Institutionalization following incident non-traumatic fractures in community-dwelling men and women

Preclinical Rodent Models for Human Bone Disease, Including a Focus on Cortical Bone

Preclinical models (typically ovariectomized rats and genetically altered mice) have underpinned much of what we know about skeletal biology. They have been pivotal for developing therapies for osteoporosis and monogenic skeletal conditions, including osteogenesis imperfecta, achondroplasia, hypophosphatasia, and craniodysplasias. Further therapeutic advances, particularly to improve cortical strength, require improved understanding and more rigorous use and reporting. We describe here how trabecular and cortical bone structure develop, are maintained, and degenerate with aging in mice, rats, and humans, and how cortical bone structure is changed in some preclinical models of endocrine conditions (eg, postmenopausal osteoporosis, chronic kidney disease, hyperparathyroidism, diabetes). We provide examples of preclinical models used to identify and test current therapies for osteoporosis, and discuss common concerns raised when comparing rodent preclinical models to the human skeleton. We focus especially on cortical bone, because it differs between small and larger mammals in its organizational structure. We discuss mechanisms common to mouse and human controlling cortical bone strength and structure, including recent examples revealing genetic contributors to cortical porosity and osteocyte network configurations during growth, maturity, and aging. We conclude with guidelines for clear reporting on mouse models with a goal for better consistency in the use and interpretation of these models.

A novel case-finding strategy based on artificial intelligence for the systematic identification and management of individuals with osteoporosis or at varying risk of fragility fracture

An artificial intelligence-based case-finding strategy has been developed to systematically identify individuals with osteoporosis or at varying risk of fragility fracture. This strategy has the potential to close the critical care gap in osteoporosis treatment in primary care, thereby lessening the societal burden imposed by fragility fractures.

BACKGROUND

Osteoporotic fractures represent a major cause of morbidity and, in older adults, a precursor of disability, loss of independence, poor quality of life and premature death. Despite the detrimental health impact, osteoporosis remains largely underdiagnosed and undertreated worldwide. Subjects at risk for osteoporosis-related fractures are identified either via organised screening or case finding. In the absence of a population-based screening policy, subjects at high risk of fragility fractures are opportunistically identified when a fracture occurs or because of other clinical risk factors (CRFs) for osteoporotic fracture and areal bone mineral density (aBMD) measured by dual-energy X-ray absorptiometry (DXA).

PURPOSE

This paper describes the development of a novel case-finding strategy, named Osteoporosis Diagnostic and Therapeutic Pathway (ODTP), which enables to identify subjects with osteoporosis or at varying risk of fragility fracture. This strategy is based on a specifically designed software tool, named "Bone Fragility Query" (BFQ), which analyses the electronic health record (EHR) databases of General Practitioners (GPs) to systematically identify individuals who should be prescribed DXA-BMD measurement, vertebral fracture assessment (VFA) and anti-osteoporosis medications (AOM).

CONCLUSIONS

The ODTP through BFQ tool is a feasible, convenient and time-saving osteoporosis model of care for GPs during routine clinical practice. It enables GPs to shift their focus from what to do (clinical guidelines) to how to do it in the primary health care setting. It also allows a systematic approach to primary and secondary prevention of fragility fractures, thereby overcoming clinical inertia and contributing to closing the gap between evidence and practice for the management of osteoporosis in primary care.

Decline in muscle strength and physical function after fracture in men - the prospective STRAMBO study

Studies on muscle strength and physical function after fracture are focused on short follow-ups and adjacent anatomical region. We compared loss of muscle strength and physical function in men after fracture with normal ageing-related decline. In 823 men aged 60-87, measurements of grip strength and clinical tests (chair stands, balance) were performed every 4 years for 12 years. In 155 men with incident fracture, we compared the status after vs. before the fracture. In men without fracture (controls), we compared the status on the first follow-up (4 years) vs. baseline. In men with fracture, grip strength decreased more than in the controls (41%, 0.28SD, P < .01). Men with fracture had higher risk of incident deterioration on the five chair-stand test vs. the controls (OR = 2.45, P < .001). They had higher risk of incident inability to stand for 10s with closed eyes vs. the controls (OR = 4.80, P < .01). They also had higher risk of deterioration on the tandem walk than the controls: forwards (OR = 2.04, P < .01), backwards (OR = 2.25, P < .005). The rapid physical decline was not limited to the region of the fracture site. In men who had incident non-upper limb fractures, grip strength decreased more (32%, P < .05) vs. the controls. In men who had incident non-lower limb fractures, the risk of decline in the tests of the lower limbs was higher vs. controls (chair stands, OR = 2.73, P < .001). The risk of decline was higher in men with clinical fractures which occurred >1 year before the next visit vs. controls (tandem walk forwards, OR = 2.98, P < .005). Overall, in older men, fractures were associated with greater loss of muscle strength and physical function vs. normal ageing. This accelerated decline was also found in the anatomical regions remote from the fracture site. Thus, programs to decrease or reverse the post-fracture decline could have beneficial effects on subsequent fracture risk.

Sex differences in clinical outcomes amongst 1105 patients admitted with hip fractures

Amongst hip fracture admissions, mortality is higher in men than in women. However, sex differences in other care-quality measures have not been well-documented. We aimed to examine sex differences in mortality as well as a wide range of underlying health indicators and clinical outcomes in adults ≥ 60 year of age admitted with hip fractures from their own homes to a single NHS hospital between April-2009 and June-2019. Sex differences in delirium, length of stay (LOS) and mortality in hospital, readmission, and discharge destination, were examined by logistic regression. There were 787 women and 318 men of similar mean age (± SD): 83.1 year (± 8.6) and 82.5 year (± 9.0), respectively (P = 0.269). There were no sex differences in history of dementia or diabetes, anticholinergic burden, pre-fracture physical function, American Society of Anesthesiologists grades, or surgical and medical management. Stroke and ischaemic heart disease, polypharmacy, and alcohol consumption were more common in men. After adjustment for these differences and age, men had greater risk of delirium (with or without cognitive impairment) within one day of surgery: OR = 1.75 (95%CI 1.14-2.68), LOS ≥ 3 weeks in hospital: OR = 1.52 (1.07-2.16), mortality in hospital: OR = 2.04 (1.14-3.64), and readmission once or more after 30 days of a discharge: OR = 1.53 (1.03-2.31). Men had a lower risk of a new discharge to residential/nursing care: OR = 0.46 (0.23-0.93). The present study revealed that, in addition to a greater risk of mortality than women, men also had many other adverse health outcomes. These findings, which have not been well-documented, serve to stimulate future targeted preventive strategies and research.

Patient perspectives on, and effects of, medication management in geriatric fallers (the EMMA study): protocol for a mixed-methods pre-post study

INTRODUCTION

Pharmacotherapy is critical in geriatric fallers owing to the vulnerability of this population. Comprehensive medication management can be an important strategy to reduce the medication-related risk of falling in this patient group. Patient-specific approaches and patient-related barriers to this intervention have rarely been explored among geriatric fallers. This study will focus on establishing a comprehensive medication management process to provide better insights into patients' individual perceptions regarding their fall-related medication as well as identifying organisational and medical-psychosocial effects and challenges of this intervention.

METHODS AND ANALYSIS

The study design is a complementary mixed-methods pre-post study which follows the approach of an embedded experimental model. Thirty fallers aged at least 65 years who were on five or more self-managed long-term drugs will be recruited from a geriatric fracture centre. The intervention consists of a five-step (recording, reviewing, discussion, communication, documentation) comprehensive medication management, which focuses on reducing the medication-related risk of falling. The intervention is framed using guided semi-structured pre-post interventional interviews, including a follow-up period of 12 weeks. These interviews will assess patients' perceptions of falls, medication-related risks and gauge the postdischarge acceptability and sustainability of the intervention. Outcomes of the intervention will be measured based on changes in the weighted and summated Medication Appropriateness Index score, number of fall-risk-increasing drugs and potentially inadequate medication according to the Fit fOR The Aged and PRISCUS lists. Qualitative and quantitative findings will be integrated to develop a comprehensive understanding of decision-making needs, the perspective of geriatric fallers and the effects of comprehensive medication management.

ETHICS AND DISSEMINATION

The study protocol was approved by the local ethics committee of Salzburg County, Austria (ID: 1059/2021). Written informed consent will be obtained from all patients. Study findings will be disseminated through peer-reviewed journals and conferences.

TRIAL REGISTRATION NUMBER

DRKS00026739.

Utilizing nomograms to predict prevalent vertebral fracture risk: An analysis of dysmobility syndrome in a community-dwelling population

BACKGROUND

To determine a reliable method to predict prevalent vertebral fractures (VF) by assessing the association between dysmobility syndrome (DS) and VF in a community-dwelling population.

METHODS

This cross-sectional study enrolled 518 participants from fracture-prevention educational activities held in multiple communities in Taiwan. Assessments included questionnaires, fracture risk assessment tool (FRAX), bone mineral density (BMD) and body composition using dual-energy x-ray absorptiometry (DXA), lateral thoracolumbar spine x-rays (specifically T8-S1), grip strength (GS), walking speed, and fall history.

RESULTS

DS was noted in 257 participants (49.6%) and VF was identified in 196 participants (37.8%). A higher prevalence of VF was noted in those with DS. The prevalence of VF was significantly associated with age, gender, FRAX both with and without BMD, osteoporosis, low GS, and DS. In multivariate models accounting for age and sex, the c-index was greater in those with low GS plus osteoporosis as compared to DS alone. Low GS, osteoporosis, and pre-BMD FRAX all had similar c-indexes. Pre-BMD FRAX plus low GS and osteoporosis was superior in predicting VF compared to pre-BMD FRAX plus low GS or osteoporosis alone. Besides the inclusion of age and gender, the nomogram with pre-BMD FRAX major osteoporosis fracture probability (MOF) plus low GS had improved correlation between the estimated and actual VF probability than those with pre-BMD FRAX MOF plus osteoporosis.

CONCLUSIONS

The constructed nomogram containing pre-BMD FRAX MOF plus low GS may be considered as a first-line prevalent VF screening method. Those with high-risk scores should subsequently undergo vertebral radiography and/or BMD.

Thiazide Diuretics and Fracture Risk: A Systematic Review and Meta-Analysis of Randomized Clinical Trials

Thiazide diuretics are commonly used antihypertensive agents. Until today, whether their use reduces fracture risk remains unclear. Our objective was to conduct a systematic review of thiazide diuretics' effects on fractures and bone mineral density (BMD) in randomized clinical trials (RCT) of adults. MEDLINE, EMBASE, CENTRAL, and the WHO's ICTRP registry were searched from inception to July 31, 2019. Two reviewers assessed studies for eligibility criteria: (i) RCTs; (ii) including adults; (iii) comparing thiazides, alone or in combination; (iv) to placebo or another medication; and (v) reporting fractures or BMD. Conference abstracts and studies comparing thiazides to antiresorptive or anabolic bone therapy were excluded. Bias was assessed using Cochrane Collaboration's Risk of Bias Tool-2. The primary outcome was fracture at any anatomical site. Secondary outcomes were osteoporotic fractures, hip fractures, and BMD at femoral neck, lumbar spine, and/or total hip. Fractures were pooled as risk ratios (RRs) using random-effect models. Prespecified subgroup analyses and post hoc sensitivity analyses were conducted. From 15,712 unique records screened, 32 trials (68,273 patients) met eligibility criteria. Thiazides were associated with decreased fractures at any site (RR = 0.87, 95% confidence interval [CI] 0.77-0.98; I 2  = 0%) and osteoporotic fractures (RR = 0.80; 95% CI 0.69-0.94; I 2  = 0%). Results were consistent in most subgroups and sensitivity analyses. Few studies reported hip fractures, and no association was found between thiazides and this outcome (RR = 0.84; 95% CI 0.67-1.04; I 2  = 0%). Only four studies reported BMD; a meta-analysis was not conducted because BMD reporting was inconsistent. Trials were deemed at low (3 studies, weight = 3%), some concerns (16 studies; 71%), or high (11 studies; 26%) risk of bias for the primary outcome. In conclusion, thiazide diuretics decreases the risk of fractures at any and at osteoporotic sites in a meta-analysis of RCTs. Additional studies are warranted in patients with high fracture risk. © 2022 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.

Hip Fractures in Older Adults Are Associated With the Low Density Bone Phenotype and Heterogeneous Deterioration of Bone Microarchitecture

Femoral neck areal bone mineral density (FN aBMD) is a key determinant of fracture risk in older adults; however, the majority of individuals who have a hip fracture are not considered osteoporotic according to their FN aBMD. This study uses novel tools to investigate the characteristics of bone microarchitecture that underpin bone fragility. Recent hip fracture patients (n = 108, 77% female) were compared with sex- and age-matched controls (n = 216) using high-resolution peripheral quantitative computed tomography (HR-pQCT) imaging of the distal radius and tibia. Standard morphological analysis of bone microarchitecture, micro-finite element analysis, and recently developed techniques to identify void spaces in bone microarchitecture were performed to evaluate differences between hip fracture patients and controls. In addition, a new approach for phenotyping bone microarchitecture was implemented to evaluate whether hip fractures in males and females occur more often in certain bone phenotypes. Overall, hip fracture patients had notable deterioration of bone microarchitecture and reduced bone mineral density compared with controls, especially at weight-bearing sites (tibia and femoral neck). Hip fracture patients were more likely to have void spaces present at either site and had void spaces that were two to four times larger on average when compared with non-fractured controls (p < 0.01). Finally, bone phenotyping revealed that hip fractures were significantly associated with the low density phenotype (p < 0.01), with the majority of patients classified in this phenotype (69%). However, female and male hip fracture populations were distributed differently across the bone phenotype continuum. These findings highlight how HR-pQCT can provide insight into the underlying mechanisms of bone fragility by using information about bone phenotypes and identification of microarchitectural defects (void spaces). The added information suggests that HR-pQCT can have a beneficial role in assessing the severity of structural deterioration in bone that is associated with osteoporotic hip fractures. © 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).

Time since prior fracture affects mortality at the time of clinical assessment: a registry-based cohort study

Fractures are associated with increased long-term mortality in patients surviving to undergo baseline DXA. Notably, excess mortality risk does not decline with increasing time since prior hip or humerus fractures, even after accounting for comorbid medical conditions and other risk factors.

INTRODUCTION

Mortality risk increases following most types of fracture. In routine clinical practice, patients with prior fractures seen for dual-energy X-ray absorptiometry scan (DXA) are "survivors;" whether they remain at increased mortality risk is unknown. We tested the association between prior fracture and all-cause mortality, stratified by time since fracture, in patients undergoing baseline DXA.

METHODS

We conducted a DXA registry-based cohort study and linked to population-based health services data for the Province of Manitoba, Canada. We identified women and men ≥ 40 years with minimum 10 years of prior healthcare coverage undergoing baseline DXA and ascertained prior fracture codes since 1984 and mortality to 2017. Time since prior fracture was calculated between the clinical encounter for the fracture and baseline DXA (index date). Cox proportional hazards models estimated hazard ratios for all-cause mortality in those with compared to those without prior fracture adjusted for (1) age and sex, and (2) age, sex, comorbidities, and other covariates.

RESULTS

The study cohort consisted of 74,474 individuals (mean age 64.6 years, 89.7% female). During mean follow-up 9.2 years, we ascertained 14,923 (20.0%) deaths. Except for forearm fractures, all fracture sites were associated with increased mortality risk compared to those without prior fracture, even after multivariable adjustment. Excess mortality risk tended to decline slightly with time since fracture and was no longer significant > 10 years after vertebral fracture. However, excess mortality persisted > 10 years following hip or humerus fracture.

CONCLUSIONS

Prior fractures are associated with increased long-term mortality in patients surviving to undergo baseline DXA. Excess mortality risk does not decline with time since prior hip or humerus fractures, after accounting for potential confounders. Fracture prevention may have important long-term benefits preserving life expectancy.

Hip fracture predicts subsequent hip fracture: a retrospective observational study to support a call to early hip fracture prevention efforts in post-fracture patients

In this real-world retrospective cohort, subsequent hip fracture occurred in one in four patients with any initial fracture, most often after hip fracture, on average within 1.5 years. These data support the need for early post-fracture interventions to help reduce imminent hip fracture risk and high societal and humanistic costs.

PURPOSE

This large retrospective cohort study aimed to provide hip fracture data, in the context of other fractures, to help inform efforts related to hip fracture prevention focusing on post-fracture patients.

METHODS

A cohort of 115,776 patients (72.3% female) aged > 65 (median age 81) with an index fracture occurring at skeletal sites related to age-related bone loss between January 1, 2011, and March 31, 2015, was identified using health services data from Ontario, Canada, and followed until March 31, 2017.

RESULTS

Hip fracture was the most common second fracture (27.8%), occurring in ≥ 19% of cases after each index fracture site and most frequently (33.0%) after hip index fracture. Median time to a second fracture of the hip was ~ 1.5 years post-index event. Patients with index hip fracture contributed the most to fracture-related initial surgeries (64.1%) and post-surgery complications (71.9%) and had the second-highest total mean healthcare cost per patient in the first year after index fracture ($62,793 ± 44,438). One-year mortality (any cause) after index hip fracture was 26.2% vs. 15.9% in the entire cohort, and 25.9% after second hip fracture.

CONCLUSION

A second fracture at the hip was observed in one in four patients after any index fracture and in one in three patients with an index hip fracture, on average within 1.5 years. Index hip fracture was associated with high mortality and post-surgery complication rates and healthcare costs relative to other fractures. These data support focusing on early hip fracture prevention efforts in post-fracture patients.

Long-term risk of subsequent major osteoporotic fracture and hip fracture in men and women: a population-based observational study with a 25-year follow-up

The risk of subsequent major osteoporotic and hip fracture following an initial fracture was increased in both sexes over 25 years, with modest time-dependent attenuation. This risk was highest in men, underscoring the importance of targeted treatment strategies particularly in this under-treated population.

INTRODUCTION

The risk of subsequent fractures is increased following an index fracture, and declines over time. We aimed to determine whether this risk was sustained over 25 years and evolved similarly in men and women.

METHODS

Using population-based databases, we performed a matched cohort study in 16,876 men and 39,230 women ≥ 50 years who sustained an index fracture during 1989-2006. Rates of subsequent major osteoporotic fractures (MOF) and hip fractures until 2016 were compared to rates for matched controls (n = 160,983). Age- and sex-stratified cumulative incidences to 25 years were estimated in the presence of competing mortality. Hazard ratios (HRs) with 95% confidence intervals (CI) for subsequent fractures were estimated for each on the first 15 years of follow-up with a final category ≥ 15 years, adjusted for comorbidities.

RESULTS

Risk for MOF and hip fractures remained elevated up to 25 years in both sexes. The cumulative incidence of fractures was higher in cases vs controls in both sexes and across all age categories except in those > 90 years. Crude rate ratios for subsequent MOF were 2.5 (95% CI 2.3-2.7) in men and 1.6 (95% CI 1.6-1.7) in women and were higher in the younger age groups. Adjusted HRs (aHRs) for subsequent MOF were higher in men than in women in the first year (men aHR 2.6, 95% CI 2.1-3.3; women aHR 1.6, 95% CI 1.4-1.7).

CONCLUSIONS

The risk of subsequent fractures following an initial fracture was increased over 25 years and the magnitude of risk was initially greater in men than in women.

Incorporating Nutrition, Vests, Education, and Strength Training (INVEST) in Bone Health: Trial Design and Methods

BACKGROUND

Achievement of 5-10% weight loss (WL) among older adults living with obesity considerably improves prognosis of health-related outcomes; however, concomitant declines in bone mineral density (BMD) limit overall benefit by increasing fracture risk. Declines in mechanical loading contribute to WL-associated BMD loss, with pilot data signaling the addition of external weight replacement (via weighted vest use) during intentional WL mitigates bone loss at weight bearing sites to a similar degree as resistance exercise training (RT). Definitive data in support of weighted vest use as a potential strategy to mitigate WL-associated bone loss in this population are needed.

METHODS

In the Incorporating Nutrition, Vests, Education, and Strength Training (INVEST) in Bone Health trial (NCT04076618), 192 older adults (60-85 years) who are overweight (BMI ≥ 27 kg/m²) with at least one obesity-related risk factor or obese (BMI = 30-40 kg/m²) will be randomly assigned to participate in one of three 12-month intervention groups: WL alone, WL + weighted vest use (WL + VEST), or WL + RT. The primary aim is to determine the effects of WL + VEST compared to WL alone and WL + RT on indicators of bone health and subsequent fracture risk.

DISCUSSION

Determining effective, translatable strategies that minimize bone loss during intentional WL among older adults holds public health potential. The INVEST in Bone Health trial offers an innovative approach for increasing mechanical stress during intentional WL in the absence of RT. If successful, findings from this study will provide evidence in support of a scalable solution to minimize bone loss during intentional WL among older adults with obesity.

Hip Structural Analysis Reveals Impaired Hip Geometry in Girls With Type 1 Diabetes

CONTEXT

Among patients with type 1 diabetes (T1D), the risk of hip fracture is up to 6-fold greater than that of the general population. However, the cause of this skeletal fragility remains poorly understood.

OBJECTIVE

To assess differences in hip geometry and imaging-based estimates of bone strength between youth with and without T1D using dual-energy x-ray absorptiometry (DXA)-based hip structural analysis.

DESIGN

Cross-sectional comparison.

PARTICIPANTS

Girls ages 10 to 16 years, including n = 62 with T1D and n = 61 controls.

RESULTS

The groups had similar age, bone age, pubertal stage, height, lean mass, and physical activity. Bone mineral density at the femoral neck and total hip did not differ in univariate comparisons but was lower at the femoral neck in T1D after adjusting for bone age, height, and lean mass. Subjects with T1D had significantly lower cross-sectional area, cross-sectional moment of inertia, section modulus, and cortical thickness at the narrow neck, with deficits of 5.7% to 10.3%. Cross-sectional area was also lower at the intertrochanteric region in girls with T1D. Among those T1D subjects with HbA1c greater than the cohort median of 8.5%, deficits in hip geometry and strength estimates were more pronounced.

CONCLUSIONS

DXA-based hip structural analysis revealed that girls with T1D have unfavorable geometry and lower estimates of bone strength at the hip, which may contribute to skeletal fragility and excess hip fracture risk in adulthood. Higher average glycemia may exacerbate effects of T1D on hip geometry.

Factors That Predict 1-Year Incident Hip and Non-Hip Fractures for Home Care Recipients: A Linked-Data Retrospective Cohort Study

OBJECTIVES

The purpose of our study was to identify factors that predict 1-year incident hip and major osteoporotic non-hip fractures (ie, wrist, spine, pelvis, humerus) for home care recipients while accounting for the competing risk of death.

DESIGN

We conducted a retrospective cohort study with linked population data.

SETTING AND PARTICIPANTS

All home care recipients in Ontario, Canada, receiving services for more than 6 months with an admission assessment between April 1, 2011, and March 31, 2015, were included.

METHODS

Clinical data from the Resident Assessment Instrument Home Care were linked to fracture data from the Discharge Abstract Database and the National Acute Care Reporting System. Competing risk proportional hazard regressions using the Fine and Grey method were performed to model the association between potential risk factors and fracture.

RESULTS

Previous fall, previous fracture, cognitive impairment, unsteady gait, alcohol use, tobacco use, and Parkinson disease were consistently associated with all fracture types. Cognitive impairment (hazard ratio 2.09; 95% confidence interval 1.86-2.36) and wandering [1.66 (1.06-1.27)] were most predictive of hip fractures and being female [1.86 (1.76-1.98)] and experiencing a previous fracture [1.86 (1.76-1.98)] were most predictive of non-hip fractures. Risk factors unique to non-hip fractures as compared with hip fractures were locomotion ability outdoors and psychotropic medication use.

CONCLUSIONS AND IMPLICATIONS

Our results indicate that, in addition to typical fracture risk factors, home care recipients have unique characteristics that increase their risk. Fracture risk assessment tools and subsequent prevention strategies should be modified to accurately identify home care recipients at risk for imminent 1-year fracture.

Hip fractures and characteristics of living area: a fine-scale spatial analysis in France

We investigated the association between hip fracture incidence and living area characteristics in France. The spatial distribution of hip fracture incidence was heterogeneous and there was a significant relationship between social deprivation, urbanization, health access, and hip fracture risk.

INTRODUCTION

Several studies have shown great disparities in spatial repartition of hip fractures (HF). The aim of the study was to analyze the association between HF incidence and characteristics of the living area.

METHODS

All patients aged 50 or older, living in France, who were hospitalized for HF between 2012 and 2014 were included, using the French national hospital discharge database. Standardized incidence ratio (SIR) was calculated for each spatial unit and adjusted on age and sex. An ecological regression was performed to analyze the association between HF standardized incidence and ecological variables. We adjusted the model for neighborhood spatial structure. We used three variables to characterize the living areas: a deprivation index (French-EDI); healthcare access (French standardized index); land use (percentage of artificialized surfaces).

RESULTS

A total of 236,328 HF were recorded in the French hospital national database, leading to an annual HF incidence of 333/100,000. The spatial analysis revealed geographical variations of HF incidence with SIR varying from 0.67 (0.52; 0.85) to 1.45 (1.23; 1.70). There was a significant association between HF incidence rates and (1) French-EDI (trend p = 0.0023); (2) general practitioner and nurse accessibility (trend p = 0.0232 and p = 0.0129, respectively); (3) percentage of artificialized surfaces (p < 0.0001).

CONCLUSION

The characteristics of the living area are associated with significant differences in the risk of hip fracture of older people.

Hip Fractures in Older Adults in Ontario, Canada-Monthly Variation, Insights, and Implications

Background

In older adults, hip fractures have been described to peak in cooler months. Seasonal differences in patient vulnerability to fracture and social/behavioural factors might contribute to these trends.

Methods

Using linked health-care databases in Ontario Canada, we examined monthly variation in hip fracture hospitalizations in those > 65 years (2011–2015). We stratified results by age category (66–79, ≥80 years). We then examined for variation in the demographic and comorbidity profiles of patients across the months, and as an index of contributing social/behavioural factors, noted variation in health-care behaviours.

Results

There were 47,971 and 52,088 hospitalizations for hip fracture in those 66–79, and ≥80 years, respectively. There was strong seasonality in fractures in both groups. Peaks occurred in October and December when patients appeared most vulnerable. Rates fell in the summer in those 66–79 years, and in the late winter in those ≥80 years (when health-care utilization also declined). A smaller peak in fractures occurred in May in both groups.

Conclusions

Hip fractures peak in the autumn, early winter, and spring in Canada. A dip in fractures occurs in the late winter in the oldest old. Environmental factors might play a role, but seasonal vulnerability to fracture and winter isolation might also be influential.

Bone Health Optimization: Beyond Own the Bone: AOA Critical Issues

Worldwide, osteoporosis management is in crisis because of inadequate delivery of care, competing guidelines, and confusing recommendations. Additionally, patients are not readily accepting the diagnosis of poor bone health and often are noncompliant with treatment recommendations. Secondary fracture prevention, through a program such as Own the Bone, has improved the diagnosis and medical management after a fragility fracture. In patients who undergo elective orthopaedic procedures, osteoporosis is common and adversely affects outcomes. Bone health optimization is the process of bone status assessment, identification and correction of metabolic deficits, and initiation of treatment, when appropriate, for skeletal structural deficits. The principles of bone health optimization are similar to those of secondary fracture prevention and can be initiated by all orthopaedic surgeons. Patients who are ≥50 years of age should be assessed for osteoporosis risk and, if they are in a high-risk group, bone density should be measured. All patients should be counseled to consume adequate vitamin D and calcium and to discontinue use of any toxins (e.g., tobacco products and excessive alcohol consumption). Patients who meet the criteria for pharmaceutical therapy for osteoporosis should consider delaying surgery for a minimum of 3 months, if feasible, and begin medication treatment. Orthopaedic surgeons need to assume a greater role in the care of bone health for our patients.

Risk of institutionalization following fragility fractures in older people

Previously independent living older people suffering fractures of the hip have a high risk of new admission to a nursing home during the subsequent months. This study shows that older people admitted to hospital for fractures of the pelvis and spine have a similar risk of admission to a nursing home.

INTRODUCTION

Fall-related fractures are a serious threat to the health and well-being of older persons. Long-term consequences of hip fractures such as institutionalization and mortality are well-known. The impact of other fragility fractures is less well-understood. The aim of this study was to estimate risks of institutionalization and death for different fragility fractures and compare them with the corresponding risks after hip fracture.

METHODS

Data was retrieved from a German health insurance company. Between 2005 and 2008 more than 56,000 community-dwelling people with a hospital admission or discharge diagnosis of a fracture of the femur, spine, pelvis, proximal humerus, distal radius, tibia, or fibula were included. Crude and age-adjusted 6-month incidence rates for institutionalization and death were calculated. To compare the risks of institutionalization or mortality of non-hip fractures with the risk after hip fracture, multivariate regression models were applied.

RESULTS

Crude institutionalization rates and mortality were highest in patients with hip fracture. However, after adjustment for age, functional status, and comorbidity, risks of institutionalization after fractures of pelvis (relative risk (RR), 0.94; 95% confidence interval (CI) 0.86; 1.02 in women and 0.89; 95% CI 0.70; 1.12 in men), and spine (RR, 0.95; 95% CI 0.87; 1.03 in women and 0.91; 95% CI 0.76; 1.08 in men) were not statistically different compared to the risk after hip fracture.

CONCLUSIONS

The risk of institutionalization after fractures of the spine and pelvis was similar to the risk after hip fracture. These fracture sites seem to be associated with a significant decline in physical function.

Accuracy of FRAX® in People With Multiple Sclerosis

People with multiple sclerosis (MS) have a higher risk of low bone mineral density (BMD), osteoporosis, and osteoporotic fractures than healthy adults. The Fracture Risk Assessment tool (FRAX^® ) has been reported to underestimate fracture risk in people with MS when BMD is unknown. We tested FRAX performance for people with MS when BMD is known, and determined if MS is a risk factor for fracture independent of FRAX score. Using population-based databases in Manitoba, Canada, we identified people with MS who underwent BMD screening after MS diagnosis (n = 744) and controls matched on age, sex, and first BMD screening date (n = 3721). We calculated FRAX 10-year probabilities at the BMD screening date, and ascertained incident major osteoporotic fractures (MOF). Using Cox proportional hazards modeling we assessed the effect of MS on the hazard of MOF, adjusting for FRAX 10-year probabilities. MS cases had a higher mean FRAX 10-year probability of MOF calculated with BMD (8.32 ± 7.53) than controls (6.98 ± 5.18; p < 0.01). MS increased the risk for MOF after controlling for FRAX 10-year probability without BMD (HR 1.67; 95% confidence interval [CI], 1.29 to 2.16), and after controlling for FRAX individual risk factors (HR 1.45; 95% CI, 1.12 to 1.89). MS remained a risk factor for MOF even when controlling for FRAX 10-year probability of MOF with BMD (HR 1.48; 95% CI, 1.14 to 1.92). The FRAX 10-year probability with and without BMD underestimated the observed 10-year MOF risk in MS cases by 3% to 5%. Calibration improved when secondary osteoporosis was used to calculate FRAX without BMD. Calibration was best when the rheumatoid arthritis input was used to calculate FRAX probability along with BMD. Using secondary osteoporosis or rheumatoid arthritis as proxies for MS improves performance of FRAX and accurately predicts MOF outcomes in those with MS. This provides clinicians with a readily available approach to improve the accuracy of fracture prediction in MS. © 2019 American Society for Bone and Mineral Research.

Hip fracture care in Manitoba, Canada and New York State, United States: an analysis of administrative data

BACKGROUND

Nearly 30 years ago, a series of studies showed increased hip fracture mortality in Manitoba compared to the United States, but these data have not been updated. Our objective was to compare the organization of hip fracture care and short-term outcomes in Manitoba and New York State using contemporary data.

METHODS

This was a retrospective cohort study of administrative data for all adults aged 50 years or more admitted to hospital with hip fracture between Jan. 1, 2011, and Oct. 31, 2013 in Manitoba and New York State. We compared the 2 jurisdictions with respect to: 1) the proportion of hospitals treating hip fracture and annual hip fracture volume, 2) hospital length of stay, 3) death and 4) hospital readmission. We used descriptive statistics, univariate methods and regression models to compare differences in care between jurisdictions.

RESULTS

We identified 2845 patients (mean age 82.2 yr, 2061 women [72.4%]) with hip fracture in Manitoba and 31 524 patients (mean age 81.9 yr, 22 973 women [72.9%]) with hip fracture in New York. A smaller proportion of hospitals in Manitoba than in New York treated hip fracture (7/30 [23%] v. 180/239 [75.3%]) (p < 0.001); the mean annual hospital hip fracture volume was higher in Manitoba (140.0) than in New York (68.9), but the difference did not reach statistical significance (p = 0.2). For patients with femoral neck fractures, the median hospital length of stay was longer in Manitoba than in New York (13 d v. 7 d). The rate of death within 7 days of admission was similar in Manitoba and New York (1.3% v. 2.0%, p = 0.07), although the rate of in-hospital death was higher in Manitoba (5.7% v. 3.5%, p < 0.001). Readmission within 30 days of discharge was less frequent in Manitoba than in New York (9.8% v. 12.0%, p = 0.02). Results were similar for patients with intertrochanteric fractures.

INTERPRETATION

Poor short-term outcomes for patients with hip fracture in Manitoba that were documented in the 1980s seem to have been eliminated. Our results should provide optimism that reengineering of clinical care can produce substantive improvements in quality.

Is there a definition of low lean mass that captures the associated low bone mineral density? A cross-sectional study of 80 men with hip fracture

BACKGROUND AND AIMS

Subjects with osteosarcopenia, the concurrent presence of sarcopenia and osteoporosis, have prognostic disadvantages and can benefit from treatments targeted at both the conditions. Our aim was to elucidate whether the available definitions of low appendicular lean mass (aLM) capture or not the men with associated low bone mineral density (BMD) following a hip fracture.

METHODS

80 men admitted to our rehabilitation hospital underwent a dual-energy X-ray absorptiometry scan 19.1 ± 4.1 (mean ± SD) days after hip fracture occurrence. Low aLM was identified according to either Baumgartner's definition (aLM/height² < 7.26 kg/m²) or the criteria from the Foundation for the National Institutes of Health (FNIH): aLM < 19.75 kg, or aLM adjusted for body mass index (BMI) < 0.789. Low BMD was diagnosed with a T-score < - 2.5 at the unfractured femur.

RESULTS

We found a significant positive correlation between aLM and BMD assessed at either femoral neck (r = 0.44; p < 0.001) or total hip (r = 0.50; p < 0.001). After categorization according to the FNIH threshold for aLM, we found a significant association between low aLM and low BMD: χ²(1, n = 80) = 5.4 (p = 0.020), which persisted after adjustment for age and fat mass. Conversely, categorization according to neither Baumgartner's threshold for aLM/height² nor to the FNIH threshold for aLM/BMI was associated with low BMD.

CONCLUSIONS

The association between low aLM and low BMD in men with hip fracture dramatically depends on the adopted definition of low aLM. FNIH threshold for aLM (< 19.75 kg) emerges as a useful tool to capture men with damage to both the components of the muscle-bone unit.

Osteoporotic vertebral endplate and cortex fractures: A pictorial review

Despite years' research, the radiographic criteria for osteoporotic vertebral fracture and its grading remain debated. The importance of identifying vertebral endplate/cortex fracture (ECF) is being recognised; however, evaluation of osteoporotic ECF requires training and experience. This article aims to serve as a teaching material for radiologists/physicians or researchers to evaluate osteoporotic ECF. Emphasis is particularly dedicated to identifying ECF that may not be associated with apparent vertebral body collapse. We suggest a combined approach based on standardised radiologic evaluation by experts and morphometry measurement is the most appropriate approach to detect and classify osteoporotic vertebral fractures.

The translational potential

A good understanding of radiologic anatomy of vertebrae and fracture signs of endplate/cortex are essential for spine fragility fracture assessment.

Maintenance of bone mass despite estrogen depletion in female common marmoset monkeys (Callithrix jacchus)

Estrogen depletion leads to bone loss in almost all mammals with frequent regular ovarian cycles. However, subordinate adult female common marmosets (Callithrix jacchus) undergo socially induced anovulation and hypoestrogenism without clinically apparent adverse skeletal consequences. Thus, we speculated that this non human primate might have evolved a mechanism to avoid estrogen-depletion bone loss. To test this possibility, we performed three experiments in which lumbar-spine (L5-L6) bone mineral content (BMC) and density (BMD) were assessed using dual-energy X-ray absorptiometry: (i) cross-sectionally in 13 long-term ovariectomized animals and 12 age- and weight-matched controls undergoing ovulatory cycles; (ii) longitudinally in 12 animals prior to, 3-4 and 6-7 months following ovariectomy (ovx), and six controls; and (iii) cross-sectionally in nine anovulatory subordinate and nine dominant females. In Experiments 1 and 3, plasma estradiol and estrone concentrations were measured and uterine dimensions were obtained by ultrasound in a subset of animals as a marker of functional estrogen depletion. Estrogen levels, uterine trans-fundus width, and uterine dorso-ventral diameter were lower in ovariectomized and subordinate females than in those undergoing ovulatory cycles. However, no differences were found in L5-L6 BMC or BMD. These results indicate that estrogen depletion, whether surgically or socially induced, is not associated with lower bone mass in female common marmosets. Thus, this species may possess unique adaptations to avoid bone loss associated with estrogen depletion.

Quality of life assessment in musculo-skeletal health

Musculoskeletal disorders affect morbidity, quality of life and mortality, and represent an increasing economic and societal burden in the context of population aging and increased life expectancy. Improvement of quality of life should be one of the priorities of any interventions to prevent and treat musculoskeletal disorders in the ageing population. Two main approaches, namely generic and disease-specific instruments, can be applied to measure health-related quality of life. Among the generic tools available in scientific literature, the short form 36 questionnaire (SF-36) and the Euroqol five item questionnaire (EQ-5D) are two of the most popular questionnaires used to quantify the health related quality of life in people with musculoskeletal disorders. However, because generic tools may not always be able to detect subtle effects of a specific condition on quality of life, a specific tool is highly valuable. Specific tools improve the ability to clinically characterize quality of life in subjects with a specific musculoskeletal disorder, as well as the capacity to assess changes over time in the QoL of these subjects. The recent development of specific tools should help to validate preventive and therapeutic interventions in this field.

Selected life quality variables of women treated surgically due to intertrochanteric femur fractures in the aspect of nursing and rehabilitation standards

Introduction: The aim of presented study was to evaluate selected quality of life indicators for women treated surgically due to intertrochanteric femur fractures in terms of implementation of physiotherapeutic and nursing standards. Clinical Hospital in Krakow (5WSK) within the period from January 2015 to December 2016. At that time, 145 women with intertrochanteric femur fracture were admitted to the hospital. The age of the patients ranged between 58 and 92 years, with an average of 83.6 years. The following questionnaires and score scales were used to assess the quality of life: Short Pfeiffer Mental Status Questionnaire (SPMSQ), Instrumental Activities of Daily Living (IADL) scale, SF-36 Quality of Life Questionnaire, Barthel scale, HOOS scale, Geriatric Depression Scale (GDS) by Yesavage, the author’s questionnaire on rehabilitation care problems related to urinary tract infections, bed sores, pneumonia, gastrointestinal disorders, gastrointestinal infections and thromboembolic complications as well as survival rate. Results and conclusions: 1. The quality of life of women operated because of intertrochanteric femoral fractures using an intramedullary Gamma nail had deteriorated in both short and long-term observation. 2. Maintenance and individualization of nursing standards and rehabilitation in women treated surgically due to intertrochanteric femoral fractures had a positive effect on the overall process of their treatment. 3.The level of physical activity declared by women operated due to intertrochanteric femur fracture prior to the occurrence of these fractures, has a signifi cant effect on their functional results in short and long-term observation. The higher the level of physical activity of these patients before the fracture, the more favourable was the functional outcome. 4. The level of mood and self-acceptance of the disease in women treated surgically for this fracture had signifi cant impact on the process of their nursing as well as rehabilitation, and on functional status in short and long-term follow-up. The higher the level of mood and self-acceptance of the disease in these women, the better the process of their nursing, rehabilitation and the functional outcome.

Lean Mass and Functional Recovery in Men With Hip Fracture: A Short-Term Prospective Pilot Study

OBJECTIVE

The aim of the study was to assess the capability of different definitions of low appendicular lean mass (aLM) to predict the short-term functional recovery in men with hip fracture.

DESIGN

We investigated 80 of 95 men with hip fracture admitted consecutively to a rehabilitation hospital. Body composition was assessed by dual-energy x-ray absorptiometry. Functional recovery after inpatient rehabilitation was evaluated using Barthel Index scores.

RESULTS

The patients with aLM above the cutoff value of 19.75 kg indicated by the Foundation for the National Institutes of Health (FNIH) had significantly higher Barthel Index scores than those with aLM below the cutoff value (P = 0.002). Patients' categorization according to the same threshold (aLM = 19.75 kg) was significantly associated with a Barthel Index score of 85 or higher after adjustment for age, cognitive impairment, hip fracture type, co-morbidities, and medications (odds ratio = 7.17, 95% confidence interval = 1.43-35.94, P = 0.017). Conversely, patients' categorization according to neither Baumgartner's cutoff value (7.26 kg/m(2)) for aLM/height(2) nor Foundation for the National Institutes of Health cutoff value (0.789) for aLM divided by body mass index was significantly associated with the Barthel Index scores.

CONCLUSIONS

Categorization according to the Foundation for the National Institutes of Health threshold for aLM, but not to the Foundation for the National Institutes of Health threshold for aLM/body mass index or Baumgartner's threshold for aLM/height, was associated with the short-term recovery in activities of daily living after a hip fracture in men.

Osteoporosis in Crisis: It's Time to Focus on Fracture

A crisis in osteoporosis treatment exists; the majority of those who sustain fracture do not receive treatment to reduce future fracture risk. This crisis presents an opportunity to focus the field from osteoporosis to fracture, the outcome of consequence. Proposed here is a change in focus suggesting that 1) attempts to define the level of trauma leading to fracture are counterproductive and that all fractures in older adults merit consideration of evaluation and 2) bone loss is not the entire problem but rather part of a broader syndrome including osteoporosis, sarcopenia, and other factors leading to fracture. With this approach, all fractures in older adults should be evaluated for potential lifestyle, non-pharmacological, and pharmacological interventions that could be implemented to reduce the risk of fracture recurrence. © 2017 American Society for Bone and Mineral Research.

Trends in Operative and Nonoperative Hip Fracture Management 1990-2014: A Longitudinal Analysis of Manitoba Administrative Data

OBJECTIVES

To evaluate longitudinal trends in the use of total hip arthroplasty (THA), hemiarthroplasty (HA), internal fixation (IF), and nonoperative management and to identify individual-level factors associated with nonoperative treatment of hip fracture (HF).

DESIGN

Longitudinal analysis of administrative data.

SETTING

Manitoba, Canada.

PARTICIPANTS

All adults who experienced nontraumatic hip fractures between 1990 and 2014 (N = 19,626; mean age 80.6, 72.3% female).

MEASUREMENTS

Billing codes were used to identify surgical treatment, and trends in treatment over time were examined. Regression models were developed to identify individual factors associated with receiving nonoperative management.

RESULTS

Use of THA increased from 0.6% for all HFs in 1990-94 to 5.3% in 2010-14, use of HA increased from 19.3% to 29.7%, and use of IF declined from 71.8% to 59.9% (P < .001 for all); increase in THA and HA were largest in individuals with femoral neck fracture. Nonoperative management declined from 8.3% in 1990-94 to 5.1% in 2010-14 (P < .001). Factors associated with nonoperative management included aged 90 and older, male sex, residing in a care facility before fracture, and rural residence.

CONCLUSION

HF is increasingly treated with THA and HA, whereas rates of nonoperative management and IF are declining. Future efforts should focus on ensuring that all individuals are optimally triaged to the best procedure for them, with nonoperative management considered for individuals with extremely poor prefracture health.

A critical review of the long-term disability outcomes following hip fracture

BACKGROUND

Hip fractures are an increasingly common consequence of falls in older people that are associated with a high risk of death and reduced function. This review aims to quantify the impact of hip fracture on older people's abilities and quality of life over the long term.

METHODS

Studies were identified through PubMed and Scopus searches and contact with experts. Cohort studies of hip fracture patients reporting outcomes 3 months post-fracture or longer were included for review. Outcomes of mobility, participation in domestic and community activities, health, accommodation or quality of life were categorised according to the World Health Organization's International Classification of Functioning and synthesised narratively. Risk of bias was assessed according to four items from the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement.

RESULTS

Thirty-eight studies from 42 publications were included for review. Most followed a clearly defined sample from the time of fracture. Hip fracture survivors experienced significantly worse mobility, independence in function, health, quality of life and higher rates of institutionalisation than age matched controls. The bulk of recovery of walking ability and activities for daily living occurred within 6 months after fracture. Between 40 and 60 % of study participants recovered their pre-fracture level of mobility and ability to perform instrumental activities of daily living, while 40-70 % regained their level of independence for basic activities of daily living. For people independent in self-care pre-fracture, 20-60 % required assistance for various tasks 1 and 2 years after fracture. Fewer people living in residential care recovered their level of function than those living in the community. In Western nations, 10-20 % of hip fracture patients are institutionalised following fracture. Few studies reported impact on participation in domestic, community, social and civic life.

CONCLUSIONS

Hip fracture has a substantial impact on older peoples' medium- to longer-term abilities, function, quality of life and accommodation. These studies indicate the range of current outcomes rather than potential improvements with different interventional approaches. Future studies should measure impact on life participation and determine the proportion of people that regain their pre-fracture level of functioning to investigate strategies for improving these important outcomes.

The predicted lifetime costs and health consequences of calcium and vitamin D supplementation for fracture prevention-the impact of cardiovascular effects

Some studies indicate that calcium supplementation increases cardiovascular risk. We assessed whether such effects could counterbalance the fracture benefits from supplementation. Accounting for cardiovascular outcomes, calcium may cause net harm and would not be cost-effective. Clinicians may do well considering cardiovascular effects when prescribing calcium supplementation.

INTRODUCTION

Accounting for possible cardiovascular effect of calcium and vitamin D supplementation (CaD), the aims of this study were to assess whether CaD on balance would improve population health and to evaluate the cost-effectiveness of such supplementation.

METHODS

We created a probabilistic Markov simulation model that was analysed at the individual patient level. We analysed 65-year-old Norwegian women with a 2.3 % 10-year risk of hip fracture and a 9.3 % risk of any major fracture according to the WHO fracture risk assessment tool (FRAX®). Consistent with a recent Cochrane review, we assumed that CaD reduces the risk of hip, vertebral, and wrist fractures by 16, 11, and 5 %, respectively. We included the increased risk of acute myocardial infarction (AMI) and stroke under a no-, medium-, and high-risk scenario.

RESULTS

Assuming no cardiovascular effects, CaD supplementation produces improved health outcomes resulting in an incremental gain of 0.0223 quality-adjusted life years (QALYs) and increases costs by €322 compared with no treatment (cost-effectiveness ratio €14,453 per QALY gained). Assuming a Norwegian cost-effectiveness threshold of €60,000 per QALY, CaD is likely to be considered a cost-effective treatment alternative. In a scenario with a medium or high increased risk of cardiovascular events, CaD produces net health losses, respectively, -0.0572 and -0.0784 QALY at additional costs of €481 and €1033.

CONCLUSIONS

We conclude that the magnitude of potential cardiovascular side effects is crucial for the effectiveness and cost-effectiveness of CaD supplementation in elderly women.

Comparative trends in incident fracture rates for all long-term care and community-dwelling seniors in Ontario, Canada, 2002-2012

SUMMARY

In this population-based study, we compared incident fracture rates in long-term care (LTC) versus community seniors between 2002 and 2012. Hip fracture rates declined more rapidly in LTC than in the community. An excess burden of fractures occurred in LTC for hip, pelvis, and humerus fractures in men and hip fractures only in women.

INTRODUCTION

This study compares trends in incident fracture rates between long-term care (LTC) and community-dwelling seniors ≥65 years, 2002-2012.

METHODS

This is a population-based cohort study using administrative data. Measurements were age/sex-adjusted incident fracture rates and rate ratios (RR) and annual percent change (APC).

RESULTS

Over 11 years, hip fracture rates had a marked decline occurring more rapidly in LTC (APC, -3.49 (95% confidence interval (CI), -3.97, -3.01)) compared with the community (APC, -2.93 (95% CI, -3.28, -2.57); p < 0.05 for difference in slopes). Humerus and wrist fracture rates decreased; however, an opposite trend occurred for pelvis and spine fractures with rates increasing over time in both cohorts (all APCs, p < 0.05). In 2012, incident hip fracture rates were higher in LTC than the community (RRs: women, 1.55 (95% CI, 1.45, 1.67); men, 2.18 (95% CI, 1.93, 2.47)). Higher rates of pelvis (RR, 1.48 (95% CI, 1.22, 1.80)) and humerus (RR, 1.40 (95% CI, 1.07, 1.84)) fractures were observed in LTC men, not women. In women, wrist (RR, 0.76 (95% CI, 0.71, 0.81)) and spine (RR, 0.52 (95% CI, 0.45, 0.61)) fracture rates were lower in LTC than the community; in men, spine (RR, 0.75 (95% CI, 0.57, 0.98) but not wrist fracture (RR, 0.91 (95% CI, 0.67, 1.23)) rates were significantly lower in LTC than the community.

CONCLUSION

Previous studies in the community have shown declining hip fracture rates over time, also demonstrated in our study but at a more rapid rate in LTC. Rates of humerus and wrist fractures also declined. An excess burden of fractures in LTC occurred for hip fractures in women and for hip, pelvis, and humerus fractures in men.

Economic evaluation of vitamin D and calcium food fortification for fracture prevention in Germany

OBJECTIVE

The study evaluates the economic benefit of population-wide vitamin D and Ca food fortification in Germany.

DESIGN

Based on a spreadsheet model, we compared the cost of a population-wide vitamin D and Ca food-fortification programme with the potential cost savings from prevented fractures in the German female population aged 65 years and older.

SETTING

The annual burden of disease and the intervention cost were assessed for two scenarios: (i) no food fortification; and (ii) voluntary food fortification with 20 µg (800 IU) of cholecalciferol (vitamin D3) and 200 mg of Ca. The analysis considered six types of fractures: hip, clinical vertebral, humerus, wrist, other femur and pelvis.

SUBJECTS

Subgroups of the German population defined by age and sex.

RESULTS

The implementation of a vitamin D and Ca food-fortification programme in Germany would lead to annual net cost savings of €315 million and prevention of 36 705 fractures in the target population.

CONCLUSIONS

Vitamin D and Ca food fortification is an economically beneficial preventive health strategy that has the potential to reduce the future health burden of osteoporotic fractures in Germany. The implementation of a vitamin D and Ca food-fortification programme should be a high priority for German health policy makers because it offers substantial cost-saving potential for the German health and social care systems.

Initiation of Antidepressant Medication After Hip Fracture in Community-Dwelling Older Adults

OBJECTIVE

To evaluate the incidence, characteristics, and correlates of antidepressant drug therapy initiation among community-dwelling older adults following hip fracture.

DESIGN

Retrospective cohort study using linked, population-based administrative data.

SETTING

Province of Ontario, Canada.

PARTICIPANTS

Older adults, aged 65 years or older, with a hip fracture and hip fracture surgery between April 1, 2003, and February 28, 2011. The study sample was restricted to individuals who returned home following surgery and who had not been dispensed an antidepressant in the year prior to their fracture (N=25,436).

MEASUREMENTS

We determined the incidence of new antidepressant use defined by the dispensing of antidepressant drug therapy within 90 days of discharge home. We identified independent correlates of antidepressant initiation using multivariate regression.

RESULTS

Overall, antidepressants were newly initiated in 8.8% of older adults with hip fracture in the 90 days following hospital discharge. There was a statistically significant, 1.3-fold increase in incidence of antidepressant prescribing from 2003 to 2010. Trazodone, frequently prescribed at a low dose, accounted for 39.0% of newly dispensed antidepressants, followed by selective serotonin reuptake inhibitors (36.9%). Rehabilitation admission, psychiatric evaluation, a diagnosis of dementia, and baseline benzodiazepine use were the strongest independent correlates of antidepressant initiation.

CONCLUSION

The period after a hip fracture is associated with a high rate of initiation of antidepressant therapy. The data raise the possibility that antidepressants are frequently prescribed off-label in these patients. Further research is needed to investigate the safety and efficacy of antidepressant use in this vulnerable population.

Recovery of Walking Ability and Return to Community Living within 60 Days of Hip Fracture Does Not Differ Between Male and Female Survivors

OBJECTIVES

To compare risk-adjusted differences between men and women 30 and 60 days after hip fracture surgery in not walking, ability to return home in a community-dwelling subset, not walking in a nursing home resident subset, and mortality within 60 days.

DESIGN

Cohort study.

SETTING

Data were from a randomized clinical trial that compared two blood transfusion protocols after hip fracture.

PARTICIPANTS

Individuals with hip fracture (N = 2,016; 489 (24%) male).

MEASUREMENTS

Walking, dwelling, and mortality were determined in telephone follow-up 30 and 60 days after randomization, which occurred within 3 days of surgery. Sex differences for each outcome were compared using univariate and multivariate regression adjusting for potential confounders.

RESULTS

Men were younger (P < .001) and more likely to have comorbidity (P = .003) than women at the time of hip fracture and to die within 60 days, even after risk adjustment (odds ratio (OR) = 1.76, 95% confidence interval (CI) = 1.15-2.69). After risk adjustment, male survivors were as likely as female survivors not to walk (OR = 1.03, 95% CI = 0.78-1.34) and no less likely to return home (OR = 0.90, 95% CI = 0.69-1.17) 60 days after hip fracture. No differences were noted between male and female nursing home residents in not walking within 60 days (OR = 0.95, 95% CI = 0.32-2.86).

CONCLUSION

Although men experience higher mortality, male survivors can expect recovery of walking ability similar to that of female survivors and are as likely to return to community living.

Risk of Nursing Home Admission After Femoral Fracture Compared With Stroke, Myocardial Infarction, and Pneumonia

OBJECTIVE

To analyze the burden of institutionalizations after femoral fracture and compare it with other "catastrophic" disease entities like stroke, myocardial infarction, or pneumonia.

DESIGN/SETTING/PARTICIPANTS

Routine data of 414,000 hospitalized German patients aged 66 years and older were used to calculate institutionalization risks after femoral fracture, stroke, myocardial infarction, pneumonia or a combined group of "all other hospitalizations."

MEASUREMENTS

Institutionalization was defined as nursing home admission within 6 months after discharge from hospital. Age- and sex-specific incidence and incidence rates of institutionalization were calculated. To compare the risk of institutionalization between the disease entities, age-standardized rates were computed and proportional hazards models were applied. In-house mortality and mortality after discharge from hospital were also calculated.

RESULTS

The risk of institutionalization increased exponentially with age in all disease entities. For example, the risk of institutionalization after femoral fracture increased from 3.6% in women aged 65 to 69 years to 34.8% in women aged 95 years and older. The highest institutionalization rates were observed in patients with stroke, followed by femoral fracture, pneumonia, and myocardial infarction. In men, the age-standardized risk of institutionalization was almost as high after femoral fracture as after stroke (7.5% vs 8.0%). In contrast to myocardial infarction and pneumonia, femoral fracture and stroke were more likely to be followed by institutionalization rather than death.

CONCLUSION

Femoral fractures result in high burden of institutionalizations. Prevention of falls, diagnosis and treatment of osteoporosis, and high-quality rehabilitation are challenges to tackle the burden of institutionalization in these patients in the future.

Spine bone texture assessed by trabecular bone score (TBS) predicts osteoporotic fractures in men: the Manitoba Bone Density Program

INTRODUCTION

One quarter of osteoporotic fractures occur in men. TBS, a gray-level measurement derived from lumbar spine DXA image texture, is related to microarchitecture and fracture risk independently of BMD. Previous studies reported the ability of spine TBS to predict osteoporotic fractures in women. Our aim was to evaluate the ability of TBS to predict clinical osteoporotic fractures in men.

METHODS

3620 men aged ≥50 (mean 67.6years) at the time of baseline DXA (femoral neck, spine) were identified from a database (Province of Manitoba, Canada). Health service records were assessed for the presence of non-traumatic osteoporotic fracture after BMD testing. Lumbar spine TBS was derived from spine DXA blinded to clinical parameters and outcomes. We used Cox proportional hazard regression to analyze time to first fracture adjusted for clinical risk factors (FRAX without BMD), osteoporosis treatment and BMD (hip or spine).

RESULTS

Mean followup was 4.5years. 183 (5.1%) men sustain major osteoporotic fractures (MOF), 91 (2.5%) clinical vertebral fractures (CVF), and 46 (1.3%) hip fractures (HF). Correlation between spine BMD and spine TBS was modest (r=0.31), less than correlation between spine and hip BMD (r=0.63). Significantly lower spine TBS were found in fracture versus non-fracture men for MOF (p<0.001), HF (p<0.001) and CVF (p=0.003). Area under the receiver operating characteristic curve (AUC) for incident fracture discrimination with TBS was significantly better than chance (MOF AUC=0.59, p<0.001; HF AUC=0.67, p<0.001; CVF AUC=0.57, p=0.032). TBS predicted MOF and HF (but not CVF) in models adjusted for FRAX without BMD and osteoporosis treatment. TBS remained a predictor of HF (but not MOF) after further adjustment for hip BMD or spine BMD.

CONCLUSION

We observed that spine TBS predicted MOF and HF independently of the clinical FRAX score, HF independently of FRAX and BMD in men. Studies with more incident fractures are needed to confirm these findings.

Expected lifetime numbers and costs of fractures in postmenopausal women with and without osteoporosis in Germany: a discrete event simulation model

BACKGROUND

Osteoporotic fractures cause a large health burden and substantial costs. This study estimated the expected fracture numbers and costs for the remaining lifetime of postmenopausal women in Germany.

METHODS

A discrete event simulation (DES) model which tracks changes in fracture risk due to osteoporosis, a previous fracture or institutionalization in a nursing home was developed. Expected lifetime fracture numbers and costs per capita were estimated for postmenopausal women (aged 50 and older) at average osteoporosis risk (AOR) and for those never suffering from osteoporosis. Direct and indirect costs were modeled. Deterministic univariate and probabilistic sensitivity analyses were conducted.

RESULTS

The expected fracture numbers over the remaining lifetime of a 50 year old woman with AOR for each fracture type (% attributable to osteoporosis) were: hip 0.282 (57.9%), wrist 0.229 (18.2%), clinical vertebral 0.206 (39.2%), humerus 0.147 (43.5%), pelvis 0.105 (47.5%), and other femur 0.033 (52.1%). Expected discounted fracture lifetime costs (excess cost attributable to osteoporosis) per 50 year old woman with AOR amounted to € 4,479 (€ 1,995). Most costs were accrued in the hospital € 1,743 (€ 751) and long-term care sectors € 1,210 (€ 620). Univariate sensitivity analysis resulted in percentage changes between -48.4% (if fracture rates decreased by 2% per year) and +83.5% (if fracture rates increased by 2% per year) compared to base case excess costs. Costs for women with osteoporosis were about 3.3 times of those never getting osteoporosis (€ 7,463 vs. € 2,247), and were markedly increased for women with a previous fracture.

CONCLUSION

The results of this study indicate that osteoporosis causes a substantial share of fracture costs in postmenopausal women, which strongly increase with age and previous fractures.

Increased health service utilization costs in the year prior to institutionalization: findings from the canadian study of health and aging

OBJECTIVES

The objective of this study was to characterize patterns of formal health service utilization costs during older adults' transition from community to institutional care.

METHODS

Participants were 127 adults (age ≥ 65) from the British Columbia sample (N = 2,057) of the Canadian Study of Health and Aging who transitioned from community to institutional care between 1991 and 2001. Health service utilization costs were measured using Cost-Per-Day-At-Risk at five time points: > 12 months, 6-12 months, and ≤ 6 months preinstitutionalization, and ≤ 6 months and 6-12 months postinstitutionalization. Cost-Per-Day-At-Risk was measured for Continuing Care, Medical Services Plan, and PharmaCare costs by calculating total health service use over time, divided by the number of days the participant was alive.

RESULTS

Significant differences in Cost-Per-Day-At-Risk were observed for Continuing Care, Medical Services Plan, and PharmaCare costs over time. All health service utilization costs increased significantly during the 6-12 months and ≤ 6 months prior to institutionalization. Postinstitutionalization Continuing Care costs continued to increase at ≤ 6 months before decreasing at 6-12 months, while decreases occurred for Medical Services Plan and PharmaCare costs relative to preinstitutionalization costs.

CONCLUSIONS

The increases in costs observed during the year prior to institutionalization, characterized by a flurry of health service utilization, provide evidence of distinct cost patterns over the transition period.

Scores on the Safe Functional Motion test predict incident vertebral compression fracture

The Safe Functional Motion test (SFM) was developed to document movement strategies used to perform everyday activities that may increase the risk for osteoporotic fracture. After adjusting for variables known to predict vertebral compression fracture (VCF), baseline score on the SFM was a significant independent predictor of incident VCF at 1- and 3-year follow-ups.

INTRODUCTION

Functional movements may contribute to risk for VCF. We hypothesize that scores on the SFM, a performance-based test of physical function, are associated with incident VCF.

METHODS

An osteoporosis clinic database was queried for men and women ≥ 50 years with an initial SFM and corresponding data for prevalent VCF, history of injurious falls, femoral neck bone mineral density (fnBMD), osteoporosis medication use, and incident morphometric VCF at 1-year (n = 878) and 3-year follow-ups (n = 503). Multiple logistic regressions, adjusted for gender, age, injurious fall(s), fnBMD, prevalent VCF at baseline, and osteoporosis medication use, were used to determine whether SFM score was associated with incident VCF at follow-up visits.

RESULTS

Baseline SFM score was a significant independent predictor of incident VCF at 1-year follow-up (adjusted odds ratio (95 % confidence intervals (CI)) = 0.818 (0.707, 0.948); p < 0.008) and 3-year follow-up (adjusted odds ratio (95 % CI) = 0.728 (0.628, 0.844); p < 0.0001). Baseline fnBMD and osteoporosis medication use were significant predictors at 1-year (p = 0.05 and < 0.0001, respectively) and 3-year (p < 0.01 and 0.001, respectively) follow-ups. At 3-year follow-up, gender and prevalent VCF were also significant predictors (p = 0.003 and 0.007, respectively).

CONCLUSIONS

For every 10-point increase in SFM score, the odds of future VCF decreases by 18 % at 1 year and 27 % at 3 years after adjusting for known covariates. The SFM may aid in the identification of modifiable functional risk factors for VCF.

Temporal trends in the incidence of osteoporotic fractures

Osteoporotic fractures are associated with excess mortality and decreased functional capacity and quality of life. Age-standardized incidence rates of fragility fractures, particularly of the hip and forearm, have been noted to be decreasing in the last decade across many countries with the notable exception of Asia. The causes for the observed changes in fracture risk have not been fully identified but are likely the result of multiple factors, including birth cohort and period effects, increasing obesity, and greater use of anti-osteoporosis medications. Changing rates of fragility fractures would be expected to have an important impact on the burden of osteoporosis.

Fracture risk assessment in long-term care: a survey of long-term care physicians

Background

The majority of frail elderly who live in long-term care (LTC) are not treated for osteoporosis despite their high risk for fragility fractures. Clinical Practice Guidelines for the diagnosis and management of osteoporosis provide guidance for the management of individuals 50 years and older at risk for fractures, however, they cannot benefit LTC residents if physicians perceive barriers to their application. Our objectives are to explore current practices to fracture risk assessment by LTC physicians and describe barriers to applying the recently published Osteoporosis Canada practice guidelines for fracture assessment and prevention in LTC.

Methods

A cross-sectional survey was conducted with the Ontario Long-Term Care Physicians Association using an online questionnaire. The survey included questions that addressed members’ attitudes, knowledge, and behaviour with respect to fracture risk assessment in LTC. Closed-ended responses were analyzed using descriptive statistics and thematic framework analysis for open-ended responses.

Results

We contacted 347 LTC physicians; 25% submitted completed surveys (81% men, mean age 60 (Standard Deviation [SD] 11) years, average 32 [SD 11] years in practice). Of the surveyed physicians, 87% considered prevention of fragility fractures to be important, but a minority (34%) reported using validated fracture risk assessment tools, while 33% did not use any. Clinical risk factors recommended by the OC guidelines for assessing fracture risk considered applicable included; glucocorticoid use (99%), fall history (93%), age (92%), and fracture history (91%). Recommended clinical measurements considered applicable included: weight (84%), thyroid-stimulating hormone (78%) and creatinine (73%) measurements, height (61%), and Get-Up-and-Go test (60%). Perceived barriers to assessing fracture risk included difficulty acquiring necessary information, lack of access to tests (bone mineral density, x-rays) or obtaining medical history; resource constraints, and a sentiment that assessing fracture risk is futile in this population because of short life expectancy and polypharmacy.

Conclusion

Perceived barriers to fracture risk assessment and osteoporosis management in LTC have not changed recently, contributing in part to the ongoing care gap in osteoporosis management. Our findings highlight the importance to adapt guidelines to be applicable to the LTC environment, and to develop partnerships with stakeholders to facilitate their use in clinical practice.

Changes in frailty-related characteristics of the hip fracture population and their implications for healthcare services: evidence from Quebec, Canada

SUMMARY

This study provides evidence that a number of frailty-related characteristics (older age, de novo admission to long-term care (LTC), comorbidities [Charlson Index, osteoporosis, osteoporosis risk factors, sarcopenia risk factors, and dementia]) have increased in the hip fracture population from 2001-2008. This will have significant impact on community resources, as the number of people discharged to the community is also increasing.

INTRODUCTION

The aim of this study is to estimate secular changes in the prevalence of selected frailty-related characteristics among the hip fracture population in the Canadian province of Quebec (2001-2008) and the potential impact of these changes on healthcare services.

METHODS

The Quebec hospitalization database was used to identify nontraumatic hip fractures for the purposes of calculating age- and sex-specific rates. Also estimated were time trends for selected frailty-related characteristics and discharge destinations.

RESULTS

A significant decline in fracture rates was evident for all age groups except for those <65; sex differences were also observed. Almost all frailty-related characteristics increased over time, ranging from 2 to 14 % per year, which translates to an estimated increase from 16 to 112 %, over the study period. For those whose prior living arrangement was LTC, rates of hip fractures declined significantly (women OR = 0.93, 0.91-0.95; men OR = 0.97, 0.94-0.99). In-hospital mortality and discharge to inpatient rehabilitation decreased, while discharges back to community and to LTC increased.

CONCLUSIONS

Although hip fracture rates decreased for older hip fracture patients, the absolute number and prevalence of specific frailty-related characteristics increased. Policy makers should review care models to ensure that adequate resources are provided to the community to offset the expected increase in demand arising from ongoing changes in patients' characteristics.

Assessment of people with cognitive impairment and hip fracture: a systematic review and meta-analysis

This study systematically assesses the literature pertaining to the diagnostic test accuracy of assessment instruments to evaluate patients following hip fracture surgery who present with cognitive impairment. A systematic review and meta-analysis was performed. Studies assessing the reliability, validity, sensitivity or specificity of assessment tools for patients following hip fracture who were cognitively impaired were included. An assessment of published (MEDLINE, EMBASE, CINHAL, AMED, Cochrane library, PEDro) and unpublished/trial registry (OpenGrey, the WHO International Clinical Trials Registry Platform, Current Controlled Trials, the UK National Research Register Archive) databases were undertaken. Methodological quality of the literature was assessed using the QUADAS-2 appraisal tool. Nine studies including 690 participants, with a mean age of 82.1 years were included. The literature demonstrated a high risk of bias for study methodology, but low risk of bias for applicability. Two assessment domains were recognized: pain and delirium. For pain, the Facial Action Coding System (FACS) and DOLOPLUS-2 tools possessed strong inter-rater reliability and internal consistency, with the FACS demonstrating concurrent validity with other pain scales. For delirium, the Delirium Rating Scale-Revisited-98 (DRS-R-98) demonstrated high inter-rater reliability and sensitivity and specificity, with the NEECHAM Confusion Scale possessing high internal consistency. To conclude, there is a paucity of literature assessing the reliability, validity and diagnostic test accuracy of instruments to assess people with cognitive impairment following hip fracture surgery. Based on the current available data, delirium may be best assessed using the NEECHAM Confusion Scale or DRS-R-98. Pain is most accurately evaluated using the FACS.

Direct healthcare costs for 5 years post-fracture in Canada: a long-term population-based assessment

High direct incremental healthcare costs post-fracture are seen in the first year, but total costs from a third-party healthcare payer perspective eventually fall below pre-fracture levels. We attribute this to higher mortality among fracture cases who are already the heaviest users of healthcare ("healthy survivor bias"). Economic analyses that do not account for the possibility of a long-term reduction in direct healthcare costs in the post-fracture population may systematically overestimate the total economic burden of fracture.

INTRODUCTION

High healthcare costs in the first 1-2 years after an osteoporotic fracture are well recognized, but long-term costs are uncertain. We evaluated incremental costs of non-traumatic fractures up to 5 years from a third-party healthcare payer perspective.

METHODS

A total of 16,198 incident fracture cases and 48,594 matched non-fracture controls were identified in the province of Manitoba, Canada (1997-2002). We calculated the difference in median direct healthcare costs for the year pre-fracture and 5 years post-fracture expressed in 2009 Canadian dollars with adjustment for expected age-related healthcare cost increases.

RESULTS

Incremental median costs for a hip fracture were highest in the first year ($25,306 in women, $21,396 in men), remaining above pre-fracture baseline to 5 years in women but falling below pre-fracture costs by 5 years in men. In those who survived 5 years following a hip fracture, incremental costs remained above pre-fracture costs at 5 years ($12,670 in women, $7,933 in men). Incremental costs were consistently increased for 5 years after spine fracture in women. Total incremental healthcare costs for all incident fractures combined showed a large increase over pre-fracture costs in the first year ($137 million in women, $57 million in men), but fell below pre-fracture costs within 3-4 years. Elevated total healthcare costs were seen at year 5 in women after wrist, humerus and spine fractures, but these were somewhat offset by decreases in total healthcare costs for other fractures.

CONCLUSIONS

High direct healthcare costs post-fracture are seen in the first year, but total costs eventually fall below pre-fracture levels. Among those who survive 5 years following a fracture, healthcare costs remain above pre-fracture levels.