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Figure 15. Estimated incidence of fracture as a function of age and bone mass. (From Hui SL et al. J Clin Invest 1988; 81:1804. Reproduced with permission of the American Society for Clinical Investigation, Inc.)

assessment should be directed towards elucidating these potential causes and any fracture history. Assessment of the risk factors for falls given in Table 5 is an important adjunct to measuring bone density. Laboratory testing can be limited to the measurement of serum calcium, alkaline phosphatase, creatinine and a complete blood count. In individuals with postmenopausal or age-related osteoporosis, all of these indices should be within the normal range. These investigations may be further expanded to include serum TSH, parathyroid hormone (PTH), serum 25-hydroxyvitamin D, protein electrophoresis, and 24 hour urinary calcium determination, as guided by clinical judgment. Although not routinely required, lateral x-rays of the thoracolumbar spine help to determine the number and type of

Figure 16. Age-related decline in mean Caucasian female T-scores for different BMD technologies based on manufacturer reference ranges. Total hip values (— ^—) are from the NHANES data implemented by all DEXA manufacturers. Also shown are L1-L4 PA spine (—□—), L2-L4 lateral spine (—♦—), "one-third" forearm (—•—) from the Hologic QDR-4500 DEXA; calcanus ultrasound (—▲—) from the Hologic Sahara, spinal QCT (—° —) from the Image Analysis system. (From Faulkner K et al. J Clin Densitometry 1999; 2:343-350. Reproduced with permission from Humana Press Inc.)

Figure 16. Age-related decline in mean Caucasian female T-scores for different BMD technologies based on manufacturer reference ranges. Total hip values (— ^—) are from the NHANES data implemented by all DEXA manufacturers. Also shown are L1-L4 PA spine (—□—), L2-L4 lateral spine (—♦—), "one-third" forearm (—•—) from the Hologic QDR-4500 DEXA; calcanus ultrasound (—▲—) from the Hologic Sahara, spinal QCT (—° —) from the Image Analysis system. (From Faulkner K et al. J Clin Densitometry 1999; 2:343-350. Reproduced with permission from Humana Press Inc.)

pre-existing vertebral fractures, and their presence indicates high risk for further fractures. Biochemical markers of bone metabolism may provide an indirect method to evaluate the rate of bone turnover. Osteocalcin, bone-specific alkaline phosphatase and procollagen I peptide can assess the level of bone formation while urinary excretion of collagen crosslinks (such as deoxypyridinoline and N-telopeptide) reflect the level of bone resorption. These markers have not been useful for diagnosing osteoporosis or for predicting bone loss, but some studies suggest that they independently predict fracture risk.

Non-Pharmacologic Therapy

General measures to reduce the risk of fractures should include assessment of hazards in the home environment, sedative use, muscle weakness, postural hypotension and uncorrected visual deficits. Exercise should also be encouraged in an attempt to preserve bone mass and to maintain or improve muscular conditioning.

Calcium supplementation is often necessary in postmenopausal and elderly women to reach recommended targets (1,200-1,500 mg per day). Calcium carbonate is the most commonly used supplement and is recommended for those who do not have achlorhydria (common in the very elderly and those on acid suppressing

Figure 17. Factors leading to fracture.
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