Keeping your Bones Strong and Healthy – All about Osteoporosis Prevention and Treatment


Osteoporosis:  A medical disorder that causes the bones to become weak, thin and fragile.  Bones that are weaker are more likely to break (fracture).  Women are more commonly affected by this disorder because after menopause lower levels of estrogen are produced by the body.  Estrogen is a hormone that helps keep the bones strong.

It is very important to detect low bone density (weak bones) because there are treatments available which can protect and actually help build up bone and prevent bone fractures in those people who are at the greatest risk.

Why do we care?  Bone fractures, especially in the hip cause a huge change in lifestyle and lead to decreased mobility, decreased ability for patients to care for themselves, and increased risk of death due to physical deconditioning, increased risk of infection (from surgery and also from decreased mobility respiratory illness).   In fact, people who sustain a hip fracture are more likely to die than a person of the same age who does not experience this injury. About 20 percent of people who have a hip fracture die within a year of their injury. It is estimated that only one in four persons have a total recovery from a hip fracture.  Most people spend from one to two weeks in the hospital after a hip fracture. The recovery period may be lengthy, and may include admission to a rehabilitation facility. People who previously were able to live independently will generally need help from home caregivers, family, or may require the services of a long-term care facility. Hip fractures can result in a loss of independence, reduced quality of life, and depression, especially in older people.

Fractures that occur in the spine due to osteoporosis can lead to pain and cause changes in the curvature of the spine.  We’ve all seen older folks who have difficulty walking due to having abnormal curvature of the spine and these patients often have osteoporotic fractures in the vertebra of the back.

Risk factors for osteoporosis:

1)  Sex – women are more likely to get osteoporosis than men

2)  Age – risk of osteoporosis is higher with increasing age

3)  Race – there is a higher risk of osteoporosis in people of white or Asian descent

4)  Family history – you are at higher risk of osteoporosis if you have a parent or sibling with osteoporosis, especially if there is a family history of bone fracture

5)  Body frame size – men or women who have a smaller body frame size are at higher risk because they have less bone mass to draw from as they age

6)  Hormone levels – osteoporosis is more common in patients who have too much or too little of certain hormones  (estrogen, testosterone, thyroid, parathyroid or adrenal hormones for example)

7)  Low calcium in the diet – a lifelong lack of getting enough calcium increases the risk of developing bones that are thinner and more fragile.

8)  Eating disorder – Patients with anorexia are at increased risk of osteoporosis due to decreased nutritional intake of calcium

9)  Weight loss surgery – those patients who have surgery to help them lose weight are at higher risk of osteoporosis because of a reduction in the size of the stomach or a bypass of some of the intestines.  This may decrease the absorption of calcium or vitamin d.

10)  Certain medications – see below

Prevention:  Several important steps to maintaining proper bone formation and density can be done without the need of medication.  These include proper diet, exercise and not smoking.

A)  Diet:  Preventing the bones from thinning involves getting enough nutrients, especially calcium and vitamin D.

  1. Calcium:  Most experts agree that men and women who have not reached the age of menopause yet consume at least 1000 mg of calcium each day (combination of diet and supplements).  Women who have already gone through menopause should consume at least 1200mg of calcium each day (combination of diet and supplements).   Foods that have calcium include dairy milk, cottage cheese, yogurt, hard cheese, green vegetables (especially kale and broccoli).  A way to calculate the amount of calcium from food is to multiply the number of servings of calcium rich foods by 300 mg.  One serving size of dairy milk or yogurt is 8 oz.  1oz of hard cheese or 16 oz of cottage cheese is one serving size.
  2. Vitamin D:  Most experts also agree that men over age 70 and women who have gone through menopause consume at least 800 international units (IU) for vitamin D each day.
  3. Alcohol:  Drinking more than 3 drinks per day can increase the risk of fracture due to increased risk of falling and poor nutrition.

B)  Exercise:  We understand that our bones maintain their strength if we continue to use them.  Patients who become immobile are at increased risk of bone fractures because their bones tend to become thinner with decreased use and activity.  Patients who are more physically active are generally stronger and less prone to falling as well.  Exercising 30 minutes or more three times per week or more is recommended to maintain bone strength.

C)  Smoking:  Smoking cigarettes is known to speed bone loss.  One study suggested that women who smoke one pack per day throughout adulthood have a 5-10% reduction in bone density by menopause.  If you smoke, I suggest you get help with stopping to help prevent osteoporosis.

We can reduce the risk of bone fractures by reducing falls.  Several ways to reduce falls in older adults include:

1)  Avoiding (as much as possible) medications that can cause dizziness

2)  Provide adequate lighting to areas both inside and outside the home

3)  Ensure there are no loose rugs or electrical cords that could lead to tripping or falling

4)  Avoid walking in areas outside that are unfamiliar

5)  Avoid slippery surfaces such as ice or wet/polished floors

6)  Ensure good eye care by visiting an eye doctor regularly

Screening for Osteoporosis:  There are several different recommendations for when to start screening for osteoporosis.  The U.S. Preventative Service Task Force (USPSTF) recommends screening women who are age 65 or older who has no increased risk of fracture as compared to a 65 yo women of Caucasian decent.  If a woman has a previous bone fracture or an early family history of osteoporosis (especially a mother with an early bone fracture) or has thyroid disease or take medications that can increase the risk of thinning the bones, screening earlier is generally recommended.

Assessment tools:  There are several tools that have been developed by the WHO (World Health Organization)  – (see FRAX) to help assess risk for osteoporotic fractures.  These tools ask questions that relate to risk factors for osteoporosis and attempt to calculate a probability of hip fracture even without knowing exact measurements of bone density measured by special x-ray tests.

DXA Bone Mineral Density Test:  A bone density test uses special x-rays to determine how many grams of calcium and other bone minerals are packed into a bone segment.  Bones that are commonly tested include the spine, hip and forearm.  We do this test to identify patients who are at higher risk for bone fracture, as well as to monitor the progress of therapy for patients who are being treated.   Bone density tests are not the same as bone scans.  Bone scans usually require the patient to get an injection before the procedure and are used to detect bone fractures, bone cancer or bone infections.

Medications that increase the risk of bone thinning:  If you take any of these medications, ask your doctor about whether you should have your bone density tested:

1)  Glucocorticoids such as prednisone or dexamethasone

2)  Anti-Seizure medications such as Dilantin, Tegretol, Phenobarbital or Primadone

3)  Heparin – medication to treat abnormal blood clotting

4)  Acid reducing medications called proton pump inhibitors (PPIs) such as Prilosec may increase the risk of osteoporosis or fractures but more research is needed.

Treatment for osteoporosis:  The treatment really depends on the reason for the decrease in bone density.  We might change the patient’s current medications to different medicines that are safer and have less risk for decreasing bone mineral density.  Correcting a patient’s thyroid, parathyroid or testosterone imbalance may improve their bone density without the need for other medications.  We usually try to ensure that they are getting adequate dietary intake of calcium and vitamin D and may due some lab tests to look for excessive loss of calcium in the urine.  We might test the patient’s vitamin D levels along with the hormone levels mentioned above.  If there has already been a hip or vertebral compression fracture we will also usually check a bone mineral density (DXA or DEXA) scan to confirm the level of osteoporosis.

The DEXA scan gives us a numerical value that corresponds to the degree of osteopenia (low bone density) or osteoporosis (greater risk of fracture).  A normal bone density is when the T-score (measured on the bone density test) is between 0 and 1 standard deviation below the mean.  A normal T score may be reported as a T-score of +1 to -1.  If the T score is -1 to -2.4 the patient is said to have osteopenia which means that they have a risk of developing osteoporosis if not treated.  If the T score is -2.5 or less, the patient is diagnosed with osteoporosis.  The lower the T score (higher the negative number), the greater the risk of fracture.

Medical treatment of osteoporosis:

1)  Calcium – at least 1200 mg of calcium/day but no more than 2000 mg/day.

2)  Vitamin D – at least 800 international units/day – sometimes very high doses such as 50,000 IU/week may be prescribed if your levels are measured to be very low.

3)  Bisphosphonates such as Fosamax , Actonel  or Boniva are medications that slow the breakdown and removal of bone (bone resorption).  These are taken first thing in the morning on an empty stomach with an 8oz glass for still water.  There has been some concern about the use of bisphosphonates in people who require invasive dental work – it may lead to avascular necrosis or osteonecrosis.  Most experts do not think that it is necessary for most people to stop bisphosphonates before invasive dental work (tooth extraction or implant) because the risk is very small for those people who take bisphosphonates for osteoporosis treatment or prevention.  People who take a bisphosphonate as part of a treatment for cancer should consult their doctor before having invasive dental work however.

There is some concern about atypical (stress) hip fractures associated with long-term use of bisphosphonates.  Patients who have been taking them for more than 5 years may need re-evaluation to see if further continuation of the medication is recommended.

4)  Selective Estrogen Receptor Modulators (SERMs) produce estrogen-like effects on the bone.  They include Evista and tamoxifen.  In addition to osteoporosis treatment/prevention there is a decrease in the risk of breast cancer in women who are at high risk.  These medications are not recommended for women who have not started menopause.

5)  Calcitonin is a hormone produced by the thyroid gland that, together with parathyroid hormone, helps regulate calcium concentrations in the body.  This may be administered via nasal spray or injection.  Nasal administration is usually preferred due to ease of use and less chance of nausea and/or flushing.  It’s not clear if calcitonin improves bone in places in the body other than the spine.

6)  Parathyroid hormone (PTH) – (prescription preparation name Forteo) produced in the parathyroid glands(non-prescription form) stimulates bone resorption and new bone formation.  Clinical trials suggest the PTH therapy is effective in both prevention and treatment of osteoporosis in post-menopausal women and men.  It has been proven to reduce spine fracture risk more than any other treatment that we know about.  It does, however require a daily injection and is expensive so it’s usually reserved for patients with severe hip or spine osteoporosis with a T score of  less than -2.5 (higher number) and osteoporosis-related fracture.

When taking Forteo, we often check a blood uric acid and calcium level at the start of the medication, after 6 weeks, 6 months later and then after 12 months of therapy.

We generally do not use this medication in pediatric and young children whose bones are still growing or in patients with bone cancer,  Paget’s disease of the bone and extreme caution is needed in patients who have a history of recent calcium kidney stones.

7)  Prolia is a medication that helps improve bone mineral density and reduce fracture in postmenopausal women with osteoporosis.  It is an injection under the skin once every 6 months.  It’s usually well tolerated but can have side effects such as skin infections or eczema.  It should not be given to patients who have a low blood calcium level.

For more information, please check out the following resources:

National Library of Medicine

Osteoporosis and Related Bone Diseases National Resource Center

National Osteoporosis Foundation

National Women’s Health Resource Center (NWHRC)

Osteoporosis Society of Canada

The Hormone Foundation

This document is for informational purposes only, and should not be considered medical advice for any individual patient.  If you have questions please contact your medical provider.


I hope that you have found this information useful.  Wishing you the best of health,

Scott Rennie, DO



Virtual doctors visits catch on with insurers, employers

By Phil Galewitz, Kaiser Health News

Tired of feeling “like the walking dead” but worried about the cost of a doctor’s visit, Amber Young sat on her bed near tears one recent Friday night in Woodbury, Minn.

Amber Young at home with her husband Bill and sons Cameron, 6, and Brody, 8, as she prepares dinner.
By Todd A. Buchanan, for USA TODAY
Amber Young at home with her husband Bill and sons Cameron, 6, and Brody, 8, as she prepares dinner.

That’s when she logged onto an Internet site, run by NowClinic online care, a subsidiary of UnitedHealth Group (parent of health insurer UnitedHealthcare), and “met” with a doctor in Texas.

After talking with the physician via instant messaging and then by telephone, Young was diagnosed with an upper respiratory illness and prescribed an antibiotic that her husband picked up at a local pharmacy. The doctor’s “visit” cost $45.

“I was as suspicious as anyone about getting treated over the computer,” said Young, 34, who was uninsured then. “But I could not have been happier with the service.”

NowClinic, which started in 2010 and has expanded into 22 states, is part of the explosion of Web- and telephone-based medical services that experts say are transforming the delivery of primary health care, giving consumers access to inexpensive, round-the-clock care for routine problems — often without having to leave home or work.

Insurers such as United Healthcare, Aetna and Cigna, and large employers such as General Electric and Delta Air Lines are getting on board, pushing telemedicine as a way to make doctor “visits” cheaper and more easily available. Proponents also see it as an answer to a worsening doctor shortage.

But some physician and consumer groups worry about the trend.

“Getting medical advice over a computer or telephone is appropriate only when patients already know their doctors,” said Glen Stream, president of the American Academy of Family Physicians. “Even for a minor illness, I think people are going to be shortchanged,” he said.

Carmen Balber, a spokeswoman for Consumer Watchdog in Santa Monica, Calif., is concerned that lower co-payments, and other incentives, will spur consumers to see doctors or nurses online just to save money. “People will choose the more economical option, even if it is not the option they want,” she said.

Employers, however, say they’re getting mostly positive reviews.

“Our employees just love the convenience, the low cost and the efficiency,” said Lynn Zonakis, managing director of health strategy and resources at Delta Air Lines, which offers NowClinic to some employees for $10 a consultation.

The global telemedicine business is projected to almost triple to $27.3 billion in 2016, according to a recent report by BBC Research, a Wellesley, Mass., research firm.

“Virtual care is a form of communication whose time has come and can be instrumental in fixing our current state of affairs within the health care system,” said Robert L. Smith, a family doctor in Canandaigua, N.Y., and co-founder of NowDox, a telemedicine consulting firm.

Although the field developed more than 40 years ago as a way to deliver care to geographically isolated patients, its growth was slow. That’s changed in the past decade thanks to the development of high-speed communications networks and the push to lower health costs.

“It’s the wave of the future,” said Joe Kvedar, director of the Center for Connected Health, founded by Harvard Medical School.

Major obstacle

One major obstacle has remained, however: Many state medical boards make it difficult for doctors to practice telemedicine, especially interstate care, by requiring a prior doctor-patient relationship, sometimes involving a prior medical exam, said Gary Capistrant, senior director of public policy at the American Telemedicine Association, a trade group. “The situation seems to be getting worse, not better,” he said.

He cited a 2010 ruling by the Texas Medical Board that effectively blocks a physician from treating new patients via telemedicine. The only exception is if the patient has been referred by another physician who evaluated him or her in person.

“It’s about accountability,” said Dr. Humayun Chaudhry, CEO of the Federation of State Medical Boards. State boards insist on licensing doctors treating patients in their states so that if patients are injured, they have a state agency they can go to for help.

“We want to enable telemedicine to flourish, but at the end of the day we want patients protected,” Chaudhry said.

Some medical boards are loosening restrictions, he noted, citing nine, mostly rural, states, including Tennessee, Nevada and New Mexico, which in recent years passed rules to ease the licensing process.

Companies marketing telemedicine services say they are seeing strong demand. Bloomington, Minn.-based HealthPartners, a health system with four hospitals and 1.4 million health plan members, began an online service in fall 2010 that allows anyone in Minnesota or Wisconsin to consult a nurse practitioner for $40 or less.

Using an online interactive tool called Virtuwell, 23,000 patients have received a treatment plan often including a prescription, after answering questions about their condition and medical history.

Laurie Fedje, of Coon Rapids, Minn., tried Virtuwell last fall when her son, Noah, had a high fever and other flu symptoms and she did not want to go out in bad weather. She said it took her about 15 minutes to answer about 50 questions about her son’s health, such as whether he had ear pain, how long he had been sick and whether he had any allergies. Within a few minutes, she received an e-mail and a call from a nurse practitioner who diagnosed him with flu and sent a prescription.

“It was wonderful,” Fedje said.

Her employer, St. Paul-based Bethel University, covers the first three visits for free as an employee benefit.

About 80% of patients using Virtuwell have insurance, and many use the service as a covered benefit, said Kevin Palattao, a vice president at HealthPartners.

He notes that Virtuwell has turned away 45,000 prospective patients because they had problems that required in-person consultations, such as chest pain or multiple chronic conditions.

The most common problems treated online are routine sinus and bladder infections, pinkeye, upper respiratory illness and minor skin rashes, Palattao said.

OptumHealth, a UnitedHealth Group subsidiary that operates the NowClinic, said it leaves it to physicians to determine if they can diagnose a patient via computer.

“This is not intended to replace the intimacy of the doctor-patient relationship,” said Chris Stidman, senior vice president.

The company would not disclose how many people have used the service or how many physicians it employs.

Testing at drugstores

Camp Hill, Pa.-based Rite Aid recently began testing NowClinic in several of its drugstores in Michigan and Pennsylvania. It’s a cheaper alternative to hiring doctors or nurse practitioners to work in store clinics.

At the stores, patients can pay $45 for a 10-minute teleconsultation with a doctor, or less if their employer has negotiated a reduced rate.

In a tiny office next to the pharmacy counter in one Harrisburg, Pa., Rite Aid, patients use a Web camera and microphone to talk to a doctor on a desktop computer, where they type in their symptoms, a brief medical history and their credit card information. A thermometer, blood pressure machine and scale are available nearby.

The physician sends an electronic prescription to the store that can be picked up minutes later.

On a recent afternoon when a reporter tested the service, there was a choice of only one doctor — Dr. Pardeep Shori, an internist in Irving, Texas, who is board-certified in family medicine.

Shori said he typically treats about a dozen NowClinic patients a day. While he is unable to look into a patient’s ears or throat, he noted, “The key thing you learn in medical school is that a lot of information comes from just listening.”

Young, the woman who talked to a NowClinic physician from her home in Woodbury, Minn., said she would use the service again even though she now has health insurance. She was impressed when the online doctor called her three days later to see how she was feeling.

“I’ve never had my own primary care doctor do that,” she said.

Contributing: Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a non-profit, non-partisan health policy research and communications organization not affiliated with Kaiser Permanente.

Tips for Managing your Elderly Parent’s Medication

shutterstock_138204188Many of my clients caring for elderly parents struggle with the fact that their parent has a tough time remembering what medications they are taking and what the purpose is for each medication that they are prescribed. Many seniors are taking multiple medications, with doses sometimes several times throughout the day. The truth is that as we age our memory frequently declines, which can make it challenging to remember all of the details of our daily routines. However, it is critical that patients are taking the proper medications, because their health may be adversely affected.

I believe that helping our patients understand why they take certain medications keeps them involved in their own care and also helps them remember to take them, and typically provide the following recommendations to help patients remember to take their medications:

1. Give the patient an updated list of his/her medications each time they are seen by a medical provider and explain how to take them. In addition, briefly describe what the medication is used for. A short description such as “Blood Pressure” or “Cholesterol” is sufficient so that the patient is able to recall why they are taking it. Make sure this list is in large font and easy to read. Laminating the list makes it more durable. Patients should post this list on the refrigerator or in a location near their medications so that they have it for easy reference. Each time a change is made to one or more of the patient’s medications, a new list is made and given to the patient. If the change is done over the phone – the list should be mailed or emailed to the patient. I routinely give my patients a copy of their updated medication list on a USB device which is carried with them daily. If they go to another medical provider or hospital, they can easily access their updated medication list on their USB drive – it is also available to be stored “in the cloud” – i.e. on a secure website, if they prefer not to carry it with them.

2. Put medicine in a location of the home that your parent visits often. – Next to the coffee maker or water dispenser, or next to the sink in the bathroom are all good places and the bottles serve as visual reminders.

3. Review your parent’s medication bottles at each visit. If you visit the patient at their home or office, look at each bottle and make sure the medication is on the patient’s list and also in the patient’s chart. If this is done at each visit, errors can be avoided, especially if an old or outdated prescription is being used by the patient. At this time, new prescriptions can be issued before the patient runs out of the medication.

4. Pill Boxes and Dispensers are a simple and relatively affordable tool that has proven to work well as it allows you to plan dosage and also track consumption. Most pill boxes can be purchased at a pharmacy and are typically under $5. Some of the higher-end pill boxes also feature built in reminders.

5. Prescription bottle alarms or reminder devices are increasingly available, which can alert them that they are due to take their medicine. Some of these bottle caps glow, and/or give a sound alert reminder. They also have bottle caps which can send a text message to the patient’s phone or an email that can be a great reminder for the tech-savvy patient. One company that produces these prescription bottle caps is: Vitality – and they make GlowCaps. A simple alarm functionality on a cell phone or a calendar meeting reminder also works well.

Vitality GlowCaps from Vitality on Vimeo.

6. There are also a set of new Mobile Applications designed for the iPhone, iPad, and other mobile devices that  help you track and manage medications. A few of the noteworthy ones to check out are: iPills, PillboxPillboxer, and The Pill Phone.

Remembering to take medications appropriately can be challenging, but caregivers can help patients do this with simple tools and a little extra time.

This document is for informational purposes only, and should not be considered medical advice for any individual patient.  If you have questions please contact your medical provider.


I hope that you have found this information useful.  Wishing you the best of health,

Scott Rennie, DO


Addressing Wishes for End of Life Care

shutterstock_57012596Last week, I was consulted by a patient who wished to discuss their wishes for end of life care, but did not know how to bring up the subject with their families and care takers. Because this can be a challenging and emotionally filled conversation, often family members are not aware of the wishes of their older loved one.

It is common medical practice to ask elderly or terminally ill patients about their wishes if they were to be taken to the hospital at a time of respiratory distress or cardiac arrest. For a younger patient there is no question that everything would be done, including insertion of an artificial airway to help them breath if needed, to give CPR including chest compressions as well as starting an IV to administer medications. An elderly patient near the end of their life may not wish to have all of these measures taken, and may even resent this treatment if it does not coincide with their wishes. Many patients are not aware that hospitals are required by law to undertake resusitation measures unless the patient has a specific order on file.

Talking with a loved one about difficult issues is not easy, but being proactive and listening to their wishes can save frustrations later and give the elderly loved one the peace of mind that their wishes have been heard. It is also easier for family members to accept these decisions and be the proper advocate for their family in times of crisis after this has been discussed in advance.

Many hospitals can provide their patients and their families with a worksheet that can help plan end of life care. If filled out in advance and posted in a convenient location such as the refrigerator, it can be easily accessed in an emergency at a time when ambulance staff arrives to take the patient to the hospital. State-specific advance directives can be downloaded on the National Hospice and Palliative Care Organization (NHPCO) Web site.

This document is for informational purposes only, and should not be considered medical advice for any individual patient.  If you have questions please contact your medical provider.


I hope that you have found this information useful.  Wishing you the best of health,

Scott Rennie, DO


How Physicians can Enable Longer Independent Living for Seniors

One of the primary goals of my practice is to help my elderly patients continue to live longer, healthier lives in their familiar surroundings and established communities.  Also, one of the most common questions I hear from the families that I care for is “How do I allow my loved one to keep their independence?”

Medical conditions that  can make living at home difficult include problems remembering to take medications, issues with mobility such as recent hip fractures, as well as complicated medical problems such as congestive heart failure, out of control diabetes and severe COPD.  Oftentimes the elderly patient’s family lives far away, even in another state so helping your elderly parent be sure that they are getting the proper care that they need also often challenging.

I believe that having a primary care provider who coordinates all of the medical care that your elderly family member needs is most important.  I find it extremely rewarding to help my patients navigate the often confusing healthcare system.

Several tools help me assist my patients at home:

1)  Prescription Bottle Caps which have a timer to help patients remember to take their medicine.

2)  Medical record on key ring that is updated at each visit.

3)  Print Medications and summary of visit for each patient at each visit as patients may forget what you tell them during the encounter.

4)  Make patients caregivers/family aware of any changes in patient’s care

5)  In-home care providers can be very helpful when needed

6)  Involve the patient in the decision making as much as possible

7)  Be careful about any medications that may cause drowsiness or falls

8.   Work with specialists and coordinate patient care with all upcoming appointments written down on their calendar

9)  A home visit will allow you to assess the patients environment and get them home equipment which will help keep them independent.  Some examples are:     Shower Chair, Raised toilet seats, bathtub/shower grab bars, Bed rails, Hospital type bed that can be adjusted to prop the patient up or an Over Bed Table.

One of the most fulfilling parts of my career is helping elderly patients retain their independence, and stay at home for as long as they can.  I enjoy working with family members to help make this possible.

This document is for informational purposes only, and should not be considered medical advice for any individual patient.  If you have questions please contact your medical provider.


I hope that you have found this information useful.  Wishing you the best of health,

Scott Rennie, DO


Nine Tips for Accessible Travel by Your Elderly Parents

by Candy B. Harrington

Are your elderly parents reluctant to travel because they just don’t get around like they used to? Well they’re not alone. According to the 2002 US Census, nearly 23 million people had difficulty standing for an hour, while 21 million people had difficulty walking up a flight of 10 stairs.

But that doesn’t mean globetrotting is out of the question for senior citizens; in fact, with a little advance planning your parents can still enjoy travel. Here are a few tips to share with them, before they make their next trip.

• Even if you can walk, reserve an airport wheelchair if you tire easily. Some airports are huge and you could easily put on several miles while in transit, and arrive at your destination exhausted.

• You are not required to remove your shoes at the airport security checkpoint if you are physically unable to do so. Just tell the TSA agent that you can’t do it, and they will hand wand you and swab your shoes for explosive residue.

• Tell the gate agent that you would like to pre-board the aircraft. This means that you will board before the rest of the passengers. Pre-boarding allows you to take things at your own pace, and gives you a little extra time to get settled in your seat.

• If you need wheelchair-accessible transportation from the airport to your hotel, choose a hotel that has a free airport shuttle. Under the Americans with Disabilities Act, if the hotel provides free transfers, they must also provide free accessible transfers, even if they have to contract out the service.

• Cruises are a great accessible travel choice, but new cruise ships are huge and it can be very tiring to walk from one end to the other. If fatigue is a factor, rent an electric scooter and have it delivered directly to your stateroom. Check with the cruise line for their approved vendors.

• If you drive to the cruise departure port, remember that parking is free at all Florida cruise ship piers for cruise passengers who have permanent accessibility modifications installed on their vehicles.

• If you tire easily, be sure and request a hotel room near the elevator. For safety’s sake, it’s also advisable to ask for a ground floor room whenever possible.

• Remember, in Europe the first floor is not at street level, so if you want a room at street level, ask for a room on the ground floor. Many small European hotels only have stairway access to the first floor, and if they have an elevator it’s usually very small.

• Don’t forget to pack your accessible parking placard with you whenever you travel. It’s good everywhere in the US (except for New York City), Canada and Europe.

Finally, encourage your parents to do extensive pre-trip research, and expand their horizons. There really are a lot of accessible travel offerings out there and the internet is a great place to find updated access information.

Candy Harrington is the editor of Emerging Horizons and the author of Barrier-Free Travel; A Nuts and Bolt Guide for Wheelers and Slow Walkers. She blogs regularly about accessible travel issues

See Related Accessible Travel Articles
For tips and information about finding and booking an accessible hotel room, read Finding an Accessible Room Beyond ADA Compliance.

If you’d prefer to rent a house instead, read In Search of an Accessible Vacation Home.