The American journal of medicine
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A 30-50% reduction in fracture risk produced by a drug is biologically "worthwhile." The detection of this benefit, when truly present, is a challenge requiring large studies of 3-5 years' duration, because only a small number of women at risk actually sustain a fracture during this time. For example, in any year, fractures occur in 1-2 per 100 women approximately 65 years of age, 6-10 per 100 women approximately 75 years of age, and only 1-2 per 2,000 of the 15% of women < 60 years of age with osteoporosis. An appreciation of this low annual event rate is important because (1) it helps patients to understand their illness, (2) it determines the power of clinical trials, (3) it underscores the large numbers of patients that must be treated to prevent one fracture, and (4) it underscores the need for safety, particularly in groups at low absolute risk of fracture; all are exposed to drug side effects, and the vast majority derive no benefit from treatment because they would not have had a fracture without it, despite being at risk. ⋯ There have been no studies of the efficacy of any treatment to prevent hip or vertebral fractures in men or in corticosteroid-related osteoporosis. The treatment of osteoporosis is becoming a reality. HRT and the bisphosphonates, particularly alendronate, appear to be the best options at present.
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The worldwide prevalence of hip fracture is increasing as the mean age of the population increases. Despite advances in anesthesia, nursing care, and surgical techniques, however, the outcome of treatment is often poor, and hip fractures remain a significant source of morbidity and mortality for the elderly population. For these patients, operative treatment is considered to be optimal and most cost-effective for displaced intracapsular fractures and all extracapsular fractures. ⋯ To maximize rehabilitation potential, a multidisciplinary approach using skilled medical, nursing, and paramedical care appears to be optimal. Prospective case-controlled studies are required to demonstrate the long-term effectiveness of specialist rehabilitation units. In today's cost-cutting environment, caution must be taken to prevent short-term cost-saving measures from compromising long-term outcome for elderly hip fracture patients.
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Approximately 40 in 100 women will experience one or more fractures after the age of 50 years. At 50 years for women the lifetime risk is 17.5% for hip fracture, 16% for vertebral fracture, and 16% for Colles' fracture; for men, the respective lifetime risks are 6%, 5%, and 2.5%. The incidence of hip fractures has increased in recent years in most but not all European countries, partly as a result of the aging of the population. ⋯ Determining the causes of the large geographic differences in hip fracture incidence and the large differences in sex ratios for hip fractures in European countries could lead to identification of hitherto unknown risk factors and provide clues for prevention of fractures. Many risk factors cannot be prevented or modified; however, these risk factors (for example, family history, past fracture, and visual loss) can identify risk groups amenable to drug treatment or to preventive measures such as protective hip pads or environmental changes. Assessment of risk factors and definition of risk profiles are important steps toward the prevention of fractures in the elderly.
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Hip fractures are a burden to both the individual and the community. Only 50% of patients regain the mobility and independence they enjoyed 12 months before the hip fracture occurred. Direct costs are high: about US$7,000 for the immediate hospital care and $21,000 in total costs for the first year. ⋯ Health economic models allow for changes in assumptions, such as extent of compliance, effectiveness of therapy, and risk of side effects. Cost-effectiveness varies according to treatment and is highly sensitive to the estimated efficacy of treatment, patient compliance, age of the patient at the start of treatment, and fracture risk assigned to the patient. Greater cost-effectiveness occurs when treatments are more efficacious and when they are directed at patients with the highest risk of fracture.
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Around 40% of white women and 13% of white men in the United States have at least one fragility fracture after the age of 50 years. The risk of fracture increases with advancing age and progressive loss of bone mass, and varies with the population being considered. The age-adjusted incidence of fragility fractures in both sexes is 25% lower in Britain and many areas of Europe than in the United States. ⋯ After a clinically diagnosed vertebral fracture, survival rate decreases gradually from that expected without fracture. Women with severe vertebral deformities have a consistently higher risk of back pain and height loss. An accurate assessment of the risk of fractures associated with osteoporosis and of their impact on quality of life is essential if appropriate and cost-effective interventions are to be designed for different populations.