of Arizona,
brings a mobile unit (with stairs, too)twice a year to his rheum clinic.
They charge our service unit a nominal fee for the scans. A few years
ago, Dr. Lisse spent quite a lot of effort trying to get a very
non-invasive study approved by the Navajo Nation's IRB to try to better
define the rates of osteoporosis among Navajo. It was a frustrating
experience. He feels a Native principal investigator might have more
success. Unfortunately, we do not have anyone here like that to
spearhead the initiative.

Interesting about the higher risk of osteoporosis in Diabetes. I will
make sure our diabetes coordinator knows about that. We could definitely
use a little more institutional support to encourage screening and even
actual treatment of declared osteoporosis after a fracture!

**Simpson, Loren \[LSimpson@ABR.IHS.GOV\]**

**Thu 2/19/2004 6:02 AM**

I find it difficult to apply Asian standards to many of my patients,
friends and relatives that are well over 6 feet tall especially in the
Northern Plains region. I agree that the standards used for non-Indian
patients may not be ideal and will keep this in mind for the future-can
we improve on our data? Can we develop guidelines for our population?
Good info!

**Brown, Steven \[Steven.Brown@MAIL.IHS.GOV\]**

**Thu 2/19/2004 10:05 AM**

I became interested in the issue of screening and treating osteoporosis
a few months back and took a close look at the evidence to present to
our medical staff. Most of the information I gathered is from the
previously mentioned USPSTF recommendation which is incredibly thorough,
detailed, and evidence-based.

Check out the link at:

<http://www.ahrq.gov/clinic/uspstf/uspsoste.htm>

The USPSTF helps clarify the magnitude of the benefit you can expect
from treatment of osteoporosis in preventing hip or vertebral fractures.
For women 65-69 you need to screen 731 women to prevent one hip fracture
and 248 women to prevent one vertebral fracture over a five-year period.
The FIT trial (1) showed that even in the highest risk women (women
55-80 with previous vertebral fracture or T-score \<2.5 by DEXA)you have
to treat 66 women with alendronate for 5 years to prevent one hip
fracture.

Another interesting part of the USPSTF recommendation is their
discussion of the test used for screening. They note that "the
probability of receiving a diagnosis of osteoporosis depends on the
choice of test and site." This is confirmed by the NORA study cited by
Dr. Finke which shows a wild variation in rates depending on the method
used to diagnose osteoporosis (3.4% prevalence with heel ultrasound to
13.5% by finger DEXA.)

There are two prospective studies utilizing heel ultrasound to determine
who is at risk for fracture (2,3). The authors of these studies conclude
it is comparable to DEXA to predict hip fracture risk.

However, there are no prospective studies showing that women with T\<2.5
by heel ultrasound reduce their fracture risk with treatment.

A very clever British study looked at 190 women in a primary care office
setting using heel ultrasound (4) comparing it to a "gold standard" of
hip DEXA. The authors showed a 71% sensitivity and 83% specificity with
the heel ultrasound to diagnose osteoporosis. To me, this means that you
miss some women who would have osteoporosis on DEXA (false negatives),
and you diagnose some people with osteoporosis who don't really have it
(false positives.)

I think the use of heel ultrasound is premature.

Also, given the magnitude of the benefit discussed above, it's not clear
to me that this type of screening should be a high priority in our
patient population. The benefit of screening markedly increases with age
(85% of atraumatic hip fractures occur after age 70) and certainly
people with previous atraumatic fractures should be treated.

This is a huge topic to cover. At the Phoenix area Women's/MCH
conference May 4-5 I will be presenting much of this data and it sounds
like there may be some sort of panel discussion, too. We hope to reach
some sort of "consensus" about the approach to this issue in our area.

Steve Brown

Whiteriver, AZ

-Black DM, et al. Fracture risk reduction with alendronate in women with
osteoporosis: The fracture intervention trial. J Clin Endocrinol Metab
2000;85: 4118-4124.

-Hans D, et al. Ultrasonographic heel measurements to predict hip
fracture in elderly women: the EPIDOS prospective study. Lancet1996;348:
511-514.

-Bauer DC, et al. Broadband ultrasound attenuation predicts fractures
strongly and independently of densitometry in older women. Arch Intern
Med 1997;157: 629-634.

-Hodson J, Marsh J. Quantitative ultrasound and risk factor enquiry as
predictors of postmenopausal osteoporosis: comparative study in primary

care. BMJ 2003;326: 1250-1251.

**Brown, Steven \[Steven.Brown@MAIL.IHS.GOV\]**

**Thu 2/19/2004 10:20 AM**

According to the USPSTF: "After a woman is screened and determined to
have osteoporosis, future screening with bone density testing would be
unnecessary." That is, there is no need to "follow" BMD on a patient on
therapy.

This is different that what we hear from our Rheum or Endocrine
colleagues.

**North, Charles**

**Thu 2/19/2004 10:24 AM**

Dr. Brown does an excellent job of summarizing the USPSTF
recommendations, which I have also read in detail and find myself
longing for more research before embarking on expensive therapy. The NNT
is large for fracture prevention but not much more than cardiac and
stroke prevention using lipid screening (\~4-500). We must keep in mind
that our populations in Native America are younger and that the demand
for the elderly services will lag the white population.

**Gooris, Paul \[pgooris@ABQ.IHS.GOV\]**

**Thu 2/19/2004 3:29 PM**

Access to DEXA's at Pine Hill pose a problem similar to Chinle's: 60
miles away, once a month, van having poor accessibility (the nearest
walk-in DEXA is 130 miles away). The real concern as I see it is the
delay in treatment (ie Fosamax) that results. While I understand the
need to quantify the extent of osteoporosis in a given patient to
monitor the effect of treatment, I wonder about the consequences of
treatment delay. Is there a way that heel densitometry can be used? Any
thoughts?

**N. Burton Attico, MD \[nbattico@POL.NET\]**

**Fri 2/20/2004 7:21 AM**

Another "high risk" factor is the high use of DMPA (inducing BMD loss)
in AI/AN patients. There still have not been satisfactory long-term
studies of the use of DMPA and its possible potential for increasing
osteoporosis incidence. Most of the reported studies are still only 1-2
year use. Is there satisfactory recovery? Should calcium intake
(supplentation) be increased? Does family planning method choice
represent a risk?

**Murphy, Neil**

**Sat 2/21/2004 7:37 AM**

Here is a message that went out on the NCCD listserv in January.

I think it could generate some helpful responses from us.

Send your responses directly to Bruce Finke at
<bruce.finke@mail.ihs.gov>

January 26, 2004 6:47 AM Message

Delete the statements that are not true about your site, insert a
signature block or other identifier, and send to:
<bruce.finke@mail.ihs.gov>

Any additional comments are welcome!

Please take a minute to answer a few questions about osteoporosis
screening in the Indian health system. We\'ll use this information to
help develop

support for your efforts to screen for and manage osteoporosis.

Question 1 (delete untrue statements)

Our clinic or hospital based primary care program is:

· Not screening for osteoporosis

· Testing for osteoporosis on a provider-by-provider or
patient-by-patient basis.

· Screening for osteoporosis with a comprehensive, population-based
approach

· Don\'t know

Question 2 (delete untrue statements)

· We have onsite or \"in town\" access to either Dexa or a peripheral
screening modality (including heel ultrasound).

· We have to refer patients out of the community for screening.

· Don\'t know

Question 3 (delete untrue statements)

· We do have a protocol for osteoporosis screening and management

· We do not have a protocol for osteoporosis screening and management

· Don\'t know

**Finke, Bruce \[bruce.finke@MAIL.IHS.GOV\]**

**Sat 2/21/2004 2:23 PM**

The NORA study that I referenced earlier in this discussion (Siris, et
al) showed that women with a T score of minus 2.5 or worse on heel
ultrasound had 4 times the risk of fracture in the ensuing year. Based
on that data, the Zuni protocol for use of heel ultrasound suggests that
if the heel ultrasound shows T score of minus 2.5 or worse it is okay to
treat with a bisphosphonate (alendronate is on formulary). It is optimal
to get a DEXA for baseline to follow treatment, but preferable to treat
without DEXA than to defer treatment.

**Neufeld, Brenda G (TUC)**

**Mon 2/23/2004 6:48 AM**

We are not doing any on-site screening at this time. The University of
Arizona rheumatology had a mobile DEXA unit that they brought here for a
time as a no-cost service, but they are no longer doing that. I am in
favor of forming a contract with them to restart that service. We do
have an Omnisense 7000 machine provided by the Phoenix Area for
ultrasound screening, but I've not been impressed by the literature on
this machine, and my understanding is that it is very operator
dependent.

Our contract health department will not pay for DEXA\'s unless they meet
Medicare criteria\--i.e. (as I understand them at least) the patient has
specific risk factors other than age.

**Rhodes, Charles \[Charles.Rhodes@na.ihs.gov\]**

**Mon 2/23/2004 9:07 AM**

I'm not sure I would agree that Ultrasound (US) is "inferior" to p-DXA.
US is a newer approach, so the data base is less robust. Most of the
items I have seen lately describing femur-and-lumbar ("axial") DXA as
the "gold standard" are written by people who have a financial interest
in "axial" DXA units. Axial DXA IS the "gold standard" in one sense: it
was the method used in the large clinical trials of bisphosphonates.
However, it was also used in trials of high-dose fluoride, in which
setting it gave misleading results. (High dose fluoride -\> increased
BMD by DXA, but also increased fracture rate.) The fracture rate is the
REAL gold standard.

Because it gives mineral content in three dimensions, instead of a
two-dimensional projection of a three-dimensional object, qCT should be
superior to DXA, but the data base is thinner and the radiation dose
higher (although still low.)

Some people believe that US will ultimately prove superior to all three
radiation methods (DXA, pDXA, qCT). Besides the absence of ionizing
radiation, they feel US can give information about continuity of
trabeculae---an aspect missed totally by all the other methods. For now,
the US folks are still working on optimizing the software to interpret
the information available from US. What we need are studies following a
tested but untreated population long enough for them to develop enough
fractures to plot the predictive value of the testing method. We have
that for DXA and pDXA, not for US and I'm not sure about qCT.

**Murphy, Neil**

**Thu 3/4/2004 8:34 AM**

A. The Expert panel suggested

"Ensure adequate calcium and vitamin D intake. Recommended intake is
1200 mg per day of calcium and 400-800 miu Vitamin D^8^. Consider
supplementation."

and

B. We know calcium levels are low in some AI/AN populations, e.g., from:
Betsy Nobmann, former Alaska Area Nutrition Director .....

"...More specifically the 74 Anchorage Native women (18-45y) that we
surveyed in 1996 had low calcium intakes (88% didn\'t meet the
recommended intakes (mean 631mg/d). In 1987-88 intakes for 186 women
(21-60) were also low (mean 516mg/d) and less than NHANES II intakes.
It's likely that women with lactose intolerance would have a hard time
meeting calcium recommended intakes. I\'ve never seen a break down of
intakes analyzed by lactose tolerance however."

Especially considering our recent discussion of osteoporosis screening,
I wonder if IHS providers how many actually giving adults calcium on a
regular basis?

2.)

The guidelines recommend lipid screening. Our facility recently changed
their method to add LDL to their initial phase

What are other providers actually using for their initial lipid screen?

**Birnbaum, Bernard \[Bernard.Birnbaum@CHINLE.IHS.GOV\]**

**Thu 3/4/2004 9:07 AM**

I do a pretty good job of giving calcium to all women over 50,
prenatal/postpartum\... recommend to all women at annual visits to take
calcium - don't do such a good job with men unless there are clear risk
factors and don't do a great job of vit d supplementation - although i
do recommend an otc multivit.

Lipids - I think a reasonable first screen in patients without risk
factors is a non-fasting total cholesterol and HDL - from this you can
calculate the "non-hdl" fraction and get some idea of the need for a
fasting lipid profile. This seems more acceptable for our patients since
many have poor transportation and find it difficult to make it in for
fasting labs. The question I always have is when to stop screening
lipids in elderly patients (or if we should ever stop since statins may
improve mortality / morbidity in older folks)?

**John Baciocco \[john.baciocco@SEARHC.ORG\]**

**Thu 3/4/2004 9:02 AM**

At MEH in Sitka, Ak, most of us primary docs Rx Ca CO3 1250 mg QD with a
MVI (PN or Reg) QD. Both MVI's have 400 iu vit D per tab so that
basically covers the basics. Pertinent to the Dexa screening discussion,
I found it very interesting that so many IHS sites do not have hip and
spine screening.

We've had a Lunar "top of the line" machine for at least 2 years and it
is common practice to get screening studies on women in their 40-60's
and older. Interestingly, we are also not uncommonly finding sig numbers
of patients with osteoporosis (t scores \< 2-2.5+). In response to this
I believe our P and T committee just approved Fosamax, which took some
time to get approved due to it's cost and current budgetary
difficulties.

**Magera, Sandra (TCRHCC) \[sandra.magera@TCIMC.IHS.GOV\]**

**Thu 3/4/2004 9:18 AM**

What type of calcium supplement do you give? At our facility there has
been some discussion with lead content of calcium carbonate\....so with
pre-natal it is of concern.

**N. Burton Attico, MD \[nbattico@POL.NET\]**

**Thu 3/4/2004 11:08 AM**

# With the high prevalence of lactose intolerance in AI/AN adults, shouldn't calcium supplements (of some kind) be given freely (and very liberally) to most of our patients? 

# Gooris, Paul \[pgooris@ABQ.IHS.GOV\]

**Thu 3/4/2004 12:40 PM**

The kind of lipid screening we do depends on whether the patient happens
to be fasting at the time: if not fasting, we get a total cholesterol
and HDL; if fasting, we get a full panel including triglycerides and
LDL.

Our first line for calcium supplement is CaCO3, 1250mg qd or bid
(especially in women); we use calcarb D bid for our homebound elders.
For those who do not tolerate CaCO3, we have Ca citrate. I did a quick
search and found that about 1/3 of our elders over 60 are receiving
calcium. Though I'm sure there are some elders refusing and/or not
tolerating the supplements, there is still room for improvement.