Abstract
Osteoporotic fractures are a common and serious health problem for older adults living
in nursing homes (NHs). Risk of fracture increases with age and dementia status, yet
gaps in evidence result in controversies around when to start and stop treatment for
osteoporosis in NH residents, particularly those who have high fracture risk but have
limited life expectancy. In this article, we discuss these areas of controversy. We
provide an overview of current guidelines that explicitly address osteoporosis treatment
strategies for NH residents, review the evidence for osteoporosis medications in NH
residents, and use these sources to suggest practical recommendations for clinical
practice and for research. Three published guidelines (from the United States, Canada,
and Australia) and several studies provide the current basis for clinical decisions
about osteoporosis treatment for NH residents. Practical approaches may include broad
use of vitamin D and selective use of osteoporosis medication based on risks, benefits,
and goals of care. Clinicians still lack strong evidence to guide treatment of NH
residents with advanced dementia, multimorbidity, or severe mobility impairment. Future
priorities for research include identifying optimal approaches to risk stratification
and prevention strategies for NH residents and evaluating the risk-benefit profile
of pharmacologic treatments for osteoporosis NH residents across key clinical strata.
In the absence of such evidence, decisions for initiating and continuing treatment
should reflect a patient-centered approach that incorporates life expectancy, goals
of care, and the potential burden of treatment.
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
- Long-term care providers and services users in the United States, 2015-2016.US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics, Washington, DC2019
- Falls, Depression, and other hospitalization risk factors for adults in residential care facilities.Int J Aging Hum Dev. 2016; 83: 44-62
- Association between skilled nursing facility quality indicators and hospital readmissions.JAMA. 2014; 312: 1542-1551
- Survival and functional outcomes after hip fracture among nursing home residents.JAMA Intern Med. 2014; 174: 1273-1280
- Postoperative pressure ulcers after geriatric hip fracture surgery are predicted by defined preoperative comorbidities and postoperative complications.J Am Acad Orthop Surg. 2020; 28: 342-351
- Prevalence and predictors of osteoporosis treatment in nursing home residents with known osteoporosis or recent fracture.Osteoporos Int. 2007; 18: 553-559
- Osteoporosis management among residents living in long-term care.Osteoporos Int. 2009; 20: 1471-1478
- Are nursing home residents with dementia appropriately treated for fracture prevention?.J Am Med Dir Assoc. 2021; 22: 28-35.e23
- Pharmacological management of osteoporosis in nursing home populations: a systematic review.J Am Geriatr Soc. 2009; 57: 327-334
- Osteoporosis prevalence and characteristics of treated and untreated nursing home residents with osteoporosis.J Am Med Dir Assoc. 2015; 16: 341-348
- Polypharmacy in nursing home residents: what is the way forward?.J Am Med Dir Assoc. 2016; 17: 4-6
- Dysphagia in nursing homes—results from the NutritionDay Project.J Am Med Dir Assoc. 2018; 19: 141-147.e142
- Prevalence and severity of chronic kidney disease and anemia in the nursing home population.J Am Med Dir Assoc. 2010; 11: 33-41
- Residential care community resident characteristics: United States, 2018.NCHS Data Brief. 2021; 404: 1-8
- Mortality in nursing home residents: a longitudinal study over three years.PLoS One. 2018; 13: e0203480
- Time to benefit of bisphosphonate therapy for the prevention of fractures among postmenopausal women with osteoporosis: a meta-analysis of randomized clinical trials.JAMA Intern Med. 2022; 182: 33-41
- The clinician’s guide to prevention and treatment of osteoporosis.Osteoporos Int. 2022; 33: 2049-2102
- 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
- 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
- Managing osteoporosis in patients on long-term bisphosphonate treatment: report of a task force of the American Society for Bone and Mineral Research.J Bone Miner Res. 2016; 31: 1910
- Osteoporosis and fracture prevention in the long-term care setting clinical practice guideline.2009 (Accessed November 10, 2021. https://paltc.org/?q=product-store/osteoporosis-and-fracture-prevention-cpg.)
- Recommendations for preventing fracture in long-term care.CMAJ. 2015; 187: 1135-1144
- Prevention of osteoporotic fractures in residential aged care: updated consensus recommendations.J Am Med Dir Assoc. 2022; 23: 756-763
- Characteristics and effectiveness of fall prevention programs in nursing homes: a systematic review and meta-analysis of randomized controlled trials.J Am Geriatr Soc. 2015; 63: 211-221
- Interventions for preventing falls in older people in care facilities and hospitals.Cochrane Database Syst Rev. 2018; 9: CD005465
- Vitamin D and vitamin D analogues for preventing fractures in post-menopausal women and older men.Cochrane Database Syst Rev. 2014; : CD000227
- Vitamin D3 and calcium to prevent hip fractures in elderly women.N Engl J Med. 1992; 327: 1637-1642
- Combined calcium and vitamin D3 supplementation in elderly women: confirmation of reversal of secondary hyperparathyroidism and hip fracture risk: the Decalyos II study.Osteoporos Int. 2002; 13: 257-264
- Vitamin D supplementation and fractures in adults: a systematic umbrella review of meta-analyses of controlled trials.J Clin Endocrinol Metab. 2022; 107: 882-898
- 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
- 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
- Effect of bisphosphonates on fracture outcomes among frail older adults.J Am Geriatr Soc. 2019; 67: 768-776
- Comparative effectiveness of denosumab, teriparatide, and zoledronic acid among frail older adults: a retrospective cohort study.Osteoporos Int. 2021; 32: 565-573
- FRAX and its applications to clinical practice.Bone. 2009; 44: 734-743
- FRAX or fiction: determining optimal screening strategies for treatment of osteoporosis in residents in long-term care facilities.J Am Geriatr Soc. 2012; 60: 684-690
- 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
- Development and validation of the Fracture Risk Scale (FRS) that predicts fracture over a 1-year time period in institutionalised frail older people living in Canada: an electronic record-linked longitudinal cohort study.BMJ Open. 2017; 7: e016477
- Estimating the time to benefit for preventive drugs with the statistical process control method: an example with alendronate.Drugs Aging. 2016; 33: 347-353
- Long-term drug therapy and drug holidays for osteoporosis fracture prevention: a systematic review.Ann Intern Med. 2019; 171: 37-50
- Bisphosphonate drug holiday: who, when and how long.Ther Adv Musculoskelet Dis. 2013; 5: 107-111
- Bisphosphonate drug holiday and fracture risk: a population-based cohort study.J Bone Miner Res. 2018; 33: 1252-1259
- Effects of continuing or stopping alendronate after 5 years of treatment: the Fracture Intervention Trial Long-term Extension (FLEX): a randomized trial.JAMA. 2006; 296: 2927-2938
- Denosumab discontinuation and the rebound phenomenon: a narrative review.J Clin Med. 2021; 10: 152
- Efficacy and generalizability of falls prevention interventions in nursing homes: a systematic review and meta-analysis.J Am Med Dir Assoc. 2020; 21: 1024-1035.e1024
- Hip protectors for preventing hip fractures in older people.Cochrane Database Syst Rev. 2014; : CD001255
- Interventions to reduce fall-risk-increasing drug use to prevent falls: a narrative review of randomized trials.Drugs Aging. 2021; 38: 301-309
- Deprescribing fall-risk increasing drugs (FRIDs) for the prevention of falls and fall-related complications: a systematic review and meta-analysis.BMJ Open. 2021; 11: e035978
- Polypharmacy in assisted living and impact on clinical outcomes.Consult Pharm. 2018; 33: 321-330
Article info
Publication history
Published online: November 03, 2022
Accepted:
September 30,
2022
Received in revised form:
September 26,
2022
Received:
June 13,
2022
Footnotes
Joshua Niznik and Meredith Gilliam are co–primary authors.
J.N. is supported by a K08 award from the National Institute on Aging (NIA; K08 AG071794). S.B. receives funds to mentor through a grant from the NIA (K24 AG070106).
The authors declare no conflicts of interest.
Identification
Copyright
© 2022 AMDA - The Society for Post-Acute and Long-Term Care Medicine.
ScienceDirect
Access this article on ScienceDirectRelated Podcast
December 15, 2022
December 2022: Deprescribing, infection control, osteoporosis treatment, and palliative care
Host: Karl Steinberg MD, HMDC, CMD
Guests: Philip Sloane MD, MPH; Mallory Brown, MD
Recorded: December 12, 2022
https://mcdn.podbean.com/mf/download/8ctbs8/JOTG-2022-12-13.mp3
Loading ...
