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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