1. Kenneth J. Koval, MD Laura Tosi, MD AOA Committee for the Own the Bone Pilot Project Created 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

3. Source: National Osteoporosis Foundation Osteoporosis-fracture Occurrences vs Other Diseases 0 500,000 1,000,000 1,500,000 2,000,000 Osteoporotic fractures 513,000 Heart Attack Stroke † Breast Cancer 250,000 hip 184,300 750,000 vertebral 250,000 other sites 228,000 Annual incidence of common diseases 1,500,000

4. Wrist Fractures: 200,000+ Hip Fractures: 300,000+ Vertebral Fractures: 700,000+ Other Fractures: 300,000+ Source: National Osteoporosis Foundation, 2000 1.5 Million Fractures Annually

5. $14 billion annually Burden of Disease Approximately $38 million daily Congestive heart failure costs $8 billion annually 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

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 - Only 23% of hip fracture patients received the care recommended on the basis of good practice standards.! Source: RAND Report

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 Alarming Fracture Statistics Source: Surgeon General’s Report, 2004, Jrnl of Bone and Mineral Research

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

10. Risk Factors for Osteoporosis Female Thin or small frame Low body weight Smoker

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

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

13. Risk Factors for Osteoporosis Amenorrhea, Anorexia & Bulimia Diet low in calcium Certain medications Low testosterone in men

14. Risk Factors for Osteoporosis Inactive lifestyle Excessive alcohol consumption

15. Ethnicity & Osteoporosis z 13-16% with osteoporosis now z 36-49% of Mexican American women 50+ have experienced significant bone loss z Hispanic women at highest risk

16. Ethnicity & Osteoporosis Caucasian & Asian-American women also high risk

17. Ethnicity & Osteoporosis 10% of African-American women 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

19. Underdiagnosed Unrecognized Underreported Inadequately researched Men & Osteoporosis

20. 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

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

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

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

25. 1.Calcium and Vitamin D All patients with bone loss or the potential for bone loss should be educated on the appropriate intake of calcium and vitamin D + = Stronger Bones! Stronger Bones! Treatment

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

27. 2. Exercise Physical activity makes bones and muscles stronger and helps prevent bone loss. All types of physical activity can contribute to bone health High impact exercise programs may be the most effective at preventing fragility fractures Treatment

28. 3. Fall Prevention Each year, more than 1.6 million older U.S. adults go to emergency departments for fall-related injuries. Among older adults, falls are the number one cause of: Fractures Hospital admissions for trauma Loss of independence Injury deaths Source: National Institute of Health/National Institute on Aging Fall 3 factors that contribute to fractures Force Fragility Treatment

29. 4. BMD/DXA Testing Single most important diagnostic test to predict whether a person will have a fracture in the future. It helps diagnose osteoporosis and predict the risk for having a fracture by comparing bone density to the bones of an average healthy young adult Treatment

30. 5. Cessation of smoking Smoking can reduce bone mass, increase fracture risk and should be avoided for a variety of health reasons Treatment

31. 6. Pharmacotherapy – Treatment & prevention Bisphosphonates are approved by the FDA and can help stop or slow bone loss, or help form new bone, and reduce the risk of fractures TypeBrand Name AlendronateFosamax IbandronateBoniva RisedronateActonel RaloxifeneEvista Zoledronic AcidReclast Treatment

32. Bisphosphonates Bisphosphonates are bone-building drugs that prevent bone resorption and remain important treatment options for patients at risk of debilitating fractures. But, where does the impact on dental health figure into the equation? What is the true incidence of osteonecrosis of the jaw (ONJ)?

33. Source: Bamias A. Osteonecrosis of the jaw in cancer after treatment with bisphosphonates: incidence and risk factors. J Clin Oncol 2005;23(34):8580-7. Approximately 125 cases of osteonecrosis have been linked to bisphosphonate usage. The majority of these cases have been administered through an IV to cancer patients The Facts

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 Bisphosphonates

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 Source: Bisphosphonate use and the risk of subtrochanteric or femoral shaft fractures in older women. Park-Wyllie LY, Mamdani MM, Juurlink DN, Hawker GA, Gunraj N, Austin PC, Whelan DB, Weiler PJ, Laupacis A. JAMA. 2011 Feb 23;305(8):783-9.

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 Treatment

37. 8. Physician Referral A letter sent to the primary care physician can provide information regarding the patient’s fracture and recommend appropriate measures be taken Treatment

38. Use handrails on stairs, bathroom Keep rooms free of clutter Keep floors clean but not slippery Wear supportive, low-heeled shoes. Don’t walk in socks; 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 Fall Prevention in the Home

39. 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 Return to General/Principles Index If you would like to volunteer as an author for the Resident Slide Project or recommend updates to any of the following slides, please send an e-mail to ota@ota.orgota@ota.org

40. Bibliography Bisphosphonate use and the risk of subtrochanteric or femoral shaft fractures in older women. Park-Wyllie LY, Mamdani MM, Juurlink DN, Hawker GA, Gunraj N, Austin PC, Whelan DB, Weiler PJ, Laupacis A. JAMA. 2011 Feb 23;305(8):783-9. The American Orthopaedic Association's "own the bone" initiative to prevent secondary fractures. Tosi LL, Gliklich R, Kannan K, Koval KJ. J Bone Joint Surg Am. 2008 Jan;90(1):163-73. Primary care-relevant interventions to prevent falling in older adults: a systematic evidence review for the U.S. Preventive Services Task Force. Michael YL, Whitlock EP, Lin JS, Fu R, O'Connor EA, Gold R; US Preventive Services Task Force. Ann Intern Med. 2010 Dec 21;153(12):815-25. Review. Bisphosphonates for osteoporosis. Favus MJ. N Engl J Med. 2010 Nov 18;363(21):2027-35.