Geratology Flashcards
what is squamous cell carcinoma
rf
skin cancer.
metastases rare
smoking
long standing leg ulcers - marjolins ulcer
genetic conditions: xeroderma pigmentosum, oculocutaneous albinism
immunosuppression : following renal transplant, hiv
actinic keratoses and bowens disease
excessive exposure to sun/psoralen uva therapy
features of squamous cell carcinoma
on sun exposed sites like head and neck or dorsum of hands and arms
rapidly expanding painless ulcerate nodules
cauliflower like appearance
poss areas of bleeding
how to tx squamous cell carcinoma
surgical excision - 4mm if lesion under 20mm in diameter
if over 20 mm then margins should be 6 mm.
MOHS micrographic surgery.
prognosis of squamous cell carcinoma
good if well differentiate under 200mm and less than 2mm deep.
poor if poorly diff, over 20mm and 4mm deep and immunosuppressed
frailty means?
diminished strength
endurance
physiological function.
physical frailty
frailty phenotype
assessments for frailty
mx
fried frailty index
groningen frailty indicator .
mx : multi-component intervention like exercise, nutrition, med review
rf for falling in elderly
lower limb muscle weakness
vision problem
balance or gait disturbance - dm, ra, parkinson
polypharmacy
incontinence
over 65
fear of falling
depression
postural hypotension
arthritis in lower limb
psychoactive drug
cognitive impairement
name some qus to ask fall pt
where they fell when they fell
anyone see it
why they think they did
have they before
system review
pmh
social hx
meds that can cause postural hypotension
nitrates
diuretics
anticholinergic meds
antidepressant
beta blockers
l dopa
acei
meds associated with falls in elderly
benzodiazepines
antipsychotics
opiates
anticonvulsants
codeine
digoxin
other sedative agents
what ix would you do in falls
bedside tests: basic obs, bp, bg, urine dip and ecg
bloods: fbc u+e, lft, bone profile
imaging: cxr vt head cardiac echo
when would you do mdt assessment for fall pt?
over 65 with
over 2 falls in last 12 months
requires med tx
poor performance to complete turn 180 test or timed up and go test.
What is benign paroxysmal positional vertigo?
average age onset
mc cause of vertigo encountered
sudden onset dizziness and vertigo triggered by head position change.
55 average. less common in younger pts
peripheral cause of vertigo: issue in inner ear rather than brain.
features of benign paroxysmal positional vertigo?
vertigo triggered by change in head position - rolling over bed or gazing upwards
nausea
each episode : 10-20 seconds
positive dix-hallpike manoeuvre
no hearing loss/tinnitus.
what is the dix hallpike manoeuvre?
patient sits upright on a examination couch head turned 45 degrees.
support pt head to stay in 45 degree but rapidly lower pt back until head hanging off end of couch 20-30 degrees
hold pt head still turned 45 degree to 1 side and extended 20-30 degrees below level of couch.
watch eyes for 30-60 seconds - look for nystagmus.
repeat test with head turned other way in other direction.
will trigger other sx of vertigo.
rotational beats of nystagmus towards affected ear. (clockwise with left ear and anti for right) (ROTARY NYSTAGMUS)
how to get symptomatic relief from bppv?
epley manoeuvre
vestibular rehab - brandt-daroff exercises
betahistine - limited value
recurrence of bppv
sx 3-5 yrs after diagnosis
what is the epley manoeuvre?
used to tx bppv.
move crystals in semicircular canal into a position that dont disrupt endolymph flow.
do dix-hallpike : pt upright head rotated 45 to lying position, head extended off bed. rotate pts head 90 degrees past central position.
get pt to roll onto side so head rotates further 90 degrees in same direction.
get pt sit up sideways with legs off side of couch.
position head in central position with neck flexed 45 degrees, with chin towards the chest.
at each stage, support pts head in place for 30 seconds and wait for any nystagmus or dizziness to settle.
what are brandt-daroff exercises?
do at home to improve sx of bppv .
sit on end of bed lie sideways, from 1 side to other, while rotating the head slightly to face the ceiling.
What is a TIA?
brief period of neurological deficit due to vascular cause - last less than 1 hr.
transient episode of neurologic dysfunction caused by focal brain, spinal cord, or retinal ischaemia, without acute infarction.
clinical features of tia
similar to stroke : sudden onset, focal neurological deficit. but dont persist. typically resolve within 1 hr
features:
- unilateral weakness or sensory loss
-aphasia or dysarthria
-ataxia, vertigo, loss of balance
- visual problems: sudden transient loss of vision in 1 eye (amaurosis fugax), diplopia, homonymous hemianopia
typical tia mimics that need excluding
hypoglycaemia
intracranial haemorrhage - if on anticoagulant or with similar rf admit for urgent imagine to exclude haemorrhage.
pt with acute focal neuroloigcal sx that resolve completely within 24 hrs of onset. what should i do?
give aspirin 300mg immediately
assess urgently with 24 hrs by stroke specialist
imaging for tia
ct only when clinical suspicion of an alternative diagnosis that ct can detect - ie haemorrhage concern
MRI - diffusion weight and blood-sensitive - determine territory of ischaemia, detect haemorrhage or alternative pathology - do same day
how would you manage tia?
Medication:
- antiplatelet therapy - as long as no CI or high risk of bleeding
- within 24 hours of onset:
- clopidogrel - initial 300mg then 75mg od + aspirin initial dose 300mg then 75mg od for 21 days - followed by monotherapy with clopidogrel 75mg od
if not appropriate for dapt:
- clopidogrel 300mg loading dose then 75mg od
ppi considered for dapt.
lipid modification: high intensity statin like atorvastatin 20-80mg daily - reduce non-hdl cholestrol by over 40%
if a patient has af and just had a tia what should happen?
give anticoagulation as soon as intracranial haemorrhage excluded
carotid imaging for tia
benefit
what might you find
what would you do ?
atherosclerosis in carotid artery might be emboli source in some pts.
carotid duplex ultrasound or ct angiography/mr angiography.
carotid endarterectomy - if pt suffered stroke/tia in carotid territory and isnt severely disabled.
if stenosis over 50%
perform asap within 7 days
urinary incontinence risk factors
elderly female
advancing age
previous pregnancy and childbirth
high bmi
hysterectomy
fhx
postmenopause
pelvic organ prolapse
pelvic floor surgery
ms - neuro conditions
cognitive impairement and dementia
classifications of urinary incontinence
overactive bladder/urge : detrusor activity - urge to urinate quickly then uncontrollable leakage range from few drops to complete empty.
stress incontinence: cough or laugh small leak
mixed: urge and stress
overflow: bladder outlet obstruction like prostate enlargement
functional incontinence: comorbid physical condition. dementia,sedative meds, injury/illness
stress incontinence happens due to weakness of what?
pelvic floor and sphincter muscles - urine can leak at times of increased pressure on bladder
overflow incontinence happens when
what testing to do
chronic urinary retention due to obstruction to outflow of urine.
anticholinergic meds
fibroids
pelvic tumours
neuro conditions: ms, diabetic neuropathy, spinal cord injuries.
do urodynamic testing
assessing for urinary incontinence
take history.
assess lifestyle: caffeine,alcohol, meds, bmi
severity: frequency of urination/incontinence, nighttime urination, pads and clothing changes
assess pelvic tone and examine to pelvic organ prolapse,atrophic vaginitis, urethral diverticulum, pelvic masses
ask for pt to cough – watch for leakage from urethra
strength of pelvic muscle contraction assessed during bimanual examination - ask women to squeeze against examining fingers.
when i measure strength of pelvic muscle contractions, i do what exam , how do i do it and how is it graded?
bimanual exam
woman squeeze against examining fingers.
modified oxford grading:
0 - no contraction
1 - faint
2 - weak
3 - moderate with some resistance
4 - good contraction with resistance
5 - strong contraction, firm squeeze, draw inwards
ix for urinary incontinence
bladder diaries - min 3 days
vaginal exam: exclude pelvic organ prolapse and ability to initiate voluntary contraction of pelvic floor muscles (kegel)
urine dip and culture
urodynamic studies
what are urodynamic studies?
rules
measure urge incontinence not responding to 1st line medical tx, difficulties urinating, urinary retention, previous surgery or unclear diagnosis.
pts stop taking anticholinergic and bladder related meds 5 days before test.
thin catheter into bladder and another into rectum. measure pressure in bladder and rectum and compare. bladder fill with liquid then measure:
- cystometry - destrusor muscle contraction and pressure
- uroflowmetry - flow rate measured
-leak point pressure- what point bladder pressure means leakage of urinel. get pt to cough move or jump when bladder filled to diff levels. stress incontinence
-post void residual bladder vol - incomplete emptying of bladder testing
-video urodynamic testing- fill bladder with contrast. take x ray image as bladder emptied.
how would you manage stress predominant urinary incontinence?
pelvic floor muscle training - min 8 contractions 3 times per day for min 3 months.
surgery: retropubic mid-urethral tape procedures
duloxetine - if women declines surgery : combined noradrenaline and serotonin reuptake inhibitor.
weight loss avoid caffeine diuretics or overfilling bladder or fluid intake.
what is duloxetine
moa
SNRI antidepressant
combined noradrenaline and serotonin reuptake inhibitor
increased synaptic conc of noradrenaline and serotonin within pudendal nerve = increased stimulation of urethral striated muscles within sphincter = enhanced contraction.
how would you manage urge predominant incontinence?
bladder retraining - lasts for min 6 weeks - increase gradually intervals between voiding
bladder stabilising drugs: antimuscarinics - 1st line : oxybutinin , tolterodine (both immediate release) or darifenacin (once daily prep)
immediate release oxybutynin avoid in fraily older woman
mirabegron - beta 3 agonist - anticholinergci se in fraily elderly patients
botulinum toxin type a - injection to bladder wall
urinary diversion - redirect urinary flow to urostomy on abdo
augmentation cystoplasty - bowel tissue to enlarge bladder
percutaneous sacral nerve stimulation - implant device in back that stimulates sacral nerves.
what anticholinergic side effects will mirabegron give in frail elderly patients?
who is it cid in
how does it work?
cognitive decline
memory problems
worsening dementia.
used as alternative for urge iwth less anticholinergic burden.
uncontrolled htn - cid;
beta 3 agonist - stimulatres sns = raised bp. = hypertensive crisis = increased tia/stroke risk.
surgical options for stress incontinence
tension free vaginal tape - mesh sling looped under urethra and up behind pubic symphysis to abdo wall. - supports urethra reducing stress incontinence.
colpsuspension - stitches connect to anterior vaginal wall and pubic symphysis around urethra- pull vaginal wall forwards adding support to urethra.
intramural urethral bulking - involves injections around urethra to reduce diameter and add support.
autologous sling procedure - similar to tfvt - strip of fascia from pt abdo wall used not tape.
what to do if stress incontinence caused by neuro disorder or other surgical methods have failed in tx
create artificial urinary sphincter.
pump into labia inflates and deflates cuff around urethra - women control their continence.
What are pressure sores?
mc places for them
localised injury to skin and underlying tissue caused by prolonged pressure on certain areas of body.
over bony prominences: sacrum, coccyx, heels or hips
risk factors for pressure sores
immobility: bed rest/wheelchair condition like spinal cord injury,frailty, sedation or coma
nutritional deficiency: malnutrition, dehydration, low protein levels impair skin health and wound healing process
incontinence: urinary/faecal - skin maceration, increase friction between skin and bedding/clothing
sensory perception deficit: limited awareness of pain/discomfort - excess pressure. neuropathies,stroke etc
potential underlying causes of pressure sores
prolonged pressure - occlusion of capillary blood flow - ischaemia and tissue necrosis.
shearing forces: shear when skin moves 1 way while underlying bone moves opposite direction. damage to bv. and tissues.
foisture: excessive moisture due to perspiration or incontinence. skin vulnerable - damage from friction and maceration.
ageing skin: older skin thinner, less elastic, more fragile. slower cell regeneration.
screening for pts at risk of pressure areas
what does it include?
waterlow score.
bmi
nutritional status
skin type
mobility
continence
grading of pressure ulcers
european pressure ulcer advisory panel classification
1 - non-blanchable erythema of intact skinl.l discolouration of skin,warmth,oedema,induraiton or hardness may be used as indicators, in individuals with darker skin.
2 - partial thickness skin loss involving epidermis or dermis, or both. ulcer superficial and presents clinically as abrasion or blister
3 - full thickness skin loss involving damage to or necros of subcutaneous tissue that might extend down to but not through underlying fascia.
4 - extensive destruction, tissue necrosis, damage to muscle bone or supporting structures with/without full thickness skin loss
how would you manage pressure sore?
what to avoid?
mosit wound environment.
hydrocolloid dressing and hydrogels help.
avoid soap.
avoid drying wound
refer to tissue viability nurse
surgical debridement
wound swab: not routine bc they all usually colonised by bacteria anyway. if abx clinical basis if you see cellulitis.
explain non-accidental injury
types of injuries
most severe form : characterised by
how to diagnose
how to manage
physical harm/injury intentionally inflicted.
can be child abuse.
fractures
burns
contusions
internal injuries
non-accidental head injury: shaken baby syndrome:
subdural haemorrhages,retinal haemorrhages, encephalopathy.
comprehensive medical evaluation,
radiological ix : skeletal survery, ct/mri.
mdt: social services,paeds,radiology, forensics
What is hyperthermia and hypothermia?
hyper: what is it? how can ithappen? what comps?
hypo? what is it? how ? what comps? what can it cause?
body temperature dysregulation.
hyper: elevated core body temp. - failed thermoregulation: could be by heat stroke, adverse drug reactions. comps: multi-organ dysfunction if not tx.
hypo: body loses heat faster than it can produce - dangerously low body temp. precipitated by prolonged exposure to cold weather or immersion in cold water. - arrhythmias, impaired conciousness, fatal comps like hypotensive shock
mx of hyperthermia and hypothermia
underlying cause rectify
stabilist pt core temp
hyper: active cooling techniques and antipyretics
hypo: passive and active rewarming methods. supportive care
What is malnutrition?
how does undernutrition manifest?
how does overnutrition manifest?
undernutrition and overnutrition.
under: stunting, wasting, deficiencies of micro-macronutrients
over: overweight or obesity.
severe form of undernutrition
how does it happen?
what can it lead to ?
protein-energy malnutrition.
insufficient intake of protein and energy.
can lead to marasmus, significant weight loss or kwashiorkor with oedema and skin changes.
overnutrition leads to the increase risk of what?
undernutrition leads to increased risk of what?
noncommunicable diseases like:
t2dm
cv disease
htn
certain cancer.
biochemical abnormalities:
anaemia
hypoalbuminaemia
electrolyte imbalances
Aetiology of malnutrition
inadequate diet intake
increased nutrient losses or requirements
decreased nutrient absorption
altered metabolic demands.
What is constipation?
features
functional disorder of the bowel
unsatisfactory defecation because of infrequent stools (<3 times weeklly)
difficult stool passage(with straining or discomfort) or seemingly incomplete defecation.
passage of infrequent hard stools
comps of constipation
overflow diarhoea
acute urinary retention
haemorrhoids
how would you manage constipation?
ix and exclude secondary causes, consider red flags
exclude faecal impaction
lifestyle: diet fibre, fluid intake, activity levels
1st laxative: bulk-forming laxative like ispaghula husk
second line: osmotic laxative like macrogol
normal times of defaecation in kids
mean of 3 times a day for infant under 6 months
once a day after 3 yrs
how to make a diagnosis of constipation in children
child under 1 yr
2 or more of :
stool pattern :
less than 3 complete stools per week. (type 3/4 on bristol stool form) (doesnt apply to exclusively breastfed after 6 weeks)
-hard large stool
-rabbit droppings) type 1
sx associated with defecation:
-distress on passing stool
-bleeding associated with hard stool
-straining
history:
- previous episodes of constipation
-previous or current anal fissure
how would you diagnose constipation of childdren?
child over 1 yrs
stool pattern:
-fever than 3 complete stools per week (type 3/4)
- overflow soiling (commonly very loose, very smelly, tool passed without sensation)
-rabbit droppings) type 1
-large infrequent stools that can block toilet
sx associated with defecation
- poor apetite improves with passage of large stool
- waxing and waning of abdo pain with passage of stool
- evidence of retentive posturing: typical straight legged,tiptoed, back arching posture
-straining
-anal pain
history:
- previous ep of constipation
-previous or current anal fissure
-painful bowel movements and bleeding associated with hard stools
causes of constipation in children
idiopathic
dehydration
low fibre diet
meds: opiates
anal fissue
over-enthusiastic potty training
hypothyroidism
hirschsprungs disease
hypercalcaemia
LD
by using the following different sections , i want you to tell me what indicates idiopathic consipation
timing
passage of meconium
stool pattern
growth
neuro/locomotor
abdomen
diet
other
timing: starts after few weeks of life. obvious precipitating factors coinciding with start of sx: fissure, change of diet, timing of potty/toilet training or acute events such as infections, moving house, starting nursery/school, fears and phobias, major change in family, taking meds
passage of meconium: under 48 hrs
stool pattern: nil
growth: generally well, weight and height within normal limits, fit and active
neuro/locomotor: no neuro problems in legs, normal locomotor development
abdomen: nil
diet: changes in infant formula, weaning, insufficient fluid intake or poor diet
other: nil
by using the following different sections i want you to tell me which indicates “red flag” for underlying disorder
timing
passage of meconium
stool pattern
growth
neuro/locomotor
abdomen
diet
other
timing: reported from birth or first few weeks of life
passage of meconium: after 48 hrs
stool pattern: ribbon stools
growth: faltering growth is amber flag
neuro/locomotor: previously unknown or undiagnosed weakness in legs, locomotor delay
abdo: distention
diet: nil
other: amber flag: disclosure or evidence that raises concern of child maltreatment
before you tx a child for constipation. you need to assess for whart?
what suggests this
faecal impaction
sx of severe constipation
overflow soiling
faecal mass palpable in abdomen - dre only done by specialist.
if faecal impaction is present, how do you treat constipation in children
polyethylene glycol 3350+ electrolytes (movicol paeds plain) - escalating dose regimen: 1st line
add stimulant laxative if movicol doesnt lead to disimpaction after 2 weeks
substitute stimulant laxative single or in combo with osmotic laxative like lactulose if movicol isnt tolerated
inform families that disimpaction tx can initially increase sx of soiling and abdo pain
maintenance therapy of constipation in children
1st line: movicol
add stimulant laxative if no respoonse
substitute stimulant laxative if movicol not tolerated. add another laxative like lactulose or docusate if stools hard
continue med at maintenance dose for several weeks after regular bowel habit established, then reduce dose gradually
general advise for infants not yet weaned under 6 months with constipation
bottle fed infants: give extra water in between feeds. try gentle abdo massage and bicycling the infants legs
breast fed infants: unsualy and organic causes consider
general advise for constipated children infants that have been weaned or are currently being weaned
offer extra water, diluted fruit juice and fruits
if not: add lactulose
what is encoperesis?
when is it pathological
sign of what?
what happens
faecal incontinence.
not pathological under 4 yrs old.
sign of chronic constipation where rectum is stretched and looses sensation.
large hard stools stay in rectum and only loose stools pass blockage and leak out, cause soiling.
rare causes of encoperesis
spina bifida
hirschprungs disease
cerebral palsy
ld
psycosocial stress
abuse
what is faecal impaction
large hard stool blocks the rectum.
give me a list of red flags around constipaiton in children
and attach them to the condition
not passing meconium within 48 hrs of birth - think cf or hirschprungs
neuro signs or symptoms: in lower limbs - think cerebral palsy or spinal cord lesion
vomiting: intestinal obstruction or hirschsprungs disease
ribbon stool: anal stenosis
abnormal anus: anal stenosis: ibd, sexual abuse
abnormal lower back or buttocks: spina bifidsa, spinal cord lesion or sacral agenesis
failure to thrive: coeliac, hypothyroid, safegaruding
acute severe abdo pain and bloating: obstruction or intussusception
when assessing falls patient, you must get lying/standing bp - how to do it and when can you diagnose orthostatic hypotension?
measure after 5 mins of lying down, then after 1 minute of standing , then after 3rd minute of standing.
when
1. drop in systolic of 20 more more (with/without sx)
2. drop to below 90 on standing even if drop is less than 20 (with/without sx)
3. drop in diastolic bp of 10 with symptoms
most appropriate tool for identifying medications where the risk outweighs the therapeutic benefits in certain conditions?
STOPP
digoxin toxicity symptoms
gi disturbance - nausea vomiting abdo pain
dizziness
confusion
blurry or yellow vision
arrhythmias
amitriptyline side effects
dry eyes dry mouth hypotension(often postural)
and delirium
constipation
urinary retention
arrhythmias (qt interval prolongation)
hypothermia.
what drugs can induce gout?
indapamide
thiazide diuretics
how should frailty be assessed?
PRISMA-7 questionaire
evaluation of gait,speed,self-reported health status
things that can cause confusion
tsh b12 folate
glucose : hypogly
tfts
what is the tool to suggest more medication to give more benefit?
START
so for example like ppi for gastroprotection in pts on meds increasing bleeding risk.
what type of drug is memantine
nmda receptor antagonist
used if first line: donepezil dont work.
stopp criteria for warfarin?
its an anticoagulant and vit k antagonist.
no proven added benefit when given for longer than 6 months for uncomplicated dvt.
main difference between osteoporosis and osteomalacia?
Osteoporosis refers to thin, porous bone with decreased mass and density but proper mineralisation. Usually due to increasing age and menopause
Osteomalacia refers to normal bony tissue but improper mineralisation, causing soft, weak bones, usually due to vitamin D deficiency
what bone changes increase risk of fragility fracture in osteoporosis?
Thinning of cortical bone
Fewer trabeculae
Widening of Haversian canals
define osteoporosis?
Skeletal disease characterised by low bone density and micro-architectural defects in bone, resulting in bone fragility and increased risk of fragility fracture.
Bone mineral density of 2.5 standard deviations below mean peak mass
risk factors for osteoporosis?
SHATTERED
S - Steroid (glucocorticoids decrease Ca2+ absorption in gut)
H - Hyperthyroid, HyperPT, hypocalcaemia/Hypercalciuria
A - Alcohol/smoking
T - Thin (low BMI)
T - Testosterone decrease
E - Early menopause
R - Renal/liver failure
E - Erosive bone disease (myeloma, RA)
D - Dietary reduced Ca2+, malabsorption, diabetes
Also, older age, female, previous fragility fracture, physical inactivity
conditions that can cause osteoporosis?
Turner syndrome
Hyperprolactinaemia
Cushings
DM
how does peak mass relate to osteoporosis?
A higher peak bone mass is protective. At 25ish we have peak bone mass then begin losing bone
signs and symptoms of osteoporosis, and most common fracture?
Usually ASYMPTOMATIC TILL fracture! If symptoms likely to be something else.
Easy fragility fracture
Most common:
Vertebral crush fracture
Distal radius/ Colles fracture (wrist)
Proximal femur/Femoral neck
In vertebral crush:
- Patient will have hunched posture (kyphosis), back pain and height loss (>4cm)
types of osteoporosis?
Type 1- Postmenopausal: Decreased oestrogen causes increased bone resorption
Type 2 - Senile: osteoblasts lose ability to form new bone.
Type 3 - Secondary: to coexisting condition
scoring tool used in osteoporosis?
FRAX Tool - Risk calculator for fragility fracture in next 10 years
Age, sex, weight, height, previous fracture, smoking, glucocorticoids, alcohol >3 units/day, femoral neck BMD.
If risk low, reassure
if intermediate - offer DEXA and recalculate
If high - Offer treatment
ix in osteoporosis?
FRAX tool conducted first.
DEXA scan (Dual Energy Xray Absorptiometry) - measures bone mineral density. Usually measured at hip
Provides 2 readings;
- Z score - number of SDs patients BMD falls below mean for their age
- T score - number of SDs patients BMD falls below mean for young healthy adult
T score
>-1 - normal
-1 to -2.5 - Osteopenia
<-2.5 - Osteoporosis
Ca2+, phosphate and ALP should all be tested (and appear normal unless underlying cause)`
lifestyle mx of osteoporosis?
Activity/exercise
Maintain healthy weight
Stop smoking/alcohol
Adequate calcium/vit D
Avoid falls
pharmacological mx of osteoporosis?
Bisphosphonates first line
- E.g. alendronate
If bisphosphonate CI
- Teriparatide (recombinant PTH)
- HRT (Testosterone/Oestrogen)
- Denosumab
- Raloxeifene
what are some side effects of bisphosphonates
Reflux/oesophagitis
Osteonecrosis of jaw
Osteonecrosis of external auditory canal
Oesophageal ulcers
how should bisphosphonates be taken?
To be given on empty stomach, first thing in the morning with a full glass of water. Stay upright for 30 mins after taking and dont eat or drink for 30 mins after.
how is osteoporosis monitored?
Follow up in 5 years if no treatment
On treatment, FRAX/DEXA in 3-5 years. Come off treatment if BMD improves with no fragility fracture
