1 Epidemiology Mortality and Morbidity in Osteoporosis

7/23/2019 1 Epidemiology Mortality and Morbidity in Osteoporosis

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R.S.LORENC

EPIDEMIOLOGY, MORTALITY and

MORBIDITY IN OSTEOPOROSIS

The Children Memorial Health Institute , Warsaw, Poland

Prague, March, 27 ,2009


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NIH Consensus Development Panel.JAMA. 2001;285:785.

Newest Definition of Osteoporosis:

NIH Consensus Conference

Osteoporosis is a skeletal disordercharacterizedby compromised bone strength predisposing to

an increased risk of fracture

Bone strength reflects the integration of two mainfeatures:

bone density bone quality


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WHO Classification for

Postmenopausal Osteoporosis

World Health Organization. Technical Report Series 843; WHO, Geneva.1994.Kanis JA et al.J Bone Miner Res. 1994;9:1137.

The T-score compares an individuals BMD with the

mean value for young normals and expresses the

difference as a standard deviation score

T-score

Normal 1.0 and higher

Low bone mass (osteopenia) Between1.0 and2.5

Osteoporosis 2.5 and lower


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Epidemiological Studies of

Osteoporosis and Low Bone Mass relates to:

Prevalence that depends on:

Definition of low bone mass (WHO)

Densitometric technique (DXA)

Location and number of skeletal sites measured

Study population (age, race)

United States estimates based on

Rochester Osteoporosis Project1

National Health and Nutrition Examination Survey

(NHANES III)2

1. Melton LJ III et al.J Bone Miner Res. 1995;10:175.2. Looker A et al.J Bone Miner Res. 1997;12:1761.


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DXA Terminology:

The Skeleton Has Different Regions

Central skeleton (axial skeleton pluships and shoulders):

Spine, ribs, pelvis, hips, shoulders

Peripheral skeleton (appendicularskeleton minus hips and shoulders):

Extremities (arms and legs)


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Different Skeletal Regions Have

Different Type of Bone

Cortical or compact bone makes up the outerenvelope of all bones and the shafts of the

long bones (appendicular skeleton)

Cancellous or trabecularbone makes up theinner parts of the bones, particularly bones of

the axial skeleton


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Cancellous and Cortical Bone Differences

in Mass, Surface Area and Turnover

*Up to 10% of the skeleton is being remodeled

at any one time

MassSurface

areaTurnovereach year*

Cancellous 20% 80% 25%Cortical 80% 20% 3%

Tr


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Osteoporotic Fractures in Women and Men

0

1,000

2,000

3,000

4,000

40 60 8040 60 8040 60 80

Distal Forearm Fractures Clinical Vertebral Fractures Hip Fractures

Inciden

ce/1,0

00,0

00pers

on-years

Women

Men

Adapted from Cooper C et al. Trends Endocrinol Metab. 1992;3:224.

Women

Men

Women

Men


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Every 30 seconds someone in the

European Union suffers a hip fracture as

a result of osteoporosis

A call to action !


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Hip Fractures(cont inued)

Diagnosis

Most are diagnosed clinically

Often confirmed with radiography

Most are hospitalized and require surgery


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Hip Fractures

0

1,000

2,000

3,000

4,000

40 60 80

Incidence/1,0

00,0

00

person-years

Women

Men

Graph modified from Cooper C et al.Trends Endocrinol Metab. 1992;3:224.

Femoral Neck ~40%

Intertrochanteric

Region ~40%


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Complications of Hip Fracture

Up to 24-30% excess mortality within 1 year1,2

Nearly 65,000 American women die fromcomplications of hip fracture each year3

50% of hip fracture survivors are permanentlyincapacitated4

20% of hip fracture survivors require long-termnursing home care5

1. Ray NF et al.J Bone Miner Res. 1997;12:24.

2. Kiebzak GM et alArch Intern Med. 2002; 162:2217

3. Col NF et al.JAMA. 1997; 227:1140.

4. Consensus Development Conference.Am J Med. 1993;94:646.

5. Chrischilles EA et al.Arch Intern Med. 1991;151:2026.


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Vertebral Fractures

Most common osteoporotic fracture (~700,000 peryear)

Vertebral fracture as marker for future fracture risk*

Forearm fracture: RR = 1.4

Vertebral fracture: RR = 4.4

Hip fracture: RR = 2.3

Risk rises in women at age 50-55, in men at age60-65, and increases linearly with age

*Klotzbuecher CM, et al.J Bone Miner Res. 2000;15:721.


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Vertebral Fractures

Images adapted from Watts NB.Am Fam Phys. 1988;38:193.

American Family Physician, used with permissionGraph modified from Cooper C et al. Trends Endocrinol Metab. 1992;3:224.

0

1,000

2,000

3,000

4,000

40 60 80

Incidence/1,0

00,0

00

person-years

Women

Men

Normal

Wedge

Endplate

Crush

Clinical Vertebral Fractures


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Consequences of Vertebral Fractures

Back pain

Loss of height

Deformity (kyphosis, protuberant abdomen)

Reduced pulmonary function

Diminished quality of life (loss of self-esteem,distorted body image, dependence on narcotic

analgesics, sleep disorder, depression, loss ofindependence)

Increased mortality


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Distal Forearm Fractures

0

1,000

2,000

3,000

4,000

40 60 80

Incide

nce/1,0

00,0

00pe

rson-years

Women

Men

Graph adapted from Cooper C, et al.Trends Endocrinol Metab. 1992;3:224.


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Complications of Distal

Forearm Fractures

Pain

Temporary disability; difficulty dressing, toileting,meal preparation

Degenerative arthritis

Reflex sympathetic dystrophy

Six months after fracture, 23% report fair to poorrecovery in functional outcome*

*Kaukonen JP et al,Ann Chir Gynaecol. 1988;77:27.


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QUALITY OF LIFE

Morbidity and Mortality associated

with Osteoporotic Fractures


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Fracture and quality of life over the life span

Morbidity

50 60 70 80 90

Colles' fractur e

Vertebral fractu re

Hip fracture

Age


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Survival Rates After Fractures

Adapted from Cooper C, et al.Am J Epidemiol. 1993;137:1001. Johns Hopkins

University School of Hygiene and Public Health, used with permission

%Survival

Time after fracture (years)

Expected

Observed100

80

60

40

20

0

1 2 3 4 5

Vertebral Fracture

(relative survival = 0.81)

100

80

60

40

20

01 2 3 4 5

Hip Fracture

(relative survival = 0.82)


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Consequences of hip fracture

Cooper. Am J Med 1997; 103(2A):12s-19s.

40%

Unable towalk

independently

30%

Permanentdisability

20%

Death withinone year

80%

Unable to carry out atleast one independentactivity of daily living

One year after hip fracture


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Patients With Prior Fracture Are at High

Risk for Future Fragility Fractures

Klotzbuecher CM et al.J Bone Miner Res. 2000;15:721.

Relative Risk of Future

Fractures

PriorFracture Wrist Vertebra Hip

Wrist 3.3 1.7 1.9

Vertebra 1.4 4.4 2.5

Hip NA 2.5 2.3


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Bone massBone

structure

Bone quality

Fall RiskImpact of

fallSkeletal

strength

Fracture risk

Type of fallEnergy reduction

External

protection

Neuromuscularfunction

Environmental risks

Age

Pathogenesis of fragility fractures


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FRAXTM: The WHO Fracture Risk Assessment Toolwww.shef.ac.uk/FRAX/


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7,98

,3

8,4 9

,29,610

10,111

,4

11,7

1

2,4

1

2,6

12,6

12,9

12,9

13,214,415,2

15,315,6

18,2

18,619,7

19,820,2

0

5

10

15

20

25

Numberof

fractures

France

Spain

Portugal

Ireland

Poland

Estonia

Latvia

Luxembourg

T

heNetherlands

Greece

Belgium

Slovenia

Hungary

Italy

Finland

UK

Cyprus

Malta

CzechRepublic

Germany

Denmark

Austria

Slovakia

Sweden

Ilo zama szyjki koci udowej na rok/ 10 000

populacjiNumber of fractures per year/10 000 population


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C

29

Number of Fractures in Percent

(I CD-10)

S72 Fracture of femur

S72.0 Fracture of neck of femur

S72.1 Pertrochanteric fracture

S72.2 Subtrochanteric fracture

S72.3 Fracture of shaft of femur

S72.4 Fracture of lower end of femur

S72.7 Multiple fractures of femur

S72.8 Fractures of other parts of femur

S72.9 Fracture of femur, part unspecified

61,7%

18,6%

16,7%

2,4%

0,3%

0,3%

2005, Mazovia province
http://stary1.portalmed.pl/finn2/klasyfikacje/icd10/info.stm?active_id=S72http://stary1.portalmed.pl/finn2/klasyfikacje/icd10/info.stm?active_id=S72.0http://stary1.portalmed.pl/finn2/klasyfikacje/icd10/info.stm?active_id=S72.1http://stary1.portalmed.pl/finn2/klasyfikacje/icd10/info.stm?active_id=S72.2http://stary1.portalmed.pl/finn2/klasyfikacje/icd10/info.stm?active_id=S72.3http://stary1.portalmed.pl/finn2/klasyfikacje/icd10/info.stm?active_id=S72.4http://stary1.portalmed.pl/finn2/klasyfikacje/icd10/info.stm?active_id=S72.7http://stary1.portalmed.pl/finn2/klasyfikacje/icd10/info.stm?active_id=S72.8http://stary1.portalmed.pl/finn2/klasyfikacje/icd10/info.stm?active_id=S72.9http://stary1.portalmed.pl/finn2/klasyfikacje/icd10/info.stm?active_id=S72.9http://stary1.portalmed.pl/finn2/klasyfikacje/icd10/info.stm?active_id=S72.8http://stary1.portalmed.pl/finn2/klasyfikacje/icd10/info.stm?active_id=S72.7http://stary1.portalmed.pl/finn2/klasyfikacje/icd10/info.stm?active_id=S72.4http://stary1.portalmed.pl/finn2/klasyfikacje/icd10/info.stm?active_id=S72.3http://stary1.portalmed.pl/finn2/klasyfikacje/icd10/info.stm?active_id=S72.2http://stary1.portalmed.pl/finn2/klasyfikacje/icd10/info.stm?active_id=S72.1http://stary1.portalmed.pl/finn2/klasyfikacje/icd10/info.stm?active_id=S72.0http://stary1.portalmed.pl/finn2/klasyfikacje/icd10/info.stm?active_id=S72


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NO

LOW RISK

FR = O 10%/10 lat

HIGH RISK

FR > 20%/10 lat

PROPHYLAXIS

RISK FACTORS

ELIMINATION,VIT.D

SUPPLEMENTATION

EVALUATION of BMD (2 years)BTM after 3 months

Differential diagnosis

Hyperparathyroidism

osteomalacia, hyperthyroidism, neoplasma

TREATMENT OF

SECONDARY

OSTEOPOROSIS

AVERAGE RISK

FR = 10 20%/10 lat

Presence of vertebral fractures (VFA)

High BTM

Corticosteroid Theraphy

TREATMENT

PHARMACOTHERAPHY,

REHABILITATION ,

FALL PREVENTION

YES

Patient selection procedure (M80/M81)


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Assessment without BMD Assessment with BMD

10yearfractureprobability(%

)

Age (years) Age (years)

Consider BMD measurement

Reassure of patient

Consider treatment

No treatment


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C

33


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RECOGNITION OF

OSTEOPOROSIS IN CLINICAL

SETTING


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Failure to Diagnose or Treat

Osteoporosis After Hip Fracture

0

20

40

60

80

100

Diagnosed DXA Calcium Vit D OP Rx

Record review: 170 hip fracture patients in majorteaching hospital over 3 years

Data from Kamel HK et al ,Am J Med. 2000;109:326.

Percent

of

subjects

1


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Unrecognized Vertebral Fractures on X-ray

Data from Gehlbach SH et al, Osteoporos Int. 2000;11:577.

934 women age 60 and older, hospitalized forvarious reasons (chest x-rays reviewed for fracture)

0

20

40

60

80

100

120

140

Fracture

present

Mentioned in

X-ray report

50%

Mentioned in

X-ray summary

23%

Osteoporosis Rx

in medical record

18%

Discharge diagnosis

of osteoporosis

13%

Number

of

subjects


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Common Chronic Diseases:

Prevalence (USA)

Data from Melton LJ III. J Bone Miner Res. 1995;10:175.

0

20

40

60

Million

Osteoporosis &

Low bone massHypertension Dyslipidemia Diabetes


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1. Riggs BL and Melton LJ III, Bone. 1995;17(suppl.):505S-511S.

2. Heart and Stroke Facts: 1996 Statistical Supplement, American Heart Assoc.

3. Cancer Facts & Figures-1996, American Cancer Society.

Consequences of Chronic

Diseases: Incidence

1,500,000

0

500,000

1,000,000

1,500,000

2,000,000

Osteoporotic

fractures (1)

* annual incidence all ages** annual estimate women 29+ annual estimate women 30+ 1996 new cases, women all ages

*

513,000

Heart attack (2)

**

228,000

Stroke (2)

184,300

Breast cancer (3)

750,000vertebral

250,000other sites

250,000

forearm

250,000hip

A

nnualincidenceof

commondiseases


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1. Exist the great need for uniform recommendations for

osteoporotic fracture prevention and treatment.

2. General treatment threshold is influenced by the level of

governmental and personal resources

3. Threshold of every country is influenced by nation related

fracture risk gradient

4. With limited resources important issue is rational utilization of

diagnostic potential together with high accepted standards of

general education program and prophylactics focused on

nutrition, physical exercises and fall prevention.

Summary and conclusions:

Documents

1 Epidemiology Mortality and Morbidity in Osteoporosis