Incident Fragility Fractures Have a Long-Term Negative Impact on Health-Related Quality of Life of Older People: The Canadian Multicentre Osteoporosis Study
Sayem Borhan, Olga Gajic‐Veljanoski, Olga Gajic-Veljanoski
C C Kennedy, G Ioannidis, Claudie Berger, David Goltzman, Christopher S Kovacs, Jerilynn C Prior, S M Kaiser, Angela M Cheung, Lehana Thabane, Jonathan D Adachi, for the CaMos Research Group , CaMos Research Group , Alexandra Papaioannou, David A Hanley, Robert G Josse, Stephanie M Kaiser, Suzanne N Morin
Department of Medicine and Joint Department of Medical Imaging, Centre of Excellence in Skeletal Health Assessment, University Health NetworkUniversity of TorontoTorontoONCanadaROR
Although the short-term impact of incident fragility fractures on health-related quality of life (HRQL) of older people has been confirmed, we lack long-term evidence. We explored the impact of incident fragility fractures on HRQL, among people aged 50 years and older, using 10-year prospective data from the Canadian Multicentre Osteoporosis Study (CaMos). This study was based on data from 7753 (2187 men and 5566 women) participants of CaMos. The HRQL, measured through the Health Utility Index (HUI), was captured at baseline and year 10. The incident fragility fractures were recorded over 10 years of follow-up at spine, hip, rib, shoulder, pelvis, or forearm. Multivariable regression analysis was conducted to measure the mean difference, termed as deficit, in the HUI scores for participants with and without fractures. We examined the effects of single or multiple fragility fractures, time (fractures that occurred between year 1 to 5 and 6 to 10) and recovery to the prefracture level. Incident spine and hip fractures were associated with significant deficits (varied from -0.19 to -0.07) on the HUI scores. Hip and spine fractures were associated with negative impact on mobility, self-care, and ambulation. Fractures that occurred closer to the follow-up assessment were associated with significant impact on HRQL compared to fractures occurring a long time before it, except for hip fracture (deficits lasted 5 years or longer). Similarly, multiple hip (-0.14), spine (-0.16), and rib (-0.21) fractures significantly impacted the HRQL of women. Women with a hip fracture never recovered to their prefracture level score (OR = 0.41; 95% confidence interval [CI], 0.19 to 0.98). Our analysis suggests that single and multiple hip fractures as well as multiple spine and rib fractures strongly impact the HRQL of older people over a prolonged period of time.
fragility fracture long-term health related quality of life older adults, Canadian Multicentre Osteoporosis Study CaMos fracture HRQL, incident hip spine fracture Health Utility Index impact, Prior JC osteoporosis fracture quality of life prospective, multiple fragility fractures women quality of life deficit, hip fracture recovery prefracture quality of life women, rib fracture health related quality of life longitudinal, osteoporotic fracture mobility self-care ambulation impairment, 10 year prospective study fragility fracture outcomes, Borhan Papaioannou fragility fracture HRQL CaMos
PMID 30723960 30723960 DOI 10.1002/jbmr.3666 10.1002/jbmr.3666
Cite this article
Borhan, S., Papaioannou, A., Gajic-Veljanoski, O., Kennedy, C., Ioannidis, G., Berger, C., Goltzman, D., Josse, R., Kovacs, C. S., Hanley, D. A., Prior, J. C., Morin, S. N., Kaiser, S. M., Cheung, A. M., Thabane, L., Adachi, J., & CaMos Research Group (2019). Incident Fragility Fractures Have a Long-Term Negative Impact on Health-Related Quality of Life of Older People: The Canadian Multicentre Osteoporosis Study. Journal of bone and mineral research : the official journal of the American Society for Bone and Mineral Research, 34(5), 838-848. https://doi.org/10.1002/jbmr.3666
Borhan S, Papaioannou A, Gajic-Veljanoski O, Kennedy C, Ioannidis G, Berger C, et al. Incident Fragility Fractures Have a Long-Term Negative Impact on Health-Related Quality of Life of Older People: The Canadian Multicentre Osteoporosis Study. J Bone Miner Res. 2019;34(5):838-848. doi:10.1002/jbmr.3666
Borhan, S., et al. "Incident Fragility Fractures Have a Long-Term Negative Impact on Health-Related Quality of Life of Older People: The Canadian Multicentre Osteoporosis Study." Journal of bone and mineral research : the official journal of the American Society for Bone and Mineral Research, vol. 34, no. 5, 2019, pp. 838-848.
To test for the possible association of past oral contraceptive (OC) use and incident fracture after menopause.
A prospective cohort of 93,725 postmenopausal women.
Forty Women's Health Initiative (WHI) clinical centers across the United States. PATIENT(S): Ethnically diverse 93,725 volunteer postmenopausal women, 50 to 79 years old. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): The main outcome was self-reported incident first fracture assessed prospectively by annual questionnaire. RESULT(S): The adjusted relative hazard (HR) for fracture among past OC users was 1.07 (95% CI, 1.01-1.15). Among women without any postmenopausal hormone treatment, past OC use for < or =5 years led to an HR of 1.15 (95% CI, 1.04-1.27) and for past OC use >5 years led to an HR of 1.09 (95% CI, 0.97-1.23) compared with never users. CONCLUSION(S): This study does not support the idea that past OC use protects against later fracture.
Bone HealthQuality of Life ImpactFracture OutcomesPopulation-Based Studies
Health-related quality of life (HRQL) was examined in relation to prevalent fractures in 4816 community-dwelling Canadian men and women 50 years and older participating in the Canadian Multicentre Osteoporosis Study (CaMos). Fractures clinically recognized main fractures, subclinical vertebral fractures and fractures at other sites. Main fractures were divided and analyzed at the hip, spine, wrist/forearm, pelvis and rib sites. Baseline assessments of anthropometric data, medical history, therapeutic drug use, spinal radiographs and prevalent fractures were obtained from all participants. The SF-36 instrument was used as a tool to measure HRQL. A total of 652 (13.5%) main fractures were reported. Results indicated that hip, spine, wrist/forearm, pelvis and rib fractures had occurred in 78 (1.6%), 40 (0.8%), 390 (8.1%), 19 (0.4%) and 125 (2.6%) individuals, respectively (subjects may have had more than one main fracture). Subjects who had experienced a main prevalent fracture had lower HRQL scores compared with non-fractured participants. The largest differences were observed in the physical functioning (-4.0; 95% confidence intervals (CI): -6.0, -2.0) and role-physical functioning domains (-5.8; 95% CI: -9.5, -2.2). In women, the physical functioning domain was most influenced by hip (-14.9%; 95% CI: -20.9, -9.0) and pelvis (-18.1; 95% CI: -27.6, -8.6) fractures. In men, the role-physical domain was most affected by hip fractures (-35.7; 95% CI: -60.4, -11.1). Subjects who experienced subclinical vertebral fractures had lower HRQL scores than those without prevalent fractures. In conclusion, HRQL was lower in the physical functioning domain in women and the role-physical domain in men who sustained main fractures at the hip. Subclinical vertebral fractures exerted a moderate effect on HRQL.
Bone HealthCognitive Decline AssociationMedication EffectsBias by Indication
We are grateful to Dr. Naharci for the interest in our study reporting the association between cognitive decline and bone loss and fracture risk. (1) We agree that bisphosphonates (BPs) have a proven effect on reducing bone loss and fracture risk. (2) Medication with anticholinergic (ACH) side effects may also affect cogni-tive function as well as propensity to fall and fracture, although these effects have not been demonstrated in all studies. (3) We did not include these medication classes in our models because in observational studies the relationship between medication and outcomes is likely driven by factors associated with medication use. This bias by indication can only be avoided by specific study design (ie, propensity score matching), which was beyond the scope of our study. (4) However, we have conducted additional analyses to determine the prevalence of BP and ACH medication in our cohort, the association between these medication classes and our study outcomes and the impact of the addition of these medication classes to our findings. BP and ACH use were self-reported and obtained by questionnaire at baseline, and years 5 and 10. Bone mineral density (BMD) was assessed by dual-energy X-ray absorptiometry (DXA) and cognitive function using the Mini Mental State Examination (MMSE) test during all clinical visits. Follow-up time for BMD
Bone HealthRisk Prediction ModelsFracture Risk AssessmentMultistate Prediction
Existing fracture risk assessment tools are not designed to predict fracture-associated consequences, possibly contributing to the current undermanagement of fragility fractures worldwide. We aimed to develop a risk assessment tool for predicting the conceptual risk of fragility fractures and its consequences. The study involved 8965 people aged ≥60 years from the Dubbo Osteoporosis Epidemiology Study and the Canadian Multicentre Osteoporosis Study. Incident fracture was identified from X-ray reports and questionnaires, and death was ascertained though contact with a family member or obituary review. We used a multistate model to quantify the effects of the predictors on the transition risks to an initial and subsequent incident fracture and mortality, accounting for their complex interrelationships, confounding effects, and death as a competing risk. There were 2364 initial fractures, 755 subsequent fractures, and 3300 deaths during a median follow-up of 13 years (interquartile range [IQR] 7-15). The prediction model included sex, age, bone mineral density, history of falls within 12 previous months, prior fracture after the age of 50 years, cardiovascular diseases, diabetes mellitus, chronic pulmonary diseases, hypertension, and cancer. The model accurately predicted fragility fractures up to 11 years of follow-up and post-fracture mortality up to 9 years, ranging from 7 years after hip fractures to 15 years after non-hip fractures. For example, a 70-year-old woman with a T-score of -1.5 and without other risk factors would have 10% chance of sustaining a fracture and an 8% risk of dying in 5 years. However, after an initial fracture, her risk of sustaining another fracture or dying doubles to 33%, ranging from 26% after a distal to 42% post hip fracture. A robust statistical technique was used to develop a prediction model for individualization of progression to fracture and its consequences, facilitating informed decision making about risk and thus treatment for individuals with different risk profiles.