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From Manila Bulletin

Ang tanda
The View from Rizal
By GOV. JUN A. YNARES, M.D.
July 24, 2011, 8:00am

MANILA, Philippines — I spotted the ever-present Lolo Sisong at a recent gathering of civic leaders in Antipolo, Rizal.

The event was one of several organized by outstanding nongovernmental organization (NGO) partners of the Rizal provincial government like the United Bayanihan Foundation. This one had to do with government and private sector putting their heads together. The aim: Help senior citizens remain productive and happy.

I know no senior citizen more intellectually productive than the inimitable Lolo Sisong, Rizal province’s self-appointed official sage. So, in that meeting where those who are superior in wisdom and years were the subject matter, the Lolo ng Lalawigan’s presence was a welcome one.

Since the word “matanda” (old) kept ringing throughout the event, I decided to signal Lolo Sisong to join my huddle with NGO leaders and ask him a question I had secretly asked myself for years.

The question: Why are those who are advanced in years called “matanda”?

“Why ask me, I am not old enough to answer the question,” Lolo Sisong said with his serious humor glowing in his face.

“It takes a young person to answer the question,” I answered, smiling, knowing he would bite the bait.

“Okay, then, I will answer the question,” Lolo Sisong said, pretending to capitulate.

“You see, Junjun, ‘matanda’ comes from the word ‘tanda’,” he began.

“So, therefore?” I egged him to make it quick.

“Well, ‘Tanda’ has three meanings,” he seemed naughtily dragging the conversation.

“Go ahead, what are they?” I asked, impatient.

“One, ‘tanda’ means ‘mark’,” he started the long process of sagely enumeration.

“Two, ‘tanda’ means ‘sign’,” Lolo Sisong continued.

“Three, ‘tanda’ means ‘recall’ or ‘remember’, or ‘reminisce’,” he ended.

“Care to explain?” I asked again, impatience growing.

“That’s where I’m going,” he answered, seemingly irked by my nagging.

“You see, a senior person has a lot of ‘tanda’ in his body and in his character – the marks of what he has gone through in life,” Lolo Sisong said. “His body and his personality shows the many marks of the happy and painful experiences that the senior person has gone through,” he added.

“Now, the quality of his body, his mind and his character as shaped by those experiences shows whether or not they made him into a better person… or a bitter one,” Lolo Sisong explained.

“So, when you see a senior person, you look at the ‘marks’ to determine what kind of person he is,” he essayed.

Impressed by the wisdom, I said, “Move on to number two – ‘tanda’ meaning ‘sign’.”

“Be patient, I am old, remember?” he answered, even more irked.

“Okay, ‘tanda’ also means ‘sign’,” he moved on. “Senior people are either ‘warning signs’ or signs similar to the beacon light of a lighthouse,” Lolo Sisong said, choosing his words carefully.

“When you find a bitter old person, he is a warning sign to you – don’t go where he went, such as his vices and his scheming ways,” he explained. “But when you find a ‘better’ senior person, ask him which path he chose and follow it – he is showing you a beacon light,” Lolo Sisong added.

I was silent, reflecting.

“May I go to point number three,” Lolo Sisong said, obviously trying to irk me reciprocally.

“Please go ahead,” I answered serious this time.

“Well, ‘tanda’ also refers to that big vault of memories of the many years we have gone through in life,” he began his final point.

“That is the gold mine of our advanced years – the definite advantage of being senior over being young,” Lolo Sisong moved on.

“We can open that vault anytime to retrieve the things that matter a lot to people – memories of love and joy, of friends and loved ones, of the many valuable experiences which prove to us that we did spend our years wisely,” he said, his aging eyes all of a sudden looking young.

“And if a senior person is generous, he lets young people into that vault and lets them frolic in the gold mine of precious memories,” he said, using his poetic abilities.

I was still silent, awed by the obvious advantage in wisdom that senior people have.

“That’s also what we mean by ‘growing old gracefully’, Junjun”, Lolo Sisong attempted to conclude.

“One ages well by being conscious of his role as ‘mark’, ‘sign’ and ‘treasure trove of memories,” he said.

“So, be careful about how experiences make their mark on you,” he continued.

“Be conscious about your role – are you a danger sign or a beacon light to the younger generation,” he moved closer to his closing.

“And consciously build the kind of memories that you bring into your vault,” he, at last, ended.

“Gotta go,” Lolo Sisong said, acting like a busy young person.

“Thanks much,” I said, trying to memorize his key points.

“By the way, those three things are also a technique on how one stays young despite advancing years,” Lolo Sisong post-scripted.

“Will remember that,” I answered.

“Only if your mind can stay young like mine,” Lolo Sisong said, underscoring that the last word is always his.

I kept my mouth shut, impressed by how he has, indeed, made great use of his years.

Feedback: provinceofrizal@yahoo.com

Authors: Silvina Levis, MD; Nancy Strickman-Stein, PhD; Parvin Ganjei-Azar, MD; Ping Xu, MPH; Daniel R. Doerge, PhD; Jeffrey Krischer, PhD

Journal: Arch Intern Med. 2011;171(15):1363-1369. doi:10.1001/archinternmed.2011.330

A 2- year randomized trial found no significant difference in bone loss or menopausal symptoms between women taking soy tablets or placebo.

Patients were women age 45-60 years, within 5 years of menopause and without osteoporosis.

Subjects were were randomly assigned, in equal proportions, to receive daily soy isoflavone tablets, 200 mg, or placebo.

Results
After 2 years, no significant differences were found between the participants receiving soy tablets (n = 122) and those receiving placebo (n = 126) regarding changes in bone mineral density in the spine (–2.0% and –2.3%, respectively), the total hip (–1.2% and –1.4%, respectively), or the femoral neck (–2.2% and –2.1%, respectively).

A significantly larger proportion of participants in the soy group experienced hot flashes and constipation compared with the control group. No significant differences were found between groups in other outcomes.

Authors’ Conclusions
In this population, the daily administration of tablets containing 200 mg of soy isoflavones for 2 years did not prevent bone loss or menopausal symptoms

REFERENCES and LINKS:

Copy of House Bill 1071 Philippine Congress 2010

Copy of Senate Bill 1809

and

HelpAge International

During a recent forum on Policy for Older Persons held at the UP Manila-National Institutes of Health, Rep. David Koh, Senior Citizen’s Party List announced the good news that House Bill 1071 was approved at the Committee level. It now seeks approval from the Senate, as Senate Bill Number 1809.

The original bill, seeks to ensure that older persons and persons with disability are protected from institutional, community and domestic violence and sexual assault and to improve outreach efforts and other services available to persons victimized by such violence.

The original bill, “Older Filipino’s Protection from Violence Act” was authored by Rufus B. Rodriguez and Maximo B. Rodriguez Jr.

Senate Bill 1809 was authored by Senator Miriam D Santiago with Sen Lito Lapid as co-author. The bill is described as AN ACT TO ESTABLISH PROGRAMS AND ACTIVITIES TO AID VICTIMS OF ELDER ABUSE, AND PROVIDE TRAINING TO HEALTH AND GOVERNMENT PROFESSIONALS IN THE ASSISTANCE OF SUCH VICTIMS, It was read on first reading in September 2010 and was referred to the Committee(s) on SOCIAL JUSTICE, WELFARE AND RURAL DEVELOPMENT and FINANCE.

In a similar action, HelpAge International calls for the following Actions:

• the 186 countries that have ratified CEDAW (UN Convention on Elimination of All Forms of Discrimination Against Women) meet their existing obligations to put in place systems, legal and other, to protect all women, young and old, from violence and abuse.

• data collection and disaggregation is improved to make the issue more visible.

• governments invest in training of health professionals, the judiciary and law enforcement agencies to recognise abuse

• more funding is allocated to community initiatives that change attitudes and tackle age discrimination and ageism.

Finally, a UN Convention of the Rights of Older People would ensure that all countries that ratify it had an obligation to put in place these protective legal systems.

June 15 is World Elder Abuse Awareness Day

Philippine General Hospital (PGH) Director Jose “Jogon” Gonzales approves an additional 30% discount, on top of the 20% senior citizen’s discount, for retired PGH and UP Manila employees who seek medical attention in the outpatient clinics, or are admitted to the Philippine General Hospital.

Click image for details.

Developed by:
American College of Cardiology Foundation Task Force on Clinical Expert Consensus Documents American Academy of Neurology American Geriatrics Society American Society for Preventive Cardiology American Society of Hypertension, American Society of Nephrology Association of Black Cardiologists European Society of Hypertension

Clinical Evaluation

Note: The reader should view the expert consensus document as the best attempt of the ACCF and document cosponsors to inform and guide clinical practice in areas where rigorous evidence may not yet be available or evidence to date is not widely applied to clinical practice.

Aside from a good and targeted history and physical examination, guidelines on laboratory testing were presented. The diagnosis is established with at least 3 blood pressure readings in at least 2 clinic visits.

Ambulatory BP monitoring (ABPM) is indicated when hypertension diagnosis or response to therapy is unclear from office visits, when syncope or hypotensive disorders are suspected, and for evaluation of vertigo and dizziness. The case for using out-of-office BP readings in the elderly, particularly home BP measurements, is strong due to potential hazards of excessive BP reduction in older people and better prognostic accuracy versus office BP.

The most important role for testing in an elderly patient
with hypertension is to assess for organ damage and modifiable
CVD risk factors, including tobacco smoking, hypercholesterolemia,
diabetes mellitus, and excessive alcohol intake.

Information on the following laboratory tests should be available:
1. Urinalysis to look for any evidence of renal damage,
especially albuminuria/microalbuminuria
2. Blood chemistry to assess electrolytes and renal function, especially potassium and creatinine with eGFR
3. Total cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, and triglycerides, preferably fasting levels
4. Fasting blood sugar and, if there are concerns about diabetes mellitus, hemoglobin A1c
5. ECG

Lifestyle Modification

Weight reduction, salt reduction, DASH diet, regular physical activity and moderation in alcohol consumption are recommended.

The general recommended BP goal in uncomplicated hypertension is 140/90 mm Hg. However, this target for elderly hypertensive patients is based on expert opinion rather than on data from randomized controlled trials (RCTs). It is unclear whether target SBP should be the same in patients 65 to 79 years of age as in patients 80 years of age.

Drug Treatment and other details may be viewed thru this link to the Journal of the American College of Cardiology Expert Consensus Document on Hypertension in the Elderly 2011

What are triglycerides?

Fat exists in the body as Triglycerides. It is a chemical that is found in blood plasma and, in association with cholesterol, form the plasma lipids.

Triglycerides come from fats eaten in foods or made in the body from other energy sources like carbohydrates. Calories ingested in a meal and not used immediately are converted to triglycerides and transported to fat cells to be stored.

How is an excess of triglycerides harmful?

Excess triglycerides in plasma is called hypertriglyceridemia. It’s linked to the occurrence of coronary artery disease and stroke in some people. Elevated triglycerides may be caused by untreated diabetes mellitus.

Like cholesterol, increases in triglyceride levels can be detected by a blood test. These measurements should be made after an overnight food and alcohol fast.

The National Cholesterol Education Program guidelines for triglycerides are:
Normal Less than 150 mg/dL
Borderline-high 150 to 199 mg/dL
High 200 to 499 mg/dL
Very high 500 mg/dL or higher

These are based on fasting plasma triglyceride levels.

AHA Recommendation — Dietary treatment goals

Changes in lifestyle habits are the main therapy for hypertriglyceridemia. These are the changes you need to make:

* If you’re overweight, cut down on calories to reach your ideal body weight. This includes all sources of calories, from fats, proteins, carbohydrates and alcohol.
* Reduce the saturated fat, trans fat and cholesterol content of your diet.
* Reduce your intake of alcohol considerably. Even small amounts of alcohol can lead to large changes in plasma triglyceride levels.
* Eat fruits, vegetables and nonfat or low-fat dairy products most often.
* Get at least 30 minutes of moderate-intensity physical activity on five or more days each week.
* People with high triglycerides may need to substitute monounsaturated and polyunsaturated fats —such as those found in canola oil, olive oil or liquid margarine — for saturated fats.

Eliminate dietary trans fatty acids, which increase triglycerides and atherogenic lipoproteins (ie, lipoprotein, LDL-C).

Substituting carbohydrates for fats may raise triglyceride levels and may decrease HDL (”good”) cholesterol in some people. Certain food products, such as bakery shortening and stick margarine, contain high trans fatty acid concentrations.

* Substitute fish high in omega-3 fatty acids instead of meats high in saturated fat like hamburger. Fatty fish like mackerel, lake trout, herring, sardines, albacore tuna and salmon are high in omega-3 fatty acids.

Overall, exercise is most effective in lowering triglycerides (eg, 20% to 30%) when baseline levels are elevated (ie, TG level of 150 mg/dL), activity is moderate to intensive, and total caloric intake is reduced.

Because other risk factors for coronary artery disease multiply the hazard from hyperlipidemia, control high blood pressure and avoid cigarette smoking. If drugs are used to treat hypertriglyceridemia, dietary management is still important. Patients should follow the specific plans laid out by their physicians and nutritionists.

Read More American Heart Association Healthy Tips

AHA Statement on Triglyceride and Cardiovascular Disease 2011

Heat exhaustion is a form of heat-related illness that can develop after several days of exposure to high temperatures and inadequate or unbalanced replacement of fluids.

Warning signs of heat exhaustion or heat stroke vary but may include the following:

* Heavy sweating
* Paleness
* Muscle Cramps
* Tiredness
* Weakness
* Dizziness
* Headache
* Nausea or vomiting
* Fainting
* Skin: may be cool and moist
* Pulse rate: fast and weak
* Breathing: fast and shallow

To protect yourself from heat stress and heat stroke, follow these tips:

# Drink cool, nonalcoholic beverages. (If your doctor generally limits the amount of fluid you drink or has you on water pills ex. furosemide or hydrochlorothiazide, ask him how much you should drink when the weather is hot. Also, avoid extremely cold liquids because they can cause cramps.)
# Rest.
# Take a cool shower, bath, or sponge bath.
# If possible, seek an air-conditioned environment. (If you don’t have air conditioning, consider visiting an air-conditioned shopping mall or public building to cool off.)
# Wear lightweight clothing.
# If possible, remain indoors in the heat of the day.
# Do not engage in strenuous activities.

If you are living with or taking care of an older person

* Visit older adults at risk at least twice a day and watch them for signs of heat exhaustion or heat stroke.
* Encourage them to increase their fluid intake by drinking cool, nonalcoholic beverages regardless of their activity level.
* Take them to air-conditioned locations if they have transportation problems.

Warning: If their doctor generally limits the amount of fluid they drink or they are on water pills, they will need to ask their doctor how much they should drink while the weather is hot.

If You Don’t Have Air Conditioning:
• Take a cool shower, bath or sponge bath.
• Create cross-ventilation by opening windows on two sides of your house.
• Keep windows open at night.
• Keep curtains, shades or blinds drawn during the hottest part of the day.
• Cover windows when they are in direct sunlight.
• Electric fans may help, but when the temperature reaches the high 90s, fans won’t prevent heat-related illness.
• Go somewhere that’s air-conditioned like the shopping mall, the movies, the library, a senior center or a friend’s house. If you don’t have a car or no longer drive, ask a friend or relative to drive you. If necessary, take a taxi. Don’t stand outside waiting for a bus.

Elderly people are more prone to heat stress than younger people for several reasons:

* Elderly people do not adjust as well as young people to sudden changes in temperature.
* They are more likely to have a chronic medical condition that changes normal body responses to heat.
* They are more likely to take prescription medicines that impair the body’s ability to regulate its temperature or that inhibit perspiration.

More heat stroke and heat stress information from the Centers for Disease Control and Prevention

By ROXANA HEGEMAN, Associated Press Roxana Hegeman, Associated Press 11 April 2011

WICHITA, Kan. – In a courtroom in Wichita, the day begins much as it has for the past 49 years: Court is in session, U.S. District Judge Wesley Brown presiding. But what happens next is no longer routine; it’s a testament to one man’s sheer determination.

As lawyers and litigants wait in respectful silence, Brown, who is 103, carefully steers his power wheelchair behind the bench, his stooped frame almost disappearing behind its wooden bulk. He adjusts under his nose the plastic tubes from the oxygen tank lying next to the day’s case documents. Then his voice rings out loud and firm to his law clerk, “Call your case.”

“I do it to be a public service,” Brown said. “You got to have a reason to live. As long as you perform a public service, you have a reason to live.”

[caption id=”attachment_675″ align=”aligncenter” width=”160″ caption=”Judge Brown Kansas “][/caption]
Brown is the oldest working federal judge in the nation, one of four appointees by President Kennedy still on the bench. Federal judgeships are lifetime appointments, and no one has taken that term more seriously than Brown.

“As a federal judge, I was appointed for life or good behavior, whichever I lose first,” Brown quipped in an interview. How does he plan to leave the post? “Feet first,” he says.

In a profession where advanced age isn’t unusual — and, indeed, is valued as a source of judicial wisdom — Brown has left legal colleagues awestruck by his stamina and devotion to work. His service also epitomizes how the federal court system keeps working even as litigation steadily increases, new judgeships remain rare, and judicial openings go unfilled for months or years.

“Senior judges keep the federal court system afloat given the rising case loads,” said David Sellers, spokesman for the Administrative Office of the U.S. Courts. Of the 1,294 sitting federal judges, Brown is one of 516 on “senior status,” a form of semi-retirement that allows a judge to collect his salary but work at a reduced case level if he chooses. They handle almost a quarter of federal district trials.

And no one alive has logged more service than Brown, who took senior status in 1979 but still worked full time until recently. In March, he stopped taking new criminal cases and lightened his case load a bit. He still takes his full share of the new civil cases.

“I will quit this job when I think it is time,” Brown said. “And I hope I do so and leave the country in better shape because I have been a part of it.”

Full Story Link

Excerpts from the American Geriatrics and British Geriatrics Society Clinical Practice Guideline for Prevention of Falls in Older Persons 2010

The complete guideline is published on the AGS website

SCREENING AND ASSESSMENT

1. All older individuals should be asked whether they have fallen (in the past year).
2. An older person who reports a fall should be asked about the frequency and circumstances of the fall(s).
3. Older individuals should be asked if they experience difficulties with walking or balance.
4. Older persons who present for medical attention because of a fall, report recurrent falls in the past year, or report difficulties in walking or balance (with or without activity curtailment) should have a multifactorial fall risk assessment.
5. Older persons presenting with a single fall should be evaluated for gait and balance.
6. Older persons who have fallen should have an assessment of gait and balance using one of the available evaluations.
7. Older persons who cannot perform or perform poorly on a standardized gait and balance test should be given a multifactorial fall risk assessment.
8. Older persons who have difficulty or demonstrate unsteadiness during the evaluation of gait and balance require a multifactorial fall risk assessment.
9. Older persons reporting only a single fall and reporting or demonstrating no difficulty or unsteadiness during the evaluation of gait and balance do not require a fall risk assessment.
10. The multifactorial fall risk assessment should be performed by a clinician (or clinicians) with appropriate skills and training.

Screening for Osteoporosis: U.S. Preventive Services Task Force Recommendation Statement

From the U.S. Preventive Services Task Force, Rockville, Maryland.

Abstract

Description: Update of the 2002 U.S. Preventive Services Task Force (USPSTF) recommendation on screening for osteoporosis.

Methods: The USPSTF evaluated evidence on the diagnostic accuracy of risk assessment instruments for osteoporosis and fractures, the performance of dual-energy x-ray absorptiometry and peripheral bone measurement tests in predicting fractures, the harms of screening for osteoporosis, and the benefits and harms of drug therapy for osteoporosis in women and men.

Recommendations: The USPSTF recommends screening for osteoporosis in women aged 65 years or older and in younger women whose fracture risk is equal to or greater than that of a 65-year-old white woman who has no additional risk factors. (Grade B recommendation)

The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for osteoporosis in men. (I statement)

Osteoporosis Screening Table USPSTF

Patient Population Under Consideration

This recommendation applies to older adults in the general U.S. population who do not have a history of an osteoporotic fracture, osteoporosis secondary to another condition, or other specific clinical indications for bone measurement testing. The USPSTF did not define a specific upper age limit for screening in women because the risk for fractures continues to increase with age and treatment harms remain no greater than small. Clinicians should take into account the patient’s remaining lifespan when deciding whether to screen patients with significant illness. In the Fracture Intervention Trial (1), the benefit of treatment emerged 18 to 24 months after initiation of treatment.

The quantity and quality of data on osteoporotic fracture risk other than hip fracture are much less for Asian, American Indian or Alaska Native, Hispanic, and black women than for white women. The USPSTF’s recommendation to screen women aged 65 years or older for osteoporosis applies to all racial and ethnic groups because the harms of the screening tests are no greater than small, the consequences of failing to identify and treat women who have low bone mineral density (BMD) are considerable, and the optimal alternative age at which to screen nonwhite women is uncertain.

Assessment of Risk

Multiple instruments to predict risk for low BMD and fractures have been developed and validated for use in postmenopausal women, but few have been validated for use in men. To predict fracture risk, the area under the receiver-operating characteristic curve ranges from 0.48 to 0.89 (2). Less complex instruments (that is, those with fewer variables) seem to perform as well as more complex ones (3). The USPSTF found no studies that assessed the effect on patient outcomes of using risk prediction instruments alone or in combination with bone measurement tests.

The USPSTF used the FRAX (Fracture Risk Assessment) tool (World Health Organization Collaborating Centre for Metabolic Bone Diseases, Sheffield, United Kingdom), available at www.shef.ac.uk/FRAX/, to estimate 10-year risks for fractures because this tool relies on easily obtainable clinical information, such as age, body mass index (BMI), parental fracture history, and tobacco and alcohol use; its development was supported by a broad international collaboration and extensively validated in 2 large U.S. cohorts; and it is freely accessible to clinicians and the public. The FRAX tool includes questions about previous DXA results but does not require this information to estimate fracture risk.

Based on the U.S. FRAX tool, a 65-year-old white woman with no other risk factors has a 9.3% 10-year risk for any osteoporotic fracture. White women between the ages of 50 and 64 years with equivalent or greater 10-year fracture risks based on specific risk factors include but are not limited to the following persons: 1) a 50-year-old current smoker with a BMI less than 21 kg/m2, daily alcohol use, and parental fracture history; 2) a 55-year-old woman with a parental fracture history; 3) a 60-year-old woman with a BMI less than 21 kg/m2 and daily alcohol use; and 4) a 60-year-old current smoker with daily alcohol use. The FRAX tool also predicts 10-year fracture risks for black, Asian, and Hispanic women in the United States. In general, estimated fracture risks in nonwhite women are lower than those for white women of the same age.

Although the USPSTF recommends using a 9.3% 10-year fracture risk threshold to screen women aged 50 to 64 years, clinicians also should consider each patient’s values and preferences and use clinical judgment when discussing screening with women in this age group. Menopausal status is one factor that may affect a decision about screening in this age group.

Considerations for Practice Regarding the I Statement

When deciding whether to screen men for osteoporosis, clinicians should consider the following factors.

Potential Preventable Burden

Bone measurement tests may potentially detect osteoporosis in a large number of men and prevent a substantial part of the burden of fractures and fracture-related illness in this population. The aging of the U.S. population is likely to increase this potentially preventable burden in future years.

Potential Harms

Potential harms of screening men are likely to be small and consist primarily of opportunity costs.

Current Practice

Routine screening of men currently is not a widespread practice.

Costs

Many additional DXA scanners may be required to screen sizeable populations of men for osteoporosis; DXA machines range in cost from $25 000 to $85 000.

Assuming that the relative benefits and harms of therapy in men are similar to those in women, the men most likely to benefit from screening would have 10-year risks for osteoporotic fracture equal to or greater than those of 65-year-old white women who have no additional risk factors. However, current evidence is insufficient to assess the balance of benefits and harms of screening for osteoporosis in men.

Screening Tests

The most commonly used bone measurement tests used to screen for osteoporosis are DXA of the hip and lumbar spine and quantitative ultrasonography of the calcaneus. Quantitative ultrasonography is less expensive and more portable than DXA and does not expose patients to ionizing radiation. Quantitative ultrasonography of the calcaneus predicts fractures of the femoral neck, hip, and spine as effectively as DXA. However, current diagnostic and treatment criteria for osteoporosis rely on DXA measurements only, and criteria based on quantitative ultrasonography or a combination of quantitative ultrasonography and DXA have not been defined.

Screening Intervals

The potential value of rescreening women whose initial screening test did not detect osteoporosis is to improve fracture risk prediction. A lack of evidence exists about optimal intervals for repeated screening and whether repeated screening is necessary in a woman with normal BMD. Because of limitations in the precision of testing, a minimum of 2 years may be needed to reliably measure a change in BMD; however, longer intervals may be necessary to improve fracture risk prediction. A prospective study of 4 124 women aged 65 years or older found that neither repeated BMD measurement nor the change in BMD after 8 years was more predictive of subsequent fracture risk than the original measurement (4).

Treatment

In addition to adequate calcium and vitamin D intake and weight-bearing exercise, multiple drug therapies are approved by the U.S. Food and Drug Administration to reduce fractures, including bisphosphonates, parathyroid hormone, raloxifene, and estrogen. The choice of therapy should be an individual one based on the patient’s clinical situation and the tradeoff between benefits and harms. Clinicians should provide patient education on how to use drug therapies to minimize adverse effects. For example, esophageal irritation from bisphosphonate therapy can be reduced by taking the medication with a full glass of water and by not lying down for at least 30 minutes afterward.

Other Approaches to Prevention

The USPSTF has updated its evidence review on falls prevention in older adults (2) and plans to issue an updated recommendation; in future months, the USPSTF also will issue a separate statement on the preventive effects of vitamin D and calcium supplements on osteoporotic fractures. When complete, these documents will be made available at www.uspreventiveservicestaskforce.org.

Useful Resources

The 10-year risk for osteoporotic fractures can be calculated for individuals by using the FRAX tool and could help to guide screening decisions for women younger than 65 years.

Summary guides for clinicians and patients on fracture prevention treatments for postmenopausal women who have osteoporosis are available from the Agency for Healthcare Research and Quality at http://effectivehealthcare.ahrq.gov. The recommendations in these guides may differ from those of the USPSTF because they were based on a systematic review that pooled data from trials that included women who had previous clinical fractures.

Other Considerations
Research Needs and Gaps

Given the absence of direct evidence that screening for osteoporosis reduces fracture-related morbidity or mortality, studies of long-term health outcomes of screened and nonscreened population groups are important. Research is needed to test the effectiveness of drug therapies for osteoporosis in men who do not have a history of fractures. The results of ongoing randomized trials of bisphosphonates for fracture prevention in men at high risk for fractures could help to assess whether these drugs are effective in men. Research to evaluate the outcome of screening women during periods of rapid bone loss (for example, during menopause) also should be supported.

Further research that would inform clinical decisions about screening for osteoporosis include studies to establish parameters for treatment using quantitative ultrasonography as a primary screening test for osteoporosis, studies that ascertain the true incidence of major osteoporotic fractures in nonwhite ethnic groups in the United States, studies clarifying optimal screening intervals, and studies of the effect of clinical and subclinical vertebral fractures on health-related quality of life.

Link to Full Article:
Ann Intern Med E-309published ahead of print January 17, 2011