David B. Hogan MD, FACP, FRCPC
Professor, Division of Geriatric Medicine, Cumming School of Medicine, University of Calgary
OBJECTIVES: Upon conclusion, the reader of this paper will be:
- Aware of the disproportionate burden of fractures in the very old (80+ years of age) and/or residents of long-term care facilities.
- Able to discuss the management challenges that arise in these particular high-risk-for-fractures populations.
- Able to outline an approach to prevent fractures in those who are 80+ years of age and/or long-term care residents.
You are responsible for the medical care of Cecelia, an 84-year-old female residing in a long-term care (LTC) facility. Cecelia is a non-smoker who does not drink. She has moderate dementia with a Cognitive Performance Scale score of 3 but no behavioral issues, such as wandering. She has no known family or personal history of fractures, nor conditions that could lead to secondary osteoporosis. From a functional standpoint she needs limited assistance with sit-to-stand transfers (including from the toilet), stand-by assistance when walking and partial-to-total assistance with all basic activities of daily living, excluding feeding. Over the last six months she has had three falls, the last one 14 days ago. She has always been thin, but she has recently lost weight. She eats less than 25% of her meals because of poor appetite. There is no dysphagia. Her height is 155 cm, weight is 42 kg and her body mass index (BMI) is 17.5. Her estimated glomerular filtration rate is 35 ml/min based on recent blood work.
Cecelia’s daughter is her agent on an enacted personal directive and attends Cecelia’s annual case conference. While pleased with her mother’s care Cecelia’s daughter is worried that a hip fracture might occur with one of her mother’s falls. As Cecelia’s physician, you are asked if you think osteoporosis treatment should be started and if there is anything else that could be done to decrease Cecelia’s fracture risk.
More than a third of the estimated 164,763 Canadians aged 50 and over (50+) who suffered a fracture in 2011 were 80 years of age or older (80+).1 The five-year fracture risk for those 80+ has been estimated as 17% in women and 11% in men.2 LTC residents, who are usually but not always 80+, are approximately 1.5-2.0 times as likely as similarly-aged persons living in the community to suffer a hip fracture.3
The recent Towards Optimized Practice guideline on osteoporosis4 is a good source of advice but does not specifically address what to do when caring for those 80+ and/or residing in LTC facilities. In this article, we’ll:
- Review what is known about treating osteoporosis and preventing fragility fractures (occurring spontaneously or from minor trauma, such as a fall from standing height or less) in these two patient populations.
- Outline an approach to their management based on recommendations made by an expert working group of the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis5 and Osteoporosis Canada.6
MANAGEMENT OF OSTEOPOROSIS IN THE VERY OLD
Treatment options for osteoporosis other than calcium and vitamin D include bisphosphonates, denosumab, raloxifene, hormone replacement therapy (HRT) and teriparatide.4 Raloxifene and HRT are not recommended for those 80+ as the risks from use are felt to outweigh likely benefits, and there are effective alternatives available.6,7 Most of the efficacy data for treating osteoporosis comes from RCTs performed on women 50-80.5 Evidence for benefit among those 80+ is based on sub-group analyses of RCTs5 and observational studies.8 While there is benefit seen for other outcomes, none of the agents available in Alberta have shown a statistically significant reduction in hip fractures in sub-group analyses of RCTs restricted to participants 80+, though denosumab did show a statistically significant reduction in hip fractures among those 75+.5 Adverse effects in the 80+ group are similar to those noted in younger populations.4 Apart from serious upper gastrointestinal bleeds that rarely occur after starting a bisphosphonate,9 no published data indicate that adverse effects are more common among the very old. The same general recommendation for re-evaluating bisphosphonate therapy after five years stands for this group.4 In this review we will not be considering the cost of therapy except to note that denosumab and especially teriparatide are significantly more expensive than the oral bisphosphonates.
Those of this age as well as residents of LTC facilities frequently suffer from multiple morbidities for which they take numerous medications. Many would be ineligible for the studies that lead to the approval of drugs we have available for osteoporosis.10 Concurrent conditions and therapy raise the likelihood of adverse drug-disease and drug-drug interactions. Age-related pharmacokinetic changes (especially with regard to renal function) may predispose the very old to adverse effects, which might have more serious consequences because of diminished resiliency. Management has to be individualized in older populations with consideration of factors such as remaining life expectancy, time until benefit from the therapeutic agent, goals of care and treatment targets when making shared treatment decisions with the patient and/or their proxy.11 To help in these discussions, aids in estimating life expectancy can be found on the ePrognosis website. For many agents used to prevent future problems little information exists on estimating time until benefit. Fortunately we have data for osteoporosis showing significant reductions within a year of treatment for vertebral5 (with bisphosphonates and denosumab) and hip (with denosumab) fractures.12
Both falls and osteoporosis increase the risk of fractures. The likelihood of fractures is particularly high when the two are present together. For example, one study found that compared to those without osteoporosis or a history of falling, women with osteoporosis but no fall history were 2.8 times more likely to have experienced a fracture in the previous year. Osteoporotic women with a fall history, though, were 24.8 times more likely.13 Another management option would be the use of hip protectors (hard plastic shields or soft foam pads usually fitted in modified underwear that cushion the impact of a sideways fall on the hip), though they have been shown to decrease fracture risk only among older persons living in residential or LTC facilities.14
The Fracture Risk Assessment (FRAX®) tool may be used to assess the likelihood of a future fracture and guide treatment decisions. Based on demographic and clinical factors plus the patient’s femoral neck bone mineral density (BMD) if available (note: an estimate can be calculated without a BMD), the tool provides 10-year probabilities of both hip and major osteoporotic fractures. A reasonable management approach for patients 80+ living in the community would be combining osteoporosis therapy in appropriate patients (based on the FRAX score) with interventions to prevent falls, such as exercise programs.5,15-17
FRACTURE PREVENTION IN LONG-TERM CARE
Risk factors for fractures in LTC residents include the functional and mobility characteristics of the resident as well as the items found on the FRAX® tool. The Fracture Risk Scale (FRS) based on items from the RAI-MDS 2.0 (i.e., ability to walk in corridor, BMI, fall in last 30 days, fall in last 180 days, wandering, ability to transfer, Cognitive Performance Scale, fracture in past 180 days, age >85) was developed for LTC residents and accurately predicts hip fracture risk over the next year.18
Canadian recommendations for fracture prevention in LTC state that all residents should aim to consume 1,200 mg/d of dietary calcium and take 800-2,000 i.u. of vitamin D/d.6 Supplements are recommended if suggested levels are not achieved via diet. Other universal measures would be the use of hip protectors14 and efforts to decrease falls (e.g., exercise program, medication review, removing environmental hazards, appropriate use of assistive devices).6 Residents at high risk for fractures who are expected to survive the next year (as noted, time until benefit is within a year for osteoporosis therapy) would be considered for osteoporosis treatment, specifically alendronate, risedronate, zoledronic acid, denosumab and teriparatide. The choice of agent would be guided by the resident’s renal function and whether they have dysphagia.6 Stage 4 (GFR 15-30 ml/min) or 5 (< 15 ml/min) chronic kidney disease would preclude use of a bisphosphonate or teriparatide while dysphagia would restrict use to agents that can be given parenterally.
BACK TO THE CASE
Cecelia’s FRAX® score without a BMD indicated high risk of suffering a fracture (major osteoporotic 27%, hip 17%) in the next 10 years while the FRS18 placed her at a very high risk for a hip fracture. Calcium and vitamin D intake should be assessed to ensure they meet the noted targets. Hip protectors would be an option for her as well as interventions to minimize future fall risk. Pharmacotherapy would be a consideration depending on her life expectancy. The Flacker calculator for long-stay nursing home residents estimates her one-year mortality risk as 31%, which indicates a better than 50/50 chance to survive a year. Her renal function is barely adequate for a bisphosphonate. Cecelia’s daughter can be told that while steps can be (and have been) taken to decrease the likelihood of a hip fracture, Cecelia’s heightened risk cannot be eliminated. Though an option for her, adding pharmacotherapy for osteoporosis would likely not lead to significant lowering of this risk according to current evidence. Whether to treat her for osteoporosis would depend on the informed consent of her daughter who is Cecilia’s substitute decision maker.
- Hopkins RB, Burke N, Von Keyerselingk, Leslie WD, Morin SN, et al: The current economic burden of illness of osteoporosis in Canada. Osteoporos Int 2016, 27: 3023-32.
- Nguyen ND, Ahlborg HG, Center JR, Eisman JA, Nguyen TV: Residual lifetime risk of fractures in women and men. L Bone Miner Res 2007, 22: 781-88.
- Papaioannou A, Kennedy CC, Ioannidis G, Cameron C, Croxford R, et al: Comparative trends in incident fracture rates for all long-term care and community-dwelling seniors in Ontario, Canada, 2002-2012. Osteoporos Int 2016, 27: 887-97.
- Toward Optimized Practice (TOP) Osteoporosis CPG Committee 2016 Feb. Diagnosis and management of osteoporosis clinical practice guideline. Edmonton, AB: Toward Optimized Practice. Available from: http://www.topalbertadoctors.org
- Rizzoli R, Branco J, Brandi M-L, Boonen S, Bruyère O, et al: Management of osteoporosis of the oldest old. Osteoporos Int 2014, 25: 2507-29.
- Papaioannou A, Santesso N, Morin SN, Feldman S, Adachi JD, et al: Recommendations for preventing fracture in long-term care. CMAJ 2015, 187: 1135-44.
- Qaseem A, Forciea MA, McLean RM, Denberg TD for the Clinical Guidelines Committee of the American College of Physicians: Treatment of Low Bone Density or Osteoporosis to Prevent Fractures in Men and Women: A Clinical Practice Guideline Update From the American College of Physicians. Ann Intern Med 2017, 166:818–839.
- Axelsson KF, Wallander M, Johansson H, Lundh D, Lorentzon M: Hip fracture risk and safety with alendronate treatment in the oldest-old. J Intern Med 2017, 282: 546-59.
- Knopp-Sihota JA, Cummings GG, Homik J, Voaklander D. The association between serious upper gastrointestinal bleeding and incident bisphosphonate use: a population-based nested cohort study. BMC Geriatrics 2013,13: 36. doi:10.1186/1471-2318-13-36.
- Reyes C,Pottegård A, Schwarz P, Javaid MK, Van Staa TP, et al: Real-Life and RCT Participants: Alendronate Users Versus FITs' Trial Eligibility Criterion. Calcif Tissue Int. 2016, 99: 243-9.
- Holmes HM, Hayley DC, Alexander GC, Sachs GA: Reconsidering Medication Appropriateness for Patients Late in Life. Arch Intern Med 2006, 166: 605-608.
- Boonen S, Adachi JD, Man Z, Cummings SR, Lippuner F, et al: Treatment with Denosumab Reduces the Incidence of New Vertebral and Hip Fractures in Postmenopausal Women at High Risk, The Journal of Clinical Endocrinology & Metabolism 2011, 96: 1727–1736.
- Geusens P,Autier P, Boonen S, Vanhoof J, Declerck K, Raus J. The relationship among history of falls, osteoporosis, and fractures in postmenopausal women. Arch Phys Med Rehabil 2002, 83: 903-906.
- Santesso N, Carrasco-Labra A, Brignardello-Petersen R. Hip protectors for preventing hip fractures in older people. Cochrane Database of Systematic Reviews 2014, Issue 3. Art. No.: CD001255. DOI: 10.1002/14651858.CD001255.pub5.
- Tricco AC, Thomas SM, Veroniki AA, Hamid JS, Cogo E, et al: Comparisons of Interventions for Preventing Falls in Older Adults - A Systematic Review and Meta-analysis. JAMA2017, 318: 1687–1699.
- Abrahamsen B: The emperor redressed: treating osteoporosis to prevent hip fractures in the oldest old. J Intern Med 2017, 282: 560-62.
- Mort T, Crandell CJ, Ganz DA: Cost-effectiveness of combined oral bisphosphonate therapy and falls prevention for fracture prevention in the USA. Osteoporos Int 2017. 28: 585-95.
- Ioannidis G, Jantzi M, Bucek J, Adachi JD, Giangregorio L, et al: Development and validation of the Fracture Risk Scale (FRS) that predicts fracture over a 1-year time period in institutionalized frail older people living in Canada: an electronic record-linked longitudinal cohort study. BMJ Open 2017, 7: e016477. Doi: 10.1136/bmjopen-2017-016477.