Should I order a Dual-Energy X-ray Absorptiometry (DEXA) scan on a patient with a history of frequent falls?

DEXA Scanning for Patients with Frequent Falls

Yes, you should order a DEXA scan for a patient with a history of frequent falls, as this is a significant risk factor for fractures and may indicate underlying osteoporosis that requires treatment. 1

Rationale for DEXA in Patients with Fall History

Falls represent a major risk factor for fractures, and patients with frequent falls should be evaluated for bone health for several reasons:

1. Fall-related fracture risk: The American Academy of Orthopaedic Surgeons (AAOS) strongly recommends bone health evaluation in patients with fall-related fractures 1

2. Preventive screening: EULAR/EFORT guidelines recommend fracture risk evaluation including DXA scanning to inform therapeutic decisions for preventing subsequent fractures in high-risk patients 1

3. Fall risk and osteoporosis correlation: Research shows fall-related risk factors are often more prevalent than femoral neck osteoporosis across all age groups, with the combination of both significantly increasing fracture risk 2

Who Should Receive DEXA Scanning

DEXA scanning is particularly indicated for:

• Patients with history of frequent falls
• Adults with risk factors for osteoporosis
• Women aged 65 years or older and men aged 70 years or older 3
• Younger individuals with specific risk factors including:
  • Low body weight (BMI <20-25 kg/m²)
  • Weight loss >10%
  • Physical inactivity
  • Prolonged corticosteroid use
  • Previous osteoporotic fracture 1, 3

Comprehensive Approach for Fall-Risk Patients

For patients with frequent falls, the evaluation should include:

1. DEXA scan of spine and hip (primary sites) 3

   • Consider forearm (one-third radius) measurement if hip or spine cannot be accurately assessed 3
   • In patients with spinal deformities, both hip and forearm scans are recommended as relying on hip data alone may miss 17% of osteoporosis diagnoses 4

2. Fall risk assessment including:

   • Visual acuity testing
   • Physical function tests (ability to stand without arm use)
   • Balance assessment (heel-toe walking) 2

3. Laboratory evaluation to identify secondary causes of osteoporosis:

   • Basic tests: ESR, calcium, albumin, creatinine, TSH
   • Additional tests when indicated: vitamin D, protein electrophoresis, testosterone in men 1

Interpretation and Follow-up

• Normal bone density: T-score > -1.0
• Osteopenia: T-score between -1.0 and -2.4
• Osteoporosis: T-score ≤ -2.5 3

Treatment is typically recommended when:

• T-score ≤ -2.5
• FRAX indicates 10-year probability of hip fracture ≥3%
• FRAX indicates 10-year probability of major osteoporotic fracture ≥20% 3

Important Caveats

• Timing matters: Secondary fracture risk is highest immediately after a fracture and gradually decreases over time 1
• Spinal assessment challenges: In patients with spinal deformities or extensive degenerative changes, hip and forearm DEXA may be more reliable than spine measurements 4
• Underutilization: DEXA scanning is underutilized, leading to potential undertreatment in approximately 70% of patients at risk for fractures 3
• Follow-up scans: Should be performed on the same machine as baseline, typically every 2 years, with shorter intervals (1 year) for patients at risk of rapid bone loss 3

In conclusion, DEXA scanning is an essential component of the evaluation for patients with frequent falls, as it helps identify those who would benefit from osteoporosis treatment to reduce fracture risk.