Reducing osteoporotic fracture risk and building healthy bones

Published in MedicineWise News

Date published: About this date

Clinical content may change after this date. This information is not intended as a substitute for medical advice from a qualified health professional. Health professionals should rely on their own expertise and enquiries when providing medical advice or treatment.

Key messages

  • Consider multiple risk factors when assessing fracture risk: a fracture risk calculator may help
  • Assess risk factors for falls and implement falls prevention measures
  • Discuss adequate calcium, vitamin D and physical activity
  • Consider an anti-osteoporotic drug after a minimal trauma fracture

Consider multiple risk factors when assessing fracture risk: a fracture risk calculator may help

Assessing osteoporotic fracture risk using a multifaceted approach helps target interventions. This is because the presence of one major risk factor (such as low bone mineral density [BMD]) does not reliably predict overall fracture risk.1

Include a range of risk factors when assessing osteoporotic fracture risk

Some risk factors are modifiable: address these wherever possible (e.g. address fall hazards in the home such as loose rugs or poor lighting). Some risk factors decrease BMD while others increase fracture risk independently of BMD. Take into account medical conditions and medicines being taken, as well as lifestyle factors (e.g. smoking, alcohol intake and physical activity).2,3

Consider using a fracture risk calculator as part of the overall assessment

A fracture risk calculator can be used to provide a guide to fracture risk in the next 5–10 years. They can be used for men and women with or without a BMD measurement or previous fracture.4,5 Two tools are available online:

Both include multiple risk factors but differ in the risk factors assessed and types of fracture risks calculated. Neither indicates when to start drug therapy (for more information, refer to NPS News 73: Reducing fracture risk in osteoporosis).

Assess risk factors for falls and implement falls prevention measures

Screen people for falls risk factors from age 65 years.6 Falls are a common cause of injury in people aged ≥ 65 years: in 2004 about 1 in 3 Australians living in the community had one or more falls in the past year. Of these, about 1 in 10 had multiple falls and about 1 in 3 needed medical attention for fall-related injuries. Fall rates in residential agedcare settings were even higher, with about 1 in 2 having one or more falls in the past year.7 Of Australians hospitalised for traumatic fracture in 2002, about half were due to accidental falls, with a greater proportion in older people, particularly those ≥ 75 years.8

Risk factors for falls

The more risk factors someone has, the more likely they are to fall (Box 1). Of several falls risk assessment tools available, none is clearly better than an other: few have been tested more than once or in more than one setting.6

Box 1: Risk factors for falls 1,6,9-11

  • History of falls
  • Increased age (especially > 80 years)
  • Problems with gait, balance or mobility
  • Impaired cognition (e.g. dementia)
  • Impaired vision (e.g. impaired visual acuity, contrast sensitivity or depth perception)
  • Muscle weakness (e.g. in the legs and/or feet)
  • Postural hypotension
  • Health conditions (e.g. arthritis, depression, vitamin D deficiency)
  • Incontinence
  • Taking > 4 medicines
  • Specific medicines (e.g. benzodiazepines, antihypertensives)
  • Female gender
  • Fear of falling
  • Environmental factors at home (e.g. poor lighting, loose rugs)

Tailor a falls prevention program to the person's risk factors

Preventing falls is one of the most important ways to reduce fracture risk.11 Consider referral to a falls clinic: these are available at most major public hospitals and community health centres.

However, the evidence around falls prevention is mixed: some trials found a single intervention reduced falls while others found that they did not. Multifaceted interventions are more likely to reduce falls: for example, one meta-analysis found these reduced the rate of falls by 18% (RR 0.82, 95% confidence interval 0.76 to 0.90) though there was a strong indication that the effect varied significantly from trial to trial (I2=52%, P=0.02).12

Despite the limitations of the evidence, it is logical to address as many risk factors as possible in an individual falls prevention program (Box 2).

Box 2: Measures that may be part of a multifaceted falls prevention program9,10

  • Education on the risk of falling and prevention measures
  • Review and/or modify medicines (e.g. Home Medicines ReviewA)
  • Individualised exercise programs which include strength and balance trainingB
  • Use appropriate assistive devices (e.g. a walking frame)C
  • Assess vision and refer if necessary
  • Treat postural hypotension and cardiovascular disorders
  • Reduce home hazards (e.g. rugs, poor lighting)C
A. See www.medicareaustralia.gov.au/provider/pbs/fourth-agreement/hmr.jsp for more information.
B. A physiotherapist or exercise physiologist can create a program specific to the person's needs, abilities and interests.
C. An occupational therapist can provide specialist advice.

Discuss adequate calcium, vitamin D and physical activity

Adequate calcium, vitamin D and physical activity are important during childhood and adolescence for optimal peak bone mass and throughout the lifespan to maintain healthy bones.1 Calcium and vitamin D absorption decrease with ageing.

Promote adequate dietary calcium intake and suitable food sources

The average dietary calcium intake in Australia is well below recommended levels.13 The recommended daily intake of calcium for various age groups, as well as the calcium content of dairy products and other foods is available on the Osteoporosis Australia website. Enough calcium for most adults can be provided by 3 serves of dairy food per day: 1 serve = 250 mL milk, or 200 g yoghurt, or 40 g cheddar cheese (calcium intake over the recommended daily intake is unlikely to provide extra benefit 14).13 Calcium-rich non-dairy foods (e.g. almonds, beans, tofu, broccoli, tinned salmon) and foods that have been calcium-fortified are good options for people who are unable to consume adequate serves of dairy foods each day.

Calcium supplements are only needed when dietary intake is insufficient and usually only in low doses. There have been some recent concerns raised about calcium supplements and myocardial infarction: for more information refer to NPS News 73: Reducing fracture risk in osteoporosis.15

Vitamin D is essential for calcium absorption

Ensure adequate vitamin D intake or sun exposure in people at risk of deficiency, particularly those with osteoporosis.13 In frail residents of agedcare facilities with inadequate calcium and/or vitamin D intake, providing calcium and vitamin D supplementation reduced the risk of hip and other non-vertebral fractures (vitamin D supplementation alone did not achieve this).16 For more information about vitamin D, refer to NPS News 72: Testing and treating vitamin D deficiency.17

Exercise helps to build strong bones and may reduce falls risk

Encourage people with osteoporosis to exercise by explaining its goals: muscle strength and endurance, balance and stability, mobility and quality of life, and falls prevention.18 Be aware that certain exercises are unsuitable for people with osteoporosis because they can cause fractures. People need adequate calcium and vitamin D to fully benefit from exercise.

Explain that regular low-impact weight-bearing exercise combined with high-intensity strength (resistance) training conserves BMD.11,19 Strength and balance training — alone or as part of a multifaceted falls prevention program — reduces falls risk.9,20 A physiotherapist or exercise physiologist can create a program specific to the person's needs, abilities and interests.10 Effective programs should progress as fitness and strength levels improve.10,19 Regularly ask about adherence and, when necessary, suggest ways to improve it (e.g. keeping a log of their exercise for regular review and feedback). Be aware of barriers (e.g. inclement weather, travel). Some people may be eligible to access private allied health professionals through Medicare after their GP has completed the required chronic disease management items.

Certain exercises are unsuitable for people with osteoporosis because they can cause fractures. Types of exercises to avoid include: dynamic abdominal exercises (e.g. sit ups), twisting movements (e.g. golf swing), trunk flexion (e.g. some exercise machines), abrupt or explosive loading and high-impact loading (e.g. running).18

Consider an anti-osteoporotic drug after a minimal trauma fracture

Reduce the risk of further fracture by using anti-osteoporotic drugs

The risk of vertebral fracture is about 4 times higher in women with a previous vertebral fracture than in those without.21 Despite this, less than 30% of Australian postmenopausal women with a previous fracture were taking an anti-osteoporotic drug and only 10% of Australian men who were eligible for a PBS-subsidised bisphosphonate were taking (or had taken) one.22,23

Bisphosphonates are suitable for men and women; raloxifene, strontium or denosumab are other options for women.3 All anti-osteoporotic drugs reduce fracture risk but differ in their specific data and adverse event profiles.

Some anti-osteoporotic drugs are available on the Pharmaceutical Benefits Scheme for people without an existing fracture but who are at high risk because they are ≥ 70 years and have a BMD T-score ≤ –3.0 (primary prevention) or for people who are taking a glucocorticoid and meet certain criteria.24 Be aware that these drugs have been evaluated in people who had adequate calcium and vitamin D: see Discuss adequate calcium, vitamin D and physical activity.3,13,25

Regularly ask about adherence to drug therapy

Adherence to drug therapy is poor, usually due to dosing inconvenience (e.g. sitting upright and avoiding food for at least 30 minutes with bisphosphonates) or adverse effects. Also, people may not perceive the benefits of drug therapy.26

Check adherence regularly by asking open questions (e.g. we all forget to take our medicines sometimes, when was the last time you missed taking it?). Ask the person how well they think their drug therapy is working and about adverse effects.26 Reiterate the purpose of drug therapy. Motivate people to continue by highlighting the benefits of persistence rather than the negative consequences of stopping.26 If they are experiencing adverse effects, provide information about how these can be prevented or reduced (e.g. consumer medicine information). If dosing inconvenience or adverse effects are unmanageable consider other drugs, routes of administration or dose regimens (e.g. alendronate and risedronate can be given daily, weekly or monthly; denosumab is given every 6 months as a subcutaneous injection; zoledronic acid is given as an annual intravenous infusion).

Expert reviewers

Leon Flicker, Professor of Geriatric Medicine, Director, Western Australian Centre for Health & Ageing, Western Australian Institute for Medical Research, University of Western Australia, Royal Perth Hospital

Any correspondence regarding content should be directed to NPS. Declarations of conflicts of interest have been sought from all reviewers. The opinions expressed do not necessarily represent those of the reviewers.

References
  1. US Department of Health and Human Services. Bone health and osteoporosis: a report of the Surgeon General. Rockville: Office of the Surgeon General, 2004. (accessed 2 February 2011).
  2. Maintaining bone health to prevent osteoporotic fractures. NPS News 53 August 2007. Sydney: National Prescribing Service Ltd, 2007. (accessed 2 February 2011).
  3. Endocrinology Writing Group. Therapeutic guidelines: endocrinology, version 4 (updated March) 2010 [eTG complete CD-ROM]. Melbourne: Therapeutic Guidelines Ltd, 2009.
  4. World Health Organization Collaborating Centre for Metabolic Bone Diseases. WHO fracture risk assessment tool. Sheffield: University of Sheffield.
    (accessed 11 January 2011).
  5. Fracture risk calculator. Sydney: Garvan Institute. (accessed 11 January 2011).
  6. The Royal Australian College of General Practitioners 'Red Book' Taskforce. Guidelines for preventive activities in general practice ('the red book') 7th edition. Melbourne: Royal Australian
    College of General Practitioners, 2009. (accessed 14 December 2010).
  7. National Ageing Research Institute. An analysis of research on preventing falls and falls injury in older people: community, residential care and hospital settings (2004 update). Canberra: Department of Health and Ageing, 2004. (accessed 5 April 2011).
  8. Bradley C, Harrison J. Descriptive epidemiology of traumatic fractures in Australia. Injury research and statistics series number 17. Canberra: Australian Institute of Health and Welfare, 2004. (accessed 5 April 2011).
  9. Falls: the assessment and prevention of falls in older people. Clinical Guideline 21. London: National Institute for Health and Clinical Excellence, 2004. (accessed 14 December 2010).
  10. Clinical guideline for the prevention and treatment of osteoporosis in post-menopausal women and older men. South Melbourne: Royal Australian College of General Practitioners, 2010. (accessed 13 April 2010).
  11. Arthritis and osteoporosis in Australia 2008. Canberra: Australian Institute of Health and Welfare, 2008. (accessed 2 February 2011).
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  13. Osteoporosis Australia. Calcium, vitamin D and osteoporosis - a guide for GPs. Sydney: Osteoporosis Australia, 2008. (accessed 14 December 2010).
  14. Sanders KM, et al. Med J Aust 2009;190:316–20.
  15. Reducing fracture risk in osteoporosis. NPS News 73 June 2011. Sydney: National Prescribing Service Ltd, 2011. (accessed 1 June 2011).
  16. Avenell A, et al. Cochrane Database Syst Rev 2009;2:CD000227.
  17. Testing and treating vitamin D deficiency. NPS News 72 April 2011. Sydney: National Prescribing Service Ltd, 2011. (accessed 4 April 2011).
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  19. Scottish Intercollegiate Guidlines Network. Management of osteoporosis: a national clinical guideline. Edinburgh: NHS Quality Improvement Scotland, 2003. (accessed 14 December 2010).
  20. Sherrington C, et al. J Am Geriatr Soc 2008;56:2234–43.
  21. Klotzbuecher CM, et al. J Bone Miner Res 2000;15:721–39.
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  23. Bleicher K, et al. Med J Aust 2010;193:387–91.
  24. Department of Health and Ageing. PBS for Health Professionals. Canberra, 2010. (accessed 8 June 2010).
  25. Australian Medicines Handbook. Adelaide: Australian Medicines Handbook Pty Ltd, 2010.
  26. International Osteoporosis Foundation. The adherence gap: why osteoporosis patients don't continue with treatment. Nyon (Switzerland): International Osteoporosis Foundation, 2005. (accessed 30 March 2011).

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