Controversies in Osteoporosis Treatment of Nursing Home Residents

  • Joshua D. Niznik
    Address correspondence to Joshua Niznik, PharmD, PhD, Division of Geriatrics and Center for Aging and Health, University of North Carolina School of Medicine, 5003 Old Clinic CB#7550, Chapel Hill, NC, 27599, USA.
    Division of Geriatric Medicine and Center for Aging and Health, University of North Carolina at Chapel Hill, School of Medicine, Chapel Hill, NC, USA

    Division of Pharmaceutical Outcomes and Policy, University of North Carolina at Chapel Hill, Eshelman School of Pharmacy, Chapel Hill, NC, USA

    Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, PA, USA
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  • Meredith A. Gilliam
    Division of Geriatric Medicine and Center for Aging and Health, University of North Carolina at Chapel Hill, School of Medicine, Chapel Hill, NC, USA
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  • Cathleen Colón-Emeric
    Division of Geriatrics, Duke University School of Medicine, Durham, NC, USA

    Durham VA Geriatric Research Education and Clinical Center, Durham, NC, USA
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  • Carolyn T. Thorpe
    Division of Pharmaceutical Outcomes and Policy, University of North Carolina at Chapel Hill, Eshelman School of Pharmacy, Chapel Hill, NC, USA

    Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, PA, USA
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  • Jennifer L. Lund
    Department of Epidemiology, University of North Carolina at Chapel Hill Gillings School of Global Public Health, Chapel Hill, NC, USA
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  • Sarah D. Berry
    Hinda and Arthur Marcus Institute for Aging Research, Hebrew Senior Life, Boston, MA, USA

    Beth Israel Deaconess Medical Center, Department of Medicine, and Harvard Medical School, Boston, MA, USA
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  • Laura C. Hanson
    Division of Geriatric Medicine and Center for Aging and Health, University of North Carolina at Chapel Hill, School of Medicine, Chapel Hill, NC, USA
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Published:November 03, 2022DOI:


      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.


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