Presentation on theme: "Own the Bone Pilot Project Created February 2007; Revised March 2011"— Presentation transcript:
1 Own the Bone Pilot Project Created February 2007; Revised March 2011 Fragility FracturesKenneth J. Koval, MDLaura Tosi, MDAOA Committee for theOwn the Bone Pilot Project Created February 2007; Revised March 2011
2 PrevalenceMore than 34 million Americans suffer from osteoporosis or low bone mass80% are women1 in 2 women over 50 years old1 in 4 men over 50 years old1 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 2002The 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.
3 Annual incidence of common diseases Osteoporosis-fractureOccurrences vs Other Diseases2,000,0001,500,0001,500,000250,000hipAnnual incidence of common diseases1,000,000250,000 other sites513,000Heart Attack†500,000750,000 vertebral228,000184,300Osteoporotic fracturesStrokeBreast CancerSource: National Osteoporosis Foundation
4 1.5 Million Fractures Annually Vertebral Fractures:700,000+Wrist Fractures:200,000+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.Hip Fractures:300,000+Other Fractures:300,000+Source: National Osteoporosis Foundation, 2000
5 Burden of Disease $14 billion annually Approximately $38 million daily Congestive heart failure costs $8 billion annuallyAsthma costs $9.8 billion annuallyThere 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 Disease1 out of 4 osteoporotic hip fractures result in long-term nursing home careOne half of these are unable to walk without assistance24% greater risk of dying within one year1 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 - Fragility Fractures & Osteoporosis - What’s the link?Fragility fracturesFractures of the distal radius, proximal humerus, vertebrae and proximalfemur that result from minimal trauma, such as a fall from a standingheight.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.Sources:Bisphosphonates and Fracture healing in Orthopaedic Fracture PatientsOnly 23% of hip fracture patients received the care recommended on the basis of good practice standards.!Source: RAND Report
8 Alarming Fracture Statistics 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 yearRisk of mortality is times greater among hip fracture patients during the first 3 months after the fractureNearly 1 in 5 hip fracture patients ends up in a nursing home within a yearSource: Surgeon General’s Report, 2004, Jrnl of Bone and Mineral Research
9 The Costs Continue to Grow Fractures cost$18 billion/yearand expected toincrease if actionis not taken.
10 Risk Factors for Osteoporosis FemaleThin or small frameLow body weightSmokerIn 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 andHaving 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 ageHistory of fragility fractureFamily history- primary relative with osteoporosis or fragility fractureReaching Advanced age, andHaving a history of fragility fracture or a primary relative with a history of fragility fracture or Osteoporosis.
12 Risk Factors for Osteoporosis Post MenopausalHormonal imbalances can result in rapid bone lossWomen can lose up to 20% of their bone mass in 5-7 yearsIn 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 & BulimiaDiet low in calciumCertain medicationsLow testosterone in menEating disorders such as Anorexia and Bulimia,A diet low in calcium,Use of certain medications andLow testosterone in men are all risk factors as well.
14 Risk Factors for Osteoporosis Inactive lifestyleExcessive alcohol consumptionEating disorders such as Anorexia and Bulimia,A diet low in calcium,Use of certain medications andLow testosterone in men are all risk factors as well.
15 Ethnicity & Osteoporosis Hispanic women at highest risk13-16% withosteoporosis nowWhile 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 ½ century.36-49% of MexicanAmerican women 50+have experiencedsignificant bone loss
16 Ethnicity & Osteoporosis Caucasian & Asian-American women also high riskCaucasian 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 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.10% of African-American women 50+ have osteoporosis30% more have low bone density
18 Ethnicity & Osteoporosis 300,000 African-American women have osteoporosis80-95% of all fractures sustained by African-Americans 64+ are osteoporoticAfrican-American women more likely to die from hip fractures than White women300,000 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 Inadequately researched Men & OsteoporosisUnderdiagnosedUnrecognizedUnderreportedWhile 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.Inadequately researched
20 Men & Osteoporosis 2 million American men have osteoporosis 3 million more are at risk1/3 of male hip fractures related to osteoporosis1/3 of these men will not survive 1 year after fracture2 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 correctionEstrogen deficiency at an early age (<45 yrs)DementiaPoor health / frailtyRecent fallsLifelong low calcium intakeLow physical activityNot 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 fold following initial fractureHistory of fragility fracture is more predictive of future fracture than bone density
23 Diagnosis: Bone Densitometry Recommendations for bone densityAnyone with a fragility fractureAll women age 65 and olderPostmenopausal younger than 65 with risk factorsMen over 50 with risk factorsWho 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, andMen over the age of 50 with risk factors.
24 Treatment Goals Prevent future fractures Treat osteoporosis Decrease the risk of mortality after fractures
25 + = Treatment 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 DStronger Bones!StrongerBones!+=
26 Treatment There is a high prevalence of vitamin D insufficiency in: Nursing home residentsHospitalized patientsAdults with hip fractures
27 Treatment2. ExercisePhysical activity makes bones and muscles stronger and helps prevent bone loss.All types of physical activity can contribute to bone healthHigh impact exercise programs may be the most effective at preventing fragility fractures
28 Treatment 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:FracturesHospital admissions for traumaLoss of independenceInjury deathsFall3factorsthat contributeto fracturesForceFragilitySource: National Institute of Health/National Institute on Aging
29 Treatment 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
30 Treatment 5. Cessation of smoking Smoking can reduce bone mass, increase fracture risk and should be avoided for a variety of health reasons
31 Treatment 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 fracturesTypeBrand NameAlendronateFosamaxIbandronateBonivaRisedronateActonelRaloxifeneEvistaZoledronic AcidReclast
32 BisphosphonatesBisphosphonates 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 The FactsApproximately 125 cases of osteonecrosis have been linked to bisphosphonate usage. The majority of these cases have been administered through an IV to cancer patientsSource: Bamias A. Osteonecrosis of the jaw in cancer after treatment with bisphosphonates: incidence and risk factors. J Clin Oncol 2005;23(34):
34 BisphosphonatesA man with a hip fracture has a 1:3 chance of dying within a yearA woman with a hip fracture has a 1:4 chance of dying within a yearThe 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 useRelatively rare occurrence compared to fragility fracturesRisk/benefit analysis still favors bisphosphonate useSource: 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 Feb 23;305(8):783-9.
36 Treatment 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 Treatment 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
38 Fall Prevention in the Home Use handrails on stairs, bathroomKeep rooms free of clutterKeep floors clean but not slipperyWear supportive, low-heeled shoes. Don’t walk in socks; floppy slippersUse 100 watt bulbs in all roomsInstall ceiling lighting in bedroomsUse rubber matt in shower/tubKeep a flashlight at bedsideCheck 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 bathroomKeep rooms free of clutterKeep floor surfaces clean but not slipperyWear supportive, low-heeled shoes. Do not walk in socks or floppy slippersUse 100 watt bulbs in all roomsInstall ceiling lighting in bedroomsUse rubber matt in shower/tubKeep a flashlight at bedsideCheck posture in mirror often
39 BibliographyThe 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 Jan;90(1):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 Dec 21;153(12): Review.Bisphosphonates for osteoporosis. Favus MJ. N Engl J Med Nov 18;363(21):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 Feb 23;305(8):783-9.
40 More … Home Fall Prevention Keep floors free from clutterUse portable phone; keep phone and electrical wires out of walkwaysSkid-proof backing on carpets / scatter rugsKeep week’s supply of prescription medications on handDaily contact with family member / neighborContract with monitoring company for 24 hour response time in emergencyKeep floors free from clutterUse a portable phone and keep phone and electrical wires out of walkwaysPlace skid-proof backing on carpets and scatter rugsKeep a week’s supply of prescription medications on handArrange for daily contact with a family member or neighborContract with a monitoring company for 24 hour response time in an emergencyIf 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 toOTAaboutQuestions/CommentsReturn toGeneral/PrinciplesIndex