Abstract
Clinicians struggle with whether to prescribe osteoporosis medications for fracture
prevention for older nursing home (NH) residents with dementia, given the lack of
evidence in this population. To better understand real-world clinical practice, we
conducted a retrospective cohort study examining patterns of fracture prevention medication
use for older NH residents with dementia and high fracture risk.
Data sources included 2015–16 Medicare claims, Part D prescriptions, and Minimum Data
Set (MDS) assessments. Among NH residents aged 65+ with dementia and prior fracture
or high fracture risk based on the MDS FRAiL (Fracture Risk Assessment in Long-term
care), we assessed medications for fracture prevention using prescription data from
1 year prior through 90 days after the first MDS assessment. Multivariable logistic
regression was used to evaluate factors associated with receiving treatment. Most
of the sample (n = 72,639) was >80 years (78%), female (82%), and white (88%); 63%
had moderate/severe dementia and 60% had an osteoporosis diagnosis. Only 11.6% received
fracture prevention medications. In adjusted analyses, treated residents were more
likely to be female, Hispanic or other non-black minority, <90 years old, and newly
admitted to the NH. Other associated factors included osteoporosis diagnosis, walker
or wheelchair use, bone disorders (eg, Paget disease), >5 medications, steroid or
proton pump inhibitor use, and regions outside of the Northeast. Resident characteristics
suggestive of comorbidity burden and worsening dementia were associated with reduced
likelihood of treatment. Low use of fracture prevention medications for NH residents
with dementia may reflect an attempt by prescribers reconcile medication use with
changing goals of care, or inappropriate underuse in patients who still have high
fracture risk. Additional research is needed to help clinicians better evaluate when
to use these medications in this heterogeneous and vulnerable population.
Keywords
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to Journal of the American Medical Directors AssociationAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- Incidence of hip fracture in U.S. nursing homes.J Gerontol A Biol Sci Med Sci. 2016; 71: 1230-1234
- Hip fracture risk in older US adults by treatment eligibility status based on new National Osteoporosis Foundation guidance.Osteoporos Int. 2011; 22: 541-549
- Incidence of lower-extremity fractures in US nursing homes.J Am Geriatr Soc. 2019; 67: 1253-1257
- Pharmacological management of osteoporosis in nursing home populations: A systematic review.J Am Geriatr Soc. 2009; 57: 327-334
- Incidence of bone protection and associated fragility injuries in patients with proximal femur fractures.Injury. 2017; 48: S27-S33
- Prevalence of vertebral fracture in oldest old nursing home residents.Osteoporos Int. 2012; 23: 2601-2606
- Osteoporosis diagnosis and management in long-term care facility.Am J Med Sci. 2015; 350: 357-363
- Prevalence and predictors of osteoporosis treatment in nursing home residents with known osteoporosis or recent fracture.Osteoporos Int. 2007; 18: 553-559
- Low prevalence of osteoporosis treatment in patients with recurrent major osteoporotic fracture.Arch Osteoporos. 2017; 12: 24
- Osteoporosis management among residents living in long-term care.Osteoporosis Int. 2009; 20: 1471-1478
- Diagnosis and treatment of osteoporosis in high-risk patients prior to hip fracture.Geriatr Orthop Surg Rehabil. 2012; 3: 79-83
- Undertreatment of osteoporosis in persons with dementia? A population-based study.Osteoporos Int. 2012; 23: 1061-1068
- Time trends in oral bisphosphonate initiation in Ontario, Canada over 20 years reflect drug policy and healthcare delivery changes.Osteoporos Int. 2019; 30: 2311-2319
- Examining the treatment gap and risk of subsequent fractures among females with a fragility fracture in the US Medicare population.Osteoporos Int. 2017; 28: 2485-2494
- Anti-osteoporosis drug prescribing after hip fracture in the UK: 2000–2010.Osteoporos Int. 2015; 26: 1919-1928
- An opportunity for improving osteoporosis treatment in home health care.Geriatr Orthop Surg Rehabil. 2010; 1: 46-51
- Incidence and duration of cumulative bisphosphonate use among community-dwelling persons with or without Alzheimer's disease.J Alzheimer Dis. 2016; 52: 127-132
- Use of osteoporosis medications in older nursing facility residents.J Am Med Dir Assoc. 2007; 8: 453-457
- Osteoporosis prevalence and characteristics of treated and untreated nursing home residents with osteoporosis.J Am Med Dir Assoc. 2015; 16: 341-348
- Long-term care providers and services users in the United States, 2015–2016.Vital Health Stat. 2019; 3: 43
- Efficacy and safety of single-dose zoledronic acid for osteoporosis in frail elderly women: A randomized clinical trial.JAMA Intern Med. 2015; 175: 913-921
- Alendronate improves bone mineral density in elderly women with osteoporosis residing in long-term care facilities. A randomized, double-blind, placebo-controlled trial.Ann Intern Med. 2002; 136: 742-746
- Effect of bisphosphonates on fracture outcomes among frail older adults.J Am Geriatr Soc. 2019; 67: 768-776
- Anti-osteoporotic therapy in Denmark—predictors and demographics of poor refill compliance and poor persistence.Osteoporos Int. 2013; 24: 2079-2097
- Dementia diagnosis and osteoporosis treatment propensity: A population-based nested case-control study.Geriatr Gerontol Int. 2014; 14: 121-129
- The residential history file: Studying nursing home residents' long-term care histories(∗).Health Serv Res. 2011; 46: 120-137
- Algorithm for identifying nursing home days using medicare claims and minimum data set assessment data.Med Care. 2016; 54: e73-e77
- The design and validation of a new algorithm to identify incident fractures in administrative claims data.J Bone Miner Res. 2019; 34: 1798-1807
- Fracture Risk Assessment in Long-term Care (FRAiL): Development and validation of a prediction model.J Gerontol A Biol Sci Med Sci. 2018; 73: 763-769
- Scaling functional status within the interRAI suite of assessment instruments.BMC Geriatr. 2013; 13: 128
- Adaptation and initial validation of Minimum Data Set (MDS) Mortality Risk Index to MDS Version 3.0.J Am Geriatr Soc. 2018; 66: 2353-2359
- The MDS Mortality Risk Index: The evolution of a method for predicting 6-month mortality in nursing home residents.BMC Res Notes. 2010; 3: 200
- Multiple-imputation reference manual.(Available at:)https://www.stata.com/bookstore/multiple-imputation-reference-manual/Date accessed: April 18, 2017
- Comparison of predictors of hip fracture and mortality after hip fracture in community-dwellers with and without Alzheimer's disease - exposure-matched cohort study.BMC Geriatr. 2016; 16: 204
- Bone health in cancer patients: ESMO Clinical Practice Guidelines.Ann Oncol. 2014; 25: iii124-iii137
- American Association of Clinical Endocrinologists/American College of Endocrinology clinical practice guidelines for the diagnosis and treatment of postmenopausal osteoporosis-2020 update.Endocr Pract. 2020; 26: 1-46
- Bisphosphonates for osteoporosis-deprescribing algorithm.(Available at:)https://www.prescqipp.info/our-resources/bulletins/bulletin-231-bisphosphonate-treatment-for-osteoporosis/Date: 2019Date accessed: October 20, 2020
- A guide to deprescribing bisphosphonates.(Available at:)https://www.primaryhealthtas.com.au/wp-content/uploads/2018/09/A-Guide-to-Deprescribing-Bisphosphonates-2019.pdfDate: 2019Date accessed: October 20, 2020
- Clinician's guide to prevention and treatment of osteoporosis.Osteoporos Int. 2014; 25: 2359-2381
- Predictors of hip fracture despite treatment with bisphosphonates among frail older adults.J Am Geriatr Soc. 2020; 68: 256-260
Article info
Publication history
Published online: December 14, 2020
Footnotes
The authors declare no conflicts of interest.
Funding was provided by The Patrick and Catherine Weldon Donaghue Medical Research Foundation. The funding source had no role in the study design, data collection and analysis, manuscript preparation, or the decision to submit the manuscript for publication.
Identification
Copyright
© 2020 AMDA - The Society for Post-Acute and Long-Term Care Medicine.
ScienceDirect
Access this article on ScienceDirectRelated Podcast
January 5, 2021
January 2021 Issue: Controversies Around Medication Use in Long-Term Care
Featuring Dr. Philip Sloane, Dr. Mallory Brown, and special guest, Dr. Joshua Nisnik; Recorded on December 13, 2021.
https://mcdn.podbean.com/mf/download/yjvjcn/jan2021.mp3
Loading ...
