[Optimization of calcium intake for the prevention of osteoporosis and osteoporotic fractures: a review of the evidence]. Development and delivery of patient treatment in the Trondheim Hip Fracture Trial. A new geriatric in-hospital pathway for elderly patients with hip fracture Hip fracture in elderly men: prognostic factors and outcomes. Cost-equivalence of different osteoporotic fractures Twelve-Months Follow-up in Forty-Nine Patients With Acute/Semiacute Osteoporotic Vertebral Fractures Treated Conservatively or With Percutaneous Vertebroplasty: A Clinical Randomized Study Osteoporosis prevalence and levels of treatment in primary care: the Australian BoneCare Study. Teriparatide Improves Fracture Healing and Early Functional Recovery in Treatment of Osteoporotic Intertrochanteric Fractures Interventions to improve inpatient osteoporosis management following first osteoporotic fracture: the PREVENT project Screening for Postmenopausal Osteoporosis: A Review of the Evidence for the U.S. Preventive Services Task Force LiDCO-based fluid management in patients undergoing hip fracture surgery under spinal anaesthesia: a randomized trial and systematic review. Randomized controlled trial of a primary care–based screening program to identify older women with prevalent osteoporotic vertebral fractures: Cohort for skeletal health in Bristol and Avon (COSHIBA) The cause of delirium in patients with hip fracture. Treatment of pain from osteoporotic vertebral collapse by percutaneous PMMA vertebroplasty Primary and secondary non-adherence to osteoporotic medications after hip fracture in Spain. The PREV2FO population-based retrospective cohort study Initial Outcome and Efficacy of “Kyphoplasty” in the Treatment of Painful Osteoporotic Vertebral Compression Fractures How the knowledge of fracture risk might influence adherence to oral therapy of osteoporosis in Italy: the ADEOST study A randomized clinical trial of the effectiveness of a discharge planning intervention in hospitalized elders with hip fracture due to falling. Rehabilitation in patients with dementia following hip fracture: a systematic review. Proximal femoral fractures: issues and challenges. Pharmacologic Treatment of Low Bone Density or Osteoporosis to Prevent Fractures: A Clinical Practice Guideline from the American College of Physicians Extra virgin olive oil consumption reduces the risk of osteoporotic fractures in the PREDIMED trial. The effect of homocysteine-lowering with B-vitamins on osteoporotic fractures in patients with cerebrovascular disease: substudy of VITATOPS, a randomised placebo-controlled trial Treatment of Low Bone Density or Osteoporosis to Prevent Fractures in Men and Women: A Clinical Practice Guideline Update From the American College of Physicians.
One of the main focuses of lifestyle modification for the prevention of osteoporosis and osteoporotic fractures  in Japan is improvement in dietary calcium intake . However , virtually no r and omized controlled trial to assess the preventive effects of administration of calcium on the risk of fractures has been conducted in Japan . In this study , we review ed all the scientific papers currently available from medical literature data bases to propose evidence -based recommendations on the preventive procedures for osteoporosis . The result of the present systematic review gives the evidence showing that calcium supplementation or optimal dietary calcium intake increases bone density in childhood and adolescence and reduces the risk of fracture due to osteoporosis in the elderly people regardless of the gender . The evidence also supports the current health policy guiding the elderly to increase their dietary calcium intake in daily life Background Hip fractures are common among frail elderly persons and often have serious consequences on function , mobility and mortality . Traditional treatment of these patients is performed in orthopedic departments without additional geriatric assessment . However , studies have shown that interdisciplinary geriatric treatment may be beneficial compared to traditional treatment . The aim of the present study is to investigate whether treatment of these patients in a Department of Geriatrics ( DG ) during the entire hospital stay gives additional benefits as compared to conventional treatment in a Department of Orthopaedic Surgery ( DOS ) . Findings A new clinical pathway for in-hospital treatment of hip fracture patients was developed . In this pathway patients were treated pre- and postoperatively in DG .  Comprehensive geriatric assessment  was performed as an interdisciplinary , multidimensional , systematic assessment of all patients focusing on each patient ’s capabilities and limitations as recommended in guidelines and systematic review s. Identification and treatment of co-morbidities , pain relief , hydration , oxygenation , nutrition , elimination , prevention and management of delirium , assessment of falls and osteoporosis were emphasized .  Discharge planning  started as early as possible . Initiation of rehabilitation with focus on early mobilisation and development of individual plans was initiated in hospital and continued after discharge from hospital . Fracture specific treatment was based upon st and ard treatment for the hospital , expert opinions and a review of the literature . Conclusion A new treatment program for old hip fracture patients was developed , introduced and run in the DG , the potential benefits of which being compared with traditional care of hip fracture patients in the DOS in a r and omised clinical trial OBJECTIVE To examine prognostic factors and outcomes after hip fracture in men aged 60 years and older . DESIGN AND SETTING Cohort study of all men presenting to St George Hospital ( a 650-bed tertiary care centre ) with hip fractures in 1995 , recruited retrospectively from medical records and evaluated prospect ively at six and 12 months after fracture . PATIENTS 51 men aged 60 years or more ( and , for comparison , 51 age-matched women ) who presented with hip fracture not caused by high impact injuries or local bone disease . MAIN OUTCOME MEASURES Prognostic factors ( such as pre-existing illness and osteoporotic risk factors ) and outcome data ( such as fracture-related complications , mortality , and level of function as measured by the Barthel index of activities of daily living at six and 12 months postfracture ) . RESULTS Median age of the 51 men was 80 years ( interquartile range , 74 - 86 years ) ; four were aged under 70 years . Outcome assessment was possible for 41 men ( 80 % ) . Similar proportions of men and women came from institutions ( 32 % v. 28 % ) , and similar additional proportions required institutionalisation after discharge ( 18 % v. 14 % ) . Fracture-related complications affected similar proportions of men and women ( 30 % v. 32 % ) , and mean length of hospital stay was similar . Fourteen per cent of men died in hospital compared with only 6 % of women ( P = 0.06 ) . Men had more risk factors for osteoporosis ( P < 0.01 ) . Physical functioning ( measured by the Barthel index ) deteriorated significantly in men from 14.9 at baseline to 13.4 at six months ( P < 0.05 ) and 12.4 at 12 months ( P < 0.05 ) after fracture . CONCLUSION Compared with women , elderly men presenting with hip fracture have higher mortality and have more risk factors for osteoporosis . Like women with hip fracture , men are usually fragile , with pre-existing medical illness and fracture-related complications contributing to their overall poor outcomes Methods Among 985 Olmsted County , Minnesota , residents who experienced an osteoporotic fracture ( distal forearm , humerus , clavicle/scapula/sternum , ribs , vertebrae , pelvis , hip , other femur or tibia/fibula [ the latter in women only ] ) , we estimated the incremental cost of direct medical care in the following year compared with age- and sex-matched controls without a fracture r and omly sample d from the same community . Results The overall median incremental ( case minus control ) cost in the succeeding year was $ 2390 , with a particularly high incremental cost for hip fractures ( $ 11,241 ) . There was fair concordance between the incremental cost of the different fractures , relative to hip fracture alone , and the previously published disutility associated with each fracture type relative to hip fracture . Overall , the incremental cost for all osteoporotic fractures combined was 46 % greater than that for hip fractures alone in women and 47 % greater in men . This is consistent with the earlier report that overall morbidity from all osteoporotic fractures combined is 47 % and 39 % greater in women and men , respectively , than the morbidity attributable solely to hip fractures . Conclusion These data lend support to the notion that other osteoporotic fractures can be quantified relative to hip fracture on the basis of their cost , as well as their morbidity and mortality . This may simplify health economic analyses by allowing all fracture outcomes to be modeled relative to hip fractures ( i.e. , hip fracture ' equivalents ' ) and will provide a more comprehensive assessment of osteoporosis outcomes than is possible by focusing only on hip fractures Study Design . Clinical r and omized study . Objective . Percutaneous vertebroplasty is compared to conservative treatment in patients with acute or subacute osteoporotic vertebral fractures with respect to pain , physical and mental outcomes . The risk of vertebral fractures adjacent to treated levels is assessed . Summary of Background Data . There are some disagreements of the benefits of PVP for the treatment of acute osteoporotic vertebral fractures , but the long-term clinical outcome of PVP compared to conservative treatment has not been evaluated in a r and omized study . Methods . The 3-months follow-up of this study has been published previously , and here we report the completed 12-months analysis . About 50 patients ( 41 females ) were included from January 2001 until January 2008 . Patients with vertebral fractures less than 8 weeks old were included and r and omized to either PVP or conservative treatment . Pain was assessed with a visual analogue scale . Physical and mental outcomes were assessed by vali date d question naires and tests . Tests , question naires , and plain radiographs were performed at the inclusion and after 3 and 12 months . Results . Pain score before and after the operation in the PVP group was 7.9 and 2.0 , respectively . There was no difference between the groups concerning pain at the 3- and 12-months follow-up . Supplementary assessment of back pain 1 month after discharge from hospital showed a significant lower VAS score in the PVP group over the conservative group . In the study period , 2 adjacent fractures in the PVP group and no adjacent fractures in the conservative group were registered . Conclusion . PVP is a good treatment for some patients with acute/subacute painful osteoporotic vertebral fractures , but the majority of fractures will heal after 8 to 12 weeks of conservative treatment with subsequent decline in pain . The risk of new fractures needs further research UNLABELLED The level of recognition and treatment of osteoporosis is not well characterized in primary care . In data from a large sample of postmenopausal women attending 927 primary care physicians , 29 % of women reported one or more fractures after menopause . The great majority ( 72 % ) were not on any osteoporosis-specific therapy . INTRODUCTION Osteoporosis is often first recognized at the time of a low-trauma fracture . However , by this stage , the risk of subsequent fractures has already risen substantially . Moreover , in many countries , only a small proportion of women , who have already sustained fractures , receive a treatment shown to reduce this increased risk of further fractures . MATERIAL S AND METHODS This project was initiated to examine the prevalence of osteoporotic fractures , risk factors for osteoporosis , and use of antifracture therapy among postmenopausal Australian women . More than 88,000 women from 927 primary care physicians returned over 69,358 surveys . Of these , 57,088 reported the presence of a postmenopausal fracture or risk factors . RESULTS Among these r and omly selected postmenopausal women , 29 % reported having had one or more low-trauma fractures after menopause ( 44 % substantiated in current records ) . One-third of these women reported multiple fractures . The prevalence of all types of fractures , except rib and ankle , increased with age and low body weight . Those who reported fractures were also more likely to report early menopause , corticosteroid use , and a family history of osteoporosis . Moreover , those with vertebral fractures were more likely to record height loss , kyphosis , and back pain . Physical inactivity , low calcium intake , and smoking had no consistent relationship with any fracture outcome . Of the women who reported a fracture after menopause , only 28 % were on any specific therapy for osteoporosis , and 7 % were on calcium alone . Of those who had been told they had osteoporosis by a doctor , 40 % were receiving specific osteoporosis therapy . CONCLUSIONS In this large study of postmenopausal Australian women attending primary care physicians , 29 % reported at least one low-trauma fracture after menopause . Less than one-third of these women were on specific treatment for osteoporosis , and only 40 % were ever told they had osteoporosis . Therefore , osteoporotic fractures are common in postmenopausal Australian women , and few , despite their substantially increased risk of further fractures , are on any specific anti-osteoporotic therapy . These data support the need for more effective education for the community and medical practitioners of the clinical significance of osteoporotic fractures and alternatives for treatment Abstract Osteoporotic intertrochanteric fractures result in serious health problems and decrease health-related quality of life ( HRQoL ) . Faster time-to-union is important for early return to daily activities and reduction of complications . Teriparatide has been shown to accelerate fracture healing , but the literature is sparse on this topic . The aim of this study is to assess whether teriparatide accelerates fracture healing .  Between 2008 and 2014 , patients with osteoporotic intertrochanteric fractures who underwent surgical interventions were enrolled in this retrospective cohort study . Group 1 included patients who were not on any osteoporosis medication prior to fracture and who postoperatively received only calcium and vitamin D ; patients in Group 2 were not on any osteoporosis medication prior to fracture  , and received teriparatide and calcium and vitamin D postoperatively .  Patients in Group 3 were those who were on alendronate prior to fracture and postfracture received teriparatide as well as calcium and vitamin D.  Demographics , time-to-union , HRQoL ( short-form health survey [SF]-12 physical component summary [ PCS ] and SF-12 mental component summary [ MCS ] ) , morbidities , mortalities , and radiographic and functional outcomes between groups were compared . A total of 189 patients were enrolled in this study . There were 83 patients in Group 1 , 47 patients in Group 2 , and 59 patients in Group 3 . A significantly shorter time-to-union was found in the teriparatide-treated groups ( mean , 13.6 , 12.3 , and 10.6 weeks , respectively [ P = 0.002 ] ) . With regard to SF-12 PCS , the scores were significantly better in teriparatide-treated groups at 3 months ( mean , 19 , 28 , and 29 , respectively [ P = 0.002 ] ) and 6 months ( mean , 28 , 37 , and 38 , respectively [ P = 0.008 ] ) . Similar inter-group differences were noted when comparing the pain scores , the ability to get around the house , the ability to get out of the house , and the ability to go shopping at 3 and 6 months . Complications and mortality were also markedly reduced in the teriparatide-treated groups . Postoperative use of teriparatide for 6 months appears to be an effective adjunct therapy in the treatment of patients with osteoporotic intertrochanteric fractures . However , because of the limited power of the study , a prospect i ve , r and omized , large-scale cohort study is still required for determining the efficacy of teriparatide Objectives To establish a protocol for the treatment of  fragility fractures in the hospital setting based on treatment of osteoporosis . Material s and methods An intervention protocol was implemented in patients with fragility fractures based on ( 1 ) indicating the diagnosis of osteoporotic fracture in the summary of discharge ; ( 2 ) “ lifestyle recommendations ” ; and ( 3 ) therapy for osteoporosis .  Thirty-one hospitals were involved and they were informed of the importance of protocol compliance . In the first phase , a retrospective study was conducted to establish the number of low-energy fractures treated and the percentage of them that had complied with the protocol ( n = 887 ) . Then , prospect ively , the same data were collected for the patients managed for 1 year ( n = 6,826 ) in three sections of 4-month intervals . Results The percentage of compliance increased from 8.2 to 57.2 % in the first point , from 12.6 to 42.4 % in the second , and from 10.3 to 43.2 % in the third . Conclusion The implementation of programs to improve osteoporosis treatment is very useful for ensuring adherence in the management of osteoporosis following admission due to fragility fracture Half of all postmenopausal women will have an osteoporosis-related fracture during their lives , including one quarter who will develop a vertebral deformity ( 1 ) and 15 % who will suffer a hip fracture ( 2 ) . Hip fractures are associated with high mortality rates and loss of independence ( 3 , 4 ) . Although many vertebral fractures are detected only incidentally on radiography , some cause severe pain , leading to 150 000 hospital admissions per year in persons older than 65 years of age , 161 000 physician office visits , and more than 5 million days of restricted activity in those 45 years of age or older ( 5 ) . Low bone density has been used to predict risk for fractures as well as to diagnose osteoporosis . Osteoporosis has been defined as a systemic skeletal disease characterized by low bone mass and microarchitectural deterioration of bone tissue , leading to enhanced bone fragility and a consequent increase in fracture risk ( 6 , 7 ) . This definition emphasizes that , in addition to bone mass , the structure of bone is an important factor in the pathogenesis of fractures . A World Health Organization working group ( 8) proposed that osteoporosis should be diagnosed in epidemiologic studies when  bone mineral density  is 2.5 SDs or more below the mean for healthy young adult women at the spine , hip , or wrist ( corresponding to a T-score 2.5 ) or when patients have a history of atraumatic fracture ( 9 ) . By the World Health Organization definition , up to 70 % of women older than 80 years of age have osteoporosis ( 10 ) . Age is also an important factor in the relationship between bone density and the absolute risk for fracture . Older women have a much higher fracture rate than younger women with the same bone density because of increasing risk from other factors , such as bone quality and tendency to fall ( 11 ) . Despite the high prevalence of osteoporosis and the effect of fractures on mortality , independence , and quality of life , it is not clear whether it is appropriate to screen asymptomatic postmenopausal women . Recent systematic review s and guidelines disagree about which women should be screened and when ( 12 - 20 ) . This disagreement reflects , in part , gaps in the evidence . For example , most guidelines recommend using risk factors to select patients for bone density testing , but because of inadequate data there is no consensus on which risk factors to use . As part of the U.S. Preventive Services Task Force up date of its 1996 recommendation ( 21 ) , we examined evidence on the benefits and harms of screening postmenopausal women for osteoporosis . Specifically , we addressed the role of risk factors in identifying high-risk women , techniques of bone density testing to identify fracture risks , effectiveness of treatment in reducing fracture risk , and harms of screening and treatment . Methods Additional methods used for this review , including determination of the quality of studies ( 22 ) , are detailed in Appendix Tables 1 , 2 , and 3 and in a separate report ( 23 ) . The analytic framework and key questions are detailed in the Appendix Figure . Relevant studies were identified from multiple search es of MEDLINE ( 1966 to May 2001 ) , HealthSTAR ( 1975 to May 2001 ) , and Cochrane data bases ; reference lists of systematic review s ; and experts . We also sent letters to manufacturers of bone density devices requesting additional information about the performance of their instruments , but we received no new data . Two review ers read each abstract to determine its eligibility . We included English- language abstract s that contained original data about postmenopausal women and osteoporosis and addressed screening or the effectiveness of risk factor assessment , bone density testing , or treatment . We considered screening to be the process of assessing postmenopausal women without known osteoporosis for risk of osteoporotic fractures by identification of risk factors , including low bone density . Postmenopausal women were those who had experienced surgical or natural menopause , regardless of age . Women with preexisting atraumatic fractures were not considered in the screening population because they had confirmed osteoporosis according to the World Health Organization definition . For studies of prediction , we selected articles that reported the relationship between risk factor assessment methods or bone density tests and bone density , bone loss , or fractures . We review ed studies of medications used for treatment and present results for bisphosphonates . We focused on r and omized , controlled trials of therapies reporting radiographically verified , nontraumatic fracture outcomes because fractures are a stronger measure of effectiveness than bone density . We excluded studies of primary prevention of osteoporosis , such as the role of nutrition , calcium consumption , and physical activity . We also excluded secondary causes of osteoporosis , such as corticosteroid use and certain chronic diseases , and studies that did not provide sufficient information to allow determination of the method for selecting patients and for analyzing data . Investigators read the full-text versions of the retrieved papers and reapplied the initial eligibility criteria . To assess the internal validity of individual studies , we applied a set of criteria developed by the third U.S. Preventive Services Task Force ( Appendix Table 1 ) ( 22 ) . In this paper , we highlight studies that are applicable to current practice st and ards , have high- quality internal validity ratings , and are most generalizable to the U.S. population of postmenopausal women under consideration for screening . We created an outcomes table to summarize the number of  hip and vertebral fractures  prevented based on age-specific prevalence rates and treatment effects obtained from results of the review ed studies . We conducted a sensitivity analysis to determine the influence of risk factors on the number needed to screen . This research was funded by the Agency for Healthcare Research and Quality under a contract to support the work of the U.S. Preventive Services Task Force . Agency staff and Task Force members participated in the initial design of the study and review ed interim analyses and the final manuscript . Additional reports were distributed for review to content experts and revised accordingly before preparation of this manuscript ( 23 , 24 ) . The authors are responsible for the content of the manuscript and the decision to su bmi t it for publication . Results Studies of Screening We identified no studies about the effectiveness of screening in reducing osteoporotic fractures . Without direct evidence from screening studies , recommendations about screening need to rely on evidence that risk factor assessment or bone density testing can adequately identify women who could ultimately benefit from treatment . Risk Factor Assessment Hundreds of studies report associations between risk factors and low bone density and fractures in postmenopausal women ( 24 ) . The most comprehensive study of risk factors in a U.S. population is the Study of Osteoporotic Fractures , a good- quality prospect i ve study of 9516 women 65 years of age and older ( 25 ) . In this study , 14 clinical risk factors were identified as significant predictors of hip fracture in multivariable models ( age ; maternal hip fracture ; no weight gain ; height ; poor self-rated health ; hyperthyroidism ; current use of benzodiazepines , anticonvulsants , or caffeine ; not walking for exercise ; lack of ambulation ; inability to rise from a chair ; poor scores on two measures of vision ; high resting pulse ; and any fracture since 50 years of age ) . The relative risk for hip fracture per decrease of 1 SD in calcaneal bone density was 1.6 ( 95 % CI , 1.3 to 1.9 ) . This was comparable to the magnitude of the relative risks of most of the other significant predictors in the model , which ranged from 1.2 to 2.0 . Women with at least 5 of the 14 risk factors had increased rates of hip fractures compared with those who had 0 to 2 risk factors at all levels of calcaneal bone density . To determine which risk factors could be important in women younger than 65 years of age , we review ed eight observational studies of risk factors and fractures of various types conducted in population s in which at least 50 % of participants were younger than 65 years of age . Table 1 lists risk factors that were statistically significant predictors for fractures in multivariable models ( 26 - 33 ) . These results could not be quantitatively combined because risk factors were defined differently in each study . Table 1 . Risk Factors for Fractures in Women 5065 Years of Age Results of risk factor studies have been used to assess risk in individuals . We identified 10 cross-sectional studies that described methods of determining risk for low bone density for individual women based on selected clinical risk factors ( Table 2 ) ( 34 - 43 ) . The most common method ologic limitations of these studies are lack of validation and lack of generalizability because of small numbers of patients or nonrepresentative patients . We also identified 8 studies of clinical risk factors to determine fracture risk ( Table 2 ) ( 44 - 51 ) . None of these studies received a good rating for internal validity . Four studies evaluated hip fracture outcomes , two evaluated vertebral fractures , and two evaluated all types of fractures . These studies described the association of risk factors with fractures known to have occurred already ( four casecontrol studies ) or how well they would predict fractures in the future ( four prospect i ve cohort studies ) . Table 2 . Studies of Risk Factor Assessment A recent study compared the performance of five clinical decision rules for bone density testing among 2365 postmenopausal women 45 years of age or older who were enrolled in a community-based study of osteoporosis in Canada ( 52 ) . These rules included guidelines from the National Osteoporosis Foundation ( 53 ) ; the Simple Calculated Osteoporosis Risk Estimation ( SCORE ) rule ( age , weight , ethnicity , estrogen use , BACKGROUND Hip fracture is a condition with high mortality and morbidity in elderly frail patients . Intraoperative fluid optimization may be associated with benefit in this population . We investigated whether intraoperative fluid management using pulse-contour analysis cardiac monitoring , compared with st and ard care in patients undergoing spinal anaesthesia , would provide benefits in terms of reduced time until medically fit for discharge and postoperative complications . METHODS Patients undergoing surgical repair of fractured neck of femur , aged > 60 yr , receiving spinal anaesthesia were enrolled in this single-centre , blinded , r and omized , parallel group trial . Patients were allocated to either anaesthetist-directed fluid therapy or a pulse-contour-guided fluid optimization strategy using colloid ( Gelofusine ) boluses to optimize stroke volume . The primary outcome was time until medically fit for discharge . Secondary outcomes included postoperative complications , mobility , and mortality . We up date d a systematic review to include relevant trials to 2014 . RESULTS We recruited 130 patients .  Time until medically fit for discharge was similar in both groups , mean [ 95 % confidence interval ( CI ) ] 12.2 ( 11.1 - 13.5 ) vs 13.1 ( 11.9 - 14.5 ) days ( P=0.31 ) , as was total length of stay 14.2 ( 12.9 - 15.8 ) vs 15.3 ( 13.8 - 17.2 ) days ( P=0.32 ) . There were no significant differences in complications , function , or mortality . An up date d meta- analysis ( four studies , 355 patients ) found non-significant reduction in early mortality [ relative risk 0.66 ( 0.24 - 1.79 ) ] and in-hospital complications [ relative risk 0.80 ( 0.61 - 1.05 ) ] . CONCLUSIONS Goal -directed fluid therapy during hip fracture repair under spinal anaesthesia does not result in a significant reduction in length of stay or postoperative complications . There is insufficient evidence to either support or discount its routine use . CLINICAL TRIAL REGISTRATION IS RCT N88284896 Approximately 12 % of postmenopausal women have osteoporotic vertebral fractures ( VFs ) ; these are associated with excess morbidity and mortality and a high risk of future osteoporotic fractures . Despite this , less than one-third come to clinical attention , partly due to lack of clear clinical triggers for referral for spinal radiographs . The aim of this study was to investigate whether a novel primary care – based screening tool could be used to identify postmenopausal women with osteoporotic VFs and increase appropriate management of osteoporosis . A r and omized controlled trial was undertaken in 15 general practice s within the Bristol area of the UK . A total of 3200 women aged 65 to 80 years were enrolled , with no exclusion criteria . A simple screening tool was carried out by a nurse in primary care to identify women at high risk of osteoporotic VFs . All identified high-risk women were offered a diagnostic thoracolumbar radiograph . Radiographs were reported using st and ard National Health Service ( NHS ) reporting , with results sent back to each participant 's general practitioner ( GP ) . Participants in the control arm did not receive the screening tool or radiographs . The main outcome measure was self-reported prescription of medication for osteoporosis at 6 months with a r and om 5 % sub sample verified against electronic GP records . Secondary outcome was self-reported incidence of new fractures . Results showed that allocation to screening increased prescription of osteoporosis medications by 124 % ( odds ratio [ OR ] for prescription 2.24 at 6 months ; 95 % confidence interval [ CI ] , 1.16 to 4.33 ) . Allocation to screening also reduced fracture incidence at 12-month follow-up ( OR for new fracture 0.60 ; 95 % CI , 0.35–1.03 ; p = 0.063 ) , although this did not reach statistical significance . This study supports the use of a simple screening tool administered in primary care to increase appropriate prescription of medications for osteoporosis in postmenopausal women in the UK . © 2012 American Society for Bone and Mineral OBJECTIVES To ascertain the most common causes of delirium , to establish the initiation and timing of delirium , and to determine the duration of delirium in patients with hip fracture . METHODS Five hundred seventy-one ( 88 % ) of 650 patients with hip fracture admitted to 4 New York City hospitals were prospect ively interviewed on a daily basis , 5 days a week , with the Confusion Assessment Method for the presence of delirium . The patients were enrolled within 48 hours of admission . Their medical charts and the data collected by the study staff were review ed and summarized . Two of us ( R.S.M. and A.L.S. ) review ed the case summaries independently and assigned a cause based on a previously developed classification system , estimated the onset of the delirious episode , and determined whether the delirium had cleared , improved , or persisted at discharge . Subsequently , discrepancies in cause , timing of initiation , and mental status on discharge between the 2 physicians review ers were discussed until consensus was reached . RESULTS The prevalence of delirium was 9.5 % ( 54/ 571 ; 95 % confidence interval , 7.0 - 11.9 ) . Seven percent of episodes were assigned a definite cause , 20 % a probable cause , 11 % a possible cause , and 61 % were attributable to 1 or more comorbid conditions . Twenty-eight ( 53 % ) of 54 subjects developed delirium after surgery . The delirium had cleared or improved in 40 ( 74 % ) of 54 subjects at the time of discharge . CONCLUSIONS Delirium in patients with hip fracture appears to be a different syndrome from that observed in patients who are otherwise medically ill ; it also appears to follow a different clinical course . These results have important implication s for the management of delirium in patients with hip fracture Summary Background . Vertebral compression fractures are common complications in advanced osteoporosis . In general , this disease of the elderly patient is characterized by severe local back pain . Pathophysiologically , bony instability triggers local pain during body movement . Serious pain immobilizes the patients and forces them to bed rest . As a result , complications like thrombosis or pneumonia occur . Invasive treatment with surgical instrumentation for vertebral stabilization is not indicated in elderly patients especially with additional diseases . The purpose of this study was to test the hypothesis that percutaneous polymethylmethacrylate ( PMMA ) vertebroplasty significantly reduces pain due to vertebral collapse in osteoporotic patients and improves quality of life . Methods . A total of 38 patients with osteoporotic vertebral compression fractures of the thoracic and lumbar spine were treated by PMMA vertebroplasty . After admission , before discharge from the hospital , six weeks , half a year and one year later patients answered the Oswestry Low Back Pain Disability ( OLBPD ) Question naire for assessment of treatment related change in disability . In all patients percutaneous vertebroplasty was performed under local anesthesia . Findings . A total of 92 % of patients reported a significant pain reduction immediately after treatment . Also one year after vertebroplasty pain remained significantly reduced .  Vertebroplasty was highly beneficial for patients with pain related to local instability of the spine . Extravasation of PMMA beyond the vertebral margins was observed in 26 % of the cases . No treatment related clinical or neurological complications were noticed . Interpretation . PMMA vertebroplasty is a useful and safe method of pain relief which rapidly regains quality of life for patients with osteoporotic vertebral compression Osteoporotic medication after hip fracture is widely recommended by clinical practice guidelines , and medication adherence is essential to meet clinical trial risk reduction figures in the real world . We assessed primary and secondary non-adherence to osteoporosis medications  in patients discharged following a hip fracture and identified factors associated with secondary non-adherence . From a population -based retrospective cohort of 19,405 patients aged 65 years and over discharged from a hip fracture in the region of Valencia ( Spain ) from January 1 , 2008 and June 30 , 2012 , we followed , over a minimum of 365 days , 4,856 patients with at least one osteoporotic medication prescribed within the first six months after discharge . Less than one third of the patients discharged alive after a hip fracture received osteoporotic treatment .  Primary non-adherence among naïve patients was low . However , long-term secondary adherence measured by Proportion of Days Covered with medication ( PDC ) and persistence was largely suboptimal , with naïve users having worse results than experienced patients . Secondary non-adherence was associated with primary non-adherence and age , dementia or sedative treatments for naïve users and with being male , being older than 85 and having dementia for experienced users . Three quarters of naïve users and two thirds of experienced users had interrupted treatment at 48 months Study Design . An Institutional Review Board-approved Phase I efficacy study of inflatable bone tamp usage in the treatment of symptomatic osteoporotic compression fractures . Objectives . To evaluate the safety and efficacy of inflatable bone tamp reduction and cement augmentation , “ kyphoplasty , ” in the treatment of painful osteoporotic vertebral compression fractures . Summary of Background Data . Osteoporotic compression fractures can result in progressive kyphosis and chronic pain . Traditional treatment for these patients includes bed rest , analgesics , and bracing . Augmentation of vertebral compression fractures with polymethylmethacrylate , “ vertebroplasty , ” has been used to treat pain . This technique , however , makes no attempt to restore the height of the collapsed vertebral body . Kyphoplasty is a new technique that involves the introduction of inflatable bone tamps into the vertebral body . Once inflated , the bone tamps restore the vertebral body back toward its original height while creating a cavity that can be filled with bone cement . Patients and Methods . Seventy consecutive kyphoplasty procedures were performed in 30 patients . The indications included painful primary or secondary osteoporotic vertebral compression fractures . Mean duration of symptoms was 5.9 months . Symptomatic levels were identified by correlating the clinical data with MRI findings . Perioperative variables and bone tamp complications or issues were recorded and analyzed . Preoperative and postoperative radiographs were compared to calculate the percentage height restored . Outcome data were obtained by comparing preoperative and latest postoperative SF-36 data . Results . At the completion of the Phase I study there were no major complications related directly to use of this technique or use of the inflatable bone tamp . In 70 % of the vertebral bodies  kyphoplasty  restored 47 % of the lost height . Cement leakage occurred at six levels ( 8.6 % ) . SF-36 scores for Bodily Pain 11.6–58.7 , ( P = 0.0001 ) and Physical Function 11.7–47.4 , ( P = 0.002 ) were among those that showed significant improvement . Conclusions . The inflatable bone tamp was efficacious in the treatment of osteoporotic vertebral compression fractures .  Kyphoplasty is associated with early clinical improvement of pain and function as well as restoration of vertebral body height in the treatment of painful osteoporotic compression fractures Abstract Summary The patients ’ adherence to osteoporosis treatments is low . In our study population a history of osteoporotic fractures was associated to better compliance and persistence ; however , a 12-month r and omized study carried out on 816 osteoporotic women showed that providing the patients with their individual fracture risk information did not prove effective . Purpose Several drugs are currently available for the treatment of osteoporosis , but the patients ’ compliance and persistence with these treatments are low . This study aim ed to both analyze the adherence to oral osteoporosis medications among Italian osteoporotic patients ( cross-sectional study ) and evaluate if providing patients with their individual fracture risk information may improve compliance and persistence ( prospect i ve study ) . Methods A total of 3379 osteoporotic patients referred as out patients for a visit 1 year after receiving a prescription of oral osteoporosis medications for the first time , were enrolled for the retrospective study . Moreover , 816 postmenopausal women receiving an oral prescription for osteoporosis for the first time , were r and omized into two groups : group 1 ( managed according to st and ard clinical practice ) and group 2 ( managed with greater patient involvement and information on the individual risk of major osteoporotic fractures calculated by DeFRA algorithm ) . Results In the retrospective study , a history of osteoporotic fractures , the frequency of drug administration and a condition of being overweight/obese had a significant influence on both compliance and persistence . Of the 816 patients enrolled in the longitudinal study , 731 ( 374 of group 1 and 357 of group 2 ) attended the 1 year follow-up visit . The percentage of women with high compliance or persistence was greater in group 2 ( 64.2 vs. 58.1 % and 66.8 vs. 62.6 % , respectively ) , but without reaching any statistical significance . Conclusions Although providing the patients with their individual fracture risk information was not statistically effective , further studies on additional interventions able to improve the patients ’ perceived risk of fracture are warranted AIM The objective of this study was to examine the effectiveness of a  discharge plan  in hospitalized elderly patients with hip fracture due to falling . BACKGROUND Hip fractures are an important cause of morbidity and mortality among older people . Hip fracture patients require ongoing medical and long-term care services . Discharge plan services can play a very important role for these patients , since the services improved their outcome conditions . METHODS Hip fracture patients aged 65 years and older ( n = 126 ) , hospitalized due to falling and discharged from a medical centre in northern Taiwan , were r and omly assigned to either a comparison group ( the routine care ) or experimental group ( the discharge planning intervention ) . The outcomes used to determine the effectiveness of the intervention were : length of hospitalized stay , rate of readmission , repeat falls and survival , and activities of daily living . RESULTS The discharge planning intervention  decreased length of stay , rate of readmission and rate of survival and improved activities of daily living for intervention group compared with those of control group . Mean total SF-36 scores of patients in the experimental group were higher than for the control group and both groups had improved quality of life . CONCLUSION The discharge planning benefited older people with hip fractures . RELEVANCE TO CLINICAL PRACTICE A discharge planning intervention by a nurse can improve physical outcomes and quality of life in hip fracture patients PURPOSE Best rehabilitation practice s after hip fracture for people with dementia have not been established . A systematic review was conducted to determine current evidence for rehabilitation in this population , including residents in continuing care . METHODS St and ardized review methodology was used to search eight data bases for literature on  hip-fracture rehabilitation for people with dementia . Eligible studies included participants with dementia who had a hip fracture ; performed a rehabilitation intervention ; and evaluated one or more of function , ambulation , discharge location , or falls . The Newcastle-Ottawa Scale was used to assess validity . RESULTS A total of 13 studies were included : five r and omized controlled trials ( RCTs ) , seven prospect i ve cohort series , and one retrospective cohort study . Average quality ratings for RCTs and cohort studies were good and fair respectively . Participants with mild to moderate dementia receiving rehabilitation showed similar relative gains in function to those without dementia . Only one study examined the effect of rehabilitation among residents in continuing care . CONCLUSIONS People with mild or moderate dementia may show improved function and ambulation and decreased fall risk after rehabilitation post hip fracture , similar to gains achieved by those without dementia . More research is required to ascertain the effect of rehabilitation in people with moderate to severe dementia , including those residing in continuing-care setting s. Purpose : Best rehabilitation practice s after hip fracture for people with dementia have not been established . A systematic review was conducted to determine current evidence for rehabilitation in this population , including residents in continuing care . Methods : St and ardized review methodology was used to search eight data bases for literature on hip-fracture rehabilitation for people with dementia . Eligible studies included participants with dementia who had a hip fracture ; performed a rehabilitation intervention ; and evaluated one or more of  function , ambulation , discharge location , or falls . The Newcastle – Ottawa Scale was used to assess validity . Results : A total of 13 studies were included : five r and omized controlled trials ( RCTs ) , seven prospect i ve cohort series , and one retrospective cohort study . Average quality ratings for RCTs and cohort studies were good and fair respectively . Participants with mild to moderate dementia receiving rehabilitation showed similar relative gains in function to those without dementia . Only one study examined the effect of rehabilitation among residents in continuing care . Conclusions : People with mild or moderate dementia may show improved function and ambulation and decreased fall risk after rehabilitation post hip fracture , similar to gains achieved by those without dementia . More research is required to ascertain the effect of rehabilitation in people with moderate to severe dementia , including those residing in continuing-care setting Proximal femur fractures ( PFF ) , place a heavy dem and on orthopaedic departments worldwide . In Engl and it is estimated that by year 2020 , 100,000 patients annually with PFF will require surgical fixation . There are unique challenges as those with PFF are older , by definition have increased co-morbidities and predisposition factors and conditions such as osteoporosis . It is of note that globally around 13 % of the population are over 65 years of age and not surprisingly 1.6 million hip fractures are secondary to osteoporosis . Interestingly , besides osteoporosis , while many other factors have been suggested to increase the risk of PFF , in Europe a high BMI decreases the incidence of hip fractures . Despite a number of initiatives , advances and guidelines that have been implemented disappointingly mortality for PFF has not changed significantly in 40 years . For this reason , PFF remain a focused topic for both commissioners and providers of health care and for the clinicians a subject of ongoing research activity . Optimising patient ’s pre and post-surgery , has been reinforced by NICE guidelines and target driven hospital remuneration in an attempt to reduce mortality , which is estimated to be 10 % at 30 days and 31 % at 3 months . Thus , early identification and the ability to predict those patients who are likely to have adverse postoperative outcomes is critical . It enables a focus of re sources and the use of adjunctive therapies . Hu et al ’s meta- analysis showed that such factors have been identified as predictive of high mortality as advanced age , male gender , nursing home or facility residence , poor preoperative walking capacity , poor activities of daily living , higher ASA grading , poor mental state , multiple co morbidities , dementia or cognitive impairment , diabetes , cancer and cardiac disease . At five years post-surgical fixation , Abbreviated Mental Test Score , mobility and living circumstances have a predicted value in mortality . Some of these factors can be identified from simply good admission clerking . Not surprisingly therefore , st and ard proforma ’s have been introduced in a number of countries to facilitate good clerking and co-ordination of a multidisciplinary approach . Nonetheless , there is lack of a large prospect i ve study establishing whether this translates into improved patient outcomes . With pressure on re sources , two hospitals in Engl and have adopted efficiency ideology from the car manufacturer Toyota , known as the ‘ ‘ Lean ’ ’ principle . It aims to improve outcomes of care at key stages of hip fracture management . Essentially the patients are aggressively moved through the patient journey from presentation to discharge , through a multidisciplinary approach aim ed at optimisation physiologically and socially to return The National Institutes of Health 's consensus conference ( 1 ) defined osteoporosis as a skeletal disorder characterized by compromised bone strength predisposing to an increased risk for fracture . Bone strength reflects the integration of two main features : bone density and bone quality .Bone quality refers to architecture , turnover , damage accumulation ( e.g. , microfractures ) , and mineralization . Although osteoporosis can affect any bone , the hip , spine , and wrist are most likely to be affected . Osteoporosis affects an estimated 44 million Americans or 55 % of people 50 years of age or older . Another 34 million Americans are estimated to have low bone mass , meaning that they are at an increased risk for osteoporosis . Osteoporosis can be diagnosed by the occurrence of fragility fracture . In patients without fragility fracture , osteoporosis is often diagnosed by low bone density .  Dual x-ray absorptiometry ( DXA ) is the current gold st and ard test for diagnosing osteoporosis in people without an osteoporotic fracture .  Dual x-ray absorptiometry results are scored as st and ard deviations ( SDs ) from a young healthy norm ( usually female ) and reported as T-scores . For example , a T-score of 2 indicates a bone mineral density that is 2 SDs below the comparative norm . The international reference st and ard for the description of osteoporosis in postmenopausal women and in men age 50 years or older is a femoral neck bone mineral density of 2.5 SD or more below the young female adult mean ( 2 ) . Low bone density , as measured by DXA , is an imperfect predictor of fracture risk , identifying fewer than half the people who go on to have an osteoporotic fracture . Screening guidelines for women are well established ( 3 ) , and the American College of Physicians ( ACP ) recently published guidelines on screening for men ( 4 ) . This guideline presents the available evidence on various pharmacologic treatments to prevent fractures in men and women with low bone density or osteoporosis . Medications used to treat osteoporosis may affect different parts of the skeletal system differently , and efficacy for vertebral fractures does not necessarily imply efficacy for nonvertebral fractures . The target audience for this guideline is all clinicians and the target patient population is all adult men and women with low bone density or osteoporosis . These recommendations are based on the systematic evidence review by MacLean and colleagues ( 5 ) and the Agency for Healthcare Research and Quality sponsored Southern California Evidence -Based Practice Center evidence report ( 6 ) . The drugs currently approved for prevention of osteoporosis include alendronate , ib and ronate , risedronate , zoledronic acid , estrogen , and raloxifene . The drugs currently approved for treatment of osteoporosis include alendronate , ib and ronate , risedronate , calcitonin , teriparatide , zoledronic acid ( in postmenopausal women ) , and raloxifene . Testosterone , pamidronate , and etidronate are not approved by the U.S. Food and Drug Administration for the treatment or prevention of osteoporosis . Methods The literature search done by MacLean and colleagues for the systematic review ( 5 ) included studies from MEDLINE ( 1966 to December 2006 ) , the ACP Journal Club data base , the Cochrane Central Register of Controlled Trials ( no date limits ) , the Cochrane Data base of Systematic Review s ( no date limits ) , Web sites of the United Kingdom National Institute of Health and Clinical Excellence ( no date limits ) , and the United Kingdom Health Technology Assessment Program ( January 1998 to December 2006 ) . The review ers limited their search to English- language publications and human studies . They derived evidence for comparative benefits of various treatments exclusively from r and omized , controlled trials , whereas they included evidence from other types of studies for short- and long-term harms . Two physicians independently abstract ed data about study population s , interventions , follow-up , and outcome ascertainment by using a structured form . For each group within a r and omized trial , a statistician extracted the sample size and number of persons reporting fractures . Two review ers , under the supervision of the statistician , independently abstract ed information about adverse events . The statistician or the principal investigator resolved disagreements . This guideline is based on an evaluation of 76 r and omized , controlled trials , 4 of which were identified in the up date d search , and 24 meta-analyses that were included in the efficacy analyses . The analyses of adverse events included 491 articles , representing 417 r and omized trials , 25 other controlled clinical trials , 11 open-label trials , 31 large observational studies , and 9 case reports of osteonecrosis among bisphosphonate users . MacLean and colleagues ' background article ( 5 ) includes details about the methods used for the systematic evidence review . The ACP rates the evidence and recommendations by using the Grading of Recommendations , Assessment , Development , and Evaluation ( GRADE ) system with minor modifications ( Table 1 ) . In addition , the evidence review ers used predefined criteria to assess the quality of systematic review s and r and omized trials , based on internal and external validity assessment s detailed in the Quality of Reporting of Meta-Analyses ( QUOROM ) statement ( 7 ) . Table 1 . The American College of Physicians ' Guideline Grading System The objective of this guideline is to synthesize the evidence for the following questions : What are the comparative benefits in fracture reduction among and also within the following treatments for low bone density :  bisphosphonates , specifically alendronate , risedronate , etidronate , ib and ronate , pamidronate , and zoledronic acid ; calcitonin ; estrogen for women ; teriparatide ; selective estrogen receptor modulators ( SERMs ) , specifically raloxifene and tamoxifen ; testosterone for men ; vitamins and minerals , specifically vitamin D and calcium ; and the combination of calcium plus vitamin D ? How does fracture reduction result ing from treatments vary among individuals with different risks for fracture as determined by bone mineral density ( borderline , low , or severe ) , previous fractures ( prevention vs. treatment ) , age , sex , glucocorticoid use , and other factors ( such as community-dwelling vs. institutionalized or vitamin Ddeficient vs. not ) ? What are the short- and long-term harms ( adverse effects ) of these therapies , and do these vary by specific sub population s ? Comparative Benefits of Drugs versus Placebo in Fracture Reduction Evidence from 24 meta-analyses ( 830 ) and 35 additional r and omized trials published after the meta-analyses ( 3165 ) described the effect of 9 of the 14 agents ( alendronate , etidronate , risedronate , calcitonin , estrogen , teriparatide , raloxifene , calcium , and vitamin D ) on fracture incidence . For 4 agents ( ib and ronate , pamidronate , zoledronic acid , and tamoxifen ) , the review ers found no meta-analyses and instead gathered the evidence from 14 r and omized trials ( 6679 ) . No studies were found that reported fracture rates for testosterone . Three r and omized trials ( 35 , 80 , 81 ) and 1 meta- analysis ( 82 ) evaluated the combination of calcium plus vitamin D  on fractures .  Bisphosphonates Good- quality evidence showed that alendronate , etidronate , ib and ronate , and risedronate prevent vertebral fractures . In addition , evidence from good- quality studies demonstrated that both alendronate and risedronate prevent nonvertebral and hip fractures . Two large r and omized trials showed that zoledronic acid prevents vertebral and nonvertebral fractures in high-risk population s and reduces the risk for hip fracture ( 67 , 74 ) . Ib and ronate has not been shown to reduce nonvertebral fractures ( 68 ) . Of the 6 fairly small trials that looked at vertebral fractures , 1 demonstrated a statistically significant reduction in fractures with pamidronate relative to placebo ( 0.14 [ 95 % CI , 0.03 to 0.72 ] ) ( 73 ) . However , after these data were pooled , the pooled risk estimate for fractures for pamidronate relative to placebo was not significant ( 0.52 [ CI , 0.21 to 1.24 ] ) ( 6 ) . Calcitonin Fair- quality evidence shows that calcitonin reduces vertebral fractures ( 83 , 84 ) . Good- quality evidence indicates that calcitonin does not reduce nonvertebral fractures ( 13 , 16 ) . Estrogen Good- quality evidence shows that estrogen reduces the incidence of vertebral ( 29 , 85 ) , nonvertebral ( 86 ) , and hip fractures ( 85 ) . Teriparatide Good- quality evidence shows that teriparatide prevents vertebral fractures . The evidence related to teriparatide preventing nonvertebral fractures is mixed ; 1 large r and omized trial showed a reduction in nonvertebral fractures ( 34 ) but 2 small trials did not ( 87 , 88 ) . SERMs Good- quality evidence shows that raloxifene prevents vertebral fractures , but that tamoxifen has no effect on vertebral fractures ( 8991 ) . In addition , both raloxifene and tamoxifen had no effect on hip fractures ( 91 ) . Tamoxifen is not approved by the U.S. Food and Drug Administration for the treatment or prevention of osteoporosis . Testosterone No studies reported fracture rates for testosterone . Calcium and Vitamin D In the studies evaluated by MacLean and colleagues ( 5 ) , the evidence for the effect of calcium alone on reduction of fractures is complex . Most studies of pharmacologic agents for osteoporosis include calcium and vitamin D as part of the treatment regimen . Evidence from 1 meta- analysis ( 27 ) and several r and omized trials ( 35 , 48 , 51 , 92 ) showed no significant difference between calcium and placebo in preventing vertebral , nonvertebral , and hip fractures in postmenopausal women . However , nonadherence to therapy may influence this result , and 1 trial with a prespecified analysis of adherent patients found a reduction in fracture risk ( 48 ) . A recent meta- analysis ( 82 ) concluded that the relative risk ( RR ) for fracture with calcium alone was 0.90 ( CI , 0.80 to 1.00 ) , but it did not include a modestly large trial with negative results ( 35 ) . MacLean and colleagues ( 5 ) BACKGROUND & AIMS The incidence of osteoporotic fractures is lower in countries in the Mediterranean basin .  Virgin olive oil , a key component of the Mediterranean Diet ( MDiet ) , with recognised beneficial effects on metabolism and cardiovascular health , may decrease the risk of osteoporotic fractures . The aim to this study was to explore the effect of chronic consumption of total olive oil and its varieties on the risk of osteoporosis-related fractures in a middle-aged and elderly Mediterranean population . METHODS We included all participants ( n = 870 ) recruited in the Reus ( Spain ) centre of the PREvención con DIeta MEDiterránea ( PREDIMED ) trial . Individuals , aged 55 - 80 years at high cardiovascular risk , were r and omized to a MedDiet supplemented with extra-virgin olive oil , a MedDiet supplemented with nuts , or a low-fat diet . The present analysis was an observational cohort study nested in the trial . A vali date d food frequency question naire was used to assess dietary habits and olive oil consumption . Information on total osteoporotic fractures was obtained from a systematic review of medical records . The association between yearly repeated measurements of olive oil consumption and fracture risk was assessed by multivariate Cox proportional hazards . RESULTS We documented 114 incident cases of  osteoporosis-related fractures during a median follow-up of 8.9 years . Treatment allocation had no effect on fracture risk . Participants in the highest tertile of extra-virgin olive oil consumption had a 51 % lower risk of fractures ( HR:0.49 ; 95 % CI:0.29 - 0.81 . P for trend = 0.004 ) compared to those in the lowest tertile after adjusting for potential confounders . Total and common olive oil consumption was not associated with fracture risk . CONCLUSIONS Higher consumption of extra-virgin olive oil is associated with a lower risk of osteoporosis-related fractures in middle-aged and elderly Mediterranean population at high cardiovascular risk Background Homocysteine has been postulated as a novel , potentially reversible risk factor for osteoporosis and related fractures . We evaluated whether homocysteine-lowering therapy with B-vitamins in patients with symptomatic cerebrovascular disease reduced the incidence of osteoporotic fractures . Methods VITAmins To Prevent Stroke ( VITATOPS ) was a prospect i ve r and omised double-blind placebo-controlled trial in which 8,164 patients with recent ( within 7 months ) stroke or transient ischemic attack were r and omly allocated to double-blind treatment with one tablet daily of either placebo ( n = 4,075 ) or B-vitamins ( folic acid 2 mg , vitamin B6 25 mg , vitamin B12 500 μg ; n = 4,089 ) . Patients were review ed every six months . Any osteoporotic fracture and osteoporotic hip fractures were secondary outcome events , and were review ed by a masked adjudication committee . Analysis was by intention to treat . Logistic regression was used to identify independent predictors of fracture . Results Participants had a mean age of 62.6 years ( SD 12.5 years ) and 64 % were male , 42 % of Western European descent and 75 % were functionally independent ( Oxford H and icap Scale of two or less ) . After a median duration of 2.8 years therapy and 3.4 years follow-up , there was no significant difference in the incidence of any osteoporotic fracture between participants assigned B-vitamins ( 67 [ 1.64 % ] ) and placebo ( 78 [ 1.91 % ] ; risk ratio [ RR ] 0.86 , 95 % confidence interval [ CI ] 0.62 - 1.18 ) or the incidence of hip fractures ( 34 [ 0.83 % ] B-vitamins vs. 36 [ 0.88 % ] placebo ; RR 0.94 , 95 % CI 0.59 - 1.5 ) . There was no significant impact of B-vitamin therapy on time to first fracture . Baseline homocysteine levels did not predict any osteoporotic fracture ( p = 0.43 ) . Independent predictors of any osteoporotic fracture were female sex , age > 64 years , Western European ethnicity and use of anti-osteoporosis medication at r and omization ( all p < 0.01 ) . Conclusions Once daily treatment with B-vitamins had no effect on incidence of osteoporotic fractures during a median of 3.4 years follow-up in patients with cerebrovascular disease . A modest effect of B-vitamin therapy is not excluded due to the low numbers of fracture outcome events . Trial registration Clinical trials.gov number : NCT00097669 and is rct n.org number : IS RCT N74743444 Description This guideline up date s the 2008 American College of Physicians ( ACP ) recommendations on treatment of low bone density and osteoporosis to prevent fractures in men and women . This guideline is endorsed by the American Academy of Family Physicians . Methods The ACP Clinical Guidelines Committee based these recommendations on a systematic review of r and omized controlled trials ; systematic review s ; large observational studies ( for adverse events ) ; and case reports ( for rare events ) that were published between 2 January 2005 and 3 June 2011 . The review was up date d to July 2016 by using a machine-learning method , and a limited up date to October 2016 was done . Clinical outcomes evaluated were fractures and adverse events . This guideline focuses on the comparative benefits and risks of short- and long-term pharmacologic treatments for low bone density , including pharmaceutical prescriptions , calcium , vitamin D , and estrogen . Evidence was grade d according to the GRADE ( Grading of Recommendations Assessment , Development and Evaluation ) system . Target Audience and Patient Population The target audience for this guideline includes all clinicians . The target patient population includes men and women with low bone density and osteoporosis . Recommendation 1 ACP recommends that clinicians offer pharmacologic treatment with alendronate , risedronate , zoledronic acid , or denosumab to reduce the risk for hip and vertebral fractures in women who have known osteoporosis . ( Grade : strong recommendation ; high- quality evidence ) . Recommendation 2 ACP recommends that clinicians treat osteoporotic women with pharmacologic therapy for 5 years . ( Grade : weak recommendation ; low- quality evidence ) . Recommendation 3 ACP recommends that clinicians offer pharmacologic treatment with bisphosphonates to reduce the risk for vertebral fracture in men who have clinical ly recognized osteoporosis . ( Grade : weak recommendation ; low- quality evidence ) . Recommendation 4 ACP recommends against bone density monitoring during the 5-year pharmacologic treatment period for osteoporosis in women . ( Grade : weak recommendation ; low- quality evidence ) . Recommendation 5 ACP recommends against using menopausal estrogen therapy or menopausal estrogen plus progestogen therapy or raloxifene for the treatment of osteoporosis in women . ( Grade : strong recommendation ; moderate- quality evidence ) . Recommendation 6 ACP recommends that clinicians should make the decision whether to treat osteopenic women 65 years of age or older who are at a high risk for fracture based on a discussion of patient preferences , fracture risk profile , and benefits , harms , and costs of medications . ( Grade : weak recommendation ; low- quality evidence )
Vertebral fracture caused the greatest health burden , but hip fracture patients were the main users of informal care after hospital discharge .
There was an increased risk of a subsequent fracture after a primary fracture compared with the control group , a cohort comparison , or the general population .
Osteoporotic fractures , especially hip fractures , are associated with higher mortality rate despite the advances in the management of osteoporotic fracture cases .
There is strong evidence to show that after hospital discharge , osteoporotic fracture patients are faced with higher morbidity , subsequent fractures , and mortality
PURPOSE Osteoporotic fracture is the main complication of osteoporosis .
The current management is to discharge patients as early as possible so they can get back to their daily activities .
Once discharged , there are three main issues relating to morbidity , mortality , and risk of a subsequent fracture that need to be addressed and discussed .
Therefore , the aim of this systematic review was to summarize and evaluate the evidence from published literature , to determine the outcome of osteoporotic fracture patients after their hospital discharge .