Should an occupational therapy (OT) referral be initiated for an older adult patient with osteopenia and a history of falls or fractures?

OT Referral for Osteopenia Patients

Occupational therapy referral should be initiated for patients with osteopenia ONLY if they have a documented history of falls or are at high risk for falls, as OT home safety assessment with direct intervention reduces fall risk, but assessment alone without active intervention does not prevent falls. 1

When to Refer to Occupational Therapy

Mandatory OT Referral Criteria

• Refer to OT if the patient has fallen in the past 12 months, as this identifies high-risk individuals who benefit from home safety evaluation with direct intervention, advice, and education 1, 2
• Refer to OT if the patient presents to emergency department after a fall, as structured interdisciplinary management including occupational therapy assessment reduces subsequent falls 1, 2
• Refer to OT if the patient has gait or balance impairment, as these are independent prognostic factors for falls and require environmental modification 1
• Refer to OT if the patient reports fear of falling or feeling unsteady while walking or standing, as positive responses warrant multifactorial falls-risk assessment 1, 2

Critical Implementation Requirements

• The OT referral must include direct intervention, not just assessment, as home assessment of risk with education alone does NOT reduce falls (Grade A evidence) 1, 3
• OT assessment must be combined with referrals to other healthcare professionals (primary care physician, physical therapy) as part of a multidisciplinary approach, since isolated interventions are ineffective 1, 2

When NOT to Refer to OT

• Do not refer to OT for osteopenia alone without fall risk factors, as bone density status by itself does not warrant occupational therapy intervention 1
• Do not refer for OT assessment only, as assessment without active intervention and follow-up does not reduce falls 1, 3

Alternative Referrals for Osteopenia Without Fall History

Physical Therapy Referral

• Refer to physical therapy instead of OT for patients with osteopenia who need exercise prescription but have no fall history, as PT focuses on bone health through weight-bearing impact exercise and resistance training 1, 4
• PT should prescribe multicomponent exercise incorporating dynamic weight-bearing, strength and balance training 2-3 days per week for at least 10 weeks, as this reduces fall risk and positively influences bone mineral density 1

Medical Management

• Refer to primary care physician or bone health clinic for osteoporosis evaluation, including DEXA scan, vitamin D, calcium, and parathyroid hormone levels 2, 5
• Initiate vitamin D supplementation (800 IU daily) for patients at increased fall risk, as this is evidence-based for fall prevention 2, 3

Multidisciplinary Approach for High-Risk Patients

Combined Interventions

• Implement multifactorial clinical assessment with comprehensive management (not just assessment alone), which includes medical evaluation, medication review, home hazard modification by OT, and exercise/physical therapy 1, 2
• Target specific modifiable risk factors: postural hypotension, polypharmacy (≥4 medications), psychotropic drugs, balance deficits, and gait abnormalities 1, 3
• Ensure assessment occurs within 7 days of a fall with development of individualized treatment plans, as this timing decreases subsequent falls and hospital admissions 3, 5

Common Pitfalls to Avoid

• Avoid referring for OT assessment without ensuring active intervention and follow-up, as three trials showed no reduction in falls when home assessment lacked referrals or active intervention 1
• Do not rely on education alone, as home assessment with risk education but without referral to healthcare professionals does NOT reduce falls 1, 3
• Recognize that osteopenia diagnosis alone is insufficient justification for OT referral unless accompanied by fall risk factors or functional impairment 1, 4