Abstract
Background: The National Clinical Guideline for Stroke recommends bone health assessment for patients at higher risk of falls. Following stroke, patients have reduced bone mineral density, correlated with functional deficit. Stroke can result in reduced mobility, asymmetric weight bearing, poor nutrition and impaired Vitamin D stores. This results in higher risk of fragility fracture. However, bone health is often overlooked. An initial review on a stroke rehabilitation unit in March 2024 found no bone health assessment process.
Objectives: Patients with stroke and high risk of fragility fracture should undergo bone health assessment and timely treatment or onward referral if indicated.
Methodology: Patients undergoing stroke rehabilitation were identified as high-risk for fragility fracture based on age, gender, falls history, cognition, visual impairment and post-stroke seizures. Patients with life expectancy 1 year or predicted to be bedbound longer term were excluded. Data was collected over two cycles for 1 month (September 2024, November 2024). If high-risk, records were reviewed for serum calcium and Vitamin D measurement, FRAX score and treatment initiation and/or onward referral.
Results: Local guidelines were developed with input from orthogeriatric and stroke physicians. Following initial analysis, 3/32 eligible inpatients (11.1%) had recorded FRAX scores with none initiated on therapy. Prompts were added to patient records and departmental teaching delivered. Significant improvement was seen in the following cycle: 43.8% (n=14) of eligible patients had bone health assessment. Serum Vitamin D measurement increased from 41% to 56% and all below threshold started replacement. Five patients were referred for bone densitometry and a further five were prescribed bisphosphonate therapy.
Conclusion: Patients with stroke are at higher risk of fragility fractures. Increased awareness and assessment in the rehabilitation setting are required. Further improvements include displaying posters of the treatment flowchart, induction education for rotating doctors and additional electronic record prompts to increase engagement.