Kristine E. Ensrud
Women aged 80 and older with osteoporosis and substantial comorbidity have a high 5-year probability of hip fracture and may still benefit from drug therapy for prevention of hip fracture, according to a study published in JAMA Internal Medicine.
“Women 80 years and older with osteoporosis, including those with more comorbid medical conditions or poorer prognosis, have a high 5-year hip fracture probability despite accounting for their competing risk of nonfracture mortality and should be targeted for drug treatment to prevent future hip fracture,” Kristine E. Ensrud, MD, MPH, professor of medicine and epidemiology/community health at the University of Minnesota and core investigator at the Center for Care Delivery and Outcomes Research at the Minneapolis VA Health Care System, told Healio Primary Care. “Among women without osteoporosis but considered to be treatment candidates on the basis of osteopenia and a fracture probability at-or-above intervention thresholds proposed by the National Osteoporosis Foundation, competing mortality risk far outweighs hip fracture probability, especially among those with more comorbidities or poorer prognosis. The absolute benefit of drug treatment is likely to be much lower among this substantial group of women because mortality probability markedly outweighs the probability of hip fracture.”
To examine the association between disease definition, number of comorbidities and prognosis with hip fracture probability in women 80 years or older, researchers conducted a prospective cohort study of 1,528 women (mean age, 84.1 years) who were identified as potential candidates for the initiation of osteoporosis drug treatment and who had survived to the year 16 examination visit. Total follow-up was for a maximum of 29.9 years, with follow-up for a mean of 4.4 years after the year 16 examination.
Participants were categorized as either having osteoporosis (n = 761) or not having osteoporosis but being at high fracture risk (n = 767).
Every 4 months, participants were contacted to provide vital status and occurrence of hip fracture.
Researchers calculated 5-year hip fracture probability while accounting for competing mortality risk, with comorbid conditions assessed through self-report and prognosis estimated through a mortality prediction index.
During follow-up, 287 women died before experiencing a hip fracture, and 125 women experienced a hip fracture.
Researchers found that 5-year mortality probability was 24.9% (95% CI, 21.8-28.1) in women with osteoporosis and 19.4% (95% CI, 16.6-22.3) in women without osteoporosis but at high fracture risk.
While mortality probability increased with more comorbidities and poorer prognosis in both groups, 5-year hip fracture probability was 13% (95% CI, 10.7-15.5) in women with osteoporosis and 4% (95% CI, 2.8-5.6) in women without.
Women aged 80 and older with osteoporosis and substantial comorbidity have a high 5-year probability of hip fracture and may still benefit from drug therapy for prevention of hip fracture.
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Researchers observed that this difference was most substantial in women with more comorbidities or worse prognosis; among women with three or more comorbid conditions, hip fracture probability was 18.1% (95% CI, 12.3-24.9) in women with osteoporosis vs. 2.5% (95% CI, 1.3-4.2) in women without osteoporosis but at high fracture risk.
“Women 80 years and older, including those with multimorbidity or estimated shorter life expectancy, should be counseled about their risk of hip fracture and be considered for osteoporosis screening with bone mineral density testing,” Ensrud said. “Clinicians should consider the initiation of drug treatment to prevent fracture in late-life women with osteoporosis (bone mineral density T-score –2.5 or below) and multiple comorbidities, as this group of women may derive the greatest absolute benefit of treatment in preventing future hip fractures. Research is needed to develop fracture prediction models in adults 80 years and older that account for individual patient competing risk of death and incorporate late-life risk factors such as multimorbidity in addition to bone mineral density. In addition, well-designed observational studies are essential to evaluate the efficacy and safety of osteoporosis medications in this rapidly growing patient population.”
In a related editorial, Sarah D. Berry, MD, MPH, Sandra Shi, MD, and Douglas P. Kiel, MD, MPH, all of the department of medicine at Beth Israel Deaconess Medical Center, Harvard Medical School, wrote: “These findings are of great clinical importance given the ongoing recognition that clinical guidelines should consider multimorbidity. Presently, the guidelines for screening and treating adults for osteoporosis offer no consideration of age, comorbidities or frailty. In contrast, guidelines for cancer screening caution against routine screening in older adults of advanced age or with limited life expectancy given the diminishing value of cancer screening and prevention therapies in the eighth and ninth decades of life. This study suggests that the risk-benefit calculation for fracture prevention in older adults differs from that of cancer. If medications to prevent fracture are equally effective in older women with multiple comorbidities as they are in younger women, then older women with comorbidities are the individuals most likely to benefit from osteoporosis treatment.” – by Melissa J. Webb
Disclosures: Ensrud reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.