SAGE Publications, Canadian Pharmacists Journal, sp1(144), p. S3-S3.e1
Osteoporosis is a major public health concern that results in consid-erable fracture-related morbidity, reduced quality of life and short-ened survival. This brittle bone condition is one of the most preva-lent diseases of aging, affecting more than 1.5 million Canadians. 1 Osteoporosis is defined clinically based on bone mineral den-sity (BMD) measurement, with prevalence in Canada increasing from 4% of men and 6% of women aged 50 to 59 years, to more than 20% of men and 40% of women aged 80 and older. 2 Osteo-porosis increases the risk for fragility fractures occurring spon-taneously or as a result of minimal trauma (e.g., fall from stand-ing height or less), 3 and higher trauma fractures. 4 Most fractures among adults, other than skull, fingers and toes, are associated with low BMD. The most common fracture sites are the forearm or wrist, vertebra and hip. Fractures of the humerus, pelvis and rib are increasingly recognized as important in terms of preva-lence and morbidity. Fragility fractures are the most important indicator of underlying osteoporosis and are a strong predictor of future fracture, 5,6 with risk greatest within the first year after an incident fracture. 7 Forearm and wrist fractures are often the first symptomatic sign of osteoporosis, manifesting primarily in women, with inci-dence rate increasing around menopause. 8 Vertebral fractures are the most common type of osteoporotic fracture; however, less than half are symptomatic and come to clinical attention. 9 The prevalence of vertebral fractures increases with age, from about 15% of men and 11% of women aged 50 to 59, to 36% of men and 45% of women aged 80 or older. 10 Clinical vertebral fractures lead to a decline in physical function, loss of independence, dis-satisfaction with body image and kyphosis, with chronic pain, narcotic use, height loss and gastrointestinal problems. 11,12 These complications can lead to loss of self-esteem, fear of falling and social isolation. 12,13 Vertebral fractures increase mortality risk. 9 Although the mechanism is not clearly known, change in posture and reduced mobility may increase infection risk, 14 and reductions in quality of life 15 may affect coping abilities, contributing to a progressive decline in health. Hip fractures are the most important type of fracture in terms of functional dependence, mortality and social cost. The incidence of hip fracture begins to increase after age 60, 16 with a mean age at time of fracture of 80. 17,18 Approximately 5% of hip fracture patients die in hospital, and 20% (women) to 30% (men) die within the year after fracture. 17-19 Men account for about 28% of hip fracture cases. 17,18 Multiple comorbidities, postoperative hip surgery complications/events and reduced mobility with loss of strength and muscle mass contribute to general frailty, functional decline and shortened survival following hip fracture. 14,20 Among hip fracture patients surviving to 1 year, 40% are unable to walk independently, 60% have difficulty with at least 1 essential activity of daily living and 80% are limited in other activities such as driving and grocery shopping. 21 In addition, 15% to 31% of hip fracture patients enter a nursing home or chronic care facility for the first time as a direct result of the fracture. 22,23 The annual cost for hip fracture treatment in Canada was $650 million in 1997, and is expected to rise to $2.4 billion by 2041. 23 Hip fractures quickly become not only a personal burden, but also a social burden. Fortunately, effective treatment exists to reduce fracture risk 6,24 and pharmacotherapy has at least partly contributed to a decline in age-adjusted fracture rates over time. 25 However, a therapeutic care gap in osteoporosis management exists — most patients at high risk for fracture are not identified for treatment, and about half of patients who start osteoporosis pharmacotherapy stop treatment within the first year. 26,27 Our aging population will result in an increased total number of fractures. Without effective interventions to bridge the therapeutic care gap in osteoporosis management, the burden of osteoporosis in Canada can be expected to increase.