Osteoporosis Diagnosis, Care Suboptimal in Older Men

Marlene Busko

February 19, 2019

Older veterans, especially men, often have a high risk for hip fracture along with low rates of recommended further testing and preventive therapy, a large study has found.

Specifically, a validated, shortened version of the FRAX risk assessment tool found that 48% of men aged 75 to 79 years being treated in a large VA center had a 3% or greater risk of experiencing a hip fracture within a decade — the threshold for starting preventive therapy, according to guidelines. The risk was almost double (88%) for men aged 80 years or older.

However, in the overall cohort of men aged 70 years and older who met this threshold, only 12% had a dual-energy X-ray absorptiometry (DXA) scan to measure bone mineral density and only 5% received bisphosphonates.

Moreover, rates of DXA and preventive therapies were still "strikingly low" in men identified as "high-risk" by FRAX as a result of a previous hip fracture or androgen deprivation therapy (ADT) for prostate cancer or long-term corticosteroid therapy.

Radhika Rao Narla, MD, from the University of Washington School of Medicine, Seattle, and colleagues published their findings online February 5 in the Journal of Investigative Medicine.

"I think we've made some progress," Narla told Medscape Medical News, "but I think there's still work to do in terms of trying to improve not only the screening for male veterans but also for female veterans, especially the elderly who are very high risk, and especially men who have a history of prior hip fracture — they should definitely be screened.

"If you do treat those patients who do have low bone density (that's defined as osteoporosis), you're trying to help them not have that fracture, because we all recognize that the morbidity and mortality from these fractures are quite high," she added. "People don't gain their prefracture independence; they're not able to take care of themselves."  

Notably, in 2010, the VA inspector general reported that a quarter of male veterans who had a hip fracture died within a year.

"Although our study was performed in a veteran population receiving care in the VA system," the authors conclude, "we believe that there is a need for developing strategies to improve the evaluation and management of osteoporosis in all older men, particularly among elderly men with a very high risk of fracture."

Osteoporosis Screening, Follow-up Tests, and Treatment

Despite the publication of several society guidelines for identifying, managing, and treating osteoporosis, it is not clear if this has been translated into clinical practice in older patients, especially men and high-risk men.

The researchers aimed to investigate the prevalence of case-finding, evaluation, and therapeutic management of osteoporosis in men and women aged 70 years and older who were treated at their VA center in Seattle during 2000 through 2010.

They identified 13,704 patients (11,604 men and 463 women) who had complete data from a validated, shortened version of the FRAX risk assessment tool based on ethnicity, age, weight, and height, and in men also based on previous fracture, glucocorticoid use, and secondary osteoporosis (using ADT as a surrogate).

Of these, 1637 men were at high risk resulting from long-term corticosteroid use (1126 men) or ADT (329) or a prior hip fracture (182).

As expected, the risk of having a hip fracture during the next decade rose with increasing age, going from 48% in 75- to 79-year-old men to 88% in men aged 80 and older, and from 89% to 99% for women in the same age groups.  

"Suboptimal" and "Strikingly Low" Rates of Tests, Therapies

More women than men met the FRAX 10-year hip fracture risk threshold for starting preventive therapy: 72% vs 39%.

Compared with men who met the treatment threshold, women were about five-times more likely to have a DXA scan (63% vs 12%), twice as likely to have a serum vitamin D test (39% vs 18%), and much more likely than men to receive calcium/vitamin D supplements (63% vs 20%) and bisphosphonate therapy (44% vs 5%).

However, rates of these diagnostic tests and preventive therapies are "still suboptimal," the researchers stress.

Moreover, 95% of men with a prior hip fracture, 69% of men on long-term prednisone, and 74% of men receiving ADT had a 3% or greater 10-year risk for hip fracture.   

These high-risk men had "strikingly low" rates of DXA (27% to 36%), serum vitamin D testing (23% to 28%), calcium/vitamin D supplements (40% to 50%), and bisphosphonate therapy (13% to 24%), the authors report.  

They note that study strengths were the older population with a mean age of 77 years, and the inclusion of data for rarely studied women veterans and separate data for men older than 80 years.

Limitations include that it was a retrospective study in a population of veterans (so costs would be less of a factor and findings may not be generalizable).

"I think conflicting guidelines [including those for primary care] make it challenging," to identify and treat osteoporosis in older patients, Narla said.

"This population [also] has a lot of comorbidities. Sometimes the diabetes or high blood pressure or the chronic pain takes precedence in that short [patient] visit rather than 'Hey, can we talk about your fall risk and if you might have osteoporosis?'"

She hopes that this study will raise awareness of shortcomings in identifying and preventing fracture risk in older patients.

As a next step, the researchers plan to investigate whether an e-consult tool could improve hip fracture prevention, especially for older veterans living in rural areas.

The study was funded by the Geriatric Research, Education and Clinical Center, Department of Veterans Affairs, and supported by the VA Special Fellowship Program in Advanced Geriatrics. The authors have disclosed no relevant financial relationships.

J Investig Med. Published online February 5, 2019. Full text

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