- Email: [email protected]
or developmental disabilities
Research in Developmental Disabilities 36 (2015) 108–113
Contents lists available at ScienceDirect
Research in Developmental Disabilities
Risk for osteopenia and osteoporosis in institution-dwelling individuals with intellectual and/or developmental disabilities Lan-Ping Lin a,b, Shang-Wei Hsu c,d, Chung-Hui Yao a, Wei-Ju Lai a, Pei-Jung Hsu e, Jia-Ling Wu f, Cordia M. Chu a,g, Jin-Ding Lin a,f,g,h,* a
School of Public Health, National Defense Medical Center, Taipei, Taiwan Department of Senior Citizen Service Management, Ching Kuo Institute of Management and Health, Keelung, Taiwan Department of Healthcare Administration, Asia University, Taichung, Taiwan d Department of Medical Research, China Medical University Hospital, China Medical University, Taichung, Taiwan e Department of Family and Community Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan f Chung-Hua Foundation for Persons with Intellectual Disabilities, New Taipei City, Taiwan g Center for Environment and Population Health, Griffith University, Brisbane, Australia h Department of Healthcare Administration, College of Public Health and Nutrition, Taipei Medical University, Taipei, Taiwan b c
A R T I C L E I N F O
A B S T R A C T
Article history: Received 14 September 2014 Accepted 22 September 2014 Available online
The purpose of this study was to investigate the prevalence of and contributing factors to osteopenia and osteoporosis among people with intellectual disabilities (ID) or/and developmental disabilities (DD) residing in a disability institution in Taiwan. The present study was conducted at one disability institution in Taiwan and recruited 184 institutionalized residents with ID and/or DD (115 men and 69 women aged 18–72 years) for analysis. For all residents with ID and/or DD, information was obtained about their age, gender, level of ID, BMI, and bone mineral density (BMD). BMD is a measurement of calcium levels in bones that can estimate the risk of osteoporosis and bone fractures. Bone tests were divided into three outcome categories based on their calcaneal BMD T-scores: Normal BMD, a T-score 3 1; Osteopenia, 2.5 2 T-score < 1; and Osteoporosis, a Tscore < 2.5. The results revealed that 46.2% of cases were normal and that 27.7% and 26.1% of cases had osteopenia and osteoporosis, respectively. Multiple logistic regression analyses found that male gender (OR = 2.482, 95% CI = 1.04–5.93, p < 0.05), age 3 40 years (OR = 3.051, 95% CI = 1.07–8.69, p < 0.05) and being overweight/obese (OR = 0.395, 95% CI = 0.17–0.93, p < 0.05) were more likely to be associated with osteoporosis. Another model indicated that males (OR = 2.169, 95% CI = 1.12–4.19, p < 0.05) and those aged 3 40 years (OR = 3.026, 95% CI = 1.32–7, p < 0.01) tended to have an increased risk for osteopenia and osteoporosis. To improve the bone quality of individuals with ID or/and DD and to decrease the occurrence of osteopenia and osteoporosis, this study highlights that we should pay much attention to the potential risk factors for bone quality in these vulnerable populations. ß 2014 Elsevier Ltd. All rights reserved.
Keywords: Bone mineral density Osteopenia Osteoporosis Intellectual disability Developmental disability Institution
* Corresponding author at: School of Public Health, National Defense Medical Center, No. 161, Minquan E. Road, Section 6, Nei-Hu, Taipei 114, Taiwan. Tel.: +886 2 8792 3100x18447; fax: +886 2 8792 3147. E-mail addresses: [email protected], [email protected] (J.-D. Lin). http://dx.doi.org/10.1016/j.ridd.2014.09.022 0891-4222/ß 2014 Elsevier Ltd. All rights reserved.
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1. Introduction Osteoporosis is a condition defined as low bone density along with microarchitectural distortions of bones that predispose them to fracture (NIH, 1993; World Congress on Osteoporosis, 1996), and osteoporosis is a chronic, progressive, metabolic bone disease that can affect almost the entire skeleton (National Osteoporosis Foundation, 1998). Osteoporotic fractures are a significant cause of morbidity and mortality, particularly in developed countries (Johnell & Kanis, 2006). The fracture rate was significantly greater in developmental disability residents with osteoporosis (Lohiya, Crinella, TanFigueroa, Caires, & Lohiya, 1999). Petrone (2012) reported that individuals with ID are at higher than average risk for many chronic conditions. One condition that is often overlooked or underdiagnosed is osteoporosis. A community survey found that the rate of osteoporosis among males with intellectual and/or developmental disabilities was higher than for males in the general population (Zylstra, Porter, Shapiro, & Prater, 2008). Bone mineral density (BMD), which is a surrogate measure of bone strength, is an important predictor of fracture (Schrager, 2004). Srikanth, Cassidy, Joiner, and Teeluckdharry (2011) reviewed relevant studies that demonstrated that an increased prevalence of osteoporosis and osteopenia was associated with low BMD. Center, Beange, and McElduff (1998) conducted a population study that showed that there was lower BMD in people with ID than in an age-matched reference population. In hospital patients, Aspray et al. (1998) found significant differences between adults with ID and control subjects. Osteoporosis is more prevalent in adults with ID. Kilpinen-Loisa, Arvio, Ilvesma¨ki, and Ma¨kitie (2009) found that Vitamin D levels in adults with ID living in nursing homes tended to be low, and enhanced screening for this condition is recommended; however, evidence-based screening recommendations are lacking (Wilkinson, Culpepper, & Cerreto, 2007), particularly in Asian countries. Therefore, the purpose of this study was to investigate the prevalence of and factors contributing to osteopenia and osteoporosis among people with ID or/and developmental disabilities (DD) residing in a disability institution in Taiwan.
2. Method The present study was conducted at one disability institution in Taiwan and recruited 184 institutionalized residents with ID and/or developmental disabilities (115 men and 69 women aged 18–72 years) for analysis. The ethics of the study were approved by the study institution. According to the Taiwan Protection Law for the Physically and Mentally Disabled (1997), ID is defined as the presence of significant intellectual retardation or incomplete mental development during the growth period. People with an ID often exist concurrently with related limitations in areas such as recognition ability and social adaptation skills. The institution-dwelling individuals with ID may have other developmental disabilities, such as autism, hearing disabilities, visual disabilities, mental disabilities, cerebral palsy or physical disabilities. For all residents with ID, information was obtained about their age, gender, level of ID, BMI, weight, height and BMD. BMD is the measurement of calcium levels in bones and can estimate the risk of osteoporosis and bone fractures. In this study, BMD was measured with a portable DMS PEGASUS SMART Bone Densitometer, which is a portable, easy-to-use, fast and efficient solution for screening and monitoring osteoporosis. Featuring the most recent technology available on an ultrasound device, the Pegasus Smart estimates the bone strength of the heel bone, a site well correlated with the femur/hip bone (DOTmed com Inc., 2014). Three trained nurses and four public health masters’ students collected BMD data in December 2013. The study participant was seated in a chair with his/her right foot rested in the machine, and the average scan time was 30 s. The results of the test were divided into three outcome categories based on their calcaneal BMD T-scores: Normal BMD, a T-score 3 1; Osteopenia, 2.5 2 T-score < 1; Osteoporosis, a T-score < 2.5.
3. Results 3.1. Respondent characteristics and BMD distribution Table 1 shows the demographic characteristics of the study participants. The mean age of the study subjects was 35.5 10.2 years (range 18–72 years); 62.5% of the subjects were male, and 37.5% were female. In the study sample, most of the people with ID were more likely to have a serious level of disability, with severe and profound disabilities accounting for 34.8% and 26.1% of the participants, respectively. With regard to disability type, 74.5% of the study subjects had ID alone, whereas 25.5% were affected by multiple disabilities (ID accompanied by autism, hearing, physical or other disabilities). The mean BMI was 24.6 5.4 (range 14.7–43.5); 45.1% of the subjects were normal, 15.2% were overweight, 31.5% were obese and 8.2% were underweight. Fig. 1 shows that 46.2% of cases had normal (T-score 3 1) BMD; 27.7% cases had osteopenia ( 2.5 2 T-score < 1), which refers to early signs of bone loss that can develop into osteoporosis; and 26.1% of cases were identified as at-risk for osteoporosis (T-score < 2.5). Among the male cases, 38.3% were normal, 29.6% cases had osteopenia and 32.2% were at-risk for osteoporosis. In the female cases, 59.4% were normal, 24.6% of cases had osteopenia and 15.9% were at-risk for osteoporosis.
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Table 1 Demographics of people with intellectual disabilities (n = 184). Variable Gender Male Female Age (years) 18–29 30–39 40–49 350 BMIa Underweight Normal Overweight Obesity Types of disability ID Multiple disabilitiesb Level of disability Mild Moderate Severe Profound a b
n
%
115 69
62.5 37.5
58 73 35 18
31.5 39.7 19.0 9.8
15 83 28 58
8.2 45.1 15.2 31.5
137 47
74.5 25.5
12 60 64 48
6.5 32.6 34.8 26.1
Mean S.D. (range)
35.5 10.2 (18.0–72.4)
24.6 5.4 (14.7–43.5)
Underweight: <18.5; normal: 18.5–23.9; overweight: 24.0–26.9; obesity: 327.0. Multiple disabilities are ID accompanied with other disabilities.
3.2. Relations of demographic characteristics and BMD scores Respondents’ demographic characteristics and BMD scores, which were divided into three groups, normal, osteopenia and osteoporosis, were subjected to a Chi-square analysis (Table 2). The results revealed that gender (p = 0.012) and BMI (p = 0.008) had significantly different BMD T-scores. Males were more likely to be at-risk for osteopenia and osteoporosis than females. Those individuals who were underweight were more likely to have osteopenia and osteoporosis than overweight or obese individuals as well. Other factors, such as age (p = 0.084), type (p = 0.288) and level (p = 0.203) of disability, were not significantly correlated with BMD T-score in the study. 3.3. Influencing factors for osteopenia and osteoporosis in logistic regression analyses Finally, multiple logistic regression analyses were conducted to examine which factors were more likely to influence the occurrence of osteopenia and osteoporosis among individuals with ID and/or DD (Table 3). We set the osteopenia (model 1), osteoporosis (model 2), osteopenia and osteoporosis (model 3) occurrence as the dependent variable, and those demographic factors of individuals with ID or/and DD were identified as independent variables. Model 1 revealed that there were no demographic factors significantly correlated with osteopenia occurrence. Model 2 showed that male gender (OR = 2.482, 95% CI = 1.04–5.93, p < 0.05), age 3 40 years (OR = 3.051, 95% CI = 1.07–8.69, p < 0.05) and being overweight/ obese (OR = 0.395, 95% CI = 0.17–0.93, p < 0.05) were more likely to be associated with osteoporosis occurrence. Model 3 indicated that male gender (OR = 2.169, 95% CI = 1.12–4.19, p < 0.05) and age 3 40 years (OR = 3.026, 95% CI = 1.32–7, [(Fig._1)TD$IG]p < 0.01) tended to have an increased risk for osteopenia and osteoporosis.
Fig. 1. The BMD T-score distribution among people with ID.
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Table 2 Chi-square test with the demographics and T-score (n = 184). Variable
Gender Male Female Age (years) 18–29 30–39 340 BMI Underweight Normal Overweight/obesity Types of disability ID Multiple disabilities Level of disability Mild/moderate Severe/profound Normal: T 3
x2
T-score
1; osteopenia:
Normal
Osteopenia
Osteoporosis
n (%)
n (%)
n (%)
44 (38.3) 41 (59.4)
34 (29.6) 17 (24.6)
37 (32.2) 11 (15.9)
30 (51.7) 39 (53.4) 16 (30.2)
16 (27.6) 17 (23.3) 18 (34.0)
12 (20.7) 17 (23.3) 19 (35.8)
4 (26.7) 36 (42.2) 46 (53.5)
4 (26.7) 19 (22.9) 28 (32.6)
7 (46.7) 29 (34.9) 12 (14.0)
67 (48.9) 18 (38.3)
34 (24.8) 17 (36.2)
36 (26.3) 12 (25.5)
39 (54.2) 46 (41.1)
18 (25.0) 33 (29.5)
15 (20.8) 33 (29.5)
2.5 2 T <
1; osteoporosis: T <
p-value
8.91
0.012
8.22
0.084
13.73
0.008
2.49
0.288
3.19
0.203
2.5.
Table 3 Logistic regression with the demographics and T-score (n = 184). Variable
Constant Gender Female Male Age (years) 18–29 30–39 340 BMI Underweight Normal Overweight/obesity Types of disability Disability Multiple disabilities Level of disability Mild/moderate Severe/profound
Model 1
Model 2
Model 3
Normal
Osteopenia
Normal
Osteoporosis
Normal
Osteopenia + Osteoporosis
b
OR (95% C.I.)
b
OR (95% C.I.)
b
OR (95% C.I.)
0.244
0.784
0.438
0.645
0.418
1.519
0.563
1 1.757 (0.81–3.83)
0.909
1 2.482 (1.04–5.93)*
0.744
1 2.169 (1.12–4.19)*
0.134 0.822
1 1.143 (0.46–2.85) 2.417 (0.94–6.24)
0.273 1.115
1 1.314 (0.50–3.48) 3.051 (1.07–8.69)*
0.268 1.107
1 1.307 (0.61–2.80) 3.026 (1.32–7.00)**
0.756 0.167
1 2.130 (0.45–10.15) 1.182 (0.56–2.53)
0.913 0.928
1 2.491 (0.59–10.48) 0.395 (0.17–0.93)*
0.847 0.315
1 2.332 (0.64–8.57) 0.730 (0.38–1.39)
0.487
1 1.627 (0.68–3.88)
0.023
1 1.023 (0.39–2.66)
0.311
1 1.365 (0.64–2.92)
0.117
1 1.124 (0.51–2.46)
0.346
1 1.413 (0.60–3.32)
0.223
1 1.250 (0.64–2.43)
* p < 0.05. ** p < 0.01.
4. Discussion Adults with ID have increased prevalence of osteoporosis (Center, Beange, & McElduff, 1998) but also difficulty in accessing bone densitometry (Hocking, McNeil, Nugent, & Laslett, 2009). This study aimed to investigate the BMD profile and to identify the risk factors contributing to osteopenia and osteoporosis among people with ID residing in a disability institution. The results revealed that 46.2% of cases were normal and that 27.7% and 26.1% of cases had osteopenia and osteoporosis, respectively. Compared with other studies, Bastiaanse, Mergler, Evenhuis, and Echteld (2014) found that the prevalence of low bone quality was 43.9% in persons with ID aged 50 years. Jaffe, Timell, Elolia, and Thatcher (2005) analyzed data from adults residing in a facility for the people with ID, and they found that more than three quarters (77.2%) of this institutionalized population had low BMD. More women aged 60+ were osteoporotic (67.1%) than were their male counterparts (48.5%). Twenty-six percent of men under 60 years of age were osteoporotic, and 36% were osteopenic. Based on data from a residential center, Leslie, Pahlavan, Roe, and Dittberner (2009) found a very high prevalence of osteoporotic BMD measurements in institutionalized adults with developmental disabilities. They found that 79.0% had osteoporosis, 13.0% had osteopenia, and only 8.0% had normal bone density. They found lower heel and forearm BMD measurements were
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significantly and independently associated with prior fragility fractures in this population. The BMD level of the present study seems lower than that of other countries. The main reason may be the age difference of samples as our sample seem younger than other studies. The present study found a gender difference in the BMD level, with men experiencing more osteopenia and osteoporosis than women. However, many previous studies have suggested more focus on women’s osteoporosis prevalence than men. Schrager (2004) reported that women with physical and cognitive disabilities are at high risk for osteoporosis and osteoporosis-related fractures. The prevalence of fractures in women with ID was high (Schrager, Kloss, & Ju, 2007), and these individuals should be screened for the risk factors associated with low BMD in adults with ID (Srikanth et al., 2011). In the chi-square analysis, gender and BMI levels were found to predict significantly different BMD T-scores in this study. Other factors, such as age, type and level of disability, were not correlated with T-scores. These findings may not be consistent with other studies, such as Fisher and Kettl (2005) who reported that as these ID individuals age, they present with increasing rate of osteoporosis. Haveman et al. (2011) found that more than 60% of older adults with ID had a sedentary lifestyle, and a statistically significant increase with age was found for osteoporosis, with the lowest rate (3.9%) for the 35–54 age group and the highest rate (11.8%) for people aged 65 and older. Osteoporosis was positively associated with advancing age. Osteoporosis may be a larger problem in those with severe ID. Wagemans, Fiolet, van der Linden, and Menheere (1998) reported that the bedridden ID adults had low bone mineral density and low vitamin D levels, and those over the age of 50 were especially likely to have long bone fractures and vertebral fractures Coppola et al. (2012) confirmed that epilepsy is comorbid with cerebral palsy and that ID may worsen bone health in children and adolescents. A severe/profound ID and spastic quadriplegia are significantly correlated with abnormal BMD in patients with and without epilepsy. In addition, mobility impairment consistently appeared to be a significant risk factor for low BMD regardless of age or sex, especially for middle-aged men with profound ID (Jaffe et al., 2005). Babayigit, Dirik, Bober, and Cakmakcı (2006) revealed that long-term antiepileptic drug treatment has unknown effects on skeletal mineralization and induces a state of decreased BMD. In terms of prevalence with other disabilities, Wu (2013) demonstrated that preadolescent boys with Down syndrome have lower bone mineral content and BMD in the pelvis, but not in the arms, legs, or total body less head and lumbar spine compared to those without DS. Guijarro, Valero, Paule, Gonzalez-Macias, and Riancho (2008) also confirmed that DS patients had lower areal BMD than controls at all regions (spine, hip and total body). This study analyzed the possible risk factors for influencing the occurrence of osteopenia and osteoporosis among individuals with ID or/and DD in multiple logistic regression models. The results revealed that male gender and BMI were more likely to be associated with osteoporosis occurrence, and males and those aged 3 40 years tended to have an increased risk for osteopenia and osteoporosis. Bastiaanse et al. (2014) found that low bone quality was positively associated with female gender, age, more severe level of ID, mobility impairment, and anticonvulsant drug use, and negatively with BMI. Arvio, Kilpinen-Loisa, Tiitinen, Huovinen, and Ma¨kitie (2009) also noted that body weight showed statistical significance in predicting BMD. Petrone (2012) reviewed the recent literature and concluded that the main reasons for this excess risk included immobility/disuse, vitamin D deficiency, hypogonadism, and the use of multiple antiepileptic and antipsychotic drugs. To improve the bone quality of individuals with ID or/and DD and to decrease their occurrence of osteopenia and osteoporosis, this study highlights that we should pay more attention to the potential risk factors for bone quality. All individuals with ID need to be considered for further screening and monitoring if risk factors are present, and we need to provide education regarding bone health to all of the caregivers (Srikanth et al., 2011). Jensen, Lomborg, Wind and Langdahl (2014) indicated that multifaceted osteoporosis group education can increase the patients’ knowledge of osteoporosis as well as their health-related quality of life, physical activity and psychosocial functioning. In addition, Guijarro et al. (2008) revealed that physical activity and sunlight exposure are associated with volumetric BMD and should be stimulated to maintain an adequate bone mass in these patients. Bastiaanse et al. (2014) suggested that people with ID who are at risk for low bone quality should periodically be screened for osteoporosis and be given advice about nutritional supplements and appropriate lifestyle. Acknowledgements The authors would like to acknowledge the Ministry of Science and Technology (Taiwan, R.O.C.) for the financial support of the research (grant no. NSC 101-2314-B-016-026-MY3) and the disability service institution that participated in the study.
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Coppola, G., Fortunato, D., Mainolfi, C., Porcaro, F., Roccaro, D., & Signoriello, G. (2012). Bone mineral density in a population of children and adolescents with cerebral palsy and mental retardation with or without epilepsy. Epilepsia, 53, 2172–2177. DOTmed.com, Inc (2014). DMS PEGASUS SMART Bone Densitometer. http://www.dotmed.com/virtual-trade-show/category/Bone-Densitometer/Bone-Densitometer/Models/Dms/Pegasus-Smart/16961 Accessed 29.05.14. Fisher, K., & Kettl, P. (2005). Aging with mental retardation: Increasing population of older adults with MR require health interventions and prevention strategies. Geriatrics, 60, 26–29. Guijarro, M., Valero, C., Paule, B., Gonzalez-Macias, J., & Riancho, J. A. (2008). Bone mass in young adults with Down syndrome. Journal of Intellectual Disability Research, 52, 182–189. Haveman, M., Perry, J., Salvador-Carulla, L., Walsh, P. N., Kerr, M., Van Schrojenstein Lantman-de Valk, H., et al. (2011). Ageing and health status in adults with intellectual disabilities: Results of the European POMONA II study. Journal of Intellectual & Developmental Disability, 36, 49–60. Hocking, J., McNeil, J., Nugent, M., & Laslett, L. (2009). Vertebral fractures in adults with an intellectual disability. Bone, 44, S78–S79. Jaffe, J. S., Timell, A. M., Elolia, R., & Thatcher, S. S. (2005). Risk factors for low bone mineral density in individuals residing in a facility for the people with intellectual disability. Journal of Intellectual Disability Research, 49, 457–462. Jensen, A. L., Lomborg, K., Wind, G., & Langdahl, B. L. (2014). Effectiveness and characteristics of multifaceted osteoporosis group education – A systematic review. Osteoporosis International, 25, 1209–1224. Johnell, O., & Kanis, J. A. (2006). An estimate of the worldwide prevalence and disability associated with osteoporotic fractures. Osteoporosis International, 17, 1726–1733. Kilpinen-Loisa, P., Arvio, M., Ilvesma¨ki, V., & Ma¨kitie, O. (2009). Vitamin D status and optimal supplementation in institutionalized adults with intellectual disability. Journal of Intellectual Disability Research, 53, 1014–1023. Leslie, W. D., Pahlavan, P. S., Roe, E. B., & Dittberner, K. (2009). Bone density and fragility fractures in patients with developmental disabilities. Osteoporosis International, 20, 379–383. Lohiya, G. S., Crinella, F. M., Tan-Figueroa, L., Caires, S., & Lohiya, S. (1999). Fracture epidemiology and control in a developmental center. Western Journal of Medicine, 170, 203–209. National Osteoporosis Foundation (1998). Osteoporosis: Review of the evidence for prevention, diagnosis and treatment and cost-effective analysis. Osteoporosis International, 8, S7–S80. NIH (1993). Consensus Development Conference: Diagnosis, prophylaxis, and treatment of osteoporosis. American Journal of Medicine, 94, 646–650. Petrone, L. R. (2012). Osteoporosis in adults with intellectual disabilities. Southern Medical Journal, 105, 87–92. Schrager, S. (2004). Osteoporosis in women with disabilities. Journal of Women’s Health, 13, 431–437. Schrager, S., Kloss, C., & Ju, A. W. (2007). Prevalence of fractures in women with intellectual disabilities: A chart review. Journal of Intellectual Disability Research, 51, 253–259. Srikanth, R., Cassidy, G., Joiner, C., & Teeluckdharry, S. (2011). Osteoporosis in people with intellectual disabilities: A review and a brief study of risk factors for osteoporosis in a community sample of people with intellectual disabilities. Journal of Intellectual Disability Research, 55, 53–62. Taiwan Protection Law for the Handicapped and Disabled (1997). The whole modified enacted text of 75 articles promulgated by President Wha-jong (1) Yi-tzi No. 8600097810, April 23, 1997. Wagemans, A. M., Fiolet, J. F., van der Linden, E. S., & Menheere, P. P. (1998). Osteoporosis and intellectual disability: Is there any relation? Journal of Intellectual Disability Research, 42, 370–374. Wilkinson, J. E., Culpepper, L., & Cerreto, M. (2007). Screening tests for adults with intellectual disabilities. Journal of the American Board of Family Medicine, 20, 399–407. World Congress on Osteoporosis (1996). Proceedings of the 1996 World Congress on Osteoporosis. Wu, J. (2013). Bone mass and density in preadolescent boys with and without Down syndrome. Osteoporosis International, 24, 2847–2854. Zylstra, R. G., Porter, L., Shapiro, J. L., & Prater, C. D. (2008). Prevalence of osteoporosis in community-dwelling individuals with intellectual and/or developmental disabilities. Journal of The American Medical Directors Association, 9, 109–113.
Contents lists available at ScienceDirect
Research in Developmental Disabilities
Risk for osteopenia and osteoporosis in institution-dwelling individuals with intellectual and/or developmental disabilities Lan-Ping Lin a,b, Shang-Wei Hsu c,d, Chung-Hui Yao a, Wei-Ju Lai a, Pei-Jung Hsu e, Jia-Ling Wu f, Cordia M. Chu a,g, Jin-Ding Lin a,f,g,h,* a
School of Public Health, National Defense Medical Center, Taipei, Taiwan Department of Senior Citizen Service Management, Ching Kuo Institute of Management and Health, Keelung, Taiwan Department of Healthcare Administration, Asia University, Taichung, Taiwan d Department of Medical Research, China Medical University Hospital, China Medical University, Taichung, Taiwan e Department of Family and Community Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan f Chung-Hua Foundation for Persons with Intellectual Disabilities, New Taipei City, Taiwan g Center for Environment and Population Health, Griffith University, Brisbane, Australia h Department of Healthcare Administration, College of Public Health and Nutrition, Taipei Medical University, Taipei, Taiwan b c
A R T I C L E I N F O
A B S T R A C T
Article history: Received 14 September 2014 Accepted 22 September 2014 Available online
The purpose of this study was to investigate the prevalence of and contributing factors to osteopenia and osteoporosis among people with intellectual disabilities (ID) or/and developmental disabilities (DD) residing in a disability institution in Taiwan. The present study was conducted at one disability institution in Taiwan and recruited 184 institutionalized residents with ID and/or DD (115 men and 69 women aged 18–72 years) for analysis. For all residents with ID and/or DD, information was obtained about their age, gender, level of ID, BMI, and bone mineral density (BMD). BMD is a measurement of calcium levels in bones that can estimate the risk of osteoporosis and bone fractures. Bone tests were divided into three outcome categories based on their calcaneal BMD T-scores: Normal BMD, a T-score 3 1; Osteopenia, 2.5 2 T-score < 1; and Osteoporosis, a Tscore < 2.5. The results revealed that 46.2% of cases were normal and that 27.7% and 26.1% of cases had osteopenia and osteoporosis, respectively. Multiple logistic regression analyses found that male gender (OR = 2.482, 95% CI = 1.04–5.93, p < 0.05), age 3 40 years (OR = 3.051, 95% CI = 1.07–8.69, p < 0.05) and being overweight/obese (OR = 0.395, 95% CI = 0.17–0.93, p < 0.05) were more likely to be associated with osteoporosis. Another model indicated that males (OR = 2.169, 95% CI = 1.12–4.19, p < 0.05) and those aged 3 40 years (OR = 3.026, 95% CI = 1.32–7, p < 0.01) tended to have an increased risk for osteopenia and osteoporosis. To improve the bone quality of individuals with ID or/and DD and to decrease the occurrence of osteopenia and osteoporosis, this study highlights that we should pay much attention to the potential risk factors for bone quality in these vulnerable populations. ß 2014 Elsevier Ltd. All rights reserved.
Keywords: Bone mineral density Osteopenia Osteoporosis Intellectual disability Developmental disability Institution
* Corresponding author at: School of Public Health, National Defense Medical Center, No. 161, Minquan E. Road, Section 6, Nei-Hu, Taipei 114, Taiwan. Tel.: +886 2 8792 3100x18447; fax: +886 2 8792 3147. E-mail addresses: [email protected], [email protected] (J.-D. Lin). http://dx.doi.org/10.1016/j.ridd.2014.09.022 0891-4222/ß 2014 Elsevier Ltd. All rights reserved.
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1. Introduction Osteoporosis is a condition defined as low bone density along with microarchitectural distortions of bones that predispose them to fracture (NIH, 1993; World Congress on Osteoporosis, 1996), and osteoporosis is a chronic, progressive, metabolic bone disease that can affect almost the entire skeleton (National Osteoporosis Foundation, 1998). Osteoporotic fractures are a significant cause of morbidity and mortality, particularly in developed countries (Johnell & Kanis, 2006). The fracture rate was significantly greater in developmental disability residents with osteoporosis (Lohiya, Crinella, TanFigueroa, Caires, & Lohiya, 1999). Petrone (2012) reported that individuals with ID are at higher than average risk for many chronic conditions. One condition that is often overlooked or underdiagnosed is osteoporosis. A community survey found that the rate of osteoporosis among males with intellectual and/or developmental disabilities was higher than for males in the general population (Zylstra, Porter, Shapiro, & Prater, 2008). Bone mineral density (BMD), which is a surrogate measure of bone strength, is an important predictor of fracture (Schrager, 2004). Srikanth, Cassidy, Joiner, and Teeluckdharry (2011) reviewed relevant studies that demonstrated that an increased prevalence of osteoporosis and osteopenia was associated with low BMD. Center, Beange, and McElduff (1998) conducted a population study that showed that there was lower BMD in people with ID than in an age-matched reference population. In hospital patients, Aspray et al. (1998) found significant differences between adults with ID and control subjects. Osteoporosis is more prevalent in adults with ID. Kilpinen-Loisa, Arvio, Ilvesma¨ki, and Ma¨kitie (2009) found that Vitamin D levels in adults with ID living in nursing homes tended to be low, and enhanced screening for this condition is recommended; however, evidence-based screening recommendations are lacking (Wilkinson, Culpepper, & Cerreto, 2007), particularly in Asian countries. Therefore, the purpose of this study was to investigate the prevalence of and factors contributing to osteopenia and osteoporosis among people with ID or/and developmental disabilities (DD) residing in a disability institution in Taiwan.
2. Method The present study was conducted at one disability institution in Taiwan and recruited 184 institutionalized residents with ID and/or developmental disabilities (115 men and 69 women aged 18–72 years) for analysis. The ethics of the study were approved by the study institution. According to the Taiwan Protection Law for the Physically and Mentally Disabled (1997), ID is defined as the presence of significant intellectual retardation or incomplete mental development during the growth period. People with an ID often exist concurrently with related limitations in areas such as recognition ability and social adaptation skills. The institution-dwelling individuals with ID may have other developmental disabilities, such as autism, hearing disabilities, visual disabilities, mental disabilities, cerebral palsy or physical disabilities. For all residents with ID, information was obtained about their age, gender, level of ID, BMI, weight, height and BMD. BMD is the measurement of calcium levels in bones and can estimate the risk of osteoporosis and bone fractures. In this study, BMD was measured with a portable DMS PEGASUS SMART Bone Densitometer, which is a portable, easy-to-use, fast and efficient solution for screening and monitoring osteoporosis. Featuring the most recent technology available on an ultrasound device, the Pegasus Smart estimates the bone strength of the heel bone, a site well correlated with the femur/hip bone (DOTmed com Inc., 2014). Three trained nurses and four public health masters’ students collected BMD data in December 2013. The study participant was seated in a chair with his/her right foot rested in the machine, and the average scan time was 30 s. The results of the test were divided into three outcome categories based on their calcaneal BMD T-scores: Normal BMD, a T-score 3 1; Osteopenia, 2.5 2 T-score < 1; Osteoporosis, a T-score < 2.5.
3. Results 3.1. Respondent characteristics and BMD distribution Table 1 shows the demographic characteristics of the study participants. The mean age of the study subjects was 35.5 10.2 years (range 18–72 years); 62.5% of the subjects were male, and 37.5% were female. In the study sample, most of the people with ID were more likely to have a serious level of disability, with severe and profound disabilities accounting for 34.8% and 26.1% of the participants, respectively. With regard to disability type, 74.5% of the study subjects had ID alone, whereas 25.5% were affected by multiple disabilities (ID accompanied by autism, hearing, physical or other disabilities). The mean BMI was 24.6 5.4 (range 14.7–43.5); 45.1% of the subjects were normal, 15.2% were overweight, 31.5% were obese and 8.2% were underweight. Fig. 1 shows that 46.2% of cases had normal (T-score 3 1) BMD; 27.7% cases had osteopenia ( 2.5 2 T-score < 1), which refers to early signs of bone loss that can develop into osteoporosis; and 26.1% of cases were identified as at-risk for osteoporosis (T-score < 2.5). Among the male cases, 38.3% were normal, 29.6% cases had osteopenia and 32.2% were at-risk for osteoporosis. In the female cases, 59.4% were normal, 24.6% of cases had osteopenia and 15.9% were at-risk for osteoporosis.
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Table 1 Demographics of people with intellectual disabilities (n = 184). Variable Gender Male Female Age (years) 18–29 30–39 40–49 350 BMIa Underweight Normal Overweight Obesity Types of disability ID Multiple disabilitiesb Level of disability Mild Moderate Severe Profound a b
n
%
115 69
62.5 37.5
58 73 35 18
31.5 39.7 19.0 9.8
15 83 28 58
8.2 45.1 15.2 31.5
137 47
74.5 25.5
12 60 64 48
6.5 32.6 34.8 26.1
Mean S.D. (range)
35.5 10.2 (18.0–72.4)
24.6 5.4 (14.7–43.5)
Underweight: <18.5; normal: 18.5–23.9; overweight: 24.0–26.9; obesity: 327.0. Multiple disabilities are ID accompanied with other disabilities.
3.2. Relations of demographic characteristics and BMD scores Respondents’ demographic characteristics and BMD scores, which were divided into three groups, normal, osteopenia and osteoporosis, were subjected to a Chi-square analysis (Table 2). The results revealed that gender (p = 0.012) and BMI (p = 0.008) had significantly different BMD T-scores. Males were more likely to be at-risk for osteopenia and osteoporosis than females. Those individuals who were underweight were more likely to have osteopenia and osteoporosis than overweight or obese individuals as well. Other factors, such as age (p = 0.084), type (p = 0.288) and level (p = 0.203) of disability, were not significantly correlated with BMD T-score in the study. 3.3. Influencing factors for osteopenia and osteoporosis in logistic regression analyses Finally, multiple logistic regression analyses were conducted to examine which factors were more likely to influence the occurrence of osteopenia and osteoporosis among individuals with ID and/or DD (Table 3). We set the osteopenia (model 1), osteoporosis (model 2), osteopenia and osteoporosis (model 3) occurrence as the dependent variable, and those demographic factors of individuals with ID or/and DD were identified as independent variables. Model 1 revealed that there were no demographic factors significantly correlated with osteopenia occurrence. Model 2 showed that male gender (OR = 2.482, 95% CI = 1.04–5.93, p < 0.05), age 3 40 years (OR = 3.051, 95% CI = 1.07–8.69, p < 0.05) and being overweight/ obese (OR = 0.395, 95% CI = 0.17–0.93, p < 0.05) were more likely to be associated with osteoporosis occurrence. Model 3 indicated that male gender (OR = 2.169, 95% CI = 1.12–4.19, p < 0.05) and age 3 40 years (OR = 3.026, 95% CI = 1.32–7, [(Fig._1)TD$IG]p < 0.01) tended to have an increased risk for osteopenia and osteoporosis.
Fig. 1. The BMD T-score distribution among people with ID.
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Table 2 Chi-square test with the demographics and T-score (n = 184). Variable
Gender Male Female Age (years) 18–29 30–39 340 BMI Underweight Normal Overweight/obesity Types of disability ID Multiple disabilities Level of disability Mild/moderate Severe/profound Normal: T 3
x2
T-score
1; osteopenia:
Normal
Osteopenia
Osteoporosis
n (%)
n (%)
n (%)
44 (38.3) 41 (59.4)
34 (29.6) 17 (24.6)
37 (32.2) 11 (15.9)
30 (51.7) 39 (53.4) 16 (30.2)
16 (27.6) 17 (23.3) 18 (34.0)
12 (20.7) 17 (23.3) 19 (35.8)
4 (26.7) 36 (42.2) 46 (53.5)
4 (26.7) 19 (22.9) 28 (32.6)
7 (46.7) 29 (34.9) 12 (14.0)
67 (48.9) 18 (38.3)
34 (24.8) 17 (36.2)
36 (26.3) 12 (25.5)
39 (54.2) 46 (41.1)
18 (25.0) 33 (29.5)
15 (20.8) 33 (29.5)
2.5 2 T <
1; osteoporosis: T <
p-value
8.91
0.012
8.22
0.084
13.73
0.008
2.49
0.288
3.19
0.203
2.5.
Table 3 Logistic regression with the demographics and T-score (n = 184). Variable
Constant Gender Female Male Age (years) 18–29 30–39 340 BMI Underweight Normal Overweight/obesity Types of disability Disability Multiple disabilities Level of disability Mild/moderate Severe/profound
Model 1
Model 2
Model 3
Normal
Osteopenia
Normal
Osteoporosis
Normal
Osteopenia + Osteoporosis
b
OR (95% C.I.)
b
OR (95% C.I.)
b
OR (95% C.I.)
0.244
0.784
0.438
0.645
0.418
1.519
0.563
1 1.757 (0.81–3.83)
0.909
1 2.482 (1.04–5.93)*
0.744
1 2.169 (1.12–4.19)*
0.134 0.822
1 1.143 (0.46–2.85) 2.417 (0.94–6.24)
0.273 1.115
1 1.314 (0.50–3.48) 3.051 (1.07–8.69)*
0.268 1.107
1 1.307 (0.61–2.80) 3.026 (1.32–7.00)**
0.756 0.167
1 2.130 (0.45–10.15) 1.182 (0.56–2.53)
0.913 0.928
1 2.491 (0.59–10.48) 0.395 (0.17–0.93)*
0.847 0.315
1 2.332 (0.64–8.57) 0.730 (0.38–1.39)
0.487
1 1.627 (0.68–3.88)
0.023
1 1.023 (0.39–2.66)
0.311
1 1.365 (0.64–2.92)
0.117
1 1.124 (0.51–2.46)
0.346
1 1.413 (0.60–3.32)
0.223
1 1.250 (0.64–2.43)
* p < 0.05. ** p < 0.01.
4. Discussion Adults with ID have increased prevalence of osteoporosis (Center, Beange, & McElduff, 1998) but also difficulty in accessing bone densitometry (Hocking, McNeil, Nugent, & Laslett, 2009). This study aimed to investigate the BMD profile and to identify the risk factors contributing to osteopenia and osteoporosis among people with ID residing in a disability institution. The results revealed that 46.2% of cases were normal and that 27.7% and 26.1% of cases had osteopenia and osteoporosis, respectively. Compared with other studies, Bastiaanse, Mergler, Evenhuis, and Echteld (2014) found that the prevalence of low bone quality was 43.9% in persons with ID aged 50 years. Jaffe, Timell, Elolia, and Thatcher (2005) analyzed data from adults residing in a facility for the people with ID, and they found that more than three quarters (77.2%) of this institutionalized population had low BMD. More women aged 60+ were osteoporotic (67.1%) than were their male counterparts (48.5%). Twenty-six percent of men under 60 years of age were osteoporotic, and 36% were osteopenic. Based on data from a residential center, Leslie, Pahlavan, Roe, and Dittberner (2009) found a very high prevalence of osteoporotic BMD measurements in institutionalized adults with developmental disabilities. They found that 79.0% had osteoporosis, 13.0% had osteopenia, and only 8.0% had normal bone density. They found lower heel and forearm BMD measurements were
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significantly and independently associated with prior fragility fractures in this population. The BMD level of the present study seems lower than that of other countries. The main reason may be the age difference of samples as our sample seem younger than other studies. The present study found a gender difference in the BMD level, with men experiencing more osteopenia and osteoporosis than women. However, many previous studies have suggested more focus on women’s osteoporosis prevalence than men. Schrager (2004) reported that women with physical and cognitive disabilities are at high risk for osteoporosis and osteoporosis-related fractures. The prevalence of fractures in women with ID was high (Schrager, Kloss, & Ju, 2007), and these individuals should be screened for the risk factors associated with low BMD in adults with ID (Srikanth et al., 2011). In the chi-square analysis, gender and BMI levels were found to predict significantly different BMD T-scores in this study. Other factors, such as age, type and level of disability, were not correlated with T-scores. These findings may not be consistent with other studies, such as Fisher and Kettl (2005) who reported that as these ID individuals age, they present with increasing rate of osteoporosis. Haveman et al. (2011) found that more than 60% of older adults with ID had a sedentary lifestyle, and a statistically significant increase with age was found for osteoporosis, with the lowest rate (3.9%) for the 35–54 age group and the highest rate (11.8%) for people aged 65 and older. Osteoporosis was positively associated with advancing age. Osteoporosis may be a larger problem in those with severe ID. Wagemans, Fiolet, van der Linden, and Menheere (1998) reported that the bedridden ID adults had low bone mineral density and low vitamin D levels, and those over the age of 50 were especially likely to have long bone fractures and vertebral fractures Coppola et al. (2012) confirmed that epilepsy is comorbid with cerebral palsy and that ID may worsen bone health in children and adolescents. A severe/profound ID and spastic quadriplegia are significantly correlated with abnormal BMD in patients with and without epilepsy. In addition, mobility impairment consistently appeared to be a significant risk factor for low BMD regardless of age or sex, especially for middle-aged men with profound ID (Jaffe et al., 2005). Babayigit, Dirik, Bober, and Cakmakcı (2006) revealed that long-term antiepileptic drug treatment has unknown effects on skeletal mineralization and induces a state of decreased BMD. In terms of prevalence with other disabilities, Wu (2013) demonstrated that preadolescent boys with Down syndrome have lower bone mineral content and BMD in the pelvis, but not in the arms, legs, or total body less head and lumbar spine compared to those without DS. Guijarro, Valero, Paule, Gonzalez-Macias, and Riancho (2008) also confirmed that DS patients had lower areal BMD than controls at all regions (spine, hip and total body). This study analyzed the possible risk factors for influencing the occurrence of osteopenia and osteoporosis among individuals with ID or/and DD in multiple logistic regression models. The results revealed that male gender and BMI were more likely to be associated with osteoporosis occurrence, and males and those aged 3 40 years tended to have an increased risk for osteopenia and osteoporosis. Bastiaanse et al. (2014) found that low bone quality was positively associated with female gender, age, more severe level of ID, mobility impairment, and anticonvulsant drug use, and negatively with BMI. Arvio, Kilpinen-Loisa, Tiitinen, Huovinen, and Ma¨kitie (2009) also noted that body weight showed statistical significance in predicting BMD. Petrone (2012) reviewed the recent literature and concluded that the main reasons for this excess risk included immobility/disuse, vitamin D deficiency, hypogonadism, and the use of multiple antiepileptic and antipsychotic drugs. To improve the bone quality of individuals with ID or/and DD and to decrease their occurrence of osteopenia and osteoporosis, this study highlights that we should pay more attention to the potential risk factors for bone quality. All individuals with ID need to be considered for further screening and monitoring if risk factors are present, and we need to provide education regarding bone health to all of the caregivers (Srikanth et al., 2011). Jensen, Lomborg, Wind and Langdahl (2014) indicated that multifaceted osteoporosis group education can increase the patients’ knowledge of osteoporosis as well as their health-related quality of life, physical activity and psychosocial functioning. In addition, Guijarro et al. (2008) revealed that physical activity and sunlight exposure are associated with volumetric BMD and should be stimulated to maintain an adequate bone mass in these patients. Bastiaanse et al. (2014) suggested that people with ID who are at risk for low bone quality should periodically be screened for osteoporosis and be given advice about nutritional supplements and appropriate lifestyle. Acknowledgements The authors would like to acknowledge the Ministry of Science and Technology (Taiwan, R.O.C.) for the financial support of the research (grant no. NSC 101-2314-B-016-026-MY3) and the disability service institution that participated in the study.
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