1. Osteoporosis: Measuring the Problem
Dr. Tuan V. Nguyen Associate Professor Bone and Mineral Research Program Garvan Institute of Medical Research Sydney, Australia

2. Measuring osteoporotic fractures
Magnitude of the problem
Consequences
Undertreated, underdiagnosed and what to do?

3. Increase in life expectancy
WHO. Human Population: Fundamentals of Growth World Health, 2000.

4. The ageing of population
Percent of population aged 65+
ABS and US Bureau of Census, 1996.

5. Osteoporosis – shift in definitions
“Low bone mass, microarchitectural deterioration of bone tissue leading to enhanced bone fragility and a consequent increase in fracture risk” (Consensus Development Conference, 1991)
“[…] compromised bone strength predisposing a person to an increased risk of fracture. Bone strength primarily reflects the integration of bone density and bone quality” (NIH Consensus Development Panel on Osteoporosis JAMA 285:785-95; 2001)

6. Shift in thinking Osteoporosis Fracture Bone Bone Bone Quality Mineral
RISK FACTOR
OUTCOME
Osteoporosis
Fracture
Bone
Quality
Bone
Mineral
Density
Bone
Strength
and
Architecture
Turnover rate
Damage accumulation
Degree of mineralization
Properties of the collagen/mineral matrix

7. BMD and fracture
T < 2.5 osteoporosis

8. 14-year risk of fractures in WOMEN aged 60+
Osteoporosis 345 (27%)
Non-osteoporosis 942 (73%)
Fx = 137 (40%)
No Fx = 208 (60%)
Fx = 191 (20%)
No Fx = 751 (80%)
42%

9. 14-year risk of fractures in MEN aged 60+
Osteoporosis N = 90 (11%)
Non-osteoporosis 731 (89%)
Fx = 27 (30%)
No Fx = 63 (70%)
Fx = 91 (12%)
No Fx = 640 (88%)
23%

10. Magnitude of the Problem

11. Incidence of all-limb fractures

12. Annual fracture incidence in Australia 1996-2051
Projected annual number of all-limb fractures in Australia aged 35+ (Sanders et al, MJA 1999)

13. Hip, vertebrae, and Colles fractures
2006
2051
Hip
20,700
60,000
Vertebrae
14,500
31,700
Colles
11,900
23,000
Humerus
7,500
16,300
Pelvis
4,100
9,800
Projected annual number of all-limb fractures in Australia aged 35+(Sanders et al, MJA 1999)

14. Lifetime risk of some diseases - women
Any osteoporotic fracture
Hip fracture
Clinical vertebral fracture
Cancer (any site)*
Breast cancer*
Lung/bronchus*
Coronary heart diseases
Diabetes Mellitus
*, from birth
(from the age of 50)

15. Lifetime risk of some diseases - men
Any osteoporotic fracture
Hip fracture
Clinical vertebral fracture
Cancer (any site)*
Prostate cancer*
Lung/bronchus*
Coronary heart diseases
Diabetes Mellitus
*, from birth
(from the age of 50)

16. Ten-year and lifetime risk of fractures
10-y risk
Lifetime risk
 with advancing age
 with advancing age

17. Ten-year and lifetime risk of fractures
Normal
T-scores >-1.0
Osteopenia
-2.5 < T-scores < -1.0
Osteoporosis
T-scores < -2.5
Lifetime risk
Age free-of-fracture (y)
10-y risk
Age free-of-fracture (y)

18. Ten-year and lifetime risk of any fracture by BMD and age
FNBMD
10-year risk
Lifetime risk
(T-score)
Age free of fracture (y) 60 70 80
WOMEN
> -1.0
3.6
13.2
13.0
23.4
22.6
-2.4 to -1.1
25.4
25.3
25.7
55.7
44.3
33.0
 -2.5
35.8
40.1
42.3
72.2
64.9
54.8
MEN
9.7
7.6
15.1
25.1
18.4
9.3
10.3
35.3
23.7
30.0
29.8
29.2
56.4
44.8
36.5

19. Consequences of Osteoporotic Fractures

20. Survival probability in those with and without fracture
Nguyen et al, 2005

21. Risk of death from hip fracture
50-year old women: Lifetime risk of mortality from:
Hip Fracture: 2.8%
Breast Cancer: 2.8%
Endometrial Cancer: 0.7%
Cummings et al. Arch Intern Med 1989; 149:

22. Impact of hip fractures
25% die within 6 months (*)
60% have restricted mobility (*)
25% remain functionally more dependent
Cardiac (8%) and pumonary complication (4%)
Transient heart attacks
Non-union and avancular necrosis
(*) Data from the Dubbo Osteoporosis Epidemiology Study

23. Impact of vertebral fractures
Symptomatic fx : Lifetime risk 1/4 women, 1/8 men
Asymptomatic fx prevalence: 20-30%
Back pain, functional limitation
Rib-against-pelvis (RAP) syndrome
Costoiliac impingement syndrome
Decrease vital lung capacity
Pongchaiyakul C et al, J Bone Miner Res 2005

24. Asymptomatic vertebral fracture increases risk of subsequent fractures
300 m+w
66 V #
234 No V #
29 Fx
37 no fx
54 Fx
180 no fx
44%
23%
Pongchaiyakul C et al, J Bone Miner Res 2005

25. Asymptomatic vertebral fracture increases risk of death
300 m+w
66 V #
234 No V #
20 deaths
46 survived
25 deaths
209 survived
30%
11%
Pongchaiyakul C et al, J Bone Miner Res 2005

26. Impact of wrist fracture
More common in women in their 50s
Post-traumatic arthritis
Account for 39% of all physical therapy sessions
Reduced daily living activies
Melton LJ, J Bone Miner Res 2003

27. Utility loss associated with fracture

28. Under-treated & Under-diagnosis

29. What the experts say?
“All women and men with a history of fragility fractures should be considered for treatment of osteoporosis to reduce their risk of future fracture.” (Seeman and Eisman, MJA 2004)
“Initiate therapy to reduce fracture risk in postmenopausal women with BMD T-scores by DXA below -2 in the absence of risk factors and in women with T-scores below -1.5 if one or more risk factors are present.” (NOF 2003)

30. What the experts say?
“Recommend BMD testing to postmenopausal women who have suffered a fragility fracture to confirm the diagnosis and determine disease severity.” (NOF 2003)

31. Levels of treatment in fractured women in primary care settings
Eisman JA, et al, J Bone Miner Res 2004

32. Level of treatment in outpatients
157 low-trauma fx
Prior fx: 76
No prior fx: 81
BMD:
35 (45%)
Any Rx:
14 (18%)
BMD:
18 (22%)
Any Rx:
3 (10%)
Bliuc D, et al, Osteoporosis Int 2004

33. Level of treatment – experience in the US
502 hospitalised hip-fracture patients:
only 14% had BMD scans
13% received calcium and/or vitamin D
18% received HRT, calcitonin, or bisphosphonates.
Harrington JT, et al. Arthritis Rheum 2002; 47:

34. Risk factor modifications for fracture
Intervention
Estimated change in fx risk
Bisphosphonates, HRT, SERMs
~30-50%
Quit smoking
-38%
Treat impaired vision
-50%
Stop sedatives
-40%
Hip protectors
-50%?

35. Summary
In individuals aged 60+: 25% women and 11% men are osteoporosis (eg low BMD)
Lifetime risk of fracture (from the age of 50): 1/3 men and 1/2 women.
With the presence of osteoporosis, lifetime risk increase to 1/2 men and 7/10 women

36. Summary
Fracture, particularly hip fracture, is a serious public health problem in the elderly.
Increase mortality risk, reduced quality of life, incurred health care costs
Osteoporosis is both under-treated and under-diagnosed.