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.     

Evidence-based review of preventive practice for osteoporosis

Preventive procedures for osteoporosis should aim to eliminate or reduce the risk of osteoporotic fractures later in life. It is important for this purpose to achieve greater peak bone mass during adolescence, to reduce postmenopausal bone loss, and to maintain bone mass and to prevent falls in the elderly. All the available evidences for this topic have been reviewed and evidence-based recommendations for the prevention of osteoporosis and osteoporotic fractures are presented.     

Osteoporosis screening and risk management

Osteoporosis is common among older adults and results in costly osteoporotic fractures. Screening for this metabolic bone disorder is warranted in most older adults and clinicians must be diligent in identifying persons at risk. The evaluation should include an assessment of risk factors for falls, a bone density test, and consideration of possible secondary causes of osteoporosis. Several medications are available to improve bone density and decrease fractures. Adequate calcium and vitamin D intake (and treatment of vitamin D deficiency) are paramount in the management of osteoporosis.     

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.     

Osteoporosis in Older Persons: Old and New Players

Osteoporosis is the most common bone disease in humans. Older persons are at higher risk of osteoporotic fractures that also result in poor quality of life, disability, loss of independence, institutionalization, and higher mortality. Osteoporosis shares a distinct pathophysiologic relationship with sarcopenia, an age‐related disease comprising declines in muscle mass, strength, or function. The combination of these two diseases is known as osteosarcopenia. Understanding the pathophysiology of osteosarcopenia, in addition to its diagnostic and therapeutic approaches, is key in providing older adults with the best falls and fractures prevention strategies. This review provides updated information on new discoveries on the combined pathophysiology of osteoporosis and sarcopenia that have led to the development of novel therapeutic approaches. New recommendations for the use of risk calculators and densitometry are also presented in this review as well as evidence on current and upcoming pharmacologic treatments to prevent falls and fractures in older persons. J Am Geriatr Soc 67:831–840, 2019.     

Osteoporosis in the elderly man

Elderly men are at substantial risk for fracture. Morbidity after osteoporotic fractures appears to be more serious and mortality more common in men than in women. Risk factors for osteoporotic fractures in men appear to be qualitatively similar to those in women. Low bone mineral density (BMD) is an important risk factor for fracture in men; however, further clarification of the relationship between BMD, bone geometry and fracture risk is needed. Our understanding of the mechanisms underlying senile bone loss and the pathogenesis of senile osteoporosis in men remains fragmentary with, in particular, the need for further clarification regarding the precise impact of hormonal status in elderly men on skeletal homeostasis. Nevertheless, the available evidence indicates a role for both testosterone and estrogens in the regulation of bone metabolism in elderly men. Recommendations concerning prevention and treatment of senile osteoporosis in men should focus on the minimization of known risk factors for bone loss and falls. Testosterone treatment may be useful only in those men with initially low serum testosterone. As to other pharmacological treatment modalities, prospective trials specifically in elderly men, and preferably with fracture incidence as the primary clinical endpoint, are required.     

Are calcium and vitamin D supplements for everyone?: Pro

Calcium and vitamin D are essential for the health of our bones and various scientific societies recommend an intake of 1,000 mg of calcium and 800 IU of vitamin D daily. Most people with osteoporosis do not eat food with this amount of calcium and also have insufficient levels of vitamin D, so supplements are recommended to provide osteoporotic patients with these amounts. Calcium supplements and vitamin D improve the effectiveness of anabolic and anti-catabolic agents and may have a small effect in reducing the number of fractures. Calcium supplements alone have not shown efficacy preventing fractures in patients with osteoporosis and may increase cardiovascular risk in healthy elderly women and is therefore not recommended for widespread use. Vitamin D supplements are recommended in persons with 25-OH vitamin D levels below 30 ng/ml, in particular the elderly and osteoporotic patients, due to its ability to halt the remodeling resulting from secondary hyperparathyroidism and reduce the loss of bone mass. Vitamin D supplements could help reduce falls and fractures in the institutionalized elderly. In addition, supplements of vitamin D may have other beneficial effects due to extra-osseous regulatory functions on the immune response and cell differentiation and proliferation that is associated with vitamin D. Trials begun in recent years clearly indicate a beneficial effect of vitamin D supplements on mortality, cardiovascular risk,development of tumors and prevention of infections.     

Treatment of postmenopausal osteoporosis

The aim of treatment of postmenopausal osteoporosis is to reduce the frequency of vertebral and non-vertebral fractures (especially at the hip), which are responsible for morbidity associated with the disease. Results of large placebo controlled trials have shown that alendronate, raloxifene, risedronate, the 1-34 fragment of parathyroid hormone, and nasal calcitonin, greatly reduce the risk of vertebral fractures. Furthermore, a large reduction of non-vertebral fractures has been shown for alendronate, risedronate, and the 1-34 fragment of parathyroid hormone. Calcium and vitamin D supplementation is not sufficient to treat individuals with osteoporosis but is useful, especially in elderly women in care homes. Hormone replacement therapy remains a valuable option for the prevention of osteoporosis in early postmenopausal women. Choice of treatment depends on age, the presence or absence of prevalent fractures, especially at the spine, and the degree of bone mineral density measured at the spine and hip. Non-pharmacological interventions include adequate calcium intake and diet, selected exercise programmes, reduction of other risk factors for osteoporotic fractures, and reduction of the risk of falls in elderly individuals.     

Osteoporosis and osteoporotic fractures in men: a clinical perspective.

The lifetime risk of any fracture of the hip, spine or distal forearm in men aged 50 years has been estimated to be 13%, compared with 40% in women. Although the overall incidence of osteoporosis is less in men than in women, the disease still represents an important public health problem. In particular, hip fractures are associated with substantial mortality and morbidity, even more so than in women. In male patients presenting with osteoporotic fractures, major causes of skeletal fragility, such as hypogonadism, glucocorticoid excess, primary hyperparathyroidism and alcohol abuse, can often be identified. In as many as 50% of osteoporotic men, however, no aetiology can be found: these men suffer from a syndrome commonly referred to as idiopathic osteoporosis, which is presumably related to some type of osteoblast dysfunction. Recent evidence indicates that the loss of skeletal integrity in ageing men may be partially related to endocrine deficiencies, including vitamin D, androgen and/or oestrogen deficiency. While the consequences of vitamin D or oestrogen deficiency in women have been well established, the skeletal impact of these (partial) age-related deficiencies in men remains to be clarified. Osteoporosis in elderly men is a multifactorial disease, as it is in women. The prevention of osteoporosis should therefore focus not only on increasing the bone strength, but also on decreasing the risk of falls. However, the prevention and therapy of osteoporotic disorders in men are virtually unexplored. To date, the use of specific osteoporotic drugs in osteoporotic men is still based on reasonable but untested assumptions.     

Strategies for the prevention and control of osteoporosis in developing countries

The frequency of osteoporosis and fragility fractures has been studied to a very limited extent in few developing countries. The aim of this paper is to review briefly the burden of osteoporosis and fragility fractures in these countries and to propose some strategies for the prevention and control of those conditions, considering barriers and facilitators for their implementation. The evolution of the demographic composition in most regions with developing countries shows a considerable increase in life expectancy and therefore, a significant growth in elderly population can be expected. Reports on the incidence of fragility fractures show figures in many of those countries that are comparable to those found in developed nations. Health resources (for acute treatment of fractures, their rehabilitation and chronic management, for diagnostic centers and drug therapy for osteoporosis) are limited in most of those regions and are allocated to other health priorities. Internationally accepted guidelines can be adapted to the realities of developing nations and may be promoted by organizations of health professionals and patients, but require endorsement and support by health authorities. The steps should include: (a) campaigns to increase awareness, both among the population at risk and relevant health workers; (b) the promotion of a preventive lifestyle in the general population; (c) the development of national or regional, evidence-based guidelines for the diagnosis and treatment of osteoporosis; (d) development and implementation of guidelines for the treatment of fragility fractures, their rehabilitation and prevention of falls; (e) collection of economic data on fractures and osteoporosis; and (f) development of country-specific fracture databases. These steps may help in reducing the increasing burden of osteoporotic fractures. Their implementation will require solid scientific basis and commitment from policy makers, health professionals, patient organizations, and ultimately the general population.     

The assessment of the reliability and the validity of the EOQOL questionnaire of osteoporotics--QOL assessment of elderly osteoporotics by EOQOL

We presented a novel and specific questionnaire for quality of life of elderly subjects with osteoporosis (EOQOL), and analyzed its reliability and validity. Based on the discussions with elderly people of osteoporosis, we extracted key words related to complaints of patients with vertebral fractures. A 49 questionnaire was developed on concepts derived from key words. The subdirectories of the questionnaire for elderly osteoporotic subjects consisted of pain, daily activity, movement, physiological activity, duty, recreation and well-being. To analyze the reliability and the validity of EOQOL, it was evaluated in 101 elderly subjects with osteoporosis. Crohnbach's alpha coeffient was 0.82 for pain, 0.86 for daily activity, 0.73 for movement, 0.83 for mood, 0.78 for anxiety against falls, 0.84 for physiological activity, 0.85 for duty, 0.66 for free time, 0.78 for a nice feeling about life. These results indicated that EOQOL is useful as a disease specific questionnaire for elderly osteoporotic patients with osteoporosis.     

Osteoporosis considerations in the frail elderly

Osteoporosis is a growing public health problem throughout the world, in part because of the increasing numbers of people living beyond the age of 65 years. Skeletal fractures are the clinical manifestation of the disease, with older patients the most severely affected. Conditions associated with frailty such as falls and reduced muscle strength likely contribute to fractures, causing substantial mortality, morbidity, and economic cost. Screening guidelines for osteoporosis have been issued recently and take into account multiple risk factors for this condition. Falls are the chief mechanism by which osteoporotic fractures occur. Nonpharmacologic interventions for osteoporosis mainly address fall and frailty prevention, whereas pharmacologic interventions target bone loss through decreasing bone resorption, increasing bone formation, or a combination of both processes. Although guidelines for intervention strategies are in flux, it is now suggested that absolute fracture risk rather than diagnostic thresholds be used to determine the timing for therapeutic intervention. Individual risks and benefits of therapies need to be considered before choosing a therapeutic regimen.     

Physiotherapeutische Interventionen bei Osteoporose

Osteoporosis is an increasing public health problem which ultimately causes fractures and a significant reduction in patient's health-related quality of life. In this context, physiotherapists are involved in a wide range of therapies related both to prevention and treatment of osteoporosis. The reduction of the risk of falling by elderly patients with osteoporosis is a very important goal for physiotherapists because it is known to significantly decrease fracture incidence. Indeed, exercise programs including elements of muscle strengthening and better body balance control have a positive effect on the risk of falling, hence reducing the incidence of fractures and increasing the health-related quality of life of osteoporotic patients. As a further consequence, the decreased fracture incidence has a key roll in reducing health care costs. Once a patient presents with an osteoporotic fracture, he may be assisted with various forms of passive, active-assisted and active therapies. This treatment will help reduce pain, increase patient's mobility and prevent the occurrence of additional fractures. In addition, a good and well-balanced education process regarding secondary osteoporosis prevention may also help to modify the behavior of patients and help to improve skeletal health in the longer term. The physiotherapist has definitively a major role to play in the interdisciplinary team aimed at preventing osteoporotic fractures in both primary and secondary prevention levels.     

Therapieleitlinien der Osteoporose

Treatment of osteoporosis aims to reduce osteoporotic fractures and to minimize fracture-related pain and functional impairment. Components of non-drug therapy include improvement of muscle strength and coordination, treatment of modifiable causes of falls, a diet rich in calcium and sufficient in calories, adequate supply of vitamin D and an individual assessment of drugs known to increase falls or osteoporosis. Bisphosphonates, raloxifene, strontium ranelate and parathyroid hormone have been shown to reduce osteoporotic fractures in postmenopausal women. Alendronate, risedronate and parathyroid hormone are also licensed for the treatment of male osteoporosis. One of the still open questions is the optimal duration of pharmacological treatment.     

Guidelines for the management of osteoporosis

Treatment of osteoporosis aims to reduce osteoporotic fractures and to minimize fracture-related pain and functional impairment. Components of non-drug therapy include improvement of muscle strength and coordination, treatment of modifiable causes of falls, a diet rich in calcium and sufficient in calories, adequate supply of vitamin D and an individual assessment of drugs known to increase falls or osteoporosis. Bisphosphonates, raloxifene, strontium ranelate and parathyroid hormone have been shown to reduce osteoporotic fractures in postmenopausal women. Alendronate, risedronate and parathyroid hormone are also licensed for the treatment of male osteoporosis. One of the still open questions is the optimal duration of pharmacological treatment.     

Consequences of osteoporotic fractures--epidemiological review

Most fractures among the elderly is a common consequence of osteoporosis and occurs very frequently in older people. Osteoporotic fractures are associated with diminished physical and functional performance, difficulties in performing activities of daily living (ADL), and a decline in several aspects of well-being or quality of life (QOL). In this article, consequence of osteoporotic fractures are reviewed based on the recent population-based epidemiological studies.     

Osteoporotic fractures in older adults

Osteoporotic fractures are emerging as a major public health problem in the aging population. Fractures result in increased morbidity, mortality and health expenditures. This article reviews current evidence for the management of common issues following osteoporotic fractures in older adults including: (1) thromboembolism prevention; (2) delirium prevention; (3) pain management; (4) rehabilitation; (5) assessing the cause of fracture; and (6) prevention of subsequent fractures. Areas for practice improvement and further research are highlighted.     

Identification and treatment of osteoporosis in fractures

Patients who present with osteoporotic fracture are at highest risk of further fractures and their associated morbidity. Despite the availability of several evidence-based therapeutic options, which have the potential to reduce the incidence of fractures by up to 50%, it is paradoxical that these high-risk patients are seldom assessed for osteoporosis and offered treatment. Secondary prevention of osteoporotic fractures should now be the priority for osteoporosis services; the challenge that remains is to devise new models of patient care that can deliver strategies for the secondary prevention of osteoporotic fractures in different healthcare settings.     

Clinical evaluation for osteoporosis

The clinical evaluation of the osteoporotic patient should include a careful assessment of risk factors for low bone mass, falls, and fractures; quantitation of BMD; a thorough medical history and physical examination; and a targeted set of laboratory, radiographic, and other diagnostic studies as indicated. Among the elderly, vitamin D deficiency ranks high as one of the most underdiagnosed and yet reversible causes of osteoporosis. Regardless of age, every patient with low bone mass or fractures deserves an evaluation to uncover reversible, treatable disorders and to detect serious underlying illnesses.