Priority Topic: Osteoporosis

Key Feature 1: Assess osteoporosis risk of all adult patients as part of their periodic health examination.
Skill: Clinical Reasoning
Phase: Hypothesis generation, Diagnosis

Key Feature 2: Use bone mineral density testing judiciously (ex: don’t test everybody, follow a guideline).
Skill: Selectivity, Professionalism
Phase: Investigation, Follow-up

Key Feature 3:  Counsel all patients about primary prevention of osteoporosis (i.e., dietary calcium, physical activity, smoking cessation), especially those at higher risk (ex: young female athletes, patients with eating disorders).
Skill: Clinical Reasoning, Communication
Phase: Treatment

Key Feature 5: In patients with osteoporosis, avoid prescribing medications that may increase the risk of falls.
Skill: Clinical Reasoning
Phase: Hypothesis generation, Treatment

Key Feature 6: Provide advice and counseling about fracture prevention to older men, as they too are at risk for osteoporosis.
Skill: Clinical Reasoning
Phase: Hypothesis generation, Treatment

Key Feature 7: Treat patients with established osteoporosis regardless of their gender (ex: use bisphosphonates in men).
Skill: Clinical Reasoning
Phase: Hypothesis generation, Treatment

In previous blog posts I have made reference to periodic health assessment tools that I use with young kids (Rourke Baby Record) and older kids and adolescents (Greig Health Record). However, I have not yet made mention of the periodic health assessment tool I use for adult patients, which is the Preventive Care Checklist by the College of Family Physicians of Canada. It prompts me to consider screening for osteoporosis with all of my adult patients, with recommendations of when and when not bone mineral testing is indicated. Regardless of whether or not someone is at more  or less risk of developing osteoporosis, the Checklist prompts me to counsel all patients on what they can do to prevent osteoporosis, which includes recommending a sufficient dietary intake of calcium and vitamin D, encouraging sufficient physical activity, and broaching smoking cessation, as indicated. Although some people are certainly at much more risk of developing osteoporosis than others, with risk factors outlined as part of the indications for obtaining a bone mineral density scan, it is a common disease that affects many people later in life, and one in which an ounce of prevention can result in a pound of cure. Recommending evidence-based measures to protect health and promote quality of life is one of the most important jobs of the Family Doctor, and the Checklist is a way of streamlining this process and thereby promoting health for all Canadians.  

If a patient is diagnosed with osteoporosis there are now multiple pharmacological treatment options to choose from. First line pharmacotherapy is usually an oral bisphosphonate. It's also important to be sure that what we are prescribing for other reasons is not further eroding bone integrity wherever possible, along with ensuring our prescriptions are not increasing the risk of falls, which can lead to falls and unfortunate fractures that significantly impair quality of life and that are associated with significant increases in mortality. This fact sheet put out by the CDC provides a list of the common medications that increase the risk of falls.