Improving bone health and reducing fractures in Parkinson’s Disease

Celia Gregson (@CeliaGregson) is an academic at University of Bristol who combines bone research with clinical work as a consultant in the Hip Fracture Unit at the Royal United Hospital Bath (@RUHBath). She and her colleague Veronica Lyell, who has also a special interest in Parkinson’s disease, have written a review article on bone health in Parkinson’s disease, and here they describe the work as recently published in Age and Ageing journal.parkinsonsFracture

A collaboration between the Royal United Hospital Bath NHS Trust and the University of Bristol has recently published the first suggested guideline regarding the assessment and management of bone health and fracture risk in patients with movement disorders for whom to date no specific guidelines exist. The full paper can be seen here and below we outline the key points.

Parkinson’s Disease (PD), affecting almost 127,000 UK adults, is the second most common neurodegenerative condition after Alzheimer’s disease. Prevalence is increasing within our ageing population, affecting an estimated 1% aged >60 years. PD is primarily a neurological disorder; causing tremor, slowness of movement and muscle rigidity. However, it is less commonly recognised that people with PD have substantially higher fracture risk.

Within the general population osteoporosis is common, often asymptomatic and therefore insidious. The consequences, primarily fractures, represent a significant societal burden, both through direct medical costs (UK >£2 billion/annum), and the costs of ongoing social care. Approximately 1 in 2 women and 1 in 5 men aged >50 years will go on to sustain a fracture during their lifetime. In England and Wales an estimated 76,000 older adults fracture a hip each year. Hip fracture can be a devastating event; even within the general population, 30 days following hip fracture 8.2% have died and fewer than half will have returned to their own home; for people with PD the outcomes are yet more challenging. Even accounting for poorer pre-fracture mobility, the consequences of hip fracture for a PD patient are worse than amongst the general population, with higher pressure sore rates, a more than doubled hospital length of stay and a greater proportion of bed/wheelchair dependency after 30 days.

Several retrospective studies have identified an increased fracture risk in PD, particularly of the hip. Analyses of over 3 million UK primary care patients identified a 2-fold hazard of hip fracture for women with PD, and 3-fold for men, even after accounting for multiple independent risk factors. Hip fractures occur relatively early in PD, with average (median) duration from PD diagnosis to first hip fracture being 4 years, such that almost three quarters of hip fractures occur in mild-moderate disease. While there are effective treatments for osteoporosis, most agents only take effect after 1 year, and so early fracture risk assessment is strongly indicated.

Women with PD under-appreciate their own fracture risk; 68% considered their risk ‘the same or lower than women of the same age’ in one prospective study. This may reflect absence of bone health assessment from PD guidelines with consequent inattention by doctors.

Falls, a major predictor of hip fracture, are a common, potentially devastating complication of PD. Multiple factors increase PD falls risk, particularly the increasing effect of PD on walking and balance, but also the drops in blood pressure and the impact of worsening cognitive function seen in PD over time. Almost half of people with PD will fall during just 3 months of follow-up.

As well as the tendency to fall, people with PD likely have more osteoporosis than the age-matched population. PD-specific risk factors include reduced physical activity and muscle strength, challenges to nutrition, vitamin D deficiency and possibly medication side effects.

Accurate fracture risk prediction is crucial to allow targeting of preventative strategies to reduce new fractures. Two risk assessment tools, FRAX and Qfracture, are endorsed by NICE.

FRAX does not specifically account for the additional fracture risk conveyed by multiple clinical risk factors including PD nor, importantly, falls.  Also, the recommendations of the National Osteoporosis Guidelines Group for investigation and management linked via the FRAX website may not be suitable for people with PD, especially older people. We therefore suggest adoption of a simple threshold risk for treatment, to apply to a Q fracture generated risk assessment.

We also review options for bone health management in PD, paying particular attention to the difficulties posed by standard osteoporosis treatments when people may have constraints on timing of medication, or difficulty in swallowing, and suggesting injected treatments which may be especially well suited to people with PD.

We combine these recommendations into a 6 step algorithm for PD bone health, developed in Bath and Bristol. We apply the advice in our algorithm to two hypothetical individuals with PD, across both sexes and a range of ages, and so demonstrate that all women with PD aged 70+ and men aged 75+ without falls would be eligible for treatment based on Qfracture calculations. In those who fall, ages for recommended treatment are lower, at 67+ for women and 70+ for men. Adding further clinical risk factors to the hypothetical cases further lowers the age for intervention.

We hope that the algorithm will increase bone health treatment within our PD population.  Best use of this algorithm will occur in conjunction with multidisciplinary team assessment and falls programmes and will include systems for monitoring and auditing practice and outcomes.  We hope to see an updating of guidelines globally concerning the management of PD, which presently fail to address bone health.

Read the paper in full on the Age and Ageing journal website.

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