Prevention of osteoporotic fractures in the elderly

Osteoporosis risk group: Screening for osteoporosis in dental clinics using panoramic radiographs

Osteoporosis is a specific condition which is characterized by low bone mineral density (BMD) and deterioration of bone structure resulting in an increased susceptibility to fractures. It contributes to a great deal of morbidity and mortality, and is a large burden to the healthcare system, especially in the case of the elderly population. In the last four decades, a plethora of studies have reported characteristic oral radiographic findings in the early stages of osteoporosis, suggesting the possible use of oral radiographic signs for the early detection of the condition. Digital orthopantomographs (OPGs) are usually taken for the screening of dental patients during routine dental evaluations. These radiographs and the characteristic changes seen on them may have a significant role in the screening for initial osteoporotic changes. A number of precise radiomorphometric indices of the mandible have also been developed to allow quantification of the mandibular bone mass for identification of the initial signs of osteoporosis. The present review focuses on the possible role of panoramic radiographs in the initial screening for osteoporosis in dental clinics in high-risk groups.

The effect of frailty on outcomes of surgically treated hip fractures in older people

BACKGROUND

Hip fractures are associated with mortality, disability, and loss of independence in older adults. While several risk factors associated with poor outcomes following a hip fracture have been identified, the effect of frailty status prior to hip fracture is not well established.

AIM

To examine the associations of frailty with mortality, change in activities of daily living (ADL) limitations, and transition to permanent residential aged care in older people following a hip fracture.

METHODS

A retrospective cohort study was conducted on people aged 65 years and older with a surgically treated hip fracture between 2003 and 2015. Frailty was estimated using a cumulative deficit-based frailty index and categorized into quartiles. Cox multivariable regression, logistic regression, and Fine-Gray multivariable regression models estimated associations of frailty with mortality, ADL limitations, and entry into permanent residential aged care, respectively. Hazard ratios (HR), odds ratios (OR), subdistribution hazard ratios (SHR), and 95% confidence intervals (95%CI) are reported.

RESULTS

Out of 4771 individuals with hip fractures, 75.6% were female and the median age was 86 (interquartile range 82-90) years old. The two-year survival of patients following hip fracture was 43.7% (95%CI 40.9-46.7%) in those in the highest quartile of frailty, compared to 54.4% (95%CI 51.8-57.2%) for those in the lowest quartile (HR = 1.25, 95%CI 1.11-1.41, p < 0.001). No associations between pre-fracture frailty and post-fracture ADL limitations were observed. Additionally, no association of frailty with transition to permanent residential aged care for patients living in the community (n = 1361) was observed (SHR = 0.98, 95%CI 0.81-1.18, p = 1.000).

CONCLUSIONS

Older patients with the highest level of frailty had an increased risk of mortality after hip fracture. Consideration for appropriate clinical interventions, including fall and frailty prevention measures, may be appropriate for this identified group of vulnerable individuals.

The Effect of Denosumab on Bone Mass in Super Elderly Patients

BACKGROUND

Denosumab is a potent antiresorptive drug leading to significant reduction in the risk of vertebral and non-vertebral fractures in postmenopausal osteoporosis. The effect of denosumab in super-elderly patients lacks data to date and few literature has proven the efficacy to this specific group. The purpose of this study was to determine the effectiveness and safety of denosumab in the super-elderly.

METHODS

We retrospectively evaluated 60 patients older than 80 with osteoporosis treated with denosumab. Patients were treated with denosumab every 6 months for 12 months 2017 to 2020. The primary endpoint was defined by the changes in bone mineral density (BMD) of 3 measurement sites: the lumbar spine, femoral neck, and total hip. Changes in bone turnover markers, serum calcium, serum phosphate, and 25-hydroxy-vitamin D were also observed.

RESULTS

All 60 patients were female, and the mean age was 83.9±3.1, from age 80 to 94. After 12 months of denosumab treatment, significant increases in BMD were observed; 3.02±2.74% for the lumbar spine (P=0.000), 3.10±6.90% for the femoral neck (P=0.005), and 2.89±5.80% for the total hip (P=0.002) The bone turnover marker C-terminal telopeptide of type I collagen and osteocalcin significantly declined after 12 months of treatment (-34.8±45.9%; P=0.002 and -35.5±38.9%; P=0.004 respectively). Symptomatic hypocalcemia and serious adverse drug reactions that required drug discontinuation were not observed during treatment.

CONCLUSIONS

Denosumab is thought to be an anti-osteoporotic medication that is sufficiently effective and safe even for the super-elderly.

Case report: electrical automated massage chair use can induce osteoporotic vertebral compression fracture

This case report describes a case of an elderly woman diagnosed with acute osteoporotic vertebral compression fracture (OVCF) at thoracic spine after using an electrical automated massage chair (EAMC). Care should be taken when using an EAMC, especially by those with or at risk of developing osteoporosis. Osteoporotic vertebral compression fracture (OVCF) is a common problem among elderly population and presents a high burden to society. Osteoporotic fractures may occur after a minimal trauma of the vertebrae. Electrical automated massage chair (EAMC) is a device that uses a programmed algorithm to perform automated massage. The massage chair, a popular device among elderly with back pain, relies on friction and rhythmic tapping created by a motorized roller. However, research regarding the safety of this device is lacking, especially in the perspective of OVCF. We present a case of an elderly woman diagnosed with acute OVCF of the thoracic spine after using an EAMC. The patient had no risk factor for fragility fracture and experienced an abrupt onset of severe upper back pain while using EAMC. Imaging studies revealed an isolated acute compression fracture at T8 vertebra (AO classification type A1) while dual-energy X-Ray absorptiometry scan confirmed osteoporosis. The patient was treated with a plastic orthosis and oral medications for osteoporosis. After 6-months follow-up, the patient showed union of the fractured T8 vertebra and no remaining symptoms. This case highlights that OVCF can be induced by EAMC. Therefore, patients with or at risk for osteoporosis should be cautious while opting for deep tissue massage using EAMC.

[Trochanteric and subtrochanteric fractures]

Proximal femoral fractures are one of the most common fractures, particularly in older people. The most common cause is a falling event due to dizziness and gait insecurity. In most cases prompt surgical treatment is necessary to achieve early mobilization and to reduce the risk of mortality. The aim is a stable osteosynthesis and patient-centered care. A great variety of implants are available for this purpose. Furthermore, perioperative management is important to prevent further problematic events, such as delirium, reoccurrence of falling events and to diagnose and adequately treat a pre-existing osteoporosis.

A Community-Based Collaborative Care Model to Improve Functional Health in Underserved Community-Dwelling Older Adults

OBJECTIVE

Examine the effects of a 6-month health multidimensional intervention on physical function, bone density, and mood in a diverse sample of community-dwelling older adults at risk for frailty and excess disability.

METHOD

A quasi-experimental, pre- post-program design was implemented. Adults aged 55 years and older ( n = 337, 60% African American) participated in the intervention and received assessments at baseline, 6 months, and 12 months.

RESULTS

Physical function was maintained during the intervention for both African American and White elders but declined at 12 months for both groups ( p < .0001). Symptoms of depression improved during the intervention ( M = 0.65 ± 0.07, M = 0.15 ± 0.04, M = 0.68 ± 0.07, p < .001, respectively) but worsened at 12 months ( M = 0.68 ± 0.07, p < .001). Bone density scores remained stable from baseline (distal: -1.62 ± 1.17, proximal: -2.73 ± 1.85) to 12 months (distal: -1.72 ± 1.21, proximal: -3.11 ± 1.85, ps > .05) for both groups.

DISCUSSION

Program findings may serve as a basis for the development of a randomized, controlled study to provide empirical evidence of intervention efficacy. Such findings may help inform the development of community-based programs to identify vulnerable older adults and provide vital preventative care to decrease frailty and excess disability.

Hip fractures in young adults: a retrospective cross-sectional study of characteristics, injury mechanism, risk factors, complications and follow-up

This study characterises risk factors, complications and follow-up of minimal trauma hip fractures in young adults, adding to limited information examining the management framework. This group have severe systemic disease and significant risk of post-operative complications and subsequent fractures. Improved medical referral pathways enable management of osteoporosis and comorbid diseases.

AIMS

There is a paucity of literature examining minimal trauma hip fractures in young adults, despite extensive management guidelines for older patients. This study aims to characterise risk factors, complications and follow-up of hip fractures to guide management pathways.

METHODS

This is a retrospective study of patients presenting with hip fracture to a single institution from 2009 to 2015. Hip fractures were identified using ICD-10 codes and clinical information documented from medical records. Patients were categorised into minimal trauma (MTF) and high-energy fracture (HEF) groups based on mechanism of injury.

RESULTS

Of 2512 patients admitted with hip fracture, 2.5% (n = 62) were aged 15-49 years. Two patients were excluded with pathological fractures, and seven were excluded with no recorded mechanism of injury. MTF occurred in 43 patients and 10 sustained HEF. These groups had similar demographics, fracture locations and treatments. The MTF group had higher American Society of Anaesthesiologists scores (MTF 2.44 ± 0.9; HEF 1.43 ± 0.5; p = 0.025) and higher rates of chronic endocrine disease (MTF 34.9%; HEF 0%; p = 0.046). Rates of post-operative surgical (MTF 24.0%; HEF 12.5%) and medical complications (MTF 27.8%; HEF 12.5%) were high in MTF patients. Subsequent fractures occurred in five (13.9%) MTF patients during the study period compared with none in the HEF group. Only 16 (44.4%) of the MTF patients were referred to endocrine care.

CONCLUSION

Young adults with MTF of the hip have more severe systemic disease and are at risk of post-operative complications and subsequent fractures. Referral of patients to endocrine care is recommended to manage osteoporosis and comorbid diseases.

Association of air particulate pollution with bone loss over time and bone fracture risk: analysis of data from two independent studies

BACKGROUND

Air particulate matter (PM) is a ubiquitous environmental exposure associated with oxidation, inflammation, and age-related chronic disease. Whether PM is associated with loss of bone mineral density (BMD) and risk of bone fractures is undetermined.

METHODS

We conducted two complementary studies of: (i) long-term PM <2.5 μm (PM_2.5) levels and osteoporosis-related fracture hospital admissions among 9.2 million Medicare enrollees of the Northeast/Mid-Atlantic United States between 2003-2010; (ii) long-term black carbon [BC] and PM_2.5 levels, serum calcium homeostasis biomarkers (parathyroid hormone, calcium, and 25-hydroxyvitamin D), and annualized BMD reduction over a 8-year follow-up of 692 middle-aged (46.7±12.3 yrs), low-income BACH/Bone cohort participants.

FINDINGS

In the Medicare analysis, risk of bone fracture admissions at osteoporosis-related sites was greater in areas with higher PM_2.5 levels (Risk ratio [RR] 1.041, 95% Confidence Interval [CI], 1.030, 1.051). This risk was particularly high among low-income communities (RR 1.076; 95% CI, 1.052, 1.100). In the longitudinal BACH/Bone study, baseline BC and PM_2.5 levels were associated with lower serum PTH (Estimate for baseline one interquartile increase in 1-year average BC= -1.16, 95% CI -1.93, -0.38; Estimate for baseline one interquartile increase in 1-year average PM_2.5= -7.39; 95%CI -14.17, -0.61). BC level was associated with higher BMD loss over time at multiple anatomical sites, including femoral neck (-0.08%/year per one interquartile increase; 95% CI -0.14, -0.02%/year) and ultradistal radius (-0.06%/year per one interquartile increase; 95% CI -0.12, -0.01%/year).

INTERPRETATION

Our results suggest that poor air quality is a modifiable risk factor for bone fractures and osteoporosis, especially in low-income communities.

The effect of 'Out of hours surgery Service' in Israel on hip fracture fixation outcomes: a retrospective analysis

BACKGROUND

'Out of Hours Surgery Service' (OHSS) was implemented in Israel, amongst other reasons, in order to reduce the time interval between hospital admission and surgery and consequently improve outcomes. The OHSS is currently operated in the public hospitals in Israel. In this study we compared the data of patients before and after OHSS implementation to determine its efficacy in improving patient care.

METHODS

This is a retrospective observational study of 792 adult patients who underwent hip fracture surgery between 2002 and 2007 in a single hospital. The study population included two groups: patients that were operated before the implementation of the OHSS (2002-2004) and after the implementation of the OHSS (2005-2007). Data regarding all patients was collected using the institution's computer program. The following variables were analyzed: patients' demographics, time interval from hospitalization to surgery, causes for delaying surgery, post-operative length of hospitalization and mortality.

RESULTS

Patients in the post-OHSS group had more illnesses and higher ASA classification than those in the pre-OHSS group. The post-OHSS group had a significantly decreased length of stay in the hospital before and after the surgery. After adjusting for ASA score and age, the post-OHSS group was found to have decreased post-operative hospitalization and lower post-operative mortality. Surgery was delayed in pre-OHSS period mainly due to operating rooms unavailability.

CONCLUSION

Implementation of OHSS facilitated operating room availability, thus early operation and reduced post-operative mortality. In accordance with other studies, patient's outcome is greatly influenced by the time from admission to hip fracture surgery.

Review: Metabolic Syndrome in Black South African Women

The prevalence of metabolic syndrome is increasing in African populations, and is particularly high in Black South African women (42%) vs women in the United Kingdom (23%) and the United States of America (36%). This population group is also known to have the highest prevalence of obesity in the sub-Saharan African region (42%), and consequently, a high risk of non-communicable diseases. In this article, we discuss factors (abdominal subcutaneous fat, visceral fat, lean mass, adiponectin, leptin, vitamin D, smoking and menopausal status) that have been investigated for their possible association with metabolic syndrome in African women, and discuss some recommendations for management of the syndrome. In particular, the infrastructural development of HIV/AIDS clinics in South Africa provides an ideal integrated platform to cater to the treatment needs of patients with multiple chronic morbidities.

Exercise frequency and bone mineral density development in exercising postmenopausal osteopenic women. Is there a critical dose of exercise for affecting bone? Results of the Erlangen Fitness and Osteoporosis Prevention Study

Due to older people's low sports participation rates, exercise frequency may be the most critical component for designing exercise protocols that address bone. The aims of the present article were to determine the independent effect of exercise frequency (ExFreq) and its corresponding changes on bone mineral density (BMD) and to identify the minimum effective dose that just relevantly affects bone. Based on the 16-year follow-up of the intense, consistently supervised Erlangen Fitness and Osteoporosis Prevention-Study, ExFreq was retrospectively determined in the exercise-group of 55 initially early-postmenopausal females with osteopenia. Linear mixed-effect regression analysis was conducted to determine the independent effect of ExFreq on BMD changes at lumbar spine and total hip. Minimum effective dose of ExFreq based on BMD changes less than the 90% quantile of the sedentary control-group (n=43). Cut-offs were determined after 4, 8, 12 and 16years using bootstrap with 5000 replications. After 16years, average ExFreq ranged between 1.02 and 2.96sessions/week (2.28±0.40sessions/week). ExFreq has an independent effect on LS-BMD (p<.001) and hip-BMD (p=.005) changes. Bootstrap analysis detected a minimum effective dose at about 2sessions/week/16years (cut-off LS-BMD: 2.11, 95% CI: 2.06-2.12; total hip-BMD: 2.22, 95% CI: 2.00-2.78sessions/week/16years). In summary, the minimum effective dose of exercise frequency that relevantly addresses BMD is quite high, at least compared with the low sport participation rate of older adults. This result might not be generalizable across all exercise types, protocols and cohorts, but it does indicate at least that even when applying high impact/high intensity programs, exercise frequency and its maintenance play a key role in bone adaptation.

Anesthetic Considerations for Common Procedures in Geriatric Patients: Hip Fracture, Emergency General Surgery, and Transcatheter Aortic Valve Replacement

The elderly population is growing. Geriatric patients undergo a large proportion of surgical procedures and have increased complications, morbidity, and mortality, which may be associated with increased intensive care unit time, length of stay, hospital readmission, and cost. Identification of optimal anesthetic care for these patients, leading to decreased complications and contributing to best possible outcomes, will have great value. This article reviews the anesthetic considerations for intraoperative care of geriatric patients and focus on 3 procedures (hip fractures, emergency abdominal surgery, and transcatheter aortic valve replacement). An approach to evaluation and management of the elderly surgical patient is described.

The effect of osteoporosis management on proximal humeral fracture

HYPOTHESIS AND BACKGROUND

Proximal humeral fractures comprise 10% of fractures in the Medicare population. The effect, if any, of treating osteoporosis to prevent these fractures has not been determined. The primary objective is to determine the effectiveness of a systematic osteoporosis screening and treatment program on the hazard of developing a fracture over the treatment period. The secondary aim is to determine demographic risk factors.

METHODS

This is a retrospective cohort study in a health care organization serving 3.3 million members. Individuals selected for dual-energy x-ray absorptiometry screening were (1) women aged 65 years or older; (2) men aged 70 years or older; and (3) individuals aged 50 years or older who have a history of fragility fracture, use glucocorticoids, have a parental history of hip fracture, have rheumatoid arthritis, use alcohol at a high rate, or are cigarette smokers. Treatment consisted primarily of pharmacologic intervention with bisphosphonates.

RESULTS

Individuals diagnosed with osteoporosis had a hazard ratio of 7.43 for sustaining a fracture over the study period. Patients screened with dual-energy x-ray absorptiometry had a hazard ratio of 0.17 whereas those treated medically had a hazard ratio of 0.55 versus untreated controls. Risk factors that significantly increased the risk of a fracture developing included age, female gender, white race, diabetes mellitus, and history of a distal radius fracture.

DISCUSSION AND CONCLUSION

Over the study period, screening and treatment for osteoporosis significantly decreased the hazard ratio for proximal humeral fracture. This information broadens the impact of such programs because current best practices are primarily based on prevention of spine and hip fractures.

Comparative analysis on arthroscopic sutures of large and extensive rotator cuff injuries in relation to the degree of osteopenia

OBJECTIVE

To analyze the results from arthroscopic suturing of large and extensive rotator cuff injuries, according to the patient's degree of osteopenia.

METHOD

138 patients who underwent arthroscopic suturing of large and extensive rotator cuff injuries between 2003 and 2011 were analyzed. Those operated from October 2008 onwards formed a prospective cohort, while the remainder formed a retrospective cohort. Also from October 2008 onwards, bone densitometry evaluation was requested at the time of the surgical treatment. For the patients operated before this date, densitometry examinations performed up to two years before or after the surgical treatment were investigated. The patients were divided into three groups. Those with osteoporosis formed group 1 (n = 16); those with osteopenia, group 2 (n = 33); and normal individuals, group 3 (n = 55).

RESULTS

In analyzing the University of California at Los Angeles (UCLA) scores of group 3 and comparing them with group 2, no statistically significant difference was seen (p = 0.070). Analysis on group 3 in comparison with group 1 showed a statistically significant difference (p = 0.027).

CONCLUSION

The results from arthroscopic suturing of large and extensive rotator cuff injuries seem to be influenced by the patient's bone mineral density, as assessed using bone densitometry.

PMMA-hydroxyapatite composite material retards fatigue failure of augmented bone compared to augmentation with plain PMMA: in vivo study using a sheep model

Polymethylmethacrylate (PMMA) is the most commonly used void filler for augmentation of osteoporotic vertebral fracture, but the differing mechanical features of PMMA and osteoporotic bone result in overload and failure of adjacent bone. The aim of this study was to compare fatigue failure of bone after augmentation with PMMA-nanocrystalline hydroxyapatite (HA) composite material or with plain PMMA in a sheep model. After characterization of the mechanical properties of a composite material consisting of PMMA and defined amounts (10, 20, and 30% volume fraction) of HA, the composite material with 30% volume fraction HA was implanted in one distal femur of sheep; plain PMMA was implanted in the other femur. Native non-augmented bone served as control. Three and 6 months after implantation, the augmented bone samples were exposed to cyclic loading and the evolution of damage was investigated. The fatigue life was highest for the ovine native bone and lowest for bone-PMMA specimens. Bone-composite specimens showed significantly higher fatigue life than the respective bone-PMMA specimens in both 3- and 6-month follow-up groups. These results suggest that modification of mechanical properties of PMMA by addition of HA to approximate those of cancellous bone retards fatigue failure of the surrounding bone compared to augmented bone with plain PMMA.

Bisphophonates in CKD patients with low bone mineral density

Patients with chronic kidney disease-mineral and bone disorder (CKD-MBD) have a high risk of bone fracture because of low bone mineral density and poor bone quality. Osteoporosis also features low bone mass, disarranged microarchitecture, and skeletal fragility, and differentiating between osteoporosis and CKD-MBD in low bone mineral density is a challenge and usually achieved by bone biopsy. Bisphosphonates can be safe and beneficial for patients with a glomerular filtration rate of 30 mL/min or higher, but prescribing bisphosphonates in advanced CKD requires caution because of the increased possibility of low bone turnover disorders such as osteomalacia, mixed uremic osteodystrophy, and adynamic bone, even aggravating hyperparathyroidism. Therefore, bone biopsy in advanced CKD is an important consideration before prescribing bisphosphonates. Treatment also may induce hypocalcemia in CKD patients with secondary hyperparathyroidism, but vitamin D supplementation may ameliorate this effect. Bisphosphonate treatment can improve both bone mineral density and vascular calcification, but the latter becomes more unlikely in patients with stage 3-4 CKD with vascular calcification but no decreased bone mineral density. Using bisphosphonates requires considerable caution in advanced CKD, and the lack of adequate clinical investigation necessitates more studies regarding its effects on these patients.

Low protein intake magnifies detrimental effects of ovariectomy and vitamin D on bone

Protein-induced changes in bone and calcium homeostasis could potentially be greater in the elderly and in women at risk for osteoporosis. We hypothesize that a low protein intake would magnify the negative changes in bone metabolism seen in vitamin D (vitD) insufficiency and/or estrogen deficiency. The present study was undertaken to better understand how a low protein diet along with vitD insufficiency could affect bone metabolism using a rodent ovariectomized (OVX) model. Rats (n = 60) underwent ovariectomy (OVX) or sham operation. The first 15 days after surgery, all rats were fed a standard rodent diet. Thereafter, rats (n = 10/group) were fed a low protein diet (LP; 2.5 %) or a control diet (NP; 12.5 %) with 100 IU% vitD (+D; cholecalciferol) or without vitD (-D) for 45 days. The groups were as follows: SHAM + NP + D (control); SHAM + LP + D; SHAM + LP - D; OVX + NP + D; OVX + LP + D; OVX + LP - D. Body weight (BW) of control and OVX + NP + D groups increased while those feeding the LP diet, independently of vitD feedings, decreased (p < 0.05). The OVX + LP - D group presented the lowest serum Ca, phosphorus and osteocalcin levels and the highest CTX levels (p < 0.05). At the end of the study, total skeleton bone mineral content, proximal tibia bone mineral density, bone volume and trabecular number levels decreased as follows: SHAM + NP + D (controls) > SHAM + LP + D > OVX + NP + D > SHAM + LP - D > OVX + LP + D > OVX + LP - D (p < 0.05). A low protein diet negatively affected bone mass and magnified the detrimental effects of vitD and/or estrogen deficiencies.

Vitaminas B12, B6, B9 e homocisteína e sua relação com a massa óssea em idosos

O número de idosos nos últimos anos tem apresentado incremento em todo o mundo, o que acaba gerando inúmeras preocupações com a saúde dessa população, já que nessa fase da vida as alterações fisiológicas os tornam mais propensos a doenças, principalmente as crônicas não-transmissíveis. A osteoporose, uma doença osteometabólica frequente nos idosos, torna-se alvo de importantes estudos, uma vez que suas consequências afetam tanto a saúde física quanto a psicossocial. Contudo, são diversos os fatores que predispõem à osteoporose, entre os quais a deficiência de vitamina B12, vitamina B9 (folato) e vitamina B6 (piridoxina). A carência dessas vitaminas eleva os níveis de homocisteína, que age interferindo nas ligações cruzadas do colágeno, resultando em diminuição da resistência óssea e, consequentemente, na osteoporose e fraturas ósseas tanto em homens quanto em mulheres. Nesse contexto, este artigo tem como objetivo realizar uma revisão de literatura nas bases de dados LILACS e PubMed, sobre a relação dos níveis séricos de vitamina B12, folato, vitamina B6 e homocisteína com a diminuição da massa óssea em idosos.

Calcium supplementation in postmenopausal women to reduce the risk of osteoporotic fractures

PURPOSE

The most recent large-scale studies evaluating the effects of calcium supplementation for prevention of osteoporosis-related fractures in postmenopausal women are reviewed.

SUMMARY

Osteoporosis is a very common disease associated with significant morbidity and mortality. For many years, use of a calcium supplement (preferably in combination with vitamin D to optimize calcium absorption) has been recommended for postmenopausal women to decrease fracture risk. However, five large-scale, randomized, controlled trials have called into question the benefits of calcium in reducing fracture risk, and four of the studies indicated that calcium users may be at increased risk for renal stones and gastrointestinal problems. However, all five studies had one or more important limitations, including possible selection bias and study participants' relatively high baseline calcium intake and generally low adherence to treatment regimens. Moreover, in some of the studies, vitamin D was not included in the treatment protocol or was not used at levels sufficient to optimize calcium absorption. In three of the five trials, subgroup analysis of the most treatment-adherent participants indicated significant reductions in osteoporotic fracture risk with calcium supplement use.

CONCLUSION

Results of recent clinical trials indicate that calcium supplementation does not significantly reduce fracture risk in postmenopausal women. However, evidence from the same studies suggests that beneficial effects on fracture risk may be seen in women who are adherent to therapy. Postmenopausal women should continue calcium supplementation to reduce osteoporosis risk.

Risk for fractures with centrally acting muscle relaxants: an analysis of a national Medicare Advantage claims database

BACKGROUND

In older adults, both muscle relaxants and benzodiazepines are associated with sedation and cognitive impairment. Although benzodiazepines have been linked to falls and fracture injuries, no studies have examined the risk of fracture associated with muscle relaxants.

OBJECTIVE

To determine whether muscle relaxants identified in the Beers criteria are associated with an increased risk of fracture injuries and to compare this risk to that with benzodiazepine use.

METHODS

We conducted a case-control study using both medical and pharmacy claims data from 1.5 million enrollees in the Medicare Advantage plans of a large health maintenance organization. We matched 8164 cases of fractures with 8164 controls based on age, sex, health plan, and comorbidities. We measured the use of muscle relaxants, short-acting benzodiazepines, and long-acting benzodiazepines. Adjusted odds ratios were estimated using conditional logistic regression.

RESULTS

After adjusting demographic and clinical covariates, muscle relaxants, long-acting benzodiazepines, and short-acting benzodiazepines were associated with a high risk of fracture injuries, with odds ratios of 1.40 (95% CI 1.15 to 1.72; p < 0.001), 1.9 (95% CI 1.49 to 2.43; p < 0.001), and 1.33 (95% CI 1.15 to 1.55; p < 0.001), respectively.

CONCLUSIONS

An elevated risk of fracture injuries was noted among older adults using muscle relaxants. Our findings provide evidence of an association between the risk of fractures and the use of centrally acting muscle relaxants in older adults. This association supports current recommendations advising extreme caution in prescribing muscle relaxants to older adults.

Jumping mechanography: a potential tool for sarcopenia evaluation in older individuals

Muscular function declines with advancing age and is associated with increased risk for falls and fragility fractures. No single methodology ideally quantitatively evaluates this decline. Jumping mechanography (JM) may prove useful to quantitatively measure muscular function in older adults. This study begins to evaluate the safety of JM and the relationship of jump power and lean mass in older adults. Eighty adults, 40 aged 20-30 yr and 40 aged 60 yr or older, distributed equally by gender, participated. They performed countermovement jumps to assess jump power and height. Self-reported pain before and after jumping and need for assistance was recorded. In the older group, dual-energy X-ray absorptiometry was used to measure bone mineral density, to estimate lean body mass, and to determine vertebral fracture status. Jumping was well tolerated without injury or increased pain. No new vertebral fractures occurred with jumping in the older group. Young individuals had greater jump power and height compared with the older group. Older age was negatively correlated, whereas lean mass positively correlated with jump power and height. JM appears to be a safe and potentially useful method to assess muscular function in older adults.

Management of osteoporosis in CKD Stages 3 to 5

Osteoporosis and chronic kidney disease (CKD) are both common conditions of older adults and both may be associated with substantial morbidity. However, biochemical and histologic changes that occur with progressive kidney disease require specific interventions, some of which may be concordant with osteoporosis management in the general population, whereas others may be less relevant or perhaps even harmful. In this article, we review the diagnosis of and management strategies for osteoporosis in individuals with CKD, placing these into perspective with the recently published KDIGO (Kidney Disease: Improving Global Outcomes) guidelines for treatment of CKD-mineral and bone disorder (CKD-MBD). Specifically, we highlight osteoporosis treatment recommendations by CKD stage and discuss new avenues for osteoporosis treatment that may be useful in individuals with CKD.

Hip and fragility fracture prediction by 4-item clinical risk score and mobile heel BMD: a women cohort study

Background

One in four Swedish women suffers a hip fracture yielding high morbidity and mortality. We wanted to revalidate a 4-item clinical risk score and evaluate a portable heel bone mineral density (BMD) technique regarding hip and fragility fracture risk among elderly women.

Methods

In a population-based prospective cohort study we used clinical risk factors from a baseline questionnaire and heel BMD to predict a two-year hip and fragility fracture outcome for women, in a fracture preventive program. Calcaneal heel BMD was measured by portable dual X-ray laser absorptiometry (DXL) and compared to hip BMD, measured with stationary dual X-ray absorptiometry (DXA) technique.

Results

Seven women suffered hip fracture and 14 women fragility fracture/s (at hip, radius, humerus and pelvis) among 285 women; 60% having heel BMD ≤ -2.5 SD. The 4-item FRAMO (Fracture and Mortality) Index combined the clinical risk factors age ≥80 years, weight <60 kg, prior fragility fracture, and impaired rise-up ability. Women having 2-4 risk factors showed odds ratio (OR) for hip fracture of 5.9 and fragility fracture of 4.4. High risk group hip fracture risk was 2.8% annually compared to 0.5% for the low risk majority (69%). Heel BMD showed hip fracture OR of 3.1 and fragility fracture OR of 2.6 per SD decrease. For 30 DXA assessed participants mean hip BMD at -2.5 SD level corresponded to a lower BMD at the heel. Five of seven hip fractures occurred within a small risk group of 32 women, identified by high FRAMO Index + prior fragility fracture + heel T-score ≤-3.5 SD.

Conclusions

In a follow-up study we identified high risk groups for hip and fragility fracture with our plain 4-item risk model. Increased fracture risk was also related to decreasing heel BMD in calcaneal bone, measured with a mobile DXL technique. A combination of high FRAMO Index, prior fragility fracture, and very low BMD restricted the high risk group to 11%, among whom most hip fractures occurred (71%). These practical screening methods could eventually reduce hip fracture incidence by concentrating preventive resources to high fracture risk women.

A biomechanical evaluation of femoroplasty under simulated fall conditions

OBJECTIVES

To test the hypotheses that, compared with controls: 1) femoroplasty (the injection of bone cement into the proximal femur in an attempt to prevent fragility fracture) increases the yield and ultimate loads, yield and ultimate energies, and stiffness of the proximal osteoporotic femur in a simulated fall model; and 2) the manner in which the cement distributes in the proximal femur affects the extent to which those mechanical properties are altered.

METHODS

In 10 pairs of osteoporotic human cadaveric femora, we injected one femur of each pair with 40 to 50 mL of polymethylmethacrylate bone cement; the noninjected femur served as the control. The filling percentage was calculated in four anatomic regions of the femur: head, neck, trochanter, and subtrochanter. All specimens were biomechanically tested in a configuration that simulated a fall on the greater trochanter. Student t test, linear regression, and multinomial logistic regression statistical analyses were conducted where appropriate with significant difference defined as P < 0.05.

RESULTS

Femoroplasty significantly increased yield load (22.0%), ultimate load (37.3%), yield energy (79.6%), and ultimate energy (154%) relative to matched controls but did not significantly change stiffness (-10.9%). There was a strong (r = 0.7) correlation between yield load and filling percentage in the femoral neck.

CONCLUSIONS

This study showed that 1) femoroplasty significantly increased fracture load and energy to fracture when osteoporotic femora were loaded in simulated fall conditions, and 2) cement filling in the femoral neck may have an important role in the extent to which femoroplasty affects mechanical strength of the proximal femur.

Overcoming barriers to osteoporosis care in vulnerable elderly patients with hip fractures

Indications for and benefits of providing osteoporosis (OP) care for hip fracture patients have become widely understood. The hip fracture patient is frequently over age 80 years, minimally ambulatory, has multiple medical comorbidities, and has cognitive impairment. Patient barriers to initiation of effective OP treatment include: age, dementia, medical comorbidities, polypharmacy, lack of adherence with treatment, alcohol abuse, postoperative delirium, language barriers, inadequate social support, and socioeconomic status. In a large teaching hospital, 244 patients presented with hip fracture over 2 years: 72% were female and 64% were over age 80. Forty percent had been diagnosed with dementia; another 29% had other severe medical comorbidities.Opportunities for OP diagnosis and treatment are numerous. In acute care hospitals, coordinator facilitated programs are effective for identification, education, assessment, referral, and treatment of underlying OP in fracture patients. System modifications may include an automated care path or automatic specialist referral for hip fracture patients. In the rehabilitation hospital, the patients are in a more stable condition, there is a focus on the recent fracture, and there are opportunities to initiate OP treatment and to promote adherence. In long-term care, dietary intake including calcium and vitamin D supplementation and persistence with pharmacotherapy can be monitored. Patient education and referral to the family physician for osteoporosis investigation and treatment have improved patient knowledge and diagnosis, but the reported impact on treatment has been limited.Effective OP care for the vulnerable hip fracture patient should be initiated early but may be complex and require coordination. In addition to calcium and vitamin D supplementation, most patients in this category have an indication for aminobisphosphonate therapy. Liaison between the orthopaedic team and the discharge destination caregivers, an established discharge diagnosis of osteoporosis, and ensuring patients are discharged on supplements and medication will promote patient, caregiver, and primary care physician awareness of the patient's OP care needs. Education programs may provide benefits at later stages, to improve adherence with treatment.

Once-yearly zoledronic acid in hip fracture prevention

Osteoporosis is an escalating global problem. Hip fractures, the most catastrophic complication of osteoporosis, continue to cause significant mortality and morbidity despite increasing availability of effective preventative agents. Among these agents, oral bisphosphonates have been the first choice for the treatment and prevention of osteoporotic fractures. However, the use of oral bisphosphonates, especially in the older population, has been limited by their side effects and method of administration thus compromising their persistent use. The resultant low adherence by patients has undermined their full potential and has been associated with an increase in the incidence of fragility fractures. Recently, annual intravenous zoledronic acid (ZOL) has been approved for osteoporosis. Randomized controlled trials have demonstrated ZOL to be safe, have good tolerability and produce significant effect on bone mass and microarchitecture. Adherence has also been shown to be better with ZOL. Furthermore two large trials firmly demonstrated significant anti-osteoporotic effect (∼59% relative risk reduction of hip fractures) and mortality benefit (28% reduction in mortality) of ZOL in older persons with recent hip fractures. In this review, we report the current evidence on the use of ZOL for the prevention of hip fractures in the elderly. We also report the pharmacological characteristics and the advantages and disadvantages of ZOL in this particular group.

Quantitative trait locus on chromosome 1q influences bone loss in young Mexican American adults

Bone loss occurs as early as the third decade and its cumulative effect throughout adulthood may impact risk for osteoporosis in later life, however, the genes and environmental factors influencing early bone loss are largely unknown. We investigated the role of genes in the change in bone mineral density (BMD) in participants in the San Antonio Family Osteoporosis Study. BMD change in 327 Mexican Americans (ages 25-45 years) from 32 extended pedigrees was calculated from DXA measurements at baseline and follow-up (3.5 to 8.9 years later). Family-based likelihood methods were used to estimate heritability (h(2)) and perform autosome-wide linkage analysis for BMD change of the proximal femur and forearm and to estimate heritability for BMD change of lumbar spine. BMD change was significantly heritable for total hip, ultradistal radius, and 33% radius (h(2) = 0.34, 0.34, and 0.27, respectively; p < 0.03 for all), modestly heritable for femoral neck (h(2) = 0.22; p = 0.06) and not heritable for spine BMD. Covariates associated with BMD change included age, sex, baseline BMD, menopause, body mass index, and interim BMI change, and accounted for 6% to 24% of phenotype variation. A significant quantitative trait locus (LOD = 3.6) for femoral neck BMD change was observed on chromosome 1q23. In conclusion, we observed that change in BMD in young adults is heritable and performed one of the first linkage studies for BMD change. Linkage to chromosome 1q23 suggests that this region may harbor one or more genes involved in regulating early BMD change of the femoral neck.

Cancer therapy and osteoporosis: approach to evaluation and management

The incidences of osteoporosis and cancer increase with age, and these two diagnoses are often made in the same individual. Both increasing age and hypogonadism associated with aging, as well as cancer therapies, can lead to loss of bone mass and increased risk for fragility fractures. Advancing age carries an association with increased incidence of cancers. Thus, cancer and its therapies may predispose an individual to osteoporosis and its associated morbidity and mortality. Prevention of bone loss and its consequent fractures is critical in the care of aging patients. This article reviews the mechanisms of bone metabolism and the principles of management of bone health in the older population with a history of cancer.

Genetic influences on bone loss in the San Antonio Family Osteoporosis study

The genetic contribution to age-related bone loss is not well understood. We estimated that genes accounted for 25-45% of variation in 5-year change in bone mineral density in men and women. An autosome-wide linkage scan yielded no significant evidence for chromosomal regions implicated in bone loss.

INTRODUCTION

The contribution of genetics to acquisition of peak bone mass is well documented, but little is known about the influence of genes on subsequent bone loss with age. We therefore measured 5-year change in bone mineral density (BMD) in 300 Mexican Americans (>45 years of age) from the San Antonio Family Osteoporosis Study to identify genetic factors influencing bone loss.

METHODS

Annualized change in BMD was calculated from measurements taken 5.5 years apart. Heritability (h(2)) of BMD change was estimated using variance components methods and autosome-wide linkage analysis was carried out using 460 microsatellite markers at a mean 7.6 cM interval density.

RESULTS

Rate of BMD change was heritable at the forearm (h(2) = 0.31, p = 0.021), hip (h(2) = 0.44, p = 0.017), spine (h(2) = 0.42, p = 0.005), but not whole body (h(2) = 0.18, p = 0.123). Covariates associated with rapid bone loss (advanced age, baseline BMD, female sex, low baseline weight, postmenopausal status, and interim weight loss) accounted for 10% to 28% of trait variation. No significant evidence of linkage was observed at any skeletal site.

CONCLUSIONS

This is one of the first studies to report significant heritability of BMD change for weight-bearing and non-weight-bearing bones in an unselected population and the first linkage scan for change in BMD.

Inadequate responders to osteoporosis treatment: proposal for an operational definition

The concept of inadequate response to osteoporosis treatment is not clear. In the literature several criteria have been used. We propose an operational definition of an inadequate responder based on the changes observed in bone mineral density and incident fractures while on therapy.

INTRODUCTION

Fractures may occur in compliant patients even while on active treatment. These cases have been defined as inadequate responders (IR).

METHODS

We reviewed the basis for this concept and propose an operational definition for IR.

RESULTS

Good compliance and adequate calcium and vitamin D supplementation are the first requirement. The second requirement is a treatment period of at least 1 year, since before that time treatment may not have been fully effective. Fractures are the gold standard for measuring efficacy and changes in bone density and turnover markers may be surrogates. We propose classifying patient response as: Inadequate--incident fracture and a decrease in BMD greater than a significant change (Trend Assessment Margin or TAM); Possibly inadequate--incident fracture or a decrease in BMD greater than a significant change (TAM); and Appropriate--no fracture and no decrease in BMD greater than a significant change (TAM). Additional criteria (biochemical markers, bone quality parameters) may be taken into account.

CONCLUSION

A wide consensus on the IR concept is required given its clinical, regulatory, and reimbursement implications.

Optimal protein intake in the elderly

The recommended dietary allowance (RDA) for protein, as promulgated by the Food and Nutrition Board of the United States National Academy of Science, is 0.8 g protein/kg body weight/day for adults, regardless of age. This value represents the minimum amount of protein required to avoid progressive loss of lean body mass in most individuals. There is an evidence that the RDA for elderly may be greater than 0.8 g/kg/day. Evidence indicates that protein intake greater than the RDA can improve muscle mass, strength and function in elderly. In addition, other factors, including immune status, wound healing, blood pressure and bone health may be improved by increasing protein intake above the RDA. Furthermore, the RDA does not address the recommended intake of protein in the context of a balanced diet. Concerns about potential detrimental effects of increased protein intake on bone health, renal function, neurological function and cardiovascular function are generally unfounded. In fact, many of these factors are improved in elderly ingesting elevated quantities of protein. It appears that an intake of 1.5 g protein/kg/day, or about 15-20% of total caloric intake, is a reasonable target for elderly individuals wishing to optimize protein intake in terms of health and function.

Influence of high and low protein intakes on age-related bone loss in rats submitted to adequate or restricted energy conditions

Low energy and protein intake has been suggested to contribute to the increased incidence of osteoporosis in the elderly. The impact of dietary protein on bone health is still a matter of debate. Therefore, we examined the effect of the modulation of protein intake under adequate or deficient energy conditions on bone status in 16-month-old male rats. The animals were randomly allocated to six groups (n = 10/group). Control animals were fed a diet providing either a normal-protein content (13%, C-NP) or a high-protein content (26%) (C-HP). The other groups received a 40% protein/energy-restricted diet (PER-NP and PER-HP) or a normal protein/energy-restricted diet (ER-NP and ER-HP). After 5 months of the experiment, protein intake (13% or 26%) did not modulate calcium retention or bone status in those rats, although a low-grade metabolic acidosis was induced with the HP diet. Both restrictions (PER and ER) decreased femoral bone mineral density and fracture load. Plasma osteocalcin and urinary deoxypyridinoline levels were lowered, suggesting a decrease in bone turnover in the PER and ER groups. Circulating insulin-like growth factor-I levels were also lowered by dietary restrictions, together with calcium retention. Adequate protein intake in the ER condition did not elicit any bone-sparing effect compared to PER rats. In conclusion, both energy and protein deficiencies may contribute to age-related bone loss. This study highlights the importance of sustaining adequate energy and protein provision to preserve skeletal integrity in the elderly.

Association of left ventricular function with bone mineral density in older women: a population-based study

Due to the increasing mortality and disability rates associated with hip and vertebral fractures in older age, research is currently focusing on "new" determinants of osteoporosis in elderly subjects. Most recently, low bone mineral density (BMD) has been repeatedly reported in patients with end-stage heart failure. We assessed the association, if any, of BMD with left ventricular ejection fraction (LVEF) in a general older population. We assessed the association of LVEF with T score, Z score, and stiffness index in all 312 subjects aged 75 and over living in Tuscania, Italy. Among women, LVEF was associated with T score (beta = 0.02, 95% CI 0.01-0.05; P = 0.033), Z score (beta = 0.02, 95% CI 0.01-0.04; P = 0.038), and stiffness index (beta = 0.25, 95% CI 0.02-0.48; P = 0.036) in multivariable linear regression analysis, after adjusting for lifestyle habits, demographic variables, comorbid conditions, polypharmacy, and objective measurements. No significant associations were observed in men. In linear discriminant analysis, the LVEF cutoff level that best predicted osteoporosis was < or =49%. Left ventricular function is directly and independently associated with all of the ultrasonographic BMD parameters in older women. As left ventricular dysfunction, often asymptomatic, is a prevalent finding in older women, this association and its potential therapeutic implications should be assessed in dedicated studies.

[Preventing dependency in the elderly.]

INTRODUCTION

dependency, i.e. the need to depend on another person to perform activities of daily living, is the main concern and cause of suffering and poor quality of life in the elderly. The prevalence of dependency increases with age and is related to the presence of prior disease and fragility. Dependency is associated with increased morbidity, mortality and institutionalization, as well as with greater health and social resource utilization, all of which increases health costs.

OBJECTIVE

to create a consensus document on the main health recommendations for the prevention of dependency in the elderly, based on the scientific evidence available to date, with the collaboration of scientific societies and public health administrations (the Spanish Ministry of Health, Autonomous Communities and Cities).

METHODS

a) a preliminary consensus document was drafted by an expert group composed of representatives of various scientific societies and health administrations. This document was based on a review of the recommendations and guidelines published by the main organizations involved in health promotion and the prevention of disease, functional deterioration and dependency in the elderly; b) the consensus document was reviewed by the remaining experts assigned by the scientific societies and central and autonomous administrations; c) the final document was approved after a session in which the text was discussed and reviewed by all the experts participating in the working group (including the academic committee); d) the document was presented and discussed in the First National Conference on Prevention and Health Promotion in Clinical Practice in Spain. All participating experts signed a conflicts of interest statement.

RESULTS

the document provides recommendations, with their grades of evidence, grouped in the following three categories: a) health promotion and disease prevention, with specific preventive activities for the elderly, including prevention of geriatric syndromes; b) prevention of functional deterioration, with clinical recommendations that can be applied in primary and specialized care; c) prevention of iatrogeny (drug prescription, inappropriate use of diagnostic and therapeutic modalities and healthcare). These recommendations were tailored to the characteristics of the older person (OP), categorized in five groups: healthy OP, OP with chronic disease, fragile or at risk OP, dependent OP, and OP at the end of life.

CONCLUSION

these recommendations should be implemented by public health administrations to improve strategies for the prevention of dependency in the elderly in the XXI century.

Impact of energy and casein or whey protein intake on bone status in a rat model of age-related bone loss

In the elderly, nutritional deficiencies, such as low energy and protein intake, are suggested to increase the risk of osteoporotic fractures. Modulation of the amount and quality of protein intake under energy deficient conditions represents an interesting strategy to prevent aged-related bone loss. We investigated the effect of a 5-month dietary restriction on bone status in 16-month-old male rats. Rats were randomised into six groups (n 10 per group). Control animals were fed a normal diet containing either casein (N-C) or whey protein (N-WP). The other groups received a 40 % protein and energy-restricted diet with casein or whey protein (PER-C and PER-WP) or a normal protein and energy-restricted diet (ER-C and ER-WP). Both restrictions (PER and ER) induced a decrease in femoral bone mineral density (BMD), consistent with impaired biomechanical properties and a reduced cortical area at the diaphysis. Plasma osteocalcin and urinary deoxypyridinoline levels suggested a decrease in bone turnover in the PER and ER groups. Interestingly, circulating insulin-like growth factor 1 (IGF-1) levels were also lowered. Overall, normal protein intake did not elicit any bone sparing effect in energy-deficient rats. Regarding protein quality, neither casein nor WP appeared to significantly prevent the BMD decrease. This study confirms that nutritional deficiencies may contribute to osteopenia through decreased IGF-1 levels. Moreover, it seems that impaired bone status could not be significantly prevented by modulating the amount and quality of dietary proteins.

Advances in the medical management of osteoporosis

Osteoporosis is a skeletal disorder characterised by compromised bone strength predisposing to increased risk of fracture, which is rapidly reaching epidemic proportions as the population ages. Many patients presenting with a fracture caused by a fall from standing height or less are not on any kind of therapy and many patients who sustain these fragility fractures are not started on therapy by their orthopaedic surgeon. In 2004, the United States Surgeon General released a report on osteoporosis recommending that physicians adopt a pyramidal approach to therapy. The base of the pyramid includes calcium, vitamin D, physical therapy and fall prevention. The second level calls for management or elimination of secondary causes of osteoporosis. The third level consists of treatment with either anti-resorptive or anabolic medications. The orthopaedic surgeon is in an ideal position to diagnose fragility fractures and suggest treatment in the hope of preventing future fractures. Anti-resorptive and anabolic therapies currently available are discussed.

Prevention and Treatment of Frailty in the Postmenopausal Woman

Frailty is a complex subject, and all aspects of frailty are intertwined. This article identifies and discusses the individual aspects of frailty. These aspects, including sarcopenia, nutrition, obesity, relative strength, inflammatory markers, osteopenia and osteoporosis, aerobic capacity, absolute strength, balance, and prevention of frailty, must be reunited, albeit in varying combinations, if the effects of frailty on women are to be understood and treated. This article does not exhaust the topic, but covers what the authors consider to be the major issues.

Calcium metabolism and vitamin D in the extreme longevity

Skeletal remodelling is a continuous process during life and is still active also in extreme senescence. In the elderly, bone resorption often prevails over bone formation, causing bone loss and fragility. Elderly subjects are exposed to the risk of fractures, and loss of self-sufficiency, if considering that the proximal femur is the most frequently involved site. Bone remodelling can maintain circulating calcium within physiological ranges, at the expense of a substantial loss of this ion from the skeleton, particularly during senescence. Calcium metabolism is regulated at cellular/molecular level by a network of cytokines, growth factors, systemic hormones that act on bone in paracrine/autocrine/systemic fashion. Among the molecules involved in bone metabolism, parathyroid hormone (PTH) and vitamin D present some peculiar aspects during senescence. The osteometabolic features in a consistent group of centenarians have been evaluated. It results that a severe hypovitaminosis D was present in 99 out of 104 centenarians (25-OH vitamin D below 5 nmol/L), and that it plays an important role as a factor inducing a vicious circle involving hypocalcemia, secondary hyperparathyroidism, together with biochemical features indicating a consistent bone loss. Serum C-terminal cross-linking telopeptide, a specific marker of bone resorption was elevated in 92% of these subjects. Moreover, it has been found that several femoral fractures had occurred after 90 years of age. These data offer a rational for the possible prevention of elevated bone turnover, bone loss and consequently the reduction of osteoporotic fractures and fractures-induced disability, in the oldest olds, through the simple supplementation with calcium and vitamin D.

Falls in older adults: risk assessment, management and prevention

Falls are a common and serious problem for older adults. This article reviews practical aspects of the evaluation and management of this disorder in the ambulatory setting. Older patients should be screened for falls or changes in mobility as part of their annual health maintenance examination. Most falls are due to multiple factors, including disorders of gait, balance, strength, and vision. Polypharmacy and certain medications contribute to falls in many patients and can be a remediable factor. Many falls can be prevented through individualized multicomponent interventions. Exercise programs, rehabilitation, medication management, and treatment of vitamin D deficiency are the most effective single interventions. Referral to a geriatrician should be considered for patients with other common geriatric syndromes, such as cognitive impairment, incontinence, or depression.

The need for increasing awareness of osteoporosis in men

Awareness of the need to evaluate men for osteoporosis is almost nonexistent among health care providers. Osteoporosis is a silent disorder in both men and women until fracture occurs. Yet, screening for osteoporosis is particularly important in men because fragility fractures are more likely to lead to fatal consequences than in women. Without a diagnosis of osteoporosis, treatment interventions that can prevent fractures in men are not initiated. Advancement of better health outcomes for men at risk for osteoporosis begins with a greater awareness of the need for osteoporosis screening and treatment whenever appropriate. The primary objective of this review article is to report on study findings that document the need for more clinical attention to osteoporosis in men. It is important to know how osteoporosis in men differs from osteoporosis in women, the classification into type 1 and type 2 primary osteoporosis and secondary osteoporosis, and how to measure bone mineral density in men. In addition, there is a great need to develop evidence-based guidelines for the diagnosis and treatment of osteoporosis in men.

Osteoporosis: pathogenesis, new therapies and surgical implications

Many developments occurred in the realm of bone healing in recent years. Genetic discoveries, new proteins affecting bone health, and new treatments have steered our treatment of traumatic and iatrogenic fractures in new directions. Osteoporosis strikes many subsets of the world population, including: women, the elderly, and those suffering from arthritis, autoimmune diseases, HIV, and the immunocompromised. This disease predisposes people to an increased risk of low trauma and fragility fractures. The baby boomer generation and an increasing lifespan may burden the economy by creating such a large group susceptible to such a potentially devastating disease. The novel treatments and coping with the potentially challenging surgical implications will aide the podiatric physician in both medical and surgical management of osteoporosis.

Validation of a 4-item score predicting hip fracture and mortality risk among elderly women

PURPOSE

One in 4 Swedish women experiences a hip fracture, an event that has high concomitant morbidity and mortality. We developed and validated a clinical predictor of fracture and mortality risk, the Fracture and Mortality (FRAMO) Index.

METHODS

This was a population-based prospective cohort study with a baseline questionnaire and 2-year outcomes of hip fracture, fragility fracture, and death. The questionnaire was sent to 1,498 women aged 70 years or older in 3 rural populations, asking them about their age, weight, height, mobility, previous fractures, smoking, medication use, and housing. Some women were also asked about previous vertebral radiographs. We defined 2 risk models before outcome data collection and subsequently renamed 1 model (age =80 years, weight <60 kg, previous fragility fracture, and the need to use arms to rise from the sitting position) the FRAMO Index. We used logistic regression analysis to study the association between the FRAMO Index and outcomes in all participants.

RESULTS

The participation rate was 83% in this elderly female population (N = 1,248). The 63% of women with 0 to 1 risk factor had a 2-year hip fracture risk of 0.8% and mortality risk of 3.2%. In contrast, women with 2 to 4 risk factors had a 2-year hip fracture risk of 5.4% (odds ratio = 7.5; 95% confidence interval, 3.0-18.4) and mortality risk of 23.7% (odds ratio = 9.5; 95% confidence interval, 6.0-14.9). These differences remained significant after adjustment for age as a continuous variable. Mortality increased with the number of risk factors. The proportion of women reporting previous vertebral fractures was higher among the group specifically questioned about vertebral radiographs (P <.001).

CONCLUSIONS

The FRAMO Index identified the majority of women who experienced hip fractures during a 2-year follow-up, who might have been candidates for intensified preventive measures. The FRAMO Index, based on 4 binary risk factors, would be practical for routine use in primary care.

Elder research: filling an important gap in psychology and law

In the past few decades, psychology-law as a discipline has made great strides in understanding and guiding public policies on issues related to eyewitnesses, confessions, juries, judges, juveniles, the mentally ill, and many others. As a field, we have largely neglected the oldest subset of the population, with only a few scholars focusing specifically on elder issues or systematically including elders in their studies. The current article is a call to research. It first outlines why elders should be considered as a specific subset of the population even though they have not been an area of focus in the field. Second, the article provides suggestions for integrating elder issues into more common psychology-law research as well as some new areas for research.