Issue 1 • 2022
© 2022 The Royal Australasian College of Physicians
Treatment for bone health often comes too late.
Assessing cognitive decline could help determine the risk of bone loss and fracture in women, a new study by the Garvan Institute of Medical Research has found.
Individuals aged 65 and over participated in the 16-year study, which revealed a unique approach to identifying people with an increased risk. Participants in the Canadian Multicentre Osteoporosis Study were observed from 1997 to 2013, and had their mini mental state examination (MMSE) and bone mineral density (BMD) scores measured at baseline, and then at five and 10 year intervals.
Bone loss in women was shown to be associated with cognitive decline in multivariable-adjusted models. Furthermore, a clinically significant cognitive decline in the first five years of the study resulted in a 1.7-fold increase in future fracture risk observed over the subsequent 10 years. It is important to note that the link between bone loss and cognitive decline was found to be less statistically significant in the men who participated in the study.
Professor Jacqueline Center, RACP Fellow and Head of the Clinical Studies and Epidemiology laboratory at Garvan, worked on this research closely with Dr Dana Bliuc from the Garvan Institute.
'Osteoporosis is poorly treated in general and many people – women and men – with low trauma fractures are not treated with appropriate medication to reduce their risk of subsequent fractures,' Professor Center explained.
'This situation is worse for people with comorbidities, such as dementia, who are much less likely to be treated.'
'More needs to be done in the women’s health space to determine how bone loss and cognitive decline are linked, as this may lead to improved and novel interventions. In men this association needs further investigation in larger studies.'
Both bone loss and cognitive decline – categorised as ‘silent diseases’ – are major public health issues where the optimal timeframe for diagnosis and treatment is often missed. Many patients only come forward once the condition has increased in severity. A global increase in life expectancy means that the number of people affected by osteoporosis (currently 200 million) or dementia (currently 35 million) is set to double over the next 20 years, making cognitive decline and bone health two of the most important and urgent health issues we need to address.
“Identification of cognitive impairment at the time of fracture may help predict patients at risk of more severe adverse post-fracture outcomes, and potentially dementia, down the track. However, this would need to be confirmed in well-designed studies.”
Professor Jacqueline Center
While the study could not identify a causal link, it does highlight the key role that cognitive health plays in improving health outcomes of older people. Health professionals are now able to use this information when consulting with older women regarding their risk of fracture and bone loss.
'Fracture can have devastating consequences, particularly in the elderly with increased risk of further fractures and significant morbidity.'
'Apart from the immediate physical consequences and limitations, depending on the fracture site, patients are often left with insecurity around risk of falling, particularly impacting physical activity and movement outside the home. The morbidity surrounding fracture can be exacerbated in patients with cognitive impairment.'
Any monitoring of cognitive decline that takes place should therefore be in conjunction with monitoring of overall bone health, as a decline in one area may indicate a need for simultaneous attention in the other.
It is hoped that future studies will determine whether interventions that improve cognitive impairment identified at the time of fracture will lead to better post-fracture outcomes, including subsequent fracture, development of dementia, and premature mortality.