FRACTURE IN GERIATRIC

Overview

 Osteoporosis
 Magnitude of the problem
 Bone mineral density (BMD) and
fracture
 Falls: etiology and risk factors
 Fracture and fall
Osteoporosis: shift in thinking
Low bone mass, microarchitectural deterioration of bone tissue
leading to enhanced bone fragility and a consequent increase in
fracture risk (Consensus Development Conference, 1991)

“[…] compromised bone strength predisposing a

person to an increased risk of fracture. Bone
strength primarily reflects the integration of
bone density and bone quality” (NIH Consensus
Development Panel on Osteoporosis JAMA 285:785-95; 2001)
 Osteoporosis in risk-and-outcome view

RISK FACTOR OUTCOME

Osteoporosis Fracture

Bone Bone
Bone
Quality and Mineral
Strength
Density

Architecture
Turnover rate
Damage accumulation
Normal vs osteoporosis
Breaking bones
Incidence of all-limb fractures

500

400
Rate per 100,000 population

300

200

100

0
0-4 5-14 15- 25- 35- 45- 55- 65- 75- 85+
24 34 44 54 64 74 84
Hip, vertebrae, and Colles
fractures
Fracture 2006 2051
Hip 20,700 60,000
Vertebrae 14,500 31,700
Colles 11,900 23,000
Humerus 7,500 16,300
Pelvis 4,100 9,800

Projected annual number of all-limb fractures in Australia aged

35+(Sanders et al, MJA 1999)
Lifetime risk of some diseases -
women
Any osteoporotic fracture 1/2
Hip fracture 1/6
Clinical vertebral fracture 1/4
Cancer (any site)* 2/5
Breast cancer* 1/8
Lung/bronchus* 1/16
Coronary heart diseases 1/4
Diabetes Mellitus 1/3

0 10 20 30 40 50 60 70
*, from birth Residual lifetime risk (%)
(from the age of 50)
Risk of death from hip fracture

50-year old women: Lifetime risk of mortality

from:
Hip Fracture: 2.8%
Breast Cancer: 2.8%
Endometrial Cancer: 0.7%

Cummings et al. Arch Intern Med 1989; 149: 2445-8

Impact of hip fractures

 25% die within 6 months (*)

 60% have restricted mobility (*)
 25% remain functionally more dependent
 Cardiac (8%) and pumonary complication
(4%)
 Transient heart attacks
 Non-union and avascular necrosis
Impact of vertebral fractures

 Symptomatic fx : Lifetime risk 1/4 women, 1/8 men

 Asymptomatic fx prevalence: 20-30%
 Back pain, functional limitation
 Decrease vital lung capacity
Impact of wrist fracture

 More common in women in their 50

 Post-traumatic arthritis
 Account for 39% of all physical therapy
sessions
 Reduced daily living activies

Melton LJ, J Bone Miner Res 2003

Fracture Prediction
A model for assessing fracture risk
Other factors (age,
weight, structural
factors)

Quadriceps
weakness
Falls
#
Postural
instability

Low bone mass

Interaction between BMD and fall-related factors in the

prediction of hip fracture
BMD and age
Changes in BMD with age

Peak bone density

Menopause
Osteopenia
Puberty Osteoporosis

Age
BMD and definition of “osteoporosis”

Gaussian distribution
Constant standard deviation
Decrease with advancing age

T-scorei = (BMDi – Peak BMD) / SD

• Define “osteoporosis” and “osteopenia”

T-score < -2.5 = “osteoporosis”

-2.5 < T-scores < -1 = “osteopenia”
Diagnosis - DEXA BMD
 Relationship (SD) to Norms
 T-Score - Reference Standard
 Comparison to “young normal” adult same sex
 Z-Score
 Comparison to age matched adult same sex
 Prevalence of osteoporosis

Women Men
70 90
T<-2.5 T<-2.5
80
60
70
50
60
40 50
Percent

Percent
30 40

30
20
20
10
10

0 0
60-69 70-70 80+ All 60-69 70-70 80+ All
Age group Age group
Fracture and BMD: summary of points

 BMD is the primary predictor of fracture risk

 Less than 50% of fractured individuals have low BMD (eg

osteoporosis)
Falls: etiology and risk factors
Falls

 The second leading cause of accidental deaths (Rivara

NEJM 1997)

 Health care costs associated with falls and rehabilitation

Incidence of falls in the elderly

50
Women Men

40
Incidence of fall (%)

30

20

10

0
60-69 70-79 80+
Age group (y)

Source: Dubbo Osteoporosis Epidemiology Study

Etiology of falls

 Accidents / environment 37%

 Weakness, balance, gait 12%
 Drop attack 11%
 Dizziness or vertigo 8%
 Orthostatic hypotension 5%
 Acute illness, medications, vision 18%
 Unknown 8%

Rubenstein et al JAGS 1988

Falls and Fractures
Relationship between falls and fractures

Falls Fx

 95% of hip fractures are caused by falls (Nyberg L, J Am

Geriatr Soc 1996)
Can we prevent fracture
by reducing falls?
Hip protector
Hip protectors reduced hip fracture risk

 Clinical trial: 1801 frail elderly individuals (age: 81 y) in

Finland
 78% women
 63% assisted walking
 Fracture incidence: 2.1% vs 4.6%/yr
 2.4% of falls resulted in hip fx when not wearing protector
vs 0.4% when wearing protector (80% reduction in risk)

P Kannus et al NEJM 2001

Primary prevention

 Intervention: adjustment in medications,

behavioral instructions, exercise programs aimed
at modifying risk factors
 One year follow up

Tinetti et al. 1994 NEJM

Primary prevention
% Control Intervention
50
Falling

40

30

20 i

10

0
0 3 6 9 12
Months
Tinetti et al. 1994 NEJM
Risk factor modifications for fracture

Change Estimated
change in fx
risk
Quit smoking 38%
Treat impaired vision 50%
Stop sedatives 40%
Hip protectors 50%?

Cummings et al. Unpublished data

Falls and fractures: summary
 Fracture, particularly hip fracture, is a serious public health
problem in the elderly

 Although low bone mineral density is a primary predictor

of fracture risk, it can not account for all fracture cases

 Fall is highly prevalent in the community and is a major

risk of fracture
Falls and fractures: summary

 Risk factors for fall also contribute to fractures

 Preventing falls can theoretically reduce fracture incidence

 A preventative program is required to reduce falls and

fractures
Treatment - Osteoporosis
 Indication for Pharmacologic Intervention
 T-score < -2.5 without other Risk Factors
 T-score < -1.0 – 2.5 with other Risk Factors
Pharmacological Therapy
 Anti-Resorptive Drugs
 Hormonal Replacement Therapy:
Estrogen/Progestin
 Bisphosphonates:
Alendronate, Ibandronate,
Risendronate, Raloxifene, Zoledronic Acid
 Selective Estrogen Receptor Modulators:
Raloxifene
 Calcitonin
 Bone Forming Drugs
 Teriparatide
 Recombinant Parathyroid Hormone
Bisphosphonates

 Long T1/2

 Side-Effects
 GI
 Jaw Osteonecrosis (Rare)

 Atypical Fractures
 Risk with Long term use
 Difficult to heal
 Conclusions

 Osteoporosis: Prevalence – Recognition is Key

 Need Effective Tx to  Fx Rate
 Nutrition
 Exercise
 Fall Prevention
 Medication
 Surgical Improvements Help
Thank you!