1. Own the Bone Pilot Project Created February 2007
Fragility Fractures
Kenneth J. Koval, MD
Laura Tosi, MD
AOA Committee for the
Own the Bone Pilot Project Created February 2007

2. Prevalence
More than 34 million Americans suffer from osteoporosis or low bone mass
80% are women
1 in 2 women over 50 years old
1 in 4 men over 50 years old
1 out of 4 osteoporotic hip fractures result in long-term nursing home care.
Half of those who suffer from osteoporotic hip fractures are unable to walk without assistance.
Those who experience the trauma of an osteoporotic hip fracture have a 24% increased risk of dying within one year following their fracture. Study at VA in Wisconsin. Similar study of no-VA patients – similar results.
There are tremendous social and economic costs to society associated with Osteoporosis.
Osteoporosis costs the U.S. healthcare system nearly $14 billion dollars annually.
This translates to approximately $38 million dollars per day.
This is more than the cost of congestive heart failure or asthma (Congestive heart failure costs $8 billion annually, while Asthma costs $9.8 billion annually).
The National Osteoporosis Foundation (NOF) estimates that the overall prevalence of osteoporosis will increase by almost 50% by the year 2020 when 61.4 million adults in the United States are expected to be affected.
This dramatic increase reflects the trend toward an increasing elderly population, for which low bone mass and osteoporosis-related concerns will be a substantial burden.
The greatest increases in prevalence, as expected, will occur in women so that by 2020, 40.9 million women will be affected.
1America’s Bone Health: The State of Osteoporosis and Low Bone Mass In our Nation. NOF 2002
The prevalence of Osteoporosis makes it a tremendous health risk.
Osteoporosis is a major public health threat for more than 28 million Americans.
While 80% of those who will be effected by Osteoporosis are women, men are also at significant risk:
1 out of 2 women and 1 out of 8 men over 50 years old will have a Osteoporosis related fracture in their lifetime.

3. Annual incidence of common diseases
Osteoporosis-fracture
Occurrences vs Other Diseases
2,000,000
1,500,000
1,500,000
250,000
hip
Annual incidence of common diseases
1,000,000
250,000 other sites
513,000
Heart Attack †
500,000
750,000 vertebral
228,000
184,300
Osteoporotic fractures
Stroke
Breast Cancer
Source: National Osteoporosis Foundation

4. 1.5 Million Fractures Annually
Vertebral Fractures:
700,000+
Wrist Fractures:
200,000+
Osteoporosis is a contributing factor in 1.5 million fractures treated each year. The approximate number of types of fractures related to Osteoporosis are:
Approximately 300,000 hip fractures.
Approximately 700,000 vertebral fractures.
Approximately 250,000 wrist fractures.
Approximately 300,000 fractures at other sites.
Hip Fractures:
300,000+
Other Fractures:
300,000+
Source: National Osteoporosis Foundation, 2000

5. Burden of Disease $14 billion annually Approximately $38 million daily
Congestive heart failure costs $8 billion annually
Asthma costs $9.8 billion annually
There are tremendous social and economic costs to society associated with Osteoporosis.
Osteoporosis costs the U.S. healthcare system nearly $14 billion dollars annually.
This translates to approximately $38 million dollars per day.
This is more than the cost of congestive heart failure or asthma (Congestive heart failure costs $8 billion annually, while Asthma costs $9.8 billion annually).

6. Burden of Disease
1 out of 4 osteoporotic hip fractures result in long-term nursing home care
One half of these are unable to walk without assistance
24% greater risk of dying within one year
1 out of 4 osteoporotic hip fractures result in long-term nursing home care.
Half of those who suffer from osteoporotic hip fractures are unable to walk without assistance.
Those who experience the trauma of an osteoporotic hip fracture have a 24% increased risk of dying within one year following their fracture.

7. - Fragility Fractures & Osteoporosis -
What’s the link?
Fragility fractures
Fractures of the distal radius, proximal humerus, vertebrae and proximal
femur that result from minimal trauma, such as a fall from a standing
height.
Up to 95% of hospitalized fracture inpatients over 75 years of age, and 80%-90% of fractures in patients between 60 and 74 years of age can be attributed to osteoporosis.
Sources:
Bisphosphonates and Fracture healing in Orthopaedic Fracture Patients
Only 23% of hip fracture patients received the care recommended on the basis of good practice standards.!
Source: RAND Report

8. Alarming Fracture Statistics
40% of postmenopausal women and ~25-33% of men will eventually experience osteoporotic fractures.
~20 percent of senior citizens who suffer a hip fracture die within a year
Risk of mortality is times greater among hip fracture patients during the first 3 months after the fracture
Nearly 1 in 5 hip fracture patients ends up in a nursing home within a year
Source: Surgeon General’s Report, 2004, Jrnl of Bone and Mineral Research

9. The Costs Continue to Grow
Fractures cost
$18 billion/year
and expected to
increase if action
is not taken.

10. Risk Factors for Osteoporosis
Female
Thin or small frame
Low body weight
Smoker
In addition to warning signs, there are a significant number of risk factors to consider for Osteoporosis. However, it is important to be aware that you can have no risk factors and still have Osteoporosis.
The following risk factors have been identified:
Being female,
Having a thin or small frame and
Having a low body weight of 127 pounds or less.
In addition, being a smoker is a major risk factor as are

11. Risk Factors for Osteoporosis
Advanced age
History of fragility fracture
Family history- primary relative with osteoporosis or fragility fracture
Reaching Advanced age, and
Having a history of fragility fracture or a primary relative with a history of fragility fracture or Osteoporosis.

12. Risk Factors for Osteoporosis
Post Menopausal
Hormonal imbalances can result in rapid bone loss
Women can lose up to 20% of their bone mass in 5-7 years
In addition, post menopausal women are at great risk because the hormonal imbalances of menopause can result in rapid bone loss.
Women can lose up to 20% of their bone mass in the 5-7 years after the onset of menopause.

13. Risk Factors for Osteoporosis
Amenorrhea, Anorexia & Bulimia
Diet low in calcium
Certain medications
Low testosterone in men
Eating disorders such as Anorexia and Bulimia,
A diet low in calcium,
Use of certain medications and
Low testosterone in men are all risk factors as well.

14. Risk Factors for Osteoporosis
Inactive lifestyle
Excessive alcohol consumption
Eating disorders such as Anorexia and Bulimia,
A diet low in calcium,
Use of certain medications and
Low testosterone in men are all risk factors as well.

15. Ethnicity & Osteoporosis
Hispanic women at highest risk
13-16% with
osteoporosis now
While significant risk has been reported in people of all ethnic backgrounds, and in both genders, Hispanic women are thought to be among those at highest risk.
13-16% have Osteoporosis now.
36-49% of Mexican-American women 50 years of age or older have experienced loss of bone density.
Hispanic women tend to consume less calcium than the RDA.
This risk is expected to increase as the estimated number of hip fractures worldwide is expected to rise sharply over the next ½ century.
36-49% of Mexican
American women 50+
have experienced
significant bone loss

16. Ethnicity & Osteoporosis
Caucasian & Asian-American women also high risk
Caucasian and Asian-American women are also at high risk. This is due largely to differences in bone mass and density.
The average calcium intake among Asian-American women is about half that of their Caucasian counterparts.
While Asian-American women generally have lower incidence of hip fractures than Caucasian women, the prevalence of vertebral fractures is about equal between the two populations.

17. Ethnicity & Osteoporosis
Although African-American women generally have higher bone density and are at somewhat lower risk than their Asian-American and Caucasian counterparts, this should not be taken to mean that there is no cause for concern among this population.
10% of African-American women over 50 have Osteoporosis.
30% more have low bone density.
10% of African-American women 50+ have osteoporosis
30% more have low bone density

18. Ethnicity & Osteoporosis
300,000 African-American women have osteoporosis
80-95% of all fractures sustained by African-Americans 64+ are osteoporotic
African-American women more likely to die from hip fractures than White women
300,000 African-American women are experiencing Osteoporosis today.
80-95% of all fractures suffered by African-American women over 64 are related to Osteoporosis.
African-American women are more likely than Caucasian women to die from hip fractures.

19. Inadequately researched
Men & Osteoporosis
Underdiagnosed
Unrecognized
Underreported
While Osteoporosis does strike women at higher rates, men are also at risk. Osteoporosis in men is underdiagnosed, unrecognized, and inadequately reported and researched. As with women, Caucasian men are at greater risk for Osteoporosis. Many of the same risk factors apply to men:
Lifestyle, age, heredity, prolonged exposure to certain medications. chronic disease and undiagnosed levels of testosterone all put men at increased risk for Osteoporosis.
Inadequately researched

20. Men & Osteoporosis 2 million American men have osteoporosis
3 million more are at risk
1/3 of male hip fractures related to osteoporosis
1/3 of these men will not survive 1 year after fracture
2 million American men suffer from Osteoporosis.
Another 3 million are at risk.
1/3 of the hip fractures experienced by men are related to Osteoporosis.
1/3 of these men will not survive 1 year after their fracture.

21. Risk Factors for Fragility Fractures
Impaired vision despite correction
Estrogen deficiency at an early age (<45 yrs)
Dementia
Poor health / frailty
Recent falls
Lifelong low calcium intake
Low physical activity
Not everyone with osteoporosis has a fragility fracture. However, if you do have osteoporosis, risk factors for osteoporotic fractures include those things that make you more likely to fall, such as inadequate vision, dementia, and fragility which can contribute to falls. Early estrogen deficiency due to either early menopause or surgically induced menopause prior to age 45 can lead to earlier bone loss in women, and these patients may require bone density monitoring earlier than usual.
Lifelong low calcium intake, a sedentary lifestyle, and increased alcohol consumption have also been associated with increased osteoporotic fracture risk in some studies.

22. Fractures beget Fractures
Risk of future fractures increases fold following initial fracture
History of fragility fracture is more predictive of future fracture than bone density

23. Diagnosis: Bone Densitometry
Recommendations for bone density
Anyone with a fragility fracture
All women age 65 and older
Postmenopausal younger than 65 with risk factors
Men over 50 with risk factors
Who should have bone densitometry testing?
Anyone with a fragility fracture.
All women age 65 and older.
Post-menopausal women younger than 65 who have other risk factors, and
Men over the age of 50 with risk factors.

24. Treatment Goals Prevent future fractures Treat osteoporosis
Decrease the risk of mortality after fractures

25. + = Treatment Calcium and Vitamin D
All patients with bone loss or the potential for bone loss should be educated on the appropriate intake of calcium and vitamin D
Stronger Bones!
Stronger
Bones! + =

26. Treatment There is a high prevalence of vitamin D insufficiency in:
Nursing home residents
Hospitalized patients
Adults with hip fractures

27. Treatment
2. Exercise
Physical activity makes bones and muscles stronger and helps prevent bone loss.
All types of physical activity can contribute to bone health

28. Treatment 3. Fall Prevention
Each year, more than 1.6 million older U.S. adults go to emergency departments for fall-related injuries. Among older adults, falls are the number one cause of:
Fractures
Hospital admissions for trauma
Loss of independence
Injury deaths
Fall 3
factors
that contribute
to fractures
Force
Fragility
Source: National Institute of Health/National Institute on Aging

29. Treatment 4. BMD/DXA Testing
Single most important diagnostic test to predict whether a person will have a fracture in the future. It helps diagnose osteoporosis and predict the risk for having a fracture by comparing bone density to the bones of an average healthy young adult

30. Treatment 5. Cessation of smoking
Smoking can reduce bone mass, increase fracture risk and should be avoided for a variety of health reasons

31. Treatment 6. Pharmacotherapy – Treatment & prevention
Bisphosphonates are approved by the FDA and can help stop or slow bone loss, or help form new bone, and reduce the risk of fractures
Type
Brand Name
Alendronate
Fosamax
Ibandronate
Boniva
Risedronate
Actonel
Raloxifene
Evista

32. Bisphosphonates
Bisphosphonates are bone-building drugs that prevent bone resorption and remain important treatment options for patients at risk of debilitating fractures.
But, where does the impact on dental health figure into the equation? What is the true incidence of osteonecrosis of the jaw (ONJ)?

33. The Facts
Approximately 125 cases of osteonecrosis have been linked to bisphosphonate usage. The majority of these cases have been administered through an IV to cancer patients
Source: Bamias A. Osteonecrosis of the jaw in cancer after treatment with bisphosphonates: incidence and risk factors. J Clin Oncol 2005;23(34):

34. Bisphosphonates
A man with a hip fracture has a 1:3 chance of dying within a year
A woman with a hip fracture has a 1:4 chance of dying within a year
The risk for ONJ among patients taking oral bisphosphonates is likely to be 1:100,000

35. Treatment 7. Patient Note
Provide the patient with written information regarding fragility fractures and preventive measures that can be taken. Encourage them to speak with their primary care physicians for additional follow-up after the fracture has healed

36. Treatment 8. Physician Referral
A letter sent to the primary care physician can provide information regarding the patient’s fracture and recommend appropriate measures be taken

37. Fall Prevention in the Home
Use handrails on stairs, bathroom
Keep rooms free of clutter
Keep floors clean but not slippery
Wear supportive, low-heeled shoes. Don’t walk in socks; floppy slippers
Use 100 watt bulbs in all rooms
Install ceiling lighting in bedrooms
Use rubber matt in shower/tub
Keep a flashlight at bedside
Check posture in mirror often
Maintaining a home environment that reduces the risk of falling is important. The next two slides list helpful considerations that patients should be made aware of.
Use handrails on stairs, in bathroom
Keep rooms free of clutter
Keep floor surfaces clean but not slippery
Wear supportive, low-heeled shoes. Do not walk in socks or floppy slippers
Use 100 watt bulbs in all rooms
Install ceiling lighting in bedrooms
Use rubber matt in shower/tub
Keep a flashlight at bedside
Check posture in mirror often

38. More … Home Fall Prevention
Keep floors free from clutter
Use portable phone; keep phone and electrical wires out of walkways
Skid-proof backing on carpets / scatter rugs
Keep week’s supply of prescription medications on hand
Daily contact with family member / neighbor
Contract with monitoring company for 24 hour response time in emergency
Keep floors free from clutter
Use a portable phone and keep phone and electrical wires out of walkways
Place skid-proof backing on carpets and scatter rugs
Keep a week’s supply of prescription medications on hand
Arrange for daily contact with a family member or neighbor
Contract with a monitoring company for 24 hour response time in an emergency
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