What typically happens when a post-menopausal woman goes to the hospital with a bone fracture in her wrist? She’s assessed by emergency room physicians, the break treated and is sent home. It may seem like a logical course of action until you consider that a fracture, especially in older women, is a red flag for osteoporosis.
Over 80 per cent of all fractures in people aged 50 and above are a result of this silent, potentially deadly disease. Data from Osteoporosis Canada indicates that 28 per cent of women and 35 per cent of men will die within a year of a hip fracture, with an estimated 70 to 90 per cent caused by osteoporosis. About 30,000 Canadians annually will fracture their hip. Any fracture should serve as a warning that another is more likely in the future – 14 per cent recurrence for those with wrist fractures, while one in two hip fracture patients will have a repeat occurrence within five years.
Statistics paint a grim picture
Despite the prevalence of the disease, more than half of osteoporosis cases go undiagnosed, according to a 2017 Global Data study. At least one in three women and one in five men will break a bone due to osteoporosis in their lifetime. And only about 20 per cent of patients after a fragility fracture will have any diagnostic or intervention follow-up within 12 months. Those troubling statistics underscore the seriousness and prevalence of the current care gap.
Why isn’t osteoporosis diagnosed more readily and more often? The reasons are complex and multifaceted. “It’s a quiet disorder,” says Dr. David Kendler, a professor of medicine with the University of British Columbia. “It’s like hypertension or high cholesterol. You don’t feel it. With things that people don’t feel, they have little awareness of. Unless it’s brought to their attention, they have little consideration of it.”
When a fracture occurs, it’s an opportunity to further investigate the reasons for the break. That’s not what happens typically. Fractures are often dismissed as minor and non-life-threatening – a one-time event chalked up to bad luck. But healthy bones should be able to withstand a fall from standing height. They should not fracture from a low-level trauma.
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Understanding the seriousness of fractures
“People often don’t realize the impact of a fracture,” explains Dr. Kendler. “Heart attack, stroke and cancer are all things that people put higher on the list of importance. The perception for many is that if you have a fracture, you go to the hospital, the orthopedic surgeon puts it back together, you get a cast and then you’re good as gold. You go back to where you were before. And that’s far, far from the truth.”
There’s a lack of awareness that fractures, especially of the hip, can significantly impact quality of life by causing a loss of independence and functionality. “If one expresses fracture in that sense to patients, then it has much more meaning than just saying the word ‘fracture’ or ‘broken bones,’” he notes.
Patients will also blame a fall or an injury for a fracture, not their bones. That does not make sense, Dr. Kendler emphasizes. It’s like believing a heart attack occurred because you shovelled snow or mowed the lawn, without having any regard for the fact that there’s underlying disease. Coronary artery disease actually caused the heart attack and not the exertion. “It’s the same with osteoporosis,” he says. “It isn’t necessarily the fall that causes the fracture. It does make apparent the underlying disorder – osteoporosis.”
Opportunities for better treatment
To help close the treatment gap, some clinical settings are using fracture liaison services (FLS). A FLS program uses a nurse to ferret out patients with fragility fractures and to target them for appropriate investigation and intervention, if necessary. These specialized services result in cost savings, according to a report published by Osteoporosis Canada. A nurse would only need to screen about 300 to 400 patients per year to justify her salary by identifying patients who might otherwise go on to have more fractures and, ultimately, cost more to the healthcare system.
Fracture liaison nurses take a patient’s medical history and make sure that there are no secondary causes for compromised bone strength. They order blood tests to make sure that there’s not hyperparathyroidism, low vitamin D levels or hyperthyroidism issues involving blood proteins – all predictors of secondary causes of bone loss or fracture. If those tests are negative, nurses can make recommendations around calcium intake, vitamin D and exercise, like walking and weight-bearing activities. A bone density test may be also suggested. Based on results, a physician or nurse practitioner could prescribe medications for patients who are at high risk of future fractures.
Fractures aren’t all bad news. Dr. Kendler sees a silver lining. “If a patient was to look at a fragility fracture as a signal event – as something which is highly predictive of her getting into trouble in the future with more major fractures that will take away her quality of life and her functionality, then she has a wonderful opportunity to be empowered. I use that word with patients. And I say, ‘Don’t be threatened by the word ‘osteoporosis.’ Having a fracture is actually a good thing because now you’re empowered to take action to prevent more major fractures. You now have a heads-up that you can do something about it.’”
Presented through a sponsorship from Amgen Canada Inc.
