Thursday, January 28, 2021

Do Something For Your Bone Health Today: Mind The Care Gap And Don’t Wait For Fractures To Happen

Let’s get loud about osteoporosis. For too long, it has flown under the radar as a “silent disease.” There are few tell-tale symptoms (like loss of height), but diagnoses are often made when it’s too late and a bone fracture has occurred. Even then, after it is treated, patients leave the hospital without the dots ever being connected between bone break and osteoporosis, the underlying cause of 80 percent of fractures among patients over the age of 50. And so, the cycle of silence continues.  

Dr. Jeffrey Habert, a family physician and an assistant professor, University of Toronto, Dept. of Family and Community Medicine, is disturbed by the pattern. “Let’s compare it to coronary disease,” he says. “If you go into a hospital because of a myocardial infarction – a heart attack, you’re instantly put on blood thinners and cholesterol drugs, then sent home for follow up with a cardiologist and a family doctor. Let’s say you’re a 57-year-old woman and you have a Colles’ fracture, a type of wrist fracture. You go to the hospital and they put you in a cast. Typically, you’ll see the orthopaedic surgeon. You’ll follow this up and that’s it. Your family doctor may not even know that happened and you won’t be assessed for osteoporosis.”

Dr. Jeffrey Habert

The danger is fractures beget fractures. Research from Osteoporosis Canada shows a first fracture is unlikely to be the last. Fourteen per cent with a wrist fracture will have another within three years. More than one in two hip fracture patients will suffer a reoccurrence within five years. As Dr. Habert points out, hip fractures are associated with significant morbidity and mortality: “Hip fractures are not benign. In women, the one-year mortality rate for a hip fracture is about 28 per cent and 37 per cent for men [for patients over the age of 80].”

Ideally, a woman with a wrist fracture will have a bone density test. At minimum, she’s going to be at moderate risk, likely high risk, of having osteoporosis and she should be treated. Some hospitals have fracture liaison services (FLS) to ensure follow-up happens and family physicians are informed of patient fractures. Unfortunately, research shows that 80 per cent of Canadians who suffer a fragility fracture do not receive treatment for osteoporosis. It represents a serious gap in care.  

The gap continues with treatments for osteoporosis – either oral medication (typically given once a week) or injectables (every six months). According to a 2019 survey, one in four Canadians admits taking less medicine than prescribed or don’t get the prescription filled at all, while 20 per cent stop taking medications before advised. About one-quarter of respondents say their lack of adherence is due to forgetfulness. In the world of osteoporosis, erratic dosing is harmful.

 “We know that if you miss your pills half the time, it’s going to affect you…,” explains Dr. Habert. “It’s important that when we start patients on antiresorptive therapy [medications used to increase bone strength] – whether it be oral or injectable – that we see patients for a follow-up appointment to make sure everything’s okay and that they’re actually taking their medication.”

He says that one benefit of injectables is that he gets to see patients and see how they are doing. His practice offers a reminder service to help patients avoid missed appointments. Dr. Habert also works closely in partnership with pharmacies to ensure medications are picked up and to talk with patients about their injections. “It’s very important to stay on track,” he points out. “There is risk in stopping that kind of injection. Within two years, your risk of fracture goes back to where it was initially. But more so, the risk of vertebral fractures go up acutely.”

“In my view, the public has the least amount of knowledge about bone health, compared to the other things we talk about.”

Patients may not follow through with taking their osteoporosis medications because they don’t think it’s important. They aren’t in pain. “It’s similar to diabetes or hypertension,” he continues. “A 56-year-old woman might have osteoporosis, but she’s never fractured. She doesn’t feel anything. She feels fine.” Osteoporosis is a silent disease, as are the medications. You aren’t aware they are working. It accentuates the need for education. Hypertension was considered a silent condition but increased public awareness has helped change that. Osteoporosis is following suit. “We need to educate in the osteoporosis world that we’re preventing vertebral fractures and hip fractures, which have dire consequences,” adds Dr. Habert.

His hope is that patients become partners in their health. When you turn 65, or if you over age 50 and have risk factors for osteoporosis, you can ask your doctor about having a bone density test. But if you don’t know enough about bone health to ask, that can’t happen. Again, education to close the knowledge gap is the key. 

As Dr. Habert notes: “It’s okay to say, ‘You know what, doctor? It’s really important to me to not fracture. I’m really active, I’m enjoying my life. I really want to prevent hip fractures and spinal fractures. What can I do?’ People should partner with their physician as they age. We look at cardiac disease, we look at cancer prevention and diabetes prevention. We should look at bone prevention, too. It should be one of the top 5 or 10 things on your list to prevent as we age.

Patient focus is often more on common conditions with high mortality rates, namely, heart disease and cancer. With osteoporosis, what is at stake is a loss of independence and quality of life, and yes, death, too. “The lifetime risk of a hip fracture for a woman is 12 per cent. That’s not rare – one in eight women will have a hip fracture. Forty per cent will need assistance walking and one in five or one in six will enter long-term care. And nearly one quarter will die within a year. These are very serious consequences.”

That underscores the necessity to mind the care gap around osteoporosis and for Canadians to make bone health a priority.

Hip Fractures By The Numbers

Hip fractures are considered the most devasting type of fragility fracture. The consequences are profound on quality of life and risk of dying. 

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70-90 per cent of hip fractures are due to osteoporosis.15-25 per cent of hip fracture patients require admission to a nursing home.Approximately half of patients had previously broken a bone, also called a ‘signal’ fracture, before breaking their hip.Osteoporotic hip fractures take up more hospital days than stroke, diabetes or heart attack.40 per cent of women hip fracture patients will need help walking, 18 per cent require long-term care, and 23 per cent will die within a year.

Presented through a sponsorship through Amgen Canada Inc.

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