Scope of Problem
Osteopenia and osteoporosis are recognized as a significant problem in the modern medical arena. Men and women, but especially women, lose bone density and bone strength as they age. This fact is reflected in the increased incidence of fractures in the elderly — most notably hip, wrist and spinal compression fractures.
It is estimated that approximately 10 million older adults have osteoporosis.1 Some estimates show that half of women will have an osteoporosis-related fracture in her life. One-quarter will develop spinal deformities and nearly 2 million will have a hip fracture.2 Osteoporosis-related fractures are known to be associated with reduced quality of life, chronic pain, disability, loss of independence and shortened lifespan.2 In 2002, the costs of osteoporosis were estimated to be $22 billion in the Medicare population. 3
Medical strategies to avoid fractures most often focus on fall prevention, calcium supplementation, dietary interventions, weight bearing exercises, and, in the past 15-20 years, pharmaceutical treatment with bisphosphonates. Screening and medical treatment options often come too late.4
Current Treatment Recommendations
The U.S. Preventive Services Task Force (USPSTF) has penned guidelines to evaluate women for osteoporosis.5
At present the USPSTF has recommended bone density screening for women older than 65 years and for women between 60–64 years at increased risk for osteoporotic fractures (B Recommendation). However, they do not have recommendations for screening postmenopausal women less than 60 years old or women between 60–64 years without increased risk. There was insufficient evidence to make screening recommendations for men.
USPSTF recommends that women obtain a bone scan, utilizing a Dual Energy X-ray Absorptiometry (DEXA) machine, at age 65. DEXA provides a comparative assessment of a patient’s bone density that is reported in two different ways: T-score which compares bone mineral density (BMD) to a group of 30 year-old inpiduals of the same gender and a Z-score analysis that compares the patient to a group of age-controlled peers.
The World Health Organization (WHO) developed bone mineral density criteria in 1992 to describe the normal skeletal baseline in a healthy 30-year-old white female reference population.6 BMD measures in grams per cm2 (g/cm2). The BMD score is assessed based on a standard deviation (SD) from the expected average value or mean. If the score shows that the bone density is greater than the mean value or less than one standard deviation below the mean (ie -1.0 to +2.5 SD), the inpidual is considered to be in the normal range. If the BMD is between one and 2.5 standard deviations below the mean (-1.0 SD to -2.5 SD), then the inpidual is considered to be osteopenic. If the BMD is greater than 2.5 standard deviations below the mean (>-2.5 SD) then the inpidual is considered osteoporotic. The FRAX (fracture risk assessment algorithm) tool developed by WHO incorporates BMD measured by DEXA to predict the probability of fractures.
There are a multitude of osteoporosis screening and treatment guidelines, or position statements, of medical societies and advocacy groups such as the National Osteoporosis Foundation (NOF), American Academy of Orthopedic Surgery (AAOS), International Osteoporosis Foundation (IOF), National Bone Health Alliance (NBHA), Public Health Foundation Enterprises (4BoneHealth), the American Orthopaedic Association (AOA), the American College of Rheumatology (ACR) and American Academy of Family Physicians (AAFP). I find that these guidelines more or less echo the USPSTF and WHO recommendations.