70 year old female asks her PCP if she should have a bone density done.
What questions should her PCP ask?
No history of fractures
Menopause was surgical at age of 55
Mother fractured her hip at 74
Microarchitectural deterioration of bone tissue leading to decreased bone mass
Susceptibility to fracture
A problem of decreased peak bone mass and accelerated bone loss
Affects 10 million in the United States
Hip Fractures Can Lead to Disability, Loss of Independence, and Even Death
Hip fracture is associated with increased risk of:
Disability: 50% never fully recover 1,2
Long-term nursing home care required: 25% 2
Increased mortality within 1 year due to complications: up to 24% 3
Lifetime risk of death: comparable to that of breast cancer 4
1. Consensus Development Conference. Am J Med . 1993;94:646-650. 2. Riggs BL, Melton LJ III. Bone . 1995;17:505S – 511S. 3. Ray NF et al. J Bone Miner Res . 1997;12(1):24 – 35. 4. Cummings SR et al. Arch Intern Med . 1989;149:2445 – 2448.
Unrelated to chronic illness
Related to aging and decreased gonadal function
Secondary to chronic illnesses that cause accelerated bone loss
Risk Factors for Osteoporotic Fracture Nonmodifiable Potentially Modifiable Gold color denotes risk factors that are key factors for risk of hip fracture, independent of bone density. National Osteoporosis Foundation, Physician’s Guide to Prevention and Treatment of Osteoporosis . Belle Mead, NJ: Excerpta Medica, Inc.; 1998. Personal history of fracture as an adult History of fracture in first-degree relative Caucasian race Advanced age Female sex Dementia Poor health/frailty Current cigarette smoking Low body weight (<127 lbs) Estrogen deficiency, including menopause onset <age 45 Low calcium intake (lifelong) Alcoholism Impaired eyesight despite adequate correction Recurrent falls Inadequate physical activity Poor health/frailty
Diagnosis of Osteoporosis
History and physical examination to exclude secondary osteoporosis
Laboratory studies if suspect secondary osteoporosis
Measurement of Bone Mineral Density (BMD)
Dual X-ray Absorptiometry (DEXA scan)
Provides most reproducible values of bone density
BMD and Fracture Risk Are Inversely Related 60 70 80 90 100 30 40 50 60 70 80 90 Age Relative BMD (%) Forearm Spine Hip and Heel 0 1000 2000 3000 4000 35- 39 85+ Colles' Vertebrae Hip Age Annual Fracture Incidence Cooper C. Baillières Clin Rheumatol. 1993;7:459 – 477. Faulkner KG. J Clin Densitom. 1998;1:279 – 285.
Central DXA Measurement
Measures multiple skeletal sites
Considered the clinical standard
Who Should Be Considered for BMD Testing?
Women 65 years of age regardless of additional risk factors
Postmenopausal women <65 years of age with at least one risk factor for osteoporosis (in addition to menopause)
Postmenopausal women 65 years of age with fractures (to confirm diagnosis and determine disease severity)
Women considering therapy for osteoporosis, if BMD testing would facilitate the decision
Women who have been on HRT for prolonged periods
National Osteoporosis Foundation, Physician’s Guide to Prevention and Treatment of Osteoporosis . Belle Mead, NJ: Excerpta Medica, Inc.; 1998. National Osteoporosis Foundation Guidelines
Other Populations To Consider for Assessment of Osteoporosis
Patients on long-term high-dose glucocorticoids
Interpreting BMD Measurement Reports
A clinically relevant value on the BMD report
Describes bone mass compared with the mean peak bone mass of healthy young adult women in terms of Standard Deviation (SD)
Can help confirm the diagnosis of low bone mass or osteoporosis
For every SD below the young adult normal, the risk of fracture approximately doubles
T-Score Is Key 1. National Osteoporosis Foundation, Physician’s Guide to Prevention and Treatment of Osteoporosis . Belle Mead, NJ: Excerpta Medica, Inc.; 1998. 2. Marshall D. Johnell O, Wedel H. Meta-analysis of how well measures of bone mineral density predict occurrence of osteoporotic fractures. BMJ . 1996;312:1254–1259.
Visualizing a Patient’s T-Score
T-score = Number of standard deviations (SDs) by which the patient’s bone mass falls above or below the mean peak bone mass for normal young adult women
= T-score for patient, a 60-year-old woman; here, T = –3.0
Light line: Change in mean bone mass over time in women
Heavy line: Mean peak bone mass for young normal adult women
SD Age (years) 2 1 0 – 1 – 2 – 3 – 4 – 5 – 6 20 30 40 50 60 70 80 90 T-score = –3.0 Peak Bone Mass National Osteoporosis Foundation, Physician’s Guide to Prevention and Treatment of Osteoporosis . Belle Mead, NJ: Excerpta Medica, Inc.; 1998.
Recommendations for Treatment Based on BMD Testing Results National Osteoporosis Foundation, Physician’s Guide to Prevention and Treatment of Osteoporosis . Belle Mead, NJ: Excerpta Medica, Inc.; 1998. T-SCORE ACTION < –2.0 Initiate therapy < –1.5 Initiate therapy (with at least 1 additional risk factor) National Osteoporosis Foundation Guidelines for postmenopausal Women
Treatment of Osteoporosis
Adequate Calcium (1200 mg elemental)
Adequate Vitamin D (at least 400 IU)
Inhibit osteoclastic bone resorption
Increased BMD and decreased fractures
Ex: alendronate, risedronate
Nasal spray or injection
Decreased vertebral fractures
No hip fracture data
Decreased vertebral fracture
Osteoporosis is a disease with serious consequences.
Bone loss associated with osteoporosis increases fracture risk, which may lead to disability, loss of independence, and death.
Patients at risk for osteoporotic fracture should be considered for BMD testing.
T-score is the most clinically relevant measure of fracture risk.
According to NOF guidelines, consider therapy in patients with a T-score of < – 2.0 and those with a T-score of < – 1.5 with at least one risk factor.