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Determining the 10-Year Absolute Fracture Risk for community-dwelling adults: CAROC and FRAX
CAROC
- In 2005, Osteoporosis Canada, in association with the Canadian Association of Radiologists, launched the 10-year absolute fracture risk assessment – CAROC.
- In addition to BMD (lowest T-score of hip and lumbar spine), age, sex, fracture history and steroid use are taken into consideration to determine an individual’s 10-year risk of fracture.
- The presence of both a fragility fracture and steroid use puts the patient at high fracture risk regardless of BMD result.
- Version 2, now available for Canadian physicians, uses only femoral neck (hip) BMD rather than the lowest of hip and lumbar spine.
Table 1 – 10 year fracture risk for women
10-year Risk Assessment for Women (CAROC Basal Risk)
| Age | Low | Moderate | High |
| 50 | above -2.5 | -2.5 to -3.8 | below -3.8 |
| 55 | above -2.5 | -2.5 to -3.8 | below -3.8 |
| 60 | above -2.3 | -2.3 to -3.7 | below -3.7 |
| 65 | above -1.9 | -1.9 to -3.5 | below -3.5 |
| 70 | above -1.7 | -1.7 to -3.2 | below -3.2 |
| 75 | above -1.2 | -1.2 to -2.9 | below -2.9 |
| 80 | above -0.5 | -0.5 to -2.6 | below -2.6 |
| 85 | above +0.1 | +0.1 to -2.2 | below -2.2 |
The T-score for the femoral neck is derived from the National Health and Nutrition Education Survey III (NHANES III) reference database for white women.
Table 2 – 10 year fracture risk for men
10-year Risk Assessment for Men (CAROC Basal Risk)
| Age | Low | Moderate | High |
| 50 | above -2.5 | -2.5 to -3.9 | below -3.9 |
| 55 | above -2.5 | -2.5 to -3.9 | below -3.9 |
| 60 | above -2.5 | -2.5 to -3.7 | below -3.7 |
| 65 | above -2.4 | -2.4 to -3.7 | below -3.7 |
| 70 | above -2.3 | -2.3 to -3.7 | below -3.7 |
| 75 | above -2.3 | -2.3 to -3.8 | below -3.8 |
| 80 | above -2.1 | -2.1 to -3.8 | below -3.8 |
| 85 | above -2.0 | -2.0 to -3.8 | below -3.8 |
The T-score for the femoral neck is derived from the National Health and Nutrition Education Survey III (NHANES III) reference database for white women.
The 10-year fracture risk will change with advancing age or with the development of new risk factors. Repeat assessment is appropriate in five to 10 years in those with low risk and in one to three years in those with moderate risk.
FRAX
In 2008, the FRAX tool (Fracture Risk Assessment) was launched – www.shef.ac.uk/FRAX. In 2010 Canadian data were added to this tool. In addition to femoral neck (hip) BMD, age, sex, fracture history and steroid use, FRAX also takes into account other clinical risk factors to calculate the absolute 10-year risk of a hip fracture or other major osteoporotic fracture (spine, forearm, upper arm). These factors include:
- BMI (weight to height ratio calculation)
- Parental hip fracture
- Rheumatoid arthritis
- Other secondary conditions that contribute to bone loss
- Current smoking
- Alcohol intake (three or more drinks per day)
CAROC/FRAX?
- The FRAX system is based upon a more complete set of clinical risk factors and it can be used without BMD results; but it requires access to FRAX software, website or paper chart.
- CAROC is less complete but captures the major risk factors for fracture and is easy to use.
- For the majority of people, the results are the same regardless of which of these tools is used. Therefore, the choice of FRAX or CAROC by the clinician is a matter of personal preference and convenience.
Determining 1-Year Fracture Risk for long-term care residents: The Fracture Risk Scale (FRS)
- The FRS automatically identifies long-term care residents’ one-year fracture risk.
- The FRS is the first tool of its kind developed specifically for the LTC population, taking into account factors like cognitive impairment, wandering, and body mass index
- The FRS is embedded within the RAI-MDS (Resident Assessment Instrument Minimum Data Set) – 2.0 or LTCF versionsIt requires no additional documentation
- It is integrated into the MDS 2.0 or LTCF assessment and can be found in the Electronic Medical Record outputs (e.g., in PointClickCare it is found in the outcomes summary report)
- The FRS has been validated across Canada
- The FRS is scored from 1-8, with 1 indicating low risk and 8 indicating high risk
