Osteoporosis causes a large and growing health burden in Australia. Effective treatments are available, but these are inconsistently implemented. There is some inconsistency in expert advice on who should be recommended to have bone densitometry.
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This review draws on the available high level evidence for what works in prevention and discusses the rationale for using absolute risk estimations for decision making. Effective interventions for the prevention and early intervention of osteoporosis have not been delivered as widely as they should be. Efforts should be focused on offering treatment to those groups with the highest risk of fracture, particularly those that have had a fragility fracture.
There is synergy in the lifestyle recommendations for bone health with other aspects of health, so these should be addressed as thoroughly as possible. Osteoporosis OP is an important primary care health problem. It is common, causes significant suffering for many and contributes to an earlier death for some. Accordingly, primary care clinicians need to be able to distinguish facts from hype. Key to this is to distinguish evidence about bone density a risk factor from evidence about fracture a health outcome prevention. Osteoporosis only causes symptoms or impact on the patient when there is a fracture, so fracture outcome data takes precedence over bone density data in guiding clinical practice.
Low bone density is one of the main risk factors for fracture, but not the only one. There are a number of established risk factors for OP Table 1. Smoking, high alcohol intake, low calcium diet, low body weight, recurrent falls, sedentary lifestyle, low sex hormone levels and malabsorption are likely to be amenable to intervention. Table 2 summarises possible modifiable factors. There is disappointingly weak evidence of impact on fracture outcomes from lifestyle interventions, although there is evidence of improved bone density for some.
The focus of fracture prevention changes with the setting, age group and patient preferences. In residential aged care facilities RACFs vitamin D supplementation should be considered for its impact on bone density and its impact on falls. Unfortunately, there are no studies reporting fracture or bone density outcomes for interventions for smoking, low body weight, high alcohol intake and sedentary lifestyle, although these factors are associated with higher fracture risk.
Exercise is generally a good thing, although it is possible that exercise programs could increase injuries, including fractures, if not cautiously planned and implemented in a frail population. Physiotherapy or exercise physiology advice can be helpful. There is growing interest in efforts to increase peak bone mass in adolescents and young adults through high impact exercise eg. Calcium supplementation alone has a small positive effect on bone density. The data show a not statistically significant trend toward reduction in vertebral fractures, but the trend is unclear for calcium reducing the incidence of nonvertebral fractures.
This risk trade-off needs to be watched as more evidence becomes available. The increased cardiovascular disease risk has not been seen with dietary calcium, only with supplements. A Cochrane review of the impact of fluoride concludes that fluoride can increase BMD at the lumbar spine, it does not reduce vertebral fractures. The evidence showed an increase risk of gastrointestinal side effects and nonvertebral fractures when used for OP in adults. Vitamin D is necessary for building bone.
Management of osteoporosis
Older people especially those in RACFs often have low vitamin D levels through lack of exposure to sunlight and low dietary intake. A review of 45 trials with 84 patients updated in found that taking vitamin D alone is unlikely to prevent fracture. Vitamin D taken with additional calcium supplements does appear to reduce risk of hip fractures in people living in institutional care.
- Postmenopausal osteoporosis!
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Although the risk of harmful effects from vitamin D and calcium is small, some people, particularly those with kidney stones, kidney disease or high blood calcium, are at increased risk of harmful effects. Vitamin D supplementation does not improve bone density in healthy children but may have a modest role in those with low vitamin D levels.
This can be important for patients in RACFs. There is good evidence for the effectiveness of various interventions to reduce falls eg. These have not however, been able to demonstrate reduced fracture rates, presumably due to the size of study needed. In RACFs, where the frail population is at very high absolute risk of fracture, hip protectors should be considered.
Taking vitamin D supplements probably does not reduce falls in the community setting except in people who have a low level of vitamin D, 16 but it does reduce the rate of falls for those in RACFs.
Cochrane reviews of primary prevention with risedronate 5 and etidronate18 showed no statistically significant effect on fractures. Oliver, D. Strategies to prevent falls and fractures in hospitals and care homes and effect of cognitive impairment: systematic review and meta-analyses. BMJ , 82—82 Harwood, R. Falls and health status in elderly women following first eye cataract surgery: a randomised controlled trial.
Fall prevention with supplemental and active forms of vitamin D: a meta-analysis of randomised controlled trials. Institute of Medicine. Michael, Y. Primary care-relevant interventions to prevent falling in older adults: a systematic evidence review for the U. Preventive Services Task Force. IOF position statement: vitamin D recommendations for older adults. Garvan Institute. Fracture Risk Calculator. Billington, E. Maturitas 85 , 11—18 Implications of absolute fracture risk assessment for osteoporosis practice guidelines in the USA.
Reid, I. Efficacy, effectiveness and side effects of medications used to prevent fractures.
Ebetino, F. The relationship between the chemistry and biological activity of the bisphosphonates. Bone 49 , 20—33 Murad, M. Comparative effectiveness of drug treatments to prevent fragility fractures: a systematic review and network meta-analysis. Black, D.
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