Treatment for osteoporosis in Australian residential aged care facilities: consensus recommendations for fracture prevention

As falls risk is an important determinant of fractures in institutionalised older people, there is agreement that all residents of RACFs should be screened for falls risk. Recently, researchers evaluated two models for screening falls risk in nursing homes.29 They concluded that these two screening models were useful for identifying older people living in RACFs who were at increased risk of falls. The screening models, summarised in Box 3, are easy to administer and contain items for which data are routinely collected in RACFs in Australia.

Furthermore, a pharmacist in association with the GP should perform a medication review annually to identify potential or actual medication-related problems and support appropriate prescribing. This medication review should be particularly focused on the use of benzodiazepines and psychotropic medications.30-32

Other interventions to prevent falls have been multifactorial in nature and have addressed risk factors pertaining to the individual (eg, strength and balance training) as well as their ability to safely interact with their environment.33 A recent Cochrane meta-analysis34 reported that multifactorial interventions reduce falls and risk of falling in hospitals and may do so in nursing care facilities. The authors confirm the evidence supporting the correction of vitamin D deficiency35 as an effective intervention to prevent falls in institutionalised older populations. However, in contrast to previous evidence showing that group exercise has an effect on falls prevention,36 the authors of the Cochrane review conclude that exercise in subacute hospital settings appears effective but its effectiveness in nursing care facilities remains uncertain.

Studies of the efficacy of hip protectors to prevent hip fractures in residents of RACFs have reported conflicting results, possibly due to potential bias from clustered randomisation designs and modest adherence to the intervention.37-39 A multicentre, randomised controlled trial in 37 nursing homes,40 which included 1042 residents, was unable to detect a protective effect against the risk of hip fracture despite good adherence to the protocol. In contrast, a Bayesian meta-analysis of four trials on the effect of hip protectors on fracture risk reported that hip protectors decrease the risk of hip fracture in elderly nursing home residents.38

There is evidence that vitamin D supplementation benefits most RACF residents.46 Benefits include prevention of falls and fractures.47,48 Cholecalciferol (vitamin D3) should be administered at a dose of 800 IU/day or higher.12,42,43 This is relatively inexpensive and achieves serum 25(OH)D concentrations > 50 nmol/L in most subjects, so can be implemented without baseline or follow-up measurement of serum 25(OH)D concentrations, which can be relatively expensive. Recent studies suggest that high intermittent doses of vitamin D may be more effective in correcting deficiency than small regular doses; increase fracture and falls prevention;49 and might achieve higher compliance,49,50 which is a major limitation of this therapy.51 In addition, access to sunshine for nursing home residents improves vitamin D status.50 See Box 5 for recommendations.

A recent position statement on calcium and bone health52 concluded that adequate vitamin D status was essential for active calcium absorption in the gut. In adults with a baseline calcium intake of 500–900 mg/day, increasing or supplementing this intake by a further 500–1000 mg/day has a beneficial effect on BMD.52 However, recent evidence suggesting supplementation may increase the risk of myocardial infarction indicates the need for caution.53 Resolving the problem of whether or not benefits outweigh risks will determine the appropriateness of supplemental non-dietary calcium in fracture prevention. The use of high doses of vitamin D, either oral or parenteral, has not been approved for falls and fracture prevention in Australia. Based on the evidence suggesting that high doses achieve earlier correction of serum levels of vitamin D and could improve patients’ compliance,54 use of higher doses of vitamin D should become an alternative for people in RACFs in the near future.

Bisphosphonates are the most commonly used medications for fracture prevention in the general population. However, the evidence supporting the use of bisphosphonates in institutionalised older persons is limited to just one randomised controlled study, which showed that alendronate improves BMD in nursing home residents.55 Moreover, the optimal frequency and route of administration of bisphosphonates to minimise adverse events and maximise benefits in the RACF population need to be defined.12 Considering the limited evidence available on the use of bisphosphonates in RACFs, the Consensus Conference reviewed, as have recent reports,12,56,57 the evidence on the effectiveness of bisphosphonates on fracture prevention in the closest type of populations — the old-old and the frail older population.12,56,57 A summary of the evidence is provided in Box 6.

A particular limitation of using oral bisphosphonates for people in RACFs is that adherence could be affected by the administrative burden on both nursing staff and patients caused by complex directions; patients with cognitive impairment; and a high prevalence of swallowing problems among residents.58 In this setting, intravenous bisphosphonates could become a useful alternative because of the lack of gastrointestinal side effects, prolonged dose intervals (1 year) and 100% adherence over 12 months at least.59

The number of potential side effects associated with bisphosphonates is a common concern of physicians when deciding on an osteoporosis treatment.5 Osteonecrosis of the jaw (ONJ) and atrial fibrillation are the potential side effects of most concern as they occur early after treatment has been initiated.58 Although there are no reports on the prevalence of ONJ in nursing home patients treated with either oral or intravenous bisphosphonates, a recent task force of the American Society for Bone and Mineral Research60 concluded that the risk of ONJ associated with oral bisphosphonate therapy for osteoporosis was low and that routine pretreatment dental assessment should only be performed in patients at high risk (cancer patients receiving intravenous bisphosphonates) and is not a cost–benefit option for all patients treated for osteoporosis. Finally, a recent systematic review and meta-analysis61 concluded that, while there are some data linking bisphosphonates to serious atrial fibrillation, heterogeneity of the existing evidence and a paucity of information on some of the agents precluded any definitive conclusions on the exact nature of the risk.

One anabolic treatment (teriparatide) and one other treatment (strontium ranelate) are available for fracture prevention in Australia (Box 7). A systematic review56 on the efficacy and safety of pharmacological agents in managing osteoporosis in the old-old concluded that there was good evidence for the benefit of current treatments in reducing vertebral fractures, but that data were limited for non-vertebral and hip fracture reduction. Strontium ranelate is the only agent to date that has demonstrated a reduction in non-vertebral and hip fracture in a high-risk elderly female population, but no studies have assessed the effect of strontium ranelate in an RACF population.

The anabolic medication teriparatide, recently approved in Australia, is administered subcutaneously once daily. Although no studies have assessed the effect of teriparatide on an RACF population, several problems, including the nursing time needed to administer the drug and its high cost, may limit its use in this population.62 In general, teriparatide should not be considered as a first-line treatment for fracture prevention, and even less so in the RACF population.

Prevention of falls and fractures in older persons living in RACFs should include risk identification, fracture and BMD documentation, non-pharmacological and pharmacological interventions, staff education and participation of patients and families in treatment decisions. In addition, research in the field of falls and fracture prevention in RACFs should be encouraged.