CLINICAL BRIEF
Suzanne M. Cadarette, PhD; Andrea M. Burden, BSc, MA
The burden of osteoporosis in Canada Osteoporosis is a major public health concern that results in considerable fracture-related morbidity, reduced quality of life and shortened survival. This brittle bone condition is one of the most prevalent diseases of aging, affecting more than 1.5 million Canadians.1 Osteoporosis is defined clinically based on bone mineral density (BMD) measurement, with prevalence in Canada increasing from 4% of men and 6% of women aged 50 to 59 years, to more than 20% of men and 40% of women aged 80 and older.2 Osteoporosis increases the risk for fragility fractures occurring spontaneously or as a result of minimal trauma (e.g., fall from standing height or less),3 and higher trauma fractures.4 Most fractures among adults, other than skull, fingers and toes, are associated with low BMD. The most common fracture sites are the forearm or wrist, vertebra and hip. Fractures of the humerus, pelvis and rib are increasingly recognized as important in terms of prevalence and morbidity. Fragility fractures are the most important indicator of underlying osteoporosis and are a strong predictor of future fracture,5,6 with risk greatest within the first year after an incident fracture.7 Forearm and wrist fractures are often the first symptomatic sign of osteoporosis, manifesting primarily in women, with incidence rate increasing around menopause.8 Vertebral fractures are the most common type of osteoporotic fracture; however, less than half are symptomatic and come to clinical attention.9 The prevalence of vertebral fractures increases with age, from about 15% of men and 11% of women aged 50 to 59, to 36% of men and 45% of women aged 80 or older.10 Clinical vertebral fractures lead to a decline in physical function, loss of independence, dissatisfaction with body image and kyphosis, with chronic pain, narcotic use, height loss and gastrointestinal problems.11,12 These complications can lead to loss of self-esteem, fear of falling and social isolation.12,13 Vertebral fractures increase mortality risk.9 Although the mechanism is not clearly known, change in posture and reduced mobility may increase infection risk,14 and reductions in quality of life15 may affect coping abilities, contributing to a progressive decline in health. Hip fractures are the most important type of fracture in terms of functional dependence, mortality and social cost. The incidence of hip fracture begins to increase after age 60,16 with a mean age at time of fracture of 80.17,18 Approximately 5% of hip fracture patients die in hospital, and 20% (women) to 30% (men) die within the year after fracture.17-19 Men account for about 28% of hip fracture cases.17,18 Multiple comorbidities, postoperative hip surgery complications/events and reduced mobility with loss of strength and muscle mass contribute to general frailty, functional decline and shortened survival following hip fracture.14,20 Among hip fracture patients surviving to 1 year, 40% are unable to walk independently, 60% have difficulty with at least 1 essential activity of daily living and 80% are limited in other C P J / R P C • M AY / J U N E 2 0 1 1 • V O L 1 4 4 [ S U P P L 1 ]
activities such as driving and grocery shopping.21 In addition, 15% to 31% of hip fracture patients enter a nursing home or chronic care facility for the first time as a direct result of the fracture.22,23 The annual cost for hip fracture treatment in Canada was $650 million in 1997, and is expected to rise to $2.4 billion by 2041.23 Hip fractures quickly become not only a personal burden, but also a social burden. Fortunately, effective treatment exists to reduce fracture risk6,24 and pharmacotherapy has at least partly contributed to a decline in age-adjusted fracture rates over time.25 However, a therapeutic care gap in osteoporosis management exists — most patients at high risk for fracture are not identified for treatment, and about half of patients who start osteoporosis pharmacotherapy stop treatment within the first year.26,27 Our aging population will result in an increased total number of fractures. Without effective interventions to bridge the therapeutic care gap in osteoporosis management, the burden of osteoporosis in Canada can be expected to increase. n From the Leslie Dan Faculty of Pharmacy at the University of Toronto in Toronto, Ontario. Contact:
[email protected]. Dr. Cadarette holds a Canadian Institutes of Health Research (CIHR) New Investigator Award in the Area of Aging and Osteoporosis and an Ontario Ministry of Research and Innovation Early Researcher Award. Ms. Burden is supported by a University of Toronto Wyeth Pharmaceutical Fellowship in Health Outcomes Research, and Bone and Mineral Group Scholarship.
References 1. Public Health Agency of Canada. What is the impact of osteoporosis in Canada and what are Canadians doing to maintain healthy bones? Fast facts from the 2009 Canadian Community Health Survey — osteoporosis rapid response. Cat.: HP35-19/2-2010E-PDF; 2010. Available: www.phac-aspc.gc.ca/cd-mc/ osteoporosis-osteoporose/index-eng.php (accessed March 15, 2011). 2. Kmetic A, Joseph L, Berger C, Tenenhouse A. Multiple imputation to account for missing data in a survey: estimating the prevalence of osteoporosis. Epidemiology 2002;13:437-44. 3. Brown J, Bessette L, Jean S, et al. Validation of a clinical definition for fragility fracture [abstract]. Bone Miner Res 2007;22 (Suppl 1):S198. 4. Mackey DC, Lui LY, Cawthon PM, et al. High-trauma fractures and low bone mineral density in older women and men. JAMA 2007;298:2381-8. 5. Klotzbuecher CM, Ross PD, Landsman PB, et al. Patients with prior fractures have an increased risk of future fractures: a summary of the literature and statistical synthesis. J Bone Miner Res 2000;15:721-39. 6. Papaioannou A, Morin S, Cheung AM, et al. 2010 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada: summary. CMAJ 2010;182:1864-73. 7. Giangregorio LM, Leslie WD. Time since prior fracture is a risk modifier for S3
10-year osteoporotic fractures. J Bone Miner Res 2010;25:1400-5.
ahead of print.
8. Orces CH, Martinez FJ. Epidemiology of fall related forearm and wrist frac-
18. Alzahrani K, Gandhi R, Davis A, et al. In-hospital mortality following hip
tures among adults treated in US hospital emergency departments. Inj Prev
fracture care in southern Ontario. Can J Surg 2010;53:294-8.
2011;17:33-6.
19. Bentler SE, Liu L, Obrizan M, et al. The aftermath of hip fracture: dis-
9. Bliuc D, Nguyen ND, Milch VE, et al. Mortality risk associated with low-
charge placement, functional status change, and mortality. Am J Epidemiol
trauma osteoporotic fracture and subsequent fracture in men and women. JAMA
2009;170:1290-9.
2009;301:513-21.
20. Haentjens P, Magaziner J, Colón-Emeric CS, et al. Meta-analysis: excess
10. Jackson SA, Tenenhouse A, Robertson L, et al. Vertebral fracture definition
mortality after hip fracture among older women and men. Ann Intern Med
from population-based data: preliminary results from the Canadian Multicenter
2010;152:380-90.
Osteoporosis Study (CaMos). Osteoporos Int 2000;11:680-7.
21. Cooper C. The crippling consequences of fractures and their impact on
11. Katzman WB, Vittinghoff E, Kado DM. Age-related hyperkyphosis,
quality of life. Am J Med 1997;103(2A):12S-19S.
independent of spinal osteoporosis, is associated with impaired mobility in older
22. Jaglal SB, Sherry PG, Schatzker J. The impact and consequences of hip frac-
community-dwelling women. Osteoporos Int 2011;22:85-90.
ture in Ontario. Can J Surg 1996;39:105-11.
12. Hallberg I, Ek AC, Toss G, et al. A striving for independence: a qualitative
23. Wiktorowicz ME, Goeree R, Papaioannou A, et al. Economic implications of
study of women living with vertebral fracture. BMC Nurs 2010;9:7.
hip fracture: health service use, institutional care and cost in Canada. Osteoporos
13. Gold DT. The clinical impact of vertebral fractures: quality of life in women
Int 2001;12:271-8.
with osteoporosis. Bone 1996;18:185S-189S.
24. MacLean C, Newberry S, Maglione M, et al. Systematic review: comparative
14. Ioannidis G, Papaioannou A, Hopman WM, et al. Relation between fractures
effectiveness of treatments to prevent fractures in men and women with low
and mortality: results from the Canadian Multicentre Osteoporosis Study. CMAJ
bone density or osteoporosis. Ann Intern Med 2008;148:197-213.
2009;181:265-71.
25. Leslie WD, O’Donnell S, Jean S, et al. Trends in hip fracture rates in Canada.
15. Papaioannou A, Kennedy CC, Ioannidis G, et al. The impact of incident
JAMA 2009;302:883-9.
fractures on health-related quality of life: 5 years of data from the Canadian
26. Fraser LA, Ioannidis G, Adachi JD, et al. Fragility fractures and the osteopor-
Multicentre Osteoporosis Study. Osteoporos Int 2009;20:703-14.
osis care gap in women: the Canadian Multicentre Osteoporosis Study. Osteo-
16. Sanders KM, Seeman E, Ugoni AM, et al. Age- and gender-specific rate of
poros Int 2011;22:789-96.
fractures in Australia: a population-based study. Osteoporos Int 1999;10:240-7.
27. Kothawala P, Badamgarav E, Ryu S, et al. Systematic review and meta-analy-
17. Morin S, Lix LM, Azimaee M, et al. Mortality rates after incident non-trau-
sis of real-world adherence to drug therapy for osteoporosis. Mayo Clin Proc
matic fractures in older men and women. Osteoporos Int 2011 Dec 16. Epub
2007;82:1493-501.
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