Discovering prior fractures in your postmenopausal patient may be the LINK to reducing her fragility fracture* risk in the future. *A fragility fracture is defined as a fracture caused by minimal trauma, such as a fall from a standing position. 1,2
You can be the LINK between your postmenopausal patients and the osteoporosis care they deserve By simply listening, identifying risk factors, notifying patients of their condition, and kickstarting the physician s involvement, you can make a difference in the osteoporosis care of your patients. Osteoporosis is characterized by decreased bone mass and weakened bone structure, leading to increased fracture risk 3 Up to 4 out of 5 postmenopausal women with osteoporosis go either undiagnosed or untreated, in part because many don t see the connection between their fractures and their underlying condition 4 Be the LINK to better osteoporosis care. L Listen I N Notify K Kickstart to your patients Identify patients at risk for fracture patients of their condition physician s involvement 2
Listen to your patients By finding out about the fracture history of your postmenopausal patients, you can help identify patients at risk of a future fragility fracture. Ask the right questions The ice-breaker: Have you recently broken a bone? How long ago was it? Which bone did you break? How did it happen? LINKtip The follow-ups: Have you had any other broken bones I should know about? Did your mother or grandmother ever have a hip or other kind of fracture? Note the obvious signs of fracture Are they wearing a cast or splint? Are they exhibiting pain or favoring a part of their body? Search for the not-so-obvious signs, too Do their clothes appear a size too big? That could be an indication of a loss in height or change in stature 5 (Remember to measure and monitor height to gauge any loss over time.) Do they speak of chores or activities that they no longer do? They may think it s just old age, but it may be an indication of impaired activity 6 (Ask follow-up questions to determine the reason behind their inactivity.) Ask them to describe the circumstances of the fracture or fall. Does the patient excuse falls as simply an accident when discussing history? (Ask probing question to determine the cause of fracture.) Some patients are more eager to share their fracture stories than others. Use your skills to determine the best way to approach each patient. 3
Identify patients at risk for fracture The better you understand your postmenopausal patients underlying condition, the better you can connect them to the help they need. Prior fractures, low bone mineral density (BMD), and advanced age are key risk factors.* Measure the BMD levels of postmenopausal patients with prior fragility fractures BMD testing provides a T-score, which compares a patient s bone density to that of healthy young adults of the same gender 7 A T-score above -1 indicates normal bone density; a score between -1 and -2.5 means the patient has osteopenia, and a score of -2.5 or lower means the patient has osteoporosis 3,7 The lower the T-score, the greater the risk of another fracture 8 Determine the severity of your patient s condition BMD accounts for up to 80% of the variation in bone strength 9 BMD testing can diagnose osteoporosis, determine the level of severity, and assess fracture risk 7 A common BMD test is the dual energy X-ray absorptiometry (DXA) scan DXA scans are safe and, when added to clinical risk factors, improve patients fracture risk assessment 7,8 BMD LINKtip Remember that identifying the present condition of your patients is just the beginning. Remind patients who have osteoporosis of the importance of BMD testing and to schedule follow-up DXA scans every 1-2 years. 10 *Additional risk factors include: parental history of hip fracture, risk of falling, excessive thinness, cigarette smoking, low calcium intake, inactivity, and vitamin D deficiency. 4
Notify patients of their condition An informed patient is often a compliant patient tell them what they need to know. Help them understand the importance of fragility fractures A fragility fracture is a sign that your patient s bones have been significantly weakened by osteoporosis 3 Fragility fractures can affect everything from the patient s independence and day-to-day activity level to the economic costs faced by family and loved ones 11,12 A fragility fracture may increase the risk of another fracture that can occur at any site 13-15 Make them aware of the risk factors for fragility fracture, especially prior fracture Key indicators of high fracture risk include prior fracture and advanced age Risk factors include low BMD, excessive thinness, smoking, excessive alcohol intake, low calcium intake, and frequent falling 3 The more risk factors they have, the greater their fracture risk 3 In addition to discussing treatment (including medication), help them identify healthy choices they can make now to potentially reduce their fragility fracture risk 3 Regular visits with their doctor to measure height and discuss risks Adequate intake of calcium and vitamin D Weight-bearing exercise, such as walking and tennis Cessation of tobacco use and avoidance of excessive alcohol intake Lifestyle choices can make a difference, but for some patients, including those with a prior fragility fracture, they may not be enough. LINKtip Making good choices to lower my risk means I don t have to think of myself as frail anymore. Patient with postmenopausal osteoporosis Encourage your postmenopausal patients to get involved in their own care and work with their doctor to explore ways to reduce fracture risk. 5
Kickstart the physician s involvement Your doctors rely on you, so you already have their attention. Be proactive and encourage action Inform them of their postmenopausal patient s fragility fracture history Give them the information they need to start a patient conversation Help them to address, evaluate, and diagnose their patient s osteoporosis Remember, the ultimate goal is to help patients who have suffered a fragility fracture get the osteoporosis evaluation they deserve LINKtip Nurses spend considerable time on the front line with patients. You have a unique opportunity to help them get the care you know they need! 6
References 1. Prentice A, Schoenmakers I, Laskey MA, de Bono S, Ginty F, Goldberg GR. Nutrition and bone growth and development. Proc Nutr Soc. 2006;65:348-360. 2. Boonen S, Singer AJ. Osteoporosis management: impact of fracture type on cost and quality of life in patients at risk for fracture I. Curr Med Res Opin. 2008;24:1781-1788. 3. Cosman F, de Beur SJ, LeBoff MS, et al. Clinician s guide to prevention and treatment of osteoporosis. Osteoporos Int. 2014;25:2359-2381. 4. Boudreau DM, Yu O, Balasubramanian A, et al. A survey of women s awareness of and reasons for lack of postfracture osteoporotic care. Am J Geriatr Soc. 2017;65(8):1829-1835. 5. Xu W, Perera S, Medich D, et al. Height loss, vertebral fractures, and the misclassification of osteoporosis. Bone. 2011;48:307-311. 6. Stamm T, Pieber K, Crevenna R, Dorner TE. Impairment in the activities of daily living in older adults with and without osteoporosis, osteoarthritis and chronic back pain: a secondary analysis of population-based health survey data. BMC Musculoskelet Disord. 2016;17:139-149. 7. US Department of Health and Human Services. Bone Health and Osteoporosis: A Report of the Surgeon General. Rockville, MD: US Department of Health and Human Services, Office of the Surgeon General; 2004. 8. Unnanuntana A, Gladnick BP, Donnelly E, Lane JM. The assessment of fracture risk. J Bone Joint Surg Am. 2010;92:743-753. 9. Ammann P, Rizzoli R. Bone strength and its determinants. Osteoporos Int. 2003;14(Suppl 3):S13-S18. 10. Camacho PM, Petak SM, Binkley N, et al. American Association of Clinical Endocrinologists and American College of Endocrinology Clinical Practice Guidelines for the Diagnosis and Treatment of Postmenopausal Osteoporosis 2016. Endocr Pract. 2016;22:1-42. 11. National Osteoporosis Society. Life with osteoporosis: the untold story. https://nos.org.uk/media/1859/life-with-osteoporosis.pdf. Published October 2014. Accessed October 28, 2016. 12. Watts JJ, Abimanyi-Ochom J, Sanders KM. Osteoporosis costing all Australians. A new burden of disease analysis 2012 to 2022. Melbourne, Australia: Osteoporosis Australia; 2012. 13. Johnell O, Kanis JA, Oden A, et al. Fracture risk following an osteoporotic fracture. Osteoporos Int. 2004;15:175-179. 14. Kanis JA, Johnell O, De Laet C, et al. A meta-analysis of previous fracture and subsequent fracture risk. Bone. 2004;35:375-382. 15. Klotzbuecher CM, Ross PD, Landsman PB, Abbott TA 3rd, Berger M. Patients with prior fractures have an increased risk of future fractures: a summary of the literature and statistical synthesis. J Bone Miner Res. 2000;15:721-739. 7
Be the LINK and help reduce the risk of fragility fractures L I N K Listen to your patients Ask them about their fracture history Look for obvious signs of fracture (like casts or splints) Note the not-so-obvious signs too (such as a loss of height) Identify fracture risk Help patients with prior fragility fractures get their BMD levels Determine the severity of their condition (impaired bone strength is associated with greater fracture risk) Notify patients of their condition Help them understand the very real impact of fragility fractures Inform them about the risk factors for fracture Discuss treatment (including medication) and encourage better osteoporosis care choices for their bones (diet, regular doctor visits, moderating alcohol and tobacco) Kickstart your physicians involvement They value your input help them evaluate your patients Provide them with what they need to start patient conversations The ultimate goal is to help patients who have suffered a fragility fracture get the osteoporosis evaluation they deserve Amgen Inc. One Amgen Center Drive Thousand Oaks, CA 91320-1799 www.amgen.com 2018 Amgen Inc. All rights reserved. Not for reproduction. USA-785-80040 06-18