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Recognizing and Treating Patients at High Risk for

Osteoporosis

The First Step: Identifying Those At Risk for Fracture

Kenneth G. Davis, MD, CPE, FAAFP

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This Day in History: May 15, 1876

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Barbaro

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Osteoporosis 2010

Definition:Osteoporosis is defined by the World Health Organization (WHO) in women as a bone mineral density 2.5 standard deviations below peak bone mass (20-year-old healthy female average) as measured by DXA.

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Audience Response Question

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Osteoporosis 2010

The link between age-related reductions in bone density and fracture risk goes back at least to Astley Cooper.

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Osteoporosis 2010

The term "osteoporosis" and recognition of its pathological appearance is generally attributed to the French pathologist Jean Lobstein .

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Osteoporosis 2010

The American endocrinologist Fuller Albright linked osteoporosis with the postmenopausal state.

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Osteoporosis 2010

A major U.S. public health threat for 44 million men and women over age 50.

Osteoporotic fractures responsible for:

• 500,000 Hospitalizations

• 800,000 ER visits

• 2.6 million physician visits

• 180,000 nursing home placements

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Osteoporosis Prevalence in U.S.

Alabama = 2nd

Georgia = 11th

Florida = 22nd

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Osteoporosis 2010

In 2005: > 2 million osteoporotic fractures reported.

Treatment Costs = $17 Billion

90% of all fractures due to underlying bone fragility.

50% of women and 25% of men will have an osteoporosis- related fracture during their lifetime

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Osteoporosis: Complications

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Osteoporosis: Complications

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Osteoporosis: Complications

Functionality Post-Fracture

Hip: 22 hospital days/ 102 days of limited activity.Vertebral: 26 hospital days / 159 days of limited activity.Forearm: 1 hospital day / 56 days of limited activity

Fink, et al: Osteoporosis Intl, 2003

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Morbidity After Vertebral Fractures

Loss of height

Back pain

Deformity

Pulmonary function

Quality of life

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Hip Fracture

1 yr. mortality= 20%

Permanent disability= 30%

Unable to walk independently = 40%

Unable to carry out > 1 ADL = 80%

Cooper, Am J. Med,1997

E

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Quality of Life

Depression.

Sleep Disorder.

Opioid dependence.

Distorted body image.

Loss of independence.

AACE Osteoporosis Guidelines, Endocr Practice, 2003

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Osteoporosis: Case Study

Dan M.

84 y. o.

Fell out of bunk at deer camp

Fx hip

Fatal Pneumonia

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Practice Barriers and Gaps

Physicians do not discuss risk factors with patients

Diagnosis made most often after fracture

Fewer than 2/3 of women over 65 have had bone density test.

Only 20.4% of women over age 67 had BMD or preventive Rx within 6 months of fracture.

Non- adherence

Non-compliance

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Audience Response Question

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Risk Factors : Age

Age trumps BMD

Impact of age is at least 10x the risk of declining BMD.

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Risk Factors: Fracture Hx

Prior forearm fracture = 2x risk

Women over 74 with vertebral fracture = 20% recur within a year.

Risk ratio only lowered slightly by BMD

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Risk Factors: Genetics

The greatest influence on a woman’s peak BMD is heredity

Hip fracture risks 50% higher with first degree relative

127% higher if hip fracture occurred in a parent

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Risk Factors: Weight and BMI

Weight under 127 lbs.

BMI < 21

Increases risk of low BMD and fracture, especially in older women

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Risk Factors: Menopause

Peri-menopausal bone loss = 1-2% per year.

Women with menopause before age 40 (spontaneous or induced) are at greater risk of low BMD than menstruating cohorts (up to age 70).

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Risk Factors: Medications

Glucocorticoids: 2x increase in risk

Depot MDA

Breast Cancer chemo agents

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Risk Factors: Comorbidities

Hyperthyroidism

DM I

Ankylosing Spondylitis

Rheumatoid Arthritis

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Lifestyle Approaches: Nutrition

Women over 60 do not consume the recommended servings of dairy products, fruits, vegetables or grains.

Healthy Eating Index score of these women is 67.4. Out of a possible 100.

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Nutrition: Calcium

WHI: hip fractures significantly reduced in older women adherent to calcium/ vitamin D regimens.

Calcium intake declines with age.

Impaired absorption with age.

Optimal intake: 1200 mg. daily

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Nutrition: Calcium

Dairy products supply 80% of calcium for women over 60.

High elemental calcium content.

High absorption rate

Cost- efficient

Spinach and wheat bran may inhibit absorption.

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Audience Response Question

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Nutrition: Vitamin D

Is actually a steroid pro-hormone rather than a vitamin.

Essential for intestinal absorption of calcium.

1000 IU daily.

Only food sources are fortified dairy products and fatty fish.

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Nutrition: Vitamin D

SPF > 8 blocks 97.5% of Vitamin D production.

Low levels found in older, frail, chronically ill, housebound, or institutionalized women.

Higher risk of Vitamin D deficiency in northern latitudes.

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Nutrition: Vitamin D

60% - 100% of patients will have a low level.

Over age 90: 100% are deficient.

Adequate Vitamin D levels associated with increased bone mass, decreased rates of falls, and significant reductions in fractures.

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Nutrition: Magnesium

Most people over 40 are deficient in magnesium intake.

Intake falls severely after age 70.

Found in green leafy vegetables, grains, and nuts.

Severe deficiency can cause hypocalcemia and Vitamin D resistance.

No evidence to support use in prevention or treatment of osteoporosis.

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Audience Response Question

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Nutrition: Protein

For older women, protein supplement may:• Help minimize bone loss

• Shorten hospital stay for hip fracture and improve clinical outcomes.

• Significantly lower rates of complication and mortality up to 7 months post-fracture.

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Nutrition: Isoflavones

Phytoestrogens found in soybeans, soy products and red clover.

No evidence to support use in prevention or treatment of osteopenia or osteoporosis.

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Exercise

Weight –bearing and strength-training exercises are beneficial to bone development and maintenance.

Mild to moderate exercise confers benefits.

Exercise increased BMD 2% in PMP women.

Exercise and strength training = 75% reduction in falls and injuries for women over 75

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Exercise

BMD in dominant arm of tennis players is greater than non-dominant arm.

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Exercise

Walking

Jogging

Running

Strength-training exercises

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Exercise

Target areas most involved in osteoporotic fractures:

• Large extensor muscles of the back

• Thigh

• Upper arms

• Forearm

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Exercise

Water aerobics for the physically impaired.

Exercises to strengthen back extensor muscles reduce risk of spine fracture in women with and without prior fracture and improve quality of life.

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Osteoporosis: Case Study

Lilly N.

81 y.o.

5ft, 4 in.

122 pounds

Non-smoker

Fell… hit shoulder..

Fx humerus

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Audience Response Question

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Falls

Precipitating factor in 90% of fractures.

One- third of women over age 60 fall at least once a year.

Over age 80, fall rate is 80%

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Falls

Risk Reduction:

Exercises to improve balance and muscle strength

Reducing fall hazards in the home

Adjusting medications (Tapering and discontinuing use of BZD’s, neuroleptics and anti-depressants found to reduce fall risk by 60%)

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Alcohol Consumption

Moderate alcohol intake possibly associated with BMD.

Increased risk of falling and fracture with. 7 drinks a week.

Two or more drinks in 6 hours = 20% of falls in working adults.

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Audience Response Question

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Smoking Cessation

Compared to non-smokers, women smokers:

• Tend to lose bone more rapidly.

• Have lower BMD

• Reach menopause 2 years earlier.

• Have a higher fracture rate.

• Second hand smoke also a risk factor.

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BMD Testing

All post-menopausal women with medical causes of bone loss.All women age 65 and over.Women age 50 and over with one of the following risk factors: 1. Previous fracture after menopause.2. BMI <213. Parental hip fracture4. Current smoker5. Rheumatoid Arthritis6. Excessive ETOH

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Summary

Osteoporosis is everywhere.Most women over 65 have not had screening.Most patients with osteoporosis go untreated.Adherence and compliance are suboptimal and lead top poor outcomes.We need to improve our communications with patients.

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Adherence and Compliance

Compliance: follows instructions about dose and interval.

Persistence: time from initiation to discontinuation.

Adherence: Persistence + compliance. (Refills)

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Audience Response Question

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Health Literacy

Health literacy is believed to be a stronger predictor of health outcomes than social and economic status, education, gender, and age.

American Medical Association, 1999.

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Health Literacy

Red and yellow are highest rates of low level literacy.

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Health Literacy

Strongest predictor of health status.

30 million Americans have literacy skills defined as "below basic.”

• (difficulty comprehending directions for taking medicine or understanding an appointment slip.)

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Health Literacy

“the cognitive and social skills which determine the motivation and ability of individuals to gain access to, understand, and use information in ways that promote and maintain good health.”

WHO, 1998, p. 10

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Health Literacy

“the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions"

Nielsen-Bohlman, Panzer, & Kindig, 2004, p. 32).

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Health Literacy

"a constellation of skills, including the ability to perform basic reading and numerical tasks required to function in the health care environment"

American Medical Association Ad Hoc Committee on Health Literacy for the Council on Scientific Affairs, 1999,

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Health Literacy

25% functionally illiterate30% marginally illiterate

Mean reading level = 8th gradeMedicaid reading level = 5th grade

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Health Literacy

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Health Literacy

Another 63 million are at the "basic" level. These individuals find it difficult to calculate a dose of an over-the-counter medication for a child or comprehend a consent form.

Most of the almost 50% of the US population in the below basic and basic literacy levels are native-born, white adults.

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Health Literacy

44% over age 65 scored at lowest level

Other risk factors for literacy problems:• Poverty• Health problems• Incarceration

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Health Literacy

Readability ScalesSMOG:To calculate SMOG1. Count a number of sentences (at least:10 from the start of a

text, 10 from the middle, and 10 from the end). 2. In those sentences, count the polysyllables (words of 3 or

more syllables). 3. Calculate using

A version is also given which is more easily used for mental

math and is sometimes known as the SMOG Index:1. Count the number of polysyllabic words, excluding proper

nouns, in a sample of thirty sentences. 2. Take the square root of the nearest perfect square 3. Add 3

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Health Literacy

http://wordscount.info/hw/service/smog/analyze.jsp

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Health Literacy

Menopause__sometimes called the change of life__is a natural part of a woman's life. As you get older, your body produces less of the hormone estrogen. As you start making less estrogen, you may notice some physical changes like hot flashes or vaginal dryness. Having les natural estrogen may also be linked to certain serious health problems such as osteoporosis and heart disease. Inside, you will find comprehensive information about osteoporosis. The chart below describes some of the most common changes associated with menopause and ways in which you can manage the effects of these changes.

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SMOG Grade Educational Level

0-6= low literacy

7= junior high school

9= some high school

10= some high school

11= high school junior

12= high school graduate

13-15= some college

16 = college degree

17= post- grad level

19+= post grad degree

Soap Opera Digest

Ladies Home Journal

Reader’s Digest

Newsweek

Sports Illustrated

Time Magazine

New York Times

Atlantic Monthly

Harvard Business Review

IRS Tax Code

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Health Literacy

A majority of available health information is written at a 12th grade reading level. This exceeds the eighth grade reading level of the average American.

Wilson, 2003

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Health Literacy

1. Use short simple sentences2. Summarize key points at end of each

section.3. Write in the active voice.4. Clarify with examples.5. Avoid technical terms and acronyms.6. Use simple relevant graphics.7. Use large font.8. Avoid blue, green, and lavender.

Kenneth G. Davis, M.D.,C.P.E. 21