Oestoporosis and Fracture Liasion Services

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Osteoporosis

Overview

Osteoporosis causes bones to become weak and brittle — so brittle that a fall or even mild stresses such as bending over or coughing can cause a fracture. Osteoporosis-related fractures most commonly occur in the hip, wrist or spine.

Bone is living tissue that is constantly being broken down and replaced. Osteoporosis occurs when the creation of new bone doesn’t keep up with the loss of old bone.

Osteoporosis affects men and women of all races. But white and Asian women — especially older women who are past menopause — are at highest risk. Medications, healthy diet and weight-bearing exercise can help prevent bone loss or strengthen already weak bones.

Symptoms

There typically are no symptoms in the early stages of bone loss. But once your bones have been weakened by osteoporosis, you might have signs and symptoms that include:

  • Back pain, caused by a fractured or collapsed vertebra
  • Loss of height over time
  • A stooped posture
  • A bone that breaks much more easily than expected

When to see a doctor

You might want to talk to your doctor about osteoporosis if you went through early menopause or took corticosteroids for several months at a time, or if either of your parents had hip fractures.

Causes

Your bones are in a constant state of renewal — new bone is made and old bone is broken down. When you’re young, your body makes new bone faster than it breaks down old bone and your bone mass increases. After the early 20s this process slows, and most people reach their peak bone mass by age 30. As people age, bone mass is lost faster than it’s created.

How likely you are to develop osteoporosis depends partly on how much bone mass you attained in your youth. Peak bone mass is somewhat inherited and varies also by ethnic group. The higher your peak bone mass, the more bone you have “in the bank” and the less likely you are to develop osteoporosis as you age.

Risk factors

A number of factors can increase the likelihood that you’ll develop osteoporosis — including your age, race, lifestyle choices, and medical conditions and treatments.

Unchangeable risks

Some risk factors for osteoporosis are out of your control, including:

  • Your sex.

    Women are much more likely to develop osteoporosis than are men.

  • Age.

    The older you get, the greater your risk of osteoporosis.

  • Race.

    You’re at greatest risk of osteoporosis if you’re white or of Asian descent.

  • Family history.

    Having a parent or sibling with osteoporosis puts you at greater risk, especially if your mother or father fractured a hip.

  • Body frame size.

    Men and women who have small body frames tend to have a higher risk because they might have less bone mass to draw from as they age.

Hormone levels

Osteoporosis is more common in people who have too much or too little of certain hormones in their bodies. Examples include:

  • Sex hormones.

    Lowered sex hormone levels tend to weaken bone. The reduction of estrogen levels in women at menopause is one of the strongest risk factors for developing osteoporosis.

Men have a gradual reduction in testosterone levels as they age. Treatments for prostate cancer that reduce testosterone levels in men and treatments for breast cancer that reduce estrogen levels in women are likely to accelerate bone loss.

  • Thyroid problems.

    Too much thyroid hormone can cause bone loss. This can occur if your thyroid is overactive or if you take too much thyroid hormone medication to treat an underactive thyroid.

  • Other glands.

    Osteoporosis has also been associated with overactive parathyroid and adrenal glands.

Dietary factors

Osteoporosis is more likely to occur in people who have:

  • Low calcium intake.

    A lifelong lack of calcium plays a role in the development of osteoporosis. Low calcium intake contributes to diminished bone density, early bone loss and an increased risk of fractures.

  • Eating disorders.

    Severely restricting food intake and being underweight weakens bone in both men and women.

  • Gastrointestinal surgery.

    Surgery to reduce the size of your stomach or to remove part of the intestine limits the amount of surface area available to absorb nutrients, including calcium. These surgeries include those to help you lose weight and for other gastrointestinal disorders.

Steroids and other medications

Long-term use of oral or injected corticosteroid medications, such as prednisone and cortisone, interferes with the bone-rebuilding process. Osteoporosis has also been associated with medications used to combat or prevent:

  • Seizures
  • Gastric reflux
  • Cancer
  • Transplant rejection

Medical conditions

The risk of osteoporosis is higher in people who have certain medical problems, including:

  • Celiac disease
  • Inflammatory bowel disease
  • Kidney or liver disease
  • Cancer
  • Lupus
  • Multiple myeloma
  • Rheumatoid arthritis

Lifestyle choices

Some bad habits can increase your risk of osteoporosis. Examples include:

  • Sedentary lifestyle.

    People who spend a lot of time sitting have a higher risk of osteoporosis than do those who are more active. Any weight-bearing exercise and activities that promote balance and good posture are beneficial for your bones, but walking, running, jumping, dancing and weightlifting seem particularly helpful.

  • Excessive alcohol consumption.

    Regular consumption of more than two alcoholic drinks a day increases your risk of osteoporosis.

  • Tobacco use.

    The exact role tobacco plays in osteoporosis isn’t clear, but it has been shown that tobacco use contributes to weak bones.

Complications

Bone fractures, particularly in the spine or hip, are the most serious complications of osteoporosis. Hip fractures often are caused by a fall and can result in disability and even an increased risk of death within the first year after the injury.

In some cases, spinal fractures can occur even if you haven’t fallen. The bones that make up your spine (vertebrae) can weaken to the point of crumpling, which can result in back pain, lost height and a hunched forward posture.

Prevention

Good nutrition and regular exercise are essential for keeping your bones healthy throughout your life.

Protein

Protein is one of the building blocks of bone. However, there’s conflicting evidence about the impact of protein intake on bone density.

Most people get plenty of protein in their diets, but some do not. Vegetarians and vegans can get enough protein in the diet if they intentionally seek suitable sources, such as soy, nuts, legumes, seeds for vegans and vegetarians, and dairy and eggs for vegetarians.

Older adults might eat less protein for various reasons. If you think you’re not getting enough protein, ask your doctor if supplementation is an option.

Body weight

Being underweight increases the chance of bone loss and fractures. Excess weight is now known to increase the risk of fractures in your arm and wrist. As such, maintaining an appropriate body weight is good for bones just as it is for health in general.

Calcium

Men and women between the ages of 18 and 50 need 1,000 milligrams of calcium a day. This daily amount increases to 1,200 milligrams when women turn 50 and men turn 70.

Good sources of calcium include:

  • Low-fat dairy products
  • Dark green leafy vegetables
  • Soy products, such as tofu
  • Calcium-fortified cereals and orange juice

If you find it difficult to get enough calcium from your diet, consider taking calcium supplements. Total calcium intake, from supplements and diet combined, should be no more than 2,000 milligrams daily for people older than 50.

Vitamin D

Vitamin D improves your body’s ability to absorb calcium and improves bone health in other ways. People can get some of their vitamin D from sunlight, but this might not be a good source if you live in a high latitude, if you’re housebound, or if you regularly use sunscreen or avoid the sun because of the risk of skin cancer.

To get enough vitamin D to maintain bone health, it’s recommended that adults ages 51 to 70 get 600 international units (IU) and 800 IU a day after age 70 through food or supplements.

People without other sources of vitamin D and especially with limited sun exposure might need a supplement. Most multivitamin products contain between 600 and 800 IU of vitamin D. Up to 4,000 IU of vitamin D a day is safe for most people.

Exercise

Exercise can help you build strong bones and slow bone loss. Exercise will benefit your bones no matter when you start, but you’ll gain the most benefits if you start exercising regularly when you’re young and continue to exercise throughout your life.

Combine strength training exercises with weight-bearing and balance exercises. Strength training helps strengthen muscles and bones in your arms and upper spine. Weight-bearing exercises — such as walking, jogging, running, stair climbing, skipping rope, skiing and impact-producing sports — affect mainly the bones in your legs, hips and lower spine. Balance exercises such as tai chi can reduce your risk of falling especially as you get older.

Swimming, cycling and exercising on machines such as elliptical trainers can provide a good cardiovascular workout, but they don’t improve bone health.

Diagnosis

Your bone density can be measured by a machine that uses low levels of X-rays to determine the proportion of mineral in your bones. During this painless test, you lie on a padded table as a scanner passes over your body. In most cases, only a few bones are checked — usually in the hip and spine.

Treatment

Treatment recommendations are often based on an estimate of your risk of breaking a bone in the next 10 years using information such as the bone density test. If your risk isn’t high, treatment might not include medication and might focus instead on modifying risk factors for bone loss and falls.

Biophosphonates

For both men and women at increased risk of fracture, the most widely prescribed osteoporosis medications are bisphosphonates. Examples include:

  • Alendronate (Binosto, Fosamax)
  • Risedronate (Actonel, Atelvia)
  • Ibandronate (Boniva)
  • Zoledronic acid (Reclast, Zometa)

Side effects include nausea, abdominal pain and heartburn-like symptoms. These are less likely to occur if the medicine is taken properly.

Intravenous forms of bisphosphonates don’t cause stomach upset but can cause fever, headache and muscle aches for up to three days. It might be easier to schedule a quarterly or yearly injection than to remember to take a weekly or monthly pill, but it can be more costly to do so.

Monoclonal antibody medications

Compared with bisphosphonates, denosumab (Prolia, Xgeva) produces similar or better bone density results and reduces the chance of all types of fractures. Denosumab is delivered via a shot under the skin every six months.

If you take denosumab, you might have to continue to do so indefinitely. Recent research indicates there could be a high risk of spinal column fractures after stopping the drug.

A very rare complication of bisphosphonates and denosumab is a break or crack in the middle of the thighbone.

A second rare complication is delayed healing of the jawbone (osteonecrosis of the jaw). This can occur after an invasive dental procedure such as removing a tooth.

You should have a dental examination before starting these medications, and you should continue to take good care of your teeth and see your dentist regularly while on them. Make sure your dentist knows that you’re taking these medications.

Hormone-related therapy

Estrogen, especially when started soon after menopause, can help maintain bone density. However, estrogen therapy can increase the risk of blood clots, endometrial cancer, breast cancer and possibly heart disease. Therefore, estrogen is typically used for bone health in younger women or in women whose menopausal symptoms also require treatment.

Raloxifene (Evista) mimics estrogen’s beneficial effects on bone density in postmenopausal women, without some of the risks associated with estrogen. Taking this drug can reduce the risk of some types of breast cancer. Hot flashes are a common side effect. Raloxifene also may increase your risk of blood clots.

In men, osteoporosis might be linked with a gradual age-related decline in testosterone levels. Testosterone replacement therapy can help improve symptoms of low testosterone, but osteoporosis medications have been better studied in men to treat osteoporosis and thus are recommended alone or in addition to testosterone.

Bone-building medications

If you can’t tolerate the more common treatments for osteoporosis — or if they don’t work well enough — your doctor might suggest trying:

  • Teriparatide (Forteo).

    This powerful drug is similar to parathyroid hormone and stimulates new bone growth. It’s given by daily injection under the skin. After two years of treatment with teriparatide, another osteoporosis drug is taken to maintain the new bone growth.

  • Abaloparatide (Tymlos) is another drug similar to parathyroid hormone.

    You can take it for only two years, which will be followed by another osteoporosis medication.

  • Romosozumab (Evenity).

    This is the newest bone-building medication to treat osteoporosis. It is given as an injection every month at your doctor’s office. It is limited to one year of treatment, followed by other osteoporosis medications.

Lifestyle and home remedies

These suggestions might help reduce your risk of developing osteoporosis or breaking bones:

  • Don’t smoke.

    Smoking increases rates of bone loss and the chance of fracture.

  • Avoid excessive alcohol.

    Consuming more than two alcoholic drinks a day might decrease bone formation. Being under the influence of alcohol also can increase your risk of falling.

  • Prevent falls.

    Wear low-heeled shoes with nonslip soles and check your house for electrical cords, area rugs and slippery surfaces that might cause you to fall. Keep rooms brightly lit, install grab bars just inside and outside your shower door, and make sure you can get into and out of your bed easily.

Alternative medicine

There is limited evidence that certain supplements, such as vitamin K-2 and soy, can help lower fracture risk in osteoporosis, but more studies are needed to prove benefits and determine risks.

Burden of disease and management approach:

Osteoporosis is a disease characterized by low bone mass and deterioration  in the microarchitecture of bone tissue, leading to an increased risk of fracture. Osteoporosis occurs when the bone mass decreases more quickly than the body can replace it, leading to a net loss of bone strength. As a result the skeleton becomes fragile,so that even a slight bump or fall can lead to a broken bone, (referred to as a fragility fracture). Osteoporosis has no signs or symptoms until a fracture occurs – this is why it is often called a ‘silent disease’.

Osteoporosis affects all bones in the body; however, fractures occur most frequently in the vertebrae (spine), wrist and hip. Osteoporotic fractures of the pelvis, upper arm and lower leg are also common. Osteoporosis itself is not painful but the broken bones can result in severe pain, significant disability and even mortality. Both hip and spine fractures are also associated with a higher risk of death – 20% of those who suffer a hip fracture die within 6 months after the fracture.

A COMMON DISEASE

It is estimated that worldwide an osteoporotic fracture occurs every three seconds. At 50 years of age, one in two women and one in five men will suffer a fracture in their remaining lifetime. For women this risk is higher than the risk of breast,ovarian and uterine cancer combined. For men, the risk is higher than the risk for prostate cancer. Approximately 50% of people with one osteoporotic fracture will have another, with the risk of new fractures rising exponentially with each fracture.

A GROWING PUBLIC HEALTH PROBLEM

The risk of sustaining a fracture increases exponentially with age due not only to the decrease in bone mineral density, but also due to the increased rate of falls among the elderly. The elderly represent the fastest growing segment of the population.Thus, as life expectancy increases for the majority of the world’s population, the financial and human costs associated with osteoporotic fractures will increase dramatically unless preventive action is taken.

Nature has provided us with an opportunity to systematically identify a significant proportion of individuals that will suffer fragility fractures in the future. This is attributable to the well recognised phenomenon that fracture begets fracture. Those patients that suffer a fragility fracture today are much more likely to suffer fractures in the future; in fact, they are twice as likely to fracture as their peers that haven’t fractured yet.

Healthcare providers have recognized the opportunity for ‘secondary fracture prevention’, by creating policies and criteria that support treatment of osteoporosis for patients presenting with fragility fractures. Regrettably, by missing the opportunity to respond to the first fracture, healthcare systems around the world are failing to prevent the second and subsequent fractures. Secondary preventive care has shown that the majorities of fragility fracture patients never learn about the underlying cause of their fracture, or receive treatment to prevent it from happening again. Half of hip fracture patients have suffered prior fragility fractures. One sixth of postmenopausal women have suffered a fragility fracture. Systems with a dedicated post-fracture coordinator at their heart have transformed post-fracture osteoporosis care, resulting in significantly lower re-fracture rates and enormous cost savings. Thus the role of a dedicated fracture liaison service is deployed.

Fracture Liaison Service (FLS)

Delivery of evidence-based secondary preventive care to patients presenting with fragility fractures provides an opportunity to break the fragility fracture cycle.

Structure of a Fracture Liaison Service(FLS)

* Older patients, where appropriate, are identified and referred for falls assessment

Key elements of the model of care

Osteoporotic refracture prevention services will include the key elements outlined below. The elements will be delivered by the osteoporotic refracture prevention team with responsibilities allocated as appropriate. Team members include the fracture liaison coordinator, medical officer, local falls prevention team members, and other collaborators.

Active identification

People aged 50 years or more presenting with minimal trauma fractures at acute, outpatient, community and primary healthcare settings will be actively identified.

Care coordination

Fracture liaison coordinators will work with people, their families and carers to facilitate the appropriate delivery of care that supports reduced risk of refracture and effective management of bone health.

Comprehensive person-centred assessment

Assessment will determine future fracture risk including bone health (i.e. osteoporosis) and falls risk. It will be holistic and person-centred, taking into consideration the medical health, physical functioning, comorbidity, psychological and social needs of the person.

Patient-reported outcome measures (PROMs)

Valuable information about the person’s health and wellbeing will be gathered with the use of patient-reported outcome measures as part of the assessment process. PROMs will be used to improve quality of care by informing care planning and management.

Supported access to investigation

Access to further investigation will be supported. That may include bone mineral density scanning for either a definitive diagnosis (though not necessarily required to start treatment), to monitor treatment over time, or to assess for future fracture risk. Serum blood assays may also be indicated to look for underlying causal disease processes.

Initiation of appropriate medical interventions

Required medical treatment will be initiated .This treatment will include the prescription of an osteoporosis medication regimen as an addition to conservative care measures, such as vitamin D and calcium supplementation.

Health education and self-management support

Health education and self-management support will be provided to enhance knowledge and support active and informed engagement in care. It will promote a healthy lifestyle, physical activity, good nutrition and healthy eating, and osteoporosis treatments that support bone health and reduce fracture risks.

Development of a personalised management plan

A personalised management plan will be established to promote planning and application of long-term chronic disease management. It will be designed to help the person address their care needs and to meet their health goals within the context of their care preferences.

Multidisciplinary support

People will be linked to the appropriate multidisciplinary support to promote bone health and reduce falls and fracture risks. This will be achieved through establishing and fostering relationships and referral pathways to services.

Access to community services

Local community resources will be used to provide ongoing self-management support for people to facilitate behaviour change (e.g. falls prevention).

Timely and efficient communicationCommunication between primary and secondary care physicians, allied health and community service providers will facilitate reinforcement and continuity of care across healthcare settings and ensure optimum adherence with treatment and recommendations.

Follow-up

Follow-up will support the maintenance of long-term lifestyle and behaviour changes and adherence with treatment and interventions.

Data systems

Services will have data systems to collect and record the person’s interventions; collate patient outcomes; and analyse and report on service outcomes.

Patient-reported experience measures (PREMs)

Patient-reported experience measures will be used to support service evaluation and inform improvements.

Engagement in quality improvement

Regular time will be assigned in the service weekly plan to critique service interventions and processes, follow up on patient care, conduct literature reviews seeking solutions to identified issues, and plan and implement quality improvement cycles as required.

-Trauma coordinator to liaison among general physician/specialist/orthopedic surgeon/endocrinologist for a centralized reporting for any primary fragility fracture/documented osteoporosis for fracture prevention and fall risk assessment.

-Auditing and implementing of the above guidelines.

OSTEOPOROSIS QUESTIONNAIRE

FRAX SCORE(INDIA SPECIFIC)

FALL RISK ASSESSMENT

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