Bone health

Over 80s with osteoporosis warrant fracture prevention

Elderly women with osteoporosis have a higher hip fracture rate than women without osteoporosis but deemed to be at high risk of fracture due to osteopenia or a previous fracture.

The US study comprised 1,528 women, average age 84 years, who were surviving participants in the Study of Osteoporotic Fractures which started in the 1980s.

None had received drug treatment for fracture prevention.

Based on their bone density and other assessments at year 16 of the study, about half were determined to have osteoporosis while the rest did not have osteoporosis but were at high fracture risk.

The 5-year absolute probability of mortality was 24.9% for with women with osteoporosis and 19.4% for those without osteoporosis but at high fracture risk.

Mortality probability steadily increased in a graded manner with greater comorbidities and poorer prognosis in both groups of women, the study said.

“In contrast, the 5-year hip fracture probability taking into account the competing risk of death was over 3-fold higher among women with osteoporosis compared with women without osteoporosis but at high fracture risk (13.0% [95% CI, 10.7%- 15.5%] vs 4.0% [95% CI, 2.8%-5.6%]).”

“This difference between groups in hip fracture (but not mortality) probabilities was even more pronounced in women with a greater number of comorbidities or poorer prognosis.”

In women with three or more comorbidities, hip fracture probability was 18.1% in those with osteoporosis compared to 2.5% in women without osteoporosis but at high fracture risk.

The study suggested that the women with osteoporosis, including those with more comorbidities or poorer prognosis, were the most likely candidates for drug treatment to prevent hip fractures.

And many elderly women would still benefit given the time horizon from treatment to benefit was less than five years.

“Despite accounting for their higher competing risk of death, the cumulative probability of hip fracture at 5 years was greater among women with osteoporosis and more comorbidities or worse prognosis compared with women with osteoporosis and fewer comorbidities or better prognosis.”

An Invited Commentary on the study, published in JAMA Internal Medicine, said clinicians were often hesitant to start drug treatment in older adults, particularly those with multiple comorbidities, polypharmacy and frailty.

“This reluctance stems in part from the concern that these patients with a shorter life expectancy may not experience the same risk-benefit profile as healthier adults when prescribed preventive therapies.”

The Commentary highlighted the fact that evidence in older adults was lacking although fracture prevention was a priority for the age group.

“Despite the obvious challenges of treating osteoporosis in older adults with multimorbidity, the study by Ensrud et al reminds us of the dangers in ignoring the problem.”

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