Physical activity and osteoporotic hip fracture risk in men

BACKGROUND: Physical activity has been related to reduced risk of osteoporotic hip fractures, but the evidence among men is weak. OBJECTIVE: To determine the association between baseline leisure physical activity and future risk of osteoporotic hip fracture in men. METHODS: At baseline in 1975 our prospective study cohort included 3,262 men who were 44 years or older and did not have chronic disease restricting their ability to exercise. At baseline, physical activity was assessed by a questionnaire. Hip fractures were followed for 21 years, or from the age of 50 years for subjects who were initially younger than 50 years. RESULTS: The hazard ratio of osteoporotic hip fracture, adjusted for other possible predictors (height, body mass index, baseline diseases, smoking, use of alcohol, work-related physical activity, and occupational group), in men participating in vigorous physical activity compared with men not participating was 0.38 (95% confidence interval, 0.16-0.91) (P = .03). CONCLUSION: These results provide further evidence that there is an inverse association between baseline physical activity and future hip fracture risk among men.     

Evaluation of exercise as a preventive therapy for osteoporosis

Osteoporosis and osteoporotic fractures have become an epidemic in the industrialized world. Osteoporosis, low bone mass, is a silent condition with microarchitectural deterioration of the bone structure leading to decreased bone strength and osteoporotic fractures. Physical activity has been advocated as offering a potential means to increase and maintain bone mineral density. Previous cross-sectional studies showed that there is a strong association between exercise and bone mineral density, especially in athletic individuals. However, there might be a self-selection bias; i.e. individuals with larger muscles and bones are more likely to choose an athletic lifestyle. Although there is a report that physical activity is associated with a reduced risk for hip fracture among older community-dwelling women, the effects of vigorous exercises building bone mass is modest and considerably less than bisphosphonates. The proper evaluation of exercise as a preventative therapy for osteoporosis should focus on prevention of falls or osteoporotic fractures.     

Management of the oldest old with osteoporosis

The incidence of osteoporotic fracture increases with age; the median age for hip fracture, the most serious manifestation of osteoporosis is approximately 83 years. Osteoporotic fracture risk is multifactorial, and is determined by the balance between bone strength and the propensity for falling. Frailty is an independent predictor of falls, hip fractures, hospitalisation, disability and death in the elderly that guides for clinical decision-making, and may emerge as a therapeutic target. Non-pharmacological strategies to reduce fall risk can contribute to prevent osteoporotic fractures. Weight-bearing exercise and balance training programmes are recommended. Nutrition, particularly dietary proteins are of importance in preventing falls and fracture, as well as in fracture rehabilitation. Vitamin D and calcium supplementation is effective in reducing both falls and osteoporotic fractures, including hip fractures. Specific efficacious anti-osteoporosis drugs are underused. The evidence base for the efficacy of most such drugs in the very elderly is incomplete, particularly with regard to nonvertebral and hip fractures. Nonadherence to treatment is a substantial problem, which precludes efficacious therapeutic regimens to fulfil their goals.     

Hip fracture in women without osteoporosis

The proportion of fractures that occur in women without osteoporosis has not been fully described, and the characteristics of nonosteoporotic women who fracture are not well understood. We measured total hip bone mineral density (BMD) and baseline characteristics including physical activity, falls, and strength for 8065 women aged 65 yr or older participating in the Study of Osteoporotic Fractures and then followed these women for hip fracture for up to 5 yr after BMD measurement. Among all participants, 17% had osteoporosis (total hip BMD T-score < or = -2.5). Of the 243 women with incident hip fracture, 54% were not osteoporotic at start of follow-up. Nonosteoporotic women who fractured were less likely than osteoporotic women with fracture to have baseline characteristics associated with frailty. Nevertheless, among nonosteoporotic participants, several characteristics increased fracture risk, including advancing age, lack of exercise in the last year, reduced visual contrast sensitivity, falls in the last year, prevalent vertebral fracture, and lower total hip BMD. These findings call attention to the many older women who suffer hip fracture but do not have particularly low antecedent BMD measures and help begin to identify risk factors associated with higher bone density levels.     

What is the role of falls?

There is now firm evidence to support interventions in the prevention of falls in older people, and emerging data support prevention of falls as a method of fracture prevention. This chapter discusses the epidemiology of falls, risk factors associated with an increased risk of falling, assessment of the older faller, and evidence-based approaches to the prevention of falls in the older person. Several randomized controlled trials have found that hip protectors, if worn, probably prevent hip fractures, but that poor compliance is a major issue limiting the effectiveness of this form of intervention. More data are needed to support the role of prevention of falls in preventing fractures, as well as comparative cost-effectiveness data with other evidence-based approaches to preventing fractures in an older population.     

Pharmacological treatment of osteoporosis for people over 70

Osteoporosis has been defined as "a systemic disease characterized by low bone mass and microarchitectural deterioration of bone tissue, with consequent increase in bone fragility and susceptibility to fracture". The impact of osteoporosis is most pronounced in elderly populations who run the greatest risk of fractures. The probability of developing mainly hip, vertebral and other non-vertebral fractures (for example, a Colles fracture) not only depends on bone mineral density (BMD) but also on age. Older patients are more susceptible to fracture than younger patients with the same BMD T-score. As the older population increases, the incidence of osteoporotic fractures is expected to rise dramatically over the next few decades. Although hip fractures are considered to be the most severe and economically important osteoporotic fracture, vertebral fractures also lead to adverse health outcomes, including back pain, height loss and kyphosis. These changes may result in significant declines in physical performance, function and, ultimately, loss of independence. The challenge for physicians is to prevent bone loss, to diagnose and treat osteoporosis before fractures occur, and to treat patients who have already experienced a fracture to prevent recurrent fractures. The objective of this review is to analyze the capacity to reduce fractures as the key element to evaluate the effectiveness of available medications: calcium and Vitamin D, bone formation drugs, antiresortive drugs, and dual-effect drugs. In view of the paucity of information about treatment of osteoporosis in the elderly population, available studies were not designed with this objective, so that this article reviews data mostly deriving from post-hoc analysis or sub-analysis of the main phase III clinical trials of each of the tested medications.     

Are patients with hip fractures more osteoporotic? Review of the evidence

This report critically reviews 15 case-control studies that disagree about whether patients who fracture their hip are significantly more osteoporotic than persons of similar age who do not. The most rigorously designed studies observed less bone mass in the hips of patients with fractures than in the hips of control subjects, but the differences were usually small and overlapping. Measurements at other sites in the skeleton did not consistently find differences. Those studies that protected against ascertainment bias generally found smaller differences than studies that did not. Patients with hip fractures do not appear to be distinctly more osteoporotic than persons of similar age. Therefore, factors besides bone mass, such as a tendency to fall, may be important determinants of which elderly persons will have fractures; thus, measurements of bone mass might not be a reliable way to identify those at greatest risk of hip fracture.     

Efficacy,effectiveness and side effects of medications used to prevent fractures

There is an increasing number of effective therapies for fracture prevention in adults at risk of osteoporosis. However, shortcomings in the evidence underpinning our management of osteoporosis still exist. Evidence of antifracture efficacy in the groups of patients who most commonly use calcium and vitamin D supplements is lacking, the safety of calcium supplements is in doubt, and the safety and efficacy of high doses of vitamin D give cause for concern. Alendronate, risedronate, zoledronate and denosumab have been shown to prevent spine, nonspine and hip fractures; in addition, teriparatide and strontium ranelate prevent both spine and nonspine fractures, and raloxifene and ibandronate prevent spine fractures. However, most trials provide little information regarding long‐term efficacy or safety. A particular concern at present is the possibility that oral bisphosphonates might cause atypical femoral fractures. Observational data suggest that the incidence of this type of fracture increases steeply with duration of bisphosphonate use, resulting in concern that the benefit–risk balance may become negative in the long term, particularly in patients in whom the osteoporotic fracture risk is not high. Therefore, reappraisal of ongoing use of bisphosphonates after about 5 years is endorsed by expert consensus, and ‘drug holidays’ should be considered at this time. Further studies are needed to guide clinical practice in this area.     

Prevention of fall and fracture

Many programs to prevent falls were designed for intervention in fall risk factors. Several meta-analyses, based on many randomized, controlled trials and conducted for the purpose of evaluating the efficacy of these interventions, have been published recently. According to these studies, multifactorial fall risk assessment and management, as well as muscle strengthening and balance retraining, succeeded in reducing falls by approximately 10-38%. Only New Zealand trials were found to decrease even injurious falls, with reduction of moderate or serious injuries by 35% using fall prevention. However, there was no significant difference between the two groups when looking at only serious injuries such as fractures. Thus, fall prevention can prevent falls, but not fractures at present.     

Is physical activity protective against hip fracture in frail older people?

BACKGROUND: there is limited evidence of a protective effect of physical activity in preventing hip fractures among older people living in institutions and in those aged 80 or over. OBJECTIVE: to examine the relationship between physical activity and risk of hip fracture in frail older people. DESIGN: a case-control study. SETTING: Auckland, New Zealand. SUBJECTS: a random sample of individuals hospitalized with a fracture of the femoral neck (n=911) and 910 randomly selected age- and sex-matched individuals from the lists of a random sample of general practitioners. METHODS: we sought information on physical activity and other potential risk factors for hip fracture from cases and controls, using a standardized interviewer-administered questionnaire. We conducted multivariate analyses, separately for those living in private homes and residential institutions. RESULTS: increasing hours of physical activity per week protected against the risk of hip fracture among individuals living in private homes, including those who are over 80. However, among individuals living in institutions, physical activity levels were extremely low (<15% participated in >/=2 h per week) and there was limited evidence of a protective effect. CONCLUSIONS: efforts to prevent hip fractures in individuals living in care homes and institutions should focus on passive interventions which are known to be effective.     

The evidence that exercise during growth or adulthood reduces the risk of fragility fractures is weak

There has never been, and will never be, a randomized double-blind placebo-controlled trial demonstrating that exercise in youth, adulthood or old age reduces fragility or osteoporosis-related fractures in old age. The next level of evidence, a randomized, controlled but unblinded study with fractures as an end-point is feasible but has never been done. The basis for the belief that exercise reduces fractures is derived from lower levels of 'evidence', namely, retrospective and prospective observation cohort studies and case-control studies. These studies are at best hypothesis generating, never hypothesis testing. They are all subject to many systematic biases and should be interpreted with extreme scepticism. Surrogate measures of anti-fracture efficacy are the next level of evidence, such as the demonstration of a reduction in risk factors for falls, a reduction in falls, a reduction in fractures due to falls, an increase in peak bone size and mass, prevention of bone loss in midlife and restoration of bone mass and structure in old age.     

Knee pain, knee osteoarthritis, and the risk of fracture

OBJECTIVE: Patients with osteoarthritis (OA) have increased bone mineral density; however, the association between knee OA and fracture is controversial. Few data exist on the association between knee pain and fracture. We examined the association of knee OA and knee pain with fracture and falls in elderly men and women. METHODS: The study group comprised 6,641 men and women ages > or =75 years who participated in a 3-year randomized controlled trial of intramuscular vitamin D therapy. Patients completed a questionnaire about knee pain and OA. Fracture and fall data were collected prospectively every 6 months. RESULTS: Knee pain prevalence and a clinician diagnosis of knee OA were 35.2% and 6.8%, respectively. A total of 436 incident nonvertebral fractures were reported, and 3,992 patients sustained a fall. Prevalent knee pain was associated with an increased risk of falls (hazard ratio [HR] 1.26, 95% confidence interval [95% CI] 1.17-1.36) and hip fracture (HR 2.0, 95% CI 1.18-3.37). Increasing severity of knee pain was associated with a greater risk of falls and hip fracture. Clinician diagnosis of knee OA was associated with an increased risk of nonvertebral fractures (HR 1.61, 95% CI 1.09-2.36). The increased risk of fracture was not substantially reduced by adjusting for falls, but was attenuated by adjustment for the use of walking aids. CONCLUSION: Patients with a clinical diagnosis of knee OA and with knee pain have an increased risk of nonvertebral and hip fracture. This is not explained by the increased risk of falls, but is more likely to be due to the severity of falls sustained. Knee pain and OA should be regarded as independent risk factors for fracture.     

Dementia medications and risk of falls, syncope, and related adverse events: meta-analysis of randomized controlled trials

OBJECTIVES: To evaluate the effect of cholinesterase inhibitors (ChEIs) and memantine on the risk of falls, syncope, and related events, defined as fracture and accidental injury. DESIGN: Meta‐analysis of randomized controlled trials that were identified from MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials (no language restriction, through July 2009), and manual search. SETTING: Community and nursing homes. PARTICIPANTS: Participants in fifty‐four placebo‐controlled randomized trials and extension studies of ChEIs and memantine that reported falls, syncope, and related events in cognitively impaired older adults. MEASUREMENTS: Falls, syncope, fracture, and accidental injury. RESULTS: ChEI use was associated with greater risk of syncope (odds ratio (OR)=1.53, 95% confidence interval (CI)=1.02–2.30) than placebo but not with other events (falls: OR=0.88, 95% CI=0.74–1.04; fracture: OR=1.39, 95% CI=0.75–2.56; accidental injury: OR=1.13, 95% CI=0.87–1.45). Memantine use was associated with fewer fractures (OR=0.21, 95% CI=0.05–0.85) but not with other events (falls: OR=0.92, 95% CI=0.72–1.18; syncope: OR=1.04, 95% CI=0.35–3.04; accidental injury: OR=0.80, 95% CI=0.56–1.12). There was no differential effect according to type and severity of cognitive impairment, residential status, or length of follow‐up, although because of underreporting and small number of events, a potential benefit or risk cannot be excluded. CONCLUSION: ChEIs may increase the risk of syncope, with no effects on falls, fracture, or accidental injury in cognitively impaired older adults. Memantine may have a favorable effect on fracture, with no effects on other events. More research is needed to confirm the reduction in fractures observed for memantine.     

EBM of hip protectors

In Japan, where the population is rapidly growing older, the prevention of hip fractures is becoming increasingly important. Although bisphosphonates were reported to prevent these fractures, their effectiveness was confirmed in relatively younger elderly patients. The prevention of hip fractures, the majority of which occur in older people, may not be achieved sufficiently only by bisphosphonates, and may require other measures including the use of a hip protector. Elderly people who tend to fall, nursing-home residents, and elderly patients who have already suffered from a hip fracture are considered to be good candidates for wearing hip protectors. The main mechanism of hip fractures is falling sideways over the trochanter. Hip protectors have been developed to attenuate the impact force on the trochanter that results from falling. There have been 6 randomized clinical trials and 4 of them confirmed the efficacy of hip protectors in preventing hip fractures. The other 2 reports did not show a statistically significant efficacy, but a large number of falls occurred without wearing hip protectors. The problem of the limited adherence with their use should be solved.     

Osteoporotic fractures and heart failure in the community

Purpose

Recent findings suggest a role for heart failure in the etiology of osteoporotic fractures, yet the temporal sequence of occurrence of the 2 conditions needs clarification.

Methods

Using the Rochester Epidemiology Project, the authors conducted a 2-phase study: a case-control study compared osteoporotic fracture history among Olmsted County, Minnesota, residents newly diagnosed with heart failure in 1979-2002 with age- and sex-matched community controls without heart failure (961 pairs; mean age 76 years; 54% women). Both groups were then followed to July 2009 to evaluate their subsequent fracture risk in a cohort study.

Results

Prior fractures were more frequent in heart failure cases than controls (23.1% vs. 18.8%, P = .02). The adjusted odds ratio (OR) for heart failure associated with prior fracture was 1.39 (95% confidence interval [CI], 1.07-1.81), mainly driven by hip fractures (OR 1.82; 95% CI, 1.25-2.66) with little or no association with other fractures. Over a mean follow-up of 7.5 years, 444 individuals developed subsequent osteoporotic fractures. The adjusted fracture risk was marginally elevated in heart failure patients compared with controls (hazard ratio [HR] 1.32; 95% CI, 0.98-1.79), again largely attributable to hip fractures (HR 1.58; 95% CI, 1.03-2.41).

Conclusions

In this community, the association with fracture risk was about as strong before as after the diagnosis of heart failure and was nearly entirely attributable to hip fractures. Additional work is needed to identify common underlying mechanisms for heart failure and hip fracture, which may define prevention opportunities.     

Intervention in lifestyle factors for the prevention of osteoporosis and osteoporotic fractures

According that osteoporosis is the common condition in an aging society such as in Japan, much progress has been made in understanding the treatment and prevention of osteoporosis. Among potential risk factors, exercise, smoking, and alcohol consumption have been recognised as important lifestyle factors that might influence the risk of osteoporosis and osteoporotic fractures. To assess the relationship between these lifestyle factors and the risk for low bone mass and osteoporosis-related fractures, a systematic literature search over past 13 years was conducted. Accumulating evidence indicates that exercises decrease the risk for hip fractures among middle aged and older men and women. Exercises also help to maintain muscle strength, muscle volume, balance, and joint flexibility, which might prevent falls and fall-related fractures. One randomised controlled trial indicates that high-impact and/or weight-bearing exercise might increase the bone density in the elderly and the peak bone mass among young women. The literature search also address that there is an association between cigarette smoking and the risk of osteoporosis. Smoking cessation is effective to decrease the risk for both osteoporosis and osteoporotic fractures. Future research should be required to evaluate the alcohol consumption and osteoporosis.     

Use of statins and fracture: results of 4 prospective studies and cumulative meta-analysis of observational studies and controlled trials

BACKGROUND: The 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors (statins) are widely used for the treatment of hyperlipidemia, and recent in vitro and animal data suggest that statins promote bone formation and increase bone strength. METHODS: To determine whether statin use is associated with a reduced risk for fracture, we analyzed statin use and fracture rates in 4 large prospective studies (the Study of Osteoporotic Fractures, the Fracture Intervention Trial, the Heart and Estrogen/Progestin Replacement Study, and the Rotterdam Study). We searched MEDLINE through January 2002 and abstracts from major scientific meetings and performed a cumulative meta-analysis of published and unpublished observational studies and clinical trials. The meta-analysis included 8 observational studies and 2 clinical trials that reported statin use and documented fracture outcomes. RESULTS: After adjustment for multiple factors, including age, body mass index, and estrogen use, we found a trend toward fewer hip fractures (relative hazards [RHs], 0.19-0.62) and, to a lesser extent, nonspine fractures (RHs, 0.49-0.95) among statin users in each of the 4 prospective studies. The meta-analysis of observational studies was consistent with these findings. The summary odds ratio (OR) for statin use and hip fracture was 0.43 (95% confidence interval [CI], 0.25-0.75), whereas that for nonspine fracture was 0.69 (95% CI, 0.55-0.88). The meta-analysis of clinical trial results did not support a protective effect with statin use for hip fracture (summary OR, 0.87; 95% CI, 0.48-1.58) or nonspine fracture (OR, 1.02; 95% CI, 0.83-1.26). CONCLUSIONS: Observational studies suggest that the risk for hip and nonspine fractures is lower among older women taking statin medications for hyperlipidemia, but post hoc analyses of cardiovascular trials do not. Controlled trials specifically designed to test the effect of statins on skeletal metabolism and fracture are needed.     

Dementia and falls: two related syndromes in old age

Dementia and cognitive impairment are known as a major risk for falls and subsequent adverse events in the elderly. In addition to result in serious injury, including fractures, falls lead to functional decline due to fear of falling again and self limitation of activity in older adults. All types of dementia and all degrees of severity are involved. Rather than resulting from a single cause, falls are the result of a combination of intrinsic, situational, and environmental factors. The most common risk factors for falls in patients with cognitive impairment and dementia are gait and balance disturbances, behavioral disorders, visual problems, malnutrition, adverse effects of drugs, fear of falling, neurocardiovascular instability (particularly orthostatic hypotension), and environmental hazards. Based on data from studies in cognitively normal people who fall, a multifaceted intervention, including a physical exercise programme and modification of the risk factors may prevent falls in older people with cognitive impairment and dementia. Preliminary research suggests that physiotherapy may have a role for falls prevention in these patients. However, randomized studies need to be performed.     

Does exercise prevent major non-communicable diseases and premature mortality? A critical review based on results from randomized controlled trials

Observational studies show that physical activity is strongly associated with a reduced risk of premature mortality and major non-communicable diseases. We reviewed to which extent these associations have been confirmed in randomized controlled trials (RCTs) for the outcomes of mortality, cardiovascular disease (CVD), type 2 diabetes (T2D), and fracture. The results show that exercise does not reduce all-cause mortality and incident CVD in older adults or in people with chronic conditions, based on RCTs comprising ∼50,000 participants. The results also indicate a lack of effect on cardiovascular mortality in people with chronic conditions, based on RCTs comprising ∼11,000 participants. Furthermore, there is inconsistent evidence regarding the effect of exercise on fractures in older adults, based on RCTs comprising ∼40,000 participants. Finally, based on RCTs comprising ∼17,000 participants, exercise reduces T2D incidence in people with prediabetes when combined with dietary modification, although evidence for the individual effect of exercise is lacking. Identified shortcomings of the current evidence include risks of publication bias, lack of high-quality studies in certain high-risk populations, and inconstant evidence with respect to some outcomes. Thus, additional large trials would be of value, especially with fracture as the primary outcome. In conclusion, according to current RCT evidence, exercise can prevent T2D assuming it is combined with dietary intervention. However, the current evidence shows that exercise does not prevent premature mortality or CVD, with inconsistent evidence for fractures.     

Exercise considerations for postmenopausal women with osteoporosis

Individuals with osteoporosis are at an increased risk of fracture due to a net loss of bone mass. The cellular mechanisms causing decreased bone mass are increased osteoclast-mediated bone resorption and/or decreased osteoblast-mediated bone formation. Clinical studies have shown that bone loss can be prevented by estrogen replacement therapy and calcium supplementation. Weight-bearing and strengthening exercise may also play a role in retarding bone loss in the postmenopausal woman, and it may even increase bone mass. The essential components of an exercise program include intensity, duration, frequency, and type of activity. Additional goals of a therapeutic exercise program are to improve flexibility and balance, and to prevent falls. Structure-function relationships in normal and osteoporotic bone and the effects of exercise on bone are reviewed. A rational approach for exercise strategies is discussed.