Bone fracture patients with the debilitating and potentially fatal condition of osteoporosis are slipping through the health services net. One consultant is campaigning to change that, writes Dr Muiris Houston.
Fracturing a bone - especially as a result of a minor fall - is one of the major risk factors for osteoporosis. One would think that hospitals would have a system in place to refer people whom they have treated for fractures on for osteoporosis screening.
Surprisingly, this is not current practice in the Republic and this represents a lost opportunity for the secondary prevention of a disease which can cause disability and, indeed, loss of life.
Instead a person who has been treated for a fracture (which is the result of early osteoporosis) may reappear in the same fracture clinic or casualty department two years later with a more serious bone fracture which can be directly attributed to a thinning of the bones.
This is a far from theoretical risk. Every year in Britain, 60,000 hip, 50,000 wrist and 40,000 spine fractures occur as a result of osteoporosis. The hip, vertebrae and the wrist bones are the three major fracture sites seen in patients with thinned-out bones. It is estimated that the total number of hip fractures in the EU will increase from 414,000 in 2000 to 972,000 in 2050 - an increase of 135 per cent.
Hip fractures are particularly nasty in their effects. One year after a hip fracture, 20 per cent of patients die of complications. Some 50 per cent are unable to look after themselves properly as a direct result of the fracture because of a loss of mobility and an inability to manage the essential activities of daily living.
Figures from the ESRI show an increase in hip fractures, from 1,509 in 1990 to 2,777 in 1998. The cost per patient to the health service was £2,353 in 1998, with an average hospital stay of 15 days required for treatment.
Also in 1998, the EU made eight key recommendations based on the premise that all governments should adopt an osteoporosis prevention programme as a major governmental health policy. The recommendations covered the funding of screening programmes, the reimbursement of proven treatments and financial support for osteoporosis research. A 2001 audit of these recommendations by the European Parliament showed little progress had been made; in particular, no government had made osteoporosis a health priority.
However, osteoporosis did feature in the Republic's National Health Strategy, published last November. In a chapter on services for older people, 600 additional hospital day beds with facilities for the management of falls, osteoporosis treatment and fracture prevention were promised.
One person who is determined to bridge the gap between fracture clinics and the detection of osteoporosis is Dr Robert Coughlan, Consultant in Rheumatology at Merlin Park Regional Hospital in Galway. Having helped set up an osteoporosis screening service for general practitioners in the west two and a half years ago, he now plans to measure bone densities at the hospital's fracture clinic with a view to defining the extent of the problem.
"I expect that a high percentage of those over 50 with fractures will have osteoporosis," he says. Coughlan hopes to develop a model whereby patients with fractures will be referred to a nurse specialist who will carry out a bone density measurement as part of an osteoporosis assessment.
He likens the present situation to a heart attack patient being discharged home with no preventive treatment.
"Osteoporosis is essentially a condition to be treated by primary care doctors. But at present there is a gap between a person's discharge from a fracture clinic and the prevention of further fractures by the early detection of osteoporosis. Ultimately, the purpose of our initiative is to show the proportion of patients with low trauma fractures who can be treated to prevent further fractures."
The Galway project will involve a simple osteoporosis screening unit called a PIXI - Peripheral Instantaneous X-ray Imaging. It measures bone density in the heel bone and only takes three minutes to complete. All the patient has to do is to remove socks or tights and place his/her foot into the machine.
As its name suggests, a PIXI unit measures the density of peripheral bone. The system will be backed up by a DEXA unit (Dual Energy X-ray Absorpitometry), which will be used in cases of borderline results or doubt. It is a more time-consuming test, but is regarded as the "gold standard" of osteoporosis testing.
The actual measurement made by these machines is Bone Mineral Density (BMD).
Studies have shown that the risk of fracture increases progressively the lower the BMD. In statistical terms, for each standard deviation decrease in BMD, the risk of a future fracture doubles. It is claimed that the ability of BMD to predict fractures is as good as the measurement of blood pressure to predict stroke.
A small number of general practitioners in the Republic have DEXA scanners. The Spiddal Family Practice, outside Galway is one. A scan here costs €88; patients with medical cards are charged a reduced rate and pressure is being brought to bear on the Department of Health to approve free treatment for GMS patients. Dr Denis Egan, one of the practice partners, says they perform scans on patients as far away as Belfast - many of them people frustrated by the lengthy delays experienced in some hospital units.
As well as fractures, osteoporosis causes back pain, pain in the shoulders and arms, indigestion and loss of height.
It impairs quality of life, affecting mobility and leisure activities. Multiple spinal fractures can lead to severe curvature and a "humped" appearance.
CLEARLY, we are missing opportunities to prevent a debilitating and potentially life-threatening disease. It is time that we had a co-ordinated screening strategy for osteoporosis, with all sections of the health service acting in concert. And it is time we implemented and funded the 1998 EU recommendations on osteoporosis prevention and treatment.
What is osteoporosis? Osteoporosis - commonly referred to as thinning of the bones - is defined by the World Health Organisation as a bone density (T-score) that is significantly below the average for the young, healthy female population. We achieve our peak bone mass as young adults; the density of our bones declines steadily after this.
Osteoporosis is not just a female disease, although it is more common in women because of the accelerated bone loss which occurs after the menopause. By age 75, almost 40 per cent of women will have osteoporosis.
Other risk factors, which apply to men as well as women, include a past history of a bone fracture, long-term use of steroid medication, smoking, physical inactivity, a family history of osteoporosis, low calcium intake in the diet and a small, thin body frame.
How can osteoporosis lead to an increased risk of fracture? Our bones are in a constant state of flux. Once our growth has stopped, a process of bone remodelling begins; bone is formed by cells called osteoblasts while at the same time it is being absorbed and broken down by osteoclasts. Later in life, the balance between the two activities swings in the direction of bone breakdown, so that there is a net loss of bone during each remodelling cycle.
So, from the time of menopause in women and the sixth decade in men, bone mass decreases steadily and the risk of fracture rises.
There are two approaches to the management of osteoporosis. One involves lifestyle advice and it applies to all patients (see panel). Drug treatment can take different forms. Apart from calcium and vitamin D supplements, the options are oestrogen replacement for women or drugs called biphosphanates for both sexes. Alendronate, a biphosphanate, has been shown to reduce the risk of fracture by 50 per cent. It is now available as a once-weekly formulation, which should help to improve patient compliance.
Oestrogen, in the from of hormone replacement therapy or selective oestrogen reuptake molecules (SERM), is an attempt to return bones to a pre-menopausal state. Oestrogen helps minimise bone loss and to reduce bone turnover. HRT has been shown to reduce fractures of the vertebrae by 50 per cent.
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