Black D M
Department of Epidemiology and Biostatistics, University of California, San Francisco 94143, USA.
Am J Med. 1995 Feb 27;98(2A):67S-75S. doi: 10.1016/s0002-9343(05)80050-6.
It has been argued that women must be screened and treatment begun for osteoporosis at menopause, since there is an irreversible and substantial loss of bone in the 10 years following menopause. Screening and treatment of women after age 65 has been understudied, since it has been assumed that bone loss in elderly women is slow and treatment would be ineffective if initiated at that time. A number of recent results now suggest that the value of screening elderly women should be reassessed. First, several large studies have demonstrated that we can identify elderly women at high risk of future hip and other fractures using bone mass, particularly bone mass at the hip, as well as other risk factors. Second, it has been shown in recent longitudinal studies that bone loss not only continues but accelerates in old age. Third, a continuing strong association of bone mass with fracture risk, even after age 80, suggests that therapies that slow bone loss will reduce fracture risk in this age group. Lastly, there is a slowly growing body of direct evidence that therapy can reduce fracture risk in the elderly. In addition, findings in a number of studies suggest that there is less necessity to screen and treat at menopause for a number of reasons. First, recent longitudinal results suggest that bone loss at menopause is less accelerated than had been believed and that the accelerated phase is briefer. Second, there is some evidence that elderly women treated with antiresorptive agents experience an increase in bone mass, with the result that an 80-year-old woman who has been treated since menopause has only slightly higher bone mass than an 80-year-old who began treatment at age 65. Lastly, at age > or = 65 we can more precisely estimate the risk of hip fracture and therefore target treatment more cost-effectively. We conclude that there is ample justification for screening and treating elderly women. Furthermore, cost-effectiveness analyses that compare early and late screening and treatment options, as well as combinations of the two, must be performed in order to develop an optimal screening and treatment algorithm for osteoporosis.
有人认为，女性必须在绝经时就进行骨质疏松症筛查并开始治疗，因为在绝经后的10年里会发生不可逆转的大量骨质流失。对65岁以上女性的筛查和治疗研究不足，因为人们认为老年女性的骨质流失缓慢，此时开始治疗将无效。现在一些最新研究结果表明，应该重新评估筛查老年女性的价值。首先，几项大型研究表明，我们可以利用骨量，特别是髋部骨量，以及其他风险因素来识别未来有髋部和其他骨折高风险的老年女性。其次，最近的纵向研究表明，骨质流失不仅在老年期持续，而且会加速。第三，即使在80岁以后，骨量与骨折风险之间仍存在持续的强关联，这表明减缓骨质流失的疗法将降低该年龄组的骨折风险。最后，越来越多的直接证据表明，治疗可以降低老年人的骨折风险。此外，多项研究结果表明，出于多种原因，在绝经时进行筛查和治疗的必要性较小。首先，最近的纵向研究结果表明，绝经时的骨质流失速度比人们认为的要慢，而且加速阶段更短。其次，有证据表明，接受抗吸收剂治疗的老年女性骨量会增加，结果是自绝经起就接受治疗的80岁女性的骨量仅略高于65岁开始治疗的80岁女性。最后，在65岁及以上时，我们可以更精确地估计髋部骨折的风险，从而更经济高效地进行靶向治疗。我们得出结论，筛查和治疗老年女性有充分的理由。此外，必须进行成本效益分析，比较早期和晚期筛查及治疗方案，以及两者的组合，以便制定出针对骨质疏松症的最佳筛查和治疗算法。
