Transcript Fragility Fractures

Fragility Fractures
Kenneth J. Koval, MD
Laura Tosi, MD
AOA Committee for the
Own the Bone Pilot Project
Created February 2007; Revised March 2011
Prevalence
• More than 34 million Americans
suffer from osteoporosis or low bone
mass
• 80% are women
• 1 in 2 women over 50 years old
• 1 in 4 men over 50 years old
Annual incidence of common diseases
Osteoporosis-fracture
Occurrences vs Other Diseases
2,000,000
1,500,000
1,500,000
250,000
hip
1,000,000
250,000
other sites
†
513,000
500,000
750,000
vertebral
228,000
184,300
0
Osteoporotic
fractures
Heart
Attack
Stroke
Breast
Cancer
Source: National Osteoporosis Foundation
1.5 Million Fractures Annually
Vertebral Fractures:
700,000+
Wrist Fractures:
200,000+
Hip Fractures:
300,000+
Source: National Osteoporosis Foundation, 2000
Other Fractures:
300,000+
Burden of Disease
$14 billion annually
• Approximately $38 million daily
• Congestive heart failure costs $8 billion
annually
• Asthma costs $9.8 billion annually
Burden of Disease
• 1 out of 4 osteoporotic hip fractures
result in long-term nursing home care
• One half of these are unable to walk
without assistance
• 24% greater risk of dying within one
year
- Fragility Fractures & Osteoporosis What’s the link?
Fragility fractures
Fractures of the distal radius, proximal humerus, vertebrae and proximal
femur that result from minimal trauma, such as a fall from a standing
height.
•
Up to 95% of hospitalized fracture inpatients over 75 years of age, and 80%90% of fractures in patients between 60 and 74 years of age can be
attributed to osteoporosis.
Only 23% of hip fracture patients received the care
recommended on the basis of good practice standards.!
Source: RAND Report
Alarming Fracture Statistics
• 40% of postmenopausal women and ~25-33% of
men will eventually experience osteoporotic
fractures.
• ~20 percent of senior citizens who suffer a hip
fracture die within a year
• Risk of mortality is 2.8-4 times greater among
hip fracture patients during the first 3 months
after the fracture
• Nearly 1 in 5 hip fracture patients ends up in a
nursing home within a year
Source: Surgeon General’s Report, 2004, Jrnl of Bone and Mineral Research
The Costs Continue to Grow
Fractures cost
$18 billion/year
and expected to
increase if action
is not taken.
Risk Factors for Osteoporosis
•
•
•
•
Female
Thin or small frame
Low body weight
Smoker
Risk Factors for Osteoporosis
• Advanced age
• History of fragility
fracture
• Family history- primary
relative with
osteoporosis or fragility
fracture
Risk Factors for Osteoporosis
• Post Menopausal
– Hormonal imbalances can result in
rapid bone loss
– Women can lose up to 20% of their
bone mass in 5-7 years
Risk Factors for Osteoporosis
•
•
•
•
Amenorrhea, Anorexia & Bulimia
Diet low in calcium
Certain medications
Low testosterone in men
Risk Factors for Osteoporosis
• Inactive lifestyle
• Excessive alcohol
consumption
Ethnicity & Osteoporosis
 Hispanic women at highest risk
 13-16% with
osteoporosis now
 36-49% of Mexican
American women 50+
have experienced
significant bone loss
Ethnicity & Osteoporosis
Caucasian & Asian-American women
also high risk
Ethnicity & Osteoporosis
• 10% of African-American women 50+ have
osteoporosis
• 30% more have low bone density
Ethnicity & Osteoporosis
• 300,000 African-American women have
osteoporosis
• 80-95% of all fractures sustained by
African-Americans 64+ are osteoporotic
• African-American women more likely to
die from hip fractures than White women
Men & Osteoporosis
Underdiagnosed
Unrecognized
Underreported
Inadequately researched
Men & Osteoporosis
• 2 million American men have
osteoporosis
• 3 million more are at risk
• 1/3 of male hip fractures related to
osteoporosis
• 1/3 of these men will not survive 1
year after fracture
Risk Factors for
Fragility Fractures
• Impaired vision despite correction
• Estrogen deficiency at an early age
(<45 yrs)
• Dementia
• Poor health / frailty
• Recent falls
• Lifelong low calcium intake
• Low physical activity
Fractures beget Fractures
• Risk of future fractures increases 1.59.5 fold following initial fracture
• History of fragility fracture is more
predictive of future fracture than bone
density
Diagnosis: Bone Densitometry
Recommendations for bone density
• Anyone with a fragility fracture
• All women age 65 and older
• Postmenopausal younger than 65 with
risk factors
• Men over 50 with risk factors
Treatment
Goals
• Prevent future fractures
• Treat osteoporosis
• Decrease the risk of mortality
after fractures
Treatment
1. Calcium and Vitamin D
All patients with bone loss or the potential for bone loss should
be educated on the appropriate intake of calcium and vitamin D
Stronger Bones!
Stronger
Bones!
+
=
Treatment
There is a high prevalence of
vitamin D insufficiency in:
• Nursing home residents
• Hospitalized patients
• Adults with hip fractures
Treatment
2. Exercise
Physical activity makes bones and
muscles stronger and helps
prevent bone loss.
All types of physical activity can
contribute to bone health
High impact exercise programs
may be the most effective at
preventing fragility fractures
Treatment
3. Fall Prevention
Each year, more than 1.6 million older U.S. adults go to
emergency departments for fall-related injuries. Among older
adults, falls are the number one cause of:
Fall
•
•
•
•
Fractures
Hospital admissions for trauma
Loss of independence
Injury deaths
3
factors
that contribute
to fractures
Force
Source: National Institute of Health/National Institute on Aging
Fragility
Treatment
4. BMD/DXA Testing
Single most important diagnostic test to predict whether
a person will have a fracture in the future. It helps
diagnose osteoporosis and predict the risk for having a
fracture by comparing bone density to the bones of an
average healthy young adult
Treatment
5. Cessation of smoking
Smoking can reduce bone mass, increase fracture risk and should
be avoided for a variety of health reasons
Treatment
6. Pharmacotherapy –
Treatment & prevention
Bisphosphonates are approved by the FDA and can help stop or
slow bone loss, or help form new bone, and reduce the risk of
fractures
Type
Brand Name
Alendronate
Fosamax
Ibandronate
Boniva
Risedronate
Actonel
Raloxifene
Evista
Zoledronic Acid
Reclast
Bisphosphonates
Bisphosphonates are bone-building drugs that
prevent bone resorption and remain important
treatment options for patients at risk of
debilitating fractures.
But, where does the impact on dental health
figure into the equation? What is the true
incidence of osteonecrosis of the jaw (ONJ)?
The Facts
Approximately 125 cases of osteonecrosis have been
linked to bisphosphonate usage. The majority of these
cases have been administered through an IV to cancer
patients
Source: Bamias A. Osteonecrosis of the jaw in cancer after treatment with
bisphosphonates: incidence and risk factors. J Clin Oncol 2005;23(34):8580-7.
Bisphosphonates
• A man with a hip fracture has a 1:3 chance of
dying within a year
• A woman with a hip fracture has a 1:4 chance
of dying within a year
• The risk for ONJ among patients taking oral
bisphosphonates is likely to be 1:100,000
Bisphosphonate Associated
Fracture
• May occur with long term
bisphosphonate use
• Relatively rare occurrence
compared to fragility
fractures
• Risk/benefit analysis still
favors bisphosphonate use
Source: Bisphosphonate use and the risk of subtrochanteric or femoral shaft fractures in
older women. Park-Wyllie LY, Mamdani MM, Juurlink DN, Hawker GA, Gunraj N, Austin
PC, Whelan DB, Weiler PJ, Laupacis A. JAMA. 2011 Feb 23;305(8):783-9.
Treatment
7. Patient Note
Provide the patient with written
information regarding fragility fractures
and preventive measures that can be
taken. Encourage them to speak with
their primary care physicians for
additional follow-up after the fracture has
healed
Treatment
8. Physician Referral
A letter sent to the primary care
physician can provide information
regarding the patient’s fracture and
recommend appropriate measures
be taken
Fall Prevention in the Home
•
•
•
•
Use handrails on stairs, bathroom
Keep rooms free of clutter
Keep floors clean but not slippery
Wear supportive, low-heeled shoes.
Don’t walk in socks; floppy slippers
• Use 100 watt bulbs in all rooms
• Install ceiling lighting in bedrooms
• Use rubber matt in shower/tub
• Keep a flashlight at bedside
• Check posture in mirror often
Bibliography
The American Orthopaedic Association's "own the bone" initiative to prevent secondary fractures.
Tosi LL, Gliklich R, Kannan K, Koval KJ. J Bone Joint Surg Am. 2008 Jan;90(1):163-73.
Primary care-relevant interventions to prevent falling in older adults: a systematic evidence review
for the U.S. Preventive Services Task Force. Michael YL, Whitlock EP, Lin JS, Fu R, O'Connor
EA, Gold R; US Preventive Services Task Force. Ann Intern Med. 2010 Dec 21;153(12):815-25.
Review.
Bisphosphonates for osteoporosis. Favus MJ. N Engl J Med. 2010 Nov 18;363(21):2027-35.
Bisphosphonate use and the risk of subtrochanteric or femoral shaft fractures in older women.
Park-Wyllie LY, Mamdani MM, Juurlink DN, Hawker GA, Gunraj N, Austin PC, Whelan DB,
Weiler PJ, Laupacis A. JAMA. 2011 Feb 23;305(8):783-9.
More … Home Fall Prevention
• Keep floors free from clutter
• Use portable phone; keep phone and electrical wires out
of walkways
• Skid-proof backing on carpets / scatter rugs
• Keep week’s supply of prescription medications on hand
• Daily contact with family member / neighbor
 Contract with monitoring company for 24 hour
response time in emergency
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