Fracture risk, BP monitoring and screening for COPD: journals update May 2016

Recent research of interest to GPs, including fracture risk among Asian women taking bisphosphonate therapy, screening for patients with COPD and BP monitoring for adults with dementia.

Fractured femur: identify at-risk groups to reduce the potential burden
Fractured femur: identify at-risk groups to reduce the potential burden

Bisphosphonate therapy and femur fracture risk 1

Osteoporosis fractures are an often devastating, long-term, debilitating problem and a significant medico-economic burden. The identification of at-risk groups and the development of effective preventive interventions are essential to reduce the large-scale impact of this complication.

Study design
This study focused on establishing or confirming the likelihood of an increased RR of an atypical femur fracture (AFF) among Asian women while taking bisphosphonate therapy, as suggested in previous epidemiological studies. A data review of 48,390 women (65.3% white, 17.1% mainland Asian) was conducted.

All of the women were registered with a large Californian healthcare delivery system and had received newly initiated bisphosphonate therapy. The median follow-up was 7.7 years.

Key findings
A total of 68 women aged over 50 years, who had started bisphosphonates between 2002 and 2007, experienced an AFF during follow-up, as defined by American Society for Bone and Mineral Research Task Force criteria.

The risk of AFF was adjusted for differences in bisphosphonate exposure and other potential risk factors, and was increased eightfold among Asians compared with white women (64.2 versus 7.6 per 100,000 person-years).

Implications for GPs
Lifestyle and medication advice to reduce the potential risk of AFF as an outcome of osteoporosis in Asian women needs to be focused.

Although the data showed Asians were more likely to have longer bisphosphonate treatment duration compared with white women (median 3.8 versus 2.7 years), and so in theory should have an increased baseline risk for osteoporosis and complications at least partially counteracted by better protection through medication, the specific endpoint (in this study, an AFF) was not positive.

This prompts an urgent requirement for more investigations to check the association of bisphosphonate treatment duration and AFF in Asian women, and possible variations of risk across Asian subgroups.

Dementia patients and BP monitoring2

Ambulatory BP monitoring (ABPM) is being increasingly used in the management of hypertension, but any potential problems with it should be considered and revealed, to ensure that limited resources are used well.

Study design
In the absence of sufficient systematic reviews of tolerability of ABPM in patients with dementia, this study reviewed and assessed the published evidence to determine if ABPM in this group can usually be deemed tolerable.

A respective specific Medline and Embase study search from 1996 to March 2015 found 221 potential abstracts, of which, 13 studies (6%) met the inclusion criteria. However, only five had sufficient data (461 patients with mild to moderate dementia) and were considered of sufficient quality to be assessed.

Key findings
Of the described patients, 77.7% (95% CI 62.2-93.2%) were able to tolerate ABPM. One study compared home BP monitoring by a relative or ABPM with surgery BP measures and found high agreement.

Increased levels of dementia appeared to be associated with reduced tolerability of ABPM, although overall numbers assessed were small.

Implications for GPs
The findings confirm what clinical and practical intuition would suggest. Individual knowledge of patients and their behaviour may help to select patients well, who may benefit from ABPM in their overall health context and who are likely to understand and co-operate with it.

The study is a reminder that an additional diagnosis, for example of a mental illness, should not automatically exclude any patient from available, particularly non-invasive, evidence-based beneficial tests and interventions to maintain or improve physical health and to prevent cardiovascular complications.

Systematic screening for patients with COPD3

Nearly half of all patients with COPD are not formally diagnosed. However, this project managed to identify a new diagnosis in a quarter of ever-smokers who attended a general chronic disease management clinic, through a fairly simple but systematic assessment of respiratory symptoms and measurement of FEV1.

This could have significant implications for earlier detection and management of COPD to delay or reduce long-term complications.

Study design
The researchers opportunistically assessed 1,333 current smokers (n = 410, 31%) or ex-smokers aged 35 years or over using a questionnaire and microspirometry in 23 general practices in south-west England. None of the participants had a diagnosis of COPD at that point.

Smoking cessation service referrals were offered to all smokers, even if there were no clinical indications to suggest a diagnosis of COPD.

Key findings
The detection rate of patients with currently undiagnosed COPD was good in this pilot, while the set-up and resources required were comparatively straightforward and effective.

High symptom scores were found in 613 (46%) patients, and 287 (22%) of these also had an abnormal FEV1.

A total of 47% of current smokers with low FEV1 suggestive of COPD accepted referral to smoking cessation services, as did 56% of the other smokers, who did not apparently have COPD. These are reasonably high rates of patients immediately accepting an intervention.

Implications for GPs
Offers of specific, isolated COPD screening clinics for smokers have been shown to be largely ineffective, owing to poor attendance rates. Opportunistic screening during other attendances at the surgery could be an alternative, provided it is quick, focused and tolerable.

Practices could develop possible opportunities to enable this, to increase the early detection and management of COPD. The resources required are relatively simple, so effective set-up is crucial for the effectiveness of such screening.

Antidepressants may increase risk of falls4

Recurrent falls are a considerable problem in many elderly patients and bear the risk of a range of possible complications and other negative physical and emotional outcomes.

As a fairly large proportion of elderly patients also show signs of clinical depression, the benefit of possible medical treatment for depression needs to be considered if there is evidence of adverse effects from the medication, such as a risk of falling.

Study design
This longitudinal study of 2,948 elderly patients (aged 70-79 years) correlated self-reported data from antidepressant use with self-reported recurrent falls (defined as at least two falls within one year) over seven years (1997-2004).

Key findings
The likelihood of recurrent falls for users of all antidepressants was increased by 48% (95% CI, 1.12-1.96) compared with non-users. There were signs of a higher risk in patients taking SSRIs (adjusted OR = 1.62, 95% CI, 1.15-2.28).

Short-term use and moderate doses appeared to influence the results to considerable degrees. The study acknowledged that direct causation remains difficult to prove and reliance on self-reporting can have weaknesses.

Implications for GPs
Any intended benefits of antidepressant use for depression in the elderly need to be weighed against potential side-effects or harm, such as recurrent falls.

If there is a history of recurrent falls in an elderly patient, which automatically puts them at higher future risk, antidepressant prescriptions should be initiated carefully, with close follow-up and regular monitoring.

All non-medication options to address low mood owing to social isolation or physical and mental disability should be considered, to reduce reliance on antidepressants.

Too much or too little sleep can be harmful5

Shortened or prolonged sleep durations could be detrimental in the long term

This study examined possible associations and RRs of overall mortality to sleep duration. Unless patients report sleeping problems to their GP, this aspect of life may be neglected when considering their general wellbeing.

Study design
This meta-analysis of 40 prospective cohort studies investigating the association between sleep duration and all-cause mortality in adults aimed to assess the association of length of sleep with long-term risk of mortality.

The studies were identified by database searches and review articles up to November 2015, which included a total of 2,200,425 patients and 271,507 reported deaths.

Key findings
Insufficient and excessive sleep were both associated with excess all-cause mortality in a J-shaped association curve fashion.

Seven hours’ sleep in 24 hours was established as the healthiest baseline, whereas reduced sleep duration, such as four to six hours, led to a suggested 4-6% increased RR of premature all-cause mortality, worse so in women.

More significantly, all long sleepers had sharply increased RRs of premature all-cause mortality of 13% (for nine hours), 25% (10 hours) and 38% (11 hours).

Implications for GPs
Discussions about sleep duration are probably rare in clinical settings, particularly if not prompted by the patient.

It has been established that 27-37% of the general population regularly experience prolonged sleep duration (more than seven hours) and 12-16% report shortened sleep duration. Both could be harmful in the long term.

It could be difficult to distinguish cause and effect of specific sleep durations and other illnesses, but this study directs the spotlight on a fundamental factor of wellbeing, which could be considered more by the medical profession when dealing with patients and assessing risks.

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  1. Bone 2016; 85: 142-7
  2. Age Ageing 2016 Apr 7; pii: afw050
  3. Chron Respir Dis 2016 Apr 12; pii: 1479972316643011
  4. Ann Pharmacother 2016 Apr 11; pii: 1060028016644466
  5. Sleep Med Rev 2016 Mar 3; pii: S1087-0792(16)00021-6

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