Osteoporosis
Figure 2: Form Used to Calculate a Patient’s Prediction Score
Risk Factor Points
More than one fall in the last 12 months 2 Slow walking speed/change in gait Loss of balance Poor sight
Weak hand grip
1.5 1 1 1
Total Score 6.5
The range of possible scores is 0–6.5, with scores over 3.5 indicating a greater risk of suffering a fall.
Figure 3: Developed Dual-emission X-ray Absorptiometry Scan Referral Form
which completely ignored the fact that older patients who suffer syncopal attacks are at high risk of trauma and sustaining fractures, especially hip fractures, and that older people with syncopal attacks need to have their bone health assessed. The American and British Geriatrics Societies published their guidelines for prevention of falls in older people including the results of univariate analysis of most common risk factors for falls identified in 16 studies; however, decisions to adopt any particular recommendation were left for the practitioner to make in light of available evidence and resources.23 Although a wide range of instruments now exists, poor standardisation and limited evidence of measurement properties can make instrument selection for clinical practice or research rather difficult. The St Thomas’s Risk Assessment Tool in Falling Elderly Inpatients (STRATIFY) was denounced by its developer.24
of syncope,22 The authors of another scoring
system, Falls Risk Assessment Tool (FRAT), for outpatients, noted limitations of the cohort studies used to identify the predictive factors in FRAT and that none of the studies reported multivariable analyses using all the factors finally chosen for FRAT, hence the authors were not certain that FRAT contains the most efficient combination of factors.25
More recently, a new questionnaire, Falls Risk Assessment Score (FRAS), was developed for both inpatients and outpatients. The prediction rule consisted of five clinical variables (see Figure 2). The prediction score ranged from 0 to 6.5 and the cut-off point of 3.5 showed the best positive predictive value and was found to be the threshold of high falls risk. The validity of the scoring system was assessed and presented in the European League against Rheumatism (EULAR) conference, Rome 2010.26
The results revealed that the FRAS
was a sensitive and specific predictor of future falls and can be recommended for standard clinical practice both in the outpatient as well as the acute hospital inpatient settings.
Osteoporosis, Falls and Fractures, Three Confounders in One Equation – Room for Development
The Osteoporosis and Falls Integrated Service was developed at Darent Valley Hospital in 2004 with the co-operation of the authors of this article. The aim of this was to provide a service that will cover the BMD measurement, as well as assessment for osteoporosis risk factors and falls risk, for all the patients referred. With the introduction of FRAX, this also had to be included in the assessment and report. There were some challenges to tackle to translate these developments into real life.
Incorporating All the Confounders in One Referral Form
Figure 4: An Ideal Dual-emission X-ray Absorptiometry Scan Report Should Include
1. Diagnosis
2. 10-year fracture risk probability
3. Falls risk score 4. Monitoring
BMD changes; significance of BMD changes, if any; recommended follow-up; statement on treatment threshold
BMD = bone mineral density. 16 BMD; T-score; World Health Organization category
Direct access to DXA scan service is open to referrals from the primary care trust and other specialities within the hospital, and following low trauma fractures. To screen for all possible risk factors and falls risk, every patient was asked to complete a lengthy questionnaire before having her/his DXA scan carried out. With the introduction of FRAX, this required either adding another section to the patient questionnaire or developing the referral form to match such changes and incorporate all the confounders in one simple, non-time consuming, patient-friendly format. This was solved by developing a new two-page DXA referral form (see Figure 3) that allows the referring doctor to highlight the reason for referring the patient for DXA scanning and, on the other page, contains two questionnaires to be completed by the patient, to assess for FRAX and the falls risk.27
The referral form and patient questionnaires were both in ‘tick-box’ format. EUROPEAN MUSCULOSKELETAL REVIEW
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