Fragility Fractures

1. Kenneth J. Koval, MD Laura Tosi, MD AOA Committee for the Own the Bone Pilot ProjectCreated February 2007; Revised March 2011 Fragility Fractures

2. 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 1 out of 4 osteoporotic hip fractures result in long-term nursing home care. Half of those who suffer from osteoporotic hip fractures are unable to walk without assistance. Those who experience the trauma of an osteoporotic hip fracture have a 24% increased risk of dying within one year following their fracture. Study at VA in Wisconsin. Similar study of no-VA patients � similar results. There are tremendous social and economic costs to society associated with Osteoporosis. Osteoporosis costs the U.S. healthcare system nearly $14 billion dollars annually. This translates to approximately $38 million dollars per day. This is more than the cost of congestive heart failure or asthma (Congestive heart failure costs $8 billion annually, while Asthma costs $9.8 billion annually). The National Osteoporosis Foundation (NOF) estimates that the overall prevalence of osteoporosis will increase by almost 50% by the year 2020 when 61.4 million adults in the United States are expected to be affected. This dramatic increase reflects the trend toward an increasing elderly population, for which low bone mass and osteoporosis-related concerns will be a substantial burden. The greatest increases in prevalence, as expected, will occur in women so that by 2020, 40.9 million women will be affected. 1America�s Bone Health: The State of Osteoporosis and Low Bone Mass In our Nation. NOF 2002 The prevalence of Osteoporosis makes it a tremendous health risk. Osteoporosis is a major public health threat for more than 28 million Americans. While 80% of those who will be effected by Osteoporosis are women, men are also at significant risk: 1 out of 2 women and 1 out of 8 men over 50 years old will have a Osteoporosis related fracture in their lifetime. 1 out of 4 osteoporotic hip fractures result in long-term nursing home care. Half of those who suffer from osteoporotic hip fractures are unable to walk without assistance. Those who experience the trauma of an osteoporotic hip fracture have a 24% increased risk of dying within one year following their fracture. Study at VA in Wisconsin. Similar study of no-VA patients � similar results. There are tremendous social and economic costs to society associated with Osteoporosis. Osteoporosis costs the U.S. healthcare system nearly $14 billion dollars annually. This translates to approximately $38 million dollars per day. This is more than the cost of congestive heart failure or asthma (Congestive heart failure costs $8 billion annually, while Asthma costs $9.8 billion annually). The National Osteoporosis Foundation (NOF) estimates that the overall prevalence of osteoporosis will increase by almost 50% by the year 2020 when 61.4 million adults in the United States are expected to be affected. This dramatic increase reflects the trend toward an increasing elderly population, for which low bone mass and osteoporosis-related concerns will be a substantial burden. The greatest increases in prevalence, as expected, will occur in women so that by 2020, 40.9 million women will be affected. 1America�s Bone Health: The State of Osteoporosis and Low Bone Mass In our Nation. NOF 2002 The prevalence of Osteoporosis makes it a tremendous health risk. Osteoporosis is a major public health threat for more than 28 million Americans. While 80% of those who will be effected by Osteoporosis are women, men are also at significant risk: 1 out of 2 women and 1 out of 8 men over 50 years old will have a Osteoporosis related fracture in their lifetime.

4. Osteoporosis is a contributing factor in 1.5 million fractures treated each year. The approximate number of types of fractures related to Osteoporosis are: Approximately 300,000 hip fractures. Approximately 700,000 vertebral fractures. Approximately 250,000 wrist fractures. Approximately 300,000 fractures at other sites. Osteoporosis is a contributing factor in 1.5 million fractures treated each year. The approximate number of types of fractures related to Osteoporosis are: Approximately 300,000 hip fractures. Approximately 700,000 vertebral fractures. Approximately 250,000 wrist fractures. Approximately 300,000 fractures at other sites.

5. Burden of Disease Approximately $38 million daily Congestive heart failure costs $8 billion annually Asthma costs $9.8 billion annually There are tremendous social and economic costs to society associated with Osteoporosis. Osteoporosis costs the U.S. healthcare system nearly $14 billion dollars annually. This translates to approximately $38 million dollars per day. This is more than the cost of congestive heart failure or asthma (Congestive heart failure costs $8 billion annually, while Asthma costs $9.8 billion annually). There are tremendous social and economic costs to society associated with Osteoporosis. Osteoporosis costs the U.S. healthcare system nearly $14 billion dollars annually. This translates to approximately $38 million dollars per day. This is more than the cost of congestive heart failure or asthma (Congestive heart failure costs $8 billion annually, while Asthma costs $9.8 billion annually).

6. 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 1 out of 4 osteoporotic hip fractures result in long-term nursing home care. Half of those who suffer from osteoporotic hip fractures are unable to walk without assistance. Those who experience the trauma of an osteoporotic hip fracture have a 24% increased risk of dying within one year following their fracture. 1 out of 4 osteoporotic hip fractures result in long-term nursing home care. Half of those who suffer from osteoporotic hip fractures are unable to walk without assistance. Those who experience the trauma of an osteoporotic hip fracture have a 24% increased risk of dying within one year following their fracture.

7. 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. - Fragility Fractures & Osteoporosis - Sources: Bisphosphonates and Fracture healing in Orthopaedic Fracture PatientsSources: Bisphosphonates and Fracture healing in Orthopaedic Fracture Patients

8. 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

9. Fractures cost $18 billion/year and expected to increase if action is not taken.

10. Risk Factors for Osteoporosis Female Thin or small frame Low body weight Smoker In addition to warning signs, there are a significant number of risk factors to consider for Osteoporosis. However, it is important to be aware that you can have no risk factors and still have Osteoporosis. The following risk factors have been identified: Being female, Having a thin or small frame and Having a low body weight of 127 pounds or less. In addition, being a smoker is a major risk factor as areIn addition to warning signs, there are a significant number of risk factors to consider for Osteoporosis. However, it is important to be aware that you can have no risk factors and still have Osteoporosis. The following risk factors have been identified: Being female, Having a thin or small frame and Having a low body weight of 127 pounds or less. In addition, being a smoker is a major risk factor as are

11. Risk Factors for Osteoporosis Advanced age History of fragility fracture Family history- primary relative with osteoporosis or fragility fracture Reaching Advanced age, and Having a history of fragility fracture or a primary relative with a history of fragility fracture or Osteoporosis. Reaching Advanced age, and Having a history of fragility fracture or a primary relative with a history of fragility fracture or Osteoporosis.

12. 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 In addition, post menopausal women are at great risk because the hormonal imbalances of menopause can result in rapid bone loss. Women can lose up to 20% of their bone mass in the 5-7 years after the onset of menopause.In addition, post menopausal women are at great risk because the hormonal imbalances of menopause can result in rapid bone loss. Women can lose up to 20% of their bone mass in the 5-7 years after the onset of menopause.

13. Risk Factors for Osteoporosis Amenorrhea, Anorexia & Bulimia Diet low in calcium Certain medications Low testosterone in men Eating disorders such as Anorexia and Bulimia, A diet low in calcium, Use of certain medications and Low testosterone in men are all risk factors as well. Eating disorders such as Anorexia and Bulimia, A diet low in calcium, Use of certain medications and Low testosterone in men are all risk factors as well.

14. Risk Factors for Osteoporosis Inactive lifestyle Excessive alcohol consumption Eating disorders such as Anorexia and Bulimia, A diet low in calcium, Use of certain medications and Low testosterone in men are all risk factors as well. Eating disorders such as Anorexia and Bulimia, A diet low in calcium, Use of certain medications and Low testosterone in men are all risk factors as well.

15. Ethnicity & Osteoporosis While significant risk has been reported in people of all ethnic backgrounds, and in both genders, Hispanic women are thought to be among those at highest risk. 13-16% have Osteoporosis now. 36-49% of Mexican-American women 50 years of age or older have experienced loss of bone density. Hispanic women tend to consume less calcium than the RDA. This risk is expected to increase as the estimated number of hip fractures worldwide is expected to rise sharply over the next � century.While significant risk has been reported in people of all ethnic backgrounds, and in both genders, Hispanic women are thought to be among those at highest risk. 13-16% have Osteoporosis now. 36-49% of Mexican-American women 50 years of age or older have experienced loss of bone density. Hispanic women tend to consume less calcium than the RDA. This risk is expected to increase as the estimated number of hip fractures worldwide is expected to rise sharply over the next � century.

16. Ethnicity & Osteoporosis Caucasian and Asian-American women are also at high risk. This is due largely to differences in bone mass and density. The average calcium intake among Asian-American women is about half that of their Caucasian counterparts. While Asian-American women generally have lower incidence of hip fractures than Caucasian women, the prevalence of vertebral fractures is about equal between the two populations.Caucasian and Asian-American women are also at high risk. This is due largely to differences in bone mass and density. The average calcium intake among Asian-American women is about half that of their Caucasian counterparts. While Asian-American women generally have lower incidence of hip fractures than Caucasian women, the prevalence of vertebral fractures is about equal between the two populations.

17. Ethnicity & Osteoporosis 10% of African-American women 50+ have osteoporosis 30% more have low bone density Although African-American women generally have higher bone density and are at somewhat lower risk than their Asian-American and Caucasian counterparts, this should not be taken to mean that there is no cause for concern among this population. 10% of African-American women over 50 have Osteoporosis. 30% more have low bone density. Although African-American women generally have higher bone density and are at somewhat lower risk than their Asian-American and Caucasian counterparts, this should not be taken to mean that there is no cause for concern among this population. 10% of African-American women over 50 have Osteoporosis. 30% more have low bone density.

18. 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 300,000 African-American women are experiencing Osteoporosis today. 80-95% of all fractures suffered by African-American women over 64 are related to Osteoporosis. African-American women are more likely than Caucasian women to die from hip fractures. 300,000 African-American women are experiencing Osteoporosis today. 80-95% of all fractures suffered by African-American women over 64 are related to Osteoporosis. African-American women are more likely than Caucasian women to die from hip fractures.

19. Men & Osteoporosis While Osteoporosis does strike women at higher rates, men are also at risk. Osteoporosis in men is underdiagnosed, unrecognized, and inadequately reported and researched. As with women, Caucasian men are at greater risk for Osteoporosis. Many of the same risk factors apply to men: Lifestyle, age, heredity, prolonged exposure to certain medications. chronic disease and undiagnosed levels of testosterone all put men at increased risk for Osteoporosis.While Osteoporosis does strike women at higher rates, men are also at risk. Osteoporosis in men is underdiagnosed, unrecognized, and inadequately reported and researched. As with women, Caucasian men are at greater risk for Osteoporosis. Many of the same risk factors apply to men: Lifestyle, age, heredity, prolonged exposure to certain medications. chronic disease and undiagnosed levels of testosterone all put men at increased risk for Osteoporosis.

20. 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 2 million American men suffer from Osteoporosis. Another 3 million are at risk. 1/3 of the hip fractures experienced by men are related to Osteoporosis. 1/3 of these men will not survive 1 year after their fracture.2 million American men suffer from Osteoporosis. Another 3 million are at risk. 1/3 of the hip fractures experienced by men are related to Osteoporosis. 1/3 of these men will not survive 1 year after their fracture.

21. 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 Not everyone with osteoporosis has a fragility fracture. However, if you do have osteoporosis, risk factors for osteoporotic fractures include those things that make you more likely to fall, such as inadequate vision, dementia, and fragility which can contribute to falls. Early estrogen deficiency due to either early menopause or surgically induced menopause prior to age 45 can lead to earlier bone loss in women, and these patients may require bone density monitoring earlier than usual. Lifelong low calcium intake, a sedentary lifestyle, and increased alcohol consumption have also been associated with increased osteoporotic fracture risk in some studies.Not everyone with osteoporosis has a fragility fracture. However, if you do have osteoporosis, risk factors for osteoporotic fractures include those things that make you more likely to fall, such as inadequate vision, dementia, and fragility which can contribute to falls. Early estrogen deficiency due to either early menopause or surgically induced menopause prior to age 45 can lead to earlier bone loss in women, and these patients may require bone density monitoring earlier than usual. Lifelong low calcium intake, a sedentary lifestyle, and increased alcohol consumption have also been associated with increased osteoporotic fracture risk in some studies.

22. Fractures beget Fractures Risk of future fractures increases 1.5-9.5 fold following initial fracture History of fragility fracture is more predictive of future fracture than bone density

23. 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 Who should have bone densitometry testing? Anyone with a fragility fracture. All women age 65 and older. Post-menopausal women younger than 65 who have other risk factors, and Men over the age of 50 with risk factors.Who should have bone densitometry testing? Anyone with a fragility fracture. All women age 65 and older. Post-menopausal women younger than 65 who have other risk factors, and Men over the age of 50 with risk factors.

24. Goals Prevent future fractures Treat osteoporosis Decrease the risk of mortality after fractures

25. Calcium and Vitamin D

26. There is a high prevalence of vitamin D insufficiency in: Nursing home residents Hospitalized patients Adults with hip fractures

27. 2. Exercise

28. 3. Fall Prevention

29. 4. BMD/DXA Testing

30. 5. Cessation of smoking

31. 6. Pharmacotherapy � Treatment & prevention

32.

34. 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

35. Bisphosphonate Associated Fracture May occur with long term bisphosphonate use Relatively rare occurrence compared to fragility fractures Risk/benefit analysis still favors bisphosphonate use

36. 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

37. 8. Physician Referral

38. Fall Prevention in the Home Maintaining a home environment that reduces the risk of falling is important. The next two slides list helpful considerations that patients should be made aware of. Use handrails on stairs, in bathroom Keep rooms free of clutter Keep floor surfaces clean but not slippery Wear supportive, low-heeled shoes. Do not walk in socks or 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 oftenMaintaining a home environment that reduces the risk of falling is important. The next two slides list helpful considerations that patients should be made aware of. Use handrails on stairs, in bathroom Keep rooms free of clutter Keep floor surfaces clean but not slippery Wear supportive, low-heeled shoes. Do not walk in socks or 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

39. Bibliography

40. 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 More � Home Fall Prevention Keep floors free from clutter Use a portable phone and keep phone and electrical wires out of walkways Place skid-proof backing on carpets and scatter rugs Keep a week�s supply of prescription medications on hand Arrange for daily contact with a family member or neighbor Contract with a monitoring company for 24 hour response time in an emergencyKeep floors free from clutter Use a portable phone and keep phone and electrical wires out of walkways Place skid-proof backing on carpets and scatter rugs Keep a week�s supply of prescription medications on hand Arrange for daily contact with a family member or neighbor Contract with a monitoring company for 24 hour response time in an emergency