Professor Timothy Kwok, Director of the Jockey Club Centre for Osteoporosis Care and Control at the Chinese University of Hong Kong, provides a fascinating insight on the challenge of the city’s rapidly ageing population
Hong Kong is facing a rapidly ageing population in the coming decades. Alongside population ageing, the incidence of hip fracture, the most disabling of common fractures in old age, has been rising steadily. In 2009, the incidence was 341.7 in men and 703.1 in women, per 100,000 people aged 65 years or over per year (Chau et al., 2013). The direct costs to the public hospital were estimated to be $10,400 in 2017 (Su et al., 2018). The indirect costs which are expected to be more substantial have not been comprehensively studied. In Taiwan, the indirect costs of a hip fracture were $1760, $480 and $173 for nursing home, caregiver and outpatient clinic annually in 2010 (Chan et al., 2017).
A cross-sectional study of 2914 fragility hip fracture patients in six hospitals in Hong Kong showed that the average age of hip fracture patients was 82.1±8.6 years. One-third of them were men, and 73.7% were community-dwelling before fracture (Leung et al., 2017). Most, if not all older people with a hip fracture have osteoporosis as defined by dual-energy X-ray absorptiometry (DXA), and drug treatment for osteoporosis has been consistently shown to reduce hip fracture incidence by 40% (Kanis et al., 2013). It is, therefore, possible to prevent hip fractures if all older people are screened for osteoporosis and receive osteoporosis drug treatment. Yet in Leung’s study, only 4.2% of hip fracture patients were diagnosed and treated for osteoporosis before the fracture. According to the profile of patients in our osteoporosis clinic which is the largest in Hong Kong, only 29.2% in 2017 were 70 years or more. These suggested that very few older people have DXA screening, despite the availability of DXA services in the private sector (Kwok et al., 2017).
A major reason for the very low take-up rate of DXA screening in older people in Hong Kong is the lack of specific public funding support. In collaboration with other local professional bodies, our centre is advocating the use of public funding support for a universal osteoporosis screening programme to benefit older people in Hong Kong. Universal osteoporosis screening by DXA for women aged 65 years and men aged 70 years or more has been recommended by professional bodies in the U.S., UK and European countries, and this strategy has been shown to be cost-effective for governments (Dell et al., 2010). Some Asian countries e.g. Japan and South Korea also provide funding support for osteoporosis screening (Mithal et al., 2013). With the availability of effective affordable generic drugs for osteoporosis, it is feasible to leave the long-term management of osteoporosis to primary care doctors who are mostly in private practices in Hong Kong.
Another major reason is the lack of awareness of fracture risk among older people. Osteoporosis is a common but most neglected disease (International Osteoporosis Foundation, 2000), especially in men (Haas et al., 2007). A randomised trial in the UK showed that the postage of a hip fracture risk questionnaire (FRAX) to women aged 70 years or more, together with training of primary care doctors in osteoporosis management resulted in more osteoporosis diagnosis and drug treatment and a 28% reduction in hip fracture incidence over five years (Shepstone et al., 2018). Our centre has been running a prospective cohort study of 4,000 older men and women to examine the risk factors of fractures in older people since 2001. According to our data, the combination of FRAX and a validated five-item questionnaire for sarcopenia increased the sensitivity for hip fracture incidence from 58.7% in men and 69.9% in women to 80% in both sexes (Su et al., 2019). The widespread use of this questionnaire in older people in the community may prompt more older people to seek DXA screening.
Most hip fractures occur after a fall, and fall history is a risk factor for a further fall, and can independently predict fracture in older men (Scott et al., 2007; Woo et al., 2009; Wu et al., 2013). The prevention of falls, especially in those who have fallen and those with osteoporosis is another effective means to prevent hip fracture in older people. Randomised trials of balance exercise including Tai Chi have shown reduction in fracture incidence in those with osteoporosis and among older fallers (Gillespie et al., 2009; Sherrington et al., 2011). Fall risk assessment should, therefore, be a routine for those who are diagnosed to have osteoporosis and have had a fall within twelve months.
In a project funded by the Hong Kong Jockey Club, our centre has assessed over 1,300 community-dwelling older people who have had a fall over the past few years. Their fall risk was systematically assessed by a validated procedure PPA (Lord, Menz, & Tiedemann, 2003). According to this assessment, 36.6% were found to have moderate to severe instability. Apart from balance exercise group, we offer a home-based balance exercise programme “LIFE” which has been shown to reduce the number of further falls (Clemson et al., 2012). We have further improved on the programme by adding in-home safety assessment by an occupational therapist, which has also been shown to prevent falls (Chu et al., 2017). A randomised trial of the modified “LIFE” programme is on-going.
Last but by no means least, according to Leung’s study, 26.3% of hip fracture patients were nursing home residents. Nursing home residents are at high risk of hip fractures and osteoporosis (Leung et al., 2017). Osteoporosis drugs are potentially useful in preventing hip fractures. But there is a practical problem in performing DXA in people with mobility problems, and because of disabilities and limited life expectancy, the risk and benefit of osteoporosis screening and drug treatment are finely balanced and should be assessed individually. Our centre is collaborating with Caritas College in identifying clinical risk factors of fractures in nursing home residents.
All in all, hip fracture in older people is a preventable condition. There is a lot of evidence that treatment for osteoporosis and fall preventive measures can prevent hip fractures (Chau et al., 2013, Kanis et al., 2013). But a more proactive and systematic approach directed by the government is required to translate knowledge into real impact on the incidence of hip fractures.
Chan, D., McCloskey, E. V., Chang, C., Lin, K., Lim, L. C., Tsai, K., et al. (2017). Establishing and evaluating FRAX probability thresholds in Taiwan. Journal of the Formosan Medical Association, 116(3), 161-168.
Chau, P. H., Wong, M., Lee, A., Ling, M., & Woo, J. (2013). Trends in hip fracture incidence and mortality in chinese population from hong kong 2001-09. Age & Ageing, 42(2), 229-233. doi:https://dx.doi.org/10.1093/ageing/afs177
Chu, M. M.-L., Fong, K. N.-K., Lit, A. C.-H., Rainer, T. H., Cheng, S. W.-C., Au, F. L.-Y., … Tong, H.-K. (2017). An Occupational Therapy Fall Reduction Home Visit Program for Community-Dwelling Older Adults in Hong Kong After an Emergency Department Visit for a Fall. Journal of the American Geriatrics Society, 65(2), 364–372. https://doi.org/10.1111/jgs.14527
Clemson, L., Fiatarone Singh, M. a., Bundy, A., Cumming, R. G., Manollaras, K., O’Loughlin, P., & Black, D. (2012). Integration of balance and strength training into daily life activity to reduce rate of falls in older people (the LiFE study): randomised parallel trial. Bmj, 345(aug07 1), e4547–e4547. https://doi.org/10.1136/bmj.e4547
Gillespie, L. D., Robertson, M. C., Gillespie, W. J., Lamb, S. E., Gates, S., Cumming, R. G., & Rowe, B. H. (2009). Interventions for preventing falls in older people living in the community. The Cochrane Database of Systematic Reviews, (2), CD007146. https://doi.org/10.1002/14651858.CD007146.pub2
Dell, R., & Greene, D. (2010). Is osteoporosis disease management cost effective? Current Osteoporosis Reports, 8(1), 49-55. doi:https://dx.doi.org/10.1007/s11914-010-0009-0
Haas, M. L., & Moore, K. (2007). Osteoporosis: An invisible, undertreated, and neglected disease of elderly men. Journal of Elder Abuse & Neglect, 19(1-2), 61-73.
International Osteoporosis Foundation (2000) The Osteoporosis Paradox: The Neglected Disease. Satellite Symposium, 2nd International Meeting on Social and Economic Aspects of Osteoporosis. Belgium: IOF.
Kanis, J. A., McCloskey, E. V., Johansson, H., Cooper, C., Rizzoli, R., Reginster, J., et al. (2013). European guidance for the diagnosis and management of osteoporosis in postmenopausal women. Osteoporosis International, 24(1), 23-57. doi:https://dx.doi.org/10.1007/s00198-012-2074-y
Kwok, T., & Choy, D. (2017). A case for osteoporosis screening and treatment in older people to prevent hip fracture. Hong Kong Medical Journal, 23(4), 421.
Leung, K. S., Yuen, W. F., Ngai, W. K., Lam, C. Y., Lau, T. W., Lee, K. B., et al. (2017). How well are we managing fragility hip fractures? A narrative report on the review with the attempt to setup a fragility fracture registry in Hong Kong. Hong Kong Medical Journal, 23(3), 264-271.
Lord, S. R., Menz, H. B., & Tiedemann, A. (2003). A physiological profile approach to falls risk assessment and prevention. Physical Therapy, 83(3), 237–252.
Mithal, A., Ebeling, P., et al. (2013). Asia-Pacific Regional Audit: Epidemiology, costs and burden of osteoporosis in 2013. International Osteoporosis Foundation. 61-7, 91-6.
Scott, V., Votova, K., Scanlan, A., & Close, J. (2007). Multifactorial and functional mobility assessment tools for fall risk among older adults in community, home-support, long-term and acute care settings. Age and Ageing, 36(2), 130–139. https://doi.org/10.1093/ageing/afl165
Shepstone, L., Lenaghan, E., Cooper, C., Clarke, S., Fong-Soe-Khioe, R., Fordham, R., et al. (2018). Screening in the community to reduce fractures in older women (SCOOP): A randomised controlled trial. Lancet, 391(10122), 741-747. doi:https://dx.doi.org/10.1016/S0140-6736(17)32640-5
Sherrington, C., Tiedemann, A., Fairhall, N., Close, J. C. T., & Lord, S. R. (2011). Exercise to prevent falls in older adults: an updated meta-analysis and best practice recommendations. New South Wales Public Health Bulletin, 22(3–4), 78–83. https://doi.org/10.1071/NB10056
Su, Y., Lai, F.T.T., Yip, B.H.K., Leung, J.C.S. and Kwok, T.C.Y. (2018). Cost-effectiveness of osteoporosis screening strategies for hip fracture prevention in older Chinese people: a decision tree modeling study in the Mr. OS and Ms. OS cohort in Hong Kong. Osteoporosis International, 29:1793–1805. doi.org/10.1007/s00198-018-4543-4
Su, Y., Woo, J., Kwok, T. (2019). The Added Value of SARC-F to Prescreening Using FRAX for Hip Fracture Prevention in Older Community Adults. Journal of the American Medical Directors Association, 20(1):83-89 DOI: 10.1016/j.jamda.2018.08.007
Woo, J., Leung, J., Wong, S., Kwok, T., Lee, J., & Lynn, H. (2009). Development of a simple scoring tool in the primary care setting for prediction of recurrent falls in men and women aged 65 years and over living in the community. Journal of Clinical Nursing, 18(7), 1038–1048. https://doi.org/10.1111/j.1365-2702.2008.02591.x
Wu, T. Y., Chie, W. C., Yang, R. Sen, Kuo, K. L., Wong, W. K., & Liaw, C. K. (2013). Risk factors for single and recurrent falls: A prospective study of falls in community dwelling seniors without cognitive impairment. Preventive Medicine, 57(5), 511–517. https://doi.org/10.1016/j.ypmed.2013.07.012
Please note: This is a commercial profile
Professor Timothy Kwok
Jockey Club Centre for Osteoporosis
Care and Control
The Chinese University of Hong Kong
Tel: +852 2252 8833
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