A comparison of bone density and bone morphology between patients presenting with hip fractures, spinal fractures or a combination of the two.

BACKGROUND: Currently it is uncertain how to define osteoporosis and who to treat after a hip fracture. There is little to support the universal treatment of all such patients but how to select those most in need of treatment is not clear. In this study we have compared cortical and trabecular bone status between patients with spinal fractures and those with hip fracture with or without spinal fracture with the aim to begin to identify, by a simple clinical method (spine x-ray), a group of hip fracture patients likely to be more responsive to treatment with current antiresorptive agents. METHODS: Comparison of convenience samples of three groups of 50 patients, one with spinal fractures, one with a hip fracture, and one with both. Measurements consist of bone mineral density at the lumbar spine, at the four standard hip sites, number, distribution and severity of spinal fractures by the method of Genant, cortical bone thickness at the infero-medial femoral neck site, femoral neck and axis length and femoral neck width. RESULTS: Patients with spinal fractures alone have the most deficient bones at both trabecular and cortical sites: those with hip fracture and no spinal fractures the best at trabecular bone and most cortical bone sites: and those with both hip and spinal fractures intermediate in most measurements. Hip axis length and neck width did not differ between groups. CONCLUSION: The presence of the spinal fracture indicates poor trabecular bone status in hip fracture patients. Hip fracture patients without spinal fractures have a bone mass similar to the reference range for their age and gender. Poor trabecular bone in hip fracture patients may point to a category of patient more likely to benefit from therapy and may be indicated by the presence of spinal fractures.

Underrepresentation of individuals 80 years of age and older in chronic disease clinical practice guidelines.

OBJECTIVE: To determine whether Canadian clinical practice guidelines (CPGs), and the evidence used to create CPGs, include individuals 80 years of age and older. DESIGN: Descriptive analysis of 14 CPGs for 5 dominant chronic conditions (diabetes, hypertension, heart failure, osteoporosis, stroke) and descriptive analysis of all research-based references with human participants in the 14 guidelines. MAIN OUTCOME MEASURES: To identify recommendations for individuals 65 years of age and older or 80 years of age and older and for those with multiple chronic conditions. RESULTS: Although 12 of 14 guidelines provided specific recommendations for individuals 65 years of age and older, only 5 provided recommendations for frail older individuals (≥ 80 years). A total of 2559 studies were used as evidence to support the recommendations in the 14 CPGs; 2272 studies provided the mean age of participants, of which only 31 (1.4%) reported a mean age of 80 years of age and older. CONCLUSION: There is very low representation of individuals in advanced old age in CPGs and in the studies upon which these guidelines are based, calling into question the applicability of current chronic disease CPGs to older individuals. The variety of medical and functional issues occurring in the elderly raises the concern of whether or not evidence-based disease-specific CPGs are appropriate for such a diverse population.

Prevention of hip fractures in long-term care: relevance of community-derived data.

Osteoporosis and falling are two major contributing factors to fractures in older persons; the relevant contribution of these may vary according to age, setting, and frailty. The purpose of this review was to examine the existing evidence on osteoporosis treatments to determine whether participants in clinical trials include or resemble the older and frailer adult population living in long-term care (LTC). The trials (N=50) used to support major Canadian guidelines for osteoporosis treatment were reviewed because these are used to recommend treatment for all older adults, and several more-recent studies were added. Trials conducted specifically with participants living in LTC were also reviewed (N=6). The majority of studies (96.0%) on osteoporosis treatments were conducted with community-dwelling participants, with many excluding participants resembling the LTC population. Mean ages ranged from 52 to 84, although for the majority of studies, the mean age was younger than 70. Similarly, 80.0% of studies conducted in LTC included only residents who were ambulatory, mobile, able to transfer independently, or not permanently bedridden. Mean ages in these studies ranged from 83 to 85. These findings suggest that frail older adults, particularly the oldest and frailest adults in LTC, are neglected in clinical trials of osteoporosis fracture prevention. There is little evidence to support the application of community-based guidelines to the LTC population, and studies directly involving this population are needed. The role of age, frailty, and the mechanics of falls in hip fracture are discussed.