Medical Alert Systems Bring Peace of Mind

Living safe and independent is an important factor for our ever growing senior population.  However statistically speaking, one out of three people over age 65 will fall this year causing life threatening injuries.  Great suffering occurs when injuries prevent a person from getting to a phone to call for help; this can last for several days and even cause death.  Despite all the fall prevention interventions we can take, some falls are unfortunately inevitable. A medical alert system acts as a safety net to get immediate help when falls or other emergencies occur so that early intervention minimizes complications and facilitates recovery.  These systems are available locally or nationwide to give seniors and their families peace of mind knowing that with just a push of a button, they will receive immediate help.  In doing so, Medical alert systems can support seniors to remain at home for longer periods of time with increased safety.

Benefits:

• Decreased anxiety of being alone
• Decreased dependence on others
• Enhanced well-being and quality of life
• Easy to operate with just pushing a button
• Psychologically reassuring by maintaining control

Operating the Medical Alert System:
Typically the system includes a help button worn around the neck or wrist allowing the user to request help when there is a medical emergency.  The lightweight, waterproof pendent allows freedom of movement within the home without the need to reach a phone.  The base unit simply plugs into a telephone jack and electrical outlet.  No special wiring is needed. 

A 24hour staffed monitoring service receives calls from the base unit when its activated by the button on the pendent.  Once activated, two way voice communication is established as the live monitoring staff will attempt to speak to the user over the base unit speaker; if the user does not answer, they will contact designated family/friends or alert emergency medical personnel.  If the user responds, the monitoring staff can determine the type of help needed and appropriate action. 

What to look for when choosing a Medical Alert System:

• UL listed 5 diamond certified 24 hr monitoring service
• Waterproof pendants that are not easily activated in error
• Base unit battery back-up
• Low installation costs with no long term contract
• Low monthly fees

Medical Alert systems are not just for frail elderly, but for anyone living alone who wants to have peace of mind and increased safety from unexpected medical emergencies or falls.  Families can also be confident their loved ones are in good hands while still allowing them their freedom and independence.  No more frequent wellness check calls to loved ones, everyone can have peace of mind when medical alert systems are in place.

Dementia: When to worry

Have you ever gone to the pantry to get something then can't remember why you went there?  Can't remember where you put your phone or keys?  Have trouble remembering someone's name?  Are you worried about your memory?  Then join the crowd and perhaps worry less.  The type of memory problems described above are entirely consistent with normal brain function in someone over 55 (or younger) and are in no way indicative of dementia.  Many people consult doctors about their poor memory and are concerned they may be in the early stages of dementia.  If YOU ALONE are concerned about your memory, there is most likely less concern about dementia than if close family members are concerned.

True dementia does involve short term memory loss with retention of long term memories, but it's more than just that.  In general it can be said that dementia involves memory impairment PLUS some inability to function independently in one's daily routine, social activities, or relationships.  These independent functions might include:

• Impairment of complex tasks such as balancing a checkbook
• Impairment of reasoning such as difficulty dealing with new and unfamiliar situations
• Impaired spatial functions (Dementia testing often will involve asking the subject to draw a clock face with a given time on it, or copy a pattern on paper)
• Impaired language such as using the wrong words to describe things

Of those who have  dementia, about 70% have Alzheimer's disease, 10-20% have Vascular (stroke related) dementia and 10-15% have Lewy body dementia (an accelerated form of Alzheimer's).  Other diseases such as Parkinson's or brain tumors can also result in related dementias.

Dementia-like symptoms that can appear to be similar in behavior (but are not) can include age related mild cognitive impairment (MCI), delirium or depression.  Those with simple age related cognitive impairment may have some memory difficulty and they may think a little more slowly, but the ability to function with day to day activities remains intact.  Patients with delirium have a sudden onset of new mentation symptoms and this is usually reversible. On the contrary, the onset of dementia is gradual and will worsen with time.   Depression can also mimic dementia-like symptoms.  Depressed individuals may perform poorly on standardized dementia tests due to lack of motivation and/or poor effort.  Medications can also create brain function changes that simulate dementia; alcohol, antihistamines, psychiatric medications, sedatives and others can impair memory and cognitive function.

Getting evaluated for dementia first involves talking to your primary care physician about your symptoms.  Then a brief brain function screening test can be administered.  If the screening test score results in a cause for concern, then blood testing for reversible causes like vitamin B12 deficiency or thyroid deficiency can be performed.  The value of brain imaging in diagnosing early dementia is controversial since the most common causes of Alzheimer's disease and Lewy Body disease will show no abnormality on imaging tests.  Neuropsychological testing is frequently valuable in anyone who is having a new brain function problem.  This testing involves several standardized cognitive skills tests administered by a neuropsychologist. 

At best, medication treatment for dementia can provide a modest improvement in symptoms and can slow down the rate at which dementia progresses.  Dementia is frequently accompanied by depression so antidepressant medication can be beneficial as well as other stimulating activities such as Physical, Occupational and Recreational therapies aimed at cognitive rehabilitation, exercise and mental stimulation. 

The benefits of social support for all individuals, families and caregivers affected by dementia related disease cannot be emphasized enough.  The prognosis from early symptoms to morbidity may last as long as ten years or more.  Joining support groups, dividing up caregiving duties and finding proper medical care or placement is imperative for the well-being of the affected individual as well as their loved ones.

Staying at home with support, placement in Skilled Nursing, Dementia Care Units or Board and Care facilities are all choices families may make for their loved ones.  Please visit the Villa Care Homes website to see how small board and care facilities can manage residents with dementia with a regimented daily program and high level of care/supervision. www.VillaCareHomes.com

Stroke Recovery: Alternative Treatments: Acupuncture

Stroke is the second most common cause of death (after coronary heart disease) and the leading cause of adult disability in the US today.  Approximately 700,000 strokes occur each year in the US leaving 500,000 survivors with residual disability.  Forty percent of those survivors have moderate impairment and functional limitations related to motor function and basic mobility, while 15-30% are severely disabled.  Physical therapists and other professionals focus recovery on relearning normal patterns of movement or facilitating a rebalance of muscle tone.  In an attempt to further improve outcomes of stroke rehabilitation alternative treatments such as acupuncture or electroacupuncture (EA) are being evaluated for their efficacy in improving functional recovery after stroke.  Acupuncture/EA has been used in eastern medicine for thousands of years to enhance stroke recovery.  It has only been in the last decade that studies of brain function with computed tomography (CT) scan and magnetic resonance imaging (MRI) has substantially expanded our understanding of neuronal recovery and their modulation by various rehabilitation interventions.

The mechanism by which acupuncture increases cerebral blood flow is not fully understood but immunohistochemical analysis in animals suggests an enhanced expression of vascular endothelial growth factor.  Clearly, post stroke outcome is dependent on stroke severity in the acute phase and that patients with intact cortical function have an advantage to better participate with motor recovery.  The location of the lesion site plays a significant role in the responsiveness to any therapeutic intervention as does the type of stroke: ischemic vs. hemorrhagic.    During the functional reorganization of  neural pathways following a stroke, therapeutic techniques rely on the neuroplasticity of the brain to achieve improved motor abilities and functional outcomes

Current evidence for clinical efficacy of acupuncture/EA for stroke recovery is promising but still controversial; it's efficacy as an adjunct to standard post-stroke rehabilitation programs can be demonstrated with accurate treatment intervention using electrical stimulation over acupuncture points, proper selection of patient and functional outcomes measures.  Additionally, acupuncture/EA may be helpful in treating pain, sleep disturbance, anxiety, depression, or other conditions which are common in stroke and often a barrier to recovery.

92 Million Older Americans Expected by 2060

Over one in eight Americans is age 65 or older, according to the latest statistics from the U.S. Census Bureau.  The number of "older Americans" is approximately 41.4 million - an 18 percent increase from 2000.  The 65 and older population is also expected to more than double to 92 million in 2060, according to a new report from the U.S. Department of Health and Human Services entitled, "A Profile of Older Americans 2012."  The report also states that the population of those 85 years and older is projected to nearly triple from 5.7 million in 2011 to 14.1 million in 2040.

The report also provides the latest national demographic information on issues ranging from health care and health insurance coverage to disability and activity limitations for older Americans.  More information is at:  http://www.aoa.gov/AoARoot/Aging Statistics/Profile/2012/docs/2012profile.pdf

The Villa Care Homes are poised to care for those with disabilities associated with advanced aging.  Our program is successful because of the consistency in care, anticipation of needs and knowledgeable, loving caregivers.  We strive to coordinate the physical, emotional, psychological and spiritual needs of each of our residents.  We collaborate as a team together with the physician, resident and family members.  Please call to arrange a tour at any time. http://www.VillaCareHomes.com

Ten Early Warning Signs of Alzheimer's:

1. Recent memory loss that affects job skills
It's normal to occasionally forget phone numbers and remember them later.  Those with dementia, such as Alzheimer's disease may forget things more often.

2. Difficulty performing familiar tasks
Those affected with Alzheimer's disease could prepare a meal and not only forget to serve it, but also forget they made it.

3. Problems with language
They may forget simple words or substitute inappropriate words, making their sentence incomprehensible.

4. Disorientation of time and place.
Those with Alzheimer's disease can become lost on their own street, not knowing where they are, how they got there or how to get back home.

5. Poor or decreased judgement
The disease can cause people to forget entirely the clild under their care; they may also dress inappropriately, wearing several shirts or blouses.

6. Problems with abstract thinking
Forgetting completely what number or words are and what needs to be done with them.

7. Misplacing things
Putting things in inappropriate places: an iron in the freezer, or a wristwatch in the sugar bowl.

8. changes in mood or behavior
Rapid mood swings from calm to tears to anger for no apparent reason.

9. Changes in personality
People's personalities ordinarily change somewhat with age, but a person with Alzheimer's disease can change drastically, becoming extremely confused, suspicious, or fearful.

10.  Loss of initiative
Becoming very passive and requires cues and/or prompting to become involved.

At Villa Care Homes, we can monitor behavior and provide a safe environment for your loved ones.  Stimulating a person mentally and physically to the best of their abilities to maintain independence is critical for quality of life.  Please visit the Villa Website at: VillaCareHomes.com

Spinal Fluid Test predicts Alzheimer's Disease

Researchers report that a spinal fluid test can be 100 percent accurate in identifying patients with significant memory loss who are on their way to developing Alzheimer’s disease.  Although there has been increasing

evidence of the value of this and other tests in finding signs of Alzheimer’s, the study, which will appear Tuesday in the Archives of Neurology, shows how accurate they can be. The new result is one of a number of remarkable recent findings about Alzheimer’s. 

 

After decades when nothing much seemed to be happening, when this progressive brain disease seemed untreatable and when its diagnosis could be confirmed only at autopsy, the field has suddenly woken up.
Alzheimer’s, medical experts now agree, starts a decade or more before people have symptoms. And by the time there are symptoms, it may be too late to save the brain. So the hope is to find good ways to identify people who are getting the disease, and use those people as subjects in studies to see how long it takes for symptoms to occur and in studies of drugs that may slow or stop the disease.

Researchers are finding simple and accurate ways to detect Alzheimer’s long before there are definite symptoms. In addition to spinal fluid tests they also have new PET scans of the brain that show the telltale amyloid plaques that are a unique feature of the disease. And they are testing hundreds of new drugs that, they hope, might change the course of the relentless brain cell death that robs people of their memories and abilities to think and reason. “This is what everyone is looking for, the bull’s-eye of perfect predictive accuracy,” Dr. Steven DeKosky, dean of the University of Virginia medical school, who is not connected to the new research, said about the spinal tap study.

Dr. John Morris, a professor of neurology at Washington University, said the new study “establishes that there is a signature of Alzheimer’s and that it means something. It is very powerful.” A lot of work lies ahead, researchers say — making sure the tests are reliable if they are used in doctors’ offices, making sure the research findings hold up in real-life situations, getting doctors and patients comfortable with the notion of spinal taps, the method used to get spinal fluid. But they see a bright future.

Although the latest PET scans for Alzheimer’s are not commercially available, the spinal fluid tests are.
So the new results also give rise to a difficult question: Should doctors offer, or patients accept, commercially available spinal tap tests to find a disease that is yet untreatable? In the research studies, patients are often not told they may have the disease, but in practice in the real world, many may be told.
Some medical experts say it should be up to doctors and their patients. Others say doctors should refrain from using the spinal fluid test in their practices. They note that it is not reliable enough — results can vary by lab — and has been studied only in research settings where patients are carefully selected to have no other conditions, like strokes or depression, that could affect their memories. “This is literally on the cutting edge of where the field is,” Dr. DeKosky said. “The field is moving fast. You can get a test that is approved by the F.D.A., and cutting edge doctors will use it.”

But, Dr. John Trojanowski, a University of Pennsylvania researcher and senior author of the paper, said that given that people can get the test now, “How early do we want to label people?” Some, like Dr. John Growdon, a neurology professor at Massachusetts General Hospital who wrote an editorial accompanying the paper, said that decision was up to doctors and their patients.  Sometimes patients with severe memory loss do not have the disease. Doctors might want to use the test in cases where they want to be sure of the diagnosis. And they might want to offer the test to people with milder symptoms who want to know whether they are developing the devastating brain disease.

One drawback is that spinal fluid is obtained with a spinal tap, and that procedure, with its reputation for pain and headaches, makes most doctors and many patients nervous. The procedure involves putting a needle in the spinal space and withdrawing a small amount of fluid.  Dr. Growdon and others say spinal taps are safe and not particularly painful for most people. But, he said, there needs to be an education campaign to make people feel more comfortable about having them. He suggested that, because most family doctors and internists are not experienced with the test, there could be special spinal tap centers where they could send patients.

The new study included more than 300 patients in their 70s, 114 with normal memories, 200 with memory problems and 102 with Alzheimer’s disease. Their spinal fluid was analyzed for amyloid beta, a protein fragment that forms plaques in the brain, and for tau, a protein that accumulates in dead and dying nerve cells in the brain. To avoid bias, the researchers analyzing the data did not know anything about the clinical status of the subjects. Also, the subjects were not told what the tests showed.  Nearly every person with Alzheimer’s had the characteristic spinal fluid protein levels. Nearly three quarters of people with mild cognitive impairment, a memory impediment that can precede Alzheimer’s, had Alzheimer’s-like spinal fluid proteins. And every one of those patients with the proteins developed Alzheimer’s within five years. And about a third of people with normal memories had spinal fluid indicating Alzheimer’s. Researchers suspect that those people will develop memory problems.

The prevailing hypothesis about Alzheimer’s says that amyloid and tau accumulation are necessary for the disease and that stopping the proteins could stop the disease. But it is not yet known what happens when these proteins accumulate in the brains of people with normal memories. They might be a risk factor like high cholesterol levels. Many people with high cholesterol levels never have heart attacks. Or it might mean that Alzheimer’s has already started and if the person lives long enough he or she will with absolute certainty get symptoms like memory loss.

Many, like Dr. DeKosky, believe that when PET scans for amyloid become available, they will be used instead of spinal taps, in part because doctors and patients are more comfortable with brain scans.
And when — researchers optimistically are saying “when” these days — drugs are shown to slow or prevent the disease, the thought is that people will start having brain scans or spinal taps for Alzheimer’s as routinely as they might have colonoscopies or mammograms today.  For now, Dr. DeKosky said, the days when Alzheimer’s could be confirmed only at autopsy are almost over. And the time when Alzheimer’s could be detected only after most of the brain damage was done seem to be ending, too.
“The new biomarkers in CSF have made the difference,” Dr. DeKosky said, referring to cerebral spinal fluid. “This confirms their accuracy in a very big way.”

Excerpt from NY Times article

Let Villa Care Homes assist you with your family member who may have Alzheimer's.  We have trained staff capable to handle complex medical conditions, including dementia and Alzheimer's.  We are located in Antioch, Martinez and Alamo, California.       www.VillaCareHomes.com

STROKE WARNING SIGNS

A stroke occurs when the flow of blood to a part of the brain is cut off. This can be due to something (usually a blood clot) blocking the flow of blood to the brain (ischemic stroke). It can also be caused by a burst blood vessel bleeding into the brain (hemorrhagic stroke). About 80% of strokes are ischemic and 20% are hemorrhagic. Without a blood supply, the brain cells in the affected area start to die.
The effects of a stroke depend on which part of the brain is affected and how severe the damage is. A stroke may affect your ability to move, your ability to speak and understand speech, your memory and problem-solving abilities, your emotions, and your senses of touch, hearing, sight, smell, and taste. In some cases, a stroke can be fatal.
It's important to recognize the warning signs of stroke, because quick treatment can reduce the risk of brain injury and death. A stroke usually comes on suddenly, over a few minutes or hours. The warning signs of stroke include:

• sudden weakness, numbness, or tingling of the face, arm, or leg (often on only one side of the body)
• sudden confusion, trouble speaking, or trouble understanding speech
• sudden vision loss (often in one eye only) or double vision
• sudden trouble walking, dizziness, loss of balance or coordination, or falls
• sudden severe headache (often described as "the worst headache of my life") with no known cause

If you notice these symptoms, call 911 (or your emergency medical number if you do not have 911 service) immediately. Stroke is a medical emergency.

Elderly are Easy Targets of Financial Scams

Senior Safety is an important issue, including financial safety.  More than ever, the elderly have become targets of financial fraud, and surprisingly the scammers are of retirement age themselves! “One out of five Americans over the age of 65 has been the victim of a financial scam, according to the Washington-based Investor Protection Trust, a nonprofit that promotes shareholder education. That means more than 7.3 million seniors have been taken advantage of financially through inappropriate investments, high fees, or fraud, which insurer MetLife says comes at a cost of more than $2.6 billion a year. “Older people are being targeted because, as 1930s robber Willie Sutton said when asked why he robs banks, ‘that’s where the money is,’” says Kathleen Quinn, executive director of the National Adult Protective Services Assn. in Springfield, Ill.”
“Many of today’s scammers have a particularly good understanding of their victims–because the fraudsters themselves are of retirement age, if not exactly retired. More elderly con artists than ever seem to be preying on retirees, perhaps because senior citizens put more confidence in someone their age, says Denise Voigt Crawford, president of the North American Securities Administrators Assn. “It’s astounding that you can’t even trust older people anymore,” Crawford says.” (Bloomberg Business Week-Scams:  A Sucker Retires Every Minute, July 15 2010)

The primary way that seniors are taken advantage of is by purchasing financial products that are inappropriate, unsuitable and at times down right fraudulent.   Seniors, including veterans, who are isolated are likely to become targets, and their retirement assets are at great risk.  If you are the caretaker of an aging senior, please take the time to make sure that their retirement savings are secure, and that any changes are truly in their best interest.  If you are have an aging parent living alone, or are a long distance caregiver, reach out for professional care giving help to insure the overall safety of your aging family member.  For help with an aging loved one in the California San Francisco Bay Area, visit VillaCareHomes.com

Osteoporosis Part III: Precautions and Treatment

PREVENTION: Elderly people with osteoporosis should take every precaution to avoid accidental falls.  This disease is responsible for many of the hip, wrist, and spinal fractures that occur in elderly women.  If glasses are necessary for general vision, they should always be worn.  A cane or walker should be used if you do not feel steady on your feet, or if one has been recommended.  Shoes and slippers should have skid-resistant soles.  Additionally, handrails in bathrooms and sturdy banister rails along all stairs inside and outside should be installed for safety.

TREATMENT: Treatment of osteoporosis is geared toward halting, or at least slowing down the progress of the disease.  This may involve increased calcium intake, estrogen replacement therapy (provided there are no contraindications), physical therapy and weight-bearing exercise. 

At least six glasses of milk or equivalent servings of other high-calcium foods such as cheese or yogurt and a small supplement of vitamin D may be prescribed to be taken daily.  Oral calcium supplements may also be prescribed.  For postmenopausal women with osteoporosis, estrogen-replacement therapy has been shown to be the most effective way of slowing down bone loss.  Today, many doctors prescribe a combination of estrogen with a synthetic progesterone to simulate the hormonal environment existing before menopause.  As with any medication, there may be certain side effects from such a regimen; report any you notice to your physician.

Exercise is very important, especially the kind of exercise that allows your body weight to bear down on your skeletal frame.  Those who are bedridden, confined to a wheelchair, or with limited ability to move, physical therapy should be received on a regular basis.  While swimming and bicycling are great cardio-workouts, simple walking or light jogging is better for those with osteoporosis.  Walking is one of the best exercises for those who do not want to take part in active sports or who cannot do so because of their general health.

SUMMARY: Bone loss to some degree is inevitable as we grow older; however, with osteoporosis, the process is much more pronounced.  Bones are weaker and thinner (especially those of the sping), and fractures can occur more easily.  New treatments are being developed that may increase bone formation and thereby reverse osteoporosis.  Meanwhile, however, the object of treatment is to stop or slow down the process of the disease.  Current treatment involves an increased intake of calcium, estrogen replacement therapy, physical therapy and weight bearing exercise.  Preventative therapy for premenopausal women consists of a diet high in calcium and vitamin D and regular exercise.

Osteoporosis Part II

Osteoporosis is sometimes called the "silent disease" because it generally remains undiscovered until a fracture occurs.  One of the earliest and most common signs of osteoporosis is a gradual decrease in height and rounding of the shoulders following menopause as a result of small, spontaneous fractures occurring in the spinal column.  The wrists and hips are also very susceptible to easy fracture.

The change in curvature of the spine may produce a nagging backache.  Severe or sharp back pains are rare, but they should be brought to your doctor's attention immediately, as they may be the result of spontaneous collapse or fracture of one or more of the bones that make up the spinal column.  As the spinal column becomes more compressed, people with osteoporosis become progressively shorter.  10-15 years after menopause a woman may lose 1-3 inches in height; 25-30 years after menopause a woman may lose as much as 6 inches or more if they have severe kyphosis (rounding of the back)

PREVENTION: By paying attention to the amount of calcium you are receiving in your diet, the amount of exercise you do daily, and the amount you smoke or drink, you can help protect yourself from developing osteoporosis. 
     Calcium: To reduce the risk of developing post menopausal osteoporosis, docotor now advise any woman who is 45 or older to increase her clcium intake.  One way of accomplishing this is by increasing your consumption of foods that are naturally high in calcium.  Some of these foods include kale, spinach, turnip greens, raw oysters, sardines and canned salmon.  The greatest source of calcium however is dairy products such as milk and cheese.  If you find it difficult to get enough calcium from your meals alone, your doctor may prescribe calcium supplements and sometimes vitamin D, which helps the body absorb calcium better.
   Exercise: Any kind of physical activity can help slow down the rate of bone loss associated with osteoporosis.  Therefore, it is highly desirable to exercise regularly.  While it may not be possible for you to engage in strenuous physical activities, you can always take daily walks.  Regular exercise, particularly if it stresses weight bearing can be very effective, since it keeps both bone and muscle healthy.
   Cigarettes and alcohol: Although there is no direct link between these two substances and osteoporosis, an unusually high percentage of women who have osteoporosis are cigarette smokers.  Also, some sources believe excessive alcohol intake may increase the risk of developing osteoporosis.

OSTEOPOROSIS

Osteoporosis is a disease marked by thinning of the bones, making them brittle and more vulnerable to spontaneous fractures.  The disease affects some twenty million people in the United States.  After the age of forty-five, it is nine times more common in women than men.  Older persons are more susceptible than middle-aged people, and whites/Orientals more than blacks.  Fair-haired, fair-skinned people are particularly vulnerable.  Osteoporosis tends to run in families; a person who has a close relative with the disease is likely to develop it later in life.  Osteoporosis is irreversible after a certain stage.  However, with treatment, its progression can be halted or at least slowed down.  You may already have osteoporosis or be at risk of getting it; in either case, there is a lot you can learn and do about the disease.

Bone Changes: Bone is living tissue that is constantly being broken down and rebuilt in very complex ways, even in adults.  Bones require calcium, vitamin D, and phosphorus; the availability and use of these substances by the skeleton is regulated by hormones and physical stress on the ends of the bones is necessasary to help them form and grow.  The contribution made by calcium in association with vitamin D seems to be the most important factor in this process.  The absorption of calcium into bone in women is ultimately dependent upon the hormone estrogen.  Some degree of bone loss is an inevitable consequence of aging.  In people with osteoporosis however, the rate of bone loss considerably exceeds that of bone formation.

Causes: Exactly what causes the increased bone loss due to osteoporosis is unknown.  However, there appears to be many contributing factors, including hormonal imbalances, which affect the absorption of calcium and phosphorus, and the decrease in estrogen production in menopausal women.  Almost one in four postmenopausal women has osteoporosis: the disease also develops early in women who have had a premature menopause due to surgical removal of the ovaries.  Women with small bones appear to be particularly susceptible to this disease.  Other factors relating to an individual's life-style may have an effect on the development of osteoporosis.  Prolonged bed rest, immobilization and inactivity promote bone loss in young people and to an even greater extent, in the elderly.  Inadequate nutrition, including a diet lacking in calcium, vitamin D, and protein, is also thought to contribute to the onset of the disease.