Chapter 30: Osteoporosis

GENERAL CONSIDERATIONS

Osteoporosis is a public health problem affecting >40 million people, one-third of postmenopausal women, and a substantial portion of the elderly in the United States and almost as many in Europe and Japan. An additional 54% of postmenopausal women have low bone density measured at the hip, spine, or wrist. Osteoporosis results in approximately 1,500,000 fractures annually in women in the United States alone and is a significant cause of fractures in men as well. The overall incidence of hip fracture in the United States increased from 1986 to 1995 and then steadily declined from 1995 to 2012, but it has now plateaued at higher levels than predicted for the years 2013 to 2015. At least 90% of all hip and spine fractures among elderly women are a consequence of osteoporosis. The direct expenditures for osteoporotic fractures have increased during the past decade from $5 billion to almost $15 billion per year. The number of women experiencing osteoporotic fractures annually exceeds the number diagnosed with heart attack, stroke, and breast cancer combined. Thus, family physicians and other primary care clinicians (1) will frequently care for patients with subclinical osteoporosis, (2) should recognize the implications of those who present with osteoporosis-related fractures, and (3) must determine when to implement prevention for younger people.

Osteoporotic fractures are more common in whites and Asians than in African Americans and Hispanics and are more common in women than in men. The female-to-male fracture ratios are reported to be 7:1 for vertebral fractures, 1.5:1 for distal forearm fractures, and 2:1 for hip fractures. Approximately 30% of hip fractures in persons age ≥65 years occur in men. Osteoporosis-related fractures in older men are associated with lower femoral neck bone mineral density (BMD), quadriceps weakness, higher body sway, lower body weight, and decreased stature. Little is known regarding the influence of ethnicity on bone turnover as a possible cause of the variance in bone density and fracture rates among different ethnic groups. Significant differences in bone turnover in premenopausal and early perimenopausal women can be documented. The bone turnover differences do not appear to parallel the patterns of BMD. Other factors, such as differences in bone accretion, are likely responsible for much of the ethnic variation in adult BMD. Estimates of numbers needed to screen to prevent one hip fracture over 5 years (from data from the Fracture Intervention Trial of bisphosphonate use in postmenopausal women age 54–81 years) are 1667, 1000, and 556 for postmenopausal women age 55–59 years, 60–64 years, and 65–69 years, respectively. These findings, as well as the absence of data on the benefits of osteoporosis treatment beginning between ages 50 and 59, suggest that early screening is not an evidence-based rationale.