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)

Rx recommend.png

(Kaiser Permanente, 2019)

3.  When to order a DEXA scan  (Kaiser Permanente, 2019)

dexa recommendations.png

4.   Examples of Medications That May Contribute to Bone Loss

 

ANTICOAGULANTS - heparin, warfarin

ANTICONVULSANTS - carbamazepine, phenytoin

AROMATASE INHIBITORS - anastazole, letrozole, exemestane

BARBITUATES - phenobarbital

CHEMOTHERAPEUTIC/CYTOTOXIC AGENTS - various

CYCLOSPORINE

DEPO-MEDROXYPROGESTERONE

GLUCOCORTICOIDS ** - various

GONADOTROPIN RELEASING HORMONE AGONISTS - buserelin, goserelin, leuprolide acetate

LITHIUM

PROTON PUMP INHIBITORS

SELECTIVE SEROTONIN REUPTAKE INHIBITORS - various

TACROLIMUS

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

cirrhosis

cholestatic liver disease

 

(4)  Thyroid disease ↑ T4 and ↓ TSH

hyperthyroidism
too much thyroid hormone Rx in hypothyroidism management

 

(5)  Hyperparathyroidism

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
unknown etiology

7.  Further Screening

 

Where appropriate screen further for :

  • Pathology

    • Appropriate panels of investigations for suspected medical conditions     causing secondary OP, highlighted by the minimal laboratory screen

  •  Functioning

    • Activities of Daily Living and

    • Instrumental Activities of Daily Living

  • Mental State

    • Clock Test

    • MoCA

  • Nutrition

    • Mini Nutritional Assessment

8. Follow-up/Monitoring: Patients Who HAVE NOT Sustained a Fracture (Kaiser Permanente, 2019)

9.  Follow-up/Monitoring: Patients Who HAVE Sustained a Fracture

FRAX® Limitations

 

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

Medication

This Read More page is an extension of Bone Health Assessment

Back To : Bone Health Assessnment

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The Bone Health Assessment is one of 5 sub-domains of the

 Medical Assessment

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The Medical Assessment is one of 8 domains of the

 Comprehensive Geriatric Assessment (CGA)

Back To : Comprehensive Geriatric Assessment