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Fracture and quality of life in older women

Fractures in older people, especially older women, can be problematical. The impact of hip fracture can be devastating. Much treasure is spent on trying to prevent fracture through treatment of osteoporosis, and by trying to reduce loss of bone, especially in postmenopausal women. If we want to know how treatments compete in the clever world of cost effectiveness, then we have to measure the negative impact of fractures, and while much has been done in that area, a new, and very large, study [1] opens another window.

Study

This was part of a prospective longitudinal study of 200,000 postmenopausal US women aged at least 50 years, without a diagnosis of osteoporosis, no bone density measurement within 12 months, and not taking treatments for osteoporosis. For inclusion they has to have completed two mail or telephone surveys, the first at about 12 months after enrolment, and the second about 36 months after enrolment.

Both surveys elicited information of new fractures, health status using a SF-12 instrument, osteoporosis-related care, and fall history. Analysis of the SF-12 data was according to two composite scores, the physical component score (PCS) and mental component score (MCS). Reported new fractures (hip, spine, wrist, rib) between the first and second surveys formed the cases, with controls being women without fracture.

Results

The analysis included 86,128 women (88% white), whose mean age was about 65 years. Just 1.2% had suffered a fracture in the year before the first survey. Fractures between the first and second survey numbered 320 hip, 445 spine, 835 wrist, and 657 rib, 2.6% over the two years. There were 83,871 women without fracture who served as controls.

Women suffering a fracture more frequently had significantly reduced bone mineral density, and were 4-6 times more likely to have suffered a fracture during the 12 months before the first survey. They also had lower quality of life scores at the first survey.

After adjusting quality of life scores for these factors, women suffering a fracture in the two years between the two surveys had significantly reduced PCS scores compared with women without a fracture (Figure 1). Statistically significant reductions were found for hip, spine, wrist and rib fractures for younger postmenopausal women (50-64 years), and for hip, spine and rib fractures in older postmenopausal women (65-99 years).



Figure 1: Reduction of physical quality of life compared with control





Women suffering a fracture in the two years between the two surveys had greater reduction in MCS scores than women without a fracture (Figure 2). Statistically significant reductions were found for spine and rib fractures for younger postmenopausal women, and for hip and spine fractures in older postmenopausal women.



Figure 2: Reduction of mental quality of life compared with control





Comment

What makes this study worth thinking about is the combination of its size and detail, and that it provides quality of life results for different fractures in younger and older postmenopausal women. It also did some useful statistical stuff, like taking into account multiple comparisons, so that statistical significance was only reported when the probability value was 0.004, so it does not tell us about associations that crept into conventional levels of significance.

Those in the know about such things may not have been surprised by the findings. For the rest of us, perhaps what stands out is the particular loss of life quality attendant on vertebral fractures. This may reflect the fact that vertebral fractures cannot be healed, and often come with a lot of back pain, and we do know that chronic pain has a large negative impact on quality of life.

It also helps to have some context. The negative impact on PCS scores for hip and spine were at the same level as those for COPD, hip impairment, or rheumatoid or osteoarthritis. Given that we will have more older people with low bone mineral density and at risk of these fractures, this should help in making sense of current and new therapy choices.

Reference:

  1. SK Brenneman et al. Impact of recent fracture on health-related quality of life in postmenopausal women. Journal of Bone and Mineral Research 2006 21: 809-816.

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