What Is FRAX & How Can I Use It?

What Is FRAX & How Can I Use It? Jacqueline Osborne PT, DPT Board Certified Geriatric Clinical Specialist Certified Exercise Expert for the Aging Adult Brooks Rehabilitation; Jacksonville, FL Florida Physical Therapy Association FCOA Annual Conference: August 28, 2017 Presentation Objectives Define osteoporosis and low bone mass as well as the risk factors for the development of poor bone health. Establish that only a small percentage of those with an osteoporosis-related fracture receive bone mineral density testing or treatment related to improving bone health, and that that bone health is usually addressed after an individual has experienced a fall or a fracture. Presentation Objectives Discuss the importance of a reliable and valid clinical measure of fracture risk and discuss how the Fracture Risk Assessment Tool (FRAX ) could be utilized by health care providers and in the community. Property of. Reproduction of material is prohibited without permission. 1

True or False? Osteoporosis is considered an inevitable part of the aging process. FALSE Osteoporosis has been labeled a pediatric disease that has consequences later in life. (Hightower 2000) Timing of Exercise to Affect Bone Mass Improve Bone Acquisition Build Bone Slow Bone Loss & Prevent Falls Bone Mass Attaining & Maintaining Maintaining Childhood Adulthood Older adult Adapted Figure 1 in Perry & Downey 2012 Timing of Exercise to Affect Bone Mass Improve Bone Acquisition Build Bone Fracture Slow Bone Loss & Prevent Falls Bone Mass Attaining & Maintaining Regaining Childhood Adulthood Older adult Adapted Figure 1 in Perry & Downey 2012 Property of. Reproduction of material is prohibited without permission. 2

What is Osteoporosis? Low Bone Mass? Healthy Younger Adult Bone resorption > bone formation Healthy Older Adult Bone resorption >>> bone formation Bone turnover is steady Increasing bone turnover OSTEOPOROSIS: the imbalance becomes clinically significant What is Osteoporosis? Low Bone Mass? At either the femoral neck or the lumbar spine Who is at Risk for Poor Bone Health? Postmenopausal female Failure to achieve peak bone mass Older Age Poor nutritional status Genetics Sedentary lifestyle Multimorbidity Property of. Reproduction of material is prohibited without permission. 3

8/28/2017 8/28/2017 8/28/2017 Peak Bone Mass (Brewer 2009) Adolescents must reach peak bone mass in order to maintain bone health throughout life Genetic potential for bone density 85-90% of adult bone mass is acquired by age 18 (girls) to 20 (boys) Trabecular bone loss begins at ~30 Cortical bone loss begins at ~40 A 10% increase in peak bone mass is predicted to delay the development of osteoporosis by 13 years Nutritional Status (Perry & Downey 2012) Low Vitamin D Impairs calcium absorption Increases PTH levels Results in increased bone resportion 700-800 IU/day dose of calcium w/ vitamin D Reduced hip fracture risk in the next year by 26% Reduced other non-vertebral fractures by 23% Nutritional Status (Perry & Downey 2012) Alcohol Consumption Hip fracture risk is 1.18 to 1.68x higher in those who consume alcohol Smoking Hip fracture risk is 1.5 to 1.8x higher in those who smoke independent of BMI or current BMD Property of. Reproduction of material is prohibited without permission. 4

8/28/2017 Recommendations in Adolescence (Warden 2009) Be physically active Weight bearing Unique mechanical loads Dynamic Multidirectional High-impact At least 60 minutes, 3x/week Consume enough calcium RDA = 1300 mg 2/10 girls and 4/10 boys aged 12-19 achieve this intake Daily Calcium & Vitamin D Recommendations https://www.nof.org/patients/treatment/calciumvitamin-d Sedentary Lifestyle Most of the adult skeleton is replaced ~ every 10 years Physical inactivity can cause a loss of ~1% bone mass/week Brewer 2009 The Prevalence of Osteoporosis (at the femoral neck & lumbar spine) 100 90 80 70 60 11.9 13.2 50 9.9 40 30 52.0 57.4 20 43.1 10 0 2010 2020 2030 32% Osteoporosis Low Bone Mass Graph adapted from Wright 2014; Kanis 2008 Property of. Reproduction of material is prohibited without permission. 5

The Prevalence of Falls 1/3 rd 29 minutes 15 seconds >95% # of older adults who fall each year An older adult dies from a fall An older adult is treated in an ED for fall related injuries % of hip fractures caused by falls https://www.cdc.gov/homeandrecreationalsafety/falls/adultfalls.html Osteoporotic Fracture Incidence 1 in 2 women & 1 in 4 men over 50 will fracture due to osteoporosis 4 in 5 women over 67 are not tested or treated for osteoporosis after they break a bone 1/3 of individuals who fracture a hip had a prior fracture Peterson 2011 Property of. Reproduction of material is prohibited without permission. 6

Older Americans in Florida 19.4% in 2015 Older Americans in Florida Falls & Fractures in FL FATAL Fall-Related, unintentional injuries: 2013 data Traumatic Brain Injury 55% Hip Fracture 25% Lower Extremity (Not Hip) Fracture 12% Unspecified Neck Fracture 4% Upper Extremity Fracture 3% TOTAL HOSPITALIZATIONS 2,459 Collated data from FL DOH State and County Profiles: Florida Injury Surveillance Data System 2013 Property of. Reproduction of material is prohibited without permission. 7

Falls & Fractures in FL Fall-Related NON-fatal unintentional injuries: 2013 data Lower Extremity (Not Hip) Fracture 35% Hip Fracture 28% Traumatic Brain Injury 9% Upper Extremity Fracture 8% Spine Fracture 7% Pelvic Fracture 6% Head, Face, or Neck Fracture 1% Other 14% TOTAL HOSPITALIZATIONS 65,128 Collated data from FL DOH State and County Profiles: Florida Injury Surveillance Data System 2013 Annual Economic Impact of 432,000 Hospital admissions 2.5 million Medical office visits 180,000 Skilled nursing admissions Cosman 2014 Public Health Concern Property of. Reproduction of material is prohibited without permission. 8

NOF Guidelines: Bone Health Diagnosis Detailed history Physical Examination BMD Testing Vertebral Imaging 10-year estimated fracture probability Cosman 2014 NOF Guidelines: Bone Health Testing Females 65; Men 70 regardless of clinical risk factors Younger postmenopausal women Women in the menopausal transition Men aged 50-69 with clinical risk factors Adults who have a fracture 50 Adults with a condition or taking medications associated with low bone mass Cosman 2014 Early Recognition Identifying low bone mass prior to the occurrence of fractures will reduce fracture risk if followed by the appropriate treatment: Nutritional supplementation Bone building exercise Medications Arceo-Mendoza 2015 Property of. Reproduction of material is prohibited without permission. 9

23% The percentage of women 67 who receive BMD testing or medications/supplements to treat osteoporosis 6 months after the fracture Cosman 2014 Preventative Care in the US (2013 Data) Barriers to Bone Health Assessment Prevention is in fact one of the last things I think about. Most of my time goes to the prescription of medications, the instruction of medication intake and the accompanying paperwork. I can t inform every older patient with osteoporosis about the benefits of physical activity due to a lack of time during my consultations. Baert 2015 Property of. Reproduction of material is prohibited without permission. 10

Osteoporosis Hypertension Fracture Stroke What Can We Do to aid our Physician Colleagues?` Open a conversation with an adult about bone health, BMD testing, fall risk and physical activity Refer an older adult to a physical therapist Utilize a clinical measure of fracture risk Limitations of BMD Testing At either the femoral neck or the lumbar spine Property of. Reproduction of material is prohibited without permission. 11

8/28/2017 8/28/2017 Limitations of BMD Testing Only a measure of bone mass (not bone architecture and turnover rate of bone) Influenced by the degree of mineralization of bone tissue (architecture) Uses patient characteristics to determine the likelihood that an individual will experience a fracture in the next 10 years Age Sex Weight Height Previous Fracture Parent fractured hip Current smoker Glucocorticoids Rheumatoid arthritis Secondary arthritis 3 units of alcohol/day Femoral neck BMD http://www.shef.ac.uk/frax/tool.aspx?country=9 Property of. Reproduction of material is prohibited without permission. 12

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8/28/2017 FRAX vs. BMD (Perry & Downey 2012) BMD Provides a risk of fracture relative to a young Caucasian female rather than matching age, sex, ethnicity, & individual characteristics FRAX Does not account for individual dose or exposure (glucocorticoids/ smoking) BMD is of the femoral neck only Does not incorporate fall related risk factors or physical activity levels Does not account for preventative medications or supplements Property of. Reproduction of material is prohibited without permission. 14

8/28/2017 NOF Consensus Guidelines (Greenspan 2012) Provide treatment for: Those with hip or vertebral fracture Those with BMD T-score -2.5 (osteoporosis) Those with a BMD t-score from -1.0 to -2.5 (low bone mass) FRAX score (using femoral neck BMD) resulting in: -- A 10 year probability of a hip fracture of 3% -- A 10 year probability of a major osteoporotic fracture of 20% Community Outreach Employ a bone health information specialist Hold a bone health seminar or Lunch N Learn Establish a process for how you will collect information, who will collect it, and what you will do with it Establish educational materials for your stakeholders For health care providers: Make referral decisions: For BMD Testing To Physical Therapy Property of. Reproduction of material is prohibited without permission. 15

Take Home Points! America is aging Physical activity is a must early in life to set up for a future that includes good bone health Older adults are at risk for poor bone health, falling, and fractures The health care system currently underutilizes preventative services for older adults for fall risk and bone health assessment Community organizations who serve older adults can help older adults become aware of their bone health status and direct them to the services they need Thank you! Jacqueline Osborne PT, DPT GCS, CEEAA Jackie.Osborne@Brooksrehab.org References Arceo-Mendoza RM and Camacho P. Prediction of fracture risk in pateints with osteoporosis: a brief review. Women s Health. 2015;11(4):477-484. Baert V, Gorus E, Mets T, and Bautmans I. Motivations and barriers for physical activity in older adults with osteoporosis. J Geriatr Phys Ther. 2015;38:105-114. Brewer K. Bone health across the life span. GeriNotes. 2009;16(4):12-16. Coasman F, de Beur SJ, et al. Clinician s guide to prevention and treatment of osteoporosis. Osteoporos Int. 2014;25:2359-2381. Florida Department of Health Injury Surveillance Data System, Florida Injury Fact: Unintentional Falls. 2013. http://www.floridahealth.gov/statistics-and-data/florida-injurysurveillance-system/_documents/data-fact-sheets/falls-2012.pdf Accessed 6/5/2016 Greenspan S et al. FRAX or fiction: determining optimal screening strategies for treatment of osteoporosis in residents in long term care facilities. J Am Geriatri Soc. 2012;60:684-690. Property of. Reproduction of material is prohibited without permission. 16

References Hightower L. Osteoporosis: pediatric disease with geriatric consequences. Orthop Nur. 2000;19(5):59-62. Kanis JA, McCloskey EV, Johansson H, Oden A, Melton LJ 3rd, Khaltaev N. A reference standard for the description of osteoporosis. Bone. 2008; 42(3):467 75. Perry SB & Downey PA. Fracture risk and prevention: a multidimensional approach. Phys Ther. 2012;92:164 178. Perterson ML et al. A survey of screening and practice patterns used for patients with osteoporosis in a sample if physical therapists from Illinois. J Geriatr Phys Ther. 2011;34(1):28-34. U.S. Census Bureau, P23-212, 65+ in the United States: 2010, U.S. Government Printing Office, Washington, DC, 2014. Accessed 2/29/2016 Warden S et al. Skeletal effects of exercise/mechanical loading across the lifespan. Presented at: APTA s Combined Sections Meeting February 2009: Las Vegas, NV. Wright NC et al. The recent prevalence of osteoporosis and low bopne mass in the United States based on bone mineral density at the femoral neck or lumbar spine. J Bone Miner Res. 2014;29(11):2520-2526. Property of. Reproduction of material is prohibited without permission. 17