Resources for the Comprehensive Geriatric Assessment based
Proactive and Personalised Primary Care of the Elderly
Bone Health Assessment
What Investigations Follow FRAX ?
1. How to use FRAX® results to make treatment decisions
Many people confuse the results of FRAX with the recommendations for treatment based on the results.
The FRAX does the best job available for predicting fractures, but it can't tell if a treatment will safely reduce the fracture rate or not. That will depend on other factors such as the underlying diseases, allergies, risks of medicines, interactions with other medicines, cost, and safety.
Interpretation of BMD test results (Group Health, 2013)
2. Evaluation and management of osteoporotic and fragility fractures (BCMA, 2012)
3. When to order a DEXA scan (Group Health, 2013)
4. Examples of Medications That May Contribute to Bone Loss (Group Health, 2013)
ANTICOAGULANTS - heparin, warfarin
ANTICONVULSANTS - carbamazepine, phenytoin
AROMATASE INHIBITORS - anastazole, letrozole, exemestane
BARBITUATES - phenobarbital
CHEMOTHERAPEUTIC/CYTOTOXIC AGENTS - various
GLUCOCORTICOIDS ** - various
GONADOTROPIN RELEASING HORMONE AGONISTS - buserelin, goserelin, leuprolide acetate
PROTON PUMP INHIBITORS
SELECTIVE SEROTONIN REUPTAKE INHIBITORS - various
THIAZOLIDINEDIONES - pioglitazone, rosiglitazone
THYROID HORMONES IN EXCESS
*This is not a complete list of medications.
**Particularly chronic glucocorticoid use i.e., ≥ 3 months of consecutive therapy at a dose of prednisone ≥ 7.5mg per day or equivalent
5. X-ray T-L spine where
vertebral fractures are suspected (may be silent)
patient has lost > 1,5 inch height
6. Testing for Suspected Secondary Causes of OP in Selected Patients
Minimum laboratory screen :
↑ = high ↗ = may be high ± = may be either high or low
↓ = low ↘ = may be low N = normal
(1) ↑ Alk.Phos (ALP) is indicative of gross increase in bone formation such as osteomalacia, fracture healing, metastatic disease, Pagets
and prolonged immobilisation
(2) Ca+, Alk.Phos. and phosphorus (PO4) are usually normal in persons with primary osteoporosis
Osteoporosis and osteomalacia may be secondary to :
(3) Chronic Liver disease
cholestatic liver disease
(4) Thyroid disease ↑ T4 and ↓ TSH
too much thyroid hormone Rx in hypothyroidism management
primary (tumour) ↑ s.Ca+ and ↑ PTH
secondary (prolonged ↓ s. Ca+ and ↓ Phosphorus) in CKD, malabsorbtion
tertiary (parathyroid gland hypertrophy) in some cases of secondary H/parath.
(6) Coeliac Disease
included in screen because may cause minimal symptoms (anemia, tiredness)
without obvious bowel symptoms
and gluten free diet improves OP in these cases also
(7) Magnesium is ↓ in Coeliac and in other malabsorbtion pathologies
(8) Diabetes Type 1
expecially if of > 5 years duration
7. Further Screening
Where appropriate screen further for :
Appropriate panels of investigations for suspected medical conditions causing secondary OP, highlighted by the minimal laboratory screen
Activities of Daily Living and
Instrumental Activities of Daily Living
Mini Nutritional Assessment
8. Follow-up/Monitoring: Patients Who HAVE NOT Sustained a Fracture (Group Health, 2013)
9. Follow-up/Monitoring: Patients Who HAVE Sustained a Fracture (Group Health, 2013)
The International Osteoporosis Foundation, who have supported FRAX, list these limitations
Does not accommodate all known risk factors.
Lacks detail on some risk factors.
Depends on adequacy of epidemiological information.
Limited country models available.
Model relevant only for untreated patients
Does not replace clinical judgment
The Bone Health Assessment is one of 5 sub-domains of the
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The Medical Assessment is one of 8 domains of the
Comprehensive Geriatric Assessment (CGA)
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