Vertebral Fractures in Elderly Adults: Atypical Presentation Rather than Asymptomatic

Abstract

To the Editor: Individuals with vertebral fractures do not often come to medical attention; it has been shown that only approximately one-third seek acute medical help, of whom 8% are hospitalized for a vertebral fracture.1 The majority of individuals with vertebral fractures, who are usually diagnosed based on vertebral deformities on X-rays that have been performed for other medical reasons (for instance, pneumonia), are often referred to as asymptomatic. In the last decade, many studies have shown that these asymptomatic vertebral fractures may lead to substantial somatic and psychological burden; individuals with vertebral fractures have more back pain and less mobility,2 poorer quality of life, and more complaints of anxiety and depression3 than age- and sex-matched controls. Associations were stronger in individuals with more-severe vertebral fractures. In addition, vertebral fractures quadruple the risk of a new vertebral fracture and double the risk of a nonvertebral fracture.4 Vertebral fractures were also found to be associated with mortality in several observational cohort studies in various countries.5 A prevalence of vertebral fractures of 50% was recently found in 395 older outpatients (mean age 82); two-thirds of these vertebral fractures were moderate (25–40% height loss) or severe (>40% height loss) fractures.6 In a comparable population-based study in the Netherlands, the prevalence of vertebral fractures in individuals of the same age (≥80) was much lower (30%), and moderate and severe fractures accounted together for only 30% of the vertebral fractures.7 In another study, after 3 years of follow-up, 182 (46%) participants had died. Mortality was independently associated with the presence of three or more vertebral fractures at baseline.8 In individuals with a prevalent vertebral fracture at baseline, the incidence of a new vertebral fracture over 3 years was 40%, which is statistically higher (odds ratio = 6.4, 95% confidence interval = 1.68–24.8, P = .006) than the incidence of 11% in individuals without a prevalent vertebral fracture.8 These data clearly emphasize the clinical relevance of these “asymptomatic” fractures in older adults. Despite the high clinical burden for individuals with vertebral fractures, there is a well-known phenomenon of underdiagnosis of these fractures. There are many reasons why these vertebral fractures are so often overlooked.9 For instance, doctors fail to diagnose vertebral fractures because of the asymptomatic presentation; the recognition rate by radiologists in various studies is approximately 50%, especially when the reason for performing an X-ray is not back pain; and doctors tend to miss the clinical relevance of diagnosing vertebral fractures, which results in failure to start treatment.9 Treatment options in case of vertebral fractures caused by osteoporosis are widely available and have proven to be effective even for the oldest old. Various studies have shown that treatment leads to a relative risk reduction after 3 years of approximately 50% for vertebral fractures and 20% to 25% for nonvertebral fractures. These relative risks correspond to a large reduction in fractures, because fracture risk is high in elderly adults. Referring to these vertebral fractures as “asymptomatic” seems to underestimate the large consequences these deformities can have for individuals. In addition, “asymptomatic” may unintentionally indicate a lack of need for preventive treatment. To enhance the recognition of vertebral fractures with or without acute symptoms, the term “atypical presentation” for prevalent vertebral fractures seems more adequate. “Atypical presentation” is used more frequently in geriatrics, for example, when elderly adults present with a pronounced infection but no fever or when delirium occurs instead of chest pain in the case of myocardial infarction. Atypical presentation refers to when the classical symptoms of a disease are vague or not specific or even absent.10 The consequence of atypical presentation is delayed diagnosis or no diagnosis at all and therefore no or delayed treatment. This letter is a call for action to recognize all vertebral fractures in older adults, to account for their clinical relevance, and to start secondary prevention of fractures by using antiosteoporotic drugs. To address the clinical relevance of vertebral fractures in older adults, “atypical presentation” should be used for vertebral fractures rather than “asymptomatic” vertebral fractures. Conflict of Interest: WFL has received speaker's fee from Merck, Amgen, Procter and Gamble, Novartis, Eli Lilly, Warner Chilcott, and Servier. Author Contributions: van der Jagt-Willems: preparation of the letter. van Munster, Lems: critical revision of the letter. Sponsor's Role: None.