Medical Care of Fragility Fracture in the Community

Transcription

1 Medical Care of Fragility Fracture in the Community 脆性骨折的社區醫療護理 Dr Peter T K Lau 劉天驥醫生 DFM, MFM (CUHK), MBBS (HK) Honorary Clinical Assistant Professor in Family Medicine, CUHK Family Medicine Consultant, Town Health International Holdings Co Ltd

2 Fracture Care in the Community Care / Rehabilitation of the current fracture Prevention of another fracture Detect any new onset fracture

3 Rehabilitation of the Current Fracture Pain management Assess progress of rehabilitation and improvement in functional status Detect any late complication of fracture. Prompt referral back to the specialist in case of complications.

4 Fracture Care in the Community Care / Rehabilitation of the current fracture Prevention of another fracture Detect any new onset fracture

5 Fracture Prevention 預防骨折 Proper management of osteoporosis and reducing the occurrence of falls constitute the twin pillars in protecting the elderly from fractures

6 Preventing Osteoporotic Fracture in the Elderly in the Primary Care Setting I Screening for individuals at risk of osteoporosis 篩選骨質疏鬆高危人士 : awareness of risk factors 危險因素, height loss 身高下降, simple tests 簡易測試 Making a diagnosis of osteoporosis / osteopenia 診斷骨質疏鬆 : DEXA, qct, presence of fracture

7 Preventing Osteoporotic Fracture in the Elderly in the Primary Care Setting II Initiate and maintain specific treatment for osteoporosis 針對性治療 Initiate and maintain calcium and Vitamin D supplementation 輔助性治療 Advice on and maintenance of lifestyle intervention 生活上調理 : diet 飲食 and exercise 運動

8 Preventing Osteoporotic Fracture in the Elderly in the Primary Care Setting III Monitor response to intervention / treatment programs 監察治療進展 : serial BMD measurement every 2 years, side effects of medication: esophagitis, osteonecrosis of the jaw A co-ordinated approach to the management of comorbidities 對病者各種病症提供一個整全而協調的治療方案

9 Preventing Osteoporotic Fracture in the Elderly in the Primary Care Setting IV Screening for individuals at risk of fall 篩選容易跌倒的人士 Identify and rectify fall hazards 辨識及改正能使人摔倒的危險狀況 : environment, medical conditions, medications Encourage participation in fall prevention programs.

10 危險因素 ( 不可改變的 ) 絕經期過早 亞裔或白種人 身材細小 家族遺傳

11 危險因素 ( 可以改變的 ) 鈣質吸收不足 足不出戶 缺乏運動 吸煙 酗酒 甲狀腺功能失調 長期服用類固醇藥物

12 BMI and Fracture Risk

13 BMD Testing In many guidelines / protocol, BMD testing is not mandatory Useful in confirming the presence of osteoporosis / osteopenia Monitor treatment response Establish a baseline value Serial measurement

14 Dual Energy X-Ray Absorptiometry, DEXA 雙能量放射線吸收密度儀 Used in large RCTs Modest radiation exposure High precision and accuracy Measure BMD at relevant sites Use of 2 x-ray beams enables corrections to be made for soft tissue

15 雙能量放射線吸收密度儀 Dual Energy X-Ray Absorptiometry, DEXA

16 DEXA Scan: One hip or both hips? In the early 1980s scan time for a single hip was 20 minutes or more, and thus, it was impractical to consider bilateral hip scans in clinical practice. With successive generations of scanning systems, scan times became much shorter, yet the practice of scanning one hip (left or right side) became entrenched as standard densitometry procedure. Studies that reported good correlation between BMD of left and right hip regions may have reinforced this practice as the prevailing dogma seems to have been that because left and right hip subregions were highly correlated and absolute BMDs very similar, there was no advantage to scanning both hips.

17 DEXA Scan: One hip or both hips? Further, relatively little data exist to suggest an effect of side dominance for lower limbs compared to reports that BMD of forearm ROIs is often greater in the dominant arm, and thus, it seemed to make little difference which side was measured. In total, these observations may be the basis of the traditional densitometric practice of scanning only one hip. In contrast to early-generation DXA systems, modern scanning systems are fast, and oftern both hips can be scanned in < 5 minutes. The ability to perform bilateral hip scans is no longer constrained by time issues.

18 DEXA Scan: One hip or both hips? Left-right differences in BMD may translate into significant differences in left-right T-scores. T-scores have been adopted as a means to standardize BMD, which cannot be directly compared between DXA systems of different generations and manufacturers. Since diagnostic classification as normal, osteopenia or osteoporosis is based on the lowest T-score of evaluable skeletal sites, the T-scorebased diagnosis could be affected by significant leftright differences in hip BMD.

19 DEXA Scan: One hip or both hips? Proponents of bilateral hip scans: There is a small percentage of patients with statistically significant left-right differences in hip BMD, which may influence the ultimate diagnosis. Bilateral scans also insure having a baseline hip scan should a patient suffer a unilateral hip fracture or have a total hip replacement. Arguments against bilateral hip scans: There is generally a high correlation between left-right hips and the frequency of observed left-right differences is small. Measurement of both hips increases the skeleton sites assessed and artificially increases the prevalence of osteoporosis. Bilateral hip scans exposes the patient to unnecessary radiation, and the benefit of bilateral hip scans vs. scanning only one side does not outweigh the risk of a stochastic effect of radiation.

20 DEXA Scan: One hip or both hips? Knowledge of both femoral neck BMD could have altered the classification of the lowest site assessed to be osteoporotic in only 2.2% of patients for right femur and spine scan and 0.9% for left femur and spine scan. Data suggest that there is only a small benefit from performing bilateral femoral neck BMD measurements. The extra time, cost and radiation dose associated with measurement of the second femur may not be justified. Osteoporos Int. 2000;11(8):675-9

21 DEXA Scan: One hip or both hips? A statistically significant number of women with osteoporosis are potentially classified differently when scanning only one hip as a result of the high prevalence of left-right differences in BMD. Although the percentages are low, the total number of women affected may be large. From a public health perspective, the practice of scanning both hips could potentially identify more women with osteoporosis and may help prevent future hip fractures. Osteoporos Int Dec;17(12):

22 Single Hip DEXA Scan: Left or Right? Although it is generally suggested that the patient s nondominant hip should be scanned (determined by asking the patient if he or she is right- or left- handed), there is little evidence to document the biologic relevance of such guidance. In practice, this decision is often based on the technical ease of performing the scan, which in turn is often dependent on the technologist s personal preference and the physical location of the densitometer in the scanning room.

23 Left-right hip classification agreement and disagreement in women with osteopenic spines.

24 雙能量放射線吸收密度儀 Dual Energy X-Ray Absorptiometry, DEXA

25 骨質密度檢查 Bone Mineral Density, BMD T-Score 骨質密度 (BMD) 值診斷評分 若體內任何一處骨骼之 BMD 值低於二十歲年輕婦女平均值之 -2.5 個標準差 (T 值小於 -2.5), 就可以診斷為骨質疏鬆 若 BMD 值介於 -1 和 -2.5 個標準差之間 (T 值介於 -1 和 -2.5 之間 ), 則稱為骨質缺乏 (osteopenia) BMD 值高於 -1 個標準差 (T 值大於 -1) 則為正常

26 DXA testing facilitates access to treatment Med Care Sep;45(9): % of those having had a DXA were treated for OP compared with 2% of those who did not. Correctly reporting that the DXA test indicated osteoporosis and higher perceived benefits of taking pharmacological agents for osteoporosis were associated with treatment Improved access to DXA and better communication to patients of both their DXA results and the benefits of treatment has the potential to reduce the burden of osteoporosis.

27 診斷骨質疏鬆 電腦掃描定量測試 qct

28 骨質疏鬆篩選 超聲波測試 Ultrasonogram 量度足跟骨的骨質密度, 適宜作為快速篩選, 但欠精確度

29 骨質疏鬆簡易測試 OSTA Score = ( 體重 Kg 年齡 Age) x 0.2 < -1: high risk > -1: low risk

30 骨質疏鬆簡易測試 OSTA Score

31 Initiate and Maintain Specific Treatment for Osteoporosis Assess the indications for treatment Convince the patient of the benefits of treatment Choosing and prescribing the right medication Monitoring adherence to treatment Monitoring response Monitoring adverse effects

32 骨質疏鬆 : 針對性治療 雌激素 Estrogen ( 激素補充劑 HRT) 長期使用雌激素補充療法, 可能增加乳癌的危險性, 而心臟病 中風 靜脈血栓的發生率也增加 激素治療僅適用於併有嚴重更年期症狀的婦女, 醫生一般不會單純因為治療骨質疏鬆而使用激素補充療法

33 骨質疏鬆 : 針對性治療 選擇性雌激素受體調節劑 Selective Estrogen Receptor Modulator, SERM 例如 raloxifene 與激素療法不同的是不會影響乳房或子宮 這些藥物能夠加強骨質, 但不會增加服藥者罹患乳癌或子宮癌的風險

34 針對性治療 降血鈣素 Calcitonin 抑制鈣質從骨骼轉移至血液 另有鎮痛療效 例如 Miacalcic 噴鼻或注射劑

35 針對性治療 雙磷酸鹽 Bisphosphonate 壓抑導致骨質流失的骨蝕細胞 對逆轉骨質流失和減少骨折發生都有療效 例如 阿磷倔酸 alendronate (Fosamax ), risedronate (Actonel ), ibandronate (Boniva ) 口服劑

36 針對性治療 副甲狀腺激素 Parathyroid Hormone Teriparatide 用來治療絕經期後婦女的骨質疏鬆症和有出現骨折的高風險的男士 能夠幫助新的骨頭生長 方法是每日注射

37 針對性治療 鍶 Strontium 鍶能刺激造骨細胞的增生, 同時抑制蝕骨細胞的活動, 既能降低骨吸收, 又能促進骨形成, 具有獨特的雙重作用 研究顯示鍶可以提升骨質密度, 降低脊椎及髖部骨折發生率 鍶制劑為口服顆粒劑, 每日一次以開水配服

38 NICE guideline for the secondary prevention of osteoporotic fragility fractures in postmenopausal women who have sustained a clinically apparent osteoporotic fracture Bisphosphonates are recommended in: women aged > 75 years, without the need for prior DEXA scanning women aged 65 ~ 74 years if the presence of osteoporosis is confirmed by DEXA scanning postmenopausal women < 65 years of age, if they have a very low BMD, that is with a T-score of approximately 3 SD or below, established by a DEXA scan, or if they have confirmed osteoporosis plus one or more additional age-independent risk factor: low BMI (< 19); family history of maternal hip fracture; premature menopause; certain medical disorders (such as chronic inflammatory bowel disease, rheumatoid arthritis, hyperthyroidism or coeliac disease); conditions associated with prolonged immobility.

39 NICE guideline for the secondary prevention of osteoporotic fragility fractures in postmenopausal women who have sustained a clinically apparent osteoporotic fracture Raloxifene is recommended as an alternative in women: for whom bisphosphonates are contraindicated, or who are physically unable to comply with the special recommendations for use of bisphosphonates, or who have had an unsatisfactory response to bisphosphonates, or who are intolerant of bisphosphonates

40 NICE guideline for the secondary prevention of osteoporotic fragility fractures in postmenopausal women who have sustained a clinically apparent osteoporotic fracture Teriparatide is recommended as an option in women aged > 65 years who have had an unsatisfactory response to bisphosphonates or intolerance to bisphosphonates and: who have an extremely low BMD (with a T- score of < 4 SD), or who have a very low BMD (with a T-score of < 3 SD plus multiple fractures (that is, more than two) plus one, or more, additional age independent risk factors

41 Specific Treatment for Osteoporosis: Choice of Agents

42 Monitor response to medical treatment Unsatisfactory response: when the patient has another fragility fracture despite adhering fully to treatment for 1 year, and evidence of a decline in BMD below the pre-treatment baseline Serial BMD measurement every 2 years may be useful Intolerance of bisphosphonates: oesophageal ulceration, erosion or stricture, or severe lower gastrointestinal symptoms Osteonecrosis of the jaw

43 Fracture Care in the Community: Non-pharmacological intervention Initiate and maintain calcium and Vitamin D supplementation Advice on and maintenance of lifestyle intervention: diet exercise

44 處理骨質疏鬆 二 一般性的預防和支援措施 健康飲食習慣 成人每天攝取 鈣質 1000 至 1500 mg 維生素丁 400 至 800 iu 奶類食物 豆類製品 十字花科的蔬菜 沙丁魚等, 都富含鈣質

45 一般性的預防和支援措施 適量的負重運動 例如緩步跑 耍太極 戒煙 節制飲酒

46 骨質疏鬆的診斷與治療 任何因輕微創傷導致之骨折 懷疑脊椎骨折 定期作骨質密度檢查以監察病情 盡快接受藥物治療 收經後之婦女 1. 年齡 65 以上 2. 家族有骨質疏鬆 病歷 3. 吸煙 4. 體重過輕 5. 使用類固醇 骨質密度檢查 考慮接受藥物治療 考慮兩年後覆驗骨質密度 APLAR Journal of Rheumatology 2006; 9:

47 Fracture Prevention: Preventing Falls Fall prevention strategies include: 1. Exercising regularly 運動 exercise programs like Tai Chi that increase strength and balance are especially good. 2. Having medicines reviewed 藥物檢討 both prescription and over-the counter to reduce side effects and interactions. 3. Having yearly eye exams 檢查視力. 4. Reducing fall hazards in the home 家居安全.

48 Identify and rectify fall hazards Fall risk can be related to 1. Environment 2. Medical conditions 3. Medications Encourage participation in fall prevention programs and the use of hip protectors

49 Assessment of Fall Risk 危險因素評估 定期健康檢查時, 詢問有關容易跌倒的危險因素 : 1. 骨質疏鬆 2. 年齡超過 歲 3. 平衡與活動能力欠佳 4. 視力與感覺衰退 5. 服用多種不同藥物 : 某些藥物可能會造成老年人暈眩的現象 6. 其他病症 : 中風 柏金遜症 失智症 關節炎 白內障 糖尿病等

50 Assessment of Fall Risk 危險因素評估 NEJM 348;1 January 2, 2003

51 起立 - 行走 計時測試

52 起立 - 行走 計時測試

53 Balance and Mobility 平衡與活動能力 平衡感 柔軟度與肌力訓練, 可以改善行動力, 更可以降低摔跤的風險 很多長者人沒有足夠的定期運動, 甚至不參加任何休閒式的體能活動 這種疏於運動的結果, 只有使得摔跤後的復原更加困難 許多老人家因害怕再次摔跤而減少更多的體能活動 有許多體能活動是可以預防摔跤又兼具創意與低衝擊性的, 例如太極拳

54 Medications that can contribute to falls in the elderly

55 慎防老人骨折 注意家居安全 浴室要裝設扶手和防滑膠墊 不要把雜物放在通道上 晚上不妨開著長明燈 不要彎腰提起重物, 避免太劇烈的體力勞動

56 Fracture Care in the Community Care / Rehabilitation of the current fracture Prevention of another fracture Detect any new onset fracture

57 Detecting New Onset Fracture Continuous, regular surveillance Sometimes simple measurements can be a great help

58 Height loss predicts osteoporotic fracture Osteoporosis Update OSTEOPOROSIS SOCIETY OF CANADA Winter 2005 vol.9 no.1

59 Height loss predicts osteoporotic fracture J Clin Densitom Spring;7(1):65-70 Height loss of 2 in. or more is a highly significant predictor of osteoporosis at the hip. Women with at least 3 in. of height loss had odds of osteoporosis of the hip that were 9.6 times greater than women with less than an inch of height loss. Loss of height may be an important clue in detecting osteoporosis of the hip, implying that evaluation of height loss should be routine in the outpatient setting.

60 Fragility fractures and the osteoporosis care gap: an international phenomenon. Semin Arthritis Rheum Apr;35(5): Osteoporosis diagnosis reported in 1 to 45% Laboratory tests ordered for 1 to 49% 1 to 32% of patients had bone density scans Calcium/vitamin D in 2 to 62% Pharmacological therapy in 1 to 65% Osteoporosis treatment was recommended more often in women than men, and more often in patients with vertebral fractures than in patients with nonvertebral fractures. Older patients were more likely to be diagnosed with osteoporosis, but treatment was more likely in younger patients. A history of prior fracture was reported in 7 to 67% of patients. Between 1 and 22% of patients had a subsequent fracture during follow-up periods of 6 months to 5 years. Falls assessments were not often reported

61 Barriers to post fracture OP investigation and treatment Osteoporos Int Oct;15(10): cost of therapy 2. patient reluctance 3. time and cost of diagnosing OP 4. side effects of medications 5. unproven effectiveness of medication 6. lack of access to BMD testing 7. lack of time to address secondary prevention Until recently, many orthopedic surgeons did not feel that OP was their responsibility and therefore did not investigate or treat it.

62 Barriers to osteoporosis identification and treatment among primary care physicians and orthopedic surgeons Mayo Clin Proc Apr;77(4):334-8 Orthopedic surgeons were consistent in their opinion that post fracture attention to osteoporosis should rest with the primary care physician. Primary care physicians agree but report that cost and possible adverse effects of medication are major barriers to this care. Despite therapies for high-risk post fracture patients showing relative safety and proven efficacy in reducing future fractures, deterrents to this care are focused on cost and potential adverse effects.

63 A co-ordinated approach to the management of co-morbidities The silent nature of osteoporosis is often the obstacle to good compliance of fracture prevention To make a comprehensive fracture management program really successful, medical service needs to expand beyond the orthopedic concern By offering general medical care to the recovered fracture patient, the community fracture clinic becomes a focal point for sustained surveillance where the patient returns from time to time A full rehabilitation program should be well integrated with regular social and recreational activities.

64 The Interdisciplinary Team Orthopedic Specialist Geriatrician Anesthetist Primary care physician / Family physician Orthopedic nurse Dietitian Physiotherapist Occupational therapist Social worker Volunteer helper and other concerned parties The family physician, espousing the family medicine concept of holistic, comprehensive and continuous care, is uniquely positioned to act as coordinator of the team. Support from and close liaison with the orthopedic specialist is essential

65 Working with the community Health Education on Osteoporosis and Fragility Fracture Mobilize community resources in fracture prevention and rehabilitation

66 Into the future It is hoped that the scope of the community fragility fracture program can be widened to encompass the primary prevention of osteoporosis targeting the at-risk population. Even a single fracture is one too many.