*,*,Click to edit Master title style,ppt课件,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,骨质疏松治疗指南,1,ppt课件,Objectives,Evidence for treating frail older adults,Why older adults are not getting treated,Deciding when and how to treat frail older adults:a framework for decision making,2,ppt课件,Would you treat this patient?,70 yr old male with EF 25%,mild dementia,T score hip-2.6,If he was 80 years old?,If he had a prior fracture?,If he lived in a nursing home?,If he was 90 years old?,If he had just broken a hip?,3,ppt课件,Does Fracture Risk Warrant Treatment?,4,ppt课件,FRAX to Estimate Fracture Risk,http:/www.shef.ac.uk/FRAX/,5,ppt课件,Does Fracture Risk Warrant Treatment?,Condition,Fracture Risk,Low BMD,Double for each SD decrease,NH Residence,RR up to 10,1/10 white women/yr,Prior Fracture,RR 2-3.5,Parkinsons Disease,RR 2.5,Prostate Cancer,RR 2-4,Stroke,RR 2.5,6,ppt课件,Bone Density Screening Recommendations for Older Veterans,All women over age 65,VA recommendations:,http:/www.hsrd.research.va.gov/publications/esp/Osteoporsis-2007.pdf,Osteoporosis Screening Test(OST):Age(yrs)Weight(kg)*0.2,score 2 are predictive of low BMD,Risk factor guided decisions:corticosteroids,prostate cancer,weight loss,physical inactivity,spinal cord injury,ACP recommendations:,Risk factor guided decisions:age,low body weight,weight loss,physical inactivity,corticosteroids,and previous fragility fracture,7,ppt课件,Is treatment safe and effective in older patients?,Bisphosphonates,Teriparatide,Raloxifene,No change in Relative Risk Reduction,Increase in Absolute Risk Reduction,Hochberg,JBMR 2005;20:971-6;Boonen,JAGS 2006;54:782-9;Bonnen,JAGS 2004;52:1832-9;Boonen,JAGS 2010,8,ppt课件,Is therapy cost effective in older patients?,Most models assume 5 years BP treatment,Estimates vary with model assumptions,BUT,nearly all show increasing cost-effectiveness with advancing age,PTH Cost-effectiveness stable with age,Schousboe,JAGS 2005;53:1607-1704;Lundquivst,Osteoporos Int 2006;17:1459-71,9,ppt课件,Cost Effectiveness with Lower Life Expectancy,Van Staa,Rheum 2007;46:460-6,10,ppt课件,What is the lag time before treatment benefit?,11,ppt课件,Objective 1 Summary,Evidence for treating frail older adults,Higher risk for fracture,Treatments appear to be equally safe,and have greater absolute fracture reduction,Cost effectiveness increases with age,Rapid onset of effectiveness,Why are older adults not getting treated?,12,ppt课件,Older Patients are Rarely Treated for Osteoporosis,After a hip fracture,Fewer than 10%receive osteoporosis evaluation,Fewer than 20%receive osteoporosis treatment,U.S.,Canada,Europe,Academic Centers,Community Practices,VA Medical Centers,Wide variation in practice,0-85%,Gupta,J Am Med Dir Assoc 2003;Jachna,JAGS,2005;Colon-Emeric,Osteoporos Int 2006,13,ppt课件,VISN-6 Osteoporosis Treatment 2006-8,Barnard,Colon-Emeric,2008,14,ppt课件,Why are Older Patients Not Treated?,15,ppt课件,Provider Factors,Knowledge,Clinical Practice Guidelines,Attitudes:Provider Survey,Safe and effective,even in NH residents,“Not as important”as competing co-morbidities,Not cost effective,Too many side effects,Beliefs:“Not my role”,Orthopedic surgeons vs.PCPs,Colon-Emeric,J Am Med Dir Assoc 2006;Skedros,JBMR 2006;Dreinhoffer,Osteop Int 2005,16,ppt课件,Patient Factors,Knowledge/Attitudes/Beliefs,Inadequate information,“Womens”disease,“Ive never broken a bone”,Concern about side effects especially ONJ,Co-morbidities,Nursing Home Residents,Life expectancy,Ribheiro et al.Health Care for Women Int,2000,17,ppt课件,Common Co-Morbidities,Parkinsons Disease,BPs Increase BMD,may decrease hip fracture,Renal Insufficiency,BPs have similar efficacy,safe at GFR 30-45 ml/min,Diabetes,BPs similar BMD and bone markers change,Atrial Fibrillation,Zoledronic acid increased serious events in younger women,but no increased risk in older hip fx patients,Sato,Neurology 2007;68:911-15;Jamal,JBMR 2007;22:503-8;Keegan,Diabetes Care 2004;27:1547-53;Black,NEJM 2007;Lyles,NEJM 2007,18,ppt课件,Nursing Home Residents,Alendronate has similar effect on BMD and no increased side effects,Raloxifene has similar effect on markers of bone turnover,Zoledronic acid after hip fracture,no interaction by NH residence,Greenspan,2002,Ann Int Med;136:742-6;Hansdotter,2004,JAGS 52:779-83;Lyles,2007 NEJM 357:1799-809.,19,ppt课件,System Factors,Multiple“silos”providing uncoordinated care,DXA availability for frail patients,Formularies,Prior Authorizations,Availability of Infusion Services,Financial disincentives for community nursing homes,20,ppt课件,Objective 2 Summary,2.Why older adults are not getting treated,Patient issues,Provider issues,System issues,3.Deciding when and how to treat frail older adults:a framework for decision making,21,ppt课件,Is Osteoporosis Treatment Worthwhile for this patient?,Consider,Life expectancy,Risk of fracture in remaining years of life,Drug Efficacy,Patient preferences,Safety,Cost,22,ppt课件,Risk of Fracture in Remaining Life Years,Concept from Walther et al.JAMA 2000;D