Joined at the hip

An interdisciplinary approach to osteoporosis means every fracture patient at St James's Hospital has a falls assessment, writes JOANNE HUNT

OSTEOPOROSIS is known as the silent disease. Quietly depleting the bones of its victims, by the time the condition reveals itself, often in a fracture, it can be too late.

“I think osteoporosis is not perceived as a real threat,” says Dr Miriam Casey of the Department of Medicine for the Elderly in St James’s Hospital.

“It’s not a heart attack and it’s not cancer.” Yet, as she points out, a staggering 25 per cent of people who suffer a hip fracture die within a year.

“They may die from the anaesthetic, from a heart attack or from a clot to their lungs because they have been lying around in bed, so the actual consequences of a hip fracture are in some ways worse than cancer,” she says.

But Casey, her colleague Prof Bernard Walsh and a team at St James’s Hospital have pioneered an interdisciplinary approach in which the teams looking after falls and fracture prevention at the hospital are, in a sense, joined at the hip.

“Every fracture patient has a falls assessment,” she explains of the integrated service. So while the service deals with thinning bones it also looks at other factors that might have led to the fall such as whether the person’s blood pressure medication is too strong for them, if night sedation medication is remaining in the person’s system in the morning or if the person’s visual acuity is impaired.

“You are covering the risk of falls as well as the risk of fracture, so it’s really a multidisciplinary assessment,” says Casey.

Bolstering the close integration of the falls and the fracture functions, the hospital also has a veritable “crack” squad of clinical nurse specialists who are constantly on the look-out for patients in the hospital’s population who are recurrent fallers.

“These nurses go around the hospital every day and identify people who may have fallen two or three times.

“The nurses will take a number of bloods, check their vision, check things like whether the patient was running to the toilet at the time of the fall and may have a kidney infection – so again they are picking them up for us and sending patients to whichever service they need to come to.”

Those identified on the wards or referred by a GP as potential osteoporosis sufferers will be given an appointment to attend the hospital’s bone pre-assessment clinic. If a heel ultrasound indicates poor bone density, a further bone densitometry or DXA scan is done to detect osteoporosis.

Where this is detected, the patient will usually be put on tablets or special drinks which work by slowing down the rate at which the patient is breaking down bone and allowing them time to make their own bone.

What’s shocking to Casey, however, is the poor adherence to treatment by many patients. “About half of the patients who come through James’s with a serious fracture like a hip fracture, on checking with community pharmacies, are not renewing their prescriptions for their osteoporosis treatment one year on.”

She feels this is attributable in part to patients not perceiving osteoporosis to be the serious threat that it is.

While things have improved from the 20 per cent compliance rate recorded before St James’s began its integrated falls and fracture service in 2004, she estimates poor drug compliance to be even higher in hospitals outside of Dublin that may not have the same bone services.

Another aspect of the service at St James’s is how closely the clinical team works with the lab in cases where the patient is taking their prescribed drugs but is not responding to them.

“The non-responders are people who have underlying diseases which are antagonising the effect of the treatment,” says Casey. In the case of those with coeliac or Crohn’s disease, the patient may not be absorbing the drug, whereas in the case of an overactive thyroid gland, the work of bone breakdown is accelerated, making it harder for the treatment to succeed.

She says smoking also blunts the effect of the treatment, while a person’s genetic make-up may also mean they respond less well to the medication.

In the most complex of these cases, where bones are continuing to deteriorate over a period of time despite the drugs, Casey works closely with the biochemistry lab to pinpoint the problem and prescribe a more tailored treatment. “We use biochemistry to determine the best treatment,” she says.

“The tests may be for vitamin D, parathyroid hormone and urinary calcium loss. These allow us to identify patients who are breaking down bone at a very fast rate or where bone formation is particularly slow and to prescribe the best treatment accordingly,” says Casey. “This combination of biochemical tests with bone density scans allows us to identify more quickly who is responding to treatment.”

Such a precise diagnosis can short-circuit the patient taking a plethora of drugs only to find out two or three years later their osteoporosis is no better.

For those for whom poor gut absorption of the medication is identified, a simple once-a-year injection can replace daily tablets to get bones back on track.

While Casey and her colleagues deal with many who have already developed osteoporosis, she warns parents and the young to get smart about bone health by drinking milk and getting plenty of vitamin D.

“Your biggest growth spurt is between birth and four years. Then you have another growth spurt in your teenage years. The amount of calcium you get into your bones then is going to give you the best quality of bone later in life,” she says.

“Your bones are really your architecture for life.”

MARY ANNE DUFFY, DUBLIN: ‘IF I FALL OFF A LADDER, AT LEAST I KNOW I’M NOT GOING TO JUST CRUMBLE’

Mary Anne Duffy’s story: I banged against the clothesline in the garden and a few weeks later I thought, gosh my ribs are still sore.

I had a DXA scan in Beaumont and they said I had the bones of a 90 year old. I was only 52, I couldn’t believe it.

I hated milk when I was younger, my mother couldn’t get me to drink it. I wasn’t big on eating cheese either.

Then I got a kidney stone about 20 years ago and I was told to keep away from all of those things.

I was sent to St James’s Hospital and Dr Casey took over my case.

I was told I’d have to take a special drink every night to activate the growth of bone, but after two or three years I was going nowhere. I was having DXA scans but my scores were not improving.

I had all kinds of blood tests and urine tests done. It turned out that I wasn’t absorbing the medication I was being given.

She decided to start me on a yearly injection. I was a public patient and it takes just half an hour as an outpatient. It’s a relief to be able to stop taking the drinks – it was like having a glass of chalk every night, it was awful.

Lo and behold, my score started to come up. My hips are now normal and my lumbar spine is coming back up to normal levels too.

I had another injection again in February and apparently I’ll have to have them once a year for life.

I’ll have a DXA once a year but if I keep getting better, it will probably be every second year.

I’m 61 now and I feel stronger. If I fall off a ladder, at least I know I’m not going to just crumble.