The prevalence and risk factors of low-energy fractures among postmenopausal women with osteoporosis in Belarus

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1 Gerontologija 2014; 15(3): GERONTOLOGIJA Original article The prevalence and risk factors of low-energy fractures among postmenopausal women with osteoporosis in Belarus Ema Rudenka 1, Natalya Predko 2, Alena Rudenka 2, Katiaryna Vasilenka 1, Anastasiya Adamenka 1 1 City center of osteoporosis, Minsk, Belarus 2 Belarusian Medical Academy of Post-Graduate Education, Minsk, Belarus Abstract Background and objective. Osteoporosis (OP) is the main cause of fractures, leading to serious complications which result in reduced quality of life, disability and increased mortality, especially in the elderly. The priority in the prevention of osteoporotic fractures is given to the identification of individuals at high risk for low-energy fractures. Materials and methods. Ambulatory women aged over 50 years who were at least 3 years postmenopausal and diagnosed of postmenopausal osteoporosis (BMD T-score < 2.5 at femoral neck or lumbar spine) were enrolled in the study. X-ray densitometry at the anterior-posterior projection of lumbar spine (L 1 ) and both proximal femurs as well as taking of medical history focused on the identification of the risk of fragility fractures and fracture history was performed in all women. Results. The history of previous low-energy fractures was reported in 53% of the examined women, the prevalence of Address: Rudenka Alena Kuibisheva str , , Minsk, Belarus Phone alenka.v.ru@gmail.com low-energy fractures increased with age. There were statistically significant differences between women with and without history of osteoporotic fractures by anthropometric data and results of dual-energy x-ray absorptiometry. Conclusions. Most postmenopausal women with diagnosed OP experienced low-energy fractures. Significant risk factors of osteoporotic fractures in the studied sample were older age, lower height and higher reduction of height during life, longer period of menopause. Key words: postmenopausal women, osteoporosis, low-energy fractures, risk factors Introduction A lot of attention is paid to the problem of osteoporosis (OP) in many countries due to the high prevalence of this disease and its serious consequences. Osteoporosis is the main cause of fractures, leading to serious complications which result in reduced quality of life, disability and increased mortality, especially in the elderly. Epidemiological

2 144 E. Rudenka, N. Predko, A. Rudenka, K. Vasilenka, A. Adamenka data indicate a high prevalence of OP: in Europe, USA and Japan OP is diagnosed in 75 millions of people [1]. In 2004, in USA 10 millions of Americans over the age of 50 years were diagnosed with OP and 34 millions had the presence of risk factors for the disease [2]. Clinically OP is recognized usually when a typical low-energy fracture occurs, the most common localization of which are distal forearm, vertebral bodies in the lumbar spine and hip. The most serious social and health consequences are associated with hip fractures [3]. Osteoporotic fractures are associated not only with increased morbidity, disability and reduced quality of life, but also with increased mortality (± 25%) within one year after the injury [4]. The risk of death is significantly higher in patients with the presence of comorbidities which are the most important reason of reduced life expectancy rather than just the presence of a fracture [5]. In the United States each year about 1.5 million people suffer from osteoporotic fractures, 300,000 cases of hospitalization due to hip fracture are recorded annually, and the direct costs of treating hip fractures compose for 18 billion dollars a year, 20% of elderly people who had suffered a fracture of the femoral neck, die within a year after the injury [2]. Similar epidemiological data are observed in the UK, where it is assumed that every other woman over age 50 and one in five men of the same age will suffer osteoporotic fracture during the remaining years of life [6]. In millions fractures, associated with the OP, were recorded in Europe, of this number 0.89 million were hip fractures: 711,000 cases in women and 179,000 in men [7]. The risk of clinically important fractures was 40%, which is comparable with the risks of cardiovascular diseases [8]. Currently, the priority in the prevention of osteoporotic fractures is given to the identification of individuals at high risk for low-energy fractures, such as family history of fragility fractures, previous osteoporotic fractures, low physical activity, prolonged intake of corticosteroids, low body weight, smoking, alcohol abuse, predisposition to falls, early menopause in women. The aim of our study was to determine the frequency and localization of low-energy fractures, as well as the presence of risk factors of fractures in women with low values of bone mineral density (BMD). Materials and Methods Random samples of the records of Caucasian postmenopausal female patients of Minsk city center of osteoporosis were taken and the medical records of 930 women were analyzed and invited to participate in the study. Ambulatory women aged over 50 years who were at least 3 years postmenopausal and diagnosed of postmenopausal osteoporosis (BMD T-score < 2.5 at femoral neck or lumbar spine) were enrolled in the study. Written informed consent was obtained from all persons willing to participate in the study. Exclusion criteria were: the presence of conditions known to affect bone metabolism: diseases (Paget s disease, osteogenesis imperfecta, rheumatoid arthritis etc.) or medication intake (glucocorticosteroids). Mean age of women enrolled in the study was 66 ± 10,2 years. X-ray densitometry at the anterior-posterior projection of lumbar spine (L 1 ) and both proximal femurs was performed in all women using dual X-ray absorptiometry (DEXA, GE Lunar Prodigy Advance, USA). The least significant change of repeated measurements in was 2.2% for the lumbar spine and 2% for the hip. The data of medical history focused on the identification of the risk of fragility fractures and fracture history was obtained by physician using a specially designed questionnaire in the computer program Osteoprognosis. Statistical analysis of the obtained data was performed using STATISTICA 10 for Windows (Statsoft Inc., USA). Differences between groups were considered statistically significant at p < For BMD, the data are presented as Mean ± standard deviation (in g/cm 2 ), as the distribution was normal. Results The majority of the examined women (493 of 930), which accounted for 53% of all the observed, had previous low-energy fractures. Of this amount 202 patients (41% of women) had recurrent fractures, and 78 (16%) of women had suffered a fracture in a third time. Analysis of the incidence of fractures in different age groups revealed that the prevalence of low-energy fractures in the examined sample of postmenopausal women increases with age: from 20% in age group years, 24% at the age group to 33% at the age group older than 70 years. Characteristics of fractures depending on their localization are shown in Figure 1. The most common sites of primary fractures were fractures of the forearm (42% of the total), following in frequency were fractures of the spine (35%) and hip fractures (23%), the same trend was observed in the analysis of repeated and tertiary fractures.

3 The prevalence and risk factors of low-energy fractures among postmenopausal women with osteoporosis in Belarus 145 Fig. 1. Localizations of osteoporotic fractures in the studied sample of women Comparative analysis using the paired t-test was performed to identify the differences in age, anthropometric data and results of DEXA of women with a history of fractures and without them (Table). According to the obtained results it was found that there were statistically significant differences between examined groups by such parameters as age, height and duration of menopause. Besides, there was a statistically significant difference in reduction of height during life between women, who had a history of low-energy fractures, compared to those who did not. Our results are consistent with other studies: it is known, that the major risk factors for osteoporotic fractures are reduced height and age of patients [9, 10]. Regarding to the data of DEXA, statistically significant changes were obtained for BMD values at all the examined sites of the skeleton: the showings of BMD at lumbar spine and both proximal femurs were lower in the group of women who had a history of fractures. In the next step, we analyzed anamnestic data obtained using a specially designed questionnaire, taking into account the peculiarities of the way of life, to identify the most significant risk factors for fractures in women in the Belarusian population (Figure 2). This analysis showed that 25% of women who experienced fractures reported family history low-energy fractures, while among those, who did not suffer from fractures, these data were obtained in only 2% of cases. It was found that women who suffered low-energy fractures, were more likely to suffer from low back pain, use crutches or a cane, had limitations in motor activity (walking at least 30 minutes per day), most likely to fall and had a fear of falling compared with women who didn t had a history of fragility fractures (Fig. 2). Table. Comparative characteristics of individuals with and without history of fragility fractures With history of fractures (n = 493) Without history of fractures (n = 437) Age, years ± ± <0.001 Weight, kg ± ± Height, cm ± ± <0.001 BMI ± ± Duration of menopause, years ± ± Reduction in height during life, cm 3.59 ± ± <0.001 BMD L 1, g/cm ± ± <0.001 T-score L ± ± BMD right proximal femur (total), g/cm ± ± <0.001 T-score right proximal femur (total) 1.6 ± ± <0.001 BMD left proximal femur (total), g/cm ± ± <0.001 T-score left proximal femur (total) 1.9 ± ± <0.001 t-value p

4 146 E. Rudenka, N. Predko, A. Rudenka, K. Vasilenka, A. Adamenka Fig. 2. Lifestyle characteristics in the studied sample Fig. 3. The incidence of comorbidities in the studied sample of women Evaluation of the incidence of comorbidities in the studied groups revealed that women with a history of osteoporotic fractures more often suffer from disorders of the gastrointestinal tract, diabetes mellitus and coronary heart disease, which may be explained by higher showings of age in this group (Fig. 3). Thus, on the basis of the analyzed data, the following conclusions were made: 1. The majority of women with low BMD had low-energy fractures. 2. The incidence of low-energy fractures in the studied sample of women increases with age and reaches a maximum in the age group over 70 years. 3. The most common localizations of osteoporotic fractures in the studied sample was distal forearm, the second highest rate the spine, the third proximal femur. 4. Significant risk factors of osteoporotic fractures in the studied sample were older age, lower height and higher reduction of height during life, longer period of menopause 5. Women with a history of osteoporotic fractures more often suffered from disorders of the gastrointestinal tract, diabetes mellitus and coronary heart disease.

5 The prevalence and risk factors of low-energy fractures among postmenopausal women with osteoporosis in Belarus 147 References 1. EFFO and NOF. Who are candidates for prevention and treatment for osteoporosis? Osteoporos Int. 1997; 7: The US Surgeon General s report, Osteoporosis Action 3/ Cooper C. The crippling consequences of fractures and their impact on quality of life. Am J Med. 1997; 103(2): 12S Chrischilles EA; Lindsay R, Silverman S, Cooper C, et al. Risk of new vertebral fracture in the year following a fracture. JAMA. 2001; 285: Cooper C, Harvey N, Dennison E (2008) Worldwide epidemiology of osteoporotic fractures. In: Innovation in skeletal medicine. 2008: Van Staa TP D, EM LHG, Cooper C. Epidemiology of fractures in Wales and England. Bone. 2001; 29: Kanis A, Johnell O. Requirements for DEXA for the management of Osteoporosis in Europe Kanis JA. Diagnosis of osteoporosis and assessment of fracture risk. Lancet. 2002; 359: Leslie WD. Absolute fracture risk reporting in clinical practice: A physician-centered survey. Osteoporos Int. 2008; 19: Moayyeri A, Luben RN, Bingham SA, et al. Measured height loss predicts fractures in middle-aged and older men and women: The EPIC-Norfolk prospective population study. J Bone Miner Res. 2008; 23: 425. Received: May 16, 2014 Accepted: August 28, 2014 mažos energijos TRAUMOS lūžių paplitimas Ir rizikos veiksniai TARP Pomenopauzine osteoporoze sergančių moterų Baltarusijoje Ema Rudenka 1, Natalya Predko 2, Alena Rudenka 2, Katiaryna Vasilenka 1, Anastasiya Adamenka 1 1 Osteoporozės centras, Minskas, Baltarusijos Respublika 2 Baltarusijos medicinos podiplominių studijų akademija, Minskas, Baltarusijos Respublika Santrauka Osteoporozė (OP) tai pagrindinė kaulų lūžių priežastis senyvame amžiuje, įtakojanti prastą gyvenimo kokybę, negalią ir padidėjusį mirtingumą. Osteoporozinių kaulų lūžių prevencijos tikslas nustatyti didelei rizikos grupei priklausančius asmenis, kuriems gresia mažos energijos traumos lūžiai. Tyrimo metodai. Tyrime dalyvavo 50 metų ir vyresnės moterys, kurioms per 3 metus po menopauzės buvo diagnozuoja pomenopauzinė osteoporozė (KMT T-lygmuo šlaunikaulio kaklo ar juosmeninės stuburo dalies < 2,5). Visoms moterims buvo atlikti priekinės-užpakalinės juosmeninės stuburo dalies projekcijos (L 1 ) ir abiejų šlaunikaulių proksimalinių dalių kaulų mineralų tankio tyrimai, surinkta informacija apie patirtus lūžius, nustatyti lūžių rizikos veiksniai. Rezultatai. Išanalizavus tyrimo dalyvių rezultatus, mažos energijos traumos lūžiai buvo nustatyti 53 proc. moterų, mažos energijos traumos lūžių dažnis didėjo su amžiumi. Moterų, patyrusių osteoporozinius lūžius, antropometriniai ir dvisrautės radioabsorbciometrijos duomenys statistiškai reikšmingai skyrėsi palyginti su moterų nepatyrusių lūžių. Išvados. Dauguma pomenopauzine osteoporoze sergančių moterų patyrė mažos energijos traumos lūžius. Tyrimo metu nustatyta, kad reikšmingi rizikos veiksniai patirti osteoporozinį lūžį yra vyresnis amžius, žemesnis ūgis, didesnis ūgio sumažėjimas senstant ir ilgesnis menopauzės periodas. Reikšminiai žodžiai: moterys po menopauzės, osteoporozė, mažos energijos traumos lūžiai, rizikos veiksniai