Death, Debility, and Destitution Following Hip Fracture and the Public Health Impact of Osteoporosis

Anne Weinberger, ANP
Bitterroot Physicians Clinic
A Marcus Daly Memorial Hospital Clinic
1200 Westwood Drive
Hamilton, MT 59840
(406) 363-1100

Death, Debility, and Destitution Following Hip Fracture and the Public Health Impact of Osteoporosis
Hip fractures in older adults are associated with increased mortality, morbidity, risk of second fracture, and decreased independence. One year mortality risk following hip fracture in patients age 65 and over has been estimated between 12% and 37%, and 5 year mortality risk can reach upwards of 60% in some elderly populations. Among hip fracture survivors, half do not regain their pre-fracture functionality, and approximately, 20% require some type of long term care.

Becoming dependent on institutional long term care is an undesirable outcome that can itself result in lower quality of life. Long term care is expensive. Estimates of private long term care costs range between $60,000 and $72,000 per year. Long term care insurance is available, but only about 2.3% of the US population and 12.4% of individuals age 65 and over have this type of insurance. Many people who experience a hip fracture run the risk of exhausting their financial resources to pay for care and can subsequently become eligible for Medicaid, adding to the social costs. Medicaid pays approximately $109 billion a year for long term care of the elderly adults.

The older adult and elderly populations are those most vulnerable to hip fractures. This is projected to grow by 60% by 2025. Also the rates of osteoporosis are projected to rise over the next decade. An aging population and increased rates of osteoporosis could lead to an increase in fractures, potentially leading to increases in direct medical expenditure, societal burden, death, debility, destitution, and a decrease in quality of life for this population if initiatives to improve the treatment of osteoporosis and the prevention of fractures are not implemented.

Osteoporosis is a major public health problem. The National Osteoporosis Foundation estimates that 10.2 million Americans have osteoporosis and that an additional 43.4 million have low bone mass. More than 2 million osteoporosis-related fractures occur annually in the United States, more than 70% of these occur in women. In the United States Medicare currently pays for most of these costs, and as the population ages, the costs of these fractures are estimated to exceed $25 billion by 2025. Despite these significant costs, fewer than 1 in 4 women aged 67 years or older with an osteoporosis-related fracture undergo bone density measurement nor do they begin osteoporosis treatment. A recent study demonstrated that the annual cost of caring for osteoporotic fracture exceeds the annual costs of caring for breast cancer, myocardial infarction, or stroke in women aged 55 years or older.

Osteoporosis is preventable and treatable, but only a small proportion of those at increased risk for fracture are evaluated and treated. Age is an important risk factor for bone loss, by age 60, half of white women have osteopenia, which is early bone loss, or osteoporosis. The average femoral neck T-score by DEXA scan for 75 year old women is -2.5, meaning that more than half of women age 75 and older meet the criterion for osteoporosis. More than 20% of postmenopausal women have prevalent vertebral fractures. Although these guidelines focus on the evaluation and treatment of osteoporosis in postmenopausal women, osteoporosis may affect men and premenopausal women.

Osteoporosis is defined as a silent skeletal disorder characterized by compromised bone strength predisposing to an increased risk of fracture. Bone strength reflects the integration of two main features, bone density and bone quality.

Clinically, osteoporosis can be diagnosed if there is a low trauma, also known as a fragility fracture, in the absence of other metabolic bone disease, independent of the Bone Mass Density or T-score value. Patient with osteopenia or low bone mass defined as T-score between -1.0 and -2.5 based on DEXA scan but with a low trauma fragility fracture of the spine, hip, proximal humerus, pelvis, or possibly distal forearm are also at an increased risk for future fractures and should be diagnosed with osteoporosis and considered for pharmacologic therapy. Osteoporosis has traditionally been diagnosed based on DEXA scan T-scores less than -2.5 in the lumbar spine, total hip and femoral neck. The National Bone Health Alliance proposed new clinical diagnosis guidelines of osteoporosis as patients with osteopenia and increased fracture risk using the FRAX score. The FRAX score is a measurement tool which predicts a 10 year probability of a hip fracture or major osteoporosis-related fracture based on the US adapted World Health Organization algorithm.

All postmenopausal women older than 50 years should undergo clinical assessment for osteoporosis and fracture risk, including a detailed history and physical examination. Tools such as the WHO clinical fracture risk assessment FRAX should be utilized when available. The US Preventive Services Task Force recommends BMD testing for all women age 65 or older and younger women whose fracture risk is equal to or greater than that of a 65 year old white woman who has no additional risk factors.

Fracture is the single most important manifestation of postmenopausal osteoporosis. Osteoporotic fractures are usually precipitated by low-energy injuries such as a fall from standing height. Osteoporosis can also be diagnosed in patients with or without fragility fractures. Vertebral fractures, however, may occur during routine daily activities, without a specific fall or injury. In clinical practice, it may be difficult or impossible to reconstruct the mechanical force applied to bone in a particular fall.

Osteoporosis-related fractures often lead to pain, disability, and deformity and reduce quality and quantity of life. Hip fractures are the most serious consequence of osteoporosis. Women with hip fracture have an increased mortality of 12% to 20% during the following 2 years. More than 50% of hip fracture survivors are unable to return to independent living. Many require long term nursing home care. Other low trauma fractures that are considered osteoporosis-related include those of the proximal humerus and pelvis and in some cases of the distal forearm.

As many as 50% of hip fractures can be prevented through the use of anti-osteoporosis medication, a substantially larger percent reduction than the 17% reduction in stroke associated with the use of pharmaceutical interventions. In light of these differences, I do not advocate for a decrease in attention to stroke prevention, but rather an increase in attention to hip fracture prevention. This information needs to be passed on to policy makers, clinicians, public health researchers, and decision makers to estimate the potential health and economic benefits of interventions to reduce hip fracture rates.

Additionally, admission into long term care residence and loss of independence as a result of hip fracture are an undesirable outcome for the elderly population with some studies reporting a majority of older women preferring death to nursing home admission. Given the increased probability of death and debility following hip fracture, the increased financial burden and loss of quality of life for individuals and families as a results of long term care residence, and the costs to the Medicare and Medicaid programs, much greater effort at promoting prevention, particularly among high risk individuals is warranted.

Osteoporosis has a direct correlation with diet, exercise, and overall health; and it is on the raise in younger ages. For more information about this important topic join Anne Weinberger, ANP of Bitterroot Physicians Clinic and Desiree Dutton, MPT on Thursday, March 9 th from 5:30 to 7pm at Marcus Daly Memorial Hospital for engaging and interactive "Bone Health Matters" class. Doors open at 5pm; arrive early and get your posture checked!

Questions and or comments regarding this week's health column please contact Anne Weinberger, ANP at the Bitterroot Physicians Clinic, a Marcus Daly Memorial Hospital owned clinic, 1200 Westwood Drive, Hamilton, MT 59840. Working together to build a healthier community!