9.1 Notes for discussion with patients and carers

9.1.1 who is at risk of osteoporosis?

There are a number of factors that can help identify individuals who are at risk of developing osteoporosis. Women are generally more at risk than men, particularly once they have passed the menopause. This does not mean that men should not consider their level of risk, particularly if they have been exposed to one or more of the secondary causes of osteoporosis (Section 2.6).

Those at highest risk of osteoporosis are people who have already suffered a broken bone, particularly in the spine or hip. Fractures that occur without an obvious cause, such as a fall or other accident, are particularly likely to be associated with osteoporosis. Osteoporotic spinal (vertebral) fractures may only be identified during investigation of pain or other symptoms.

Other factors that increase the risk of osteoporosis include:

• Family history
• Increasing age
• Caucasian ethnic origin
• Low BMI
• Sedentary lifestyle
• Smoking
• Long term use of corticosteroids

None of these factors positively indicate the presence of osteoporosis either on their own or in combination. As a general rule, however, the more risk factors that apply to an individual the more likely they are to develop osteoporosis.

9.1.2 Who should be sent for a bone scan?

The decision on whether to provide a bone scanning service, and at what level, is a complex one that depends on a range of clinical and economic factors. This guideline identifies DXA scanning as the most effective means of diagnosing osteoporosis, and advocates the availability of such scanners in all Health Board areas. Even when scanners are available, however, the decision on who to scan must be based on a balance between the level of risk for individual patients and the availability of local resources.

The use of other techniques based on measurements of bone density at the heel or forearm have been considered, but it has not been demonstrated that any of these techniques are sufficiently reliable to be used as diagnostic tools for osteoporosis.

There is no evidence that repeated scans are useful for monitoring progress or the success of treatments. There is evidence that scans carried out less than two years after commencing treatment can give misleading results. This guideline recommends that repeat scans should only be used where they are likely to influence future treatment.

9.1.3 what can be done to minimise risk of osteoporosis?

Some risk factors, such as age or gender, cannot be altered. Many others can be modified, and the overall level of risk reduced accordingly. Chief among these are diet and exercise. A diet rich in calcium and vitamin D will help to reduce the level of risk, particularly if associated with weight control. A programme of exercise aimed at increasing strength and balance is also helpful, particularly as it can help reduce the risk of falling and causing further fractures.

Frail elderly women are at particular risk and should be offered assistance with fall risk reduction if they have already suffered any kind of fracture. If housebound or living in residential care, they should be offered calcium and vitamin D supplementation.

Further information and advice on the control of risk factors is available from the sources listed later in this section of the guideline, and from the Osteoporosis in Scotland website at http://www.osteoporosisinscotland.org (to be launched late summer 2003).

9.1.4 are there any risks associated with medications given for osteoporosis?

Many of the medicines prescribed for osteoporosis have potential side effects. Some of these can be minimised by strictly adhering to the (sometimes fairly complicated) instructions for taking these drugs. The question of risk associated with HRT is particularly complex, and should be discussed with all patients being offered this option

Patients should be advised of the importance of continuing to take medication, and invited to discuss alternatives if a particular prescription is producing side effects or is otherwise giving them cause for concern. All medication prescribed for osteoporosis should be reviewed periodically to ensure its continued effectiveness.

9.1.5 managing pain

Many of the consequences of osteoporosis, particularly vertebral fractures, are associated with severe pain. There are a number of ways, some involving painkillers and some non-pharmaceutical measures, in which this pain can be alleviated. Patients should be advised of all the options, and encouraged to try different approaches until they find one that works well for them. It is important to stress that patients do not need to put up with pain, but should discuss it and the problems it causes with their GP.

9.2 Sources of further information for patients and carers

National Osteoporosis Society
Camerton, Bath BA2 0PJ
Tel: 01761 471771 (for general enquiries), Helpline: 0845 4500230 (for medical queries)
Fax: 01761 471104
E-mail: info@nos.org.uk Website: http://www.nos.org.uk

The NOS is the only national charity dedicated to improving the diagnosis, prevention and treatment of osteoporosis. They provide a wide range of materials and support including access to a wide range of information and the organisation of support groups.

NHS Health Scotland
Woodburn House, Canaan Lane, Edinburgh EH10 4SG
Tel: 0131 536 5500, Textphone: 0131 536 5503, Fax: 0131 536 5501

NHS Health Scotland provides access to a wide range of health information resources relating to falls and fall prevention, as well as osteoporosis.

Contact Health Promotion Library Scotland to access library services and to get help with general health information enquiries.

Tel: 0845 912 5442, Textphone: 0131 536 5503, Fax: 0131 536 5502
Email: library.enquiries@hebs.scot.nhs.uk, Website: http://www.hebs.com/library

Age Concern Scotland
Leonard Small House, 113 Rose Street, Edinburgh EH2 3DT
Telephone: 0131 220 3345, Freephone: 0800 00 99 66 (7am - 7pm, 7 days a week)
Fax: 0131 220 2779
E-mail: enquiries@acscot.org.uk, Website: http://www.ageconcernscotland.org.uk

Age Concern provides information on a wide range of topics that may be useful for those wishing to prevent or manage osteoporosis, including information on healthy eating and the prevention of falls.