Osteoporosis Risk Assessment

Osteoporosis is characterised by low bone mineral density and deterioration of bone structure, resulting in an increased susceptibility to fractures of the hip, spine, and wrist.¹

• Based on measures of bone mineral density (BMD) in Caucasians, osteoporosis is present in 15% of those 50–59 years of age, but these figures increase quickly to 70% of those over 80 years of age.
• The most costly result of osteoporosis is the hip fracture, which nearly always requires hospitalisation, is fatal 20% of the time and permanently disables a further 50%; only 30% fully recover.
• 1.7 million hip fractures occurred worldwide in 1990; this figure is expected to rise to 6 million in 2050.¹

Primary Care is ideally situated to try and identify patients at increased risk before symptoms develop, whilst both orthopaedic surgeons and Primary Care should be vigilant to assess all patients with suspected fragility fractures. There are several risk factors which often coexist to substantially increase risk:

As far as "case finding" is concerned - consider doing full assessments and/or BMD DEXA scans on patients with one or more risk factors:³

• Known low BMD (DXA at spine or hip)
• Prior vertebral fracture or fragility fracture
• Long-term glucocorticoid treatment
• Rheumatoid arthritis
• Other secondary case of osteoporosis: type 1 diabetes, osteogenesis imperfecta in adults, anorexia nervosa, hyperparathyroidism, untreated long-standing hyperthyroidism, hypogonadism or premature menopause (<45 years), chronic malnutrition or malabsorption (e.g. coeliac disease, inflammatory bowel disease) and chronic liver disease
• Family history of osteoporosis (maternal, paternal and sisters - including history of fragility fractures aged >50)⁴
• Low BMI (particularly in post-menopausal women)
• Alcohol intake >3units per day³
• Cigarette smoker

See Osteoporosis Management in Primary Care.

• Primary care surgeries might identify all reported cases of fractures (hip, pelvis, vertebral, humerus or wrist) from discharge summaries and perform FRAX™ risk assessments³ on these patients. Patients <75 years of age may be referred for a dexa scan, whereas those over this age with definite fragility fracture can be assumed to have osteoporosis and treated anyway.
• Search practice database to identify all patients on long term glucocorticoids, chronic liver disease, type 1 diabetes and FRAX™ risk assess these patients as well.³
• Consider osteoporosis risk during the annual reviews of other chronic diseases (eg CHD, hypertension, etc.).

Patients found to be at increased risk of fracture should be offered a bone preserving agent, depending on agreed threshold. The National Osteoporosis Guideline Group suggest interventions according to the patient's risk - click on the NOGG button available after using the FRAX™ calculator. See our osteoporosis article for discussion on treatments.