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ABSTRACT
Background: Osteoporosis is predominantly a condition of the elderly, and the median age for hip fracture in women is approximately 83 years. Osteoporotic fracture risk is multifactorial, and often involves the balance between bone strength and propensity for falling.
Objective: To present an overview of the available evidence, located primarily by Medline searches up to April, 2009, for the different management strategies aimed at reducing the risk of falls and osteoporotic fractures in the elderly.
Results: Frailty is an independent predictor of falls, hip fractures, hospitalisation, disability and death in the elderly that is receiving increasing attention. Non-pharmacological strategies to reduce fall risk can prevent osteoporotic fractures. Exercise programmes, especially those involving high doses of exercise and incorporating balance training, have been shown to be effective. Many older people, especially the very elderly and those living in care institutions, have vitamin D inadequacy. In appropriate patients and given in sufficient doses, vitamin D and calcium supplementation is effective in reducing both falls and osteoporotic fractures, including hip fractures. Specific anti-osteoporosis drugs are underused, even in those most at risk of osteoporotic fracture. The evidence base for the efficacy of most such drugs in the elderly is incomplete, particularly with regard to nonvertebral and hip fractures. The evidence base is perhaps most complete for the relatively recently introduced drug, strontium ranelate. Non-adherence to treatment is a substantial problem, and may be exacerbated by the requirements for safe oral administration of bisphosphonates.
Conclusion: Evidence-based strategies are available for reducing osteoporotic fracture risk in the elderly, and include exercise training, vitamin D and calcium supplementation, and use of evidence-based anti-osteoporotic drugs. A positive and determined approach to optimising the use of such strategies could reduce the burden of osteoporotic fractures in this high-risk group.
Transparency
Declaration of funding
The European Society for Clinical and Economical Aspects of Osteoporosis and Osteoarthritis (ESCEO), funded, through an unrestricted educational grant, the Experts' consensus meeting and the preparation of the manuscript. Servier International agreed to fund the publication support of the article after submission of the manuscript but were not involved in its preparation or drafting, for which the authors take full responsibility.
Declaration of financial/other interests
The authors are all members of ESCEO – a society that has been the recipient of unrestricted educational grants from Servier. R.R. has disclosed that he is a consultant/advisor to Merck, Roche, Servier, Danone, Nycomed, Eli Lilly and Amgen; and that he is on the speakers bureau for Roche, Novartis, Servier and Amgen. O.B. has disclosed that he has been the recipient of sponsorship/research funding from Servier, MSD, GlaxoSmithKline, Theramex, Rottapharm; and that he is a consultant/advisor to Servier, GlaxoSmithKline, Galapagos NV, Rottapharm. J.B.C.-A. has disclosed that he is a consultant/advisor to Shire, and is on the speakers bureau for Servier, Shire and Amgen. J.-P.D. has disclosed that he has received research grant funding from Novartis and Schering-Plough; that he is a consultant/advisor for Novartis; and that he is on the speakers bureau for Eli Lilly, Servier and Novartis. G.L. has disclosed that he has no relevant financial relationships. J.D.R. has disclosed that he is a consultant/advisor for Novartis, Merck, Amgen, Servier; and that he is on the speakers bureau for Merck, Procter & Gamble, Roche, Amgen and Servier. B.V. has disclosed that he is a consultant/advisor for Servier. J.-Y.R. has disclosed that he has been the recipient of research grants from Bristol Myers Squibb, Merck Sharp & Dohme, Rottapharm, Teva, Lilly, Novartis, Roche, GlaxoSmithKline, Amgen, Servier; that he is a consultant/advisor to Servier, Novartis, Negma, Lilly, Wyeth, Amgen, GlaxoSmithKline, Roche, Merckle, Nycomed, NPS, Theramex, UCB; and that he has been the recipient of lecture fees for speaking at meetings on behalf of Merck Sharp and Dohme, Lilly, Rottapharm, IBSA, Genevrier, Novartis, Servier, Roche, GlaxoSmithKline, Teijin, Teva, Ebewee Pharma, Zodiac, Analis, Theramex, Nycomed, Novo-Nordisk.
All peer reviewers receive honoraria from CMRO for their review work. Peer Reviewer 1 has disclosed that he/she has no relevant financial relationships. Peer Reviewer 2 has disclosed that he has been the recipient of grant/research support from Amgen, Eli Lilly, GSK, Novartis, Pfizer, Procter & Gamble, Roche, sanofi Aventis, Wyeth; that he is on the speakers bureau and the advisory board for Eli Lilly, Novartis, Roche/GSK; that he is on the advisory board for Amgen, Upsher-Smith and Wyeth; and that he is a direct stockholder in Procter & Gamble and Teva.
Acknowledgements
The authors thank Mr Alan Larkman for his help in preparing this review. This assistance was funded by ESCEO.