1. Osteoporosis Part 2 of 3: Diagnosis
Ellen Davis-Hall, PhD, PA-C
Professor
Clare J. Kennedy, MPAS, PA-C
Assistant Professor, PA Program
SAHP , COM
UNMC
Omaha, NE.
office:
Hello, my name is Clara Kennedy. I am a physician assistant with UNMC academic and clinical training in Geriatrics and osteoporosis management. I am also faculty at UNMC and the Nebraska Geriatric Education Center. I’d like to welcome you to Osteoporosis module two in our study of geriatrics. This series has been divided into three modules. If you have not completed Module 1, please close out of this module and do Module 1 at this time then return and do Module 2.

2. PROCESS Series of modules and questions
Step #1: Power point module with voice overlay
Step #2: Case-based question and answer
Step # 3: Proceed to additional modules or take a break
Our process will be to review the topic with PowerPoint modules with voice overlay. This will be followed by a case based questions with answers to explain the right and wrong answers. Then you will have the option to continue with the next module on OSTEOPOROSIS or stop at that time. The learner is recommended to complete a module before disengaging. When the module and questions are completed click on “Mark Reviewed on the main page of the minifellowship to indicate your completion.

3. Objectives
Part 1: Identify risk factors for osteoporosis with an emphasis on modifiable risk factors.
Part 2: Describe the most current methods of, and standards for, diagnosis and monitoring of treatment
Part 3: Describe the available treatment modalities for osteoporosis and their effectiveness
You are familiar with the overall objectives from your review of module one, but they have been reviewed here for your convenience. This section will focus on the most current diagnostic methods for osteopenia and osteoporosis.

4. Assessment and Screening
Paper/Pencil tests
National Osteoporosis Foundation-NOF self assessment checklist
Osteoporosis Risk Assessment Instrument (ORAI) based on age, weight and estrogen use (Cadarette et al, 2000)
Simple Calculated Osteoporosis Risk Estimation (SCORE)-based on age, race, weight, estrogen use, rheumatoid arthritis and fracture history (Lydick et al, 1998)
Nomogram
Osteoporosis Self-Assessment Tool (OST)-based on age and weight on an easy to read chart (Cadarette et al, 2004)
There are several forms of paper tests available for initial screening for osteoporosis. The self-assessments can be carried out independently by the patient and then brought to the practitioner for discussion. Such paper and pencil tests can also be completed in the office waiting rooms prior to appointments for other problems. The Osteoporosis Risk Assessment Instrument (ORAI) was first published by Cadarette et al, in This instrument, developed to attempt to determine who should have DEXA, focused on only three parameters: age in years, weight in kg, and Current estrogen use. The SCORE assessment used 6 parameters, but has results similar to the ORAI. Cadarette also developed a nomogram called the Osteoporosis Self-Assessment Tool (OST). This utilizes only age and weight in an easy to read chart. This pencil and paper approach is only a beginning, but it adds to clinical judgment of who should be screened by more formal methods. We will discuss various screening methods later.

5. U.S Preventive Services Task Force Screening Recommendations
USPSTF
All women over 65
Women if “at risk”
“At Risk”:
Best predictor = low body weight
Others: early menopause, white/Asian, sedentary, smoker, alcohol abuse, caffeine use, low calcium and vitamin D intake, family history, primary hyperparathyroid, hyperthytroid, corticosteroids, phenytoin
Cadarette SM, Jaglal SB, Murray T, et al. Evaluation of decision rules for referring women for bone densitometry by dual-energy x-ray absorptiometry. JAMA 2001;286(1):57-63.
The U.S Preventive Services Task Force (USPSTF) recommends evaluation of all women over 65, and younger women considered “at risk.” (Unfortunately there is no formal definition of what “at risk” means). This group generally considers things such as low body weight and not being on ERT, but certainly other factors that we discussed in module one should trigger Bone mineral density screening earlier than age 65.

6. National Osteoporosis Foundation
Screen if these risk factors are present:
All women 65 and older
Postmenopausal women under age 65 with:
Family history of osteoporosis
Past history of low trauma fracture if over 45
Cigarette smoking
Low body weight (under 127 #)
National Osteoporosis Foundation justifies early screening these four risk factors are present: a family history of the disease, a past history of a low trauma fracture over age 45, are smokers and have a low body weight, usually considered to be under 127#.

7. Other Screening Considerations
Hyperthyroidism
Hyperparthyroidism
X-ray evidence of low bone mass
Vitamin D deficiency (osteo-malacia)
Rheumatoid arthritis
Medications known to cause bone loss
Diseases that cause poor intestinal absorption
Long term menstrual irregularities
These additional screening considerations, as you will recall, relate back to the information presented in part one…factors placing a patient at higher risk for this disease process….hyperthyroidism and hyperparathyroidism, x-ray evidence of low bone mass, osteo-malacia, RA, medications used such as GnRH agonists for men under treatment for prostate cancer and long term corticosteroid use. Long term menstrual irregularities or menstrual cessation should also be considered.
Now, once we have identified a patient for whom we think screening is necessary, how do we go about testing for this diagnosis?

8. Tools for Diagnosing and Monitoring Response to Treatment
Thorough H&PE
Lab
X-rays
Bone densiometry US
Bone markers
The following is a list of tools for diagnosis and monitoring the response to treatment: The most basic and essential testing method we have is our very thorough History and Physical exam. Individualized laboratory testing may be carried out based on patient history. X-rays might be a consideration, but bone densiometry is probably the most definitive testing we can carry out. We will discuss the role of ultrasound as well as the use of bone markers. So, let’s look at each of these in more detail…….

9. History and Physical Assessment
Assess risk factors
Identify a history of falls/fractures
Weight, height, general health
Spine/bony structure assessment
Gait and balance
As has been mentioned, a history that includes an assessment of the earlier risk factors should put us on alert for this disease. A history of low impact fractures should be another red flag. The height/weight and general health will offer information on body frame and state of health.
Physical exam of the spine for deformities may be one of the most helpful physical exam findings. An evaluation of the patient’s fall risk using the “Get up and go” test, described in the modules on dizziness.

10. Laboratory and X-Ray Studies
CBC, serum calcium, phosphorus, alkaline phosphatase, renal function, TSH.
Possible additional lab: 24 hours urine for creatinine and calcium, parathyroid hormone assay, LFTs, serum testosterone, cortisol assays, protein electrophoresis
X-Ray:
Useful when fractures are suspected, not effective for screening
When osteoporosis has been diagnosed certain lab tests are fairly basic for the workup. CBC, serum calcium, phosphorus, alkaline phosphatase, renal function, 25 hydroxy vitamin D and TSH. Other lab may be considered based on the patient history; 24 hour urine for creatinine and calcium to look for renal induced bone disease. Parathyroid hormone assay (PTH) if hyperparathyroidism is suspected. Serum testosterone should always be included in osteoporotic males who are candidates for testosterone replacement. Cortisol assays for hyperadrenalism and protein electrophoresis when multiple myeloma is suspected.
X-rays-(radiology) plain x-rays useful when fractures are suspected. X-rays, CT and bone scans are good to evaluate persistent pain. X-rays are not effective for screening, by the time osteopenia can be seen on x-ray, 30% of bone density has been lost. An incidental finding of vertebral wedging suggests the presence of already severe osteopenia.

11. Dual Energy X-ray Absorptiometry (DEXA)
The gold standard for diagnosis and monitoring
Non-invasive
Low x-ray exposure
High sensitivity and specificity
Limitations:
Osteoarthritis, aortic calcification, or compression fracture may yield erroneous values in the spine Use proximal femur measurements.
DEXA is considered to be the gold standard for diagnosis and monitoring. It is non-invasive, there is low x-ray exposure. It has high sensitivity and specificity. It does have some limitations, however, when a patient has osteoarthritis, aortic calcification, or a compression fracture there may be erroneous values in the spine. In this case it is best to use the proximal femur measurements

12. DEXA Interpretation Category Definition by BMD Score
Diagnostic Criteria for Osteoporosis in
Post-menopausal Women
Category Definition by BMD Score
Normal BMD <1 SD below mean value for young adult white females
Osteopenia BMD SD below mean value for young adult white females
Osteoporosis BMD > 2.5 SD below the mean value for young adult white females
These criteria are fairly clear-cut and probably well known to you. All BMD comparisons are compared to what is considered optimal bone density achieved by young white females, say age Someone is considered to have severe or established osteoporosis if they have a BMD > 2.5 below the mean plus one or more fragility fractures.

13. Other Tools for Osteoporosis Evaluation
Quantitative ultrasound
Heel, finger, tibia, patellar measurements
Inexpensive
No radiation
Less sensitive than DEXA
Bone markers
Measure osteoblastic or osteoclastic activity
Research instrument
Quantitative ultrasound- has become very popular as a heel measurement (also fingers, tibia, patella)…This can be obtained in drug stores and various other non-medical settings. It is inexpensive, no radiation., but less sensitive than DEXA. Bone markers-measures of osteoblastic or osteoclastic activity. These are mainly used in research and sometimes clinically to measure response to treatment. Usefullness for patients generally has not been established.

14. Monitoring and Evaluating Treatment of Osteopenia/Osteoporosis
Follow-up DEXAs only when change might result
Follow-up DEXA for patients with normal or minimally low BMD every 3-5 years
Patients on medication-repeat DEXA 18 to 24 months after therapy was begun
A patient or practitioner may want to check into various insurance plans to see how often they will cover repeat testing. What is listed here are good clinical criteria, but you may need to write the insurance company and convince them of this. The important thing for practitioner to consider is “why are your ordering it?” You should ask yourself if the results might indicate that beginning therapy of a change in therapy is necessary. If you have tested and found your treatment to be effective, (ie confirmed by the test performed after 18 to 24 months of therapy) testing does not have to be carried out frequently. Testing would probably be indicated if pharmacological therapy is to be discontinued.

15. Summary of Part 2: Diagnosis and Monitoring
There are various screening methods
paper and pencil testing
History and physical risk assessment
Formal laboratory/x-ray studies
DEXA is the gold standard for diagnosis and monitoring of both osteopenia and osteoporosis
There are various screening methods. The motivated patient may present to you with their own self-assessment and ask for direction. Your assessment of risk factors as discussed in this section and also Part 1, will help you identify the patient most at risk and therefore is a candidate for early screening. Various testing can be carried out depending on the patient and their history. The gold standard for both diagnosis and monitoring is DEXA.

16. The End of Module Two on Osteoporosis
References
Bone Health and Osteoporosis: A Report of the Surgeon General, USDHHS, issued October 14,
Cadarette et al, Development and validation of the osteoporosis risk assessment instrument to facilitate selection of women for bone densiometry. CMAJ, 2000, May 2,162(9):
Cadarette et al, The validity of decision rules for selecting women with primary osteoporosis for BMD testing. Osteoporosis Int, 2004, Jan 17
Lydick et al, Development and validation of a simple questionnaire to facilitate identification of women likely to have low bone density. Am J Manag Care, 1998, Jan 4(1):37-48
National Osteoporosis Foundation. America’s bone health: The state of osteoporosis and low bone mass in our nation. Washington (DC): National Osteoporosis Foundation; 2002
US Preventive Services Task Force. Screening for osteoporosis in postmenopausal; women: Recommendations and rationale. Ann Intern Med, 2002, Sept 17; 137(6):526-8
This completes our second module on Osteoporosis. To complete the question for credit for this module, please close out this module, and advance to the question in 2 in Blackboard, then answer the question and review the answer. Then, when ready proceed to module #3 where we will continue to work on some more evaluation and management.

17. Post-test
A 65 year old woman returns to your office after DEXA testing to discuss her results. Noting that her total BMD is , you inform her she has:
Normal bone mass
Osteopenia
Osteoporosis
Severe osteoporosis

18. Correct Answer: Osteopenia
Feedback: Osteopenia. Bone mass is considered to be in the normal range if < Results falling between -1.0 and -2.5 diagnose osteopenia, and results > -2.5 make the diagnosis for osteoporosis. A patient in the osteoporotic range who has also had a fracture can be said to have severe osteoporosis. End