Pharmacological Management of Osteoporosis in Nursing Home Populations: A Systematic Review

Abstract

Nursing home (NH) residents fall 11 times as frequently as their age-matched community-dwelling counterparts. The benefits of fall prevention strategies and hip protectors in terms of fracture risk in this setting are unclear. Moreover, there is no consensus on the efficacy of osteoporosis medication in NH residents. A systematic review was conducted to evaluate the efficacy of medications for osteoporosis in this population and to examine utilization studies in the NH setting to define prescribing practices. Electronic searches of MEDLINE, EMBASE, CINAHL, and the Cochrane Central Register of Controlled Trials were supplemented with a hand search of bibliographies. All English-language studies published between January 1, 1974, and December 31, 2006, that studied osteoporosis pharmacotherapy in the NH environment were obtained, and studies of medication benefits and utilization patterns were identified. No restrictions were placed on study method. Studies required inclusion of NH patients and extractable data with bone mineral density (BMD) or fracture outcomes. Forty full-text articles were retrieved, of which 15 studies met selection criteria. In the nine studies examining medication effects, calcium (1,200 mg) and vitamin D (800 IU) supplementation were shown to reduce fracture risk and improve BMD. One study supported the role of alendronate, but none documented the utility of raloxifene, calcitonin, or teriparatide in NH residents. All six medication utilization studies reported infrequent use of osteoporosis medications (9-25%). Prescribing for elderly NH patients is difficult, considering the risk:benefit ratio and issues of longevity, but these medications may be underused in the NH environment.

Management of Osteoporosis among the Elderly with Other Chronic Medical Conditions

“…[89] In a study of ambulatory female residents aged >65 years (mean age 78.5 years) with a T-score of −2.0 or less at the posterior–anterior lumbar spine or total hip, significant increases in BMD at all sites measured over a 24-month period were seen after treatment with alendronate compared with placebo. [90] In this study, alendronate was well tolerated, with incidences of gastrointestinal adverse effects that were similar in the treated and placebo groups. This study and others suggest that treatment of patients with osteoporosis in long-term care facilities is efficacious.…”

“…This study and others suggest that treatment of patients with osteoporosis in long-term care facilities is efficacious. [90] The barriers to providing osteoporosis care include multiple patient co-morbidities, reimbursement issues, length of stay, regulatory oversight, wheelchair use, cognitive impairment, depression and swallowing difficulties. [91] Cognitive impairment and polypharmacy can create challenges for adherence to medications, especially in those patients with multiple co-morbidities.…”

Osteoporosis Prescribing in Long-Term Care: Impact of a Provincial Knowledge Translation Strategy

“…Pharmacologic therapy is indicated for patients at (1) high absolute fracture risk (> 20% probability over 10 years) based on risk tools Leslie et al, 2011a) and (2) individuals over age 50 with a hip or vertebral fracture or more than one fragility fracture (Papaioannou et al, 2010b). Several studies in Ontario (Giangregorio et al, 2009;Ioannidis et al, 2012a) and other regions (Colon-Emeric et al, 2007b;Jachna, Shireman, Whittle, Ellerbeck, & Rigler, 2005;Kamel, 2007;Parikh, Avorn, & Solomon, 2009;Parikh, Mogun, Avorn, & Solomon, 2008;Wright, 2007) have demonstrated that the management of osteoporosis and fractures is sub-optimal in LTC residents.In 2007, at the outset of the Ontario Osteoporosis Strategy for LTC, we conducted an environmental scan to examine the prescribing of vitamin D, calcium, and osteoporosis medications in a convenience sample of 10 Ontario LTC homes. In 2012, we had access to prescribing records and facility characteristics for a large, unselected cohort of Ontario LTC homes (n = 166).…”

The true cost of pharmacological disease prevention

“…12 Significant reductions in hip fractures occurred in a restricted subpopulation of women (aged 65-80 with osteoporosis or previous fractures), whereas the evidence for efficacy among those who most typically suffer from hip fractures-people aged ≥80 and those living in nursing homes-is lacking. [13][14][15] And although osteoporosis is considered a predominantly female disease, about 40% of age related fractures occur in elderly men. 16 Despite this, all current analyses of cost effectiveness of bisphosphonates assume a universal reduction in fracture risk among all older people.…”