National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people

Chapter 5. The health of older people

Osteporosis

☰ Table of contents

Recommendations: Osteoporosis

Preventive intervention type

Who is at risk?

What should be done?

How often?

Level/ strength of evidence

References

Screening

 All postmenopausal women and men over 50 years of age Assess risk factors for osteoporosis (Box 1) As part of an annual health assessment IIB 8
People at moderate and high risk (Box 1) Measure bone mineral density (BMD)* by dual-energy X-ray absorptiometry (DXA) scanning on at least two skeletal sites, including the lumbar spine and hip, unless these sites are unsuitable (eg due to hip prosthesis)

If DXA confirms osteoporosis then manage as high risk (refer to recommendations below for behavioural, chemoprophylaxis and environmental interventions)		 At baseline, then as needed, depending on baseline BMD and management

Repeat if it will change management, generally no more frequently than second yearly		 IA 8

Behavioural

 All postmenopausal women and men >50 years of age at all levels of risk
 		 Advise adequate dietary calcium intake: 1300 mg/day for women >50 and men >70 years of age; 1000 mg/day for men 50–70 years of age Opportunistic and as part of an annual health assessment


 		 IA for bone loss, III–2 for fracture prevention 8
Recommend smoking cessation (refer to Chapter 1: Lifestyle, ‘Smoking’) IA 21
Advise adequate but safe sunlight exposure as a source of vitamin D1 IIC 24
Avoid excessive alcohol consumption IIC 22
Residents of aged care facilities (RACFs) at risk of falling Consider the use of hip protectors to lower the risk of harm related to a fall IA 28
Individuals >50 years of age without osteoporosis Recommend regular highintensity weight-bearing exercise if appropriate. Recommend progressive resistance training and balance training. Resistance exercise should be regular (2–3 days per week), moderate–vigorous, progressive and varied Opportunistic IA 5, 8
Individuals with osteoporosis Recommend low-impact, high-intensity progressive resistance and balance training Frequency as above

Examples of low-impact activities include standing activities with one foot always on the floor		      

Chemo-prophylaxis

 All postmenopausal women and men >50 years of age at all levels of risk Calcium and vitamin D supplementation are not recommended for routine use in non-institutionalised older people   IC 8
  People at high fracture risk:
  • with previous fragility fracture
  • T-score of –2.5 or less†
  • on long-term corticosteroids with a T-score of 1.5 or less
 Consider specific antiosteoporosis medication:
  • bisphosphonates‡
  • denosumab§
  • oestrogen replacement
Consider calcium supplementation in people at high risk being treated with specific osteoporosis medications, if their dietary calcium intake is <1300 mg daily

People being treated with a specific osteoporosis medication should have vitamin D supplementation prior to commencement if their level is <50 nmol/L		 At diagnosis IB for denosumab in men IA for all others 8

Environmental

 People at high risk of fracture Consider a multifactorial falls reduction program (refer to ‘Recommendations: Falls’) At diagnosis ID  
*Bone densitometry testing is available on the Medicare Benefits Schedule (MBS) for the following groups:
  • people >70 years of age
  • people with one or more fractures occurring after minimal trauma
  • follow-up of people with established low BMD
  • people with one of the following medical conditions putting them at increased risk
    • prolonged glucocorticoid therapy
    • conditions associated with excess glucocorticoid secretion
    • male hypogonadism
    • female hypogonadism lasting more than six months before the age of 45 years
    • primary hyperparathyroidism
    • chronic liver disease
    • chronic renal disease
    • proven malabsorptive disorders
    • rheumatoid arthritis
    • conditions associated with thyroxine excess.32
†A T-score of –2.5 or lower is diagnostic of osteoporosis, and a T-score between –1.0 and –2.5 is diagnostic of osteopenia.
‡Bisphosphonates are subsidised under the Pharmaceutical Benefits Scheme (PBS) for the following conditions:
  • concurrent use of oral corticosteroids (>7.5 mg/day prednisone or equivalent) for three months or more and a BMD T-score of –1.5 or less
  • people aged ≥70 years with a BMD T-score or –2.5 or less
  • any person with a radiologically confirmed fracture due to minimal trauma.30
§Denosumab is subsidised under the PBS for:
  • people aged ≥70 years with a BMD T-score or –2.5 or less
  • any person with a radiologically confirmed fracture due to minimal trauma.30
Notes:
  • The recommendations for sun exposure vary by latitude, skin colour and time of year. For more information, refer to ‘Resources’.
  • Refer to clinical practice guidelines for specific treatment recommendations.8

Box 1. Risk levels for osteoporosis8

Average risk

Moderate risk

High risk

All postmenopausal women and men aged >50 years

Aged >70 years

Previous fracture due to minimal trauma

Aged 60–70 years and any of the following:

  • family history of osteoporotic fractures
  • history of falls
  • smoking
  • high alcohol intake (>4 standard drinks per day for men and >2 for women)
  • prolonged immobility or poor mobility (eg unable to leave the house or do housework)
  • low body weight (BMI <20) and unintentional weight loss
  • medical conditions causing secondary osteoporosis, such as
    • endocrine disorders: hypogonadism, hyper-parathyroidism, hyperthyroidism, Cushing’s syndrome
    • premature menopause
    • anorexia nervosa or >1 year amenorrhoea before age 45 years, not related to pregnancy
    • inflammatory conditions (eg rheumatoid arthritis)
    • malabsorption (eg coeliac disease)
    • chronic kidney or liver disease
    • multiple myeloma or monoclonal gammopathies
    • HIV and its treatment
    • diabetes type 1 and type 2
  • on medications such as
    • prolonged glucocorticoid use (>7.5 mg for >3 months)
    • anti-convulsants
    • aromatase inhibitors
    • anti-androgens
    • excessive thyroxine
    • possibly selective serotonin reuptake inhibitors (SSRIs)

Vertebral fractures with minimal trauma

These fractures should be ruled out if clinically suspected due to loss of height >3 cm, kyphosis or back pain


Background

Osteoporosis is defined as a condition in which there is low bone mass and deterioration of the microarchitecture of the bones, causing bone fragility and an increased risk of fracture. It can be diagnosed on the basis of a fragility fracture (a fracture from trauma equivalent to a fall from normal standing height or less) or by a bone mineral density (BMD) test, dual-energy X-ray absorptiometry (DXA), which measures BMD at the hip and spine. BMD is expressed as a T-score, defined by the World Health Organization (WHO) as a measure of standard deviation from the reference values of bone density for a 30-year-old of the same sex.4 A T-score of –2.5 or lower is diagnostic of osteoporosis, and a T-score between –1.0 and –2.5 is diagnostic of osteopenia. However, as noted above, a low T-score is not required for the diagnosis in a person who has a history of fragility fracture.5

Osteoporosis is common in the general population, with 43% of women and 13% of men over 70 years of age meeting the WHO criteria for osteoporosis.6 The residual lifetime risk of a minimal trauma fracture in non-Indigenous Australians is approximately 44% for women over 60 years of age and 25% for men over 60 years of age.7 These fractures often occur at sites other than the classic osteoporotic sites of wrist, hip and vertebra. However, hip fractures are important because they are associated with significant mortality and loss of independence. Vertebral fractures are associated with significant long-term disability related to pain and kyphosis.8

Recent reports suggest that Aboriginal and Torres Strait Islander peoples are at higher risk for osteoporotic hip fractures, and that these fractures occur at younger ages. A report based on national hospital separations data from 2005 to 2007 demonstrated that the rate of hip fracture for Aboriginal and Torres Strait Islander males was twice as high as the rate for non-Indigenous males, and for Aboriginal and Torres Strait Islander females was 26% higher than for non-Indigenous females.9 The average age at time of hip fracture was younger: an average of 65 years for Aboriginal and Torres Strait Islander men (compared with 81 years for non-Indigenous men), and 74 years for Aboriginal and Torres Strait Islander women (compared with 83 years for non-Indigenous women).9

This increased rate was corroborated by a study looking at hospital data in Western Australia between 1999 and 2009. It confirmed a higher rate of hip fracture due to minimal trauma in both Aboriginal men and women, with Aboriginal men having more than twice the age-standardised risk of fracture compared with non-Indigenous men.10 This was especially so in younger age groups, with no apparent differences in risk for people over 80 years of age. The rate of minimal trauma hip fracture in Aboriginal peoples increased on average by 7.2% per year over the ten years of the study, whereas the rate of fracture in non-Aboriginal people decreased by an average of 3.4% per year.10

However, there are limited data on whether this apparent increased risk of fracture is correlated with differences in BMD or DXA scanning. A body composition study of young, healthy Aboriginal and Torres Strait Islander volunteers demonstrated higher femoral neck bone mineral densities than for a Caucasian group, although there was no difference in lumbar spine bone mineral density.11

There is a significant treatment gap with osteoporosis, with only 30% of those at highest risk for fracture (those with a previous fragility fracture) taking specific osteoporosis treatments.12 In addition, the use of DXA scans varies within the population, with DXA use in urban areas three times higher than in rural and remote locations,13 which is important given a high proportion of Aboriginal and Torres Strait Islander peoples live outside major cities. Also, despite the fact that in the general population the female:male ratio of osteoporotic fractures is 2:1, the rate of DXA use is 4:1, suggesting that men are being under-tested.13

A number of factors increase the risk of osteoporotic fractures. In the general population women have approximately double the lifetime risk of men; however, as discussed above, this may not be true in Aboriginal and Torres Strait Islander populations. Fracture incidence increases exponentially with age in both men and women, approximately doubling with each decade.14,15 A previous fracture doubles the risk of subsequent fracture, and a previous vertebral fracture carries around a five-fold increased risk of a further vertebral fracture.16,17 Low bone density as measured by DXA approximately doubles the fracture risk for each unit of standard deviation from the mean (each –1.0 of T-score).18 A history of falls at least doubles the risk of an osteoporotic fracture compared to those with no such history.19

A family history of fragility fractures after age 50, kyphosis or diagnosed osteoporosis in a father, mother or sister increases the risk of osteoporotic fractures.20 Smoking is associated with a modest increase in osteoporotic fracture rate, and especially hip fracture rate. A minority (23%) of this increased risk is attributable to lower BMD.21 A meta-analysis has shown that daily alcohol or >10 standard drinks per week increases the risk of fracture in men by 28%.22 Low body mass index (BMI) has also been shown to be associated with lower bone density after menopause, and more rapid bone loss than in women with a higher BMI.18 Other risk factors include immobility; vitamin D deficiency; and certain medications, especially corticosteroids, excessive thyroxine, anti-androgen and anti-oestrogen treatments, selective serotonin reuptake inhibitors, thiazolidenediones and particular anti-epileptic drugs.19
Two fracture risk calculators are available and recommended for use.8 FRAX (Fracture Risk Assessment Tool) was developed at the University of Sheffield in conjunction with the WHO, and uses country-specific data to calculate a 10-year risk of major osteoporotic fracture, and a 10-year risk of hip fracture. It is available as a web-based version or a mobile app (refer to ‘Resources’). The Garvan Fracture Risk Calculator is an Australian calculator that includes input on the number of falls in the last 12 months (refer to ‘Resources’). Note that both calculators can be used without BMD (DXA) results. These calculators have not been validated using data from Indigenous populations.

The evidence is mixed on how accurate these calculators are. For people at the highest risk, they are probably not necessary because treatment is indicated already. They may be useful for people who are in the osteopenic range who are nonetheless at moderate risk (tipping the balance towards preventive treatment); conversely, they may be useful in preventing over-treatment in people who are at low risk. Note that the absolute fracture risk calculated does not take into consideration the different criteria for qualifying for subsidised medications under the Pharmaceutical Benefits Scheme (PBS). Research is continuing into whether the use of these calculators to support clinical decision making for populations is cost effective.8

 

Interventions

Calcium intake

The recommended daily intake of calcium varies according to age. The best dietary sources of calcium are milk, hard cheeses and yoghurt. Other sources with moderate calcium content include firm tofu, almonds, sesame seeds, tinned fish, some green leafy vegetables and calcium-enriched soy milk.8 The evidence around dietary calcium and fracture risk is mixed, with some studies showing an increased risk of fracture in people with the lowest quintile of self-reported calcium intake.23 However, meta-analyses have failed to demonstrate a correlation between dietary calcium intake and fracture risk. In addition, there is some evidence of harm with supplemental calcium, and supplements are not generally recommended. However, dietary intake should be assessed in people who are commencing specific anti-osteoporosis therapies as the effectiveness of these medications was researched in people who were calcium and vitamin D replete. Those commencing medication may need calcium supplementation.8

Vitamin D

Vitamin D is primarily formed in the skin from sunlight exposure, although small amounts are found in the diet. How much is produced in the skin depends on the colour of the skin, the geographical location and the time of year.24 In winter, in southern parts of Australia, and in people with darker skin, this exposure needs to be longer. The evidence for the use of vitamin D supplementation in preventing bone loss and osteoporotic fractures is mixed. A benefit has been shown for treating those at high risk of vitamin D deficiency (eg residents of aged care facilities and housebound people), and for these groups, vitamin D supplementation is considered standard care. For those in the community, the results are less clear and supplementation is not usually necessary. The benefits of specific anti-osteoporotic therapies have been demonstrated in the context of adequate vitamin D levels. Patients who are to be commenced on specific anti-osteoporotic medication should have their vitamin D levels checked and should commence supplementation if their level is less than 50 nmol/L.8

Exercise

Regular, high-intensity weight-bearing exercise has been shown to slow bone density loss in postmenopausal women and older men. High-impact activities such as jogging, dancing, tennis and step aerobics are effective for increasing bone strength in those without joint problems and not at risk of falling. Strength and resistance training (such as weight lifting) is also recommended and should be progressive and varied, and ideally should be performed for about 30 minutes, two to three times per week.8 For bone health, short, intense exercise sessions are better than prolonged, less intense exercise. High-intensity balance training, which involves standing with feet close together or on one leg and challenges balance, does not increase bone strength but does decrease the risk of falling and fractures.25 There is some evidence that regular exercise across the lifespan increases bone density. Children and adolescents who are more active achieve higher bone density, and this is maintained into middle age.26

People diagnosed with osteoporosis need to have physical activity recommendations modified because of their increased risk of fracture. They should undergo high-intensity resistance training and balance training.8 High-intensity strength training is the use of moderate to high overload resistance to increase muscle strength and BMD. High impact activities such as jumping are not appropriate for people with established osteoporosis. A physiotherapist, exercise physiologist or other appropriately trained professional should supervise the introduction of an exercise program for people with osteoporosis.

Smoking cessation

Current smoking and a history of smoking are associated with an increased risk of fracture, even after accounting for BMI (people who smoke tend to have lower BMI).21 The increased risk of fracture significantly declines from around 10 years after giving up smoking.27

Hip protectors

Hip protectors are either foam pads (soft) or plastic shields (hard), which are worn over the hips in specially designed underwear. They act to protect the hips in case of a fall to the side. They have been shown to reduce the risk of hip fracture in older people living in aged care facilities, though the number needed to treat (NNT) for one year to prevent one fracture is 91. They have not been shown to reduce the risk of hip fracture among people living in the community, probably because people choose not to wear them.28

Pharmacological treatment

There is some evidence that Aboriginal and Torres Strait Island people may have osteoporotic fractures at an earlier age, but there is little evidence to guide whether pharmacological recommendations based on age cut-points should be revised.

Bisphosphonates

Bisphosphonates may be used in both primary prevention and after osteoporosis is established.29 In a Cochrane review, biphosphonates were shown to prevent vertebral fractures (but not hip or other non-vertebral fractures) in primary prevention studies of postmenopausal women.29 For vertebral fractures, the NNT is 50 for primary prevention, but 17 for secondary prevention. In those with osteoporosis (ie secondary prevention), the number needed to prevent a hip fracture is 100, and to prevent other non-vertebral fractures is 50.29 The benefit is greatest for those at highest risk of fracture. Note that bisphosphonates are not listed on the PBS for primary prevention. They are listed for those with fractures due to minimal trauma, those with low BMD and aged over 70 years, and those on long-term corticosteroids with a BMD T-score of 1.5 or less.30

Denosumab

Denosumab may be used for those with established osteoporosis, and after fracture in both women and men. It is given as a six-monthly injection. It is a human monoclonal IgG antibody that binds to specific proteins responsible for bone resorption, thereby preventing bone resorption and increasing bone mass and strength.
Over three years, the NNT to prevent one fracture in women with osteoporosis varies from 21 for new vertebral fractures, 67 for non-vertebral fractures, and 200 for hip fractures.31 There is evidence for effectiveness in increasing BMD in men treated with denosumab, though as yet limited data around fracture reduction in men.8

Hormone replacement therapy

Oestrogen +/– progestogens are effective in improving BMD and reducing the risk of fractures in postmenopausal women. They have been shown to be effective in primary prevention and in treating established osteoporosis.29 However, there are adverse effects, including an increased risk of breast cancer, stroke and thromboembolic events. These risks seem to be less in women commenced on hormone replacement therapy (HRT) within 10 years of the menopause, and younger women in general have a lower baseline risk of vascular events.29 The potential benefits and harms must be carefully considered. However, there are benefits for the bones for women using HRT for management of menopausal symptoms. Longterm use is not recommended in current guidelines.8,20

 

Resources
National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people

 





 
 
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