Management of osteoporosis of the oldest old

Advancing care: optimizing osteoporosis treatment in the older and oldest old population

Osteoporosis is a critical public health issue, particularly in the "older" (those aged over 75) and "oldest old" population (those aged 85 and above), who are at a heightened risk for fractures and related complications. This article reviews current osteoporosis treatments tailored for these age groups, emphasizing the balance between efficacy and safety, while considering cost/benefit aspects. We discuss pharmacological therapies available nowadays and their respective benefits and risks in the old population, based on the available literature on the subject. Special attention is given to specific features of this age category, like challenges of polypharmacy, physiological changes associated with age, comorbidities and patient adherence. This paper highlights the need for individualised treatment plans that consider the patient's overall health status, life expectancy and quality of life and the importance of continued innovation and personalized care in managing osteoporosis especially among the "older" population.

Impact of dementia and mild cognitive impairment on bone health in older people

Mild cognitive impairment, dementia and osteoporosis are common diseases of ageing and, with the increasingly ageing global population, are increasing in prevalence. These conditions are closely associated, with shared risk factors, common underlying biological mechanisms and potential direct causal pathways. In this review, the epidemiological and mechanistic links between mild cognitive impairment, dementia and skeletal health are explored. Discussion will focus on how changes in brain and bone signalling can underly associations between these conditions, and will consider the molecular and cellular drivers in the context of inflammation and the gut microbiome. There is a complex interplay between nutritional changes, which may precede or follow the onset of mild cognitive impairment (MCI) or dementia, and bone health. Polypharmacy is common in patients with MCI or dementia, and there are difficult prescribing decisions to be made due to the elevated risk of falls associated with many drugs used for associated problems, which can consequently increase fracture risk. Some medications prescribed for cognitive impairment may directly impact bone health. In addition, patients may have difficulty remembering medication without assistance, meaning that osteoporosis drugs may be prescribed but not taken. Cognitive impairment may be improved or delayed by physical activity and exercise, and there is evidence for the additional benefits of physical activity on falls and fractures. Research gaps and priorities with the aim of reducing the burden of osteoporosis and fractures in people with MCI or dementia will also be discussed.

Mid-upper arm circumference as a screening tool for identifying physical frailty in community-dwelling older adults: The Korean Frailty and Aging Cohort Study

AIMS

Frailty in older adults is influenced by various factors, such as poor nutritional status. Mid-upper arm circumference (MUAC) is a validated, simple, and non-invasive tool for assessing nutritional status. Despite its potential, no study has explored the association between MUAC and physical frailty in older adults. This study aims to investigate this association and assess whether MUAC can be used as a screening tool in community and primary clinical practice.

METHODS

A cross-sectional study was conducted with 1178 participants aged 71.8 to 86.7 years from the 2019 Korean Frailty and Aging Cohort Study (KFACS). Physical frailty was defined using the Fried frailty phenotype criteria. MUAC was measured as the average circumference of both upper arms without compressing the subcutaneous tissue. Odds ratios (ORs) and 95% confidence intervals (CIs) for physical frailty, stratified by sex, were estimated using multiple logistic regression analysis after adjustments.

RESULTS

MUAC was lower in physically frail men compared with non-frail men (28.0 ± 2.9 vs. 29.4 ± 2.6 cm, P < 0.001). MUAC was negatively correlated with the Frailty Index (r = -0.155, P < 0.001). Multiple logistic regression analysis revealed that MUAC was an independent factor for physical frailty in men (OR  0.986, 95% CI  0.973-1.000, P = 0.049). The optimal MUAC cutoff for identifying physical frailty in men was 28.2 cm (sensitivity 60.7%, specificity 71.4%, AUC  0.672, 95% CI 0.595-0.749, P < 0.001). No significant results were found for women.

CONCLUSION

Low MUAC is significantly associated with physical frailty in older men, suggesting the potential for MUAC to be utilized as a screening tool for physical frailty in community and primary clinical settings. Geriatr Gerontol Int 2024; 24: 1292-1299.

The Use of Bone Density Scan in Monitoring Treatment Response in Patients Diagnosed with Osteoporosis: A Retrospective Cohort Study

Osteoporosis is characterized as a metabolic bone disease defined by low bone mineral density (BMD) and bone tissue degeneration, particularly a reduction in the number of trabeculae and a drop in cortical bone thickness, and a rise in porosity, which is mainly due to an imbalance between bone resorption and formation. As a result, it increases bone fragility, and the susceptibility to fracture increases, especially among the elderly. The objective is to assess the effectiveness of dual-energy X-ray absorptiometry (DXA) scan in monitoring the response to osteoporosis treatment and compare the scan's response to different osteoporosis treatments. This retrospective cohort study included 51 adults selected from 300 patients diagnosed with osteoporosis based on World Health Organization (WHO) diagnostic criteria of a T-score of -2.5. Data were acquired from the electronic medical records between 2016 and 2019 from a private hospital in Dubai, United Arab Emirates (UAE). The study included sociodemographic characteristics, biomedical parameters, comorbidities, history of fracture, medications, laboratory, and DXA scan results. Ninety-four percent of the patients were females; the mean (±SD) age was 58.1 ± 11.5 years. Most patients were expatriates (84.3%), of which Asian ethnicity was 66.7%. The mean (±SD) duration of osteoporosis was 2.82 ± 1.8 years. Eleven (21.6%) patients had a history of fragility fracture. Ninety-six percent of the patients had vitamin D deficiency. One-third (29.4%) of the patients had hyperparathyroidism. Alendronate/cholecalciferol, received by nine patients (17.6%), showed a significant improvement (p = 0.018) in the BMD of the femoral neck among the study group. In conclusion, the DXA scan as a monitoring tool has shown a significant improvement in the BMD of the femoral neck among patients taking alendronate/cholecalciferol treatment compared to other medications.

Telomere Length and Risk of Incident Fracture and Arthroplasty: Findings From UK Biobank

We investigated independent associations between telomere length and risk of fracture and arthroplasty in UK Biobank participants. Leukocyte telomere length (LTL) was measured in baseline samples using a validated polymerase chain reaction (PCR) method. We used, in men and women separately, Cox proportional hazards models to calculate the hazard ratio (HR) for incident fracture (any, osteoporotic) or arthroplasty (hip or knee) over 1,186,410 person-years of follow-up. Covariates included age, white cell count, ethnicity, smoking, alcohol, physical activity, and menopause (women). In further analyses we adjusted for either estimated bone mineral density (eBMD) from heel quantitative ultrasound, handgrip strength, gait speed, total fat mass (bioimpedance), or blood biomarkers, all measured at baseline (2006-2010). We studied 59,500 women and 51,895 men, mean ± standard deviation (SD) age 56.4 ± 8.0 and 57.0 ± 8.3 years, respectively. During follow-up there were 5619 fractures; 5285 hip and 4261 knee arthroplasties. In confounder-adjusted models, longer LTL was associated with reduced risk of incident knee arthroplasty in both men (HR/SD 0.93; 95% confidence interval [CI], 0.88-0.97) and women (0.92; 95% CI, 0.88-0.96), and hip arthroplasty in men (0.91; 95% CI, 0.87-0.95), but not women (0.98; 95% CI, 0.94-1.01). Longer LTL was weakly associated with reduced risk of any incident fracture in women (HR/SD 0.96; 95% CI, 0.93-1.00) with less evidence in men (0.98; 95% CI, 0.93-1.02). Associations with incident outcomes were not materially altered by adjustment for heel eBMD, grip strength, gait speed, fat mass, or blood biomarker measures. In this, the largest study to date, longer LTL was associated with lower risk of incident knee or hip arthroplasty, but only weakly associated with lower risk of fracture. The relative risks were low at a population level, but our findings suggest that common factors acting on the myeloid and musculoskeletal systems might influence later life musculoskeletal outcomes. © 2022 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).

The Impact of Frailty, Falls and Cognition on Osteoporosis Management in the Oldest Old

Data and clinical guidelines on the management of osteoporosis in nonagenarians are lacking. The aim of this study was to assess the characteristics of osteoporosis management and identify any gaps or trends in a cohort of nonagenarians who were newly diagnosed with osteoporosis during an inpatient admission. A retrospective analysis of nonagenarians admitted to the medicine department of a tertiary hospital who were newly diagnosed with osteoporosis based on extracted ICD-10 codes. Baseline demographics, frailty based on the clinical frailty scale, comorbidities, initiation, compliance and adverse effects on osteoporosis medication were analysed. Mean age of the study group was 93.0 ± 2.5 years. There was a high prevalence of frailty (71.7%), cognitive impairment (34.2%) and recurrent falls (30.0%). 82.5% were started on osteoporosis treatment with denosumab (43.4%) being the most prescribed, followed by alendronate (41.4%). Cognitive impairment and male gender were associated with less likelihood of being on osteoporosis treatment on multivariate analysis. Having a previous fracture was associated with a higher likelihood of being on osteoporosis treatment. There was a discontinuation rate of 49.5% with a mean time to discontinuation of 26.3 ± 22.9 months. There was a high rate of osteoporosis treatment in nonagenarians with osteoporosis. The presence of previous fractures was associated with initiation of osteoporosis medications, whereas frailty and falls had no impact on treatment decisions. Cognitive impairment and males were associated with a lower rate of initiation of osteoporosis medication.

Compromised intestinal integrity in older adults during daily activities: a pilot study

BACKGROUND

Malnutrition is a common and significant problem in older adults. Insight into factors underlying malnutrition is needed to develop strategies that can improve the nutritional status. Compromised intestinal integrity caused by gut wall hypoperfusion due to atherosclerosis of the mesenteric arteries in the aging gastrointestinal tract may adversely affect nutrient uptake. The presence of compromised intestinal integrity in older adults is not known. The aim of this study is to provide a proof-of-concept that intestinal integrity is compromised in older adults during daily activities.

METHODS

Adults aged ≥75 years living independently without previous gastrointestinal disease or abdominal surgery were asked to complete a standardized walking test and to consume a standardized meal directly afterwards to challenge the mesenteric blood flow. Intestinal fatty acid-binding protein (I-FABP) was measured as a plasma marker of intestinal integrity, in blood samples collected before (baseline) and after the walking test, directly after the meal, and every 15 min thereafter to 75 min postprandially.

RESULTS

Thirty-four participants (median age 81 years; 56% female) were included. Of the participants, 18% were malnourished (PG-SGA score ≥ 4), and 32% were at risk of malnutrition (PG-SGA score, 2 or 3). An I-FABP increase of ≥50% from baseline was considered a meaningful loss of intestinal integrity and was observed in 12 participants (35%; 8 females; median age 80 years). No significant differences were observed in either baseline characteristics, walking test scores, or calorie/macronutrient intake between the groups with and without a ≥ 50% I-FABP peak.

CONCLUSION

This study is first to indicate that intestinal integrity is compromised during daily activities in a considerable part of older adults living independently.

Mesenchymal stem cells plus bone repair materials as a therapeutic strategy for abnormal bone metabolism: Evidence of clinical efficacy and mechanisms of action implied

The regeneration process of human bones is very complicated, the management and treatment of bone damage caused by diseases are the main problems faced by clinicians worldwide. It is known that cell-based stem cell therapy together with biomaterials is a fast-developing method of tissue regeneration. This review focuses on the different types and main characteristics of scaffolds and stem cells suitable for bone regeneration, and aims to provide a state-of-the-art description of the current treatment of common bone metabolism related diseases such as osteoarthritis, osteoporosis and osteosarcoma and the strategies based on stem cell biological scaffolds used in bone tissue engineering. This method may provide a new treatment option for the treatment of common bone metabolism-related diseases that cannot be cured by ordinary and routine applications. Three databases (PubMed, CNKI and Web of Science) search terms used to write this review are: "arthritis", "osteoporosis", "osteosarcoma", "bone tissue engineering", "mesenchymal stem cells", "materials", "bioactive scaffolds" and their combinations, and the most relevant studies are selected. As a conclusion, it needs to be emphasized that despite the encouraging results, further development is needed due to the need for more in-depth research, standardization of stem cell manufacturing processes, large-scale development of clinical methods for bone tissue engineering, and market regulatory approval. Although the research and application of tissue regeneration technology and stem cells are still in their infancy, the application prospect is broad and it is expected to solve the current clinical problems.

Abaloparatide followed by alendronate in women ≥80 years with osteoporosis: post hoc analysis of ACTIVExtend

Supplemental Digital Content is available in the text

Objective:

Fracture risk increases with age, but few studies focus on persons ≥80 years. In the ACTIVE trial, treatment with abaloparatide for 18 months reduced osteoporotic fracture risk and increased bone mineral density. These effects were maintained with 24 months alendronate treatment in ACTIVExtend. We postulated that similar improvements in bone mineral density and safety would be demonstrated in women ≥80 years.

Methods:

Post hoc analyses of bone mineral density and fracture incidence in women with osteoporosis at high risk of fracture ≥80 years from ACTIVExtend.

Results:

In total, 56 women aged ≥80 years at ACTIVE baseline entered the ACTIVExtend study; 46 of these completed the study. Mean age was 83.3 years; other baseline characteristics were similar. At the end of ACTIVE, bone mineral density increased at all sites for abaloparatide versus placebo. Bone mineral density increased in parallel in both groups during alendronate therapy (19 to 43 months) in ACTIVExtend. At month 43, mean percent change in bone mineral density from baseline was 17.2% abaloparatide/alendronate versus 8.6% placebo/alendronate (P < 0.0001) at the lumbar spine, 5.3% abaloparatide/alendronate versus 3.0% placebo/alendronate (P = 0.024) at the total hip, and 4.6% abaloparatide/alendronate versus 3.1% placebo/alendronate (P = 0.044) at the femoral neck. Fracture incidence was low and did not differ significantly between groups. Sequential treatment with abaloparatide followed by alendronate was well tolerated; the proportion of participants reporting adverse events was similar between groups.

Conclusions:

Sequential treatment with abaloparatide followed by alendronate (43 months follow-up) in this small subgroup of ACTIVExtend participants suggests abaloparatide is well tolerated and effective in women aged ≥80 years.

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Bone Mineral Density in Severely Obese Women: Health Risk and Health Protective Risk Factors in Three Different Bone Sites

Factors associated with bone mineral density (BMD) are poorly known in severely obese individuals i.e., a body mass index (BMI) > 35 kg/m2. The objectives of this study were to describe the bone health profile of severely obese Brazilian women, to identify the health risk and health protective factors for BMD in this group and to assess whether these factors vary according to three different bone sites. BMD was assessed using dual-energy X-ray absorptiometry (DXA). This study analyzed baseline data from 104 women who had an average BMI of 43.7 ± 4.5 kg/m2 and presented the following BMD status: 1.283 ± 0.094 g/cm2 for total body, 1.062 ± 0.159 g/cm2 for vertebral column and 1.195 ± 0.134 g/cm2 for hip. They took part in the "Effect of nutritional intervention and olive oil in severe obesity" randomized clinical trial (DieTBra Trial). The risk factors negatively associated with lower BMD were age ≥50 years for the three bone sites i.e., total body, vertebral column and hip. Smoking for total body BMD (p = 0.045); BMI ≥ 50kg/m2 for vertebral column and hip; menopause for hip; high C-reactive protein (CRP) levels (p = 0.049), insufficient zinc (p = 0.010) and previous fracture for vertebral column (p = 0.007). The protective factors positively associated with BMD were physical activity (≥150 min/week (p = 0.001)) for hip; type 2 diabetes mellitus (DM2) (p < 0.0001) total body and adequate vitamin D levels from food consumption (p = 0.039) for vertebral column. A BMI ≥ 50 kg/m2 was a risk factor for lower BMD. The findings showed that protective and risk factors varied by bone site. The original study is registered with ClinicalTrials.gov. (protocol number: NCT02463435).

Real-world effectiveness of osteoporosis treatment in the oldest old

We studied effectiveness of osteoporosis treatment in women older than 80 years, who often are not included in clinical trials. Treatments were as effective on bone density and fractures as in younger women.

INTRODUCTION

To study real-world effectiveness of osteoporosis treatment on BMD and fractures in the oldest old women (≥ 80 years) compared with women (60-79 years) in the clinical setting using Swedish health register data.

METHODS

National registers and data from DXA machines were used to study effectiveness of all available osteoporosis treatments in women 60-79 and ≥ 80 years using three approaches: (1) Total Hip BMD change up to 8 years after treatment start; (2) fracture incidence where patients served as their own controls, comparing the first 3 months after treatment start with the subsequent 12 months; and (3) comparison of fracture incidence post-fracture in women ≥ 80 years treated with osteoporosis treatment or calcium/vitamin D.

RESULTS

Analysis 1: Total Hip BMD increased by up to 6.7% and 7.7% in women 60-79 and ≥ 80 years old, respectively. The mean increase in BMD was 1.1%-units per year in both age groups. Analysis 2: Relative to the 3-month baseline, fracture incidence decreased during the subsequent 12 months of treatment. Incidence rate ratios were estimated at 0.65, 0.74, 0.29, and 0.81 for any, hip, vertebral, and non-hip-non-vertebral fracture, respectively. Analysis 3: A 24-month incidence of any fracture in women ≥ 80 years given post-fracture osteoporosis treatment was lower (HR = 0.78) than in women given calcium/vitamin D, but treatment allocation was not random, with lower mortality (HR = 0.51) in patients receiving OP treatment.

CONCLUSIONS

Osteoporosis medication in women > 80 years in clinical practice likely works, and the magnitude of effect is similar to what was estimated in younger women. The choice between osteoporosis treatment and calcium/vitamin D after fracture in women ≥ 80 years is not random but appears associated with the patient's health status and presence of vertebral fractures, rather than the known risk profile of sustaining a fracture at a high age.

Fall Prevention and Anti-Osteoporosis in Osteopenia Patients of 80 Years of Age and Older: A Randomized Controlled Study

To evaluate the effects of two fall‐prevention and anti‐osteoporotic protocols in elderly patients with osteopenia (OPA).

Methods

The present randomized controlled study included patients with OPA (n =123). The age of these patients was ≥80 years old, with the mean age of 83.54 ± 2.99 years, and the male‐to‐female ratio was 2.97:1.00. Fall‐prevention guidance was given to all patients. Patients in the experiment group (n = 62) orally received 600 mg/d of calcium carbonate, 0.5 μg/d of alfacalcidol, and 70 mg/week of alendronate, while patients in the control group (n = 61) orally received 600 mg/d of calcium carbonate and 0.5 μg/d of alfacalcidol for 18 months. The grip strength, gait speed, bone turnover markers, serum calcium, serum phosphorus, parathyroid hormone (PTH), and bone mineral density were measured, and the Timed Up and Go (TUG) test and the chair rising test (CRT) were performed. Falls, fragility fractures, medication compliance, and side effects of the drugs were recorded.

Results

The serum levels of bone turnover markers (type I procollagen amino‐terminal peptide [P1NP], type I collagen carboxyl terminal peptide [β‐CTx], and osteocalcin [OC]) decreased, while the bone mineral density of the lumbar spine and bilateral femoral neck increased after treatment in the experiment group (P < 0.05, P < 0.01). The rate of change in bone mineral density of the bilateral femoral neck was higher in the experiment group than the control group (3.43% vs 0.03%, P < 0.05; 2.86% vs −0.02%, P < 0.01). After treatment, the proportion of patients with increased hip T scores in the experiment group (66.1%, 41/62) was significantly higher than the proportion (35.0%, 21/60) in the control group (P = 0.001). The incidence of fall decreased in both groups after treatment compared to that before treatment (54.8% vs 33.9% and 54.1% vs 36.7%, respectively; P < 0.05). The incidence of fragility fractures was lower in the experiment group than the control group (8.1% vs 20.0%, P = 0.057). During the intervention period, the incidence of fragility fractures in patients who did not fall (3.8%, 3/79) was significantly lower than that in patients who fell (32.6%, 14/43) (P = 0.000). The risk of fragility fractures was significantly lower in patients who did not fall compared to patients who fell (relative risk: 0.117, 95% confidence interval: 0.035–0.384).

Conclusion

The combination of alendronate sodium with alfacalcidol and calcium can significantly improve the bone mineral density of the lumbar spine and femoral neck. For older patients with OPA, subjectively paying attention to avoiding falls can significantly reduce the risk of fragility fractures.

Compositional Influence of Movement Behaviors on Bone Health during Aging

INTRODUCTION AND PURPOSE

Physical activity (PA) is considered the best nonpharmacological treatment for the decrease in bone mass (BM) produced during aging. Therefore, it is essential to assess how the time spent in PA is distributed to control further changes. This work examines the relationship between movement behaviors and BM during aging, using compositional data analysis.

METHODS

We studied 227 older people 65 to 94 yr old (102 men and 125 women), divided by sex and bone status, over a period of 4 yr. Time spent in sedentary behavior (SB), light PA (LPA), and moderate to vigorous PA (MVPA), was assessed using accelerometry. BM was determined by dual-energy x-ray absorptiometry.

RESULTS

The changes in MVPA were positively associated with the rate of BM decay at spine and leg in the whole sample and men's subgroup (P ≤ 0.05). In women, the rate of BM decay at spine and Ward's triangle were negatively associated with SB changes, and BM decay at femoral neck and Ward's triangle were positively associated with LPA (P ≤ 0.05).

CONCLUSION

Increasing MVPA related to other movement behaviors produces improvements in the rate of bone change in older men, whereas to increase LPA and maintain MVPA would be the best approach to enhance BM in older women.

Effects of abaloparatide on bone mineral density and risk of fracture in postmenopausal women aged 80 years or older with osteoporosis

OBJECTIVE

Advanced age is an important risk factor for fracture. The Abaloparatide Comparator Trial In Vertebral Endpoints (ACTIVE) trial showed that subcutaneous abaloparatide increased bone mineral density (BMD) and reduced the risk of vertebral and nonvertebral fractures in postmenopausal women with osteoporosis. This study describes the effects of abaloparatide in the subgroup of women aged 80 or more years in ACTIVE.

METHODS

Post hoc analyses of BMD and fracture incidence in this subgroup of women who received abaloparatide or placebo in the 18-month, phase 3, double-blind, randomized controlled ACTIVE trial.

RESULTS

The mean ages of the women ≥80 years were 81.9 and 81.7 years in the placebo (n = 43) and abaloparatide (n = 51) groups, respectively. The increases in BMD from baseline to 18 months with abaloparatide treatment were 3.9% at the total hip (P < 0.001), 3.6% at the femoral neck (P < 0.01), and 12.1% at the lumbar spine (P < 0.001), and were similar to those observed in the overall population. Abaloparatide therapy was associated with numerical, but not statistically significant, reductions in the risk of vertebral and nonvertebral fractures in this subpopulation, compared with placebo. The proportion of participants reporting adverse events was similar between treatment groups and between the older subgroup and the overall population.

CONCLUSION

Abaloparatide was effective in increasing BMD in the very elderly subgroup of ACTIVE, with a safety profile similar to that of the overall study population.

Efficacy of Xianling Gubao capsule in treating sarco-osteopenia: Protocol for a systematic review and meta-analysis

BACKGROUND

Sarco-osteopenia (SOP) is a new type of geriatric syndrome, resulting from the combination of sarcopenia (SP) and osteoporosis (OP). Xianling Gubao capsule (XLGBC), made from several traditional Chinese medicine, is reported to have a therapeutic effect on diseases of bones and joints. This protocol will be designed to assess the efficacy of XLGBC in the treatment of SOP.

METHODS

Relevant randomized controlled trial literatures evaluating the effect of XLGBC on patients with SOP will be obtained by searching the following 7 electronic databases: Cochrane Library, PubMed, Embase, Chinese National Knowledge Infrastructure (CNKI), Chinese Scientific Journal Database (VIP), Chinese Biomedical and Medical Database (CBM), and Wanfang Database, from inception to March 2019. The primary outcomes will be bone mineral density, skeletal muscle mass index, handgrip strength, and gait speed. Stata V.13.0 software will be used for data synthesis and analysis, sensitivity analysis, subgroup analysis, and risk of bias assessment. Reporting bias will be evaluated utilizing a funnel, with Egger tests assessing funnel plot symmetries. Quality of evidence will be evaluated according to guidance of the Recommendations Assessment, Development, and Evaluation guideline.

RESULT

This study will provide a rational synthesis of current evidences for XLGBC on SOP.

CONCLUSION

The conclusion of this study will provide evidence to judge the effectiveness and safety of XLGBC on SOP.

ETHICS AND DISSEMINATION

This systematic review will be contributed to peer-reviewed publications, aiming to provide evidence about efficacy of XLGBC on SOP.

TRIAL REGISTRATION NUMBER

CRD42019128223.

Differing impact of clinical factors on the risk of fracture in younger and older women in the general population and an osteoporosis clinic population

This study assesses the impact of risk factors for fracture in women aged 80+ and 60-79. The results suggest that risk assessment which fits younger women may not be suited for the 80+ strata as many common risk factors are less predictive in the older compared to the younger cohort.

PURPOSE

This study assesses whether the impact of classical risk factors for fracture due to osteoporosis is different in women aged 80+ and women aged 60-79. Since most prior research on the contribution of risk factors is based on patients below 80 years of age, this study aims to fill this knowledge gap to increase the accuracy of risk assessment in the oldest old.

METHODS

Retrospective, observational cohort study using Swedish national health register data and BMD data from osteoporosis clinics. Women aged at least 60 were identified from a random sample of the general population and from the BMD databases and allocated to two populations representing patients at different stages of risk assessment. The relative impact of risk factors on fracture risk was assessed using multivariate competing risk regression with fracture as outcome and death as competing event.

RESULTS

A total of 163,329 women were included from the general population (52,499 aged 80+) and 22,378 from the BMD databases (4563 aged 80+). The clinical risk factors with relatively highest effect on fracture risk in the older patients were prior fracture and hip T-score below - 2.5 SD. Other included risk factors showed lower impact in the older compared to the younger strata.

CONCLUSIONS

This study confirms our understanding of the key risk factors for fracture: age, prior fracture, and a low T-score. Regarding remaining risk factors, risk assessment which fits younger women may not be suited for the 80+ strata as many common risk factors are less predictive in the older compared to the younger cohort.

The Impact of Movement Behaviors on Bone Health in Elderly with Adequate Nutritional Status: Compositional Data Analysis Depending on the Frailty Status

The aim of this study was to determine the relationship between bone mass (BM) and physical activity (PA) and sedentary behavior (SB) according to frailty status and sex using compositional data analysis. We analyzed 871 older people with an adequate nutritional status. Fried criteria were used to classify by frailty status. Time spent in SB, light intensity PA (LPA) and moderate-to-vigorous intensity PA (MVPA) was assessed from accelerometry for 7 days. BM was determined by dual-energy X-ray absorptiometry (DXA). The combined effect of PA and SB was significantly associated with BM in robust men and women (p ≤ 0.05). In relation to the other behaviors, SB was negatively associated with BM in robust men while BM was positively associated with SB and negatively with LPA and MVPA in robust women. Moreover, LPA also was positively associated with arm BM (p ≤ 0.01). Finally, in pre-frail women, BM was positively associated with MVPA. In our sample, to decrease SB could be a good strategy to improve BM in robust men. In contrast, in pre-frail women, MVPA may be an important factor to consider regarding bone health.

[Osteosarcopenia: A narrative review]

Osteosarcopenia is a phenotype resulting from the combination of sarcopenia and low bone mineral density. Based on the relationship between bone and muscle, this phenotype is associated with a higher risk of falls, fractures, dependence, and health care costs than its individual components. Given its characteristics, it can be considered as a new geriatric syndrome. Therefore, understanding its pathophysiology and diagnosis, as well as its non-pharmacological and pharmacological management is a task of great importance. The problem in addressing this phenotype arises from the tradition of managing sarcopenia and osteoporosis separately. There is also a lack of consensus on what to call it (sarco-osteopenia, sarco-osteoporosis, osteosarcopenia). The aim of this review is to outline the epidemiology, pathophysiology, diagnoses, adverse events, and management of osteosarcopenia.

Fulminant Skeletal Failure in a Centenarian: The Impact of Nutrition and Immobility

This case describes a 103-year-old lady who presented from home with an incidental diagnosis of a left femoral fracture. She had no history of trauma and denied pain. She had a known diagnosis of osteoporosis, and sustained a fracture of the contralateral femur aged 93 which was managed conservatively. She was bed-bound with fixed contractures, poor oral intake and was non-compliant with prescribed calcium/vitamin D supplementation. Clinical biochemical measurements showed severe vitamin D deficiency and mild hypocalcaemia. Secondary hyperparathyroidism in the setting of an inappropriately normal phosphate suggested concurrent renal bone disease. Biomarkers of bone turnover were also consistent with bone remodelling. The history of prior fragility fractures, severe vitamin D deficiency and immobility supports a diagnosis of osteoporotic fracture, however other causes of spontaneous fracture were also considered. This case highlights the complexity of interpreting clinical biochemistry results in the setting of multi-morbidity and addresses the challenges of bone health management in the frail older person.

Efficacy, cost, and aspects to take into account in the treatment of osteoporosis in the elderly

Age is one of the principal risk factors for development of frailty fractures. Age pyramids show a population that is becoming increasingly more elderly, with an increasing incidence of fractures, and the forecasts for the future are truly alarming. Adequate handling of these patients who are especially at risk, at both the preventive and care levels, with a well-defined orthogeriatric model is necessary to respond to this clinical challenge. The objective of this review is to analyze the efficacy of the different strategies for the handling of geriatric patients with fracture risk.

Associations between sedentary time, physical activity and bone health among older people using compositional data analysis

INTRODUCTION

Aging is associated with a progressive decrease in bone mass (BM), and being physical active is one of the main strategies to combat this continuous loss. Nonetheless, because daily time is limited, time spent on each movement behavior is co-dependent. The aim of this study was to determine the relationship between BM and movement behaviors in elderly people using compositional data analysis.

METHODS

We analyzed 871 older people [395 men (76.9±5.3y) and 476 women (76.7±4.7y)]. Time spent in sedentary behavior (SB), light physical activity (LPA) and moderate-to-vigorous physical activity (MVPA), was assessed using accelerometry. BM was determined by bone densitometry (DXA). The sample was divided according to sex and bone health indicators.

RESULTS

The combined effect of all movement behaviors (PA and SB) was significantly associated with whole body, leg and femoral region BM in the whole sample (p≤0.05), with leg and pelvic BM (p<0.05) in men and, with whole body, arm and leg BM (p<0.05) in women. In men, arm and pelvic BM were negatively associated with SB and whole body, pelvic and leg BM were positively associated with MVPA (p≤0.05). In women, whole body and leg BM were positively associated with SB. Arm and whole body BM were positively associated and leg BM was negatively associated with LPA and arm BM was negatively associated with MVPA (p≤0.05). Women without bone fractures spent less time in SB and more in LPA and MVPA than the subgroup with bone fractures.

CONCLUSION

We identified that the positive effect of MVPA relative to the other behaviors on bone mass is the strongest overall effect in men. Furthermore, women might decrease bone fracture risk through PA increase and SB reduction, despite the fact that no clear benefits of PA for bone mass were found.

Postmenopausal osteoporosis: Assessment and management

Osteoporosis increases the risk of fractures, which are associated with increased mortality and lower quality of life. Patients with prevalent fracture are at high risk to of sustaining another one. Optimal protein and calcium intakes, and vitamin D supplies, together with regular weight bearing physical exercise are the corner stones of fracture prevention. Evidence for anti-fracture efficacy of pharmacological interventions relies on results from randomised controlled trials in postmenopausal women with fractures as the primary outcome. Treatments with bone resorption inhibitors, like bisphosphonates or denosumab, and bone formation stimulator like teriparatide, reduce vertebral and non-vertebral fracture risk. A reduction in vertebral fracture risk can already be detected within a year after starting therapy.

Hypovitaminosis D: comparison between patients with hip fracture and patients with vertebral fractures

This study analyses the difference in 25OH-vitamin D values between two groups of patients both affected by severe osteoporosis with fragility fractures, but one group has vertebral fractures and the other one has hip fractures. Patients with hip fractures have vitamin D values lower than patients with vertebral fractures.

INTRODUCTION

The purpose of this study was to evaluate 25OHD levels in patients with fragility vertebral fractures (VF) and hip fractures (HF) and make a comparison between the groups.

METHODS

In the first group were enrolled ambulatory patients with 3 or more moderate to severe VF; in the second group were enrolled patients hospitalized in the Department of Orthogeriatrics undergoing surgery for HF. For all patients, we collected values of 25OHD and PTH. The group of patients with VF was further subdivided into pre-existing VF or recent VF treated within 30 days with vertebroplasty.

RESULTS

The sample consists of 180 subjects divided into two groups: 90 with VF and 90 with HF. The average value of 25OHD in the total sample was 13.2 ± 9.6 ng/ml, Vitamin D was significantly lower in the HF group than the VF group (p < 0.001)(VF 18.6 ± 9.7 ng/ml, HF 7.9 ± 5.7 ng/ml). The mean PTH value in the total sample was 67.5 ± 54.9 pg/ml and PTH was significantly higher in the HF group compared to the group with VF (p < 0.001) (VF 55.6 ± 27.2 pg/ml, HF 78.7 ± 70.2 pg/ml). The mean 25OHD value in the recent VF group is 16.0 ± 6.6 ng/ml while in the pre-existing VF group is 19.5 ± 10.4 ng/ml with a statistically significant difference (p < 0.001).

CONCLUSIONS

Patients of the same age with severe osteoporosis have a lower 25OHD value when the fracture occur at the hip and is recent, probably this is due to the inflammation caused by fracture and/or surgical intervention.

Monitoring bone changes due to calcium, magnesium, and phosphorus loss in rat femurs using Quantitative Ultrasound

Bone mineral density is an important parameter for the diagnosis of bone diseases, as well as for predicting fractures and treatment monitoring. Thus, the aim of the present study was to evaluate the potential of Quantitative Ultrasound (QUS) to monitor bone changes after calcium, phosphorus, and magnesium loss in rat femurs in vitro during a demineralization process. Four quantitative ultrasound parameters were estimated from bone surface echoes in eight femur diaphysis of rats. The echo signals were acquired during a decalcification process by Ethylenediaminetetraacetic Acid (EDTA). The results were compared to Quantitative Computed Tomography (QCT) and inductively coupled plasma optical emission spectrometry measurements for validation. Integrated Reflection Coefficient (IRC) reflection parameters and Frequency Slope of Reflection Transfer Function (FSRTF) during demineralization tended to decrease, while the backscattering parameter Apparent Integrated Backscatter (AIB) increased and Frequency Slope of Apparent Backscatter (FSAB) showed an oscillatory behavior with no defined trend. Results indicate a clear relation between demineralization and the corresponding decrease in the reflection parameters and increase in the scattering parameters. The trend analysis of the fall curve of the chemical elements showed a better relationship between IRC and QCT. It was possible to monitor bone changes after ions losses, through the QUS. Thus, it is an indication that the proposed protocol has potential to characterize bone tissue in animal models, providing consistent results towards standardization of bone characterization studies by QUS endorsing its use in humans.

Investigation and analysis of osteoporosis, falls, and fragility fractures in elderly people in the Beijing area: a study on the bone health status of elderly people ≥ 80 years old with life self-care

Among ≥ 80 years old and under life self-care in the Beijing area, the prevalences of osteoporosis, falls, and fragility fracture were high; and these prevalences were even higher in women. The treatment rate of osteoporosis is very low. Therefore, comprehensive and standardized prevention and treatment should be promoted.

PURPOSE

The purpose of this study is to investigate prevalence of osteoporosis, falls, and fragility fractures in this population, and analyze related factors, in order to provide a basis for standardized prevention and treatment.

METHODS

From August 2015 to August 2016 in Beijing City, a total of 175 elderly individuals, who were ≥ 80 years old and had good self-care ability, were included into this study. The questionnaire, risk of falls, grip force, and walking speed were measured, and the Timed Up and Go test (TUG) and chair-rising test (CRT) were performed.

RESULTS

Compared to women, men have higher rates of smoking, drinking, drinking strong tea, longer outdoor activity time, as well as larger muscle strength and pace, and lower consumption of dairy products, fall risk assessment scale (FRA) score, 25OHD, administration rates of calcium and anti-osteoporosis drugs (P < 0.05, P < 0.01). Compared with men, women had higher bone turnover markers (P1NP, β-CTx, and OC) (P < 0.05, P < 0.01) and lower levels of sex hormones (E2, T) (P < 0.01). The overall prevalence of osteoporosis was 24.6%, and this was significantly higher in women than in men (52.5 vs. 9.6%, P < 0.01). Among these subjects, 62.9% had a history of fall after 80 years old, and this rate was higher in women than in men (77 vs. 55.3%, P < 0.01). The overall prevalence of fragility fractures was 25.1%, which was higher in women than in men (45.9 vs. 14.0%, P < 0.01). Risk factors included falls after age 80, high FRA score, and reduction in bone density of lumbar vertebrae 1-4, and odds ratio (OR) was 12.195, 1.339, and 0.076, respectively (P < 0.01). Anti-osteoporosis therapy was only performed on a small number of patients with fractures.

CONCLUSION

The prevalences of falls, prior fracture, and low BMD were high among ≥ 80 years old and under life self-care in the Beijing area. Therefore, a comprehensive approach to assessment and treatment should be promoted.

Low prevalence of osteoporosis treatment in patients with recurrent major osteoporotic fracture

The majority of patients do not receive anti-osteoporotic treatment following a major osteoporotic fracture, despite the guidelines and the availability of effective anti-osteoporotic treatments. The fight against factors limiting the diagnosis and treatment of osteoporosis should become a priority to improve secondary prevention after an initial osteoporotic fracture.

PURPOSE

Despite the availability of effective anti-osteoporotic treatments, osteoporosis management is currently insufficient. The main objective of this study was to assess the prevalence of anti-osteoporotic treatments introduced after an initial prior major osteoporotic fracture during hospitalization for recurring fractures.

METHODS

We conducted an observational, cross-sectional, bicentric study that included all patients aged over 50 years who were hospitalized or seen in consultation for major osteoporotic fracture.

RESULTS

One hundred twenty-eight out of two hundred four (62.7%) patients had a past history of major osteoporotic fracture and therefore had an indication of treatment based on guidelines. Among these patients, only 43/128 (33.5%) had received anti-osteoporotic treatment as secondary prevention after the initial fracture. The main causes of non-prescription identified were the attending physicians' ignorance of the indication of treatment (n = 30; 35.3%), ignorance of the fracture (n = 17; 20%), and comorbidities (n = 12; 14.1%). The failure to introduce treatment was associated with the presence of comorbidities with a Charlson Comorbidity Index ≥6 (OR = 0.34 [0.16-0.73], p < 0.05), dementia (OR = 0.23 [0.08-0.72], p < 0.05), and past history of proximal femur fracture (OR = 0.20 [0.04-0.91], p < 0.05).

CONCLUSIONS

Two thirds of patients with a past history of major osteoporotic fracture presenting with a new fracture were not treated. The main reason for lack of treatment seems to stem from the incorrect assessment of the patient's fracture risk. Although major osteoporotic fracture leads to an increased risk of mortality and requires treatment, the significance of patient comorbidities was an independent risk factor leading to non-treatment.

The use of cholecalciferol in patients with hip fracture

INTRODUCTION

Major osteoporotic fractures are steadily increasing due to population aging. Programs of secondary prevention against refracture are essential to decrease morbidity and mortality and the cost for individuals and the society. Vitamin D supplementation and optimization of calcium intake are of a pivotal importance to start specific osteoporosis treatment and for its safety and efficacy. Cholecalciferol is the most widely employed drug for vitamin D supplementation.

PURPOSE

Aim of this study was to assess the trends in the use of vitamin D supplements containing cholecalciferol in the population of hip fracture patients older than 65 years, resident in the region of Tuscany (Italy) in the years 2011-2015 and to describe vitamin D status in a subgroup of this individuals directly referred to a bone clinic for further evaluation after hip osteoporotic fracture.

METHODS

Data were retrieved from the electronic anonymous regional administrative database administered by the Region of Tuscany (Italy) in the years 2011-2015 within the T.A.R.Ge.T. project (Trattamento Appropriato delle Rifratture Geriatriche in Toscana, i.e., "Appropriate treatment of geriatric refractures in Tuscany"), a program endorsed by the region itself. Data pertaining to cholecalciferol prescriptions and hospital discharge codes were retrieved and appropriately crossed to get data on the use of cholecalciferol supplements in patients before and after a hip fracture. A retrospective analysis was carried out in a subgroup of subjects (n 254) appropriately referred to the local fracture liaison service after the major osteoporotic fracture and vitamin D status in terms of serum 25(OH) vitamin D levels was assessed.

RESULTS

The majority of subjects experiencing a hip fracture (98.2% and 88.3% in 2011 and 2015, respectively) did not receive vitamin D supplements at the time of the fracture event. Although a trend in increase in prescriptions for cholecalciferol supplements could be observed in the years of the study, the percentage of treated individuals remained low even after the fracture, since only 30-35% of subjects receives cholecalciferol supplements at one year after the fracture. Cholecalciferol remained the most prescribed drug in this population, while a substantial decrease of cholecalciferol in association with calcium salts was observed. The use of high doses of cholecalciferol has decreased in this population, while diminished the use of the drops has been accompanied by an increase in prescriptions of single monthly dose supplements.

CONCLUSIONS

The correction of vitamin D inadequacy is preliminary to any treatment for osteoporosis and together with calcium may reduce fracture risk by itself. The prescription of vitamin D supplements is low in patients before and after a hip fracture in a Mediterranean region and despite the overall increase in vitamin use and abuse in the general population. Proper educational programs and active fracture liaison services are needed in order to bridge this gap.

Pharmacological treatment of osteoporosis in the oldest old

The incidence of osteoporotic fractures increases with age. Consequently, the global prevalence of osteoporotic fractures will increase with the aging of the population. In old age, osteoporosis is associated with a substantial burden in terms of morbidity and mortality. Nevertheless, osteoporosis in old age continues to be underdiagnosed and undertreated. This may, at least partly, be explained by the fact that evidence of the antifracture efficacy of osteoporosis treatments comes mainly from randomized controlled trials in postmenopausal women with a mean age of 70-75 years. However, in the last years, subgroup analyses of these landmark trials have been published investigating the efficacy and safety of osteoporosis treatment in the very elderly. Based on this evidence, this narrative review discusses the pharmacological management of osteoporosis in the oldest old (≥80 years). Because of the high prevalence of calcium and/or vitamin D deficiency in old age, these supplements are essential in the management of osteoporosis in the elderly people. Adding antiresorptive or anabolic treatments or combinations, thereof, reduces the risk of vertebral fractures even more, at least in the elderly with documented osteoporosis. The reduction of hip fracture risk by antiresorptive treatments is less convincing, which may be explained by insufficient statistical power in some subanalyses and/or a higher impact of nonskeletal risk factors in the occurrence of hip fractures. Compared with younger individuals, a larger absolute risk reduction is observed in the elderly because of the higher baseline fracture risk. Therefore, the elderly will benefit more of treatment. In addition, current osteoporosis therapies also appear to be safe in the elderly. Although more research is required to further clarify the effect of osteoporosis drugs in the elderly, especially with respect to hip fractures, there is currently sufficient evidence to initiate appropriate treatment in the elderly with osteoporosis and osteoporotic fractures.

Identification and management of patients at increased risk of osteoporotic fracture: outcomes of an ESCEO expert consensus meeting

Osteoporosis represents a significant and increasing healthcare burden in Europe, but most patients at increased risk of fracture do not receive medication, resulting in a large treatment gap. Identification of patients who are at particularly high risk will help clinicians target appropriate treatment more precisely and cost-effectively, and should be the focus of future research.

INTRODUCTION

The purpose of the study was to review data on the identification and treatment of patients with osteoporosis at increased risk of fracture.

METHODS

A working group convened by the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis met to review current data on the epidemiology and burden of osteoporosis and the patterns of medical management throughout Europe.

RESULTS

In Europe in 2010, the cost of managing osteoporosis was estimated at €37 billion and notably the costs of treatment and long-term care of patients with fractures were considerably higher than the costs for pharmacological prevention. Despite the availability of effective treatments, the uptake of osteoporosis therapy is low and declining, in particular for secondary fracture prevention where the risk of a subsequent fracture following a first fracture is high. Consequently, there is a significant treatment gap between those who would benefit from treatment and those who receive it, which urgently needs to be addressed so that the burden of disease can be reduced.

CONCLUSIONS

Implementation of global fracture prevention strategies is a critical need. Future research should focus on identifying specific risk factors for imminent fractures, periods of high fracture risk, patients who are at increased risk of fracture and therapies that are most suited to such high-risk patients and optimal implementation strategies in primary, secondary and tertiary care.

Sarcopenia in daily practice: assessment and management

BACKGROUND

Sarcopenia is increasingly recognized as a correlate of ageing and is associated with increased likelihood of adverse outcomes including falls, fractures, frailty and mortality. Several tools have been recommended to assess muscle mass, muscle strength and physical performance in clinical trials. Whilst these tools have proven to be accurate and reliable in investigational settings, many are not easily applied to daily practice.

METHODS

This paper is based on literature reviews performed by members of the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO) working group on frailty and sarcopenia. Face-to-face meetings were afterwards organized for the whole group to make amendments and discuss further recommendations.

RESULTS

This paper proposes some user-friendly and inexpensive methods that can be used to assess sarcopenia in real-life settings. Healthcare providers, particularly in primary care, should consider an assessment of sarcopenia in individuals at increased risk; suggested tools for assessing risk include the Red Flag Method, the SARC-F questionnaire, the SMI method or different prediction equations. Management of sarcopenia should primarily be patient centered and involve the combination of both resistance and endurance based activity programmes with or without dietary interventions. Development of a number of pharmacological interventions is also in progress.

CONCLUSIONS

Assessment of sarcopenia in individuals with risk factors, symptoms and/or conditions exposing them to the risk of disability will become particularly important in the near future.

Bone mass and vitamin D levels in Parkinson's disease: is there any difference between genders?

[Purpose] The aim of this study was to determine the bone mineral density, vitamin D level, and frequencies of osteopenia and osteoporosis in patients with Parkinson's disease and to compare male and female patients with the controls separately. [Subjects and Methods] One hundred fifteen Parkinson's disease patients (47 males, 68 females; age range: 55-85 years) and 117 age- and gender-matched controls (47 males, 70 females) were enrolled in the study. Bone mineral density measured by dual-energy X-ray absorptiometry and serum D vitamin levels of each participant were recorded. [Results] The mean lumbar spine, femur neck, and total femur bone mineral density levels, T-scores, and vitamin D levels were found to be significantly lower in Parkinson's disease patients in both genders. Furthermore, osteoporosis rates were found be significantly higher only in female Parkinson's disease patients compared with female controls. [Conclusion] Data from the present study revealed that while osteoporosis was significantly higher only in female Parkinson's disease patients, all Parkinson's disease patients had lower bone mineral density scores and vitamin D levels compared with the controls regardless of gender, suggesting that clinicians should pay attention to the osteoporosis risk in Parkinson's disease and that adequate preventive measures should be taken in order to limit the future risk due to osteoporotic fractures.

Framing moving and handling as a complex healthcare intervention within the acute care of older people with osteoporosis: a qualitative study

AIMS AND OBJECTIVES

To investigate healthcare staff's views and experiences of caring for older hospitalised adults (aged 60+) with osteoporosis focusing on moving and handling. Specific objectives were to explore the composition of manual handling risk assessments and interventions in osteoporosis.

BACKGROUND

Osteoporosis is a skeletal disease that reduces bone density and causes increased fracture risk. Incidence rises with age and osteoporotic fractures cause increased morbidity and mortality. It is a major global health problem. In the UK older hospitalised adults are normally screened for falls risk but not necessarily for osteoporosis. As presentation of osteoporosis is normally silent until fractures are evident, it is frequently undiagnosed. Healthcare staff's knowledge of osteoporosis is often suboptimal and specific manual handling implications are under-researched.

DESIGN

An exploratory qualitative content analysis research design informed by critical realism.

METHODS

The purposive sample comprised 26 nursing and allied health professionals. Semi-structured interviews addressed topics including knowledge of osteoporosis, implications for acute care, moving and handling and clinical guidelines. Qualitative content data analysis was used.

RESULTS

Awareness of osteoporosis prevalence in older populations varies and implications for nursing are indistinct to nonspecialists. In-hospital fractures potentially linked to suboptimal moving and handling seemed rare, but prospective studies are needed. Categories of 'Understanding moving and handling as routine care or as a healthcare intervention', with further categories 'healthcare practitioners' capacities and capabilities for dealing with people with osteoporosis' and 'the structural and organisational context for moving and handling' are reported alongside safety, frailty and dependency dimensions.

CONCLUSIONS

This study informs moving and handling in higher risk groups such as osteoporosis. Clinical knowledge/expertise is required when adapting generic manual handling guidelines to specific patients/contexts. Patients' experiences of moving and handling have received limited attention.

RELEVANCE TO CLINICAL PRACTICE

Increased focus on musculoskeletal conditions and moving and handling implications is required.

The role of biochemical of bone turnover markers in osteoporosis and metabolic bone disease: a consensus paper of the Belgian Bone Club

The exact role of biochemical markers of bone turnover in the management of metabolic bone diseases remains a topic of controversy. In this consensus paper, the Belgian Bone Club aimed to provide a state of the art on the use of these biomarkers in different clinical or physiological situations like in postmenopausal women, osteoporosis in men, in elderly patients, in patients suffering from bone metastasis, in patients with chronic renal failure, in pregnant or lactating women, in intensive care patients, and in diabetics. We also gave our considerations on the analytical issues linked to the use of these biomarkers, on potential new emerging biomarkers, and on the use of bone turnover biomarkers in the follow-up of patients treated with new drugs for osteoporosis.

A comprehensive fracture prevention strategy in older adults: the European Union Geriatric Medicine Society (EUGMS) statement

Prevention of fragility fractures in older people has become a public health priority, although the most appropriate and cost-effective strategy remains unclear. In the present statement, the Interest Group on Falls and Fracture Prevention of the European Union Geriatric Medicine Society, in collaboration with the International Association of Gerontology and Geriatrics for the European Region, the European Union of Medical Specialists, and the International Osteoporosis Foundation-European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis, outlines its views on the main points in the current debate in relation to the primary and secondary prevention of falls, the diagnosis and treatment of bone fragility, and the place of combined falls and fracture liaison services for fracture prevention in older people.

Continuous treatment with odanacatib for up to 8 years in postmenopausal women with low bone mineral density: a phase 2 study

The efficacy and safety of weekly oral odanacatib (ODN) 50 mg for up to 8 years were assessed in postmenopausal women with low bone mineral density (BMD). Treatment with ODN for up to 8 years resulted in continued or maintained increases in BMD at multiple sites and was well tolerated.

INTRODUCTION

ODN is a selective inhibitor of cathepsin K. In a 2-year phase 2b study (3/10/25/50 mg ODN once weekly [QW] or placebo) and extensions (50 mg ODN QW or placebo), ODN treatment for 5 years progressively increased BMD and decreased bone resorption markers in postmenopausal women with low BMD ( ClinicalTrials.gov NCT00112437).

METHODS

In this prespecified interim analysis at year 8 of an additional 5-year extension (years 6 to 10), patients (n = 117) received open-label ODN 50 mg QW plus weekly vitamin D3 (5600 IU) and calcium supplementation as needed. Primary end points were lumbar spine BMD and safety. Patients were grouped by ODN exposure duration.

RESULTS

Mean (95 % confidence interval [CI]) lumbar spine BMD changes from baseline were 4.6 % (2.4, 6.7; 3-year continuous ODN exposure), 12.9 % (8.1, 17.7; 5 years), 12.8 % (10.0, 15.7; 6 years), and 14.8 % (11.0, 18.6; 8 years). Similar patterns of results were observed for BMD of trochanter, femoral neck, and total hip versus baseline. Geometric mean changes from baseline to year 8 for bone resorption markers were approximately -50 % (uNTx/Cr) and -45 % (sCTx), respectively (all groups); bone formation markers remained near baseline levels. No osteonecrosis of the jaw, delayed fracture union, or morphea-like skin reactions were reported.

CONCLUSIONS

Treatment with ODN for up to 8 years resulted in gains in BMD at multiple sites. Bone resorption markers remained reduced, with no significant change observed in bone formation markers. Treatment with ODN for up to 8 years was well tolerated.

Unmet needs and current and future approaches for osteoporotic patients at high risk of hip fracture

This review provides a critical analysis of currently available approaches to increase bone mass, structure and strength through drug therapy and of possible direct intra-osseous interventions for the management of patients at imminent risk of hip fracture.

PURPOSE

Osteoporotic hip fractures represent a particularly high burden in morbidity-, mortality- and health care-related costs. There are challenges and unmet needs in the early prevention of hip fractures, opening the perspective of new developments for the management of osteoporotic patients at imminent and/or at very high risk of hip fracture. Amongst them, preventive surgical intervention needs to be considered.

METHODS

A European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO)/International Osteoporosis Foundation (IOF) working group reviewed the presently available intervention modalities including preventive surgical options for hip fragility. This paper represents a summary of the discussions.

RESULTS

Prevention of hip fracture is currently based on regular physical activity; prevention of falls; correction of nutritional deficiencies, including vitamin D repletion; and pharmacological intervention. However, efficacy of these various measures to reduce hip fractures is at most 50% and may need months or years before becoming effective. To face the challenges of early prevention of hip fractures for osteoporotic patients at imminent and/or at very high risk of hip fracture, preventive surgical intervention needs further investigation.

CONCLUSION

Preventive surgical intervention needs to be appraised for osteoporotic patients at imminent and/or at very high risk of hip fracture.

A Comprehensive Fracture Prevention Strategy in Older Adults: The European Union Geriatric Medicine Society (EUGMS) Statement

Prevention of fragility fractures in older people has become a public health priority, although the most appropriate and cost-effective strategy remains unclear. In the present statement, the Interest Group on Falls and Fracture Prevention of the European Union Geriatric Medicine Society (EUGMS), in collaboration with the International Association of Gerontology and Geriatrics for the European Region (IAGG-ER), the European Union of Medical Specialists (EUMS), the International Osteoporosis Foundation - European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis, outlines its views on the main points in the current debate in relation to the primary and secondary prevention of falls, the diagnosis and treatment of bone fragility, and the place of combined falls and fracture liaison services for fracture prevention in older people.

BMP-2 Enhances Lgr4 Gene Expression in Osteoblastic Cells

Osteoporosis is one of the most prevalent diseases and the number of patients suffering from this disease is soaring due to the increase in the aged population in the world. The severity of bone loss in osteoporosis is based on the levels of impairment in the balance between bone formation and bone resorption, two arms of the bone metabolism, and bone remodeling. However, determination of bone formation levels is under many layers of control that are as yet fully defined. Bone morphogenetic protein (BMP) plays a key role in regulation of bone formation while its downstream targets are still incompletely understood. Lgr4 gene encodes an orphan receptor and has been identified as a genetic determinant for bone mass in osteoporotic patients. Here, we examine the effects of BMP on the expression of Lgr4 in osteoblastic cells. Lgr4 gene is expressed in an osteoblastic cell line, MC3T3E1 in a time dependent manner during the culture. BMP treatment enhances Lgr4 mRNA expression at least in part via transcriptional event. When Lgr4 mRNA is knocked down, the levels of BMP-induced increase in alkaline phosphatase (Alp) activity and Alp mRNA are suppressed. BMP enhancement of Lgr4 gene expression is suppressed by FGF and reversed by dexamethasone. BMP also enhances Lgr4 expression in primary cultures of calvarial osteoblasts. These data indicate that Lgr4 gene is regulated by BMP and is required for BMP effects on osteoblastic differentiation. J. Cell. Physiol. 231: 887-895, 2016. © 2015 Wiley Periodicals, Inc.

The use of bisphosphonates in women: when to use and when to stop

INTRODUCTION

Bisphosphonates (BPs) are the most commonly used drugs in osteoporosis.

AREAS COVERED

This review focuses on the criteria for identifying patients who should be treated with BPs and also the rational for the duration of treatment.

EXPERT OPINION

BPs remain the mainstay for the treatment of osteoporosis. For their low cost, the treatment threshold is related exclusively to the ratio between expected benefits and the risk of side effects. This is the case of patients with prior fragility fracture or with low bone density and the presence of other relevant risk factors. The treatment should continue for 3 - 5 years or until fracture risk is no longer high. Afterward a treatment holiday should be considered on the light of the increasing risk of side effects but its duration is still controversial. The duration of this treatment holiday depends on the drug used. Discontinuation of risedronate and ibandronate is associated with the quick loss of the acquired benefits and with these two BPs discontinuation should not exceed 6 months. Alendronate and zoledronate are characterized by a persistent effect after discontinuing treatment and this would allow a more prolonged drug holiday.