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11 Recognizing and Treating Patients at High Risk for Osteoporosis The First Step: Identifying Those At Risk for Fracture Kenneth G. Davis, MD, CPE, FAAFP.

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Presentation on theme: "11 Recognizing and Treating Patients at High Risk for Osteoporosis The First Step: Identifying Those At Risk for Fracture Kenneth G. Davis, MD, CPE, FAAFP."— Presentation transcript:

1 11 Recognizing and Treating Patients at High Risk for Osteoporosis The First Step: Identifying Those At Risk for Fracture Kenneth G. Davis, MD, CPE, FAAFP

2 2 This Day in History: May 15, 1876

3 3 Barbaro

4 4 Osteoporosis 2010 Definition: Osteoporosis is defined by the World Health Organization (WHO) in women as a bone mineral density 2.5 standard deviations below peak bone mass (20-year-old healthy female average) as measured by DXA.

5 55 Audience Response Question

6 6 My current knowledge and understanding of osteoporosis is best described by which of the following: 1.I should be giving this lecture. 2.I recognize most risk factors and treatment protocols but could use a refresher or tune-up. 3.I am a bit rusty but it will all come back to me. 4.Osteo - what?

7 7 Osteoporosis 2010 The link between age-related reductions in bone density and fracture risk goes back at least to Astley Cooper.

8 8 Osteoporosis 2010 The term "osteoporosis" and recognition of its pathological appearance is generally attributed to the French pathologist Jean Lobstein.

9 9 Osteoporosis 2010 The American endocrinologist Fuller Albright linked osteoporosis with the postmenopausal state.

10 10 Osteoporosis 2010 A major U.S. public health threat for 44 million men and women over age 50. Osteoporotic fractures responsible for: 500,000 Hospitalizations 800,000 ER visits 2.6 million physician visits 180,000 nursing home placements

11 11 Osteoporosis Prevalence in U.S. Alabama = 2 nd Georgia= 11 th Florida=22nd

12 12 Osteoporosis 2010 In 2005: > 2 million osteoporotic fractures reported. Treatment Costs = $17 Billion 90% of all fractures due to underlying bone fragility. 50% of women and 25% of men will have an osteoporosis- related fracture during their lifetime

13 13 Osteoporosis: Complications

14 14 Osteoporosis: Complications

15 15 Osteoporosis: Complications Functionality Post-Fracture Hip: 22 hospital days/ 102 days of limited activity. Vertebral: 26 hospital days / 159 days of limited activity. Forearm: 1 hospital day / 56 days of limited activity Fink, et al: Osteoporosis Intl, 2003

16 16 Morbidity After Vertebral Fractures Loss of height Back pain Deformity Pulmonary function Quality of life

17 17 Hip Fracture 1 yr. mortality= 20% Permanent disability= 30% Unable to walk independently = 40% Unable to carry out > 1 ADL = 80% Cooper, Am J. Med,1997

18 E

19 19 Quality of Life Depression. Sleep Disorder. Opioid dependence. Distorted body image. Loss of independence. AACE Osteoporosis Guidelines, Endocr Practice, 2003

20 20 Osteoporosis: Case Study Dan M. 84 y. o. Fell out of bunk at deer camp Fx hip Fatal Pneumonia

21 21 Practice Barriers and Gaps Physicians do not discuss risk factors with patients Diagnosis made most often after fracture Fewer than 2/3 of women over 65 have had bone density test. Only 20.4% of women over age 67 had BMD or preventive Rx within 6 months of fracture. Non- adherence Non-compliance

22 22 Audience Response Question

23 23 Audience Response Question Which of the following is NOT considered a risk factor for osteoporosis: 1. Taking an anticoagulant such as warfarin. 2. Age 3. Genetics 4. Education level

24 24 Risk Factors : Age Age trumps BMD Impact of age is at least 10x the risk of declining BMD.

25 25 Risk Factors: Fracture Hx Prior forearm fracture = 2x risk Women over 74 with vertebral fracture = 20% recur within a year. Risk ratio only lowered slightly by BMD

26 26 Risk Factors: Genetics The greatest influence on a womans peak BMD is heredity Hip fracture risks 50% higher with first degree relative 127% higher if hip fracture occurred in a parent

27 27 Risk Factors: Weight and BMI Weight under 127 lbs. BMI < 21 Increases risk of low BMD and fracture, especially in older women


29 29 Risk Factors: Menopause Peri-menopausal bone loss = 1-2% per year. Women with menopause before age 40 (spontaneous or induced) are at greater risk of low BMD than menstruating cohorts (up to age 70).

30 30 Risk Factors: Medications Glucocorticoids: 2x increase in risk Depot MDA Breast Cancer chemo agents

31 31 Risk Factors: Comorbidities Hyperthyroidism DM I Ankylosing Spondylitis Rheumatoid Arthritis

32 32 Lifestyle Approaches: Nutrition Women over 60 do not consume the recommended servings of dairy products, fruits, vegetables or grains. Healthy Eating Index score of these women is Out of a possible 100.

33 33 Nutrition: Calcium WHI: hip fractures significantly reduced in older women adherent to calcium/ vitamin D regimens. Calcium intake declines with age. Impaired absorption with age. Optimal intake: 1200 mg. daily


35 35 Nutrition: Calcium Dairy products supply 80% of calcium for women over 60. High elemental calcium content. High absorption rate Cost- efficient Spinach and wheat bran may inhibit absorption.

36 36 Audience Response Question

37 37 Audience Response Question Vitamin D: 1.Is not really a Vitamin 2.Is not affected by Sunscreens < 30 SPF 3.Is abundant in most fresh foods. 4.Has a narrow therapeutic window between efficacy and toxicity.

38 38 Nutrition: Vitamin D Is actually a steroid pro-hormone rather than a vitamin. Essential for intestinal absorption of calcium IU daily. Only food sources are fortified dairy products and fatty fish.

39 39 Nutrition: Vitamin D SPF > 8 blocks 97.5% of Vitamin D production. Low levels found in older, frail, chronically ill, housebound, or institutionalized women. Higher risk of Vitamin D deficiency in northern latitudes.

40 40 Nutrition: Vitamin D 60% - 100% of patients will have a low level. Over age 90: 100% are deficient. Adequate Vitamin D levels associated with increased bone mass, decreased rates of falls, and significant reductions in fractures.

41 41 Nutrition: Magnesium Most people over 40 are deficient in magnesium intake. Intake falls severely after age 70. Found in green leafy vegetables, grains, and nuts. Severe deficiency can cause hypocalcemia and Vitamin D resistance. No evidence to support use in prevention or treatment of osteoporosis.

42 42 Audience Response Question

43 43 Audience Response Question For older women, protein supplement may: 1.Help minimize bone loss 2.Shorten hospital stay for hip fracture and improve clinical outcomes. 3.Significantly lower rates of complication and mortality up to 7 months post- fracture. 4.All of the above

44 44 Nutrition: Protein For older women, protein supplement may: Help minimize bone loss Shorten hospital stay for hip fracture and improve clinical outcomes. Significantly lower rates of complication and mortality up to 7 months post- fracture.

45 45 Nutrition: Isoflavones Phytoestrogens found in soybeans, soy products and red clover. No evidence to support use in prevention or treatment of osteopenia or osteoporosis.

46 46 Exercise Weight –bearing and strength-training exercises are beneficial to bone development and maintenance. Mild to moderate exercise confers benefits. Exercise increased BMD 2% in PMP women. Exercise and strength training = 75% reduction in falls and injuries for women over 75

47 47 Exercise BMD in dominant arm of tennis players is greater than non-dominant arm.

48 48 Exercise Walking Jogging Running Strength-training exercises

49 49

50 50 Exercise Target areas most involved in osteoporotic fractures: Large extensor muscles of the back Thigh Upper arms Forearm

51 51 Exercise Water aerobics for the physically impaired. Exercises to strengthen back extensor muscles reduce risk of spine fracture in women with and without prior fracture and improve quality of life.

52 52 Osteoporosis: Case Study Lilly N. 81 y.o. 5ft, 4 in. 122 pounds Non-smoker Fell… hit shoulder.. Fx humerus

53 53 Audience Response Question

54 54 Audience Response Question Concerning falls: 1.They are a precipitating factor in 90% of fractures. 2.A third of women over age 50 fall at least once a year. 3.Over age 80, the fall rate declines for men, but not women. 4.Elevated Mg++ levels are protective.

55 55 Falls Precipitating factor in 90% of fractures. One- third of women over age 60 fall at least once a year. Over age 80, fall rate is 80%

56 56 Falls Risk Reduction: Exercises to improve balance and muscle strength Reducing fall hazards in the home Adjusting medications (Tapering and discontinuing use of BZDs, neuroleptics and anti-depressants found to reduce fall risk by 60%)

57 57 Alcohol Consumption Moderate alcohol intake possibly associated with BMD. Increased risk of falling and fracture with. 7 drinks a week. Two or more drinks in 6 hours = 20% of falls in working adults.

58 58 Audience Response Question

59 59 Audience Response Question Compared to non-smokers, women smokers: 1.Tend to lose bone more rapidly. 2.Have equivalent BMD 3.Reach menopause 2 years later. 4.Have a similar fracture rate.

60 60 Smoking Cessation Compared to non-smokers, women smokers: Tend to lose bone more rapidly. Have lower BMD Reach menopause 2 years earlier. Have a higher fracture rate. Second hand smoke also a risk factor.

61 61 BMD Testing All post-menopausal women with medical causes of bone loss. All women age 65 and over. Women age 50 and over with one of the following risk factors: 1. Previous fracture after menopause. 2. BMI <21 3. Parental hip fracture 4. Current smoker 5. Rheumatoid Arthritis 6. Excessive ETOH


63 63 Summary Osteoporosis is everywhere. Most women over 65 have not had screening. Most patients with osteoporosis go untreated. Adherence and compliance are suboptimal and lead top poor outcomes. We need to improve our communications with patients.

64 64 Adherence and Compliance Compliance: follows instructions about dose and interval. Persistence: time from initiation to discontinuation. Adherence: Persistence + compliance. (Refills)

65 65 Audience Response Question

66 66 Audience Response Question Which of the following statements about health literacy is true?: 1. Health literacy is a weak predictor of health status 2. The mean reading level in America is 8 th grade. 3. Most illiteracy occurs in foreigners and ethnic groups. 4. The majority of Americans can read and understand prescription instructions.

67 67 Health Literacy Health literacy is believed to be a stronger predictor of health outcomes than social and economic status, education, gender, and age. American Medical Association, 1999.

68 68 Health Literacy Red and yellow are highest rates of low level literacy.

69 69 Health Literacy Strongest predictor of health status. 30 million Americans have literacy skills defined as "below basic. (difficulty comprehending directions for taking medicine or understanding an appointment slip.)

70 70 Health Literacy the cognitive and social skills which determine the motivation and ability of individuals to gain access to, understand, and use information in ways that promote and maintain good health. WHO, 1998, p. 10

71 71 Health Literacy the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions" Nielsen-Bohlman, Panzer, & Kindig, 2004, p. 32).

72 72 Health Literacy "a constellation of skills, including the ability to perform basic reading and numerical tasks required to function in the health care environment" American Medical Association Ad Hoc Committee on Health Literacy for the Council on Scientific Affairs, 1999,

73 73 Health Literacy 25% functionally illiterate 30% marginally illiterate Mean reading level = 8 th grade Medicaid reading level = 5 th grade

74 74 Health Literacy Osborne (2005) reports that a 1992 survey of literacy in the United States found that: "nearly half of all adults...have at most, only marginal literacy skills. This means they are apt to have trouble understanding complex text, filling out bank statements and using maps and schedules"

75 75 Health Literacy Another 63 million are at the "basic" level. These individuals find it difficult to calculate a dose of an over-the-counter medication for a child or comprehend a consent form. Most of the almost 50% of the US population in the below basic and basic literacy levels are native-born, white adults.

76 76 Health Literacy 44% over age 65 scored at lowest level Other risk factors for literacy problems: Poverty Health problems Incarceration

77 77

78 78 Health Literacy Readability Scales SMOG: To calculate SMOG 1.Count a number of sentences (at least:10 from the start of a text, 10 from the middle, and 10 from the end). 2.In those sentences, count the polysyllables (words of 3 or more syllables). 3.Calculate using A version is also given which is more easily used for mental math and is sometimes known as the SMOG Index: 1.Count the number of polysyllabic words, excluding proper nouns, in a sample of thirty sentences. 2.Take the square root of the nearest perfect square 3.Add 3

79 79 Health Literacy

80 80 Health Literacy Menopause__sometimes called the change of life__is a natural part of a woman's life. As you get older, your body produces less of the hormone estrogen. As you start making less estrogen, you may notice some physical changes like hot flashes or vaginal dryness. Having les natural estrogen may also be linked to certain serious health problems such as osteoporosis and heart disease. Inside, you will find comprehensive information about osteoporosis. The chart below describes some of the most common changes associated with menopause and ways in which you can manage the effects of these changes.

81 81 SMOG Grade Educational Level 0-6= low literacy 7= junior high school 9=some high school 10=some high school 11= high school junior 12= high school graduate 13-15= some college 16 = college degree 17= post- grad level 19+= post grad degree Soap Opera Digest Ladies Home Journal Readers Digest Newsweek Sports Illustrated Time Magazine New York Times Atlantic Monthly Harvard Business Review IRS Tax Code

82 82 Health Literacy A majority of available health information is written at a 12 th grade reading level. This exceeds the eighth grade reading level of the average American. Wilson, 2003

83 83 Health Literacy 1.Use short simple sentences 2.Summarize key points at end of each section. 3.Write in the active voice. 4.Clarify with examples. 5.Avoid technical terms and acronyms. 6.Use simple relevant graphics. 7.Use large font. 8.Avoid blue, green, and lavender.


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