Updated fracture incidence rates for the US version of FRAX.

UNLABELLED: On the basis of updated fracture and mortality data, we recommend that the base population values used in the US version of FRAX be revised. The impact of suggested changes is likely to be a lowering of 10-year fracture probabilities. INTRODUCTION: Evaluation of results produced by the US version of FRAX indicates that this tool overestimates the likelihood of major osteoporotic fracture. In an attempt to correct this, we updated underlying fracture and mortality rates for the model. METHODS: We used US hospital discharge data from 2006 to calculate annual age- and sex-specific hip fracture rates and age-specific ratios to estimate clinical vertebral fracture rates. To estimate the incidence of any one of four major osteoporotic fractures, we first summed these newly derived hip and vertebral fracture estimates with Olmsted County, MN, wrist and upper humerus fracture rates, and then applied 10-20% discounts for overlap. RESULTS: Compared with rates used in the current FRAX tool, 2006 hip fracture rates are about 16% lower, with greatest reductions observed among those below age 65 years; major osteoporotic fracture rates are about one quarter lower, with similar reductions across all ages. CONCLUSIONS: We recommend revising the US-FRAX by updating current base population values for hip fracture and major osteoporotic fracture. The impact of these revisions on FRAX is likely to be lowering of 10-year fracture probabilities, but more precise estimates of the impact of these changes will be available after these new rates are incorporated into the FRAX tool.

Persistence with weekly alendronate therapy among postmenopausal women.

INTRODUCTION: Although clinical trials indicate that oral bisphosphonates reduce osteoporotic fracture risk, compliance with bisphosphonate therapy in practice is suboptimal, with 1-year discontinuation rates exceeding 50%. METHODS: We conducted a retrospective cohort study among female members of a large integrated health care delivery system (Kaiser Permanente of Northern California), age 45 years and older, to determine their persistence with weekly alendronate (defined as continuous use, allowing for a refill gap of 60 days), predictors of discontinuation, and subsequent osteoporosis therapy. We also examined the effect of varying the refill gap from 30 to 120 days on the discontinuation rate. From 2002 through 2003, we identified 13,455 women (age 68.8+/-10.4 years) who initiated weekly oral alendronate therapy. RESULTS: Using a 60-day refill gap, the 1-year discontinuation rate was 49.6% [95% confidence interval (CI) 48.8-50.4%]; this increased to 58.0% (CI 57.2-58.8%) with a 30-day gap and decreased to 42.2% (CI 41.1-43.0%) with a 120-day gap. Among those who discontinued therapy, about one-third restarted alendronate or another osteoporosis drug within 6 months. Baseline factors associated with alendronate discontinuation included prior bone mineral density testing [adjusted odds ratio (OR) 0.64, CI 0.60-0.69], prior postmenopausal hormone therapy (OR 0.78, CI 0.73-0.84), prior high-dose oral glucocorticoid therapy (OR 1.26, CI 1.05-1.51), prior gastrointestinal diagnoses (OR 1.21, CI 1.09-1.36), and high number of therapeutic classes of prescriptions filled in the prior year (OR 1.21, CI 1.10-1.32), although the final model had limited explanatory power. CONCLUSIONS: We conclude that apparent discontinuation rates are high within 1 year after treatment initiation, although a subset of women appears to restart bisphosphonate or other osteoporosis therapy. Because intermittent use and/or poor adherence is common, discontinuation rates based on data from administrative databases are sensitive to the refill gap length. In addition, we identified no clinical factors highly predictive of discontinuation.

Outcomes of a disease-management program for patients with recent osteoporotic fracture.

INTRODUCTION: The purpose of this study was to evaluate outcomes of a disease-management program designed to increase rates of bone-mineral-density (BMD) testing and initiation of osteoporosis medication among patients with a recent osteoporotic fracture. STUDY DESIGN: We identified 744 consecutive patients aged>or=55 years who were seen at either of 2 of 14 Kaiser Permanente medical facilities in Northern California (KPNC) after sustaining a fracture of the hip, spine, wrist, or humerus between April 2003 and May 2004. These patients were invited to participate in a study of the Fragile Fracture Management Program, whose protocol used fracture-risk assessment tools to determine treatment recommendations. Postfracture care of study participants was compared with usual postfracture care received by osteoporotic-fracture patients at 12 other KPNC facilities. RESULTS: Of the 744 patients who were invited to participate in the study, 293 (39%) agreed to participate, and 169 (23%) completed the evaluation. Of these 169 patients (127 women, 42 men), 65 (51%) of the women and 7 (17%) of the men qualified for drug treatment; of these 72 patients, 6 (86%) of the men and 41 (63%) of the women accepted the offered treatment. At the two study locations, rates of care (BMD testing or prescribing osteoporosis medication) were about twice as high as rates of usual postfracture care observed at 12 other medical centers in KPNC. CONCLUSIONS: Compared with patients who received usual care for osteoporotic fracture, patients participating in a postfracture disease management program had substantially higher rates of medical attention given for osteoporosis; however, the overall yield of the program was low. This low uptake rate was related to factors not previously appreciated: many patients refused participation in the program; a high proportion of younger women-and men of all ages-did not qualify for treatment; and treatment was refused by one in three study-qualified women and by one in seven study-qualified men. Additional efforts are needed to overcome patient barriers to improved osteoporosis evaluation, treatment and participation in postfracture programs.

Predictors of physical activity in community-dwelling elderly white women.

OBJECTIVE: To describe patterns of physical activity and to determine factors associated with engaging in regular exercise, especially walking, in elderly white women. DESIGN: Cross-sectional study of 9,442 independently living elderly white women aged 65 years and over participating in the Study of Osteoporotic Fractures. MEASUREMENTS AND MAIN RESULTS: We studied the association between lifestyle habits, social factors, health status and self-reported physical activity (assessed by modified Paffenbarger scale) during the past twelve months. Walking was the most common form of exercise: 4,837 (51%) women reported doing so a mean of 12 (SD = 10) blocks per day, 3.9 (SD = 2.9) times per week. Other common activities were gardening (35%), swimming (16%), and bicycling (13%). Less than a third of women reported engaging in medium- or high-intensity exercise in the past year. In a multivariate age-adjusted analysis, factors independently (P < .01) associated with walking for exercise included greater than high school education (52% vs 48%), history of physical activity for exercise at ages 30 years (51% vs 46%) and 50 years (51% vs 45%), and stronger social network (51% vs 47%). Women who were current smokers, obese, or depressed were less likely to take walks for exercise. Marital status, self-reported arthritis, current estrogen use, and a history of falls in the past year were not independently associated with taking walks for exercise. CONCLUSIONS: In this healthy cohort, walking for exercise is associated with other positive health behaviors. Given the mounting evidence about the health benefits of walking, and since many of these community dwelling women can and do walk for exercise, but rarely engage in other common prescribed physical activities, clinicians might best focus their efforts on encouraging walking.

Osteoarthritis and risk of falls, rates of bone loss, and osteoporotic fractures. Study of Osteoporotic Fractures Research Group.

OBJECTIVE: To examine the association between osteoarthritis (OA), as defined by radiographic evidence and self report, and osteoporotic fractures, falls, and bone loss in a cohort of elderly white women. METHODS: A cohort of 5,552 elderly women from the Study of Osteoporotic Fractures was followed up prospectively for a mean of 7.4 years. Self-reported, physician-diagnosed OA was recorded at interview, and radiologic OA of the hip and hand were defined from pelvis and hand radiographs obtained at baseline by validated techniques. Prevalent and incident vertebral fractures were detected by vertebral morphometry, and data on incident fractures and falls were collected by postcard surveys; fractures were confirmed by radiography. Bone mineral density (BMD) was measured on 2 occasions at the hip, lumbar spine, and calcaneus, and rates of bone loss were calculated. RESULTS: Women with radiographic hip OA had a reduced risk of recurrent falls in the first year (relative risk [RR] 0.7, 95% confidence interval [95% CI] 0.5-0.95). However, those with self-reported OA had an increased risk of falls (RR 1.4, 95% CI 1.2-1.5). Radiographic hip OA was associated with reduced bone loss in the femoral neck compared with controls (mean +/- SD -0.29+/-0.09%/year versus -0.51+/-0.03%/year; P = 0.018). However, radiographic hip OA showed nonsignificant trends toward increased bone loss at the calcaneus and lumbar spine. There was no significant association between self-reported OA or radiographic hand OA with bone loss. No definition of OA was associated with incident nonvertebral fracture, hip fracture, or vertebral fracture. CONCLUSION: Despite having increased BMD compared with controls, subjects with OA did not have a significantly reduced risk of osteoporotic fracture, although there was a trend toward a reduced risk of femoral neck fractures in subjects with severe radiographic OA. The failure of the observed increase in BMD to translate into a reduced fracture risk may be due, in part, to the number and type of falls sustained by subjects with OA. Patients with OA should not be considered to be at a lower risk of fracture than the general population. Physicians should be aware that a high BMD in patients with OA may be falsely reassuring.

Association between serum fructosamine and mortality in elderly women: the study of osteoporotic fractures.

Serum fructosamine levels can be used to estimate long-term serum glucose values and can be measured in frozen serum. The authors examined whether fructosamine levels were associated with mortality in a cohort of 9,704 white women (> or = 65 years of age) recruited from September 1986 to October 1988 at four clinical centers in the United States. A random sample of women who had died during a mean of 6 years of follow-up (n = 55) was compared with randomly selected controls (n = 276, 54 of whom had died). Fructosamine assays were performed blinded to vital status. Hazard ratios with 95% confidence intervals were adjusted for age, clinical center, smoking, hypertension, and serum albumin and cholesterol levels. Each standard deviation (46 micromol) increase in fructosamine level was associated with a 1.3-fold (95% confidence interval (CI) 1.0-1.6, p = 0.04) increased rate of all-cause mortality, including a 1.5-fold (95% CI 1.0-2.1, p = 0.03) increase in cardiovascular disease mortality. Elevated fructosamine levels (>285 micromol/liter) were associated with a 4.3-fold (95% CI 1.6-12, p = 0.004) increased rate of cardiovascular mortality; in women without a history of diabetes, the hazard ratio was 4.6 (95% CI 1.3-16, p = 0.02). Fructosamine level, or another indicator of glycemia, should be included when the risk of cardiovascular disease among older patients is evaluated.

Aspirin and nonsteroidal antiinflammatory drug use in elderly women: effects on a marker of bone resorption. The Study of Osteoporotic Fractures Research Group.

OBJECTIVE: Epidemiological studies suggest nonsteroidal antiinflammatory drug (NSAID) and aspirin use is associated with a modest increase in bone mineral density of the hip and lumbar spine. The ability of NSAID to block prostaglandin E2 production has been shown to impair osteoclast activity in animal models. To determine if regular use of these compounds inhibits bone resorption, we assessed NSAID or aspirin use and N-telopeptide crosslink excretion in elderly postmenopausal women. METHODS: N-telopeptide crosslink excretion was assessed from a consecutive sample of 499 women from the Study of Osteoporotic Fractures, age > 65 years, who provided a morning urine sample. Questionnaire, examination, and bone mineral density data were obtained at the same visit. RESULTS: In unadjusted models, daily use of NSAID or aspirin was associated with a reduction of 12.5% (95% CI 0.5, 24.5) in N-telopeptide crosslink excretion (p < 0.05). After adjustment for potential confounders, N-telopeptide crosslink excretion was -4.8% (95% CI -24.4, 14.8) in NSAID users and +7.6% (-9.3, 24.5) in aspirin users compared to nonusers. CONCLUSION: Regular use of either NSAID or aspirin by elderly women was not associated with reduction in N-telopeptide crosslink excretion compared to nonusers.

Association of estrogen replacement therapy with the risk of osteoarthritis of the hip in elderly white women. Study of Osteoporotic Fractures Research Group.

OBJECTIVE: To determine whether postmenopausal estrogen replacement therapy is associated with a reduced risk of radiographic findings of osteoarthritis (OA) of the hip. DESIGN: Cross-sectional study. SUBJECTS: White women (N = 4366; age, > or = 65 years) who were participants in a cohort study of osteoporotic fractures. MEASUREMENTS AND METHODS: Radiographs of the pelvis that were obtained in all subjects were assessed for radiographic features of OA of the hip on a summary scale of 0 (none) to 4 (severe OA). Postmenopausal estrogen use was assessed by interview. The association of current and past oral estrogen use with OA of the hip was analyzed by using logistic regression, adjusting for potential confounding variables (eg, indicators of osteoporosis and correlates of estrogen use). RESULTS: Five hundred thirty-nine women (12.3%) had mild or greater radiographic findings of OA of the hip in at least 1 hip, and 214 women (4.9%) had moderate to severe findings; 17% and 24% of the women were current and past users of oral estrogen, respectively. Women who were currently using oral estrogen had a significantly reduced risk of any OA of the hip (adjusted odds ratio [OR], 0.62; 95% confidence interval [CI], 0.49-0.86) and moderate to severe manifestation of disease (OR, 0.54; 95% CI, 0.33-0.88). Current users who had taken estrogen for 10 years or longer had a greater reduction in the risk of any OA of the hip (OR, 0.57; 95% CI, 0.40-0.82) compared with that of users for less than 10 years (OR, 0.75; 95% CI, 0.47-1.24). Current estrogen use for 10 years or longer was associated with a nonsignificant trend for a reduced risk of moderate to severe symptomatic disease (OR, 0.59; 95% CI, 0.28-1.29). CONCLUSION: Postmenopausal estrogen replacement therapy may protect against OA of the hip in elderly white women.

Mortality following fractures in older women. The study of osteoporotic fractures.

BACKGROUND: Most investigators have hypothesized that the increase in mortality following osteoporotic fractures reflects poor underlying health status in addition to the acute effects of the fracture. METHODS: We observed 9704 ambulatory women aged 65 years or older enrolled in the Study of Osteoporotic Fractures. We obtained reports of fractures and deaths every 4 months and reviewed death certificates and hospital discharge summaries. Multivariable proportional hazards models were used to determine the association between fractures and age-adjusted mortality. RESULTS: During a mean follow-up of 5.9 years, 1737 women had nonspine fractures, with a postfracture mortality rate of 3 per 100 woman-years, compared with 1.8 per 100 woman-years in those who did not have fractures (P < .001). After adjusting for other factors associated with mortality, women (n = 361) with fractures of the hip or pelvis had a 2.4-fold (95% confidence interval, 1.7-3.3) increase in mortality. However, only 9 (14%) of the 64 deaths that occurred after hip or pelvic fractures were caused or hastened by the fracture. By contrast, 11 (17%) of these deaths seemed to have been a result of chronic conditions that has contributed to the hip or pelvic fracture, and 44 (69%) of the deaths were not clearly related to the fracture. CONCLUSIONS: Mortality is increased following several types of fractures in older women. Most of the increase following hip and pelvic fractures is due to underlying conditions and probably would not be affected by reductions in the incidence of these fractures.

Estrogen replacement therapy. A survey of older women's attitudes.

OBJECTIVES: To understand the low prevalence of estrogen use among older women. To examine the reasons for the use and nonuse of estrogen replacement therapy. SUBJECTS AND METHODS: Nonblack women (n = 7667), aged 65 years or older, who participated in the Multicenter Study of Osteoporotic Fractures completed an estrogen questionnaire. RESULTS: Of the subjects, 1335 (17.4%) were currently using oral estrogens, 2084 (27.2%) were past users, and 4248 (55.4%) had never used oral estrogen therapy. The self-reported primary reasons for current users to have initiated therapy included hysterectomy (43.5%), menopausal symptoms (39.3%), prescribed by a physician (38.7%), or prevention or treatment of osteoporosis (33.6%). Of the 2084 former estrogen users (27.2%), the main reasons for starting therapy included prescribed by a physician (44.7%), menopausal symptoms (49.2%), and hysterectomy (28.5%). Approximately 30% of past estrogen users reported the primary reason for discontinuing therapy as "feeling that they didn't need it," whereas 16.4% reported undesirable side effects with bleeding as the most common (45.0%). The main reason women never started estrogen therapy (55.4%) was they feared that the medication was harmful (38.1%) or they felt they did not need it (29.5%). CONCLUSIONS: We conclude that older women in the United States remain skeptical about long-term estrogen use despite its potential for protection against 2 major chronic diseases, osteoporosis and cardiovascular disease. Greater understanding about the barriers to estrogen replacement therapy and improved knowledge of its risks and benefits may reduce the skepticism surrounding estrogen replacement therapy among older women.

The association of radiographic changes of osteoarthritis of the hand and hip in elderly women.

OBJECTIVE: To examine the association of radiographic features of hand and hip osteoarthritis (OA) in elderly women. METHODS: Hand and hip radiographs were read for changes of OA from a sample of 1422 women aged 65 and above who were participants in the Study of Osteoporotic Fractures. Definite hip OA required the presence of 2 or more of the following: moderate or large osteophytes, moderate or severe joint space narrowing, subchondral sclerosis, cysts, and femoral head deformity. Definite hand OA required moderate or large osteophytes at 2 or more of the following 6 sites: 2nd and 3rd distal and proximal interphalangeal joints and 1st interphalangeal and carpometacarpal joints. Data were analyzed using multiple logistic regression adjusting for age, weight at age 50, and current height. RESULTS: Overall, 147 (10.4%) women had radiographic changes of definite hip OA and 68 (4.8%) had severe hip OA; 56 had bilateral and 87 had unilateral disease. Definite hand OA was present in 732 (51.4%) women. Hand OA was significantly associated with definite hip OA [odds ratio (OR) = 3.25, 95% confidence intervals (CI) 2.19, 4.84], and severe hip OA (OR = 3.23, 95% CI 1.82, 5.73). Hand OA was significantly associated with bilateral hip OA (OR = 3.54, 95% CI 1.87, 6.73) as well as unilateral hip OA (OR = 3.06, 95% CI 1.84, 5.08). CONCLUSION: These data are consistent with the inclusion of radiographically defined hip OA in the construct of generalized OA, particularly in elderly women.

Radiographic osteoarthritis of the hip and bone mineral density. The Study of Osteoporotic Fractures Research Group.

OBJECTIVE: To examine the cross-sectional association between radiographic features of hip osteoarthritis (OA) and bone mineral density (BMD) of the hip, spine, and appendicular skeleton among Caucasian women ages 65 and older who were participating in the Study of Osteoporotic Fractures. METHODS: Pelvis radiographs of 4,855 subjects were assessed for individual radiographic features of hip OA: osteophytes, joint space narrowing, subchondral sclerosis, cysts, and femoral head deformity. Hips were graded on a summary scale of 0 (no OA) to 4 (severe OA) based on the number of radiographic features present. Appendicular BMD was measured in all subjects, and hip and spine BMD in 84% of the group. We used linear regression to examine the association of BMD with hip OA, and to adjust for age, weight, and other determinants of bone mass. RESULTS: Three hundred fifty-one women (7.2%) had mild (grade 2) and 228 (4.7%) had moderate to severe (grade 3-4) radiographic evidence of hip OA. Women with grade 3-4 hip OA had a higher age-adjusted BMD at the femoral neck and Ward's triangle (9-10%; P < 0.0001), trochanter (4%; P < 0.01), lumbar spine (8%; P < 0.0001), and distal radius and calcaneus (5%; P < 0.0001 [for each comparison]) compared with those with grade 0-1 OA in the worse hip. Elevations in BMD were greatest in the femoral neck of hips with OA, in women with bilateral hip OA, and in women with hip osteophytes. These findings were essentially unchanged by adjustment for determinants of bone mass. CONCLUSION: Elderly Caucasian women with moderate to severe radiographic hip OA had higher BMD in the hip, spine, and appendicular skeleton than did women without hip OA. Our findings are consistent with a role of elevated BMD in the pathogenesis of hip OA.

Rheumatoid arthritis and bone mineral density in elderly women. The Study of Osteoporotic Fractures Research Group.

Previous studies have suggested that women with rheumatoid arthritis (RA) have decreased bone mineral density (BMD) in both the appendicular and axial skeleton. The purpose of this investigation was to determine the association of RA and BMD from a community-based sample of ambulatory Caucasian women age 65 and over. BMD was measured by dual-energy X-ray absorptiometry (DXA) at the hip and lumbar spine and by single photon absorptiometry (SPA) at the distal radius and calcaneus. Study subjects included 120 postmenopausal women with RA who were further classified according to corticosteroid use, i.e., never users, current users, and ex-users, and 7966 age-similar controls. Elderly women with RA had a lower age-adjusted bone density of the distal radius, calcaneus, hip, and lumbar spine. Women with RA who were current users of steroids had the lowest BMD at both appendicular sites and at the hip, but those who never used steroids also had a significantly decreased BMD at all sites. The BMD of women with RA who had never used steroids remained significantly decreased at the distal radius, calcaneus, and hip after adjustment for age, BMD determinants, and functional outcomes of RA. Functional outcomes of RA largely accounted for the lower BMD of women who were currently using steroids. Women with RA have lower appendicular and axial bone mass that is not attributable to the use of steroids. Those currently taking steroids have even lower appendicular and axial bone mass that may reflect their poorer functional outcome and is likely to increase the risk of fractures.(ABSTRACT TRUNCATED AT 250 WORDS)

Association between low bone density and stroke in elderly women. The study of osteoporotic fractures.

BACKGROUND AND PURPOSE: To determine whether women with low bone mineral density are at increased risk of stroke, the present study was conducted. METHODS: We studied 4024 ambulatory women aged 65 years or older participating in the prospective Study of Osteoporotic Fractures. Bone mineral density was measured at baseline using single photon absorptiometry; strokes were ascertained using a computerized Medicare data base and death certificates. RESULTS: During a mean of 1.98 years of follow-up, 83 women suffered first strokes (five fatal). Osteopenia was associated with an increased stroke risk: Each SD decrease in bone mineral density at the calcaneus (0.09 g/cm2) was associated with a 1.31-fold increase in stroke (95% confidence interval, 1.03-1.65), adjusted for age, follow-up time, and several potential confounders, including diabetes, systolic blood pressure, use of alcohol, cigarettes or postmenopausal estrogens, cognitive ability, grip strength, and functional ability. The observed relation between bone density and stroke was strongest for intracerebral hemorrhages and occlusions. CONCLUSIONS: Most likely, low bone density does not cause stroke; some other process probably results in both osteopenia and cerebrovascular disease.

Long-term follow-up of relaxation training for pediatric headache disorders.

The long-term effects of relaxation training for pediatric headache disorders was determined for 17 of 20 original participants from a prospective control-group experimental design study with random assignment to autogenic relaxation, progressive relaxation, autogenic plus progressive relaxation, or waiting list control groups. Long-term follow-up data were obtained at an average of 51 months post-treatment. All participants reported some increases in headache activity. Participants in the three relaxation treatment groups, however, had significantly more headache-free days and less severe headaches compared to the control group. There were no significant effects of treatment for headache duration, medication intake and rest time due to headache. Twelve of the 13 treated participants indicated relaxation training was effective in relieving headaches, with 7 reporting they practiced relaxation exercises within the past month. The results generally support the long-term benefits of relaxation in reducing headaches originating in childhood.