Fracture Liaison Service

1. Fracture Liaison Service Jess Browne, RN, BN, PGCert(HSc) Clinical Nurse Specialist, 2015

2. Overview • Our service, who do we see? • Fragility fractures • What happens already • NDHB Current position • Osteoporosis • Hip Fracture and its burden • History taking • Testing • Medication • Falls Prevention • What can you do? Health Promotion

3. About our Service • Based at Whangarei Hospital • Casefind patients from ED • Referrals from Wards/Radiology/Outpatients • Liaise with MDT • Liaise with patients

4. Who do we see? • Women ≥50 yrs age, Men ≥60 yrs who, • Presents to Whangarei Hospital ED with, or while in Ward/Outpatients incidentally found to have • Fragility Fracture.

5. Fragility Fractures • Fragility fracture is defined by the World Health Organisation as "a fracture caused by injury that would be insufficient to fracture a normal bone...the result of reduced compressive and/or torsional strength of bone". Clinically, a fragility fracture may be defined as a fracture "...that occurs as a result of a minimal trauma, such as a fall from a standing height or less, or no identifiable trauma"

6. What happens (or doesn’t) already? • By missing the opportunity to respond to the first fracture, healthcare systems around the world are failing to prevent the second and subsequent fractures. • In October 2014, NZ population 4.5 million estimated to increase to 5.7 million in 2061. • 19,000 Fragility Fractures present to urgent care every year in NZ. • A recent audit conducted within New Zealand found that • The majority of NZ orthopaedic surgeons felt they lacked formal training in osteoporosis treatment. • Less than 25% of Fragility Fracture patients would routinely be referred for a bone density test after fracture. • More than 80% of surgeons would not prescribe osteoporosis medication.

7. Current position at NDHB • Data collected over a 12 month period during 2012/2013 at Northland District Health Board showed 161 hip fractures and 534 fragility fractures in total annually. After observing the outcomes seen elsewhere it is predicted we could reduce these by 20% by implementing a FLS, meaning that approximately 32 hip fractures would be prevented each year. Potentially saving $901,600 of the $4,508,000 currently spent on hip fractures annually.

8. Osteoporosis • Leading bone disease in the world • “Brittle bone disease” Osteoporosis has no signs or symptoms until a fracture occurs – this is why it is often called a ‘silent disease’. • Weakens bones leading to increased risk of fracture. • Affects men and women, however women higher risk. 1:2 women over 50 1:5 men over 50. • Good news is it is largely treatable and preventable. (Capture the fracture, IOF, 2012)

9. Normal Bone Osteoporotic Bone http://share.iofbonehealth.org/A0E37717-25A6-4B12-8A16-86EA38405CC6/FinalDownload/DownloadId-4A282A0B2C307633E1C988D36860C30B/A0E37717-25A6-4B12-8A16-86EA38405CC6/WOD/2012/report/WOD12-Report.pdf

10. Hip Fracture “All too often, hip fracture represents the final destination of a 30 year journey fuelled by decreasing bone strength and increasing falls risk.” • Each year 4,000 older New Zealanders break a hip. http://osteoporosis.org.nz/wp-content/uploads/FLS-resource-pack.pdf

11. The Burden of Hip Fracture • Only half of those who survive hip fracture will walk unaided again and many of those wont regain their former mobility • 10-20% will be admitted to residential care as a result of the fracture. • 60% will require assistance with activities of daily living a year after the event • 27% will die within a year of their hip fracture and of these just under 2/3 would not have died if they had not fractured their hip. • Each hip fracture costs the government approx $47,000 Topic 6 Why hip fracture prevention and care matters.

12. History taking • Age • Bone Mineral Density (BMD) (This can be affected by risk factors such as cigarette smoking, excessive alcohol consumption, use of high dose corticosteroids(doubles the risk), family history of fracture). • Body weight • History of prior fracture after the age of 50yrs • Any falls in the past 12 months. • Gender, more likely if female. • Post-menopause, loss of oestrogen • Limited physical activity • Inadequate dietary calcium intake • Limited exposure to sunlight resulting in low Vit D intake • Some diseases incl. hyperparathyroidism and intestinal malabsorption. • Rheumatoid Arthritis diagnosis

13. Blood tests • FBC • Biochemistry ie. Na/K/Cl, Creatinine, Glucose Urea • Calcium • PTH and Serum Protein Electrophoresis if Calcium abnormal

14. DEXA scans • What is a bone density scan? • A bone density scan is an imaging test which uses minimal radiation to measure the calcium content of the bone. It is used to determine bone strength. • How does it work? • Bone density scanning, also called dual-energy X-ray absorptiometry (DEXA), or bone densitometry, is an enhanced form of X-ray technology used to measure bone loss or osteoporosis. It uses a DEXA scanner and gives a reading of bone density in relation to the average for a person of your size and weight. • These are currently done at Northern Radiology, Whangarei http://www.trggroup.co.nz/services/bone-density/

15. Who Needs DEXA Scans? • Bone Mineral Density. Current criteria for subsidised DEXA scans: • Age less than 75 years with low trauma fracture, or • Long –term use of glucocorticoid steroids, or • Premature menopause under 40 years or hypogonadism if not already on HRT • Unsubsidised Cost of $153 (standard) or $228 (complex) • NB. DEXA not required if • 2 or more significant osteoporotic fractures • 1 significant osteoporotic fracture and the patient is aged >75 yrs • Technically or logistically difficult to arrange.

16. Bone Protection Medication • Calcium Supplements • Vitamin D Single tablet, monthly • Fosamax Single tablet, weekly • Fosamax plus ContainsVit D • Aclasta IV infusion once per year

17. Falls Prevention Falls prevention exercise programmes reduce injuries. Systematic reviews and meta-analyses have shown that exercise programmes designed to prevent falls in older adults reduce the injuries caused by falls by 37% in community-living older people (17 trials, 4305 participants), and reduce the risk of sustaining a fall-related fracture by 66% (six trials, 810 participants) These programmes also reduce the rate of falls requiring medical care by 43%. http://www.hqsc.govt.nz/assets/Falls/10-Topics/topic9-improving-balance-and-strength-to-prevent-falls.pdf

18. What Falls Prevention programmes do we have? • No longer offered by ACC but this may change in the near future • Green Prescription – Sport Northland • Age Concern runs 1x per year for 20 people.

19. What can you do? • Raise awareness – talk about it • A large number of this age group are on Careplus – check nutrition and other factors during ‘history taking’ • Refer to GP if risk of Osteoporosis suspected. • Nurses can provide timely information for those at risk of osteoporosis. An in-depth understanding of the underlying pathology and treatment options will allow nurses to support those at risk or suffering from Osteoporosis

20. Health Promotion Ensure a diet rich in bone healthy nutrients Exercise regularly Avoid negative lifestyle habits and maintain a healthy weight Identify your risk factors Talk to your doctor – get tested, - get treated if required.

21. Conclusion

22. References Capture The Fracture, a global campaign to break the fragility fracture cycle. International Osteoporosis Foundation. 2012 www.iofbonehealth.org Fracture Liaison Services Resource Pack, Osteoporosis New Zealand, 2014 Strong women make stronger women, five essential strategies for bone care after 50. International Osteoporosis Foundation. 2013 www.iofbonehealth.org

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