Current approach to prevent hip fracture in elderly not working

It’s time to re-examine the current assumption that a diagnosis and subsequent treatment of osteoporosis will prevent hip fractures in the elderly, according to a recent report in the BMJ.

International researchers conducted a systematic review of the literature and found large gaps in the evidence for the prophylactic treatment of bone fragility in the elderly to help reduce the risk of hip fractures. Of 23 trials in their review, they found only three studies included enough women who were older than 75 years to analyze the incidence of hip fracture. Of these studies, none of them showed any significant effect of drug therapy on hip fractures in this elderly group.

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“The evidence thus suggests that those most prone to hip fractures do not benefit from bisphosphonate treatment. This discouraging finding was corroborated by a recent randomized trial of single dose zoledronic acid for osteoporosis in frail elderly women,” noted Teppo Jarvinen, the lead author of the meta-analysis.

Jarvinen and his colleagues also discovered that there is no randomized trial evidence on hip fracture prevention in men despite the fact that 30 to 40 percent of hip fractures occur in elderly men.

In addition, the evidence on how long to treat for hip fracture prevention is limited, the authors noted. The FDA did publish a pooled data analysis of randomized trials to examine the impact of continuous versus limited drug treatment. The analysis showed that continuous bisphosphonate treatment for 6 or more years did not benefit individuals in terms of vertebral and non-vertebral fracture rates compared with placebo.

“This is still the best available evidence, and at least provides no rationale for long-term use of bisphosphonates,” the authors wrote.

Also, the “evidence on cost-effectiveness of pharmacological fracture prevention is completely lacking,” they noted. “Current assertions that drug treatment is cost effective are based on computer modeled analyses that disregard the evidence gaps and extrapolate efficacy estimate derived from younger women (aged 60-80) to their older peers (age >80) and to men.”

Reason for hip fractures

Only about one in three hip fractures occur because of bone fragility. Most are due to trauma from falls, especially in the eldery who are frail.

“Incidence of hip fracture in women rises 44-fold from the age of 55 to 85, and the effect of ageing is 11-fold greater than that of reduced bone mineral density,” the authors said.

What is more important to ask elderly patients is if they have impaired balance as this can predict approximately 40 percent of all hip fractures.

Better strategies than drug treatment for the prevention of hip fracture should include fall prevention programs with exercise training. Also, quitting smoking is a major modifiable risk factor for hip fractures.

“The substantive approaches to preventing hip fractures have not changes in nearly 25 years: stop smoking, be active, and eat well. This advice works for anyone, regardless of bone fragility, and the benefits encompass the entire human body,” the authors noted.