Elderly Care & Frailty
A 78 year old woman presents to the Emergency Department following a fall. She has a deformed, painful right wrist. Her wrist x-ray shows a Colles' fracture and you consider if she has underlying osteoporosis. Which of the following is a risk factor for osteoporosis?
Answer:
Risk factors for having a fragility fracture:- Risks factors affecting bone strength that reduce BMD:
- Endocrine disease e.g. diabetes mellitus, hyperthyroidism, hyperparathyroidism
- Malabsorptive disease e.g. IBD, coeliac disease, chronic pancreatitis
- Chronic kidney disease
- Chronic liver disease
- COPD
- Menopause
- Immobility
- BMI < 18.5 kg/m2
- Risks factors affecting bone strength that do not reduce BMD:
- Age
- Oral corticosteroids
- Smoking
- Alcohol
- Previous fragility fracture
- Rheumatological disease e.g. rheumatoid arthritis
- Parental history of hip fracture
- Risk factors affecting bone strength with unestablished mechanisms:
- Selective serotonin reuptake inhibitors (SSRIs)
- Proton pump inhibitors (PPI)
- Anticonvulsant drugs e.g. carbamazepine
- Risk factors for falls:
- Impaired vision
- Neuromuscular weakness and incoordination
- Cognitive impairment
- Use of alcohol and sedative drugs
Osteoporosis and Fragility Fractures
Elderly Care & Frailty
Last Updated: 5th March 2021
Osteoporosis is a disease characterised by low bone mass and structural deterioration of bone tissue, with a consequent increase in bone fragility and susceptibility to fracture. Osteoporosis is the end result of an imbalance in the normal process of bone remodelling by osteoclasts and osteoblasts. It is asymptomatic and often remains undiagnosed until a fragility fracture occurs.
Definitions
- Osteoporosis is defined by the World Health Organization as a bone mineral density (BMD) of 2.5 standard deviations below the mean peak mass (average of young healthy adults) as measured by dual-energy X-ray absorptiometry (DXA) applied to the femoral neck and reported as a T-score.
- An osteoporotic fracture is a fragility fracture occurring as a consequence of osteoporosis. Osteoporotic fractures characteristically occur in the wrist, spine and hip, but can also occur in the arm, pelvis, ribs and other bones.
- A fragility fracture is defined as a fracture following a fall from standing height or less, although vertebral fractures may occur spontaneously, or as a result of routine activities such as bending or lifting.
Risk factors
The risk of getting an osteoporotic fracture depends on the person's risk of falls, their bone strength (determined by bone mineral density), and other risk factors.
Risk factors for having a fragility fracture:
- Risks factors affecting bone strength that reduce BMD:
- Endocrine disease e.g. diabetes mellitus, hyperthyroidism, hyperparathyroidism
- Malabsorptive disease e.g. IBD, coeliac disease, chronic pancreatitis
- Chronic kidney disease
- Chronic liver disease
- COPD
- Menopause
- Immobility
- BMI < 18.5 kg/m2
- Risks factors affecting bone strength that do not reduce BMD:
- Age
- Oral corticosteroids
- Smoking
- Alcohol
- Previous fragility fracture
- Rheumatological disease e.g. rheumatoid arthritis
- Parental history of hip fracture
- Risk factors affecting bone strength with unestablished mechanisms:
- Selective serotonin reuptake inhibitors (SSRIs)
- Proton pump inhibitors (PPI)
- Anticonvulsant drugs e.g. carbamazepine
- Risk factors for falls:
- Impaired vision
- Neuromuscular weakness and incoordination
- Cognitive impairment
- Use of alcohol and sedative drugs
Assessment for fragility fracture risk
- Exclude non-osteoporotic causes for fragility fractures:
- Metastatic bone disease (bone pain, history of cancer (especially lung, thyroid, prostate, kidney, or breast cancer), or symptoms of undiagnosed cancer (for example unexplained general malaise or weight loss)
- Multiple myeloma (bone pain, anaemia, recurrent infection, bleeding, hypercalcaemia, kidney disease)
- Osteomalacia (bone pain, muscle pain or proximal muscle weakness)
- Paget’s disease (bone pain or deformity)
- Aneurysmal bone cyst or hemangioma
- Infection e.g. osteomyelitis, Pott's disease
- Exclude secondary causes of osteoporosis especially in people with a fragility fracture who are at low risk, including men of any age, pre-menopausal women, and women with premature menopause (under 40 years of age)
- Consider starting drug treatment in people with vertebral or hip fractures without undertaking DXA if this is considered inappropriate or impractical
- Offer a dual-energy X-ray absorptiometry (DXA) scan to measure bone mineral density (BMD) without calculating the fragility fracture risk in people:
- Over 50 years of age with a history of fragility fracture
- Younger than 40 years of age who have a major risk factor for fragility fracture
- For all other people with risk factors for osteoporosis, calculate the 10-year fragility fracture risk prior to arranging a DXA scan to measure BMD; consider using the online risk calculators QFracture® (preferred) or FRAX®, which predict the absolute risk of hip fracture and major osteoporotic fractures (spine, wrist, hip, or shoulder) over 10 years
- High risk: For people whose fracture risk is above the recommended threshold, offer a dual-energy x-ray absorptiometry (DXA) scan, then bone-sparing drug treatment if the T-score is -2.5 or less; if the T-score is greater than -2.5, modify risk factors where possible, treat any underlying conditions, and repeat the DXA at an interval appropriate for the person based on their risk profile, using clinical judgement (but usually within 2 years)
- Intermediate risk: For people whose fracture risk is close to the recommended threshold and who have risk factors that may be underestimated by FRAX®, arrange a DXA scan to measure their bone mineral density (BMD) and offer drug treatment if the T-score is -2.5 or less
- Low risk: For people whose fracture risk is below the recommended threshold, do not offer drug treatment, offer lifestyle advice and follow up within 5 years
- Assess for vitamin D deficiency and inadequate calcium intake.
- People are at risk of vitamin D deficiency if they are aged over 65 years, or are not exposed to much sunlight (because they are confined indoors for long periods, or because they wear clothes that cover the whole body)
- A calcium intake of at least 1000 mg/day is recommended for people at increased risk of a fragility fracture
- Identify any risk factors for falls
Management
- Lifestyle advice
- Advise the person to:
- Take regular exercise to improve muscle strength
- Eat a balanced diet
- Stop smoking if needed
- Drink alcohol within recommended limits
- Advise the person to:
- Bone-sparing treatment
- Prescribe a bisphosphonate (alendronate 10 mg once daily or 70 mg once weekly, or risedronate 5 mg once daily or 35 mg once weekly), if there are no contraindications and after appropriate counselling, to postmenopausal women and men over 50 years of age who have been confirmed by dual-energy X-ray absorptiometry (DXA) scan to have osteoporosis (bone mineral density [BMD] T-score of -2.5 or less).
- Consider prescribing to people who are taking high doses of oral corticosteroids (more than or equivalent to prednisolone 7.5 mg daily for 3 months or longer).
- If an oral bisphosphonate is not tolerated or is contraindicated, consider specialist referral. Specialist treatment options include zoledronic acid, strontium ranelate, raloxifene, denosumab, and teriparatide.
- Calcium and vitamin D supplements
- If the person's calcium intake is adequate (700 mg/day), prescribe 10 micrograms (400 international units) of vitamin D (without calcium) for people not exposed to much sunlight.
- If calcium intake is inadequate prescribe 10 micrograms (400 international units) of vitamin D with at least 1000 mg of calcium daily; prescribe 20 micrograms (800 international units) of vitamin D with at least 1000 mg of calcium daily for elderly people who are housebound or living in a nursing home.
- Hormone replacement therapy
- Consider prescribing hormone replacement therapy (HRT) to women who have a premature menopause (menopause before 40 years of age) to reduce the risk of fragility fractures and for the relief of menopausal symptoms.
Vertebral compression fractures
Vertebral compression fractures are the most common type of osteoporotic fracture. They often occur at the midthoracic (T7 - T8) spine and the thoracolumbar junction (T12 - L1).
Fractures may result in significant back pain, limited physical functioning and activities of daily living, and can lead to loss of independence, depression, and chronic pain. Osteoporotic vertebral compression that occurs slowly over time is often asymptomatic. Old or healed fractures may be an incidental finding on radiographs of the chest or abdomen. In other patients, the presence of vertebral fractures may become apparent because of height loss or kyphosis. In contrast, acute episodes of significant vertebral body compression are associated with pain.
In patients who have acute symptomatic vertebral body fracture, there is often no history of preceding trauma. The typical patient presents with acute back pain after sudden bending, coughing, or lifting. The pain is usually well localised to the midline spine but often refers in a unilateral or bilateral pattern into the flank, anterior abdomen, or the posterior superior iliac spine. On physical examination, the patient may experience pain upon palpation and percussion of the corresponding spinous process and paravertebral structures.
Acute episodes of pain following a vertebral body fracture usually resolve after four to six weeks, but pain may persist for longer periods (many months), indicating an unhealed or slowly healing fracture. The initial management of osteoporotic vertebral compression fractures should include pain control and activity modification (bed rest is not recommended). The indications for and timing of vertebral augmentation procedures are controversial. Most patients with vertebral compression fractures can be treated successfully with conservative management.
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- Biochemistry
- Blood Gases
- Haematology
| Biochemistry | Normal Value |
|---|---|
| Sodium | 135 – 145 mmol/l |
| Potassium | 3.0 – 4.5 mmol/l |
| Urea | 2.5 – 7.5 mmol/l |
| Glucose | 3.5 – 5.0 mmol/l |
| Creatinine | 35 – 135 μmol/l |
| Alanine Aminotransferase (ALT) | 5 – 35 U/l |
| Gamma-glutamyl Transferase (GGT) | < 65 U/l |
| Alkaline Phosphatase (ALP) | 30 – 135 U/l |
| Aspartate Aminotransferase (AST) | < 40 U/l |
| Total Protein | 60 – 80 g/l |
| Albumin | 35 – 50 g/l |
| Globulin | 2.4 – 3.5 g/dl |
| Amylase | < 70 U/l |
| Total Bilirubin | 3 – 17 μmol/l |
| Calcium | 2.1 – 2.5 mmol/l |
| Chloride | 95 – 105 mmol/l |
| Phosphate | 0.8 – 1.4 mmol/l |
| Haematology | Normal Value |
|---|---|
| Haemoglobin | 11.5 – 16.6 g/dl |
| White Blood Cells | 4.0 – 11.0 x 109/l |
| Platelets | 150 – 450 x 109/l |
| MCV | 80 – 96 fl |
| MCHC | 32 – 36 g/dl |
| Neutrophils | 2.0 – 7.5 x 109/l |
| Lymphocytes | 1.5 – 4.0 x 109/l |
| Monocytes | 0.3 – 1.0 x 109/l |
| Eosinophils | 0.1 – 0.5 x 109/l |
| Basophils | < 0.2 x 109/l |
| Reticulocytes | < 2% |
| Haematocrit | 0.35 – 0.49 |
| Red Cell Distribution Width | 11 – 15% |
| Blood Gases | Normal Value |
|---|---|
| pH | 7.35 – 7.45 |
| pO2 | 11 – 14 kPa |
| pCO2 | 4.5 – 6.0 kPa |
| Base Excess | -2 – +2 mmol/l |
| Bicarbonate | 24 – 30 mmol/l |
| Lactate | < 2 mmol/l |
