Search

A triage strategy, based on a clinical hip fracture risk score, may be used to classify elderly women into three groups: one at high risk and requiring treatment, another needing further assessment by bone densitometry, and a third at low risk. We used prospective data from the EPIDOS study (7512 women older than 75 years and followed for an average of 3.9 years) to assess the potential value of such a strategy for identifying elderly women with a hip fracture risk twice the cohort average (i.e. > or =20 per 1000 woman-years). An individual fracture risk score was calculated with the final risk function (Cox model). To compare this strategy with systematic BMD measurement and with current European recommendations, we examined the number of high-risk women identified, their average risk levels, sensitivity for hip fracture, and the number of high-risk women who need to be treated to prevent one hip fracture (hypotheses: all identified women are treated; sensitivity is equal to the point estimate; treatment reduces fracture risk by 35%). A triage strategy based on age, fracture history since the age of 40 years, body mass index, number of instrumental activities of daily living for which assistance is needed, grip strength, and visual acuity can identify 20% of the cohort as at high risk, 75% of them from clinical factors only, and the rest after BMD measurements (threshold: -2.5 T-score). The triage strategy would be significantly more sensitive than systematic BMD screening (51 versus 35%) and would require many fewer BMD examinations (10%). Compared with current recommendations, triage would identify fewer women (20 versus 28%) but at a significantly higher average risk of hip fracture (30 versus 20 per 1000 woman-years). Fewer high-risk women would be treated to prevent one hip fracture (29 versus 41) and fewer bone densitometry tests would be needed (10% versus 54%). The proposed triage strategy may be a useful clinical tool for selecting elderly women for treatment or bone densitometry.

We have previously shown that hip bone mineral density (BMD), heel broadband ultrasound attenuation (BUA) and bone resorption markers are independent predictors of hip fracture in elderly women. We investigated whether a combination of these three parameters could improve the predictive value of a single test in a nested case-control analysis (75 hip fractures and 228 age-matched controls) of the EPIDOS prospective study comprising 7598 healthy women 75 years of age and older followed prospectively for a mean 22 months. At baseline, prior fracture, femoral neck BMD by dual-energy X-ray absorptiometry (DXA), heel BUA and urinary type I collagen C-telopeptide breakdown products (CTX) were assessed. The area under the receiver operating characteristic curve was significant for the three diagnostic tests, heel BUA being the best single predictor. The added value of urinary CTX to either BMD or BUA depends on the cutoff point chosen to define patients at risk and on the therapeutic strategy that is considered. Defining patients at risk as those with low BMD (or low BUA) or high CTX resulted in a significant increase in the sensitivity compared with BMD or BUA alone--a strategy that could be applied when a broad treatment is considered. However, this increased sensitivity was also obtained simply by increasing the BMD and BUA cutoffs, suggesting that a combination of CTX with BMD/BUA is not useful for that type of treatment strategy. Conversely, defining patients at risk as those with both low BMD and high CTX increases the specificity (88% vs 78%) with a similar number of hip fracture patients being identified (30% vs 32%)--a combination that could be useful when the strategy is to target treatment to a subset of high-risk patients. This strategy appears to be more cost-effective than bone mass measurement alone as indicated by the 37% fewer patients who need to be treated to avoid one fracture per year. If DXA or ultrasound is not available, the combination of a bone resorption marker with a history of any type of fracture after the age of 50 years gave a predictive value similar to that obtained with femoral neck BMD or heel BUA alone, for both types of treatment strategy. We conclude that the combination of urinary CTX with hip BMD could be useful for the identification of elderly women at high risk for hip fracture, resulting in higher specificity for a given sensitivity threshold than BMD measurement alone. If DXA is not available, the combination of history of fracture and urinary CTX performs as well as hip BMD to assess hip fracture risk in elderly women.

: Currently, few elderly women have a measurement of bone mineral density (BMD). The aim of this study was to assess the potential value of a two-step screening process to identify the elderly women who are at greatest risk of fracture because of very low BMD: (1) use simple clinical criteria to select women who are highly likely to have a very low BMD and (2) measure the BMD of the women so selected. We used baseline data from 6958 women aged 75 years or older who were participants in the EPIDOS prospective study of risk factors for hip fracture. The outcome variable was very low BMD measured at the femoral neck by dual-energy X-ray absorptiometry and defined as a T-score ≤-3.5. The factors most predictive of very low BMD were low weight, history of fracture after the age of 50 years, slow gait, balance impairment, low grip strength, and dependence for instrumental activities of daily living. A score based on the risk function including these factors has a sensitivity of 80% at the median cut-off. Hence, by measuring the BMD of only half the population, 80% of the women with very low BMD can be identified. Weight is the strongest determinant of very low BMD and has approximately the same sensitivity as the complete score. In conclusion, a risk score for very low BMD based on simple criteria such as weight could be a useful clinical tool to select elderly women for bone densitometry. [ABSTRACT FROM AUTHOR]

Abstract: Rationale : Hip fractures can be separated into cervical and trochanteric fractures. Trochanteric fractures have been associated with up to twice the short-term mortality of cervical fractures in the elderly. There is also evidence suggesting that the mechanisms are different. Evidence from the literature remains limited on the predictive power of bone mineral density (BMD) and quantitative ultrasounds (QUS) for both types of hip fractures. Methods : 5703 elderly women aged 75 years or more, who were recruited from the voting lists in the EPIDOS study, and had baseline calcaneal ultrasounds (QUS) and DXA measurements at the hip and the whole body, were analyzed in this paper. Among those, 192 hip fractures occurred during an average follow-up of 4 years, 108 cervical and 84 trochanteric fractures. Results : Femoral neck, trochanteric and whole body BMD were able to predict trochanteric hip fracture (RR’s and 95% CI were, respectively, 3.2 (2.4–4.2); 4.8 (3.5–6.6); and 2.8 (2.2–3.6)) more accurately than cervical fractures (respectively, 2.1 (1.7–2.7); 2.3 (1.8–3.0); 1.2 (1.0–1.6)). All ultrasound parameters, SOS, BUA, and stiffness index (SI) were significant predictors of trochanteric (RR’s respectively 3.0 (2.2–4.1), 2.5(2.0–3.1), and 3.5(2.6–4.7)) but not cervical fractures. After adjustment for femoral neck or trochanteric BMD ultrasound parameters were still significant predictors of trochanteric fracture, and stiffness tended to be a better predictor of trochanteric fractures than either BUA or SOS with a relative risk of 2.25 (1.6–3.1). Conclusions : A significant decrease of all bone measurements, BMD and QUS, was highly predictive of trochanteric fractures, whereas a decrease of femoral neck and trochanteric BMD were only associated with a slight increase in cervical fracture risk and a low total body BMD or QUS parameters were not significant predictors of cervical fractures. In women who sustained a hip fracture, the decrease of BMD and QUS values increases the risk of trochanteric fracture as compared to cervical fracture. Trochanteric fractures were mostly a consequence of a generalized low BMD and QUS, whereas other parameters might be involved in cervical fractures. [Copyright &y& Elsevier]