Download Screening for Osteoporotic Fractures in the Elderly: Current

Screening for Osteoporotic Fractures in the Elderly:
Current Guidelines and Future Directions.
*Anna P Njarlangattil, BMSc, MD Class of 2012
1 Undergraduate
Medicine, Schulich School of Medicine and Dentistry, University of
Western Ontario
Susan McNair, BA, MD, CCFP, MCLSC (FM) FCFP
1 St.
Joseph’s Family Medical and Dental Center
2
Department of Family Medicine, Schulich School of Medicine and Dentistry, University
of Western Ontario
Mailing Addresses:
Schulich School of Medicine and Dentistry,
Clinical Skills Building Room 3700,
University of Western Ontario,
London, Ontario
St. Joseph’s Family Medical and Dental Center,
346 Platts Lane, London, Ontario
CORRESPONDING AUTHOR EMAIL ADDRESS: [email protected]
Abstract
Osteoporotic fragility fractures are a major health concern causing increased morbidity
and mortality in the elderly population. Major risk factors for fragility fractures include,
but are not limited to, advanced age, low Bone Mineral Density (BMD), and a personal
or familial history of a prior adult fragility fracture. Additional factors, such as chronic oral
corticosteroid use and a history of recurrent falls, have also been identified to be
important risk factors in the development of fragility fractures in the elderly. Current
Canadian screening and treatment guidelines are based on regular BMD testing to
identify individuals at risk; however, emerging evidence continues to emphasize the
importance of analysis of the many risk factors for fragility fractures in combination with
BMD measurements. Risk factor assessment tools, such as the FRAX™ tool developed
by the World Health Organization, are promising new methods for screening and
preventative care of the elderly. In addition, changes in screening methodology within
the family practice setting, such as the utilization of specific electronic medical record
templates for the elderly, are potential directions for improving screening of fragility
fractures in the elderly patient population.
KEYWORDS: Osteoporosis Screening Guidelines, Osteoporosis, Fragility Fractures
Introduction
Osteoporosis is a common clinical condition with a multifactorial pathophysiology
involving disruption of bone micro-architecture and reduction in bone mass resulting in
increased fragility and risk of fracture.1 The World Health Organization (WHO) clinically
defines normal bone density as a Bone Mineral Density (BMD) or Bone Mineral Content
(BMC) score between + 1 Standard Deviations (SDs) around the young adult mean, as
measured by central (hip or spine) Dual Energy Xray Absorpitometry (DEXA) scan.2,3
Osteopenia is clinically defined as a BMD score between -1 and -2.5 SDs and
osteoporosis as a BMD score 2.5 SDs or more below the young adult mean (T score <2.5).2 Fragility fractures, the most challenging consequence of osteoporotic bony
change, are pathological fractures due to non-traumatic falls from standing height or
less, and are associated with significant morbidity and increased mortality to elderly
patients, and result in increased costs to the healthcare system.2,4
The prevalence of osteoporosis has been demonstrated to increase with age, as
over 45% of North American 85-89 year olds are currently estimated to suffer from
osteoporosis.3,5 In addition, elderly patients are at an increased risk of falls and
consequent fragility fractures as a result of their decreased mobility, vision, and
presence of multiple co-morbid medical concerns.6 The long-term consequences of
fragility fractures, especially those affecting the hip, are well documented: up to 20% of
women and 40% of men will die within one year of a hip fracture, and up to 50% of
women with a hip fracture are no longer able to independently perform their activities of
daily living with up to 19% requiring long-term nursing care as a result.6 In terms of
healthcare costs, the 1993 cost of acute care of osteoporosis in Canada - including
hospitalization, medication, and outpatient care - was estimated at $1.3 billion; by 2041,
the healthcare costs of hip fractures alone in Canada are expected to rise to $2.4
billion7,8 Given the significant consequences of fragility fractures on both the patient and
the healthcare system, early identification and management of elderly patients at risk for
fragility fractures should be a priority in the primary care setting. This article briefly
reviews the major risk factors for fragility fractures followed by a discussion of the
current screening guidelines and future directions for improving screening of fragility
fractures in the elderly population.
Risk Factors for Fragility Fractures
Risk factors for fragility fractures can be categorized as modifiable and nonmodifiable, and then further classified as major or minor risk factors. The major nonmodifiable risk factors include advanced age, a personal history of fractures as an adult,
and a history of fragility fracture in a first degree relative.3,5, 9,10 Major modifiable risk
factors include a low BMD, chronic oral corticosteroid use (greater than 3 months of
use), a history of recurrent falls, and a low body weight (less than 127 lbs).3,5, 9,10 Minor
risk factors for fragility fractures include, but are not limited to, inadequate nutritional
supplementation of Vitamin D and Calcium, impaired eyesight despite correction,
physical de-conditioning, and immobilization.3,5,9 In addition, elderly patients often
present with complex medical issues requiring multiple medications; this can also
contribute as secondary causes of osteoporosis in adults.9,10 Extrinsic modifiable
factors, such as the absence of mobility aids or the lack of sturdy grab bars or shower
benches in the bathroom, can also increase the risk for fragility fractures in the elderly. 10
Current Screening Guidelines
Current Canadian screening recommendations for individuals greater than 65
years of age include routine screening via BMD with central DEXA scanning every 2-3
years if normal and then every 1-2 years if BMD scores are abnormal.3,11 BMD
measurements with central DEXA scanning is considered the gold standard for the
diagnosis of osteoporosis, and can involve measurements of the lumbar vertebrae and
hip.3,5,12 BMD results are reported as T and Z scores to help in comparison with the
young adult mean, and femoral neck measurements, which are often included in
measurements of hip BMD, are considered to be the most useful in prediction of
fracture risk.12,13 Quantitative Computed Tomography (CT) as well as Peripheral BMD
measurements are also available; however, these imaging modalities are not currently
validated for use in the diagnosis of osteoporosis and fracture risk prediction.12
The close relationship between BMD and risk of fragility fractures is supported by
robust clinical evidence, and a low BMD score is considered one of the strongest
individual risk factors for osteoporosis and fragility fractures.3,5,14 In addition, BMD
scores provide an easily quantifiable assessment of fracture risk and are an important
component of current osteoporosis treatment and management guidelines. 5,11,15 BMD
screening alone, however, is a tool with high specificity but low sensitivity, as it and fails
to identify high risk patients with normal BMDs who may also benefit from
comprehensive preventative therapy for fragility fractures.5,11 In addition, substantial
research evidence indicates that the combination of clinical evaluation of risk factors
with BMD screening produces the most effective risk assessment for fragility fractures
as opposed to assessment of any one risk factor alone.5,11
Future Directions for Predicting Fragility Fractures
In the past few years the WHO conducted several meta-analyses on the different
factors affecting fragility fracture risk and consequently, developed a Fracture Risk
Assessment Tool (FRAX™) that estimates the 10-year probability of a major
osteoporotic fracture.5,16,17 This tool estimates risk based on 12 of the previously
identified modifiable and non-modifiable risk factors including BMD, age, and previous
history of an adult fragility fracture.5 However, as indicated in the January 2010
Technical Standards statement by the Canadian Association of Radiology (CAR), the
FRAX™ tool is currently not recommended for use as part of regular fracture risk
assessment in Canada until a validated Canadian FRAX™ model exists.13 Instead, the
CAR recommends use of the BMD based estimation of 10-year fracture risk which,
however, only includes 5 of the 12 risk factors used in the FRAX™ model.13,5 FRAX™
has been externally validated by several research groups throughout the world, and a
recent study conducted in Manitoba indicated that the FRAX™ tool calibrated to
Canadian populations demonstrates fracture risk probabilities that are consistent with
observed fracture rates.5,18 Therefore, with further analysis and validation of the
Canadian FRAX™ model, it is very likely that the Canadian guidelines for screening and
treatment of osteoporosis will change in the next few years to include a more
comprehensive analysis of fracture risk factors.13
Current evaluation of the FRAX™ tool focuses on the development of
intervention thresholds and clinical guidelines for different age groups at risk for
fractures. Based on US and European studies, treatment thresholds can vary from as
low as 1.2% to as high as 20% 10-year fracture risk probability as determined by
analysis of cost-effective ratios.19,20,21 The UK adaptation of the FRAX™ assessment
tool for the elderly suggests treatment when FRAX™ scores are greater than 6%, with
an average expected treatment effectiveness of 35% fracture risk reduction over 5
years.5,21 As there are currently no clinical guidelines outlining the use of the FRAX™
tool in Canada, it is not yet possible to determine the intervention threshold most
appropriate for the Canadian elderly population.
Future Directions for Screening in the Family Practice Setting
Although FRAX™ risk assessment tools are not part of the current Canadian
screening guidelines, it is clear that a thorough and comprehensive risk factor
identification in elderly patients along with BMD measurements are important
components of fragility fracture screening. However, in order to build new strategies for
screening in the family practice setting, a better exploration of the barriers and
facilitators to screening must develop alongside the research into validated risk
assessment tools.
The barriers to screening and risk assessment for fragility fractures in the elderly are
numerous but can include patient factors, physician factors, as well as systemic
factors.22 Patient factors can include poor understanding of osteoporosis and insufficient
awareness of the risks and consequences to fragility fractures.22 As a consequence,
patients may not be compliant with screening assessments, making fracture risk difficult
to estimate. Family physicians can play a pivotal role in patient understanding and
awareness of osteoporosis, and are also able to direct patients to additional resources
regarding fracture risk. Many resources are available online, but hardcopy information
pamphlets should also be readily available in waiting areas and clinic rooms for the
elderly patient without access to internet resources to take home.
Physician factors that can impede fracture risk assessment include physician
failure to keep up to date with changes to screening and treatment guidelines. As more
information regarding FRAX™ use and clinical guidelines emerge, family physicians
have a responsibility to increase their own knowledge of fracture risk factors and
management. In addition, as family physicians are already limited in their time for each
patient encounter, and as elderly patients often have multiple co-morbidities and
medications, trying to balance the elderly patient’s competing healthcare issues may
result in less time allocated for fracture risk assessment at the time of the annual health
and physical exam. In such cases, family physicians should follow up with patients at
future clinical encounters and implement recall systems to ensure that all elderly
patients in their practice are being screened according to the current guidelines.
Systemic factors are largely related to the transition towards electronic medical
records (EMR) and include poor implementation of recall systems, incomplete transfer
of data from paper to electronic records, as well as the use of templates that are not
appropriate for the elderly patient’s needs. As physicians become more skilled with the
use of EMR technology, medical records will transform from mere ‘word-processed’
charts to dynamic tools to document patient health, monitor clinical events, and prompt
for timely preventative screening measures.23 For example, templates for diabetes or
hypertension monitoring can be programmed to identify patients at high-risk based on
selected parameters and then automatically prompt for follow-up assessment. More
specifically for the elderly population, 10-year fracture risk probabilities, whether based
on FRAX™ or BMD calculations, could be included in the patient’s cumulative medical
record and automated prompts can be programmed to remind physicians to follow-up
on patients who have not yet been evaluated. Application of the EMR in this dynamic
fashion, however, will take time and will require technology specific training of the
healthcare providers involved.
One commonly used EMR template by Canadian family physicians is that for the
annual health and physical exam and is based on the Preventative Care Checklists
developed by the College of Family Physicians of Canada (CFPC).24 These evidenced
based templates are presented in a checklist format that is easy to use and covers a
variety of health concerns for the adult male and female patient. 24 The Preventative
Care Checklists include education and counseling reminders for adequate Calcium and
Vitamin D intake, smoking cessation, elderly fall assessments, as well as reminders for
labs and investigations like mammography, fasting lipids, and BMD.24
While the original paper form of the checklist does include some preventative
recommendations for the elderly population, it does not provide a comprehensive
assessment of specific elderly medical conditions and concerns.24 Fall assessment in
the elderly patient, for example, is limited to a checkbox indicating that the topic was
discussed with no concerns; however, evidenced based guidelines for fall assessments
for at-risk patients require a complete review of factors like gait and muscle strength,
and even include simple clinical tests like the “Get Up and Go” test.24,25,26 With the
transition to EMR, some family physicians have opted to create templates adapted from
this CFPC checklist for use during the annual health exam which, depending on the
design, can range from inclusion of all of the information in the original paper checklist
to specific templates dedicated for the elderly patient. If electronic templates or
checklists are used for annual health exam, the templates should be specifically
designed for the elderly patient and include screening questions targeted at the risk
factors for falling and fragility fractures.
Conclusions
Given the large body of evidence for regular screening and preventative
management of fragility fractures, risk factor assessment should be conducted at least
once per year at the annual health exam of the elderly patient to help identify high risk
patients who would otherwise be overlooked with the use of BMD screening alone. In
addition, as the evidence for 10-year fragility fracture assessment tools like FRAX™
increases, and as physician skill with screening and use of the EMR improves,
Canadian family physicians will be able to offer enhanced preventive care for elderly
patients and therefore, help prevent the consequences of osteoporotic fragility fractures.
Acknowledgements
The Authors would like to thank the St. Joseph’s Family Medical and Dental Center for
their support throughout this project.
Conflicts of Interest
The authors do not have any personal or financial conflicts of interests to declare.
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
Gehlbach SH, Avrunin JS, Puleo E, Spaeth R. Fracture risk and antiresorptive
medication use in older women in the USA. Osteoporos Int. 2007;18: 805–810.
Prevention and management of osteoporosis. Report of a WHO Scientific Group.
Geneva, World Health Organization, 2003 (WHO Technical Report Series, NO
921).
Brown JP, Fortier M, Frame H, Lalonde A, Papaioannou A, Senikas V, Yuen CK.
Canadian Consensus Conference on Osteoporosis, 2006 Update. J Obstet
Gynaecol Can. 2006 Feb; 28(2s1): S95-S112
Definition of pathological fracture [Internet]. National Cancer Institute: U.S.
National Institute of Health. [cited 2010 Sep 22]. Available from:
<http://www.cancer.gov >
WHO Publication - Kanis JA, on behalf of the World Health Organization
Scientific Group. Assessment of Osteoporosis at the primary care level. WHO
Collaborating Centre for Metabolic Bone Diseases, University of Sheffield 2007.
Chrischilles EA, Butler CD, Davis CS, Wallace RB. A model of lifetime
osteoporosis impact. Arch Intern Med. 1991;151:2026–32.
Tenenhouse A, Joseph L, Kreiger N, Poliquin S, Murray TM, Blondeau L, Berger
C, Hanley DA, Prior JC; CaMos Research Group. Canadian Multicentre
Osteoporosis Study. Estimation of the prevalence of low bone density in Canadian
women and men using a population-specific DXA reference standard: The
Canadian Multicentre Osteoporosis Study (CaMos). Osteoporos Int. 2000;11:897–
904.
Wiktorowicz ME, Goeree R, Papaioannou A, Adachi JD, Papadimitropoulos E.
Economic implications of hip fracture: health service use, institutional care and
cost in Canada. Osteoporos Int. 2001;12:271–8.
Kannus P, Parkkari J, Slevanen H, Heinonen A, Vuori I, Jarvinen M. Epidemiology
of hip fractures. Bone. 1996 Jan;18 (1s): 57S-63S.
Boonen S, Dejaeger E, Vanderschueren D, Venken K, Bogaerts A, Verschueren
S, Milisen K. Osteoporosis and osteoporotic fracture occurrence and prevention
in the elderly: a geriatric perspective. Best Pract Res Clin Endocrinol Metabol
2008 Oct; 22(5): 765-785.
Brown JP, Josse RG. 2002 clinical practice guidelines for the diagnosis and
management of osteoporosis in Canada. CMAJ. 2002 Nov;167(10s): S1-S34.
Raisz LG. Screening for osteoporosis. N Engl J Med 2005;353:164-171
Siminoski K, O’Keeffe M, Levesque J, Hanley D, Brown JP. CAR Technical
Standards for Bone Mineral Densitometry Reporting. Canadian Association of
Radiologists, Jan 2010.
U.S. Preventive Services Task Force. Screening for Osteoporosis in
postmenopausal women: recommendations and rationale. Ann Intern Med.
2002;137:526-8.
Marshall D, Johnell O, Wedel H. Meta-analysis of how well measures of bone
mineral density predict occurrence of osteoporotic fractures. BMJ 1996;312:12549.
. J Bone Miner Res 2005; 20: 1185-1194
Kanis JA, Johnell O, De Laet C, Johansson H, Oden A, Delmas P, Eisman J,
Fujiwara S, Garnero P, Kroger H, McCloskey EV, Mellstrom D, Melton III LJ, Pols
18.
19.
20.
21.
22.
23.
24.
25.
26.
H, Reeve J, Silman A, Tenenhouse A. A meta-analysis of previous fracture and
subsequent fracture risk. Bone 2004; 35: 375-382.
Leslie WD, Lix LM, Johansson H, Oden A, McCloskey E, Kanis JA. Independent
Clinical validation of a Canadian FRAX™ tool; Fracture prediction and model
calibration. J Bone Miner Res. 2010 Oct; 25.
Tosteson Anna NA, Melton JL, Dawson-Hughes B, Baim S, Favus MJ, Khosla S,
Lindsay RL. Cost-effective Osteoporosis Treatment Thresholds: The United
States Perspective From the National Osteoporosis Foundation Guide Committee.
Osteoporos Int. 2008 April; 19(4): 437-447.
Kanis JA, Burlet N, Cooper C, Delmas PD, Reginster JY, Borgstrom F, Fizzoli R.
European guidance for the diagnosis and management of osteoporosis in postmenopausal women. Osteoporos Int. 2008;19:399-428
Kanis JA, Johnell O, Oden A, Johansson H, McCloskey E. FRAX™™ and the
assessment of fracture probability in men and women from the UK. Osteoporos
Int. 2008 April; 19 (4): 385-397.
Elliot-Gibson V, Bogoch ER, Jamal SA, Beaton DE. Practice patterns in the
diagnosis and treatment of osteoporosis after a fragility fracture: a systematic
review. Osteoporos Int. 2004 Oct; 15(10): 767-78.
Sujansky WV. The Benefits and Challenges of an Electronic Medical Record:
Much More than a "Word-Processed" Patient Chart. West J Med 1 998; 169:176183
Dubey V, Glazier R. Preventive Care Checklist Form. Evidence-based tool to
improve preventive health care during complete health assessment of adults. Can
Fam Physician. 2006; 52: 48- 55.
American Geriatrics Society, British Geriatrics Society, American Academy of
Orthopaedic Surgeons Panel on Falls Prevention. Guideline for the prevention of
falls in older persons. J Am Geriatr Soc 2001;49:664-672
Preventive Services Task Force. Guide to clinical preventive services: report of
the U.S. Preventive Services Task Force. 2nd ed. Baltimore: Williams & Wilkins,
1996:659-85.
Electronic Links for References listed above
1. http://www.springerlink.com/content/161764r212665x73/
2. http://whqlibdoc.who.int/trs/who_trs_921.pdf
3. http://www.sogc.org/guidelines/public/172E-CONS-February2006.pdf
4. http://www.cancer.gov
5. http://www.shef.ac.uk/FRAX™/pdfs/WHO_Technical_Report.pdf
6. http://archinte.ama-assn.org/cgi/reprint/151/10/2026
7. http://www.springerlink.com/content/kvtpt4q5k8vfpcau/
8. http://www.springerlink.com/content/62r75ac3tk39132v/
9. http://www.thebonejournal.com/article/8756-3282(95)00381-9/abstract
10. http://www.bprcem.com/article/S1521-690X(08)00080-8/abstract
11. http://www.cmaj.ca/cgi/content/full/167/10_suppl/s1
12. http://www.nejm.org/doi/full/10.1056/NEJMcp042092
13. http://www.car.ca/uploads/standards%20guidelines/201001_CAR_BMD_Technica
l_Standards_EN.pdf
14. http://www.annals.org/content/137/6/526.abstract?ijkey=c88579cb7ac51b66a379
57efef1c79c8d27eedcd&keytype2=tf_ipsecsha
15. http://www.bmj.com/content/312/7041/1254.abstract?ijkey=c28003db07ccfae8efef
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
61c0f948abb70d6dfe69&keytype2=tf_ipsecsha
http://onlinelibrary.wiley.com/doi/10.1359/JBMR.050304/abstract
http://www.thebonejournal.com/article/S8756-3282(04)00130-9/abstract
http://onlinelibrary.wiley.com/doi/10.1002/jbmr.123/abstract
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2729707/
http://www.iofbonehealth.org/download/osteofound/filemanager/health_profession
als/pdf/endorsed-papers/european-guidance-Kanis-2008-OI.pdf
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2267485/
http://www.springerlink.com/content/uwtd1cxq3m8xg3xd
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1305206/pdf/westjmed003240050.pdf
http://www.cfp.ca/cgi/reprint/52/1/48
http://onlinelibrary.wiley.com/doi/10.1046/j.1532-5415.2001.49115.x/full
http://odphp.osophs.dhhs.gov/pubs/guidecps/text/CH46.txt