Estimating osteoporosis risk in older men

According to a recent review in American Family Physician, 1 to 2 million American men have osteoporosis, 13 percent of white U.S. men older than age 50 will experience an osteoporotic fracture in their lifetimes, and men are twice as likely as women to die in the hospital following a hip fracture. However, unlike screening guidelines in women, there is no consensus on when to screen for osteoporosis in men. The American College of Physicians recommends an individualized osteoporosis risk assessment for men age 65 or older, and dual energy x-ray absorptiometry (DXA) scans to measure bone density in men at increased risk. On the other hand, the U.S. Preventive Services Task Force found insufficient evidence to assess the balance of benefits and harms of screening for osteoporosis in men, although it observed that "men most likely to benefit from screening would have 10-year risks of osteoporotic fracture equal to or greater than those of 65-year-old white women with no additional risk factors."

Since neither organization recommends routinely screening older men for osteoporosis, family physicians require clinical tools to determine which men are at higher risk and therefore candidates for bone density measurement. One such tool, the Male Osteoporosis Risk Estimation Score (MORES), uses age, weight, and the presence or absence of chronic obstructive pulmonary disease to calculate a risk score and recommends further evaluation in men at a certain point threshold. However, since MORES was derived and validated in an historic national survey sample, until recently its utility in a present-day primary care setting was unknown.

In the July/August issue of the Journal of the American Board of Family Medicine, Drs. Alvah Cass and Angela Shepherd evaluated the performance of MORES in a cross-sectional sample of 346 men age 60 years or older presenting to family medicine, internal medicine, or geriatric outpatient practices at the University of Texas, Galveston. MORES correctly identified 12 of the 15 men in the study with osteoporosis of the hip, yielding a sensitivity of 80% and a specificity of 70%. Based on these results, 259 men would need to be screened with MORES to prevent one major osteoporotic fracture over 10 years, compared to 636 with a universal DXA strategy.

Will the results of this study make physicians more likely to use MORES to assess the risk of osteoporosis in older men? Or will clinicians gravitate toward a universal age-based DXA screening strategy (analogous to screening all women age 65 years or older) to avoid missing any men with osteoporosis?

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A slightly different version of the above post was first published on the AFP Community Blog.