Dual-energy X-ray absorptiometry (DXA) is currently the gold standard by which bone mineral density (BMD) is measured. It can be used for the diagnosis, prognosis and monitoring of osteoporosis. Currently, a DXA T-score of ≤ -2.5, or BMD less than or equal to 2.5 standard deviations (SDs) below that of the young-adult mean, is used to diagnose osteoporosis in postmenopausal women and men age 50 years and older. A T-score <-1.0 but >-2.5 signifies Osteopenia or low bone mass, whereas a T-score ≥ -1.0 indicates normal bone density. The relative risk of fracture can be calculated as approximately 2 T-score. When a patient has been treated, the change in BMD can be used to show whether there has been a significant improvement or not. Finally, the Z-score, or number of standard deviations of BMD compared to that of an adult of the same age and sex, if less than -2, can give a clue that there are secondary causes to the bone loss. However, the DXA scan must be done as precisely and accurately as possible, and there may be artefacts that interfere with accurate interpretation.

Non-pharmacological recommendations for osteoporosis prevention are based on lifestyle measures to reduce bone loss and modify factors that can influence fracture risk. Lifestyle measures include smoking cessation, avoidance of heavy alcohol, adequate intake of calcium and vitamin D, exercise, and counselling on fall prevention. Calcium from dietary intake if adequate will not need supplementation; however vitamin D supplementation is usually required. The target of calcium 1000mg and 800iu of vitamin D daily are advised.

Objective: The current study explored the perceptions of General Practitioners (GPs) on barriers to care for dementia patients, reasons for referring them to tertiary hospitals for dementia-related symptoms, and the types of training and support that GPs would like to have to provide better dementia care in Singapore.Method: A total of 400 respondents completed the barriers to care in dementia management and training needs questionnaire, yielding a response rate of 52.3 percent. An invitation letter with a web link to the online survey form and a hardcopy of the questionnaires were mailed to GP clinics. The survey form was completed either online or by mailing back the hardcopy questionnaire. Results: Most GPs (n=391; 98 percent) agreed that the main barrier was that dementia patients tend to require more consultation time. The most common reason cited by GPs (n= 327; 82 percent) for referring patients to tertiary hospitals was the severity of symptoms. Out of 226 GPs who were agreeable to managing dementia patients, 75 percent (n=170) of them identified the fact that having direct access to a multidisciplinary team would support them in providing dementia care. Web-based training on the management of dementia patients (n=148; 65 percent) was the top training need recognised. Conclusion: GPs play a crucial role in managing dementia care in Singapore. The main difficulty they face is the longer consultation that a dementia patient requires and the need for support through multidisciplinary care. Web-based training programmes on diagnosis and management of dementia patients would address GPs’ uncertainties and equip them to better promote dementia care in Singapore.

This is a case of a patient with Behavioural and Psychological Symptoms of Dementia (BPSD) causing caregiver burden in her husband. The family physician was able to lead a multidisciplinary team to manage and optimise her care in the community.

Asthma is a common chronic respiratory disease in Singapore and it is the primary cause of chronic respiratory disease burden in childhood and early adulthood. Despite having one of the best healthcare systems in the world, our asthma mortality rates are several folds higher than other first world countries. Most asthma deaths are preventable. We illustrate a case of fatal asthma and highlight some learning points from this case.

Chronic diseases have a serious impact on individuals and on society in general. They affect the quality of life of individuals and can be a financial burden on those who are affected. There is a disease continuum of lifestyle, high risk diseases, and end organ damage. Lifestyle change is necessary if we are to reduce the prevalence of these chronic diseases. The Health Choices, Lifestyle Advice Resource for Healthcare Professionals provides a tool for lifestyle counselling.

Smoking cessation is a most cost-effective medical intervention and helping our patients stop smoking is a highly worthwhile endeavor. A doctor providing smoking cessation counseling will do well to first realise why many smokers are unwilling (or unable) to quit. This article focuses on why a doctor should emphasise smoking cessation in the prevention and management of chronic obstructive pulmonary disease.

Patients are often advised to adopt healthier behaviours or change unhealthy ones on the basis that what they are doing or not doing is detrimental to their health. Some of these changes may include going on a diet, exercising, stopping cigarette smoking and even relaxing and sleeping more. MI was initially developed by Rollnick and Miller as a strategy for addictive behaviour change, but it has found many applications in helping patients change other health related behaviours. MI was initially defined as a client-oriented, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence. The guiding stance, whilst respecting the patient's autonomy and the patient as the agency of change, maintain controls of the direction and structure of the consultation to evoke the patient's own arguments and strategies for change. The guiding process thus avoids the struggle or "fights" with the patient over changing behaviour and has been likened more to "dancing" with the patient. The four counselling principles in MI are: Develop discrepancy; Express empathy; Roll with resistance; and Support self-efficacy. Facilitating the patient to process and speak more about why and how to change then becomes one of the strategies to motivate change. In MI, this is known as change talk. Once change talk is elicited, the ways the practitioner can respond are: Elicit more (with open questions); Affirm; Reflect; and Summarise. Once the patient decides to change, goal setting becomes the next important process. Needless to say, the goal setting process must be done in collaboration with the patient, with the patient having the final say.

The ability to make informed health decisions is a complex process. Knowing when to consult a healthcare professional, understanding one's medical condition and learning how to take medicines correctly require that health information can be accessed, processed and applied effectively by the individual. These statements underpin the concept of "health literacy" which may be defined as the degree to which people have the ability to find, understand, act and communicate health information to make informed health decisions. To communicate at a level that helps patients to make use of health information, there is a need for the healthcare professional to first be able to identify and understand the patient's health literacy by considering age, gender, cultural background, education level, thoughts and behaviours associated with the topic under discussion, and perceived benefits and barriers towards the topic. Five strategies can then be applied for improving that patient's understanding and self management of his or her medical condition: (1) Assess patients' health literacy using open-ended questions; (2) Speak in plain language; (3) Limit the number of teaching points; (4) Use visual aids, and (5) Incorporate the 'teach-back' method to ensure patient understanding.

Smoking cessation is used to illustrate the application of health literacy principles to meet patients' needs. There are three areas to focus on : developing a health literate patient ; presenting information in a way that is easy to understand and use ; and creating a health literate delivery system that provides ready access to and delivery of health information and health services. The Health Choices ‐ flip chart tool kit for healthcare professionals launched on 1 September 2012 ‐ illustrates the elements of a health literate tool for communicating smoking cessation.