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Should age influence the choice of quantitative bone assessment technique in elderly women? The EPIDOS study

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In a prospective cohort of 7,598 women aged 75 and over, we analyzed the effect of age on the ability of femoral neck bone mineral density (BMD) and of ultrasound (BUA and SOS) of the calcaneus to predict hip fracture. Unadjusted regression analysis showed that the risk of hip fracture was increased 1.7 times for one standard deviation increase in age (3.7 years). Overall, for a decrease of one standard deviation in quantitative bone measures, the risk was significantly increased by 2.2 times for BMD (1.9–2.5), 1.8 for BUA (1.6–2.1), and 1.9 for SOS (1.6–2.2). However the average relative risk associated with a decrease in BMD tends to diminish with advancing age, meaning that a smaller part of the risk is explained by BMD in the very elderly. This is confirmed by the areas under the ROC curves (AUC) of BMD that are significantly better before 80 years (0.75 [0.73–0.76]) than after (0.65 [0.63–0.67] in group 80–84 years and 0.65 [0.61–0.68] in group ≥85). On the other hand, as the absolute risk increases exponentially with age, the number of hip fractures attributable to a low BMD is still important in the very elderly, the risk difference between the lowest and the highest quartile of BMD is 25 hip fractures / 1,000 woman-years in the group ≥85 compared with 16 in the two other groups. Thus, after 80, quantitative assessment of bone may still be of interest for clinical decisions. Compared with quantitative ultrasound parameters, the ability of BMD to predict hip fracture was significantly superior to that of BUA and SOS only before the age of 80 (AUC of BMD 0.75 [0.73–0.76], BUA 0.67 [0.66–0.69], SOS 0.67 [0.65–0.69]). For patients older than 80, we did not observe significant differences in AUC between DXA and QUS to predict hip fracture.

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  1. Melton LJ III (1993) Hip fractures: a worldwide problem today and tomorrow. Bone 14[Suppl 1]:S1–S8

    Google Scholar 

  2. Baudoin C, Fardellone P, Potard V et al (1993) Fractures of the proximal femur in Picardy, France, in 1987. Osteoporos Int 3(1):43–49

    CAS  PubMed  Google Scholar 

  3. Kanis JA (1993) The incidence of hip fracture in Europe. Osteoporos Int 3[Suppl 1]:10–15

    Google Scholar 

  4. Cummings SR, Black DM, Nevitt MC et al (1993) Bone density at various sites for prediction of hip fractures. The Study of Osteoporotic Fractures Research Group. Lancet 341(8837):72–75

    CAS  PubMed  Google Scholar 

  5. Marshall D, Johnell O,Wedel H (1996) Meta-analysis of how well measures of bone mineral density predict occurrence of osteoporotic fractures [see comments]. BMJ 312(7041):1254–1259

    CAS  PubMed  Google Scholar 

  6. Melton LJ III, Atkinson EJ, O’Fallon WM et al (1993) Long-term fracture prediction by bone mineral assessed at different skeletal sites. J Bone Miner Res 8(10):1227–1233

    PubMed  Google Scholar 

  7. Schott AM, Cormier C, Hans D et al (1998) How hip and whole-body bone mineral density predict hip fracture in elderly women: the EPIDOS Prospective Study. Osteoporos Int 8(3):247–254

    Article  CAS  PubMed  Google Scholar 

  8. Bauer DC, Gluer CC, Cauley JA et al (1997) Broadband ultrasound attenuation predicts fractures strongly and independently of densitometry in older women: a prospective study. Study of Osteoporotic Fractures Research Group [see comments]. Arch Intern Med 157(6):629–634

    CAS  PubMed  Google Scholar 

  9. Hans D, Dargent-Molina P, Schott AM et al (1996) Ultrasonographic heel measurements to predict hip fracture in elderly women: the EPIDOS prospective study. Lancet 348(9026):511–514

    CAS  PubMed  Google Scholar 

  10. Thompson PW, Taylor J, Oliver R et al (1998) Quantitative ultrasound (QUS) of the heel predicts wrist and osteoporosis related fractures in women age 45–75 years. J Clin Densitom 1(3):219–226

    Article  Google Scholar 

  11. Nevitt MC, Johnell O, Black DM et al (1994) Bone mineral density predicts non-spine fractures in very elderly women. Study of Osteoporotic Fractures Research Group. Osteoporos Int 4(6):325–331

    CAS  PubMed  Google Scholar 

  12. Johansson C, Mellstrom D,Milsom I (1993) Reproductive factors as predictors of bone density and fractures in women at the age of 70. Maturitas 17(1):39–50

    CAS  PubMed  Google Scholar 

  13. Sackett DL, Haynes RB, Tugwell P (1985) Clinical epidemiology: a basic science for clinical medicine. Little, Brown, Boston

    Google Scholar 

  14. Dargent-Molina P, Favier F, Grandjean H et al (1996) Fall-related factors and risk of hip fracture: the EPIDOS prospective study. Epidemiologie de l’osteoporose. Lancet 348(9021):145–149

    CAS  PubMed  Google Scholar 

  15. Njeh CF, Blake GM (1999) Calcaneal quantitative ultrasound: water-coupled. In: Calcaneal quantitative ultrasound: water-coupled. Martin Dunitz, London, pp 109–124

  16. Hans D, Schott AM, Chapuy MC et al (1994) Ultrasound measurements on the os calcis in a prospective multicenter study. Calcif Tissue Int 55(2):94–99

    CAS  PubMed  Google Scholar 

  17. Seemann MD, Englmeier K, Schuhmann DR et al (1999) Evaluation of the carotid and vertebral arteries: comparison of 3D SCTA and IA-DSA-work in progress. Eur Radiol 9(1):105–112

    Article  CAS  PubMed  Google Scholar 

  18. Estève J, Benhamou E, Raymond L (1994) Statistical methods in cancer research. IARC Scientific Publications, Lyon

  19. Hanley JA, McNeil BJ (1983) A method of comparing the areas under receiver operating characteristic curves derived from the same cases. Radiology 148(3):839–843

    CAS  PubMed  Google Scholar 

  20. National Osteoporosis Foundation (1998) Physician’s guide to prevention and treatment of osteoporosis. NOF, Washington, DC

  21. McClung MR, Geusens P, Miller PD et al (2001) Effect of risedronate on the risk of hip fracture in elderly women. Hip Intervention Program Study Group. N Engl J Med 344(5):333–340

    Article  CAS  PubMed  Google Scholar 

  22. Kanis JA,Gluer CC (2000) An update on the diagnosis and assessment of osteoporosis with densitometry. Committee of Scientific Advisors, International Osteoporosis Foundation. Osteoporos Int 11(3):192–202

    Article  CAS  PubMed  Google Scholar 

  23. National Institutes of Health (2000) NIH consensus development conference on osteoporosis prevention, diagnosis and therapy. National Institutes of Health, Bethesda, MD

  24. Luukinen H, Koski K, Kivela SL et al (1996) Social status, life changes, housing conditions, health, functional abilities and life-style as risk factors for recurrent falls among the home-dwelling elderly. Public Health 110(2):115–118

    CAS  PubMed  Google Scholar 

  25. Cesari M, Landi F, Torre S et al (2002) Prevalence and risk factors for falls in an older community-dwelling population. J Gerontol A Biol Sci Med Sci 57(11):M722–M726

    Google Scholar 

  26. Stalenhoef PA, Diederiks JP, Knottnerus JA et al (2002) A risk model for the prediction of recurrent falls in community-dwelling elderly: a prospective cohort study. J Clin Epidemiol 55(11):1088–1094

    CAS  PubMed  Google Scholar 

  27. Kiely DK, Kiel DP, Burrows AB et al (1998) Identifying nursing home residents at risk for falling. J Am Geriatr Soc 46(5):551–555

    Google Scholar 

  28. Frost ML, Blake GM,Fogelman I (2001) Does the combination of quantitative ultrasound and dual-energy X-ray absorptiometry improve fracture discrimination? Osteoporos Int 12(6):471–477

    CAS  PubMed  Google Scholar 

  29. Frost ML, Blake GM,Fogelman I (2002) A comparison of fracture discrimination using calcaneal quantitative ultrasound and dual X-ray absorptiometry in women with a history of fracture at sites other than the spine and hip. Calcif Tissue Int 71(3):207–211

    CAS  PubMed  Google Scholar 

  30. He YQ, Fan B, Hans D et al (2000) Assessment of a new quantitative ultrasound calcaneus measurement: precision and discrimination of hip fractures in elderly women compared with dual X-ray absorptiometry. Osteoporos Int 11(4):354–360

    CAS  PubMed  Google Scholar 

  31. Frost ML, Blake GM,Fogelman I (2001) Quantitative ultrasound and bone mineral density are equally strongly associated with risk factors for osteoporosis. J Bone Miner Res 16(2):406–416

    CAS  PubMed  Google Scholar 

  32. Gnudi S, Ripamonti C,Malavolta N (2000) Quantitative ultrasound and bone densitometry to evaluate the risk of nonspine fractures: a prospective study. Osteoporos Int 11(6):518–523

    Article  CAS  PubMed  Google Scholar 

  33. Glüer CC,Hans D (1999) How to use ultrasound for risk assessment: a need for defining strategies. Osteoporos Int 9(3):193–195

    Article  PubMed  Google Scholar 

  34. Hartl F, Tyndall A, Kraenzlin M et al (2002) Discriminatory ability of quantitative ultrasound parameters and bone mineral density in a population-based sample of postmenopausal women with vertebral fractures: results of the Basel Osteoporosis Study. J Bone Miner Res 17(2):321–330

    CAS  PubMed  Google Scholar 

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The EPIDOS study was supported by an INSERM/MSD-Chibret contract. We are grateful to Ms M. Rabilloud, MD, MsH, for her valuable assistance in the statistical analysis with SAS. We also thank Ms C. Casalini, G. Genolet, and P. Roy, for their technical assistance as well as Dr J. Iwaz for reviewing the English translation.

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Correspondence to A. M. Schott.

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The named authors wrote this article on behalf of the EPIDOS Study Group. Coordinators: G. Bréart and P. Dargent-Molina (epidemiology), P.J. Meunier and A.M. Schott (clinical aspects), D. Hans (DXA and ultrasound quality control), P.D. Delmas (biochemistry). Principal investigators: J.L. Sebert and C. Baudoin (Amiens), A.M. Schott and M.C. Chapuy (Lyon), C. Marcelli and F. Favier (Montpellier), C.J. Menkès, C. Cormier, and E. Hausherr (Paris), and H. Grandjean and C. Ribot (Toulouse).

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Schott, A.M., Kassaï Koupaï, B., Hans, D. et al. Should age influence the choice of quantitative bone assessment technique in elderly women? The EPIDOS study. Osteoporos Int 15, 196–203 (2004).

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