11. CGA in Primary Care Settings: Bone health
Older people with frailty, those with reduced mobility and those with multiple co-morbidities are all susceptible to problems with bone health. This will include people with Parkinson's disease and other movement disorders, people with dementia and those with obesity or other manifestations of the metabolic syndrome. Anyone presenting with a fragility fracture (defined as fractures caused by falls or trauma from standing height or less) must be screened for bone health.
The commonest bone problems found in older people are osteoporosis and vitamin D deficiency, which are typically clinically silent. However other diseases, such as Paget’s disease of the bone, osteomalacia (clinically evident vitamin D deficiency), and hyperparathyroidism may be relevant, and older people may present with bony pain or hypercalcaemia due to bony metastases or primary malignancy of the bone.
In general a comprehensive assessment of an older person with regard to bone health should include:
History: Bony pain? Loss of height/change of posture? Weight loss?
PMHx: Previous fractures? Age at menopause? FHx: Osteoporosis?
DHx: Current (or previous) glucocorticoids? SHx: Diet? Alcohol? Smoking? Sunlight exposure? Exercise?
Examination: Height, weight and posture. Evidence of arthritis. Muscle strength.
Use a screening tool to assess osteoporosis risk. Q Fracture is helpful in primary care as it does not require bone mineral density to be known in advance (although it is possible to use a preliminary version of FRAX which is then reclassified once bone mineral density is known). Both of these tools have associated Apps available from itunes.
Osteoporosis risk assessment: Use the FRAX-UK score.
Investigations
Urea & Electrolytes, Calcium, Phosphate, Alkaline Phosphatase, Thyroid Function.
DXA scanning to assess bone mineral density is useful in patients with a high FRAX/QF score to determine if treatment for osteoporosis is indicated. Previous low impact fragility fractures in people over 75 can be sufficient to diagnose osteoporosis without DXA.
Vitamin D Serum Vitamin D levels (25-OH Vitamin D) can be difficult to interpret and there is controversy about replacement. Supplementation in patients with osteoporosis, or at high risk of low vitamin D, without checking serum levels is acceptable.
Further Information
More detail about fragility fractures and the prevention of osteoporosis: NICE Clinical Knowledge Summary – Osteoporosis.