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Grand Rounds

Hip Fractures in Older Women: Who is at Risk and Would Benefit Most from Treatment?

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BACKGROUND AND PURPOSE:

  • Older women, especially those with multiple comorbidities, are less likely to receive medications to prevent hip fracture despite increased risk of fracture in this population
  • Fracture probability
    • 80 to 84 years: 7.1%
    • ≥90 years: 20.9%
  • It may be difficult to determine who will benefit from preventative treatment as medical comorbidities may also place women at increased risk for competing mortality, unrelated to hip fracture
    • Concern that patient may be more likely to die from other causes prior to suffering a hip fracture
  • Ensrud et al. (JAMA Internal Medicine, 2019) studied the possible risk factors and associations to determine which women ≥80 years of age may be candidates for medication to prevent hip fracture

METHODS:

  • Prospective cohort study
  • Participants
    • Community-dwelling women ≥80 years of age
    • Possible candidates for initiation of osteoporosis drug treatment
  • Participants were classified in 2 groups (National Bone Health Alliance criteria)
    • With osteoporosis
    • Without osteoporosis but still at a high fracture risk due to osteopenia or has experienced a confirmed distal forearm, proximal humerus, or pelvis fracture
  • Data collection and analysis
    • Women were contacted every 4 months to determine vital status and whether they had experienced a hip fracture
    • 5-year hip fraction probability was calculated while accounting for competing mortality risk
    • Comorbid conditions were assessed by self-report
    • Prognosis was estimated using a mortality prediction index

RESULTS:

  • 1,528 women were included
    • With osteoporosis group: 761
    • Without osteoporosis but at a high fracture risk group: 767
    • Mean (SD) age: 84.1 (3.4) years
  • During follow-up
    • 8% experienced a hip fracture | 18.8% died before experiencing a hip fracture
  • Five-year mortality probability
    • With osteoporosis: 24.9% (95% CI, 21.8 to 28.1)
    • Without osteoporosis but at a high fracture risk: 19.4% (95% CI, 16.6 to 22.3)
    • In both groups, mortality probability increased with more comorbidities and poorer prognosis
  • 5-year hip fracture probability
    • With osteoporosis: 13.0% (95% CI, 10.7 to 15.5)
    • Without osteoporosis but at a high fracture risk: 4.0% (95% CI, 2.8 to 5.6)
  • Greatest difference in 5-year hip fracture probability was most pronounced in those with more comorbidities or worse prognosis
    • Hip fracture probability with ≥3 comorbid conditions:
      • With osteoporosis: 18.1% (95% CI, 12.3 to 24.9)
      • Without osteoporosis but at a high fracture risk: 2.5% (95% CI, 1.3 to 4.2)

CONCLUSION:

  • The 5-year probability of hip fracture is high among women with osteoporosis in women ≥80 years, even when accounting for competing mortality risk
  • Women without osteoporosis but at high fracture risk are more likely to die from other causes and will derive less benefit from treatment
  • The authors conclude

…late-life women with osteoporosis, including those with comorbidities or poorer prognosis, have a high hip fracture probability despite accounting for competing mortality risk and may still be drug treatment candidates to prevent future hip fracture.

Learn More – Primary Sources:

Association of Disease Definition, Comorbidity Burden, and Prognosis With Hip Fracture Probability Among Late-Life Women

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Related ObG Topics:

The VERO Trial Results: Teriparatide vs Risedronate for the Treatment of Osteoporosis
ARCH Study Results: Does Romosozumab Prevent Fracture in Women with Osteoporosis?
The SCOOP trial: Does Osteoporosis Screening Reduce Hip Fracture Rates in Older Women?
ACP Releases Guidance Update on Osteoporosis Treatment
USPSTF Recommendations: Screening for Osteoporosis to Prevent Fractures
Osteoporosis Treatment for Postmenopausal Women at High Risk for Fracture

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