Are osteoporotic fractures due to osteoporosis? Impacts of a frailty pandemic in an aging world.

Osteoporosis is a major risk factor for fractures in the elderly. Osteoporotic (hip, forearm, and vertebral) fractures today strike hard on Western populations, with a lifetime risk in women similar to the risk for cardiovascular disease. The risk of dying from hip fracture equals breast cancer mortality. Osteoporotic fractures are associated with pain, crippling and social dependency; annual costs in the United States are between $7 to $20 billion, and the contribution from hip fractures is above 60%. Of all hospital beds in Europe, 1 to 1.5% are occupied by osteoporotic patients, a figure expected to more than double during the next fifty years. Whereas vertebral fractures mainly seem to be caused by osteoporosis alone, hip fractures are heavily affected by an age-dependent contributory risk factor, frailty. Frailty might act as an involutionary phenomenon or as comorbidity, particularly neurological; it affects fracture risk along several causal paths, but the increasing frequency and severity of falls are essential. Results of attempts to prevent falls are discouragingly poor. Nevertheless, identification of risk possessors, particularly demented elderly living in institutions, is substantial for directing preventive and treatment programs, mainly acting on general health and on osteoporosis. Frailty of populations increases with longevity. Consequently, projections of fracture occurrence are too conservative. The annual hip fracture incidence in Asia in 2050 might pass 10 million, rather than the hitherto forecasted 3.2 million, thus shifting tomorrow's burden of age-related fractures from the wealthier to the poorer countries. There is an immediate call for vigorous global actions to reallocate resources, to reorganize health care, and to institute high-risk prevention programs.