Osteoporosis and Falls Dr. John Puxty

Session overview

Relevance of osteoporosis, falls and fractures in seniors and LTC

Assessing osteoporosis and fracture risk in seniors and LTC

Management strategies Special situations

Definition of Osteoporosis

A skeletal disorder characterized by compromised bone strength predisposing to an increased risk of fracture.

Normal Bone Osteoporotic Bone

Epidemiology Osteoporosis (General)

Prevalence in Canadian women aged 50 years and over was 12.1% at the lumbar spine and 7.9% at the femoral neck, with a combined prevalence of 15.8%. (Canadian Multicentre Osteoporosis Study).

The prevalence of Osteoporosis increases with age from approximately 6% at 50 years of age to over 50% above 80years of age.

Expected to increase by about 40% by 2020. Estimated Direct costs in 2001 = $ 11.6 - 17.1 billion

annually, or $6 - $40 million every single day in Canada

Mortality increased 2 - 3 fold in women after all types of osteoporotic fractures

Male Osteoporosis: Morbidity and Mortality

As compared to women, while lifetime fracture risk may be less: Men have higher rates of

morbidity and mortality due to fractures.

Men are twice as likely to die in hospital after a hip fracture.

Men have a higher mortality rate than women one year after a hip fracture.

Cooper C, et al. Osteoporos Int 1992;2:285-9; Singer BR, et al. J Bone Joint Surg Br 1998;80:243-8; Center JR, et al. The Lancet 1999;353:878-82; Forsen L, et al. Osteoporos Int 1999;10:73-8; Johnell O., et al. Calcif Tissue Int 2001;69:182-4; Amin S. Curr Osteoporos Rep 2003;1:71-7; Campion JM, et al. Am Fam Phys 2003;67:1521-6.

Fragility Fracture: Definition

A fracture occurring spontaneously or following minor trauma such as a fall from standing height or less1,2

Excluding craniofacial, hand, ankle and foot fractures

1. Kanis JA, et al. Osteoporos Int 2001; 12(5):417-427.2. Bessette L, et al. Osteoporos Int 2008; 19:79-86.

The Majority of Fractures in Canadian Women Age 50 and over are Fragility Fractures

Bessette L, et al. Osteoporos Int 2008; 19:79-86.

% o

f all

fract

ures

that

ar

e fra

gilit

y fra

ctur

es

75.7%

91.8%Overall: 81%

95%

90%

85%

80%

75%

70%

65%

60% 50-59 60-69 70-79 80+

Age groups

Example of Impact-Based on VCF -Downward Spiral

Falls Facts - Hip Fractures (General)

There are over 4.5 million seniors in Canada.This means for this year: There will be 25,500 hip #s (hip fracture rate of 1.7%) Only 8415 (1/3) will regain their previous level of

function 1785 (7%) will die within 30 days of hospitalization 5100 (20%) will die within 1 year $27,000 per person average cost to health care

system $6.9 billion total cost to healthcare system

A fracture is to osteoporosis what a heart attack is to cardiovascular disease but treatment gap is far wider

~15%

~80%

0

20

40

60

80

100

Anti‐osteoporosis medication postfracture

Beta‐blockers post heart attack

% o

f pat

ient

s be

ing

trea

ted

1. Bessette L, et al. Osteoporos Int 2008; 19:79-86.2. Austin PC, et al. CMAJ 2008; 179(9):901-908.

Therapeutic Care Gap: Most Men Do Not Receive Treatment for Osteoporosis after Fracture

94.2% 94.0% 91.6% 92.6% 90.5%99.5%

0%

20%

40%

60%

80%

100%

Baseline Year 1 Year 2 Year 3 Year 4 Year 5

% o

f men

with

frag

ility

frac

ture

who

do

not r

ecei

ve th

erap

y

Papaioannou A, et al. Osteoporos Int 2008; 19(4):581-587.

Osteoporosis and Falls Facts in LTC

40% of all nursing home admissions are related to falls and 50% fall per year (10% serious)

65-85% prevalence of osteoporosis estimated Fractured hip incidence is twice that of age-

matched controls and prognosis worsePrevious # predictive of future #’sAt least 2,400 Hips #’s per year in Ontario LTC

residents

Prior Fracture Increase Risk for Subsequent Fracture

Klotzbuecher et al. J Bone Miner Res 2000; 15:721-727

Risk of subsequent fractureSite of prior fracture

Hip Spine Forearm Minor fracture

Hip 2.3 2.5 1.4 1.9Spine 2.3 4.4 1.4 1.8Forearm 1.9 1.7 3.3 2.4Minor Fracture 2.0 1.9 1.8 1.9

Survey of LTC in Ontario and Manitoba 2005-06 (Giangregorio LM et al)Bisphosphonate use was reported in 38%

residents Calcium and Vit D supplementation were

reported in 27% (half not optimal) 10.3% residents were on a bisphosphonate but

were not taking Vit D or CalciumVariables negatively associated with

osteoporosis therapy: ≥6 comorbidities, wheelchair use, cognitive impairment, depression, swallowing difficulties

Case Presentation

82-year-old woman who fell in first week after admission to LTC (slipped while in the bathroom)

History of two previous falls in last 3 months and fear of falling Hydrochlorothiazide 25 mg, Amlodipine 10 mg, Ramipril 10 mg

daily, Sertraline 100 mg daily, Thyroxine 0.1 mg, Lorazepam 1 mg daily (at bedtime), Calcium 500 mg Multivitamin 1

Non-smoker, one glass wine daily, Relatively inactive physically (“no one to walk with”)

Widow for 2 years. Retired accountant PMH: GERD, HBP, Hypothyroid, Depression, MCI

Physical Examination

Height: 155 cm (61 inches) -“I used to be 5’ 6” Weight: 54.5 kg (120 lbs), Body mass index (BMI): 22.7 Blood pressure: supine,125/80 mmHg; standing 105/70 mmHg Rib-to-pelvis: one finger Timed up and go test: Can’t rise from chair without arm

rests; Needs to steady herself before walking; 16 secs for 3 m Mild kyphosis MoCA 20/30

Question

Comment on risk for further falls and probable 10 year fracture risk?

What further investigations would you consider?What treatments pharmacological and non-

pharmacological would you consider?

Falls Assessment

Risk of Serious Fall: 82-year-old woman who fell in first week after admission to

LTC (slipped while in the bathroom) History of two previous falls in last 3 months and fear of falling Timed up and go test: Can’t rise from chair without arm

rests; Needs to steady herself before walking; 16 secs for 3 metres

Contributory Factors Hydrochlorothiazide 25 mg, Amlodipine 10 mg, Ramipril 10 mg

daily, Sertraline 100 mg daily, Thyroxine 0.1 mg, Lorazepam 1 mg daily (at bedtime), Calcium 500 mg Multivitamin 1

Blood pressure: supine,125/80 mmHg; standing 105/70 mmHg Cognition Posture: Kyphosis

Assessing fracture risk: History

Assessment Recommended Elements of Clinical Assessment

History

Identify risk factors for low bone-mineral density (BMD), future fractures, and falls ✓ Prior fragility fractures Parental hip fracture Glucocorticoid use Current smoking High alcohol intake (> 3 units per day) Rheumatoid arthritis ✓ Inquire about falls in the previous 12 months ✓ Inquire about gait and balance

Assessing fracture risk: Physical examination

Assessment Recommended Elements of Clinical Assessment

Physical examination

Measure weight (weight loss of >10% since age 25 is significant)

Measure height annually (prospective loss > 2cm)(historical height loss > 6 cm) ✓

Measure rib to pelvis distance < 2 fingers' breadth ✓Measure occiput-to-wall distance (for kyphosis) > 5cm

Assess fall risk by using Get-Up-and-Go Test (ability to get out of chair without using arms, walk several steps and return) ✓

Assessing fracture risk: Lab Investigations

Recommendation Grade

Patients with osteoporosis need only limited laboratory investigations performed: complete blood count, calcium corrected for albumin, creatinine, alkaline phosphatase, and thyroid stimulating hormone ✓

D

Measurement of serum 25-OH-D is recommended among individuals with the following conditions: treatment with pharmacologic therapy for osteoporosis, recurrent fractures, bone loss despite osteoporosis treatment, or those with co-morbid conditions that affect vitamin D absorption or action

D

Serum protein electrophoresis should be performed in individuals with vertebral fractures D

Assessing fracture risk: Radiographic Investigations

Lateral Thoracolumbar Spine plain film Vertebral compression fractures of T10 and T12 (> 25% vertebral height loss

with end-plate disruption); significant degenerative changes throughout

Does she need BMD?

Indications for BMD Testing in Older Adults (Age > 50 Years)

All women and men age > 65 Postmenopausal women, and men aged 50 – 64 with clinical risk factors

for fracture: Fragility fracture after age 40 Prolonged glucocorticoid use†

Other high-risk medication use* Parental hip fracture Vertebral fracture or osteopenia

identified on X-ray Current smoking High alcohol intake Low body weight or major weight loss Rheumatoid arthritis Other disorders strongly associated with osteoporosis

† At least three months cumulative therapy in the previous year at a prednisone-equivalent dose ≥ 7.5 mg daily;* e.g. aromatase inhibitors, androgen deprivation therapy.

BMD Reporting Categories

Age Category Criteria*

< 50 yearsBelow expected range for age Z-score < -2.0

Within expected range for age Z-score > -2.0

> 50 years

Severe (established) osteoporosis T-score < -2.5 with fragility fracture

Osteoporosis T-score < -2.5

Low bone mass T-score -1.0 to -2.5

Normal T-score > -1.0

Absolute 10-year Fracture-Risk Tools

Tools validated in Canada (choice based on personal preference and convenience) CAROC: Joint initiative of the Canadian Association of

Radiologists and Osteoporosis Canada FRAX: Fracture Risk Assessment Tool developed by the

World Health Organization (can be calculated independent of BMD)

10-year Risk Assessment for Women (CAROC Basal Risk)

Age Low Risk Moderate Risk High Risk50 above -2.5 -2.5 to -3.8 below -3.8

55 above -2.5 -2.5 to -3.8 below -3.8

60 above -2.3 -2.3 to -3.7 below -3.7

65 above -1.9 -1.9 to -3.5 below -3.5

70 above -1.7 -1.7 to -3.2 below -3.2

75 above -1.2 -1.2 to -2.9 below -2.9

80 above -0.5 -0.5 to -2.6 below -2.6

85 above +0.1 +0.1 to -2.2 below -2.2

Papaioannou A, et al. CMAJ 2010 Oct 12. [Epub ahead of print].

FRAX Tool: On-line Calculator

www.shef.ac.uk/FRAX.

Absolute 10-year Fracture-Risk Tools

Tools validated in Canada (choice based on personal preference and convenience) CAROC: Joint initiative of the Canadian Association of

Radiologists and Osteoporosis Canada FRAX: Fracture Risk Assessment Tool developed by the

World Health Organization (can be calculated independent of BMD)

Age, previous fragility fracture and prolonged mineralocorticoid use predicts high 10 year risk independent of BMD

Results of BMD Investigations

BMD Femoral neck T score = -2.3 Lumbar spine (L1-L4) T-score = -1.9

Risk Assessment with CAROC: Important Additional Risk Factors

Factors that increase CAROC basal risk by one category (i.e., from low to moderate or moderate to high) Fragility fracture after age 40*1,2

Recent prolonged systemic glucocorticoid use**2

Our case goes from moderate risk to high risk because of her history of fragility fractures

1. Siminoski K, et al. Can Assoc Radiol J 2005; 56(3):178-188.2. Kanis JA, et al. J Bone Miner Res 2004; 19(6):893-899.

* Hip fracture, vertebral fracture, or multiple fracture events should be considered high risk** >3 months use in the prior year at a prednisone-equivalent dose > 7.5 mg daily

FRAX: Risk Calculation

www.shef.ac.uk/FRAX.

High riskusing FRAX

What treatments pharmacological and non-pharmacological would you consider?

Lifestyle modifications Vitamin D Calcium Exercise Falls prevention

Pharmacologic therapy Bisphosphonates Other anti-resorptives

• Calcitonin• Denosumab • Hormone therapy• Raloxifene

Parathyroid hormone Combination therapy

Summary Statements forCalcium & Vitamin D

Statement Strength

Vitamin D3 with calcium supplementation increases bone density in postmenopausal women and men over age 50 and reduces the risk of fractures

Level 1

Vitamin D3 at daily doses of 800 IU (20 mcg) with calcium (1000 mg) reduces the risk of hip and non-vertebral fractures in elderly populations in institutions

Level 1

The evidence in community-dwelling individuals is less strong Level 2

There is evidence that daily 800 IU (20 mcg) vitamin D3 reduces fall risk, particularly in trials that adequately ascertained falls Level 2

A daily intake of 1000 IU vitamin D3 (25 mcg)—a commonly available safe dose—will raise serum 25-OH-D level on average by 15 – 25 nmol/L Level 2

Recommended Calcium Intake

From diet and supplementscombined: 1200 mg daily

Evidence shows a benefit ofcalcium on reduction of fracture risk1

Concerns about serious adverse effects with high-dose supplementation2-4

Renal calculi in older women Cardiovascular events in older women Prostate cancer in older men

1. Tang BM, et al. Lancet 2007; 370(9588):657-666.2. Bolland MJ, et al. J Clin Endocrinol Metab 2010; 95(3):1174-1181.

3. Bolland MJ, et al. BMJ 2008; 336(7638):262-266.4 Reid IR, et al. Osteoporos Int 2008; 19(8):1119-1123.

Nonpharmacologic Interventions

Exercise-focused interventions for community-dwelling older people1

Tai chi, gait, and balance training1-3

1. Gillespie LD, et al. Cochrane Database Syst Rev 2009; CD007146.2. Cameron ID, et al. Cochrane Database Syst Rev 2010; 1(CD005465).3. McClure RJ, et al. Cochrane Database Syst Rev 2008; 1(CD004441).

Benefits of Exercise:Fractures and Bone Health

Programs > 1 yearincluding aerobic exercises and strengthtraining havedemonstrated positiveeffects on BMD andthoracic kyphosis buthave limited evidencefor fracture reduction1

Moderate to vigorous exercise has demonstrated an ability to reduce hip fracture risk2

1. De Kam D, et al. Osteoporos Int 2009; 20(12):2111-25.2. Moayyeri A. Ann Epidemiol 2008; 18:827-835.

Bone Health Protection Strategies

37

Promoting Exercises:Resistance exercises improve mobility, balance and strength.Gait training, stairs, muscle strengthening, coordination and postural training, parallel bar exercise, walking, Tai ChiWheelchair dependent older adults can use free weights.

Nonpharmacologic Interventions

Exercise-focused interventions for community-dwelling older people1

Tai chi, gait, and balance training1-3

Home safety assessment (only effective in those at high risk for falls)1

Cataract removal3

Hip Protectors Safe Transfers

1. Gillespie LD, et al. Cochrane Database Syst Rev 2009; CD007146.2. Cameron ID, et al. Cochrane Database Syst Rev 2010; 1(CD005465).3. McClure RJ, et al. Cochrane Database Syst Rev 2008; 1(CD004441).

Bone Health Protection Strategies

39

Promoting the use of Hip ProtectorsHip protectors are padded undergarments designed to decrease the impact of a fall on the hip by either absorbing or shunting energy away from the hip, thus decreasing the risk of hip fracture.

Who should wear Hip Protectors?Most promising studies indicate that for high risk LTC resident with a history of hip fracture, using hard-shelled hip protectors seems to reduce the number of fractures. Studies looking at the community are not as successful, mainly due to compliance with wearing them.

(Brown et al, 2008; Sawka et al. 2007; Sawka et al., 2005)

Oral Bisphosphonates: Summary

Drug (Brand name)

Dosing SchedulesRisk Reduction Vertebral #

Risk Reduction Femoral #

Alendronate(Fosamax®, Fosavance®)

10 mg daily70 mg weekly 45% 53%

Risedronate (Actonel®)

5 mg daily 35 mg weekly

150 mg monthly39% 20%

Etidronate (Didrocal®)

Cyclical therapy of daily 200 mg for 14 days followed by calcium supplements for 10 weeks

41% NS

Zoledronic Acid (Aclasta®)

5 mg intravenously once yearly 67% 38%

Other Medications: Summary

Drug (Brand name)

Dosing ScheduleRisk Reduction Vertebral #

Risk Reduction Femoral #

Calcitonin(Miacalcin®) 200 IU intranasally daily 35% NS

Denosumab(Prolia®)

60 mg subcutaneous injection every six months 20% 40%

Raloxifene (Evista®) 60 mg daily 36% NS

Teriparatide (Forteo®) 20 μg subcutaneously daily 64% 50% (?)

Recommendations for High-risk Individuals

Recommendation Grade

For menopausal women requiring osteoporosis treatment, alendronate, denosumab, risedronate, and zoledronic acid can be used as first-line therapies for prevention of hip, non-vertebral, and vertebral fractures

A

For menopausal women requiring osteoporosis treatment, teriparatide can be used as a first-line therapy for prevention of non-vertebral and vertebral fractures

A

For menopausal women requiring osteoporosis treatment, raloxifene can be used as a first-line therapy for prevention of vertebral fractures A

Recommendations for High-risk Individuals (Cont'd)

Recommendation Grade

For menopausal women requiring osteoporosis treatment and who require treatment for vasomotor symptoms, hormone therapy can be used as a first-line therapy for prevention of hip, non-vertebral, and vertebral fractures

A

Clinicians should avoid prescribing more than one anti-resorptive agent concurrently for fracture reduction A

For menopausal women intolerant of first-line therapies, calcitonin or etidronate can be considered for prevention of vertebral fractures B

For men requiring osteoporosis treatment, alendronate, risedronate, and zoledronic acid can be used as first-line therapies for prevention of fractures D

Recommendation for Duration of Therapy

Recommendation Grade

Individuals at high risk for fracture should continue osteoporosis therapy without a drug holiday A

• Evidence supporting recommendations for duration of treatment is limited• Data for the above recommendation come from the FLEX study (long-term

alendronate treatment)1 and the risedronate discontinuation study2

1. Black DM, et al. JAMA 2006; 296(24):2927-2938.2. Watts NB, et al. Osteoporos Int 2008; 19(3):365-372.

Summary Statements for Special Groups

Statement : Glucocorticoid Use Strength

In patients who initiated glucocorticoids, fractures can occur quickly (within three to six months) with prednisone doses as low as 2.5 –7.5 mg daily with a rapid decline in fracture risk toward baseline after cessation

Level 1

Osteoporosis therapies including alendronate, risedronate, and teriparatide reduce the risk of vertebral fractures and maintain BMD in those prescribed glucocorticoid for 3 months or longer

Level 1

Etidronate, zoledronic acid, and calcitonin maintain BMD in in those prescribed glucocorticoid for 3 months or longer Level 2

Summary Statements for Special Groups

Statement : Cancer Therapy Strength

Bisphosphonates and denosumab maintain BMD in women prescribed aromatase inhibitors and men prescribed androgen-deprivation therapy

Level 1