According to the U.S. Preventive Services Task Force (USPSTF) (2), the National Osteoporosis Foundation (3) and the International Society for Clinical Densitometry (4), all women aged 65 years and above should be screened for osteoporosis by BMD measurement at the hip and lumbar spine by means of DXA. Although as high as 25% of this patient population are known to suffer from osteoporosis (5), 1 in 4 women aged 65–85 years have never been tested for BMD (6).
Bone loss at the lumbar spine is known to occur at a more rapid rate during the menopausal transition. However, younger postmenopausal women have a much lower absolute fracture risk for any given BMD than older women. According to Doherty et al. (7), the absolute 5-year probability of hip fracture is less than 1% until age 70–79 years, when the risk starts to increase exponentially. The risk assessment strategy to recommend screening for osteoporosis in younger postmenopausal women remains unclear. This is further confounded by the fact that data on the benefits and harms of drug therapy beginning at age 50–64 years and continuing over the next three decades of life are not available. Thus, currently there is no consensus regarding all the specific risk factors that should be considered in younger women.
The Osteoporosis Self-Assessment Tool (OST) is a simple formula based on age and weight, which can identify individuals who are at risk of low BMD, and can be evaluated as follows:
Osteoporosis Self-assessment Tool Score = [weight (kg) - age (years)] × 0.2
There is evidence (9, 10) suggesting that an OST score of less than 2 can serve as a reliable indicator to select younger postmenopausal women for BMD testing. In keeping with being an accepted strategy for older women, osteoporosis screening in older men has also been proposed. However, available data indicate that it is less common in men, with the prevalence of BMD-defined osteoporosis among men aged 65 years or older being 5.6% (5). Likewise, the efficacy of pharmacotherapy in preventing fractures in men is not well-established. Data from randomized trials in osteoporotic men have only evaluated radiographic vertebral fracture as an end point. There are guidelines (3, 13) recommending BMD testing in all men aged 70 years or above and in those aged 50 – 69 years with risk factors. Additional studies suggest using the OST to identify men for screening (14). To date, there is one study (15) which has compared proposed strategies for selecting men aged 70 years or older for osteoporosis screening, and which reports that the OST (cutoff <2) performed slightly better than the more complex FRAX strategy.
More research on osteoporosis risk assessment tools and randomized trials with clinical fracture end points are warranted to elucidate clinical requirement for targeted screening strategies or universal screening in this patient population.
Screening frequency in older adults
It is well documented that the baseline BMD T-score serves as an important factor in determining how often older adults without osteoporosis at the initial assessment should be tested. Those with lower BMD at baseline should have a shorter rescreening interval.
Findings from one study (16) that estimated the cumulative incidence of osteoporosis in older women without osteoporosis at initial assessment have shown that less than 10% became osteoporotic during follow-up if rescreening intervals were 15 years for those with normal BMD (T-score ≥1.0) or mild osteopenia (T-score <1.0 and >1.5), 5 years for those with moderate osteopenia (T-score <1.5 and >2.0), and 1 year for those with advanced osteopenia (T-score <2.0 and >2.5).
A similar study conducted in older men without osteoporosis at initial assessment has reported that only 0.2% of those with normal BMD or mild osteopenia progressed to osteoporosis during follow-up; the time for 10% of men to progress to osteoporosis was 8.5 years in the presence of moderate osteopenia and 2.7 years for advanced osteopenia (17).
To date, there is no documented evidence on either when to cease or decrease BMD testing to screen for osteoporosis. It is known that older women with higher BMD T-scores (>1.5) have a very low risk for disabling fracture before their estimated time to death, and so there is no clinical benefit of rescreening. In contrast, older women with lower BMD T-scores (<2.0 and >2.5) have a high risk for disabling fracture before their estimated time to death, so they may benefit more from rescreening. The age to stop screening may be lower in men than in women because of the higher competing risk for death.
How to assess absolute risk
Fracture risk assessment tools have been developed to estimate a patient's absolute long-term risk for fracture (11, 18, 19). It is worth mentioning that the WHO does not recommend the use of any specific instrument. FRAX is a tool that is endorsed in the United States for use in clinical decision making. It is a computer-based algorithm that uses selected clinical risk factors (see the Box) with or without femoral neck BMD to estimate 10-year probability of hip and major osteoporotic fracture (11).
There are several attributes of FRAX (20). First, it incorporates country-specific models that take into account countrywide fracture and mortality rates. Second, its performance has been tested and the algorithm is revised and updated dynamically. However, the FRAX also has some limitations (21, 22). The most pertinent one is that there is no data from randomized trials demonstrating the benefit of pharmacotherapy for clinical fracture prevention in patients enrolled according to FRAX intervention thresholds as recommended by the National Osteoporosis Foundation (NOF) (3). FRAX has also been highlighted as not transparent since information used to derive the equations is not publicly available. Other limiting factors are that it includes only femoral neck BMD and so, it may underestimate fracture probability among patients whose spine BMD is markedly lower than femoral neck measurements. Additionally, it does not account for the dose–response relationship that exists for some clinical risk factors. For example, prior fracture is a FRAX clinical risk factor, but the algorithm does not consider how recent the incident was, the number, severity, or site of prior fractures, all of which affect subsequent risk. The history or likelihood of a fall was not included as a clinical risk factor because the developers noted that markers of fall propensity identify a fracture risk that probably is not amenable to treatment with medications affecting bone metabolism. Hence, the tool may underestimate fracture risk in a patient with a higher fall propensity. Finally, it should only be used to estimate fracture probability in treatment-naive patients.
A systematic review (23) of data in postmenopausal women has demonstrated that no single fracture risk assessment tool is optimal. The findings (23, 24) indicate that even simple tools can perform as well as more complex ones. Performance analysis of existing tools has shown to be inadequate in specific patient populations, including younger postmenopausal women (25) and older men (26, 27). The results imply that predicting fracture risk in these patient groups requires assessment of factors not incorporated into available strategies. The benefit of including fracture risk assessment tools into joint decision making is also unclear. Current evidence (28) suggests that a decision aid incorporating FRAX probability may improve patient knowledge, but no effect on rates of treatment initiation or adherence was demonstrated. Further research to improve identification of patients at higher absolute risk for fracture is needed, with special attention to simple models that fit into the time constraints and competing demands of primary care practice.
Recommended lifestyle measures for prevention
Fractures can be prevented by lifestyle measures such as maintaining a healthy body weight (body mass index >20 kg/m2) and adequate dietary protein intake (0.8 g/kg of body weight per day). Advice also includes abstinence from cigarette smoking and excessive alcohol intake. Whilst physical activity is recommended to improve skeletal health, there is no evidence from randomized trials to identify the type, frequency, or duration necessary to prevent fractures. Current guidelines (3, 8) advise lifelong physical activity (both weight-bearing exercise and muscle-strengthening exercise) for osteoporosis prevention. However, the frequency and intensity of activity are not specified in guidelines. Nonetheless, 30 minutes of daily walking and gentle resistance exercises are recommended.
It is known that falls account for the majority of fractures, but only 10–15% of falls in older adults result in fractures. The pathogenesis of falls in older adults is complex and multi-factorial. Several factors are associated with increased risk, including age-related deficits in visual, proprioceptive, and vestibular systems; decreased lower extremity performance; medical conditions and comorbidity burden; use of selected medications and polypharmacy; and environmental factors (29-30).
It is recommended that risk factors for falls in all osteoporotic patients are evaluated (3, 8). The USPSTF (31-32) recommends individualized decision making and advocates exercise or physical therapy and vitamin D supplementation (800 IU/d) to prevent falls in community-dwelling older adults at increased risk. A reasonable strategy is to request physical therapy evaluation and intervention (namely gait assessment, balance training, and lower extremity strengthening programs) in older patients with deconditioning, reduced mobility, or balance or gait abnormalities.
Recommending calcium and vitamin D
The recommended dietary allowance (RDA) of calcium for women is 1000 mg/d for ages 19 –50 years and 1200 mg/d for those above age 50 years; for men, the RDA is 1000 mg/d for ages 19 –70 years and 1200 mg/d for those above the age of 70 years (33). It is advisable to avoid an intake of above 2500 mg/d. The preferred sources of calcium should be calcium-rich foods and beverages (34). The RDA for vitamin D is 600 IU/d for men and women aged 19 –70 years and increases to 800 IU/d for those older than 70 years (33). These values are based on minimal or no sun exposure. The RDA for vitamin D corresponds to a serum 25-hydroxyvitamin D (25-[OH]D) level of 20 ng/mL.
This article is intended for medical professionals.
Dr Reshma Ramracheya
Diabetes UK RD Lawrence Research Fellow
Senior Research Fellow at Wolfson College
Investigator at Oxford Centre for Diabetes, Endocrinology & Metabolism
University of Oxford, UK
Reshma.ramracheya@ocdem.ox.ac.uk
Tel: 59111128
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