Elsevier

Bone

Volume 38, Issue 2, Supplement 1, February 2006, Pages 4-9
Bone

Osteoporosis: A still increasing prevalence

https://doi.org/10.1016/j.bone.2005.11.024Get rights and content

Abstract

It is estimated that over 200 million people worldwide have osteoporosis. The prevalence of osteoporosis is continuing to escalate with the increasingly elderly population. The major complication of osteoporosis is an increase in fragility fractures leading to morbidity, mortality, and decreased quality of life. In the European Union, in 2000, the number of osteoporotic fractures was estimated at 3.79 million. A baseline fracture is a very strong predictor of further fractures with 20% of patients experiencing a second fracture within the first year. The costs to health care services are already considerable and, on current trends, are predicted to double by 2050. The direct costs of osteoporotic fractures to the health services in the European Union in the year 2000 were estimated at €32 billion. Guidelines for the diagnosis and treatment of osteoporosis are available in many countries; however, implementation is generally poor despite the availability of treatments with proven efficacy. Programs to increase awareness of osteoporosis and its outcomes are necessary for healthcare specialists and the general public. Earlier diagnosis and intervention prior to the first fracture are highly desirable.

Introduction

The incidence of osteoporosis in postmenopausal women continues to increase with progressively aging populations. Currently, it is estimated that over 200 million people worldwide have osteoporosis [1] and 44 million of these are in the United States [2]. The reduction in bone strength associated with this disease markedly increases the risk of skeletal and nonskeletal fractures, and the consequent pain and loss of function impinge adversely on the quality of life. In the United States and the European Union, about 30% of all postmenopausal women have osteoporosis, and it has been predicted that more than 40% of them will suffer one or more fragility fractures during their remaining lifetime [3].

Advanced age is the best predictor of osteoporosis, but early menopause, a maternal history of hip fracture, a fracture after 40 years of age, low body weight, or specific diseases and treatments increase susceptibility to fractures. All fractures (wrist, ribs, vertebrae, and hip) are associated with considerable morbidity, a decline in quality of life, and increased mortality [4]. Approximately 1.5 million fractures annually are attributable to osteoporosis in the United States [5]. In the European Union, in the year 2000, the number of osteoporotic fractures was estimated at 3.79 million, of which 0.89 million were hip fractures [6]. Of all fractures due to osteoporosis, hip fractures are the ones that are most disabling. In 1990, about 1.7 million new hip fractures occurred worldwide, and this figure is expected to rise to 2.6 million by 2025 [7]. In the United States, approximately 300,000 patients aged over 45 years were hospitalized because of hip fractures in 1991 [2]. Furthermore, women who have sustained a hip fracture have a 10% to 20% higher mortality than would be expected for their age [8].

Osteoporotic fragility fractures impose a considerable financial burden on health services due to reduced mobility, hospitalization, and nursing home requirements [9]. In the European Union, in 1998, osteoporosis patients occupied 500,000 hospital bed-nights per year, and this was expected to double by 2050 [10]. In most of the developed countries, it is currently recommended that postmenopausal women, with the highest risk, should be screened for osteoporosis and a 10-year probability of fracture assessed for each individual to determine intervention thresholds [11]. Despite these recommendations, osteoporosis is frequently not diagnosed even after the first vertebral fracture has occurred. In this review, we discuss the evidence that supports the need for cost-effective diagnosis and treatment prior to a first fracture.

Section snippets

Diagnosis of osteoporosis

Osteoporosis is associated with decreased bone strength, which is a consequence of bone density and quality. Many prospective studies have shown that there is a significant correlation between low bone mineral density (BMD) and fracture frequency [5]. Current diagnosis of osteoporosis is largely based on measurement of BMD, using dual energy X-ray absorptiometry (DXA) of the hip or lumbar spine. An individual BMD value compared with the mean of a healthy young population in terms of the number

Risk assessment for osteoporotic fracture

Initial assessment of osteoporosis and prediction of fracture risk in postmenopausal women are based on T-scores from BMD measurements as defined by the WHO [12]. Age is the most important independent indicator of risk of fractures (Fig. 1). Although not universally accepted, WHO guidelines for osteoporosis suggest routine screening and treatment for women over 65 years of age and for postmenopausal women with histories of fragility fractures or who have one or more risk factors [12].

BMD is

Impact on morbidity, mortality, and quality of life

Women with vertebral fractures may have decreased physical function, back pain, loss of height due to crush fractures of the spine, and impairment of social contact. A cross-sectional, population-based study from 36 centers in 19 European countries, involving 15,570 males and females with no history of fracture, between the ages of 50 and 79 years showed that one in eight had evidence of vertebral deformity. It was of interest that there was a three-fold variation in this occurrence across the

Available therapies

An increased understanding of the pathophysiology of osteoporosis has led to the development of treatments targeting BMD, bone turnover, and fracture. Many large trials have shown that a variety of agents reduce the incidence of new fractures between 30% and 50% in women at high risk for subsequent fractures [33], [34]. Less attention has been paid to the outcomes of treatment in postmenopausal women without previous fractures, but there is now some evidence from randomized, double-blind,

Cost of osteoporotic fractures

In the United States, the estimated direct expenditure in hospitals and nursing homes for osteoporosis-associated fractures was US $17 billion ($47 million/day) in 2001, and the cost continues to rise [2]. The direct costs of such fractures to the health services in the European Union in the year 2000 were estimated at €32 billion, and, based on expected demographic changes, it has been predicted that this will increase to €77 billion by 2050 [6].

Little is known about costs incurred prior to

Current and future management

At the present time, many patients at risk of osteoporosis do not undergo BMD testing or receive treatment, and it is of concern that many consequent vertebral fractures go undetected [39], [41]. Even when fragility fractures are diagnosed, many patients still do not receive treatment for osteoporosis. In the largest study of menopausal osteoporosis conducted in the United States to date, 11% of women over 45 years had baseline fractures of wrist, rib, hip, and spine. Although the majority of

Summary and conclusions

Aging of populations worldwide is changing the epidemiology of osteoporosis. The disease is common, asymptomatic, and often undetected until a fracture occurs. Early screening is still not widespread in many countries, although national guidelines for osteoporosis and its management are often available. Even after diagnosis of osteoporosis or a first fragility fracture, intervention is not universal. This lack of care has a major impact on morbidity, mortality, quality of life, and health care

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