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effect on quality of life and functional independence than most other fractures. The one-year mortality rate following a hip fracture is 20-30%,8 and 30-50% of hip fracture patients lose the ability to walk without assistance or to live independently.4 DIAGNOSIS AND MANAGEMENT OF OSTEOPOROSIS Despite national and global initiatives to increase awareness and detection, osteoporosis diagnosis and treatment remains at dismal levels, with only 23% of women over the age of 66 with an osteoporosis-related fracture receiving bone density testing or treatment for osteoporosis within six months of the fracture.2 The diagnosis and management of osteoporosis should be directed by a physician comfortable with doing so. In that regard, many primary care physicians are proficient at osteoporosis management, but some may either lack expertise, or may simply be overwhelmed by the demands of patients with more acute health care problems. Evaluation of patients should begin with a detailed history and physical examination, followed by bone density testing and/or FRAX assessment (see below), with further consideration of pharmacologic treatment. In addition, it is important to address exercise, calcium and vitamin D intake, fall prevention, lifestyle (including use of tobacco and alcohol), as well as any potential secondary causes of osteoporosis.8 Bone Mineral Density and Prediction of Fractures The U.S. Preventive Services Task Force offers guidelines for bone mineral density testing.4 (Table 1, next page.) Dual-energy X-ray Absorptiometry (DXA) was developed in the 1980s and has become the mainstay of bone mineral density testing.1,4 X-rays of the spine, hip, and sometimes wrist are taken, and the bone density at each area is compared either with a reference population matched for age, gender, and ethnicity (Z score), or with a young and healthy individual matched 113 Osteoporosis, the Silent Disease for gender (T score). The World Health Organization (WHO) has defined four categories of bone density.4 (Table 2) The WHO FRAX tool is a fracture prediction model that was developed recently by following 60,000 patients who sustained over 5,000 fractures. The model predicts the absolute risk of major osteoporotic fractures (hip, spine, forearm, and humerus), as well as the 10-year risk of hip fractures.1 (Table 3) Many “bone protective” medications, including bisphosphonates, have been shown to be very effective at slowing the progression of osteoporosis. They are well tolerated by most patients, but occasional side effects and a few very rare but drastic complications have produced an unnecessary fear of these medications among the public. Indeed, three separate reports by the U.S. Food and Drug Administration from 2005 to 2010 on extremely rare adverse effects have led to a severe decline in bisphosphonate use. In over 22,000 patients with hip fracture, the use of bisphosphonate medication decreased from an already-dismal 15% in 2004 to an abysmal 3% in 2013.9 The lives saved and/or improved by the judicious use of appropriate bone-protective medications would far outweigh the potential risks of these rare side effects. A detailed discussion of the different pharmacologic options is beyond the scope of this article. The rheumatologists and endocrinologists at LGH have specialized training in understanding, diagnosing, and managing the complexities of osteoporosis and treatment of its consequences. A VISION FOR A GERIATRIC FRACTURE PROGRAM AT LGH Studies of hip fracture management have shown that a structured approach with standardized and comanaged care can reduce length of stay and cost of care, and can improve functional outcomes after discharge.10 In light of the societal and personal burden of hip fractures, over the past two decades there has been a rise in the number of comprehensive fracture programs that seek to optimize outcomes.8 In 2009 Gerald W Rothacker Jr., M.D., returned from the annual meeting of the Pennsylvania Orthopedic Society with a vision for a Geriatric Fracture Program (GFP) at Lancaster General Hospital dedicated to improving the care of elderly patients with a fracture of the hip or femur. He was inspired by a model program developed by the orthopedic implant company Synthesis, but he was the visionary who developed the GFP and brought it to fruition at LGH. The program began in September 2009 with monthly meetings involving representatives from a broad spectrum of teams that help care for these patients. Initial discussions involved physicians, midlevel providers, and nurses from Emergency Medicine, Orthopedics, Internal Medicine, Cardiology, Anesthesia, Geriatrics, and Rheumatology. There were also representatives from pharmacy, surgical services, social work, nutrition, physical therapy, hospital administration, data management, and marketing. Melody Dillman, R.N., was the LGH Orthopedic Program coordinator at the time and was also instrumental The Journal of Lancaster General Hospital • Winter 2016 • Vol. 11 – No. 4 113 Table 1. Bone Mineral Density Testing Factors Women age 65+ & men 70+ regardless of risk factors Younger post-menopausal women, women in menopausal transition, & men ages 50-69 with clinical risk factors for osteoporotic fractures Adults who have a fracture at age 50 or more Adults with a condition such
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