osteoporosis

Question 1

falls - risk factors (5)

Answer 1

Balance disorder
Visual impairment
Muscle weakness
Sedating drugs
Antihypertensive drugs

Question 2

falls - prevention strategies (8)

Answer 2

• Improve vision- eg. cataract
• Optometrist for multifocal/bifocal glasses
• Foot care and review + orthosis - podiatrist
• Decrease period of immobilisation
• Promoting exercise - land-based balance exercise
• Occupational therapist intervention for home safety assessment
• Provide aid for daily living (walking aids)
• Medication review to prevent postural hypotension eg B-blockers, sedating medications

Question 3

minimal fractures - common site (5)

Answer 3

• vertebral body
• NOF
• hip
• neck of humerus
• distal radius

Question 4

minimal fracture - prevention strategies (8)

Answer 4

• Implement strategies to prevent falls
• Increase weight-bearing exercise
• Maintain Ideal weight
• Adequate calcium intake 1300mg/day
• Ensure vitamin D sufficiency
• 15-30 min sun exposure
• Limit alcohol intake to 2 standard drink /day
• Smoking cessation

Question 5

R/F for minimal fracture and osteoporosis

Answer 5

A. Non modifiable
    - Previous fracture
B. Modifiable and lifestyle
    - Multiple falls
    - Immobilization / low physical activity
    - BMI <20
    - Poor muscle strength
    - Poor balance
    - Protein / Ca low intake
    - Vit D insufficiency
    - Alcohol > 2 standard/day
    - smoking
    - Late menarche
    - Early menopause
C. Disease
     1. Endocrine
        - Cushing disease
        - DM
        - Hyperthyroidism
        - Hyperparathyroidism
     2. Chronic disease
        - CKD
        - Chronic liver disease
     3. Other diseases
        - RA
        - Coeliac disease / malabsorption
        - Multiple myeloma
        - Organ transplant / Bone marrow transplant
        - HIV
        - depression
D. Medication ( large effect)
    - Steroid > 7.5mg/day for > 3 months
    - Thyroxin
    - Antiandrogen therapy
E. Medication ( moderate effect)
    - SSRI
    - Antipsychotic
    - Antiepileptic
    - PPIs

Question 6

osteoporosis - screen

Answer 6

1. low risk
   - women > 45
   - men > 50
   do: risk factor assessment
2. intermediate risk
   - women > 50 + risk factors
   - men > 60 + risk factors
   do: DXA every unknown period
3. high risk
   • any age, any sex with minimal trauma fracture
     do: DXA every 2 years

Question 7

when to suspect 2ndary causes of osteoporosis (7)

Answer 7

1. T- score

Question 8

what investigation to rule out 2ndary causes (9)

Answer 8

PTH, Ca, PO4
EUC
LFTs
BSL
TSH
Vit D
serum electrophoresis
coeliac disease screen
Cushing syndrome screen

Question 9

osteoporosis- medication

Answer 9

1. alendronate 70mg PO weekly
2. zoledronic acid 5mg IV yearly
3. Denosumab (prolia)
   - increase risk of fracture if > 4 weeks delay
   - for 10 years then to switch to alendronate
4. estrogen and tibolone: for postmenopausal <0 years
5. Raloxifene: > 3 years menopausal
   - decrease risk of breast Ca
   - increase risk of DVT/Stroke/hot flashes

Question 10

complication of bisphosphonate

Answer 10

1. osteonecrosis of jaw esp after dental extraction
   to avoid it
   a. good dental hygiene
   b. regular dental review
   c. early management of any dental concern
   d. stop smoking
2. atypical femur fracture- subtrochanteric

Question 11

osteoporosis- exmination

Answer 11

1. Wall-occiput test

2. rib-pelvis distance