The contribution of musculoskeletal factors to physical frailty: a cross-sectional study

Background Musculoskeletal conditions and physical frailty have overlapping constructs. We aimed to quantify individual contributions of musculoskeletal factors to frailty. Methods Participants included 347 men and 360 women aged ≥60 yr (median ages; 70.8 (66.1–78.6) and 71.0 (65.2–77.5), respectively) from the Geelong Osteoporosis Study. Frailty was defined as ≥3, pre-frail 1–2, and robust 0, of the following; unintentional weight loss, weakness, low physical activity, exhaustion, and slowness. Measures were made of femoral neck BMD, appendicular lean mass index (ALMI, kg/m2) and whole-body fat mass index (FMI, kg/m2) by DXA (Lunar), SOS, BUA and SI at the calcaneus (Lunar Achilles Insight) and handgrip strength by dynamometers. Binary and ordinal logistic regression models and AUROC curves were used to quantify the contribution of musculoskeletal parameters to frailty. Potential confounders included anthropometry, smoking, alcohol, prior fracture, FMI, SES and comorbidities. Results Overall, 54(15.6%) men and 62(17.2%) women were frail. In adjusted-binary logistic models, SI, ALMI and HGS were associated with frailty in men (OR = 0.73, 95%CI 0.53–1.01; OR=0.48, 0.34–0.68; and OR = 0.11, 0.06–0.22; respectively). Muscle measures (ALMI and HGS) contributed more to this association than did bone (SI) (AUROCs 0.77, 0.85 vs 0.71, respectively). In women, only HGS was associated with frailty in adjusted models (OR = 0.30 95%CI 0.20–0.45, AUROC = 0.83). In adjusted ordinal models, similar results were observed in men; for women, HGS and ALMI were associated with frailty (ordered OR = 0.30 95%CI 0.20–0.45; OR = 0.56, 0.40–0.80, respectively). Conclusion Muscle deficits appeared to contribute more than bone deficits to frailty. This may have implications for identifying potential musculoskeletal targets for preventing or managing the progression of frailty.

Burden of osteoporosis in Vietnam: An analysis of population risk

Purpose To estimate the proportion of men and women aged 50 years and older who would be classified as "high risk" for fracture and eligible for anti-fracture treatment. Methods The study involved 1421 women and 652 men aged 50 years and older, who were recruited from the general population in Ho Chi Minh City, Vietnam. Fracture history was ascertained from each individual. Bone mineral density (BMD) was measured at the lumbar spine and femoral neck by DXA (Hologic Horizon). The diagnosis of osteoporosis was based on the T-scores ≤ -2.50 derived from either femoral neck or lumbar spine BMD. The 10-year risks of major fractureand hip fracture were estimated from FRAX version for Thai population. The criteria for recommended treatment were based on the US National Osteoporosis Foundation (NOF). Results The average age of women and men was ~60 yr (SD 7.8). Approximately 11% (n = 152) of women and 14% (n = 92) of men had a prior fracture. The prevalence of osteoporosis was 27% (n = 381; 95% CI, 25 to 29%) in women and 13% (n = 87; 95% CI, 11 to 16%) in men. Only 1% (n = 11) of women and 0.1% (n = 1) of men had 10-year risk of major fracture ≥ 20%. However, 23% (n = 327) of women and 9.5% (n = 62) of men had 10-year risk of hip fracture ≥ 3%. Using the NOF recommended criteria, 49% (n = 702; 95% CI, 47 to 52%) of women and 35% (n = 228; 95% CI, 31 to 39%) of men would be eligible for therapy. Conclusion Almost half of women and just over one-third of men aged 50 years and older in Vietnam meet the NOF criteria for osteoporosis treatment. This finding can help develop guidelines for osteoporosis treatment in Vietnam.

Prognostic Factors of Refractures among Post-Surgical Hip Fracture Patients in Chiang Rai Provincial Hospital, Chiang Rai Province

Objective: To investigate which of the prognostic factors affects the post-surgical first hip fracture patients and continues to affect the development of the refractures later. Materials and Methods: The present study was the retrospective case-control. The data were collected from 232 of the first hip fracture patients aged 50 years or more that included 75 males and 157 females. The comparison was observation of the patients from 58 refracture patients (group 1) to 174 first hip fracture patients (group 2). Most of them were admitted and evaluated at Chiang Rai Prachanukroh Hospital between October 1, 2013 and September 30, 2020. Results: The findings of the present study indicated that the prior fracture history patients (adjusted OR 19.836; 95% CI 1.674 to 235.015, p=0.018) with lower Singh index grades 3 or less (adjusted OR 8.082; 95% CI 2.535 to 25.466, p≤0.001) and eye disease (adjusted OR 11.361; 95% CI 0.971 to 11.708, p=0.055) were the prognostic factors of refractures. Conclusion: In the prior fracture history, a lower Singh index (grade 3 or lower) and eye disease were the prognostic factors of refractures in the post-surgical hip fracture patients. Early detection of these factors can help to identify the high risk of the refracture group and improve the efficiency and targeting the prevention of refractures. Keywords: Prognostic factors; Refractures; Post-surgical first hip fracture

FRAX-Based Intervention Thresholds for Osteoporosis Treatment in Ukraine

Objectives. Osteoporosis, in addition to its consequent fracture burden, is a common and costly condition. FRAX® is a well-established, validated, web-based tool which calculates the 10-year probability of fragility fractures. A FRAX model for Ukraine has been available since 2016 but its output has not yet been translated into intervention thresholds for the treatment of osteoporosis in Ukraine; we aimed to address this unmet need in this analysis. Methods. In a referral population sample of 3790 Ukrainian women, 10-year probabilities of major osteoporotic fracture (MOF) and hip fracture separately were calculated using the Ukrainian FRAX model, with and without femoral neck bone mineral density (BMD). We used a similar approach to that first proposed by the UK National Osteoporosis Guideline Group, whereby treatment is indicated if the probability equals or exceeds that of a woman of the same age with a prior fracture. Results. The MOF intervention threshold in females (the age-specific 10-year fracture probability) increased with age from 5.5% at the age of 40 years to 11% at the age of 75 years where it plateaued and then decreased slightly at age 90 (10%). Lower and upper thresholds were also defined to determine the need for BMD, if not already measured; the approach targets BMD measurements to those at or near the intervention threshold. The proportion of the referral populations eligible for treatment, based on prior fracture or similar or greater probability, ranged from 44% to 69% depending on age. The prevalence of the previous fracture rose with age, as did the proportion eligible for treatment. In contrast, the requirement for BMD testing decreased with age. Conclusions. The present study describes the development and application of FRAX-based assessment guidelines in Ukraine. The thresholds can be used in the presence or absence of access to BMD and optimize the use of BMD where access is restricted.

Ethnicity, Ethnic Language, and Fracture Risk Conditions in Women Initiating Osteoporosis Therapy

Introduction: The ethnic diversity of women with osteoporosis has increased, but data on acculturation and health remain limited. Having a primary language (PL) other than English may reflect acculturation level and/or immigration as an adult. We used electronic health record (EHR) data from a large US health plan to examine the association of baseline clinical risk conditions and PL among US Chinese and US Hispanic women who initiated osteoporosis therapy. Methods: We identified women age 65-74y who initiated osteoporosis therapy in 2002–2014, excluding those with skeletal disorders, advanced kidney disease and metastatic cancer. PL was ascertained from the EHR. The study included 1676 Chinese women with English-PL (50%) vs Chinese-PL (50%); 3453 Hispanic women with English-PL (72%) vs Spanish-PL (28%); and 20,289 non-Hispanic White (White) women with English-PL. Clinical conditions assessed included: current smoking; BMI <19 kg/m2; Charlson-Deyo Comorbidity Index (CCI); diabetes (DM) based on diagnosis with treatment; rheumatoid arthritis (RA) based on 2 diagnoses; and fracture diagnosis in the prior 5 years. Language subgroups (* denotes significant difference by PL, p<.05) and ethnic groups (all ethnic differences cited are significant at p<.05) were compared using chi-square tests. Results: Mean age was (69±3y) for Chinese, Hispanics, Whites, and PL subgroups. Prior fracture was lower in Chinese (12.8%) and Hispanics (25.6%) vs Whites (29.7%), with Chinese lower than Hispanics. Smoking was lower in Chinese (1.6%) and Hispanics (6.7%) vs Whites (11.3%). CCI score ≥3 was lower in Chinese (5.2%) and higher in Hispanics (13.0%) vs Whites (10.4%). RA was low overall and lowest in Chinese, especially Chinese-PL. More Chinese (4.2%) and fewer Hispanics (0.8%) had a BMI <19 vs Whites (2.2%). DM was higher in Hispanics (14.8%) and Chinese (8.2%) compared to Whites (5.7%). Significant and non-significant differences by PL were observed for current smoking (0.8%* vs 2.4% for Chinese-PL vs English-PL; 4.0% vs 7.8% for Spanish-PL vs English-PL), prior fracture (11.4%* vs 14.2% for Chinese-PL vs English-PL; 24.3% vs 26.1% for Spanish-PL vs English-PL) and DM (10.5%* vs 5.8% for Chinese-PL vs English-PL; 24.3% vs 26.1% for Spanish-PL vs English-PL) in Chinese and Hispanic women. Conclusion: Among older women initiating osteoporosis therapy, US Chinese women have lower comorbidity but a higher DM prevalence compared to white women, especially those with Chinese-PL. Hispanic women have higher comorbidity and higher DM prevalence than White women, with no differences by PL. Variation in prior fracture, low BMI, RA, and smoking were also seen. These findings highlight ethnic differences in women receiving osteoporosis care, including differences by primary language in Chinese women. Future studies should examine fracture risk factors and outcomes in US immigrant populations, especially Asians.

Predictors of imminent risk of fracture in Medicare-enrolled men and women

Summary Advancing age, female sex, recent prior fracture and falls, and specific comorbidities and medications contribute to imminent (within 1–2 years) risk of fracture in Medicare enrollees. Clinician awareness of these risk factors and their dynamic nature may lead to improved osteoporosis care for elderly patients. Purpose The burden of osteoporotic fracture disproportionately affects the elderly. Growing awareness that fracture risk can change substantially over time underscores the need to understand risk factors for imminent (within 1–2 years) fracture. This study assessed predictors of imminent risk of fracture in the US Medicare population. Methods Administrative claims data from a random sample of Medicare beneficiaries were analyzed for patients aged ≥ 67 years on January 1, 2011 (index date), with continuous coverage between January 1, 2009 and March 31, 2011, excluding patients with non-melanoma cancer or Paget’s disease. Incident osteoporotic fractures were identified during 12 and 24 months post-index. Potential predictors were age, sex, race, history of fracture, history of falls, presence of osteoporosis, cardiovascular diseases, chronic obstructive pulmonary disorder (COPD), mood/anxiety disorders, polyinflammatory conditions, difficulty walking, use of durable medical equipment, ambulance/life support, and pre-index use of osteoporosis medications, steroids, or central nervous system medications. Cox proportional hazards models were used to evaluate predictors of fracture risk in the two follow-up intervals. Results Among 1,780,451 individuals included (mean age 77.7 years, 66% female), 8.3% had prior fracture and 6.1% had a history of falls. During the 12- and 24-month follow-up periods, 3.0% and 5.4% of patients had an incident osteoporotic fracture, respectively. Imminent risk of fracture increased with older age (double/triple), female sex (> 80%), recent prior fracture (> double) and falls, and specific comorbidities and medications. Conclusions Demographics and factors including fall/fracture history, comorbidities, and medications contribute to imminent risk of fracture in elderly patients.

SUN-383 Potential Impact of Using Male vs Female T-Scores for BMD Classification in Men

BACKGROUND: Osteoporosis is traditionally associated with post-menopausal women, but up to up to one-third of osteoporosis-related fractures occur in elderly men. The International Society for Clinical Densitometry (ISCD), the World Health Organization, and the Fracture Risk Assessment Tool (FRAX) all recommend using a white female reference for BMD T-score for men. However, in clinical practice and previous clinical trials, a sex-specific white male reference T-score is used. This report examines the implications of using a female versus male reference for T-score calculation in men. METHODS: We reviewed BMD findings in 703 men (age 70-85y) who experienced a proximal femur, humerus, or distal radius/ulna fracture. For this cohort, femoral neck BMD was used to calculate a BMD T-score using either the young adult male and young adult female peak values (mean BMD 0.930 ± 0.136 and 0.849 ± 0.111 g/cm2, respectively). Osteoporosis was defined by BMD T-score ≤ -2.5, and osteopenia by BMD T-score < -1.0 and > -2.5. We also calculated FRAX-estimated fracture risk for hypothetical men ages 60-85y, with and without prior fracture. We used the National Osteoporosis Foundation (NOF) recommendations for treatment based on BMD (osteoporosis by BMD, or osteopenia by BMD with a 10-year risk of hip fracture ≥ 3% or 10-year risk of major osteoporotic fracture ≥ 20%). RESULTS: The mean BMD for this cohort was 0.670 g/cm2 and the median T scores were -2.0 (male reference) and -1.7 (female reference). Using the male T-score, 29% of men were classified as having osteoporosis, while using the female T-score, only 21% were so classified. 36% of men age 70-79y and 19% of men age 80-85y with osteoporosis (using the male T-score) would be reclassified from osteoporosis to osteopenia when a female T-score is used. Hypothetical cases of men age 60-85y (height 170 cm, weight 70 kg, BMD 0.590 g/cm2 equivalent to a male T -2.5 or female T -2.2) were used to calculate 10-year hip fracture risk using FRAX. For these hypothetical cases, the calculated 10-year risk of hip fracture exceeded the NOF treatment threshold of 3% (10-year hip fracture risk) for all cases, with or without prior fracture. CONCLUSION: For elderly men with fracture with male-T osteoporosis and female-T osteopenia, the T-score reference population used does not alter treatment recommendations because the calculated hip fracture risk is already above the treatment threshold of 3%. This is also true for men age ≥70 without a prior fracture. Hence the debate pertaining to the appropriate T-score reference population for men has limited relevance for men age ≥ 70 years who are being screened for osteoporosis.

SUN-380 Opportunistic Screening with Abdominal CT in Patients with Diabetes Can Identify Those at High Risk of Osteoporosis and Osteopenia

Background: Diabetes mellitus (DM) increases the risk of fracture at any given bone mineral density (BMD). However, the optimal strategy for osteoporosis screening with DXA is unknown in those with DM. A previously described strategy in the general population known as “Opportunistic Osteoporosis Screening” uses computer tomography (CT) images done for other reasons to assess the attenuation (density) of L1 in Hounsfield units (HU)—this was found to correlate with DXA-derived T-score. However, neither the methodology nor the cut-points have been specifically validated in those with DM. Thus, the goal of this study was to examine the performance of this methodology and define thresholds corresponding with low BMD in those with DM. Methods: This was retrospective study using electronic medical record data. Patients with DM were identified by ICD code. Those with both abdominal CT and DXA within a 6-month period were included, excluding patients with CKD stage 5, solid organ transplantation, bariatric surgery, or L1 hardware. L1 attenuation, measured by 2 readers on sagittal view, were averaged. A different reader assessed for vertebral fractures. Fractures of the hip, forearm, humerus, and pelvis were identified by ICD code. The lowest T-score of lumbar spine, femoral neck, total hip, or forearm (available in 11 subjects) was used to compare to L1 attenuation. ROC curves were derived from univariate logistic regression. Results: 320 subjects met study criteria; 10 (3.2%) had vertebral fractures, 8 (2.6%) had prior major non-vertebral fracture, and 33 (10.3%) had osteoporosis by BMD. The 18 subjects with major fractures had lower T-scores (-2.3 ± 1.4 vs. -0.8 ± 1.4, p<0.001) and lower L1 attenuation (104 ± 46 vs. 149 ± 47 HU, p<0.001). T-score and L1 attenuation had similar discrimination for prior fracture by area under the ROC curve (0.77 vs. 0.76, p=NS). Moderate osteopenia (T-score -1.5 or less) and L1 attenuation of 130 HU or less had identical sensitivities (72.2% for both) and similar specificities (69.2% vs. 62.5%, respectively) for prior fracture. In regards to L1 attenuation corresponding to DXA diagnosis of osteoporosis, 160 HU was 94% sensitive, while 110 HU was 80% specific. This is similar to the 90% sensitivity for 160 HU and 90% specificity for 110 HU previously reported in the general population. Given higher fracture risk in DM, moderate osteopenia (n=106) was also examined as an outcome: 130 HU was 61% sensitive and 71% specific. This threshold had similar or improved sensitivity and specificity among subgroups of insulin users, men, and women under age 65. Conclusion: Our results validate the use of opportunistic osteoporosis screening in patients with DM, which could help clinicians decide on the need for screening DXA. Patients with diabetes and L1 attenuation below 130 HU on CT scan should be considered for DXA screening to formally assess the risk of fracture.