Comprehensive testing strategies
For patients with a high risk of falls and fractures, a multi-faceted evaluation goes beyond standard bone density testing to paint a clearer picture of overall fracture risk.
Dual-energy X-ray absorptiometry (DXA)
DXA scanning remains the gold standard for measuring bone mineral density (BMD) and diagnosing osteoporosis. For high-risk patients, a central DXA of the hip and spine is essential for accurate risk assessment and tracking treatment response over time.
Vertebral fracture assessment (VFA)
A VFA may be performed during a DXA scan to image the thoracic and lumbar spine. It is particularly useful for detecting asymptomatic vertebral compression fractures, which are common in osteoporosis and significantly increase the risk of future fractures.
Fracture risk assessment tools (FRAX)
The Fracture Risk Assessment Tool (FRAX) combines clinical risk factors (including age, gender, prior fracture history, and use of glucocorticoids) with or without femoral neck BMD to estimate a patient's 10-year probability of a major osteoporotic or hip fracture. Some tools, like FRAX+, can also incorporate a falls history to improve accuracy.
Fall risk assessment
Since most fragility fractures result from a fall, a formal falls risk assessment is a key component of the evaluation. Factors assessed include gait and balance, muscle strength, vision, and medications that may increase fall risk. Many older adults fear falling, which can paradoxically increase their risk by leading to decreased activity and strength.
Laboratory testing
Initial blood work can help identify secondary causes of osteoporosis, which may be treatable. Recommended tests include calcium, creatinine, and 25-hydroxyvitamin D levels.
Targeted treatment for dual risk
Treatment for high-risk patients must address both fragile bones and the underlying risk of falling.
Pharmacological therapy
For patients with established osteoporosis (T-score $\le -2.5$) or a high FRAX score, pharmacological treatment is recommended to reduce fracture risk.
- Bisphosphonates: Often the first-line treatment, drugs like alendronate, risedronate, and zoledronic acid work by slowing bone breakdown. Zoledronate, administered intravenously, is a strong option for patients with hip fractures.
- Anabolic agents: For very high-risk individuals, especially those with multiple severe fractures, anabolic agents like teriparatide and romosozumab can stimulate new bone formation.
- Denosumab: A monoclonal antibody that inhibits bone resorption, denosumab can be an effective alternative to bisphosphonates. It is crucial to have a long-term plan in place, as stopping it abruptly can increase vertebral fracture risk.
Non-pharmacological interventions
These interventions focus on preventing the fall itself.
- Exercise programs: Regular weight-bearing and muscle-strengthening exercises, such as walking, yoga, and tai chi, can improve balance, agility, and muscle strength to help prevent falls. Physical therapy can also be tailored to individual needs.
- Environmental modifications: Removing trip hazards like loose rugs, installing handrails, and ensuring adequate lighting are simple yet effective strategies to make a home safer.
- Medication review: A review of all medications can identify and adjust any that may increase the risk of falls, such as sedatives or certain blood pressure drugs.
- Calcium and Vitamin D: Ensuring adequate intake of calcium and vitamin D through diet or supplementation is fundamental to supporting bone health and muscle function.
Testing vs. treatment: a comparison for high-risk patients
When considering the best approach for a patient at high risk for falls and fractures, the decision often involves balancing diagnostic testing with direct therapeutic intervention. The following table compares strategies based on their primary focus.
| Feature | Diagnostic Testing | Therapeutic Intervention |
|---|---|---|
| Primary Goal | To identify osteoporosis, assess fracture risk, and detect secondary causes. | To reduce fracture risk and prevent falls through medication, lifestyle changes, and fall-prevention measures. |
| Key Tools | DXA scan, FRAX tool, VFA, lab tests. | Bisphosphonates, anabolic agents, denosumab, physical therapy, home safety modifications. |
| Patient Benefit | Pinpoints specific areas of bone weakness and identifies those most likely to benefit from treatment. | Strengthens bones and improves balance, directly reducing the incidence of falls and fractures. |
| Risk Identification | Quantifies fracture risk based on BMD and clinical factors. | Incorporates fall risk assessment and addresses modifiable fall factors. |
| Timing | Typically performed during initial evaluation and periodically to monitor treatment. | Initiated once high-risk status is confirmed and continued over the long term. |
| Patient Action | Undergoes medical tests; passive role during the test. | Actively participates in exercise, medication adherence, and home safety; active role in management. |
Conclusion
In patients at high risk for falls and fractures, a comprehensive approach is necessary, integrating accurate diagnostic testing with targeted therapeutic interventions. A central DXA scan, VFA, and fracture risk assessment using tools like FRAX provide the critical diagnostic foundation. Simultaneously, treatment should involve pharmacological options—such as bisphosphonates or anabolic agents—and robust non-pharmacological measures to address fall risk. A thorough fall risk assessment and medication review are vital for preventing the initial trigger of most fragility fractures. By actively combining these strategies, clinicians can most effectively manage and reduce the significant morbidity and mortality associated with osteoporosis-related fractures in this vulnerable population.
Note: This is an informational article and does not constitute medical advice. Patients should consult a healthcare professional for diagnosis and treatment. For more information on assessing and treating osteoporosis, resources are available from organizations like the Bone Health and Osteoporosis Foundation.
What is the most important factor to consider in treatment for patients with high fall risk?
Addressing Fall Risk: While medication can strengthen bones, preventing the fall is paramount. A comprehensive fall risk assessment and targeted interventions, including balance exercises and home safety improvements, are essential for reducing fracture incidence.
How does FRAX differ for high-risk patients versus others?
High-Risk Patient Considerations: FRAX helps identify high-risk individuals, but for those with known high risk (like prior fragility fractures), treatment may be warranted regardless of the score. FRAX can also be adjusted with additional data like a falls history for better accuracy.
How is a vertebral fracture assessment (VFA) different from a standard DXA scan?
Imaging vs. Density: A standard DXA scan measures bone mineral density, while a VFA, performed concurrently, specifically uses a lateral image to detect vertebral fractures, which are often asymptomatic but increase future fracture risk.
Should bone turnover markers be used for fracture risk assessment in high-risk patients?
Limited Usefulness: Bone turnover markers have a limited role in assessing universal fracture risk, and their applicability is not yet established for all populations. Their main use is to monitor response to therapy rather than for initial risk assessment.
Is it always necessary to perform a DXA scan before starting osteoporosis medication in high-risk patients?
Individualized Decision: While a DXA scan provides a baseline, a patient with a recent hip or vertebral fragility fracture may be considered for treatment based on that event alone, regardless of their T-score. Clinical judgment and risk factors are key.
What is the role of anabolic therapy versus bisphosphonates in high-risk patients?
Anabolic vs. Antiresorptive: Anabolic agents build new bone and are typically reserved for patients at very high risk, often with multiple prior fractures. Bisphosphonates are antiresorptive, meaning they slow bone loss and are often used as a first-line therapy.
How often should patients at high risk for falls and fractures be monitored after starting treatment?
Monitoring Frequency: BMD testing is generally performed 1 to 2 years after starting or changing therapy, and then at appropriate intervals depending on clinical circumstances. Frequent monitoring may be needed for higher-risk individuals.
