An outline of the epidemiology, risk factors, risk assessment and treatment for this common but often neglected condition, which is set to increase in prevalence
Nuttan Tanna, PhD, DComP, MRPharmS, is pharmacist consultant, women’s health and older people, The North West London Hospitals Trust.
Tanna, N. (2009) Osteoporosis and fragility fractures: identifying those at risk and raising public awareness. Nursing Times; 105: 38, early online publication.
This article outlines key points for nurses in delivering optimal osteoporosis care. It describes the epidemiology of the condition, risk factors, risk assessment, screening and treatment. It also discusses the importance of raising awareness and future developments in treating this increasingly common condition.
Keywords: Osteoporosis, Screening, Assessment, Risk factors
- This article has been double-blind peer reviewed
- Osteoporosis results in substantial morbidity and mortality and raising awareness of risk factors is vital.
- Nurses have a key role in supporting or leading the development of services to improve screening and risk assessment.
- The UK’s ageing population means there is an urgent need to commission services to meet patients’ needs.
Osteoporosis is a progressive systemic skeletal disease characterised by low bone mass and micro architectural deterioration of bone tissue. There is a consequent increase in bone fragility and susceptibility to fracture (National Institute of Health Consensus Development Panel, 2001).
The most significant clinical outcome is the increased likelihood of fracture. Although the spine, hip and wrist are most typical sites, fractures of other bones such as the ribs, humerus and pelvis are not uncommon.
Osteoporosis is a silent condition. In most patients the condition is diagnosed on presentation of a low trauma fracture. Wrist or spinal fractures are presenting signs in younger postmenopausal women, while hip fractures are more common in older people. Generally the lower the bone mass, the lower the trauma necessary to incur a fracture.
Current medical consensus is that the bone mineral density (BMD) measurement of the hip is the gold standard for diagnosing osteoporosis. This is undertaken using a dual energy X ray absorptiometry (DEXA) scanner (NICE, 2008a; 2008b).
To monitor changes in BMD over time and with treatment, the value for the spine is more useful. A DEXA report provides BMD values calculated as T scores and Z scores for the spine, femoral neck and total hip. Box1outlines the World Health Organization’s (1994) criteria for diagnosing osteoporosis.
In general the fracture risk doubles for each standard deviation fall in BMD, and a fracture is associated with an increased risk of a subsequent one (NICE, 2008b).
Currently, a high-risk case screening approach is used in some organisations; for other areas, patients are identified opportunistically. Many organisations do not have guidelines in place and there is wide variation in services available across the UK.
Box 1. Osteoporosis defined using WHO criteria
A T score is the number of standard deviations which separate the patient from the mean value of a healthy young population. A Z score is the number of standard deviations which separate the patient from an age-matched healthy population.
The WHO (1994) definition characterises:
- Osteopenia as a T score between -1 and -2.5 SD;
- Osteoporosis as a T score of -2.5 SD or below;
- Established (severe) osteoporosis as a T score of –2.5 SD or below with one or more associated fractures.
Prevalence of osteoporosis increases markedly with age after menopause. By the age of 60, approximately 15% of all women have osteoporosis, and this figure increases to over 25% by the age of 80 (NICE, 2008a) (see Fig 1).
The annual incidence of osteoporotic fractures (including recurrent ones) is 180,000 in England and Wales. This does not include the majority of vertebral fractures, which are difficult to diagnose (Ralston and Kleerekoper, 2003).
Osteoporosis therefore represents a major health problem. The combined lifetime risk for hip, forearm and vertebral fractures coming to clinical attention is around 40%, equivalent to the risk for cardiovascular disease (Kanis, 2002).
The condition has a huge personal and economic toll. In Europe, the disability due to osteoporosis is greater than that caused by cancers (with the exception of lung cancer) and is comparable with or greater than that resulting from a variety of chronic non-communicable diseases, such as rheumatoid arthritis (Johnell and Kanis, 2006).
Fractures result in severe pain and disability. The cost of osteoporotic fractures to the NHS per year is over £1.8bn (Burge et al, 2001). With an ageing population, it is estimated that the number of osteoporotic fractures over the next 50 years will double in Europe (Elffors, 1998).
There is considerable morbidity after hip fracture, with 25-50% of patients becoming more dependent, and many needing residential or nursing care (Cryer and Patel, 2001). With mortality of around 10-20% after hip fracture, an estimated 14,000 people die each year in the UK after an osteoporotic hip fracture (Bandolier, 1998).
Since the clinical outcome of osteoporosis is bone fracture, attention now increasingly focuses on identifying patients at high risk of fracture rather than those with osteoporosis as defined by BMD alone (Kanis et al, 2008; Siris and Delmas, 2008).
Although osteoporosis is defined in terms of BMD and micro architectural deterioration of bone tissue, BMD is just one component of fracture risk. Accurate assessment of fracture risk should ideally take into account other proven risk factors that add further information (Kanis et al, 2008; Siris and Delmas, 2008).
Osteoporosis has been shown to have a large genetic component. A parental history of fracture (particularly hip fracture) confers an increased risk of fracture independent of BMD (Kanis et al, 2004a). Studies have demonstrated that weight in infancy is a determinant of bone mass in adulthood (Cooper et al, 1997).
Physical inactivity, a sedentary lifestyle and impaired neuromuscular function (such as reduced muscle strength, impaired gait and balance) are risk factors for fragility fractures (Albrand et al, 2003; Nguyen et al, 1998). Smoking can lead to lower bone density and higher risk of fracture and this risk increases with age (Kanis et al, 2005a). High alcohol intake confers a significant risk of future fracture (for example, over four units of alcohol per day can double the risk of hip fracture) (Kanis et al, 2005b).
Prolonged use of corticosteroids is the most common cause of secondary osteoporosis. It is estimated that 30-50% of patients on long term corticosteroid therapy will experience fractures (Reid, 1997), with a two-fold increased risk of hip fracture in women and 2.6-fold in men (Kanis et al, 2004b).
Proton pump inhibitors can reduce the absorption of calcium from the stomach and long term use can significantly increase the risk of osteoporosis-related fractures (Targownik et al, 2008).
Low body weight and weight loss is associated with greater bone loss and increased risk of fracture (De Laet et al, 2005). Some young women, particularly those training for elite athletic competition, exercise too much, eat too little, and consequently experience amenorrhoea, which puts them at risk of low bone mass and fractures.
After an initial low trauma fracture from a simple fall, both older men and women have an increased equivalent risk of all types of subsequent fractures, especially in the next 5-10 years (Center et al, 2007).
Falls contribute to fractures, and around 90% of hip fractures result from falls (Tinetti, 2003). A third of people over 65 fall annually, with approximately 10-15% of falls in older people resulting in fracture, and almost 60% of those who fell the previous year will fall again (Tinetti, 2003).
Fracture risk assessment
The adoption of the WHO (1994) definition of osteoporosis brought enormous benefits to the routine clinical application of bone densitometry, and was a major factor behind its rapid expansion. Not only did this offer a method of identifying high risk patients before sustaining a fracture, the WHO T-score algorithm is also easy and simple to apply in practice.
Marshall et al (1996) reported on how well BMD predicted occurrence of osteoporotic fractures. This led to the widespread acceptance that a hip BMD measurement is the most reliable method of assessing hip fracture risk and spine BMD is optimal for assessing vertebral fracture risk. An important limitation with using T scores, however, is that age as well as BMD is an important factor when deciding patients’ short term risk of osteoporotic fracture (Kanis, 2002). This means it may be more appropriate to treat at the age of 50 but not at 90 for the same T score.
The WHO Fracture Risk Assessment (FRAX) approach seeks to improve clinical decision making on treatment by basing assessment on the 10 year probability of osteoporotic fracture, and DEXA scan results, if available, can also be incorporated in the decision making pathway.
The FRAX algorithm is based on a series of meta-analyses of data from 12 independent fracture studies covering North America, Europe, Asia and Australia. A further validation study incorporated data from another 11 independent population based patient cohorts.
The FRAX tool (www.shef.ac.uk/FRAX) incorporates BMD information from hip DEXA scans. Although femoral neck BMD was used to develop the algorithm, the website states that total BMD may be used instead. Accepting that all DEXA sites are more or less equally effective at predicting a fragility fracture at any site, FRAX provides information on the 10 year probability of hip fracture and any major osteoporotic fracture (defined as a hip, wrist, humerus or clinical vertebral fracture).
The UK National Osteoporosis Guidelines Group uses a traffic light system to divide patients who have had a FRAX assessment into groups for appropriate management.
Screening and detection
As the prevalence of osteoporosis is higher among older postmenopausal women, at over 25% by the age of 80 (NICE, 2008a), it is hard to justify extensive investigation in all cases as many are simply due to age related bone loss. Investigations should be targeted to high risk groups to include:
- Low BMD for age – this may indicate low peak bone mass, accelerated bone loss or a combination;
- Presence of vertebral fractures;
- Unexplained, accelerated bone loss as assessed from serial scans;
- Clinical suspicion of an underlying disorder - an underlying cause for osteoporosis may be present in around 50% of patients. Identification is important as it enables management to be optimised and treatment of the underlying cause may in itself lead to an improvement in bone health (for example, demineralisation due to vitamin D deficiency may be the cause of low BMD rather than osteoporosis).
NICE has published technology appraisals for primary and secondary prevention of osteoporosis (NICE, 2008a; 2008b). They identify treatment thresholds for or make recommendations on various osteoporosis treatments including:
- The oral bisphosphonates alendronate, etidronate and risedronate;
- The selective oestrogen receptor modulator raloxifene;
- Strontium ranelate with its dual anti-resorptive and bone forming modes of action;
- Teriparatide, a parathyroid anabolic treatment given by injection, and reserved for high risk patients intolerant to more traditional treatments.
NICE recommends generic alendronate as the first-line treatment suitable for most patients with osteoporosis (see the technology appraisals for details on when other treatments are recommended). Treatments not evaluated by NICE as they were outside the scope set include the injectable bisphosphonates ibandronate (given three monthly) and zoledronate (annual infusion) and oral ibandronate.
NICE is in the process of developing a clinical guideline for osteoporosis. The remit includes supporting clinical decision making on patient care, and advising on treatment for patient groups not considered in the technology appraisals. These include patients using long term oral corticosteroids and people with osteopenia (NICE, 2008a; 2008b; 2003). No publication date has yet been set for this guideline.
It is important that all patients have sufficient levels of calcium and vitamin D; if there is a nutritional deficiency then supplements should be prescribed, before bone-sparing therapy is initiated.
Compliance and persistence rates for such therapy are poor, especially for bisphosphonate drugs where these range from 30-80% (Cotté et al, 2009; Siris et al, 2009; NICE, 2008a). These drugs are extremely sensitive and patients need to adhere to a strict routine to ensure efficacy (NICE, 2008a). Older patients on multiple treatments may find it difficult to remember to take all their medicines and may also inadvertently miss doses or take treatments incorrectly (Varenna and Sinigaglia, 2009). They need to be supported to ensure good compliance.
Prevention and raising awareness
There is a real need to raise awareness of risks of osteoporosis and the importance of lifestyle interventions to ensure good bone health throughout life. This could be done effectively by public health campaigns. The availability of the FRAX tool should also be highlighted. Finally, there should be adequate commissioning of dedicated services for patients with osteoporosis and fractures.
Public health campaigns at national and local level would pay great dividends at population level, helping to raise awareness of both the importance of maintaining BMD and reducing risks for osteoporotic fractures. Such campaigns should highlight osteoporosis-associated modifiable risk factors.
Lifestyle interventions that are important for good bone health include a healthy balanced diet, containing adequate protein, carbohydrates with good calcium and vitamin D intake (Ralston and Kleerekoper, 2003). Regular weightbearing exercise is important to ensure good bone turnover. Smoking and alcohol intake equal to or above four units per day are risk factors for osteoporosis, as is a low BMI (<22 kg/m2) (NICE, 2008b).
The results of a recent survey conducted on behalf of the National Osteoporosis Society (2008) show that young adults have poor understanding of bone health and what they can do to reduce their risk of osteoporosis. For example, over two thirds of respondents were not aware they can take positive steps to improve bone health, while only a third were aware that physical inactivity increases the risk of osteoporosis. Less than half knew that eating dairy products is beneficial.
Key steps are to increase knowledge and understanding about bone health during childhood and adolescence. Nurses are ideally placed to support public health campaigns, ensuring key messages are delivered to mothers and children. They could also raise awareness of the ‘bones4life’ campaign which comprises a web-based tool for children, parents and teachers (www.bones4life.org).
At practice level, results from the FRAX assessment could be used in consultations to decide on appropriate management for osteoporosis risk, including referral for a DEXA scan and specialist advice if appropriate. Currently osteoporosis clinical criteria are not included in the GP Quality and Outcomes Framework, raising concern that this disadvantages care for patients with osteoporosis in primary care (Sutcliffe, 2006).
In April 2008, the Department of Health published its clinical directed enhanced service (DES) specification for osteoporosis for the general medical services contract, based on NICE technology appraisal criteria for secondary prevention. However, no information is available on its uptake by practices across the UK. Nurses working in primary care could improve patient care by proactively supporting implementation of this DES.
Fracture liaison services and medicines management
There is increasing evidence for the benefits of dedicated fracture liaison services (FLS). These include dedicated nurses tasked with ensuring integrated patient care delivery across the primary and acute care interface (Murray et al, 2005).
In Harrow, work is underway to develop a multidisciplinary model incorporating a fracture liaison service integrated with our local falls service. This model will work closely with the falls coordinator, orthogeriatricians, orthopaedic consultants, consultant for metabolic bone disorders and a pharmacist-led medication management service (Tanna, 2004). The Harrow model will also ensure data input to the National Hip Fracture Database (www.nhfd.co.uk). Indeed, supporting this database may become mandatory for all NHS services from next year.
Medication management and patient support - ensuring good compliance and concordance with osteoporosis management plans and with prescribed treatments - are vital. Not only is there a need to ensure that patients adhere to management plans, but if they have difficulty with medication it is also important to ensure they are appropriately supported.
The Northwick Park medication management clinic has been designed to support patients with medication related issues. The service also provides quick access for advice for all practitioners via a dedicated healthcare professional linkline (Tanna et al, 2007).
FLS services have the potential to further improve osteoporosis medication management, and in primary care, an extension of the model could include cross-referral to community pharmacists with a request to undertake a medicines usage review.
Work has also been reported on supporting staff and patients in care homes with correct medication taking, with a particular focus on ensuring good calcium and vitamin D intake by elderly frail patients with risk factors for osteoporosis (Mayne et al, 2008).
There is a need for further research on the effective use of bone turnover markers and their role in osteoporosis care.
Further research is ongoing to develop the FRAX tool to include vertebral fractures. Newer treatment modalities include denosumab, a fully human monoclonal antibody which is currently being tested to see if it will prove to be an effective treatment for osteoporosis. There is interest in the newer tissue-selective oestrogen complex (TSEC),a combination of bazedoxifene, which is a selective oestrogen receptor modulator, and conjugated equine oestrogen, as the oestrogen component in the TSEC. The working hypothesis is that these treatments will be the future “designer” type of drugs, used to treat patients with expected benefits but reduced risk.
This article has examined diagnostic criteria for osteoporosis, the importance of preventing fractures and the current medical consensus that evidence based risk factors in addition to BMD measurements provide improved assessment for future fracture risk.
The FRAX risk assessment tool may become the future method of assessment. Bone turnover markers are currently used only by specialist units, as there is a need to identify their role before wider use. Multidisciplinary teams, with nurses playing a central role, are vital in delivering optimal care for patients with osteoporosis.
Albrand, G. et al (2003) Independent predictors of all osteoporosis-related fractures in healthy postmenopausal women: the OFELY study. Bone; 32: 78.
Bandolier (1998) Outcome after hip fracture. Bandolier Evidence Based Healthcare, March 1998. Issue 48, 2.
Burge, R. et al (2001) The cost of osteoporotic fractures in the UK: projections for 2000-2020. Journal of Medical Economics; 4: 51-62.
Center, J.R. et al(2007) Risk of subsequent fracture after low-trauma fracture in men and women. JAMA; 297: 387.
Compston, J.E. (1990) Osteoporosis. Clinical Endocrinology; 33: 653-682.
Cooper, C. et al (1997) Growth in infancy and bone mass in later life. Annals of the Rheumatic Diseases; 56: 17.
Cotté, F.E. et al (2009) Adherence to monthly and weekly oral bisphosphonates in women with osteoporosis. Osteoporosis International. Published online 21 May 2009.
Cryer, C., Patel, S. (2001) Falls, Fragility and Fractures. National Service Framework for Older People: The Case for and Strategies to Implement a JointHealth Improvement and Modernisation Plan for Falls and Osteoporosis. London: Alliance for Better Bone Health.
De Laet, C. et al (2005) Body mass index as a predictor of fracture risk: a meta-analysis. Osteoporosis International; 16: 1330.
Elffors, L. (1998) Are osteoporotic fractures due to osteoporosis? Impacts of a frailty pandemic in an aging world. Aging (Milano); 10: 3, 191-204.
Johnell, O., Kanis, J.A. (2006) An estimate of the worldwide prevalence and disability associated with osteoporotic fractures. Osteoporosis International; 17: 1726.
Kanis, J.A. (2002) Diagnosis of osteoporosis and assessment of fracture risk. Lancet; 359: 1929-1936.
Kanis, J.A. et al (2008) FRAX trade mark and the assessment of fracture probability in men and women from the UK. Osteoporosis International; 19: 385.
Kanis, J.A. et al (2005a) Smoking and fracture risk: a meta-analysis. Osteoporosis International; 16: 155.
Kanis, J.A. et al (2005b) Alcohol intake as a risk factor for fracture. Osteoporosis International; 16: 737.
Kanis, J.A. et al (2004a) A family history of fracture and fracture risk: a meta-analysis. Bone; 35: 1029.
Kanis, J.A. et al (2004b) A meta-analysis of prior corticosteroid use and fracture risk. Journal of Bone and Mineral Research; 19: 893.
Marshall, D. et al (1996) Meta-analysis of how well measures on bone mineral density predict occurence of osteoporotic fractures. BMJ; 312: 1254-1259.
Mayne, D. et al (2008) Calcium and vitamin D supplementation in elderly care home residents. Endocrine Abstracts; 15: 13.
Murray, A.W. et al (2005) Osteoporosis risk assessment and treatment intervention after hip or shoulder fracture. A comparison of two centres in the United Kingdom. Injury; 36: 9, 1080-4.
National Osteoporosis Society (2008) Your Bones and Osteoporosis: What Every Man, Woman and Child Should Know. Bath: NOS.
National Institute of Health Consensus Development Panel (2001) Osteoporosis prevention, diagnosis, and therapy.JAMA; 285: 6, 785-795.
NICE (2008a) Alendronate, Etidronate, Risedronate, Raloxifene and Strontium Ranelate for the Primary Prevention of Osteoporotic Fragility Fractures inPostmenopausal Women. London: NICE. http://www.nice.org.uk/Guidance/TA160
NICE (2008b) Alendronate, Etidronate, Risedronate, Raloxifene, Strontium Ranelate and Teriparatide for the Secondary Prevention of Osteoporotic FragilityFractures in Postmenopausal Women. London: NICE.
NICE (2003) Osteoporosis: Scope. London: NICE.
Nguyen, T.V. et al (1998) Bone loss, physical activity, and weight change in elderly women: the Dubbo Osteoporosis Epidemiology Study. Journal of Boneand Mineral Research; 13: 1458.
Ralston, S.H., Kleerekoper, M. (2003) Osteoporosis. Oxford:Mosby, Elsevier Science.
Reid, I.R. (1997) Glucocorticoid osteoporosis - mechanisms and management. European Journal of Endocrinology; 137: 209.
Sutcliffe, A. (2006) Osteoporosis. A Guide for Healthcare Professionals. Oxford: Wiley Blackwell.
Siris, E., Delmas, P.D. (2008) Assessment of 10-year absolute fracture risk: a new paradigm with worldwide application. Osteoporosis International; 19: 4, 383.
Siris, E.S. et al (2009) Impact of osteoporosis treatment adherence on fracture rates in North America and Europe. American Journal of Medicine; 122: S2, S3-13.
Tanna, N. (2004) Care of the elderly – an osteoporosis medication management clinic. Hospital Pharmacist; 11: 6, 231-238.
Tanna, N. et al (2007) A menopause and osteoporosis health professional linkline: Re-audit highlights continued need for this support service. OsteoporosisInternational; 18: S3, S269.
Targownik, L.E. et al (2008) Use of proton pump inhibitors and risk of osteoporosis-related fractures. CMAJ; 179: 319.
Tinetti, M.E. (2003) Clinical practice. Preventing falls in elderly persons. New EnglandJournal of Medicine; 348: 42.
Varenna, M., Sinigaglia, L. (2009) Adherence to treatment of osteoporosis: an open question. Reumatismo; 61: 1, 4-9.
World Health Organization (1994) Assessment of Fracture Risk and its Application to Screening for Postmenopausal Osteoporosis. Geneva: WHO.