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Underrecognition of Osteoporosis in Men in the Long-Term Care Setting
Affiliations: 1Department of Geriatrics, North Shore-LIJ Health System, New Hyde Park, NY; 2Department of Medicine, North Shore-LIJ Health System, Great Neck, NY; 3Biostatistics Unit, The Feinstein Institute for Medical Research, North Shore-LIJ Health System, Manhasset, NY
Abstract: According to the National Osteoporosis Foundation (NOF), approximately 12 million American men are at risk for developing osteoporosis, and 2 million have already received the diagnosis. In addition, the NOF estimates that 1 in 4 men aged 50 years and older will experience a fracture as a result of osteoporosis, placing men in this age group at greater risk of fracture than of developing prostate cancer. The 1-year mortality rate after hip fracture has been found to be as high as 32% for men—almost double the 17% documented for women. Each year, it is estimated that 80,000 men will experience a hip fracture, often leading to permanent institutionalization in a long-term care (LTC) facility. Despite the danger associated with this progressive bone disease, it is often underdiagnosed and undertreated in men in clinical and LTC settings.
Key words: Osteoporosis in men, osteoporosis diagnosis, osteoporosis treatment, long-term care, bone mineral density, osteoporosis screening, fragility fractures.
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The worldwide prevalence of osteoporotic fracture is 33% in persons aged 50 years and older; this rate is projected to increase due to growing numbers of octogenarians and nonagenarians.1 These figures are particularly of concern for men, given the steadily increasing prevalence of osteoporosis-related complications reported in male patients, and the growing number of men who are living longer.1,2 Older men lose approximately 1% of their bone mineral density (BMD) per year.3 According to the National Osteoporosis Foundation (NOF), osteoporosis has already been diagnosed in 2 million men in the United States and approximately 12 million more are at risk of developing the disease.4 In a 2011 systematic review of the literature, prevalence of osteoporosis and low bone mineral density in men aged 65 years and older was found to be approximately 45%.5 In addition, the NOF estimates that one in four men aged 50 years and older will experience a fracture as a result of osteoporosis, placing men in this age group at greater likelihood of fracture than of developing prostate cancer.4 It is estimated that approximately 80,000 men will experience a hip fracture each year, which may lead to many of these men becoming permanently institutionalized in long-term care (LTC) settings.4 Researchers project that by 2050, 1.8 million men worldwide will experience a hip fracture as a result of osteoporosis.6
Previous fracture increases the risk for subsequent fracture.7,8 This heightened risk has been observed for up to 10 years postfracture and is greater in men than in women.9-11 Moreover, hip fractures have been shown to be associated with a variety of negative outcomes, including morbidity and mortality, which also occur at a greater frequency in men as compared with women.12,13 One study reported that more men than women experienced impairment in walking 10 feet at 12 months following hip fracture treatment.14 The men also reported more impairment in activities of daily living involving the lower extremity. Because men are less likely than women to return to independent function at home after a hip fracture, they tend to require LTC services at a higher rate than women.15,16 In addition, the 1-year mortality rate after hip fracture has been found to be as high as 32% for men—almost double the 17% documented for women.12,17
Despite these alarming trends, numerous studies have found osteoporosis prevention efforts for men to be severely lacking.12,18-23 Kiebzak and associates12 found that only 4.5% of men who had been admitted to a hospital for treatment of a hip fracture over a 4-year period had received any kind of treatment for osteoporosis, compared with 27% of women admitted during the same time period (P<.001). This trend continued through 1- and 5-year follow-up, where 27% of men were receiving any kind of treatment for osteoporosis, compared with 71% of the women (P<.001). Of those receiving treatment, men were more likely than the women to be receiving calcium and/or vitamin D only (67% vs 32%, respectively), and 11% of men had undergone a BMD screen, compared with 27% of women.12 Giangregorio and associates24 conducted a systematic review of 35 studies published between 1996 and 2005 to ascertain how clinicians managed osteoporosis in patients with fragility fractures. Overall, their findings revealed a care gap across both male and female patients; however, men were found to have been less likely to receive a diagnosis or treatment compared with women.24
Papaioannou and associates25 examined physician patterns of recognition and treatment of osteoporosis in community-dwelling men aged 50 years and older. The 5-year study, which annually surveyed 2187 participants, found that an overwhelming 90% of men who had sustained a fragility fracture had not received treatment for osteoporosis, nor had they received an osteoporosis diagnosis during the study period. This study also found that an osteoporosis diagnosis resulted in a greater rate of treatment. At year 5 of the study, 67% of patients who had received an osteoporosis diagnosis were being treated with bisphosphonate and 87% had been given calcium and/or vitamin D.25 These findings highlight the importance of screening and diagnosis in ensuring appropriate prescribing of treatment.
Misperceptions About Osteoporosis
Despite the prevalence and risks of osteoporotic fractures in men, research shows that men perceive osteoporosis to be a women’s disease,5,26,27 and a 2011 systematic review found that older men know little about the disease process, its risks, or prevention measures.5 Previous researchers have found that, whereas women perceive of osteoporosis as a serious disease and recognize themselves as being susceptible, men do not tend to recognize the importance of the disease, nor their vulnerability, and they do not engage regularly in preventive behaviors such as weight-bearing exercise or daily calcium supplementation.26,27 As a result, there is a great need for education in this area, and healthcare providers caring for older male patients should take the time to educate them about the reality of osteoporosis and encourage the same preventive behaviors as are encouraged in women; however this will not be possible until more healthcare providers themselves recognize osteoporosis to be a problem in this population.
Guidelines for Screening and Diagnosing Osteoporosis in Men
In 2008, the American College of Physicians (ACP) identified osteoporosis an underreported disease in men and called for improvement in the rates of diagnosis and treatment for this patient population.28 As a result, the ACP published guidelines for the assessment of risk factors and appropriate use of screening tools to assist in the diagnosis of osteoporosis in men. Risk factors for osteoporotic fractures in men were defined as: age greater than 70 years, body mass index lower than 20 kg/m2 to 25 kg/m2, weight loss exceeding 10% within the prior 6 months, lack of physical activity, history of corticosteroid use, history of androgen deprivation therapy, and previous osteoporotic fracture. With regard to screening, the ACP recommended use of the dual-energy X-ray absorptiometry (DXA) scan, the gold standard in diagnosing osteoporosis in both men and women.29 In 2012, the Endocrine Society also published similar guidelines regarding the management of osteoporosis in men.30
Risk Assessment and Treatment of Osteoporosis in Institutionalized Men
We conducted a chart review to determine whether physicians in the LTC setting recognize specific risk factors and initiate treatment for osteoporosis, based on the well-established ACP guidelines. We reviewed the charts of the first 60 male and 60 female patients admitted for low-trauma hip fractures to subacute rehabilitation care at an LTC facility located in New York between January 1, 2010 and September 30, 2011.
The primary outcome variable was osteoporosis screening as documented in the patients’ charts, either: (1) in the initial history section completed by the admitting physician; (2) in subsequent progress notes; or (3) via documentation of DXA scan. There were no documented diagnoses of osteoporosis for any of the male patients, compared with 16 (26.7%) of the female patients (P<.0001). Only three men (5%) were documented to have received calcium and vitamin D supplements, compared with 17 women (28.3%; P=.0006). In addition, only one male patient (1.7%) received a DXA scan compared with three women (5%), but this finding did not reach statistical significance. When examining whether there were differences between the sexes with regard to some of the common risk factors for osteoporosis identified in the ACP guidelines, we found no significant differences between the male and female patients (Table). Most (86.7%) of the male patients had at least one documented risk factor for osteoporosis and 23.3% had two or more.
Implications of Our Findings
Our aim in conducting this study was to determine whether authoritative guidelines issued by the ACP had prompted a change in screening patterns for older men in LTC. Like other reports,12,13 our findings showed that osteoporosis is indeed underrecognized and undertreated in men, including among those residing in LTC facilities. Furthermore, the presence of published guidelines does not appear to impact clinical practice with regard to diagnosis and management of osteoporosis in this population.
The physicians in our study did not adequately screen or provide their male patients with appropriate preventive and therapeutic options for osteoporosis, despite recognized ACP screening guidelines that include simple preventive measures, such as calcium and vitamin D supplementation, which are considered a standard therapeutic approach for prevention in at-risk patients.31 It should be noted, however, that there has been some debate in the healthcare community over the benefit of daily vitamin D and calcium supplementation as a preventive measure for fractures, particularly after the US Preventive Services Task Force (USPSTF) released its recommendations in February 2013 against the use of these supplements for this purpose.32 The USPSTF found that the current evidence is insufficient to assess the balance of the benefits and harms of combined vitamin D and calcium supplementation for the primary prevention of fractures in premenopausal women or in men.32 Subsequently, even fewer physicians may be inclined to recommend vitamin D and/or calcium to their patients, regardless of their patients’ sex. However, in January 2014, the American Geriatrics Society released a consensus statement in favor of vitamin D and calcium supplementation to prevent both falls and fractures, recommending that healthcare providers discuss different vitamin D and calcium supplementation schedules with their patients and/or their caregivers to find a regimen that can help meet their patients’ needs while ensuring adherence.33 We concur with this recommendation that healthcare providers carefully consider vitamin D and calcium supplementation for their at-risk patients, regardless of sex.
Conclusion
Medical professionals, particularly in LTC settings, have a unique opportunity to impact their male patients’ awareness and education about osteoporosis, including risk factors and preventive measures to avoid bone mineral density loss and fracture. Given the projected growth in worldwide aging within the coming decades, it is imperative that osteoporosis screening becomes mandatory practice in the male patient population. Current advances in medicine have successfully increased longevity worldwide; it is now our duty to ensure that older men reach these milestones with genuine quality of life.
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Disclosures: The authors report no relevant financial relationships.
Address correspondence to: Andrzej Kozikowski, PhD, 175 Community Drive, Great Neck, NY 11021; akozikowski@nshs.edu
