Future Developments: Risk Assessment
Figure 26.1 illustrates how the risk assessment would proceed using the methods described in this chapter.
Patients with a hip or vertebral fracture almost certainly have a high risk of subsequent fractures and can be treated even if BMD measurements are not available.
In patients without an obvious history of fracture , the prevalent vertebral fracture index (PVFI) can help determine when to obtain spine radiographs to look for undiagnosed vertebral fractures.
In patients without fractures, the Osteoporosis Self-assessment Tool (OST), the Osteoporosis Self-assessment Tool for Asians (OSTA), and other tools such as the Simple Calculated Osteoporosis Risk Estimation (SCORE) can help determine whether BMD should be measured.
After measuring BMD, fracture probability can be calculated to decide whether treatment is warranted.
If BMD is not available, consider treatment if body weight is low and the patient is over 65 years of age, or if the patient is classified as high-risk based on one of the other non-BMD risk indices.
Patients receiving treatment should have regular follow-up visits to encourage adherence to treatment.
Other patients should be re-evaluated at least every two to five years to see whether their fracture status or risk status has changed.
The focus of this chapter is on assessing the risk of osteoporosis and fractures related to skeletal fragility. Thus, the emphasis is on identifying patients with low BMD and those who have already had a fracture and then using this information to estimate the risk of future fractures. An algorithm is provided in Figure 26.1 to assist the reader in deciding when to use each of the tools described below for evaluating patients. Although falls are an important factor in increasing the risk of fractures among patients with osteoporosis, the etiology and interventions to prevent falls are generally independent of skeletal fragility and therefore receive less attention here.
KeywordsVertebral Fracture Fracture Risk Fracture Probability Vertebral Deformity Fracture Intervention Trial
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- Geusens P, Hochberg MC, van der Voort DJ, et al. (2002) Performance of risk indices for identifying low bone density in postmenopausal women. Mayo Clin Proc 77: 629–637.Google Scholar
- McLellan AR, Gallacher SJ, Fraser M, McQuillian C. (2004) The Fracture Liaison Service: Success of a programme for the evaluation and management of patients with osteoporotic fracture. Osteoporos Int (in press).Google Scholar
- Vogt TM, Ross PD, Palermo L, et al. (2000) Vertebral fracture prevalence among women screened for the Fracture Intervention Trial and a simple clinical tool to screen for undiagnosed vertebral fractures. Mayo Clin Proc 75: 888–896.Google Scholar
- Ben Sedrine W, Park H-M, Reginster J-Y, for the Osteoporosis Self-Assessment Tool for Asia (OSTA) Research Group (2001) Korean experience with the OSTA risk index for osteoporosis: a validation study. Arthritis Rheum 44 (supplement): S260.Google Scholar
- Ben Sedrine W, Huang Q-R, Reginster J-Y, for the Osteoporosis Self-Assessment Tool for Asia (OSTA) Research Group (2001) Using the OSTA index to identify women at risk of osteoporosis: a validation study in China. Arthritis Rheum 44 (supplement): S258.Google Scholar
- Black DM (2001) A proposal to establish comparable diagnostic categories for bone densitometry based on hip fracture risk among Caucasian women over age 65. J Bone Miner Res 16 (supplement 1): S342.Google Scholar
- Black D, Cummings S, Karpf D, et al. (1996) Randomised trial of effect of alendronate on risk of fracture in women with existing vertebral fractures. Lancet 348: 1535–1541.Google Scholar
- Black DM, Steinbuch M, Palermo L, et al. (2001) An assessment tool for predicting fracture risk in postmenopausal women. Osteoporos Int 12: 519–528.Google Scholar
- Cadarette SM, Iaglal SB, Murray TM, et al. (2001) Evaluation of decision rules for referring women for bone densitometry by dual-energy X-ray absorptiometry. J Am Med Assoc 286: 57–63.Google Scholar
- Campbell AI, Robertson MC, Gardner MM, et al. (1997) Randomised controlled trial of a general practice programme of home based exercise to prevent falls in elderly women. Br Med J 315: 1065–1069.Google Scholar
- Cummings S, Black D, Thompson D, et al. (1998) Effect of alendronate on risk of fracture in women with low bone density but without vertebral fractures. Results from the fracture intervention trial. J Am Med Assoc 280:2077–2082.Google Scholar
- Delmas PD, Fraser M (2000) Strong bones in later life: luxury or necessity? Bull World Health Organ 77: 416–421.Google Scholar
- Gillespie LD, Gillespie WJ, Robertson MC, Lamb SE, Cumming RG, Rowe BH (2001) Interventions for preventing falls in elderly people (Cochrane Review). In: The Cochrane Library, Issue 4, Oxford: Update Software.Google Scholar
- Henry MJ, Paseo JA, Nicholson GC, et al. (2000) Prevalence of osteoporosis in Australian women. Geelong Osteoporosis Study. J Clin Densitom 3: 261–268.Google Scholar
- Hochberg MC, Ross PD, Thompson D (2001) Risk factors for clinical fracture in postmenopausal women: data from the Fracture Intervention Trial (FIT). Bone 28 (supplement): S191.Google Scholar
- Kanis JA, Iohnell O, Oden A, et al. (2000) Risk of hip fracture according to the World Health Organization criteria for osteopenia and osteoporosis. Bone 27: 585–590.Google Scholar
- Kanis JA, Iohnell O, Oden A, et al. (2000) Long-term risk of osteoporotic fracture in Malmo. Osteoporos Int 11:669–674.Google Scholar
- Koh L, Ben Sedrine W, Torralba T, et al. (2001) A simple tool to identify Asian women at increased risk of osteoporosis. Osteoporos Int 12:699–705.Google Scholar
- Koh LKH, Hoon P, Ng DCE, Sundram FX (2001) Applying a simple clinical tool to identify osteoporosis in a cohort of Singapore women. J Bone Miner Res 16 (supplement 1): S396.Google Scholar
- Kroger H, Lunt M, Reeve J. et al. (1999) Bone density reduction in various measurement sites in men and women with osteoporotic fractures of spine and hip: the European Quantitation of Osteoporosis Study. Calcif Tissue Int 64: 191–199.Google Scholar
- Lindsay R, Silverman SL, Cooper C, et al. (2001) Risk of new vertebral fracture in the year following a fracture. J Am Med Assoc 285: 320–323.Google Scholar
- Lydick E, Cook K, Turpin J, et al. (1998) Development and validation of a simple questionnaire to facilitate identification of women likely to have low bone mass. Am J Man Care 4: 37–48.Google Scholar
- National Osteoporosis Foundation (1998) Physician’s Guide to Prevention and Treatment of Osteoporosis. Belle Mead, NJ: Excerpta Medica.Google Scholar
- Nevitt M, Ross P, Palermo L, Musliner T, Genant HK, Thompson DE, for the Fracture Intervention Trial Research Group (1999) The association of prevalent vertebral fractures, bone density and alendronate treatment with incident vertebral fractures: the effect of number and spinal location of fractures. Bone 25: 613–619.Google Scholar
- Presentation-on-demand. Risk assessment tools, www.presentation-on-demand.com/ Fosamax/register.aspGoogle Scholar
- Rea JA, Li J, Blake GM, et al. (2000) Visual assessment of vertebral deformity by X-ray absorptiometry: a highly predictive method to exclude vertebral deformity. Osteoporos Int 11: 660–668.Google Scholar