Diagnosis and treatment of osteoporosis in high-risk patients prior to hip fracture

Mind Gaps and Bone Snaps: Exploring the Connection Between Alzheimer's Disease and Osteoporosis

PURPOSE OF REVIEW

This comprehensive review discusses the complex relationship between Alzheimer's disease (AD) and osteoporosis, two conditions that are prevalent in the aging population and result in adverse complications on quality of life. The purpose of this review is to succinctly elucidate the many commonalities between the two conditions, including shared pathways, inflammatory and oxidative mechanisms, and hormonal deficiencies.

RECENT FINDINGS

AD and osteoporosis share many aspects of their respective disease-defining pathophysiology. These commonalities include amyloid beta deposition, the Wnt/β-catenin signaling pathway, and estrogen deficiency. The shared mechanisms and risk factors associated with AD and osteoporosis result in a large percentage of patients that develop both diseases. Previous literature has established that the progression of AD increases the risk of sustaining a fracture. Recent findings demonstrate that the reverse may also be true, suggesting that a fracture early in the life course can predispose one to developing AD due to the activation of these shared mechanisms. The discovery of these commonalities further guides the development of novel therapeutics in which both conditions are targeted. This detailed review delves into the commonalities between AD and osteoporosis to uncover the shared players that bring these two seemingly unrelated conditions together. The discussion throughout this review ultimately posits that the occurrence of fractures and the mechanism behind fracture healing can predispose one to developing AD later on in life, similar to how AD patients are at an increased risk of developing fractures. By focusing on the shared mechanisms between AD and osteoporosis, one can better understand the conditions individually and as a unit, thus informing therapeutic approaches and further research. This review article is part of a series of multiple manuscripts designed to determine the utility of using artificial intelligence for writing scientific reviews.

From the Mind to the Spine: The Intersecting World of Alzheimer's and Osteoporosis

PURPOSE OF REVIEW

This comprehensive review delves into the intricate interplay between Alzheimer's disease (AD) and osteoporosis, two prevalent conditions with significant implications for individuals' quality of life. The purpose is to explore their bidirectional association, underpinned by common pathological processes such as aging, genetic factors, inflammation, and estrogen deficiency.

RECENT FINDINGS

Recent advances have shown promise in treating both Alzheimer's disease (AD) and osteoporosis by targeting disease-specific proteins and bone metabolism regulators. Monoclonal antibodies against beta-amyloid and tau for AD, as well as RANKL and sclerostin for osteoporosis, have displayed therapeutic potential. Additionally, ongoing research has identified neuroinflammatory genes shared between AD and osteoporosis, offering insight into the interconnected inflammatory mechanisms. This knowledge opens avenues for innovative dual-purpose therapies that could address both conditions, potentially revolutionizing treatment approaches for AD and osteoporosis simultaneously. This review underscores the potential for groundbreaking advancements in early diagnosis and treatment by unraveling the intricate connection between AD and bone health. It advocates for a holistic, patient-centered approach to medical care that considers both cognitive and bone health, ultimately aiming to enhance the overall well-being of individuals affected by these conditions. This review article is part of a series of multiple manuscripts designed to determine the utility of using artificial intelligence for writing scientific reviews.

National trends in osteoporosis medication use among Medicare beneficiaries with and without Alzheimer's disease/related dementias

BACKGROUND

Osteoporotic fractures  are a leading cause of disability and premature death in the elderly. Patients with Alzheimer's and related dementia (ADRD) have high rates of osteoporosis (OP) and substantial risk of osteoporotic fractures. Yet research is sparse on trends and predictors of OP medication use in ADRD.

METHODS

Medicare beneficiaries with OP aged ≥ 67 years have Medicare parts A/B/D without HMO from 2016 to 2018. Our outcome was receipt of OP medications in 2018. A multivariable logistic regression assessed association between ADRD and OP drug prescribing, adjusted for age, sex, race, region, Medicare entitlement, dual Medicaid eligibility, chronic conditions, number of provider visits/hospitalizations, and nursing home (NH) resident status. Age/ADRD and NH residency/ADRD interactions were tested.

RESULTS

Our sample consisted of 47,871 people with OP and ADRD and 201,840 with OP without ADRD. OP drug use was 38.6% in ADRD patients vs. 52.7% in non-ADRD. After adjustment for demographics, chronic conditions, and previous hospitalizations/physician visits, the OR for OP drug in ADRD vs. non-ADRD was 0.85 (95% CI: 0.83-0.87). NH residents had lower odds for OP medication (OR: 0.61, 95% CI: 0.58-0.64). There were significant interactions between ADRD and age, and between ADRD and NH residency. The OR for OP drug use associated with ADRD was 0.88 (95% CI: 0.86-0.90) among community-dwelling elders and 0.66 (95% CI: 0.64-0.69) among NH residents.

CONCLUSIONS

ADRD patients received OP drugs at a lower rate than their non-ADRD counterparts. More research is needed on when to prescribe or deprescribe OP drugs in the context of different ADRD severity, patient preferences, remaining life expectancy, and time-to-benefit from OP drugs.

Osteoporosis Care Gap After Hip Fracture - Worse With Low Healthcare Access and Quality

Despite the burden of osteoporosis-related fractures and availability of effective treatment, a substantial osteoporosis care gap persists. We evaluated this gap following fragility hip fracture, testing the hypothesis that patients who live in areas with low health care access or quality are less likely to undergo evaluation or treatment following hip fragility fracture. This retrospective analysis quantified osteoporosis evaluation and treatment just prior and for 12 mo following fragility hip fracture at an academic medical center in the upper Midwest. Initiation of pharmacologic therapy, Vitamin D screening and dual energy X-ray absorptiometry (DXA) scanning were measured. Each patient was assigned a value for 3 metrics of regional healthcare access and quality: (1) population per PCP ratio, (2) percent un-insured <65 yrs old, and (3) preventable hospitalization >65 yrs old. Generalized estimating equations, with county as a random effect, were used to assess the association of patient characteristics and/or heath care metrics with osteoporosis treatment at the time of admission and/or osteoporosis evaluation and treatment during hospitalization and post-discharge. A total of 585 patients were 80.7 ± 8.4 yrs of age at the time of hip fragility fracture; 68% were women. In 12 mo post-fracture, 17% underwent vitamin D screening, 12% received a DXA scan and 17% began a new bone anti-resorptive medication. Only in-hospital Vitamin D screening was more common in patients from counties with low healthcare access; all other pre- and post-fracture care was more common for patients with greater healthcare access and quality. Overall rates of initiating pharmacologic treatment and/or obtaining a Vitamin D screen or DXA scan following hip fragility fracture were very low and were worse in patients from counties with low access and quality of healthcare. These results remind the practitioner to diagnose and treat osteoporosis following hip fracture and suggests a role for targeting high-risk groups.

Predictors of falls and fractures leading to hospitalisation in 36 101 people with affective disorders: a large representative cohort study

OBJECTIVES

To investigate predictors of falls and fractures leading to hospitalisation in people with affective disorders.

DESIGN

Cohort study.

SETTING

The South London and Maudsley National Health Service (NHS) Foundation Trust (SLaM) Biomedical Research Centre (BRC) Case Register.

PARTICIPANTS

A large cohort of people with affective disorders (International Classification of Diseases- 10th version [ICD-10] codes F30-F34) diagnosed between January 2008 and March 2016 was assembled using data from the SLaM BRC Case Register.

PRIMARY AND SECONDARY OUTCOME MEASURES

Falls and fractures leading to hospitalisation were ascertained from linked national hospitalisation data. Multivariable Cox proportional hazards analyses were administrated to identify predictors of first falls and fractures.

RESULTS

Of 36 101 people with affective disorders (mean age 44.4 years, 60.2% female), 816 (incidence rate 9.91 per 1000 person-years) and 1117 (incidence rate 11.92 per 1000 person-years) experienced either a fall or fracture, respectively. In multivariable analyses, older age, analgesic use, increased physical illness burden, previous hospital admission due to certain comorbid physical illnesses and increase in attendances to accident and emergency services following diagnosis were significant risk factors for both falls and fractures. Having a history of falls was a strong risk factor for recurrent falls, and a previous fracture was also associated with future fractures.

CONCLUSIONS

Over a mean 5 years' follow-up, approximately 8% of people with affective disorders were hospitalised with a fall or fracture. Several similar factors were found to predict risk of falls and fracture, for example, older age, comorbid physical disorders and analgesic use. Routine screening for bone mineral density and fall prevention programmes should be considered for this clinical group.

Treatment pattern in postmenopausal women with osteoporosis: a population-based cohort study in South Korea

INTRODUCTION

The treatment landscape of postmenopausal osteoporosis (OP) in an Asian population is yet to be explored.

MATERIALS AND METHODS

We conducted a retrospective cohort study to explore treatment patterns and characteristics associated with treatment interruption in postmenopausal women diagnosed with OP between 2008 and 2014. Treatment pattern assessment included the initial distribution of OP medications and treatment interruption rate according to the treatment groups during a 3-year follow-up period. We used multivariate logistic regression to estimate odds ratio (OR) and 95% confidence interval (CI) to identify factors associated with treatment interruption.

RESULTS

Of 21,813 patients, 87.9% initiated oral bisphosphonates (BP), followed by ibandronate intravenous (IV; 5.4%), selective estrogen receptor modulators (SERMs; 5.2%), pamidronate IV (1.4%) and zoledronic acid (0.06%). Treatment interruption was most notable in the first year of treatment, with cumulative treatment interruption rates highest for oral BP (76.3%) and lowest for pamidronate IV (50.5%). Compared to oral BP users, users of ibandronate IV (OR 0.34, 95% CI 0.30-0.39), pamidronate IV (0.49, 0.39-0.63), zoledronic acid (0.26, 0.09-0.77), and SERMs (0.50, 0.44-0.57) were less likely to interrupt treatment. Of characteristics assessed, presence of rheumatoid arthritis increased the odds of treatment interruption in ibandronate IV group (3.94, 2.12-7.33), and concomitant use of glucocorticoids for oral BP (1.11, 1.03-1.19) and pamidronate IV (2.04, 1.06-3.93) groups, respectively.

CONCLUSION

Given the frequent treatment interruptions across all OP medications, our findings on the factors associated with treatment interruption will serve to implement targeted interventions in reinforcing persistence to OP treatment.

Are Nursing Home Residents With Dementia Appropriately Treated for Fracture Prevention?

Clinicians struggle with whether to prescribe osteoporosis medications for fracture prevention for older nursing home (NH) residents with dementia, given the lack of evidence in this population. To better understand real-world clinical practice, we conducted a retrospective cohort study examining patterns of fracture prevention medication use for older NH residents with dementia and high fracture risk. Data sources included 2015-16 Medicare claims, Part D prescriptions, and Minimum Data Set (MDS) assessments. Among NH residents aged 65+ with dementia and prior fracture or high fracture risk based on the MDS FRAiL (Fracture Risk Assessment in Long-term care), we assessed medications for fracture prevention using prescription data from 1 year prior through 90 days after the first MDS assessment. Multivariable logistic regression was used to evaluate factors associated with receiving treatment. Most of the sample (n = 72,639) was >80 years (78%), female (82%), and white (88%); 63% had moderate/severe dementia and 60% had an osteoporosis diagnosis. Only 11.6% received fracture prevention medications. In adjusted analyses, treated residents were more likely to be female, Hispanic or other non-black minority, <90 years old, and newly admitted to the NH. Other associated factors included osteoporosis diagnosis, walker or wheelchair use, bone disorders (eg, Paget disease), >5 medications, steroid or proton pump inhibitor use, and regions outside of the Northeast. Resident characteristics suggestive of comorbidity burden and worsening dementia were associated with reduced likelihood of treatment. Low use of fracture prevention medications for NH residents with dementia may reflect an attempt by prescribers reconcile medication use with changing goals of care, or inappropriate underuse in patients who still have high fracture risk. Additional research is needed to help clinicians better evaluate when to use these medications in this heterogeneous and vulnerable population.

Dementia is Associated with an Increased Risk of Hip Fractures: A Nationwide Analysis in Korea

Background and Purpose

Dementia has been reported to be associated with an increased risk of hip fracture, but few case-control studies have been performed to actually confirm this. This study investigated the association between dementia and hip fracture by comparing the risk of hip fracture between subjects with and without dementia.

Methods

We examined a population-based matched cohort from the National Health Insurance Service-Senior Cohort data set that covers approximately half a million recipients of medical insurance in South Korea. Subjects with new clinically verified dementia during 2003–2007 were included, and five subjects without dementia were matched for age, sex, and index year to each subject with dementia as the controls. The risk of hip fracture for dementia was evaluated up to 2015 using Cox regression analysis.

Results

During the 12-year follow-up period, 284 subjects with dementia (10.66%) and 603 subjects without dementia (4.53%) experienced hip fractures. Dementia was independently associated with a higher risk of hip fracture [hazard ratio (HR)=2.840, 95% CI=2.449–3.293] and the adjusted HR for hip fracture in the subjects with dementia was highest within 2 years after the initial diagnosis (HR=2.862, 95% CI=2.053–3.990).

Conclusions

This study found that dementia could be an independent risk factor for hip fracture even at the early stage. This necessitates consideration of the future risk of falls and balance deficits in terms of physical activity after a diagnosis of dementia.

Evaluation of a Multimodal, Direct-to-Patient Educational Intervention Targeting Barriers to Osteoporosis Care: A Randomized Clinical Trial

Osteoporosis treatment rates are declining, even among those with past fractures. Novel, low-cost approaches are needed to improve osteoporosis care. We conducted a parallel group, controlled, randomized clinical trial evaluating a behavioral intervention for improving osteoporosis medication use. A total of 2684 women with self-reported fracture history after age 45 years not using osteoporosis therapy from US Global Longitudinal Study of Osteoporosis in Women (GLOW) sites were randomized 1:1 to receive a multimodal, tailored, direct-to-patient, video intervention versus usual care. The primary study outcome was self-report of osteoporosis medication use at 6 months. Other outcomes included calcium and vitamin D supplementation, bone mineral density (BMD) testing, readiness for behavioral change, and barriers to treatment. In intent-to-treat analyses, there were no significant differences between groups (intervention versus control) in osteoporosis medication use (11.7% versus 11.4%, p = 0.8), calcium supplementation (31.8% versus 32.6%, p = 0.7), vitamin D intake (41.3% versus 41.9%, p = 0.8), or BMD testing (61.8% versus 57.1%, p = 0.2). In the intervention group, fewer women were in the precontemplative stage of behavior change, more women reported seeing their primary care provider, had concerns regarding osteonecrosis of the jaw, and difficulty in taking/remembering to take osteoporosis medications. We found differences in BMD testing among the subgroup of women with no prior osteoporosis treatment, those who provided contact information, and those with no past BMD testing. In per protocol analyses, women with appreciable exposure to the online intervention (n = 257) were more likely to start nonbisphosphonates (odds ratio [OR] = 2.70; 95% confidence interval [CI] 1.26-5.79) compared with the usual care group. Although our intervention did not increase the use of osteoporosis therapy at 6 months, it increased nonbisphosphonate medication use and BMD testing in select subgroups, shifted participants' readiness for behavior change, and altered perceptions of barriers to osteoporosis treatment. Achieving changes in osteoporosis care using patient activation approaches alone is challenging. © 2018 American Society for Bone and Mineral Research.

Dementia and fragility fractures: Issues and solutions

Dementia and fragility fractures are two conditions that pose significant morbidity and mortality to the elderly population. The occurrence of the 'gerontic' boom as a result of improved healthcare meant a continued increase in the prevalence of fragility fractures and dementia. This represents a major public health problem with significant socioeconomic repercussions. It is therefore important for healthcare professionals to gain a better understanding on the relationship between these two commonly co-existing conditions. In this review, we present the available literature surrounding the relationship between fragility fractures and dementia, and the common challenges faced in the management of these two conditions. Combining evidence from the literature along with our current clinical practice, we propose a management pathway aimed at early diagnosis, prevention and management of these two often co-existing conditions. This alongside with a multidisciplinary approach will not only translate to improved patient outcomes and survivorship, but also reduced healthcare cost and socio-economic burden. To date, there is insufficient evidence from the literature to suggest whether dementia is the cause or effect for fragility fractures, or if indeed there is a bidirectional relationship between the two conditions. Further studies are required to shed light onto this important clinical topic.

High rate of non-treatment among osteoporotic women enrolled in a US Medicare plan

OBJECTIVE

To estimate the rate of non-treatment among elderly women with osteoporosis (OP) and to examine the association between patient characteristics and receiving treatment.

RESEARCH DESIGN AND METHODS

This cross-sectional, retrospective, observational study utilized patient information and claims from the Humana database to identify Medicare covered women aged ≥65 years old and continuously enrolled with evidence of either an OP diagnosis or an OP-related fracture during 2007-2011. The main outcome was receipt of pharmacological treatment of OP during 2012 (follow-up). The percentage of non-treatment was calculated and a stepwise selection logistic regression model was employed to estimate the association between baseline demographic and clinical characteristics and receiving treatment.

RESULTS

A total of 109,829 patients were included. Mean age was 75.7 years and 79.4% were identified with OP through OP diagnosis codes and did not have evidence of a prior fracture. Approximately one-third (32%) of patients had used OP medications during the baseline period, and 39% had experienced at least one gastro-intestinal event during baseline. Among all patients, 71.4% did not receive OP therapy during follow-up. The strongest factor associated with receiving treatment was prior use of OP therapy (odds ratio [OR] = 31.3; p < .001). Among the subgroup of patients with baseline fractures, 75.9% did not receive OP therapy during follow-up and the strongest factor associated with receiving treatment remained prior use of OP therapy (OR = 20.4; p < .001). Those with high comorbidity burden were less likely to receive treatment in both the overall cohort and within the subgroup with baseline fractures.

CONCLUSIONS

Among Medicare-eligible women aged ≥65 identified with OP between 2007 and 2011, 71.4% did not receive OP treatment during 2012, including 75.9% of the subgroup of patients with a prior fracture. The use of diagnosis and procedures codes to identify patients with osteoporosis is subject to variation in coding.

Undertreatment of osteoporosis and the role of gastrointestinal events among elderly osteoporotic women with Medicare Part D drug coverage

Objectives

To examine the rate of osteoporosis (OP) undertreatment and the association between gastrointestinal (GI) events and OP treatment initiation among elderly osteoporotic women with Medicare Part D drug coverage.

Methods

This retrospective cohort study utilized a 20% random sample of Medicare beneficiaries. Included were women ≥66 years old with Medicare Part D drug coverage, newly diagnosed with OP in 2007–2008 (first diagnosis date as the index date), and with no prior OP treatment. GI event was defined as a diagnosis or procedure for a GI condition between OP diagnosis and treatment initiation or at the end of a 12-month follow-up, whichever occurred first. OP treatment initiation was defined as the use of any bisphosphonate (BIS) or non-BIS within 1 year postindex. Logistic regression, adjusted for patient characteristics, was used to model the association between 1) GI events and OP treatment initiation (treated versus nontreated); and 2) GI events and type of initial therapy (BIS versus non-BIS) among treated patients only.

Results

A total of 126,188 women met the inclusion criteria: 72.1% did not receive OP medication within 1 year of diagnosis and 27.9% had GI events. Patients with a GI event were 75.7% less likely to start OP treatment (odds ratio [OR]=0.243; P<0.001); among treated patients, patients with a GI event had 11.3% lower odds of starting with BIS versus non-BIS (OR=0.887; P<0.001).

Conclusion

Among elderly women newly diagnosed with OP, only 28% initiated OP treatment. GI events were associated with a higher likelihood of not being treated and, among treated patients, a lower likelihood of being treated with BIS versus non-BIS.

Effective secondary fracture prevention: implementation of a global benchmarking of clinical quality using the IOF Capture the Fracture® Best Practice Framework tool

Fracture Liaison Services are the best model to prevent secondary fractures. The International Osteoporosis Foundation developed a Best Practice Framework to provide a quality benchmark. After a year of implementation, we confirmed that a single framework with set criteria is able to benchmark services across healthcare systems worldwide.

INTRODUCTION

Despite evidence for the clinical effectiveness of secondary fracture prevention, translation in the real-world setting remains disappointing. Where implemented, a wide variety of service models are used to deliver effective secondary fracture prevention. To support use of effective models of care across the globe, the International Osteoporosis Foundation's Capture the Fracture® programme developed a Best Practice Framework (BPF) tool of criteria and standards to provide a quality benchmark. We now report findings after the first 12 months of implementation.

METHODS

A questionnaire for the BPF was created and made available to institutions on the Capture the Fracture website. Responses from institutions were used to assign gold, silver, bronze or black (insufficient) level of achievements mapped across five domains. Through an interactive process with the institution, a final score was determined and published on the Capture the Fracture website Fracture Liaison Service (FLS) map.

RESULTS

Sixty hospitals across six continents submitted their questionnaires. The hospitals served populations from 20,000 to 15 million and were a mix of private and publicly funded. Each FLS managed 146 to 6200 fragility fracture patients per year with a total of 55,160 patients across all sites. Overall, 27 hospitals scored gold, 23 silver and 10 bronze. The pathway for the hip fracture patients had the highest proportion of gold grading while vertebral fracture the lowest.

CONCLUSION

In the first 12 months, we have successfully tested the BPF tool in a range of health settings across the globe. Initial findings confirm a significant heterogeneity in service provision and highlight the importance of a global approach to ensure high quality secondary fracture prevention services.

Association of gastrointestinal events and osteoporosis treatment initiation in newly diagnosed osteoporotic Israeli women

BACKGROUND

The objective was to examine the association of gastrointestinal (GI) events and osteoporosis treatment initiation patterns among postmenopausal women following an osteoporosis diagnosis from an Israeli health plan.

METHODS

This retrospective analysis of claims records included women aged ≥ 55 years with ≥ 1 osteoporosis diagnosis (date of first diagnosis was index date). Osteoporosis treatment initiation was defined as use of osteoporosis therapy (oral bisphosphonates or other) during 12 months postindex. GI events (diagnosis of GI conditions) were reported for 12 months preindex and postindex (from index to treatment initiation or 1 year postindex, whichever occurred first). The association of postindex GI events (yes/no) with the initiation of osteoporosis treatment (yes/no) and with type of therapy initiated (oral bisphosphonate vs. other) were examined with logistic regression and Cox proportional hazard regression (as sensitivity analysis).

RESULTS

Among 30,788 eligible patients, 17.5% had preindex GI events and 13.0% had postindex GI events. About 70.6% of patients received no osteoporosis therapy within 1 year of diagnosis, 24.9% received oral bisphosphonates and 4.5% received other medications. Postindex GI events were associated with lower odds of osteoporosis medication initiation (85-86% reduced likelihood; p < 0.01). Upon treatment initiation, postindex GI was not significantly associated with the type of osteoporosis therapy initiated, controlling for baseline GI events and patient characteristics.

CONCLUSIONS

Among newly diagnosed osteoporotic women from a large Israeli health plan, 70.6% did not receive osteoporosis treatment within 1 year of diagnosis. The presence of GI events was associated with reduced likelihood of osteoporosis treatment initiation.

Bone status of acetylcholinesterase-knockout mice

Acetylcholinesterase (AChE) hydrolyzes acetylcholine (ACh) to acetate and choline and thereby terminates nerve impulse transmission. ACh is also expressed in bone tissue and enhances here proliferation and differentiation of osteoblasts, which makes it interesting to investigate effects of AChE deficiency on bone. To our knowledge, this is the first study that analyzed bone of heterozygous acetylcholinesterase-knockout (AChE-KO) mice. Tibia, femur, thoracic and lumbar vertebrae of 16-week-old female heterozygous AChE-KO mice and their corresponding wildtypes (WT) were analyzed using real-time RT-PCR, dual-energy X-ray absorptiometry, biomechanics, micro-computed tomography, histology and histomorphometry. Our data revealed that heterozygous AChE-KO did not cause negative effects upon bone parameters analyzed. In contrast, the number of osteoclasts per perimeter was significantly reduced in lumbar vertebrae. In addition, we found a significant decrease in trabecular perimeter of lumbar vertebrae and cortical area fraction (Ct.Ar/Tt.Ar) in the mid-diaphysis of femurs of AChE-KO mice compared to their WT. Therefore, presumably a local homozygous knockout of AChE or AChE-inhibitor administration might be beneficial for bone formation due to ACh accumulation. However, many other bone parameters analyzed did not differ statistically significantly between AChE-KO and WT mice. That might be reasoned by the compensating effect of butyrylcholinesterase (BChE).

Fragility fracture programs: are they effective and what is the surgeon's role?

Fragility fractures are occurring at an ever-increasing rate, creating an enormous economic and societal impact. Outpatient-based fragility fracture programs have been developed to identify at-risk patients, initiate effective treatment of metabolic bone disease, and improve coordination between members of the patient's care team with the goal of reducing future fractures. Inpatient programs focus on effective, efficient management of patients presenting with acute fractures. Both have proven successful in reducing the impact of fragility fractures, but many challenges exist. The orthopedic surgeon, as part of an integrated team of providers, is integral in identifying at-risk patients, ensuring appropriate care of acute fractures, and initiating treatment protocols to reduce the risk of further injuries.

Increased risk of hip fractures in patients with dementia: a nationwide population-based study

BACKGROUND

Dementia has been associated with an increased risk of hip fracture. However, little research has been conducted on the impact of dementia on wrist or vertebral fracture development. The aim of this study was to investigate whether dementia is a risk factor for different types of fracture in Taiwan.

METHODS

The study sample was drawn from Taiwan's National Health Insurance Research Database of reimbursement claims, and comprised 1408 patients who visited ambulatory care centers or were hospitalized with a diagnosis of dementia. The comparison group consisted of 7040 randomly selected individuals. Cox proportional hazard regression model was used to examine associations between dementia and the risk of different types of fracture.

RESULTS

During a 3-year follow-up period, 264 patients with dementia (18.75%) and 1098 patients without dementia (15.60%) developed fractures. Dementia was independently associated with increased risk of hip fracture [adjusted hazard ratio (HR) 1.92, 95% CI 1.48-2.49]. Patients with dementia and osteoporosis had the highest risk of developing hip fracture (adjusted HR 2.27, 95% CI 1.28-4.01). Dementia did not increase wrist fracture or vertebral fracture risk when compared to the control group, even in patients with osteoporosis.

CONCLUSIONS

Individuals with dementia are at greater risk of developing hip fracture, particularly if they also have osteoporosis. Early mental screening programs and health education should be initiated to decrease disability and dependence in patients with dementia.

Exercise, nutrition and managing hip fracture in older persons

PURPOSE OF REVIEW

Lifestyle factors play a role in both the genesis and recovery from fragility fracture. The purpose of this review is to summarize recent evidence for exercise and nutrition in the management of hip fracture.

RECENT FINDINGS

Recent randomized controlled trials of exercise have primarily consisted of isolated resistance training or multimodal home-based programs. More robust, long-term, or supervised training is generally associated with greater clinical benefits, including muscle strength, mobility, and function. Recent nutritional interventions have included multinutrient supplements, nutritional counseling and support, and vitamin D/calcium supplementation. Isolated nutritional interventions have not consistently shown significant impact on long-term outcomes after hip fracture, although improvements in body weight, biochemical indices, complication rates, and mobility have been reported. Overall, there is marked heterogeneity in the robustness of responses seen to hip fracture treatment studies. Few large, long-term, multicomponent interventions with clinically relevant outcomes of functional independence, need for residential care, mortality, and quality of life have been reported.

SUMMARY

Evidence-based approaches to hip fracture should include comprehensive risk-factor assessment and treatment for sarcopenia/dynapenia, balance impairment, undernutrition of protein, energy, vitamin D and calcium, depression, cognitive impairment, sensory impairment, social isolation, and comorbid illness with exercise, nutrition and other modalities.

Substantial under-treatment among women diagnosed with osteoporosis in a US managed-care population: a retrospective analysis

BACKGROUND

Multiple therapies are approved for the treatment of osteoporosis (OP), but many patients with osteoporosis may not initiate treatment upon osteoporosis diagnosis.

OBJECTIVE

To characterize initiation of pharmacologic OP treatment among women within 1 year of OP diagnosis in a US managed care population.

RESEARCH DESIGN AND METHODS

The retrospective cohort study included women aged ≥55 years with a claims-documented diagnosis of OP who were naïve to OP medications prior to OP diagnosis (index date) during 2001-2010. Continuous enrollment for 12 months before (baseline) and after (follow-up) the index date was required. Patients who received OP medications but did not have an OP diagnosis were excluded. Differences in baseline characteristics between the treated and untreated cohorts were compared using Wilcoxon rank-sum (continuous variables) and chi-square tests (categorical variables).

MAIN OUTCOMES MEASURES

During the follow-up period, the percentages of patients treated with bisphosphonates (alendronate, ibandronate, risedronate, zoledronic acid) and non-bisphosphonates (calcitonin, raloxifene, teriparatide) were determined.

RESULTS

A total of 65,344 patients, mean age 65.7 years, met study inclusion exclusion criteria. During the follow-up period, 42,033 patients (64.3%) received no OP medication and 23,311 patients (35.7%) received OP treatment. A total of 20,200 patients (30.9% of total study population) received bisphosphonates and 3111 (4.8% of total) patients received non-bisphosphonates as their index medication. At baseline, untreated patients were slightly older and had higher rates of hypertension, chronic inflammatory joint disease, diabetes mellitus, and gastrointestinal events (p ≤ 0.01) compared with treated patients.

CONCLUSIONS

Among women aged ≥55 years in a US managed-care population, 64.3% received no pharmacologic treatment within 1 year after being diagnosed with OP. The authors were not able to determine if untreated patients did not receive or did not fill a prescription. Further research is needed to understand the barriers to OP treatment and reasons for non-treatment.