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Hsieh WT, Groot TM, Yen HK, Wang CY, Hu MH, Groot OQ, Yu PY, Fu SH. Validation of Ten Osteoporosis Screening Tools in Rural Communities of Taiwan. Calcif Tissue Int 2024:10.1007/s00223-024-01273-6. [PMID: 39155291 DOI: 10.1007/s00223-024-01273-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2023] [Accepted: 08/07/2024] [Indexed: 08/20/2024]
Abstract
PURPOSE Patients with osteoporosis are at risk of fractures, which can lead to immobility and reduced quality of life. Early diagnosis and treatment are crucial for preventing fractures, but many patients are not diagnosed until after a fracture has occurred. This study aimed to evaluate the performance of 10 osteoporosis screening tools (OSTs) in rural communities of Taiwan. In this prospective study, a total of 567 senior citizens from rural communities underwent bone mineral density (BMD) measurement using dual-energy X-ray absorptiometry (DXA) and ten OSTs were administered. Discrimination analysis was performed using the area under the receiver operating characteristic curve (AUROC). Primary outcomes included area under curve (AUC) value, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). The DXA examination revealed that 63.0% of females and 22.4% of males had osteoporosis. Among females, Osteoporosis Index of Risk (OSIRIS) and Osteoporosis Self-Assessment Tool for Asians (OSTA) presented the best AUC value with 0.71 (0.66-0.76) and 0.70 (0.66-0.75), respectively. Among males, BWC had the best AUC value of 0.77 (0.67-0.86), followed by OSTA, Simple Calculated Osteoporosis Risk Estimation (SCORE), and OSIRIS. OSTA and OSIRIS showed acceptable performance in both genders. The specificity of Fracture Risk Assessment Tool (FRAX-H), SCORE, National Osteoporosis Foundation Score, OSIRIS, Osteoporosis Risk Assessment Instrument, Age, Bulk, One or Never Estrogen (ABONE), and Body weight criteria increased in both genders after applying the optimum cut-off. Considering it high AUC and simplicity of use, OSTA appeared to be the recommended tool for seniors of both genders among the ten OSTs. This study provides a viable reference for future development of OSTs in Taiwan. Further adjustment according to epidemiological data and risk factors is recommended while applying OSTs to different cohorts.
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Affiliation(s)
- Wen-Tung Hsieh
- Department of Orthopedic, National Taiwan University Hospital Hsin-Chu branch, Hsinchu, Taiwan
| | - Tom Maarten Groot
- Department of Orthopedic Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Hung-Kuan Yen
- Department of Orthopedic, National Taiwan University Hospital Hsin-Chu branch, Hsinchu, Taiwan
- Department of Orthopedic, National Taiwan University Hospital, Taipei, Taiwan
| | - Chen-Yu Wang
- School of Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan
- Graduate Institute of Clinical Pharmacy, College of Medicine, National Taiwan, University, Taipei, Taiwan
- Department of Pharmacy, National Taiwan University Hospital Yun-Lin Branch, Douliu, Taiwan
- National Center for Geriatrics and Welfare Research, National Health Research, Institutes, Douliu, Taiwan
| | - Ming-Hsiao Hu
- Department of Orthopedic, National Taiwan University Hospital, Taipei, Taiwan
| | - Olivier Q Groot
- Department of Orthopaedics, University Medical Center Utrecht, Utrecht, The Netherlands
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, USA
| | - Ping-Ying Yu
- Department of General Internal Medicine, Mackay Memorial Hospital, New Taipei, Taiwan.
| | - Shau-Huai Fu
- Department of Orthopedics, National Taiwan University Hospital Yun-Lin Branch, Douliu City, Yunlin County, Taiwan.
- Department of Public Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan.
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Duprey MS, Zullo AR, Gouskova NA, Lee Y, Capuano A, Kiel DP, Daiello LA, Kim DH, Berry SD. Development and validation of the fall-related injury risk in nursing homes (INJURE-NH) prediction tool. J Am Geriatr Soc 2023; 71:1851-1860. [PMID: 36883262 PMCID: PMC10258142 DOI: 10.1111/jgs.18277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 12/21/2022] [Accepted: 01/15/2023] [Indexed: 03/09/2023]
Abstract
BACKGROUND Existing models to predict fall-related injuries (FRI) in nursing homes (NH) focus on hip fractures, yet hip fractures comprise less than half of all FRIs. We developed and validated a series of models to predict the absolute risk of FRIs in NH residents. METHODS Retrospective cohort study of long-stay US NH residents (≥100 days in the same facility) between January 1, 2016 and December 31, 2017 (n = 733,427) using Medicare claims and Minimum Data Set v3.0 clinical assessments. Predictors of FRIs were selected through LASSO logistic regression in a 2/3 random derivation sample and tested in a 1/3 validation sample. Sub-distribution hazard ratios (HR) and 95% confidence intervals (95% CI) were estimated for 6-month and 2-year follow-up. Discrimination was evaluated via C-statistic, and calibration compared the predicted rate of FRI to the observed rate. To develop a parsimonious clinical tool, we calculated a score using the five strongest predictors in the Fine-Gray model. Model performance was repeated in the validation sample. RESULTS Mean (Q1, Q3) age was 85.0 (77.5, 90.6) years and 69.6% were women. Within 2 years of follow-up, 43,976 (6.0%) residents experienced ≥1 FRI. Seventy predictors were included in the model. The discrimination of the 2-year prediction model was good (C-index = 0.70), and the calibration was excellent. Calibration and discrimination of the 6-month model were similar (C-index = 0.71). In the clinical tool to predict 2-year risk, the five characteristics included independence in activities of daily living (ADLs) (HR 2.27; 95% CI 2.14-2.41) and a history of non-hip fracture (HR 2.02; 95% CI 1.94-2.12). Performance results were similar in the validation sample. CONCLUSIONS We developed and validated a series of risk prediction models that can identify NH residents at greatest risk for FRI. In NH, these models should help target preventive strategies.
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Affiliation(s)
- Matthew S. Duprey
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI 02912
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, KY 40536
| | - Andrew R. Zullo
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI 02912
- Department of Pharmacy, Lifespan Rhode Island Hospital, Providence, RI 02903
- Department of Epidemiology, Brown University School of Public Health, Providence, Rhode Island, USA
- Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, Rhode Island, USA
| | - Natalia A. Gouskova
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew Senior Life, Roslindale, MA 02131
| | - Yoojin Lee
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI 02912
| | - Alyssa Capuano
- Department of Pharmacy, Lifespan Rhode Island Hospital, Providence, RI 02903
| | - Douglas P. Kiel
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew Senior Life, Roslindale, MA 02131
- Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA 02215
| | - Lori A. Daiello
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI 02912
| | - Dae Hyun Kim
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew Senior Life, Roslindale, MA 02131
- Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA 02215
| | - Sarah D. Berry
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew Senior Life, Roslindale, MA 02131
- Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA 02215
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Yang JJ, Yen HK, Li CY, Chen HJ, Liou HH, Fu SH, Wang CY. Ten existing osteoporosis prediction tools for the successful application of National Health Insurance-reimbursed anti-osteoporosis medications in long-term care residents in Taiwan. J Formos Med Assoc 2023; 122:139-147. [PMID: 36041990 DOI: 10.1016/j.jfma.2022.08.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 07/01/2022] [Accepted: 08/09/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND/PURPOSE Osteoporotic fracture introduce enormous societal and economic burden, especially for long-term care residents (LTCRs). Although osteoporosis prevention for LTCRs is urgently needed, obstacles such as frail status and inconvenient hospital visits hurdled them from necessary examinations and diagnoses. We aimed to test 10 existing osteoporosis screening tools (OSTs), which can be easily used in institutions and serve as a prediction, for accurately determining the outcome of a Taiwan's National Health Insurance (NHI)-reimbursed anti-osteoporosis medications (AOMs) application for LTCRs. METHODS This prospective analysis recruited 444 patients from LTC institutions between October 2018 and November 2019. Predictions of whether the NHI-reimbursed AOMs criteria was met were tested for 10 OSTs. The results of OSTs categorized into self-reported or validated based on previous fracture history were self-reported by LTCRs or validated by imaging data and medical records, respectively. The receiver operating characteristic curve and the optimal cut-off points for LTCRs based on Youden's index were explored. RESULTS Overall, the validated OSTs had a higher positive predictive value (PPV) and negative predictive value (NPV) summation than the corresponding reported OSTs. The validated FRAX-Major was the best OST (PPV = 63.6%, NPV = 82.4% for the male group and, PPV = 78.8%, NPV = 90.0% for the female group). After applying the optimum cut-off derived from Youden's index, the validated FRAX-Major (PPV = 75.4%, NPV = 92.0%)) remained performed best for men. In female population, validated FRAX-Major (PPV = 87.2%, NPV = 84.1%) and validated osteoporosis prescreening risk assessment (OPERA; PPV = 96.1%, NPV = 79.7%)) both provided good prediction results. CONCLUSION FRAX-Major and OPERA have better prediction ability for LTCRs to acquire NHI-reimbursed AOMs. The validated fracture history and adjusted cut-off points could prominently increase the PPV during prediction.
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Affiliation(s)
- Jiun-Jen Yang
- Department of Medical Education, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu, Taiwan
| | - Hung-Kuan Yen
- Department of Medical Education, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu, Taiwan
| | - Chung-Yi Li
- Department of Healthcare Administration, College of Medical and Health Science, Asia University, Taichung, Taiwan
| | - Hong-Jhe Chen
- Department of Family Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Horng-Huei Liou
- Department of Neurology, National Taiwan University Hospital Yun-Lin Branch, Douliu, Taiwan
| | - Shau-Huai Fu
- Department of Orthopedics, National Taiwan University Hospital Yun-Lin Branch, Douliu, Taiwan.
| | - Chen-Yu Wang
- National Center for Geriatrics and Welfare Research, National Health Research Institutes, Yun-Lin County, Taiwan; Department of Pharmacy, National Taiwan University Hospital Yun-Lin Branch, Douliu, Taiwan; School of Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan; Graduate Institute of Clinical Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan.
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Fu SH, Lai CY, Wang CY, Hung CC, Ye JD, Yen HK, Wu CH, Ku LJE, Yu T, Yang RS, Hsiao FY, Li CY. Screening of Fracture Risk and Osteoporosis Among Older Long-term Care Residents: A Prospective Study. J Nutr Health Aging 2023; 27:1255-1261. [PMID: 38151877 DOI: 10.1007/s12603-023-2045-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 11/02/2023] [Indexed: 12/29/2023]
Abstract
This prospective study assessed the effectiveness of screening older long-term care residents (LTCRs) for fracture risk and osteoporosis in Taiwan. Fracture risk screening was done using the Fracture Risk Assessment Tool (FRAX), and those with high or moderate risk were offered osteoporosis workup and treatment at the hospital. Among 785 LTCRs screened, 338 men (mean age 75.6) and 447 women (mean age 81.2) were included. Only 5.2% of women and no men were using anti-osteoporosis medication. Based on the Bone Health and Osteoporosis Foundation (BHOF) recommendations, 69.2% of men and 92.6% of women were classified as high fracture risk. In 110 participants willing to receive bone mineral density examination, osteoporosis was diagnosed in 86.2% of women and half of men. FRAX could effectively differentiate fracture risk in 648 LTCRs who completed 2-year follow-ups; no fracture occurred in the low-risk group. The study emphasizes the importance of fracture risk screening to enhance osteoporosis diagnosis and treatment among LTCRs.
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Affiliation(s)
- S-H Fu
- Chung-Yi Li, Department of Public Health, College of Medicine, National Cheng Kung University, Tainan, No. 138, Sheng Li Road, Tainan City 704, Taiwan, , Tel: +886-6-2353535, ext. 5862 and 5863
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Niznik JD, Gilliam MA, Colón-Emeric C, Thorpe CT, Lund JL, Berry SD, Hanson LC. Controversies in Osteoporosis Treatment of Nursing Home Residents. J Am Med Dir Assoc 2022; 23:1928-1934. [PMID: 36335990 PMCID: PMC9885478 DOI: 10.1016/j.jamda.2022.09.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 09/26/2022] [Accepted: 09/30/2022] [Indexed: 11/06/2022]
Abstract
Osteoporotic fractures are a common and serious health problem for older adults living in nursing homes (NHs). Risk of fracture increases with age and dementia status, yet gaps in evidence result in controversies around when to start and stop treatment for osteoporosis in NH residents, particularly those who have high fracture risk but have limited life expectancy. In this article, we discuss these areas of controversy. We provide an overview of current guidelines that explicitly address osteoporosis treatment strategies for NH residents, review the evidence for osteoporosis medications in NH residents, and use these sources to suggest practical recommendations for clinical practice and for research. Three published guidelines (from the United States, Canada, and Australia) and several studies provide the current basis for clinical decisions about osteoporosis treatment for NH residents. Practical approaches may include broad use of vitamin D and selective use of osteoporosis medication based on risks, benefits, and goals of care. Clinicians still lack strong evidence to guide treatment of NH residents with advanced dementia, multimorbidity, or severe mobility impairment. Future priorities for research include identifying optimal approaches to risk stratification and prevention strategies for NH residents and evaluating the risk-benefit profile of pharmacologic treatments for osteoporosis NH residents across key clinical strata. In the absence of such evidence, decisions for initiating and continuing treatment should reflect a patient-centered approach that incorporates life expectancy, goals of care, and the potential burden of treatment.
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Affiliation(s)
- Joshua D Niznik
- Division of Geriatric Medicine and Center for Aging and Health, University of North Carolina at Chapel Hill, School of Medicine, Chapel Hill, NC, USA; Division of Pharmaceutical Outcomes and Policy, University of North Carolina at Chapel Hill, Eshelman School of Pharmacy, Chapel Hill, NC, USA; Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, PA, USA.
| | - Meredith A Gilliam
- Division of Geriatric Medicine and Center for Aging and Health, University of North Carolina at Chapel Hill, School of Medicine, Chapel Hill, NC, USA
| | - Cathleen Colón-Emeric
- Division of Geriatrics, Duke University School of Medicine, Durham, NC, USA; Durham VA Geriatric Research Education and Clinical Center, Durham, NC, USA
| | - Carolyn T Thorpe
- Division of Pharmaceutical Outcomes and Policy, University of North Carolina at Chapel Hill, Eshelman School of Pharmacy, Chapel Hill, NC, USA; Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Jennifer L Lund
- Department of Epidemiology, University of North Carolina at Chapel Hill Gillings School of Global Public Health, Chapel Hill, NC, USA
| | - Sarah D Berry
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew Senior Life, Boston, MA, USA; Beth Israel Deaconess Medical Center, Department of Medicine, and Harvard Medical School, Boston, MA, USA
| | - Laura C Hanson
- Division of Geriatric Medicine and Center for Aging and Health, University of North Carolina at Chapel Hill, School of Medicine, Chapel Hill, NC, USA
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LeBoff MS, Greenspan SL, Insogna KL, Lewiecki EM, Saag KG, Singer AJ, Siris ES. The clinician's guide to prevention and treatment of osteoporosis. Osteoporos Int 2022; 33:2049-2102. [PMID: 35478046 PMCID: PMC9546973 DOI: 10.1007/s00198-021-05900-y] [Citation(s) in RCA: 279] [Impact Index Per Article: 139.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 02/19/2021] [Indexed: 12/16/2022]
Abstract
Osteoporosis is the most common metabolic bone disease in the USA and the world. It is a subclinical condition until complicated by fracture(s). These fractures place an enormous medical and personal burden on individuals who suffer from them and take a significant economic toll. Any new fracture in an adult aged 50 years or older signifies imminent elevated risk for subsequent fractures, particularly in the year following the initial fracture. What a patient perceives as an unfortunate accident may be seen as a sentinel event indicative of bone fragility and increased future fracture risk even when the result of considerable trauma. Clinical or subclinical vertebral fractures, the most common type of osteoporotic fractures, are associated with a 5-fold increased risk for additional vertebral fractures and a 2- to 3-fold increased risk for fractures at other sites. Untreated osteoporosis can lead to a vicious cycle of recurrent fracture(s), often resulting in disability and premature death. In appropriate patients, treatment with effective antifracture medication prevents fractures and improves outcomes. Primary care providers and medical specialists are critical gatekeepers who can identify fractures and initiate proven osteoporosis interventions. Osteoporosis detection, diagnosis, and treatment should be routine practice in all adult healthcare settings. The Bone Health and Osteoporosis Foundation (BHOF) - formerly the National Osteoporosis Foundation - first published the Clinician's Guide in 1999 to provide accurate information on osteoporosis prevention and treatment. Since that time, significant improvements have been made in diagnostic technologies and treatments for osteoporosis. Despite these advances, a disturbing gap persists in patient care. At-risk patients are often not screened to establish fracture probability and not educated about fracture prevention. Most concerning, the majority of highest risk women and men who have a fracture(s) are not diagnosed and do not receive effective, FDA-approved therapies. Even those prescribed appropriate therapy are unlikely to take the medication as prescribed. The Clinician's Guide offers concise recommendations regarding prevention, risk assessment, diagnosis, and treatment of osteoporosis in postmenopausal women and men aged 50 years and older. It includes indications for bone densitometry as well as fracture risk thresholds for pharmacologic intervention. Current medications build bone and/or decrease bone breakdown and dramatically reduce incident fractures. All antifracture therapeutics treat but do not cure the disease. Skeletal deterioration resumes sooner or later when a medication is discontinued-sooner for nonbisphosphonates and later for bisphosphonates. Even if normal BMD is achieved, osteoporosis and elevated risk for fracture are still present. The diagnosis of osteoporosis persists even if subsequent DXA T-scores are above - 2.5. Ongoing monitoring and strategic interventions will be necessary if fractures are to be avoided. In addition to pharmacotherapy, adequate intake of calcium and vitamin D, avoidance of smoking and excessive alcohol intake, weight-bearing and resistance-training exercise, and fall prevention are included in the fracture prevention armamentarium. Where possible, recommendations in this guide are based on evidence from RCTs; however, relevant published data and guidance from expert clinical experience provides the basis for recommendations in those areas where RCT evidence is currently deficient or not applicable to the many osteoporosis patients not considered for RCT participation due to age and morbidity.
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Affiliation(s)
- M. S. LeBoff
- grid.38142.3c000000041936754XBrigham and Women’s Hospital, Harvard Medical School, 221 Longwood Ave, Boston, MA 02115 USA
| | - S. L. Greenspan
- grid.412689.00000 0001 0650 7433University of Pittsburgh Medical Center, 1110 Kaufmann Building, 3471 Fifth Ave, Pittsburgh, PA 15213 USA
| | - K. L. Insogna
- grid.47100.320000000419368710Yale School of Medicine, 333 Cedar St, New Haven, CT 06520 USA
| | - E. M. Lewiecki
- grid.266832.b0000 0001 2188 8502University of New Mexico Health Sciences Center, 300 Oak St NE, Albuquerque, NM 87106 USA
| | - K. G. Saag
- grid.265892.20000000106344187University of Alabama at Birmingham, 1720 2nd Avenue South, FOT 820, Birmingham, AL 35294 USA
| | - A. J. Singer
- grid.411663.70000 0000 8937 0972MedStar Georgetown University Hospital and Georgetown University Medical Center, 3800 Reservoir Road NW, 3rd Floor, Washington, DC 20007 USA
| | - E. S. Siris
- grid.21729.3f0000000419368729Columbia University Irving Medical Center, 180 Fort Washington Ave, Suite 9-903, New York, NY 10032 USA
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Colón-Emeric CS, Hecker EJ, McConnell E, Herndon L, Little M, Xue T, Berry S. Improving shared decision-making for osteoporosis pharmacologic therapy in nursing homes: a qualitative analysis. Arch Osteoporos 2022; 17:11. [PMID: 34981246 PMCID: PMC9479090 DOI: 10.1007/s11657-021-01050-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 12/16/2021] [Indexed: 02/03/2023]
Abstract
Decisions on whether to use pharmacologic osteoporosis therapy in skilled nursing facility residents are complex and require shared decision-making. Residents, proxies, and staff desire individualized fracture risk estimates that consider advanced age, dementia, and mobility. They want options for reducing administration burden, monitoring instructions, and periodic reassessment of risk vs. benefit. PURPOSE Decisions about pharmacologic osteoporosis treatment in nursing home (NH) residents with advanced age and multimorbidity are complex and should occur using shared decision-making. Our objective was to identify processes and tools to improve shared decision-making about pharmacologic osteoporosis treatment in NHs. METHODS Qualitative analysis of data collected in three NHs from residents at high fracture risk, their proxies, nursing assistants, nurses, and one nurse practitioner (n = 28). Interviews explored participants' stories, attitudes, and experiences with oral osteoporosis medication management. Framework analysis was used to identify barriers to shared decision-making regarding osteoporosis treatment in this setting. RESULTS Participants wanted individualized fracture risk estimates that consider immobility, advanced age, and comorbid dementia. Residents and proxies expected nursing staff to be involved in the decision-making; nursing staff wished to be informed on the relative risks vs. benefits of medications and given monitoring instructions. Two important competing demands to address during the shared decision-making process were burdensome administration requirements and polypharmacy. Participants wanted to reassess pharmacologic treatment appropriateness over time as clinical status or goals of care change. CONCLUSIONS Shared decision-making using strategies and tools identified in this analysis may move osteoporosis pharmacologic treatment in NHs and for other older adults with multimorbidity from inappropriate inertia to appropriate prescribing or appropriate inaction.
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Affiliation(s)
- Cathleen S Colón-Emeric
- Duke University, Box 3003 DUMC, Durham, NC, 27710, USA. .,Durham VA Geriatric Research Education and Clinical Center, Durham, NC, 27705, USA.
| | | | - Eleanor McConnell
- Duke University, Box 3003 DUMC, Durham, NC, 27710, USA.,Durham VA Geriatric Research Education and Clinical Center, Durham, NC, 27705, USA
| | | | - Milta Little
- Duke University, Box 3003 DUMC, Durham, NC, 27710, USA
| | - Tingzhong Xue
- Duke University, Box 3003 DUMC, Durham, NC, 27710, USA
| | - Sarah Berry
- Hebrew Center for Senior Life, Boston, MA, USA
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McArthur C, Hillier L, Ioannidis G, Adachi JD, Giangregorio L, Hirdes J, Papaioannou A. Developing a Fracture Risk Clinical Assessment Protocol for Long-Term Care: A Modified Delphi Consensus Process. J Am Med Dir Assoc 2021; 22:1726-1734.e8. [PMID: 32972869 DOI: 10.1016/j.jamda.2020.08.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 07/21/2020] [Accepted: 08/13/2020] [Indexed: 01/07/2023]
Abstract
OBJECTIVES To develop a fracture risk Clinical Assessment Protocol (CAP) based on long-term care (LTC) fracture prevention recommendations and an embedded fracture risk assessment tool. DESIGN A modified Delphi consensus approach including 2 survey rounds and a face-to-face meeting was implemented to reach consensus on matching of LTC fracture prevention guideline statements to Fracture Risk Scale (FRS) risk levels. SETTING AND PARTICIPANTS A national panel of recognized experts in osteoporosis, fractures, and long-term care, including an LTC resident and family members. METHODS Round 1 survey respondents (n = 24) were provided the LTC fracture prevention guidelines matched to FRS risk levels and were asked whether they agreed the guideline was appropriate for the risk level (yes, no, I don't know, I agree with some but not all of it) and to provide comments. In round 2, guideline statements that did not achieve consensus (≥80% agreement) were revised consistent with comments provided in round 1 and respondents were asked again if they agreed with the guideline statement. Statements that did not achieve consensus were to be discussed and resolved in an in-person meeting (n = 17). RESULTS In round 1 (75% response rate), consensus was achieved in 7/14 guideline statements. In round 2 (56% response rate), 5 statements were revised based on round 1 feedback and for 2 statements additional information was provided. Consensus was achieved in all but one statement related to the inappropriateness of pharmacologic therapy for residents with life expectancy less than 1 year. Following facilitated meeting discussions, consensus was obtained to revise the guideline statement to reflect that life expectancy was but one of several criteria that should be used to inform medication decisions. CONCLUSIONS AND IMPLICATIONS An evidence-based fracture risk CAP was developed that will be embedded in international routine clinical assessment tools to guide fracture prevention in LTC.
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Affiliation(s)
- Caitlin McArthur
- McMaster University, Hamilton, Ontario, Canada; GERAS Centre for Aging Research, Hamilton, Ontario, Canada.
| | | | - George Ioannidis
- McMaster University, Hamilton, Ontario, Canada; GERAS Centre for Aging Research, Hamilton, Ontario, Canada
| | | | - Lora Giangregorio
- University of Waterloo, Waterloo, Ontario, Canada; Schlegel-UW Research Institute for Aging, Hamilton, Ontario, Canada
| | - John Hirdes
- University of Waterloo, Waterloo, Ontario, Canada
| | - Alexandra Papaioannou
- McMaster University, Hamilton, Ontario, Canada; GERAS Centre for Aging Research, Hamilton, Ontario, Canada
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Fan Q, Wang J. The Efficacy and Safety of Bisphosphonates for Osteoporosis in Women Older Than 65 Years: A Meta-Analysis. Curr Pharm Des 2021; 26:4022-4030. [PMID: 32324507 DOI: 10.2174/1381612826666200423092602] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2019] [Accepted: 04/07/2020] [Indexed: 01/07/2023]
Abstract
BACKGROUND Osteoporosis presents a major threat to the health of women older than 65 years. Bisphosphonates (BPs) are now the principal class of medications for osteoporosis. OBJECTIVE To evaluate the efficacy and safety of BPs in women older than 65 years. METHODS A comprehensive search in the PubMed, EMBASE, Web of Science and Cochrane Central databases was undertaken for randomized controlled trials (RCTs) on the efficacy and safety of BPs in women older than 65 years. The primary outcome measures were the change in bone mass density (BMD), serum bone turnover marker levels, fracture rate and the adverse effect (AE) rate. The final search was performed in August 2019. RESULTS Seven RCTs were included. A total of 23287 patients met the inclusion criteria. BPs significantly increased the BMD of the posteroanterior (PA) spine, lateral spine and femoral neck, and reduced the fracture, vertebrate fracture and hip fracture rates in women older than 65 years. In addition, BPs increased the risks for pyrexia, myalgia, arthralgia, headache and influenza-like symptoms and had no statistical effect on any AEs, any serious AEs, discontinuation due to AEs, oesophagitis, any upper gastrointestinal adverse event, atrial fibrillation and myocardial infarction occurrence in women older than 65 years. Finally, intravenous BPs reduced hip fracture risk but increased AEs in women older than 65 years. CONCLUSION Despite the fact that AEs significantly increased after drug delivery, BPs are highly effective and safe for managing osteoporosis in women older than 65 years. Zoledronic acid caused an increased rate of AEs in women older than 65 years, but these AEs seemed to be mild to moderate. In addition, the hip fracture rate in women older than 80 years old treated with BPs was different than that in the other included patients. Therefore, doctors may prescribe BPs for women older than 65 years in order to increase BMD, and AEs and hip fractures in women older than 80 years should be given attention.
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Affiliation(s)
- Qin Fan
- Shanxi Bethune Hospital, Taiyuan, Shanxi Province, China
| | - Junjie Wang
- Changzhi Medical College, Changzhi, Shanxi Province, China
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Yang J, Mao Y, Nieves JW. Identification of prevalent vertebral fractures using Vertebral Fracture Assessment (VFA) in asymptomatic postmenopausal women: A systematic review and meta-analysis. Bone 2020; 136:115358. [PMID: 32268210 DOI: 10.1016/j.bone.2020.115358] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 03/20/2020] [Accepted: 04/03/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Vertebral fracture (VF) is the most common osteoporotic fracture in postmenopausal women, although most VFs are subclinical. Prevalent VFs are a significant predictor of subsequent fracture and therefore, identification of VF improves the identification of those with high fracture risk. The aim of present study was to systematically review the literature that assessed the prevalence of VF in asymptomatic postmenopausal women, using Vertebral Fracture Assessment (VFA) by dual-energy X-ray absorptiometry. METHOD Medline, Web of Science and Cochrane databases were searched between Jan 1st, 2000 and Jan 31st, 2018, for publications in English that reported the prevalence of VFA-detected VF in asymptomatic postmenopausal women. We also searched for reports, conference papers and grey literature. Reviewers screened studies for eligibility and extracted data for included studies. Random effects meta-analyses were performed to calculate the prevalence of VF. The presence of publication bias was assessed using funnel plots by precision and Egger's Test of the Intercept. RESULTS A total of 1777 articles were identified, 94 studies were fully reviewed and 28 studies (n = 25,418) met the inclusion criteria and were analyzed. More than two thirds of the studies were cross-sectional and the sample size varied widely across the studies (from 63 to 5156). The mean age ranged from 59.5 to 86.2 years old. The prevalence of osteoporosis and osteopenia varied between 6-57.0% and 25.1-58.9%, respectively. However, among women who had prevalent VFs, up to 43% had osteopenia and as many as 32% had normal bone density. The weighted pooled prevalence of VFA-detected VF in asymptomatic women was 28% (95% CI: 23%-32%). CONCLUSION VFA is able to identify prevalent VF in asymptomatic postmenopausal women. The use of VFA identified an average of 28% of asymptomatic women with VFs, many of whom did not have a diagnosis of osteoporosis. Implementation of VFA as a routine screening tool may detect high risk women. Detection of VF might lead to pharmacological treatment in individuals who may not otherwise be treated.
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Affiliation(s)
- Jingyan Yang
- Institute for Social and Economic Research and Policy (ISERP), Columbia University, New York, NY, USA; Patient Health and Impact, Pfizer Inc., New York, NY, USA
| | - Yushan Mao
- Department of Endocrinology, The Affiliated Hospital of Medical School, Ningbo University, Zhejiang, China
| | - Jeri W Nieves
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA; Hospital for Special Surgery, New York, NY, USA.
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11
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Cawthon PM, Travison TG, Manini TM, Patel S, Pencina KM, Fielding RA, Magaziner JM, Newman AB, Brown T, Kiel DP, Cummings SR, Shardell M, Guralnik JM, Woodhouse LJ, Pahor M, Binder E, D’Agostino RB, Quian-Li X, Orwoll E, Landi F, Orwig D, Schaap L, Latham NK, Hirani V, Kwok T, Pereira SL, Rooks D, Kashiwa M, Torres-Gonzalez M, Menetski JP, Correa-De-Araujo R, Bhasin S. Establishing the Link Between Lean Mass and Grip Strength Cut Points With Mobility Disability and Other Health Outcomes: Proceedings of the Sarcopenia Definition and Outcomes Consortium Conference. J Gerontol A Biol Sci Med Sci 2020; 75:1317-1323. [PMID: 30869772 PMCID: PMC7447857 DOI: 10.1093/gerona/glz081] [Citation(s) in RCA: 79] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2018] [Accepted: 03/13/2019] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Lack of consensus on how to diagnose sarcopenia has limited the ability to diagnose this condition and hindered drug development. The Sarcopenia Definitions and Outcomes Consortium (SDOC) was formed to develop evidence-based diagnostic cut points for lean mass and/or muscle strength that identify people at increased risk of mobility disability. We describe here the proceedings of a meeting of SDOC and other experts to discuss strategic considerations in the development of evidence-based sarcopenia definition. METHODS Presentations and panel discussions reviewed the usefulness of sarcopenia as a biomarker, the analytical approach used by SDOC to establish cut points, and preliminary findings, and provided strategic direction to develop an evidence-based definition of sarcopenia. RESULTS The SDOC assembled data from eight epidemiological cohorts consisting of 18,831 participants, clinical populations from 10 randomized trials and observational studies, and 2 nationally representative cohorts. In preliminary assessments, grip strength or grip strength divided by body mass index was identified as discriminators of risk for mobility disability (walking speed <0.8 m/s), whereas dual-energy X-ray absorptiometry-derived lean mass measures were not good discriminators of mobility disability. Candidate definitions based on grip strength variables were associated with increased risk of mortality, falls, mobility disability, and instrumental activities of daily living disability. The prevalence of low grip strength increased with age. The attendees recommended the establishment of an International Expert Panel to review a series of position statements on sarcopenia definition that are informed by the findings of the SDOC analyses and synthesis of literature. CONCLUSIONS International consensus on an evidence-based definition of sarcopenia is needed. Grip strength-absolute or adjusted for body mass index-is an important discriminator of mobility disability and other endpoints. Additional research is needed to develop a predictive risk model that takes into account sarcopenia components as well as age, sex, race, and comorbidities.
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Affiliation(s)
- Peggy M Cawthon
- California Pacific Medical Center Research Institute, San Francisco Coordinating Center, California
| | - Thomas G Travison
- Department of Medicine, Marcus Institute for Aging Research, Hebrew SeniorLife, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
| | | | - Sheena Patel
- California Pacific Medical Center Research Institute, San Francisco Coordinating Center, California
| | - Karol M Pencina
- Boston Claude D. Pepper Older Americans Independence Center, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Roger A Fielding
- Nutrition, Exercise Physiology and Sarcopenia Laboratory, Jean Mayer U.S. Department of Agriculture Human Nutrition Research Center on Aging, Tufts University, Boston, Massachusetts
| | - Jay M Magaziner
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore
| | - Anne B Newman
- Department of Epidemiology, University of Pittsburgh, Pennsylvania
| | - Todd Brown
- Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University, Baltimore, Maryland
| | - Douglas P Kiel
- Department of Medicine, Marcus Institute for Aging Research, Hebrew SeniorLife, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts,Longitudinal Studies Section, The National Institute on Aging, Baltimore, Maryland
| | - Steve R Cummings
- California Pacific Medical Center Research Institute, San Francisco Coordinating Center, California
| | - Michelle Shardell
- Longitudinal Studies Section, The National Institute on Aging, Baltimore, Maryland
| | - Jack M Guralnik
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore
| | - Linda J Woodhouse
- Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, Canada
| | | | - Ellen Binder
- Division of Geriatrics, Washington University School of Medicine, St Louis, Missouri
| | - Ralph B D’Agostino
- Department of Mathematics, Framingham Heart Study, Boston University, Massachusetts
| | - Xue Quian-Li
- Director of Biostatistics, Division of Geriatric Medicine and Gerontology and Center on Aging and Health, Johns Hopkins Medical Institute, Baltimore, Maryland
| | - Eric Orwoll
- Division of Endocrinology, Metabolism and Clinical Nutrition, Oregon Health and Sciences University, Portland
| | - Francesco Landi
- Department of Medicine and Geriatrics, Catholic University of Sacred Heart, Rome, Italy
| | - Denise Orwig
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore
| | - Laura Schaap
- Faculty of Science, Nutrition and Health Aging and Later Life, Free University of Amsterdam, The Netherlands
| | - Nancy K Latham
- Boston Claude D. Pepper Older Americans Independence Center, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Vasant Hirani
- School of Life and Environmental Sciences, University of Sydney, Australia
| | - Timothy Kwok
- Department of Medicine and Therapeutics, Faculty of Medicine,School of Public Health, The Chinese University of Hong Kong, China
| | | | - Daniel Rooks
- Novartis Biomedical Research Institute, Cambridge, Massachusetts
| | | | | | - Joseph P Menetski
- The Foundation for the National Institutes of Health, Bethesda, Maryland
| | | | - Shalender Bhasin
- Boston Claude D. Pepper Older Americans Independence Center, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts,Address correspondence to: Shalender Bhasin, MB, BS, Boston Claude D. Pepper Older Americans Independence Center, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115. E-mail:
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12
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Unknown osteoporosis in older patients admitted to post-acute rehabilitation. Aging Clin Exp Res 2020; 32:1145-1152. [PMID: 31463924 DOI: 10.1007/s40520-019-01302-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Accepted: 08/02/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Osteoporotic fractures are associated with increased morbidity, mortality, and increased health care use. As the number of older adults increases, identifying those at increased risk for osteoporotic fractures has become of utmost importance to providing them with preventive and therapeutic interventions. AIMS To determine the prevalence of unknown clinical and densitometric osteoporosis and to investigate the performance of different diagnostic strategies for osteoporosis in elderly patients admitted to rehabilitation. METHOD This is an observational study. Eligible participants were older adults admitted to rehabilitation in an academic hospital in Switzerland over an 11-month period. Patients with previously unknown osteoporosis underwent dual-energy X-ray absorptiometry (DXA), vertebral fracture assessment (VFA), and history review for past fractures. RESULTS Complete assessment was available for 252 patients. Previously undiagnosed osteoporosis was identified in 62.3% of these patients, a proportion that was higher among women (71.5%) than men (44.8%). DXA proved most sensitive, followed by VFA and history review. Results differed across gender: DXA remained the most sensitive single test among women, but VFA proved most sensitive in men. The best test to combine with history review was DXA in women (detection increasing from 47.5 to 93.2%) and VFA in men (detection increasing from 35.9 to 84.6%). CONCLUSIONS Prevalence of previously unknown osteoporosis appears very high in elderly patients admitted to post-acute rehabilitation. The combination of history review of previous fractures with DXA in women and with VFA in men appears the best two-step strategy to improving detection of osteoporosis in this population.
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Lewiecki EM, Bilezikian JP, Giangregorio L, Greenspan SL, Khosla S, Kostenuik P, Krohn K, McClung MR, Miller PD, Pacifici R. Proceedings of the 2018 Santa Fe Bone Symposium: Advances in the Management of Osteoporosis. J Clin Densitom 2019; 22:1-19. [PMID: 30366683 DOI: 10.1016/j.jocd.2018.09.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2018] [Accepted: 09/19/2018] [Indexed: 12/16/2022]
Abstract
The Santa Fe Bone Symposium is an annual meeting devoted to clinical applications of recent advances in skeletal research. The 19th Santa Fe Bone Symposium convened August 3-4, 2018, in Santa Fe, New Mexico, USA. Attendees included physicians of many specialties, fellows in training, advanced practice providers, clinical researchers, and bone density technologists. The format consisted of lectures, case presentations by endocrinology fellows, and panel discussions, with all involving extensive interactive discussions. Topics were diverse, including an evolutionary history of calcium homeostasis, osteoporosis treatment in the very old, optimizing outcomes with orthopedic surgery, microbiome and bone, new strategies for combination and sequential therapy of osteoporosis, exercise as medicine, manifestations of parathyroid hormone excess and deficiency, parathyroid hormone as a therapeutic agent, cell senescence and bone health, and managing patients outside clinical practice guidelines. The National Bone Health Alliance conducted a premeeting on development of fracture liaison services. A workshop was devoted to Bone Health TeleECHO (Bone Health Extension for Community Healthcare Outcomes), a strategy of ongoing medical education for healthcare professions to expand capacity to deliver best practice skeletal healthcare in underserved communities and reduce the osteoporosis treatment gap.
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Affiliation(s)
- E Michael Lewiecki
- New Mexico Clinical Research & Osteoporosis Center, Albuquerque, NM, USA.
| | - John P Bilezikian
- Columbia University College of Physicians and Surgeons, NYC, NY, USA
| | - Lora Giangregorio
- University of Waterloo and Schlegel-UW Research Institute for Aging, Waterloo, Ontario, Canada
| | | | | | | | | | - Michael R McClung
- Oregon Osteoporosis Center, Portland, OR, USA; MacKillop Institute for Health Research, Australian Catholic University, Melbourne, VIC, Australia
| | - Paul D Miller
- University of Colorado Health Sciences Center, Denver, CO, USA
| | - Roberto Pacifici
- Division of Endocrinology, Metabolism and Lipids, Department of Medicine, Emory University, Atlanta, GA, USA
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14
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Ioannidis G, Jantzi M, Bucek J, Adachi JD, Giangregorio L, Hirdes J, Pickard L, Papaioannou A. Development and validation of the Fracture Risk Scale (FRS) that predicts fracture over a 1-year time period in institutionalised frail older people living in Canada: an electronic record-linked longitudinal cohort study. BMJ Open 2017; 7:e016477. [PMID: 28864698 PMCID: PMC5588955 DOI: 10.1136/bmjopen-2017-016477] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVES To develop and validate our Fracture Risk Scale (FRS) over a 1-year time period, using the long-term care (LTC) Resident Assessment Instrument Minimum Data Set Version 2.0 (RAI-MDS 2.0). DESIGN A retrospective cohort study. SETTING LTC homes in Ontario, Canada. PARTICIPANTS Older adults who were admitted to LTC and received a RAI-MDS 2.0 admission assessment between 2006 and 2010. RESULTS A total of 29 848 LTC residents were enrolled in the study. Of these 22 386 were included in the derivation dataset and 7462 individual were included in the validation dataset. Approximately 2/3 of the entire sample were women and 45% were 85 years of age or older. A total of 1553 (5.2%) fractures were reported over the 1-year time period. Of these, 959 (61.8%) were hip fractures. Following a hip fracture, 6.3% of individuals died in the emergency department or as an inpatient admission and did not return to their LTC home. Using decision tree analysis, our final outcome scale had eight risk levels of differentiation. The percentage of individuals with a hip fracture ranged from 0.6% (lowest risk level) to 12.6% (highest risk level). The area under the curve of the outcome scale was similar for the derivation (0.67) and validation (0.69) samples, and the scale exhibited a good level of consistency. CONCLUSIONS Our FRS predicts hip fracture over a 1-year time period and should be used as an aid to support clinical decisions in the care planning of LTC residents. Future research should focus on the transformation of our scale to a Clinical Assessment Protocol and to assess the FRS in other healthcare settings.
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Affiliation(s)
- George Ioannidis
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Geriatric Education and Research in Ageing Sciences Centre, Hamilton, Ontario, Canada
| | - Micaela Jantzi
- Department of Health Studies and Gerontology, University of Waterloo, Waterloo, Ontario, Canada
| | - Jenn Bucek
- Department of Health Studies and Gerontology, University of Waterloo, Waterloo, Ontario, Canada
| | - Jonathan D Adachi
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Geriatric Education and Research in Ageing Sciences Centre, Hamilton, Ontario, Canada
| | - Lora Giangregorio
- Department of Kinesiology, University of Waterloo, Waterloo, Ontario, Canada
| | - John Hirdes
- Department of Health Studies and Gerontology, University of Waterloo, Waterloo, Ontario, Canada
| | - Laura Pickard
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Geriatric Education and Research in Ageing Sciences Centre, Hamilton, Ontario, Canada
| | - Alexandra Papaioannou
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Geriatric Education and Research in Ageing Sciences Centre, Hamilton, Ontario, Canada
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15
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Chao AS, Chen FP, Lin YC, Huang TS, Fan CM, Yu YW. Application of the World Health Organization Fracture Risk Assessment Tool to predict need for dual-energy X-ray absorptiometry scanning in postmenopausal women. Taiwan J Obstet Gynecol 2016; 54:722-5. [PMID: 26700992 DOI: 10.1016/j.tjog.2015.10.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/05/2015] [Indexed: 10/22/2022] Open
Abstract
OBJECTIVE To evaluate the efficacy of the World Health Organization Fracture Risk Assessment Tool, excluding bone mineral density (pre-BMD FRAX), in identifying Taiwanese postmenopausal women needing dual-energy X-ray absorptiometry (DXA) examination for further treatment. MATERIALS AND METHODS The pre-BMD FRAX score was calculated for 231 postmenopausal women who participated in public health education workshops in the local Keelung community, Taiwan. DXA scanning and vertebral fracture assessment (VFA) were arranged for women classified as intermediate or high risk for fracture using the pre-BMD FRAX fracture probability. RESULTS Pre-BMD FRAX classified 26 women as intermediate risk and 37 as having high risk for fracture. Subsequent DXA scans for these 63 women showed that 36 were osteoporotic, 19 were osteopenic, and eight had normal bone density. Concurrent VFA revealed 25 spine factures in which 14 were osteoporotic, seven were osteopenic, and four had normal bone density. The efficacy of the pre-BMD FRAX score to identify those patients with low bone mass by DXA was 87.3% (55/63). When VFA was combined with BMD to identify those patients with high risk (osteopenia, osteoporosis, or spinal fracture), the efficacy of the pre-BMD score increased to 93.7% (59/63). According to the National Osteoporosis Foundation, the overall concordance between pre-BMD FRAX and BMD, expressed through the kappa index, was 0.967. Compared with the evaluation when BMD was used alone, there was a significant increase in efficacy in identifying women who need treatment using BMD plus VFA or FRAX plus BMD. Furthermore, the highest efficacy was achieved when FRAX with BMD and VFA was used. CONCLUSION The pre-BMD FRAX score not only efficiently predicts postmenopausal patients who are potentially at risk and might require treatment but also reduces unnecessary DXA use. Concurrent VFA during DXA use increases spine fracture detection. This improvement in diagnostic efficacy allows clinicians to provide the most appropriate therapeutic recommendation.
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Affiliation(s)
- An-Shine Chao
- Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital, Chang Gung University, Keelung, Taiwan
| | - Fang-Ping Chen
- Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital, Chang Gung University, Keelung, Taiwan.
| | - Yu-Ching Lin
- Department of Radiology, Chang Gung Memorial Hospital, Chang Gung University, Keelung, Taiwan
| | - Ting-Shuo Huang
- Department of General Surgery, Chang Gung Memorial Hospital, Chang Gung University, Keelung, Taiwan
| | - Chih-Ming Fan
- Department of Radiology, Chang Gung Memorial Hospital, Chang Gung University, Keelung, Taiwan
| | - Yu-Wei Yu
- Department of Medical Research and Development, Chang Gung Memorial Hospital, Chang Gung University, Keelung, Taiwan
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16
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Osterhoff G, Morgan EF, Shefelbine SJ, Karim L, McNamara LM, Augat P. Bone mechanical properties and changes with osteoporosis. Injury 2016; 47 Suppl 2:S11-20. [PMID: 27338221 PMCID: PMC4955555 DOI: 10.1016/s0020-1383(16)47003-8] [Citation(s) in RCA: 281] [Impact Index Per Article: 35.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
This review will define the role of collagen and within-bone heterogeneity and elaborate the importance of trabecular and cortical architecture with regard to their effect on the mechanical strength of bone. For each of these factors, the changes seen with osteoporosis and ageing will be described and how they can compromise strength and eventually lead to bone fragility.
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Affiliation(s)
- Georg Osterhoff
- Division of Orthopaedic Trauma, Department of Orthopaedic Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Elise F. Morgan
- Department of Mechanical Engineering, Boston University, Boston, MA 02215, USA
| | - Sandra J. Shefelbine
- Department of Mechanical and Industrial Engineering, Northeastern University, Boston, MA 02115, USA
| | - Lamya Karim
- Center for Advanced Orthopedic Studies, Beth Israel Deaconess Medical Center and Department of Orthopedic Surgery, Harvard Medical School, Boston, MA 02215, USA
| | - Laoise M. McNamara
- Centre for Biomechanics Research (BMEC), Department of Biomedical Engineering, NUI Galway, Galway, Republic of Ireland,National Centre for Biomedical Engineering Science (NCBES), NUI Galway, Galway, Republic of Ireland
| | - Peter Augat
- Institute of Biomechanics, Trauma Center Murnau, Murnau, Germany and Paracelsus Medical University Salzburg, Salzburg, Austria,Corresponding author at: Institute of Biomechanics, Berufsgenossenschaftliche Unfallklinik, Murnau Prof.-Kuentscher-Str. 8, D-82418 Murnau am Staffelsee, Germany. Tel.: +49 8841 484563; fax: +49 8841 484573. (P. Augat)
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18
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Greenspan SL, Perera S, Resnick NM. Dosing Strategies of Bone-Targeting Agents-Reply. JAMA Intern Med 2015; 175:1865-6. [PMID: 26524746 PMCID: PMC4869321 DOI: 10.1001/jamainternmed.2015.4799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Susan L Greenspan
- Division of Geriatric Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Subashan Perera
- Division of Geriatric Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Neil M Resnick
- Division of Geriatric Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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19
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Greenspan SL, Perera S, Ferchak MA, Nace DA, Resnick NM. Efficacy and safety of single-dose zoledronic acid for osteoporosis in frail elderly women: a randomized clinical trial. JAMA Intern Med 2015; 175:913-21. [PMID: 25867538 PMCID: PMC4843134 DOI: 10.1001/jamainternmed.2015.0747] [Citation(s) in RCA: 94] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
IMPORTANCE Eighty-five percent of institutionalized elderly people have osteoporosis and bone fracture rates 8 to 9 times higher than rates observed among community-dwelling elderly people. Nevertheless, most of these persons are left untreated and are excluded from pivotal osteoporosis trials. OBJECTIVE To determine the efficacy and safety of zoledronic acid to treat osteoporosis in frail elderly women in long-term care facilities. DESIGN, SETTING, AND PARTICIPANTS We conducted a 2-year, randomized, placebo-controlled, double-blinded study from December 2007 through March 2012. Included were 181 women 65 or older with osteoporosis, including those with cognitive impairment, immobility, and multimorbidity, who were living in nursing homes and assisted-living facilities. INTERVENTIONS One 5-mg dose of zoledronic acid or placebo intravenously and daily calcium and vitamin D supplementation. MAIN OUTCOMES AND MEASURES Hip and spine bone mineral density (BMD) at 12 and 24 months and adverse events. RESULTS There were no baseline differences in mean (SE) age (85.4 [0.6] years), BMD, or functional or cognitive status, but the treatment group included more participants with frailty, falls history, diabetes, and anticonvulsant medication use. Values for BMD were available for 87% of participants at 12 months and 73% at 24 months. Mean (SE) BMD changes were greater in the treatment group: 3.2 (0.7) and 3.9 (0.7) percentage-point differences in the total hip at 12 and 24 months, respectively (P < .01 for both comparisons), and 1.8 (0.7) and 3.6 (0.7) percentage-point differences at the spine (P < .01); adjusted analyses were similar. The treatment and placebo groups' fracture rates were 20% and 16%, respectively (OR, 1.30; 95% CI, 0.61-2.78); mortality rates were 16% and 13% (OR, 1.24; 95% CI, 0.54-2.86). Groups did not differ in the proportion of single fallers (28% vs 24%; OR, 1.24; 95% CI, 0.64-2.42; P = .52), but more participants in the treatment group had multiple falls (49% vs 35%; OR, 1.83; 95% CI, 1.01-3.33; P = .047); however, this difference was no longer significant when adjusted for baseline frailty. CONCLUSIONS AND RELEVANCE In this group of frail elderly women with osteoporosis, 1 dose of zoledronic acid improved BMD over 2 years. The clinical importance of nonsignificant increases in fracture and mortality rates in the treatment group needs further study. Since it is not known whether such therapy reduces the risk of fracture in this cohort, any change in nursing home practice must await results of larger trials powered to assess fracture rates. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00558012.
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Affiliation(s)
- Susan L Greenspan
- Division of Geriatric Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania2Division of Endocrinology and Metabolism, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Subashan Perera
- Division of Geriatric Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania3Department of Biostatistics, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Mary Anne Ferchak
- Division of Geriatric Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - David A Nace
- Division of Geriatric Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Neil M Resnick
- Division of Geriatric Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
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Affiliation(s)
- Alexandra Papaioannou
- Division of Geriatric Medicine, McMaster University, St Peter's Hospital, GERAS Centre, Hamilton, ON L8M 1W9, Canada.
| | - Courtney Kennedy
- Division of Geriatric Medicine, McMaster University, St Peter's Hospital, GERAS Centre, Hamilton, ON L8M 1W9, Canada
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21
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Kaasalainen S, Papaioannou A, Burgess J, Van der Horst ML. Exploring the nurse practitioner role in managing fractures in long-term care. Clin Nurs Res 2015; 24:567-88. [PMID: 25825270 DOI: 10.1177/1054773815577577] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The purpose of this study was to assess the current level of involvement of nurse practitioners (NPs) in activities related to preventing and managing fractures in long-term care (LTC). This study used a sequential explanatory mixed methods design that included two phases-a cross-sectional survey followed by qualitative interviews. A final sample of 12 NPs completed the online survey for a response rate of 67%. Eleven of the 12 NPs who completed the survey agreed to participate in a follow-up interview. NPs reported that they were quite engaged in managing fractures in LTC; specifically, they were most active in caring for residents post-fracture. NPs described their role as being holistic in nature in their assessment and treatments related to managing fractures. The findings from this mixed method study add to the growing body of knowledge related to how NPs manage fractures in LTC.
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Affiliation(s)
| | | | - Jennifer Burgess
- Nurse-Led Outreach Team, Shalom Village, Hamilton, Ontario, Canada
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Jantzi M, Maher AC, Ioannidis G, Hirdes JP, Giangregorio LM, Papaioannou A. Individuals with neurological diseases are at increased risk of fractures within 180 days of admission to long-term care in Ontario. Age Ageing 2015; 44:252-7. [PMID: 25398885 DOI: 10.1093/ageing/afu156] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Individuals residing in long-term care (LTC) are more likely to have a fragility fracture than community-dwelling seniors. The purpose of this study was to determine whether the presence of neurological diseases was associated with an increased risk of fracture within 180 days of admission to LTC. METHODS This retrospective cohort study used data collected in the LTC setting using the Resident Assessment Instrument (RAI) 2.0 during the period from 2006 to 2011 (N=42,089). Multivariable logistic regression analyses were conducted to determine the associations between the presence of neurological conditions and incident fractures, with and without adjustment for clinical variables. RESULTS The incident fracture rate for all LTC residents was 2.6% (N=1,094). Neurological condition group size ranged from n=21,015 for Alzheimer's disease or related dementias (ADRD) to n=21 for muscular dystrophy (MD). The incidence of fracture among residents with specific neurological diseases was as follows: ADRD, 3.2% (n=672), MD, 4.8% (n=1), Parkinson's disease, 2.5% (n=57), stroke, 2.3% (n=166), epilepsy, 2.5% (n=38), Huntington's disease, 1.4% (n=1), multiple sclerosis, 0.3% (n=1) and traumatic brain injury, 3.8% (n=11); among the comparison group with no neurological conditions, the fracture rate was 2.0% (n=366). The neurological diseases that were associated with a significantly greater odds of having an incident fracture in the first 180 days of LTC admission were as follows: ADRD (1.3; 95% CI: 1.1-1.5), epilepsy (1.5; 95% CI: 1.0-2.1) and traumatic brain injury (2.7; 95% CI: 1.4-5.0). CONCLUSION LTC residents with ADRD, epilepsy and traumatic brain injury are at a higher risk for sustaining an incident fracture in the first 180 days of admission and should be considered for fracture prevention strategies.
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Affiliation(s)
- Micaela Jantzi
- School of Public Health and Health Systems, University of Waterloo, Waterloo, Ontario, Canada
| | - Amy C Maher
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - George Ioannidis
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - John P Hirdes
- School of Public Health and Health Systems, University of Waterloo, Waterloo, Ontario, Canada
| | - Lora M Giangregorio
- Department of Kinesiology, University of Waterloo, Waterloo, Ontario, Canada
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Khatib R, Santesso N, Pickard L, Osman O, Giangregorio L, Skidmore C, Papaioannou A. Fracture risk in long term care: a systematic review and meta-analysis of prospective observational studies. BMC Geriatr 2014; 14:130. [PMID: 25471485 PMCID: PMC4266898 DOI: 10.1186/1471-2318-14-130] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2014] [Accepted: 11/20/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The risk factors associated with fractures have been well-characterized in community dwelling populations, but have not been clearly defined in long-term care (LTC) settings. The objective of this review was to identify risk factors for fractures in LTC settings. METHODS We searched MEDLINE, the Cochrane Library, EMBASE and CINAHL up to June 2014, scanned reference lists of articles and consulted with experts in the field to identify relevant prospective cohort studies that evaluated risk factors associated with fracture incidence in LTC. We included studies that assessed the association between risk factors included in the WHO-Fracture Risk Assessment Tool (FRAX®) or other predictors relevant to LTC (psychotropic medications, cognitive impairment, mobility, and falls). All articles were screened and extracted by two authors. Available data on the association between a given risk factor and fracture incidence were pooled when possible. We used the GRADE criteria to provide a summary of evidence. The GRADE approach defines the quality of a body of evidence as the extent to which one can be confident that an estimate of effect or association is close to the quantity of specific interest. RESULTS We identified 13 prospective cohort studies which examined fracture incidence among LTC residents. Most predictors showed moderate increases in fracture risk, but the quality of the evidence was often low. Moderate quality evidence showed that prior fractures and falls may moderately increase the risk of fractures. Being a woman and cognitive impairment are probably associated with a small increase. The effect of mobility and psychotropic medication use is still uncertain primarily due to the various definitions used in the studies and difficulty summarising the results. CONCLUSIONS In addition to criteria used in the FRAX assessment tool, such as a previous fracture and female gender, we found that falls and cognitive impairment are also associated with a small to moderate increases in the risk of fractures in LTC. Developing an assessment tool that includes risk factors that are specific to LTC may improve the identification of individuals who can benefit from fracture prevention programs in these settings.
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Affiliation(s)
| | | | | | | | | | | | - Alexandra Papaioannou
- Clinical Epidemiology and Biostatistics, McMaster University, 1280 Main Street West, Hamilton, ON L8S 4 K1, Canada.
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Abstract
Osteoporosis and related fractures disproportionately impact patients with advanced age, those with the frailty phenotype, and those with multiple comorbidities. Recent studies report a changing incidence in fracture type among the oldest old throughout the world, a finding not satisfactorily explained by advances in treatment of lifestyle factors. A growing recognition of the importance of muscle and bone interaction is leading to improved understanding of the underlying biochemical pathways linking them and new therapeutic targets. New models of care for frail older populations, particularly after hip fracture, are being developed but have been challenged to identify appropriate outcomes to target. An appreciation for the relationship between age-related comorbidities, fracture risk, and competing mortality risk is essential for practitioners caring for the oldest-old population.
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Affiliation(s)
- Cathleen S Colón-Emeric
- Duke University Medical Center and the Durham VA Geriatrics Research Education and Clinical Center, 508 Fulton St. GRECC 182, Durham, NC, 27705, USA,
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Shil AB, Greer JR. Screening strategies for treatment of osteoporosis in long-term care residents. J Am Geriatr Soc 2012; 60:2383-4; author reply 2384. [PMID: 23231569 DOI: 10.1111/jgs.12024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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Greenspan SL, Resnick NM. Response to Shil and Greer. J Am Geriatr Soc 2012. [DOI: 10.1111/jgs.12016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Susan L. Greenspan
- Division of Endocrinology; Department of Medicine; University of Pittsburgh; Pittsburgh Pennsylvania
| | - Neil M. Resnick
- Division of Geriatrics; Department of Medicine; University of Pittsburgh; Pittsburgh Pennsylvania
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