Bone Health Plan Post-Hip Fracture: A Ward Doctor's Guide (UK, 2026)

Context and Rationale

Part 1: Formulating the Bone Health Plan

Step 1: Identify the Patient - Who Needs a Plan?

• No prior DXA scan is required before initiating treatment
• FRAX can be used to quantify 10-year risk but do not delay treatment waiting for it
• Start treatment promptly - imminent risk is highest in the days and weeks after the fracture

Step 2: Clinical Assessment

• Age, sex, menopausal status (women) / hypogonadism (men)
• Prior fragility fractures (spine, wrist, hip, humerus)
• Parental hip fracture history
• Corticosteroid use (≥7.5 mg prednisolone/day for ≥3 months)
• Alcohol intake (≥3 units/day is a risk factor)
• Smoking (current or ex)
• Rheumatoid arthritis
• Secondary osteoporosis causes: hyperthyroidism, hyperparathyroidism, chronic liver disease, coeliac disease, inflammatory bowel disease, chronic kidney disease, hypogonadism, prolonged immobility
• Falls history: number of falls in past year, circumstances, dizziness/syncope, visual problems
• Medications contributing to falls: antihypertensives, diuretics, benzodiazepines, antipsychotics, antidepressants, opioids, antiepileptics
• Review medications increasing fracture risk: long-term steroids, proton pump inhibitors, SSRIs, antiepileptics, thiazolidinediones, androgen deprivation therapy, aromatase inhibitors

• Height (ideally compared to historical height - >4 cm loss suggests vertebral fractures)
• Body weight / BMI (low BMI <19 kg/m² is a risk factor)
• Kyphosis (vertebral fractures)
• Gait, balance, functional assessment
• Cognitive assessment (affects adherence counselling)
• Dental assessment history (relevant before bisphosphonate/denosumab)

Step 3: Investigations

• Lateral spine X-ray (or VFA on DXA) to identify morphometric vertebral fractures - these may be asymptomatic but increase fracture risk further and change treatment category
• DXA scan: Request at admission or as an outpatient. For post-hip fracture, treatment is initiated regardless of DXA result, but DXA:
  • Provides baseline for treatment monitoring
  • Confirms T-score (may influence choice between oral vs. IV bisphosphonate)
  • Identifies vertebral fractures on VFA
  • A T-score ≤ -3.5 or multiple vertebral fractures should trigger specialist referral

• Use the Sheffield FRAX tool (frax.shef.ac.uk) with BMD input if available
• For post-hip fracture patients ≥50 years, FRAX will virtually always indicate high/very high risk
• If DXA not practical (frailty, age >89), use FRAX without BMD and NOGG intervention thresholds
• Repeat FRAX after any new fracture, regardless of when the last one was done

Step 4: Risk Stratification Using NOGG 2024

Step 5: Correct Deficiencies Before Starting Bone Treatment

• Check 25-OH vitamin D level
• If deficient (<25 nmol/L): loading dose (e.g. 300,000 IU colecalciferol over 6-10 weeks), then maintenance
• If insufficient (25-50 nmol/L): standard loading or start maintenance directly
• Maintenance: 800-2000 IU colecalciferol daily (NOGG/NICE recommendation)
• Do not start bisphosphonates or denosumab with uncorrected vitamin D deficiency - risk of severe hypocalcaemia

• Aim for total intake 700-1200 mg/day (diet + supplement)
• Check dietary intake first - many patients only need a modest supplement
• Typical supplement: calcium carbonate 500-1000 mg daily if diet is insufficient
• Do not over-supplement: calcium supplements alone show limited benefit on fracture prevention and excessive intake carries cardiovascular concerns

Step 6: Pharmacological Treatment

First-Line Choices (per NOGG 2024 and Nottinghamshire/local NHS guidelines)

• First line for most patients
• Requires CrCl ≥35 mL/min
• Must be taken on an empty stomach with a full glass of water (200 mL), sitting/standing upright for 30 minutes, no food/drink/other medication for 30 minutes after
• Contraindications: oesophageal abnormalities (stricture, achalasia), inability to sit/stand upright for 30 minutes, hypocalcaemia, CrCl <35 mL/min
• Duration: plan for at least 5 years, reassess at 5 years; for post-hip fracture patients age ≥70 or with prior vertebral fractures, continue for at least 6-10 years before considering drug holiday

• Second line if alendronate not tolerated
• Requires CrCl ≥30 mL/min
• Same administration instructions as alendronate

• Strongly preferred post-hip fracture in many UK centres (Nottinghamshire, SIGN guidance) because:
  • Eliminates adherence issues (single annual infusion)
  • The HORIZON trial showed 35% reduction in hip fractures, 70% reduction in vertebral fractures
  • Can be given inpatient or as outpatient infusion (within ~2 weeks of surgery, ideally after the patient is mobile)
  • Wait 2 weeks post-operatively to give the first infusion (avoids acute phase reaction; also IV route preferred over oral in the immediate post-surgical period)
  • Requires CrCl ≥35 mL/min (use 5 mg dose for osteoporosis; note: 4 mg used off-label in some centres for hip fracture per local consensus)
  • Common side effect: acute phase reaction (flu-like illness, fever, myalgia, arthralgia) 1-3 days after first infusion; warn patients; resolves within 72 hours; pre-medication with paracetamol/ibuprofen reduces severity
  • Requires adequate hydration before infusion
  • Duration: at least 3 doses (3 years), then reassess; for post-hip fracture age ≥70, prior vertebral fracture, or ongoing steroids: extend to 6 years
  • Off-label extended interval: up to 18 months between doses in selected low-risk patients (on specialist advice only - not for hip fracture patients)

When to Refer to Bone Specialist (Rheumatology/Endocrinology/Metabolic Bone Clinic)

• BMD T-score ≤ -3.5
• Recent (within 2 years) vertebral fractures Grade 2/3, or multiple vertebral fractures
• Hip fracture (these should all be referred per Nottinghamshire APC v3.4, March 2026)
• CrCl <30 mL/min and bone treatment indicated
• Fracture despite good adherence to oral bisphosphonate for >12 months
• Intolerance/contraindication to bisphosphonates
• Need for anabolic therapy consideration

Second/Specialist-Line Drugs

Special Situations

• CrCl 30-35 mL/min: risedronate preferred (CrCl ≥30 mL/min)
• CrCl <30 mL/min: denosumab (no dose adjustment), with caution; refer specialist

• Zoledronate IV or denosumab SC are preferred

• IV zoledronate strongly preferred - ensures treatment delivery
• Consider life expectancy and patient values carefully - initiate bone treatment if life expectancy >12 months

• NOGG 2024 applies to men aged ≥50 years - same pathway
• Check testosterone levels
• Alendronate and zoledronate are licensed in men

Step 7: Falls Risk Assessment and Prevention

• Delirium assessment and management
• Review and rationalise fall-risk medications (benzodiazepines, antipsychotics, antihypertensives, antiepileptics, opioids)
• Physiotherapy referral for mobility and strength assessment
• Occupational therapy for functional independence and home assessment
• Visual assessment (refer ophthalmology if cataracts/visual impairment)

• Refer to community falls prevention programme (NICE CG161)
• Tai chi / structured exercise
• Home hazard removal
• Footwear advice
• Hip protectors in care home residents

Step 8: Fracture Liaison Service (FLS)

• Ensures fracture and falls risk assessment
• Initiates/oversees bone protection
• Coordinates with primary care
• Follow-up at 16 weeks and 52 weeks post-fracture (NOGG recommendation)
• Monitors: medication adherence, calcium/vitamin D status, new fractures, side effects

• Follow up at 4 and 12 months
• Review medication adherence and fracture risk
• Ensure calcium and vitamin D adequacy
• Calculate/repeat FRAX after any new fracture

Part 2: Patient Counselling

Framework: The Two-Step Process

Step 1: Set the Stage - Timing and Environment

• Have the conversation within the first 24-48 hours of admission once pain is controlled and delirium (if present) has been treated
• If the patient has cognitive impairment, involve the next of kin/lasting power of attorney
• Use plain language; avoid jargon
• Ask about prior knowledge: "Has anyone ever talked to you about osteoporosis or bone thinning?"
• A follow-up written information sheet (ROS 'Strong, Steady and Straight' booklet or similar) reinforces verbal counselling

Step 2: Explain Why Bone Health Matters (The "So What" Conversation)

"Your hip broke because of a condition called osteoporosis - thin, fragile bones. This is very common as we get older. The important thing is that we can treat it and significantly reduce the chance of you breaking another bone. If we don't treat it, you have a high chance - around 1 in 3 - of breaking another bone in the first year. With treatment, we can cut that risk substantially."

• This is a medical condition, not a failure - fragility fractures are not just the result of a bad fall
• Osteoporosis is treatable and common - it affects 1 in 3 women and 1 in 5 men in their lifetime
• Post-hip fracture = high imminent risk of the next fracture, which may be more disabling
• Treatment is long-term but effective

Step 3: Explain Calcium and Vitamin D

"The first thing we'll give you are supplements - vitamin D and calcium. Vitamin D helps your bones absorb calcium properly. Most people in the UK don't get enough sunlight to make enough vitamin D, especially in winter. Low vitamin D also weakens muscles and increases the risk of falls. These supplements alone aren't enough to stop further fractures, but they're the foundation of everything else."

• Calcium: explain dietary sources first (dairy, leafy greens, fortified foods); supplement only the gap
• Vitamin D: 800-2000 IU daily (maintenance); explain that sunlight exposure in the UK is insufficient for most of the year
• Reassure these are well-tolerated and inexpensive

Step 4: Explain Bone Protection Medication

"We're also going to start a bone-strengthening tablet called alendronic acid. This works by slowing down the natural breakdown of bone that happens as we age. It has been shown to halve the risk of further spine fractures and significantly reduce hip fracture risk."

"This tablet is taken once a week, on the same day each week. It must be taken on an empty stomach, first thing in the morning, with a large glass of plain water - at least 200 ml, about a full cup. You must sit or stand upright for at least 30 minutes after taking it - no lying down. Don't eat, drink, or take any other tablets for 30 minutes after. Taking it incorrectly can cause irritation to the food pipe."

• Oesophageal irritation: chest pain, difficulty swallowing - if this occurs, stop and contact their GP or go to A&E
• Flu-like illness with first dose (mainly IV zoledronate): fever, muscle aches, joint pains - usually mild and resolves within 72 hours; take paracetamol regularly for the first 48-72 hours
• Jaw problems (osteonecrosis of jaw - ONJ): very rare with oral bisphosphonates (much less common than with high-dose IV for cancer treatment); good dental hygiene reduces risk; advise patient to inform dentist they are on bisphosphonates before any dental extraction - but do not let fear of ONJ prevent treatment
• Atypical femoral fracture: very rare (around 1 in 100,000 patient-years); if thigh, groin, or hip pain develops between fracture events, report to GP promptly

"Instead of a weekly tablet, we can give you a once-yearly infusion through a drip. This has the advantage that you don't need to remember to take a tablet every week. It's equally effective and the evidence is very good. The first infusion might cause flu-like symptoms for a day or two - we'll give you paracetamol to take for the first couple of days just in case."

"This is a twice-yearly injection under the skin. It's particularly useful if your kidneys don't tolerate the other medications. One important thing: this medication must not be stopped abruptly - if you ever want to stop it, it must be done in consultation with your doctor who will transition you to a different bone medication. Stopping suddenly can cause a sudden risk of spinal fractures."

Step 5: Address Common Concerns

Step 6: Lifestyle and Non-Pharmacological Counselling

• Protein intake: aim above the RDA of 0.75 g/kg/day - important for bone and muscle (higher protein is associated with better hip BMD per NOGG 2024)
• Calcium-rich foods: dairy (200 mL milk ~240 mg Ca), fortified plant milks, sardines with bones, leafy greens
• Reduce alcohol: ≤2 units/day recommended; more than 3 units/day is an independent fracture risk factor
• Maintain healthy weight: low BMI (<19) increases fracture risk

"Exercise is one of the most important things you can do for your bones and your balance. We're not talking about running - the right kinds of exercise are weight-bearing activities like walking, dancing, and climbing stairs, combined with muscle-strengthening exercises like using resistance bands or light weights. Balance training like tai chi has also been shown to reduce falls. Once you've recovered from surgery, aim for at least 150 minutes of moderate activity per week."

• Current smoking increases fracture risk and impairs fracture healing
• Offer smoking cessation support (refer to Stop Smoking services)

• Brief sun exposure (arms and face, ~15 minutes) during summer months
• In winter (October-March in the UK), sun is insufficient; supplements are essential

Step 7: Falls Prevention Counselling

"Preventing falls is just as important as strengthening your bones. Some of the things we can help with include: a review of any medications that might make you dizzy or unsteady; an assessment of your home to remove trip hazards; physiotherapy to improve your strength and balance; and a referral to a falls prevention programme in your local community."

• Non-slip footwear, well-fitted shoes
• Adequate lighting in home, especially at night
• Grab rails/handrails on stairs
• Removal of loose rugs, trailing cables
• Night lights for bathroom trips
• Vision check (cataracts double fall risk)
• In care home residents: hip protectors

Step 8: Discharge Planning and Follow-up

1. Diagnosis of osteoporosis (or osteopenia if relevant) - code this explicitly
2. Blood results and any pending investigations (DXA, bloods)
3. Medications started (with administration instructions for alendronate)
4. Referral to FLS (if not yet seen)
5. GP follow-up instructions: review at 4 and 12 months, medication adherence, calcium/vitamin D, FRAX repeat

• Written information (Royal Osteoporosis Society leaflets - available at theros.org.uk)
• Clear list of all new medications with instructions
• Red flag symptoms to report: chest pain after alendronate, thigh/groin pain, jaw problems, new back pain

"Your GP will get a full letter about everything we've done. You should have a follow-up appointment with them within about 4 weeks to check how you're doing with the new medications. The fracture clinic/bone health clinic will also be in touch to do a bone scan (DXA) if we haven't done one already."

Summary Checklist for the Ward Doctor

• Secondary causes investigated (bloods including vitamin D, calcium, eGFR, TFTs)
• Vitamin D deficiency corrected / calcium and vitamin D supplement prescribed
• Bone protection medication initiated (alendronate, risedronate, OR zoledronate) OR documented reason for deferral/specialist referral
• Renal function checked and drug dose/choice adjusted accordingly
• DXA requested (inpatient or outpatient)
• Falls risk medications reviewed and rationalised
• Physiotherapy and occupational therapy referrals made
• FLS referral made
• Patients counselled verbally + written information given
• Discharge summary documents osteoporosis diagnosis and plan clearly
• GP follow-up arranged (4 weeks and 12 months)

Key Guidelines Referenced

• NOGG 2024 - 2024 UK Clinical Guideline for Prevention and Treatment of Osteoporosis (updated December 2024)
• NICE CG124 - Hip fracture: management
• NHFD 2025 Annual Report - National Hip Fracture Database
• FLS-DB 2026 Annual Report - RCP Fracture Liaison Service Database
• Systematic Review 2026 (PMID 41653468): Pharmacological treatment reduces refracture rates (cumulative 12-month refracture 4% with treatment vs. 10% without); FLS associated with 44% increase in treatment initiation
• Systematic Review 2025 (PMID 40838777): Patient education and healthcare professional awareness are critical to AOM initiation post-hip fracture

Mental Capacity Assessment for Discharge Home: What to Ask and What to Document

The Legal Framework

"Does this patient have the capacity to decide where they will live/be discharged to?"

The 5 Statutory Principles (MCA s.1) - Know These Before You Start

1. A person must be assumed to have capacity unless established otherwise
2. A person is not to be treated as lacking capacity unless all practicable steps to help them decide have been tried and failed
3. A person is not lacking capacity just because they make an unwise decision
4. Anything done or decided for a person lacking capacity must be done in their best interests
5. Before acting, consider whether the purpose can be achieved in a less restrictive way

The Two-Stage Test

Stage 1: Is there an Impairment or Disturbance of the Mind or Brain?

• Dementia (Alzheimer's, vascular, Lewy body, mixed)
• Delirium (very common post-operatively - and importantly, it may be temporary, so reassess)
• Acquired brain injury
• Severe depression
• Severe learning disability
• Effects of medication (sedatives, opioids)
• Alcohol/substance intoxication

If there is no impairment at all, stop - the patient has capacity (by presumption). Do not conduct a capacity assessment on a patient with no suspected impairment.

Stage 2: Does That Impairment Mean the Patient Cannot Make This Decision?

The Four Functional Elements: Questions to Ask

• Is this the best time of day? (dementia patients often have better cognition in the morning)
• Is the environment calm, quiet, private?
• Has delirium been treated and resolved as much as possible?
• Does the patient need glasses or hearing aids?
• Is a communication aid / interpreter / speech and language therapist needed?
• Should you delay the assessment (e.g. wait for delirium to clear)?

Element 1: Can They UNDERSTAND the Relevant Information?

"You have had a hip fracture and an operation. You are in hospital. We need to talk about where you will go when you leave hospital. You could go back home, or you could go to a care home, or you could go to a rehabilitation unit. At home, you would need help with [washing/dressing/cooking etc.]. There are risks if you go home - for example, the risk of falling again. There are also benefits - being in familiar surroundings, your independence. What do you understand about your situation?"

• "Can you tell me in your own words why you are in hospital?"
• "What happened to your hip/leg?"
• "Do you understand that we are trying to decide where you will go when you leave hospital?"
• "What are the options we've discussed for where you could go?"
• "What does going home involve for you? What help would you need?"
• "What would happen if you went home without any help?"
• "Do you understand that your mobility has changed since before your fall?"

• What information you provided to the patient (verbatim or paraphrased)
• The patient's response in their own words
• Whether they could understand and demonstrate comprehension of the key facts

Element 2: Can They RETAIN That Information?

• Ask the patient to repeat back the key points a few minutes after you explained them (re-ask without re-giving the information)
• "Can you remind me - what are the options we discussed?"
• "Earlier I explained the risks of going home without support - can you tell me what those were?"
• "We talked about needing care at home - do you remember what kinds of help we said you'd need?"

• How long after providing information you tested recall
• Whether the patient could recall the key elements
• If they could not - what specifically they could not retain

Element 3: Can They USE OR WEIGH the Information?

• "What are the good things about going home?"
• "What are the concerns or risks about going home?"
• "What would make going home work? What would you need in place?"
• "What would happen to you if you fell again at home?"
• "What are the advantages and disadvantages of going to a care home / rehabilitation unit?"
• "How are you weighing those things up - what matters most to you?"
• "Why do you want to go home / to a care home?" (ask them to explain their reasoning, not just state a preference)
• "If the care package fell through and there was no one to help you, what would you do?"

• The patient's reasoning in their own words
• Whether they demonstrated understanding of consequences
• Whether they could articulate pros and cons
• If they could not weigh - describe specifically how their reasoning was impaired

Element 4: Can They COMMUNICATE Their Decision?

• "So, having thought about everything, what is your decision about where you would like to go?"
• If verbal communication is impaired: can they indicate yes/no with head nod? Point to written options? Use a picture board?
• "Can you tell me clearly: do you want to go home, to a care home, or to a rehabilitation unit?"

• The method of communication used
• The decision as stated by the patient
• If communication was not possible - what was tried and why it failed

What to Document - A Structured Template

• Did you conduct the assessment at the optimal time of day?
• Was delirium investigated and managed?
• Were sensory aids (glasses, hearing aids) in place?
• Was the environment calm and private?
• Was information given in simple, clear language?
• Was an interpreter used?
• Was an IMCA considered (if no family or friends to consult)?
• Was the assessment timed to avoid medication side effects?

• Who was consulted (family, carers, MDT, social worker)?
• Does the patient have a Lasting Power of Attorney (LPA) for health and welfare? If so, that person makes the decision - not the doctor.
• Does the patient have an Advance Care Plan or Advance Decision (ADRT)?
• Has an IMCA (Independent Mental Capacity Advocate) been involved? (Required if the patient has no family/friends who can be consulted AND the decision involves serious medical treatment or a change in residence)
• What are the patient's past and present wishes and feelings? (Prior expressed wishes, values, religious/cultural beliefs)
• What would the patient have wanted if they had capacity?
• Is the proposed plan the least restrictive option?
• What is the proposed best interests decision and why?

Common Pitfalls to Avoid

Post-Hip Fracture Specific Points

• Delirium affects up to 50% of hip fracture patients peri-operatively. It is often temporary - always reassess once delirium has resolved before making a definitive best interests decision about discharge
• The "Discharge to Assess" model (NHS England 2023 guidance) says the default is to discharge home first with support and assess ongoing needs there - this reinforces that home is the presumed first option, not a last resort
• If the patient wants to go home and has capacity to make that decision, that decision must be respected even if the MDT thinks it is risky
• Where there is genuine uncertainty, the Social Work team and/or the Old Age Psychiatry liaison team can assist with the assessment
• If there is a dispute between family/carers and the MDT about a patient lacking capacity and the best interests decision, this may ultimately need to go to the Court of Protection

• The exact verbatim questions to ask the patient during the assessment (not the legal theory)?
• A quick practical proforma/script you can use at the bedside?
• Something more specific to discharge home after hip fracture rather than generic MCA stuff?
• Something else entirely?

Capacity Assessment for Discharge Home: The Complete Practical Version

What You're Actually Assessing

1. MCA capacity assessment - legal test under the Mental Capacity Act 2005 (the four functional elements)
2. Functional safety assessment - practical "can they manage at home safely?" - this is where the fire/flood/intruder questions live

The Safety Questions (What You Were Asking About)

Fire

"If you were at home and you smelled smoke or saw a fire, what would you do?"

Flood / Gas leak

"If you came downstairs and found water flooding into your home / smelled gas, what would you do?"

Intruder

"If you were at home at night and you heard someone trying to break in, what would you do?"

Feeling unwell / medical emergency

"If you were at home and felt very unwell - for example, you fell and couldn't get up, or had a bad chest pain - what would you do?"

Medication

"How do you manage your tablets at home? What would you do if you weren't sure whether you'd taken them?"

How to Test It Practically (OT Method)

Patient says they would call 999 for a fire → hand them the phone → "Show me what you'd do" → patient dials 999 → you act as operator → "What service do you require?" → "What is the problem?" → "What is your address?"

The Full Practical Assessment at the Bedside

Part 1: Orientation and Situational Awareness

• "Can you tell me where you are right now?"
• "Do you know what day/date it is today?"
• "What happened to bring you into hospital?"
• "Do you know what the plan is when you leave here?"

Part 2: Understanding Their Home Situation

• "Where do you live? Can you tell me your address?"
• "Do you live alone or with someone?"
• "Who usually helps you at home?"
• "What do you normally manage by yourself - cooking, washing, getting dressed?"
• "How do you normally get around the house? Do you use a walking stick/frame?"

Part 3: Safety Scenario Questions

• Fire: "What would you do if there was a fire at home?"
• Medical emergency: "What would you do if you fell and couldn't get up?"
• Intruder: "What would you do if someone tried to break in?"
• Feeling very unwell: "What would you do if you felt very ill and needed urgent help?"
• Medications: "How do you manage your medications? What if you weren't sure if you'd taken them?"

Part 4: MCA Functional Elements (weigh up the discharge decision)

• "Do you understand that your mobility has changed since your fall?"
• "What do you think you can and can't do for yourself at home now?"
• "What are the risks of going home at the moment?"
• "What support do you think you'd need?"
• "What would you do if the care package wasn't in place?"

What to Document

"When asked what they would do in a house fire, patient stated: 'I'd ring 999'. When asked what their address was, patient was unable to recall their home address despite prompting."

"Patient correctly identified they would leave the house and call 999 in a fire. Patient was able to state their address accurately."

"Patient stated they would 'wait for my daughter' if they fell at home. When asked what they would do if their daughter was not available, patient was unable to generate an alternative plan."

The Key Insight

• Can the patient recognise danger?
• Can they generate an appropriate response?
• Can they access help (know their address, use a phone)?