Osteoporosis                                         

Diagnosis & Incidence

In the 2004 U.S. Surgeon General’s Report on Bone Health and Osteoporosis, osteoporosis was called a major public health concern that is both under diagnosed and undertreated.[i] Eight million women and 2 million men in the U.S. have osteoporosis according that same report. Another 34 million persons have osteopenia.  In 2008, the estimated U.S. population was 304,059,724, and those over 65 years of age represented 24.5% of that population. About 16% of that group was between 35 and 44 years, the predicted ages for beginning decreases in the maximum bone density (MBD).[ii]  As for the cost of this disease, the Clinician’s Handbook of Preventive Services cites “an estimated $13.8 billion was spent in the United States (1995) for osteoporosis - related medical, nursing home, and social costs.3[iii]  Imagine the cost today!

The 2002 the cost of a hip fracture was estimated to be from $34,000 to $43,000. Overall, hip fractures cause over 20% mortality at during the first year, and up to 25% of patients require long-term nursing home care.[iv] Osteoporosis-related fractures caused more than 432,000 hospital admissions in 2005, and the projected number of osteoporotic hip fractures is 6.3 million by 2050.[v] Try to fill in the current cost of a hip fracture at your referral hospital.

The impact of osteoporosis on disability, social isolation, psychological stresses, and worsening physical deterioration and fragility disrupts individuals and society. The social and financial burden continues to mount as populations live longer with multiple chronic health conditions. Despite widely accepted screening, diagnosis, and treatment guidelines, there is a wide gap between knowledge and effective clinical practice.  One study showed that only 49% of women were evaluated or treated with accepted guidelines.[vi]

Simply put, osteoporosis is a “skeletal disease characterized by compromised bone strength that predisposes the individual to an increased risk of fracture. 
Slide01, Slide02
Low bone mass is known as osteopenia.”[vii] Osteopenia is defined as a spinal or hip BMD between 1 and 2.5 standard deviations below the mean.[viii]  Slide03

  The International Classification of Diseases (ICD-9) described osteporosis as “Bone mass reduction that ultimately results in fractures after minimal trauma; dorsal kyphosis or loss of height occur  (Code 733.0),” and lists 5 defining features for diagnosis category.[ix] The World Health Organization (WHO) defines osteoporosis as a spinal or hip bone mineral density (BMD) of 2.5 standard deviations or more below the mean for healthy young women (T-score -2.5 or below) as measured by dual energy x-ray absorptiometry (DXA). Slide04  Slide05

Screening recommendations vary because the criteria used in formulation of guidelines often varies. For example, evidence-based practice, consensus panels, and expert opinion all play a role in promoting screening, prevention, and treatment guidelines. The U.S. Preventive Services Task Force (USPSTF) guidelines differ from the National Osteoporosis Foundation (NOF). [x],[xi]

Osteoporosis is generally symptom-free, until a fracture occurs. Then, often the fracture is treated and the patient released from hospital without continuing treatment for osteoporosis. An evidence gap among physicians showed that even after hip or other fragility fractures, patients were not diagnosed or treated for osteoporosis.[xii] Osteoporosis can develop in women or men of any age, however, postmenopausal women are at particular risk because of the estrogen deficiency and its adverse effect on the skeleton. Slide06

The opportunity to identify and treat post-menopausal osteoporosis  (PMO) in the office setting is high, as women often continue to seek health care from the PCP or specialist with whom they are familiar. Older men often seek treatment for urinary symptoms or other symptoms of aging, often with a PCP or specialist who is unfamiliar to them. Regardless of whether the patient is new or continuing in the office setting a treatment gap can exist. A treatment gap is the difference between the number of patients who could benefit from treatment and those who actually receive it.[xiii]  Lewieck challenges clinicians to reduce the treatment gap by identifying patients at high risk for fracture, evaluating patients for factors that would contribute to osteoporosis, initiating therapy when needed, and following up to assure that medication is taken regularly and correctly.[xiv]

Diagnosis

Diagnosis of osteoporosis is key to prevention and treatment.  Recommendations of major authorities for screening and treatment of osteoporosis vary. A clinical practice or independent medical office might consider adopting one of the  authoritative recommendations to provide guidelines for  primary care or specialist treatment within the office setting. Eight different professional medical groups have published recommendations on diagnosis and treatment of osteoporosis. 

Diagnosis of osteoporosis is key to prevention and treatment.  BMD, by itself, is an excellent predictor of fracture risk; however, clinical risk factors play an important part in determining patient education and treatment options.  Validated clinical rules, such as the Simple Calculated Osteoporosis Risk Estimation (SCORE) may be considered. The SCORE tool consists of 6 items with a sensitivity of 91 %, and a specificity of 31 %. It is used to predict which women may benefit from DXA screening.[xv] 

Women receive most of the screening and followed by education and teaching about osteoporosis and osteopenia. Slide07  However, one third of all hip fractures occur in men and the one year mortality rate is twice that of women. [xvi]  About one in eight men will sustain an osteoporotic facture in his lifetime. Remember that osteoporosis is men is both under recognized and undertreated!

An American College of Physicians  (ACP) Systematic Review identified risk factors for osteoporotic fractures in men: age over 70 years, BMI less than 20 kg/m2, 10% or more weight loss, physical inactivity, long term glucocorticoid use, and androgen-deprivation therapy.[xvii]  Like women, cigarette smoking and excessive alcohol use affect BDM. The ACP issued Screening for Osteoporosis in Men: Clinical Practice Guidelines (2009) and a guide to pharmaceutical treatment. [xviii] More research and guidelines directed toward elderly men should improve the health and quality of life for aging men.

A clinical diagnosis can be made through clinical appearance, physical examination, and risk factors. If indicated, by history and presenting profile, bone mineral density (BMD), x-rays, and laboratory studies can be added. Criteria currently focus on Caucasian postmenopausal women, although studies are emerging that include non-Caucasian women and men. 

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