Controversies in Osteoporosis Treatment of Nursing Home Residents

How Should Clinicians Discuss Deprescribing with Caregivers of Older Adults Living with Dementia? A Qualitative Study

BACKGROUND

Preventive medications are potential targets for deprescribing in older adults with dementia as goals of care change from preventive to palliative. Yet, prescribers lack communication guidance to address deprescribing.

OBJECTIVE

Using bisphosphonates as a case example, we sought to characterize and compare communication preferences of prescribers and family/informal caregivers regarding deprescribing.

METHODS

We conducted 23 semi-structured interviews with prescribers (12) and caregivers (11) of older adults with Alzheimer's disease or related dementias (ADRD). Prescribers and caregivers were asked to provide their impressions of seven conversation starters for discussing deprescribing, focusing on a case example using bisphosphonates. These phrases focused on topics including life expectancy, treatment burden, adverse effects, and costs. We used a qualitative framework analysis to identify relevant themes as prescribers and caregivers discussed their general perceptions of the potential benefits and harms of bisphosphonates and experiences with deprescribing.

RESULTS

Among prescribers, there were ten physicians and two nurse practitioners; most (nine) female and white. Among caregivers, eight were female, seven were white, and five were Latino/a. For both prescribers and caregivers, preferred conversation starters initiated a risk versus benefit discussion, emphasizing medication adverse effects and patient-specific factors, such as functional status and indication for treatment. While prescribers emphasized discussing common medication adverse effects, caregivers noted the importance of knowing a medication's potential impact on ADRD. The least preferred conversation starter for deprescribing among both groups focused on the extra effort and cost of continuing bisphosphonates. Discordance between caregivers and prescribers were identified in several phrases; notably, caregivers disliked statements that introduced discussions of prognosis and life expectancy.

CONCLUSIONS

Deprescribing conversations may be best perceived by caregivers when introduced with a discussion of a medication's adverse effects and potential impact on cognition. In addition, deprescribing conversations should be tailored to patient-specific factors, including functional status, goals of care, and the role of their caregiver in medical decision-making. Avoiding discussions of medication cost, pill burden, and life expectancy may help reassure the caregiver that deprescribing is a form of medication optimization and not a withdrawal of care.

Assessing the feasibility of an integrated collection of education modules for fall and fracture prevention (iCARE) for healthcare providers in long term care: A longitudinal study

Falls and hip fractures are a major health concern among older adults in long term care (LTC) with almost 50% of residents experiencing a fall annually. Hip fractures are one of the most important and frequent fall-related injuries in LTC. There is moderate to strong certainty evidence that multifactorial interventions may reduce the risk of falls and fractures; however, there is little evidence to support its implementation. The purpose of this study was to determine the feasibility (recruitment rate and adaptations) with a subobjective to understand facilitators to and barriers of implementing the PREVENT (Person-centred Routine Fracture PreEVENTion) model in practice. The model includes a multifactorial intervention on diet, exercise, environmental adaptations, hip protectors, medications (including calcium and vitamin D), and medication reviews to treat residents at high risk of fracture. Our secondary outcomes were to determine if there was a change in knowledge uptake of the guidelines among healthcare providers and in the proportion of fracture prevention prescriptions post-intervention. We conducted a mixed-methods longitudinal cohort study in three LTC homes across southern Ontario. A local champion was selected to help guide the implementation of the model and promote best practices. We reported recruitment rates using descriptive statistics and challenges to implementation using content analysis. We reported changes in knowledge uptake and in the proportion of fracture prevention medications using the McNemar's test. We recruited three LTC homes and identified one local champion for each home. We required two months to identify and train the local champion over three, 1.5-hour train-the-trainer sessions, and the local champion required three months to deliver the intervention to a team of healthcare professionals. We identified several facilitators, barriers, and adaptations to PREVENT. Benefits of the model include easy access to the Fracture Risk Scale (FRS), clear and succinct educational material catered to each healthcare professional, and an accredited Continuing Medical Educational module for physicians and nurses. Challenges included misperceptions between the differences in fall and fracture prevention strategies, fear of perceived side effects associated with fracture prevention medications, and time barriers with completing the audit report. Our study found an increase knowledge uptake of the guidelines and an increase in the proportion of fracture prevention prescriptions post-intervention.

Denosumab for osteoporosis in older adults in long-term care: A randomized trial

BACKGROUND

In long-term care (LTC), the incidence of hip or vertebral fractures are eight times that in the community. Despite the wide availability of osteoporosis therapy, LTC residents are omitted from pivotal trials and not treated. Denosumab is a relatively new, monoclonal antibody therapy for osteoporosis treatment. Via a randomized trial, we sought to determine the safety and efficacy of denosumab in LTC residents.

METHODS

We conducted a 2-year, double-blind, placebo-controlled, randomized clinical trial in 201 osteoporotic men and women aged ≥ 65 years, living in LTC communities. Participants with multimorbidity, dysmobility, and cognitive impairment were not excluded. The intervention was denosumab 60 mg subcutaneous every 6 months or placebo. Our primary outcome measures were hip and spine bone mineral density (BMD) improvement at 24 months. Secondary outcomes included BMD at other skeletal sites, function, and safety.

RESULTS

We included 123 women and 78 men with a mean ± standard error age of 81.5 ± 0.6. Overall, 83% and 71% completed 12 and 24 months, respectively. Compared with placebo, the women receiving denosumab had a greater 24-month percent increase in spine (7.41 ± 0.93 vs. 2.15 + 0.56; p = 0.014), and total hip BMD (4.62 ± 0.62 vs. -0.19 ± 0.79; p = 0.007); and men in spine (7.91 ± 0.96 vs. 1.12 ± 1.13; p = 0.002) and total hip (3.74 ± 0.55 vs. 0.48 ± 0.74; p = 0.018). There were no significant differences in safety metrics.

CONCLUSIONS

Denosumab was a safe and effective therapy for improving BMD in osteoporotic older men and women with multiple comorbidities in LTC.

Hip fracture rate and osteoporosis treatment in Ontario: A population-based retrospective cohort study

This population-based study analyzes hip fracture and osteoporosis treatment rates among older adults, stratified by place of residence prior to fracture. Hip fracture rates were higher among older adults living in the community and discharged to long-term care (LTC) after fracture, compared to LTC residents and older adults living in the community. Only 23% of LTC residents at high fracture risk received osteoporosis treatment.

PURPOSE

This population-based study examines hip fracture rate and osteoporosis management among long-term care (LTC) residents > 65 years of age compared to community-dwelling older adults at the time of fracture and admitted to LTC after fracture, in Ontario, Canada.

METHODS

Healthcare utilization and administrative databases were linked using unique, encoded identifiers from the ICES Data Repository to estimate hip fractures (identified using the Public Health Agency of Canada algorithm and International Classification of Diseases (ICD)-10 codes) and osteoporosis management (pharmacotherapy) among adults > 66 years from April 1, 2014 to March 31, 2018. Sex-specific and age-standardized rates were compared by pre-fracture residency and discharge location (i.e., LTC to LTC, community to LTC, or community to community). Fracture risk was determined using the Fracture Risk Scale (FRS).

RESULTS

At baseline (2014/15), the overall age-standardized hip fracture rate among LTC residents was 223 per 10,000 person-years (173 per 10,000 females and 157 per 10,000 males), 509 per 10,000 person-years (468 per 10,000 females and 320 per 10,000 males) among the community to LTC cohort, and 31.5 per 10,000 person-years (43.1 per 10,000 females and 25.6 per 10,000 males). During the 5-year observation period, the overall annual average percent change (APC) for hip fracture increased significantly in LTC (AAPC =  + 8.6 (95% CI 5.0 to 12.3; p = 0.004) compared to the community to LTC group (AAPC =  + 2.5 (95% CI - 3.0 to 8.2; p = 0.248)) and the community-to-community cohort (AAPC - 3.8 (95% CI - 6.7 to - 0.7; p = 030)). However, hip fracture rate remained higher in the community to LTC group over the study period. There were 33,594 LTC residents identified as high risk of fracture (FRS score 4 +), of which 7777 were on treatment (23.3%).

CONCLUSION

Overall, hip fracture rates have increased in LTC and among community-dwelling adults admitted to LTC after fracture. However, hip fracture rates among community-dwelling adults have decreased over time. A non-significant increase in osteoporosis treatment rates was observed among LTC residents at high risk of fracture (FRS4 +). Residents in LTC are at very high risk for fracture and require individualized based on goals of care and life expectancy.

Chronic Kidney Disease in Patients with Hip Fracture: Prevalence and Outcomes

Objective. Although the association between chronic kidney disease (CKD) and osteoporotic fractures is well established, data on CKD combined with hip fracture (HF) are scarce and controversial. We aimed to assess in patients with HF the prevalence of CKD, its impact on hospital mortality and length of stay (LOS) and to determine the prognostic value of CKD to predict hospital outcomes. Methods. Prospectively collected clinical data were analysed in 3623 consecutive HF patients aged ≥65 years (mean age 83.4 ± 7.50 [standard deviation] years; 74.4% females). Results. CKD among older patients with HF is highly prevalent (39.9%), has different clinical characteristics, a 2.5-fold higher mortality rate, and 40% greater risk of prolonged LOS. The strongest risk for a poor outcome was advanced age (>80 years). The risk of death substantially increases in combination with chronic disorders, especially coronary artery disease, anaemia, hyperparathyroidism, and atrial fibrillation; models based only on three variables—CKD stage, age >80, and presence of a specific chronic condition—predicted in-hospital death with good discrimination capability (AUC ≥ 0.700) and reasonable accuracy, the number needed to predict ranged between 5.7 and 14.5. Only 12% of HF patients received osteoporotic drugs prefracture. Conclusion. In HF patients with CKD, the risk of adverse outcomes largely increases in parallel with worsening kidney function and, especially, in combination with comorbidities; models based on three admission variables predict a fatal outcome. Assessment of renal function is essential to preventing osteoporotic fractures.

Deprescribing bisphosphonates for older adults with dementia: perspectives of caregivers

Little is known about caregivers' perspectives on deprescribing bisphosphonates for older adults with dementia. Caregivers agreed that fracture prevention was important for maintaining functional independence but acknowledged that changing goals of care may justify deprescribing. Conversations grounded in "what matters most" can align fracture prevention treatment with goals of care.

PURPOSE

The long-term fracture prevention benefits of bisphosphonates may begin to be overshadowed by the potential burden of adverse effects and polypharmacy for older adults living with dementia as the disease progresses. We characterized factors that influence caregiver decision-making for continuing versus deprescribing bisphosphonates for persons living with dementia.

METHODS

We conducted 11 interviews with family or informal caregivers of older adults living with dementia in the community or in long-term care who had been treated with bisphosphonates. Interviews focused on experiences caring for someone who has experienced a fracture, perceived benefits and harms of bisphosphonates, and experiences with deprescribing. Analyses were conducted using a qualitative framework methodology guided by the Health Belief Model.

RESULTS

Most caregivers were male (n = 8), younger than 65 (n = 8) and were an adult child caregiver (n = 8). Three caregivers were Black and five were Latino/a. Attempts to maintain functional independence despite high likelihood of falls was frequently discussed as contributing to fracture risk, in this population. Many caregivers perceived fracture prevention treatment as important, while several noted that it may become less important near the end of life. Perceived benefits of fracture prevention treatment for persons with dementia included improved quality of life and maintaining independence. Although most indicated that bisphosphonates were well tolerated, gastrointestinal adverse effects, preference for fewer treatments, and dementia-related behaviors that interfere with medication administration may be reasons for deprescribing.

CONCLUSION

Conversations grounded in caregiver experiences and "what matters most" may help optimize fracture prevention treatment for older adults with dementia.

Liuwei Dihuang Pills Enhance Osteogenic Differentiation in MC3T3-E1 Cells through the Activation of the Wnt/β-Catenin Signaling Pathway

OBJECTIVE

The therapeutic efficacy and molecular mechanisms of traditional Chinese medicines (TCMs), such as Liuwei Dihuang pills (LWDH pills), in treating osteoporosis (OP) remain an area of active research and interest in modern medicine. This study investigated the mechanistic underpinnings of LWDH pills in the treatment of OP based on network pharmacology, bioinformatics, and in vitro experiments.

METHODS

The active ingredients and targets of LWDH pills were retrieved through the TCMSP database. OP-related targets were identified using the CTD, GeneCards, and DisGeNET databases. The STRING platform was employed to construct a protein-protein interaction (PPI) network, and core targets for LWDH pills in treating OP were identified. The GO functional and KEGG pathway enrichment analyses for potential targets were performed using the R package "clusterProfiler". A "drug-target" network diagram was created using Cytoscape 3.7.1 software. The viability of MC3T3-E1 cells was evaluated using the CCK-8 method after treatment with various concentrations (1.25%, 2.5%, 5%, and 10%) of LWDH pill-medicated serum for 24, 48, and 72 h. Following a 48 h treatment of MC3T3-E1 cells with LWDH pill-medicated serum, the protein levels of collagen Ⅰ, RUNX2, Wnt3, and β-catenin were quantified using the Western blot analysis, and the activity of alkaline phosphatase (ALP) was measured.

RESULTS

A total of 197 putative targets for LWDH pills for OP treatment were pinpointed, from which 20 core targets were singled out, including TP53, JUN, TNF, CTNNB1 (β-catenin), and GSK3B. The putative targets were predominantly involved in signaling pathways such as the Wnt signaling pathway, the MAPK signaling pathway, and the PI3K-Akt signaling pathway. The intervention with LWDH pill-medicated serum for 24, 48, and 72 h did not result in any notable alterations in the cell viability of MC3T3-E1 cells relative to the control group (all p > 0.05). Significant upregulation in protein levels of collagen Ⅰ, RUNX2, Wnt3, and β-catenin in MC3T3-E1 cells was observed in response to the treatment with 2.5%, 5%, and 10% of LWDH pill-medicated serum in comparison to that with the 10% rabbit serum group (all p < 0.05). Furthermore, the intervention with LWDH pill-medicated serum resulted in the formation of red calcified nodules in MC3T3-E1 cells, as indicated by ARS staining.

CONCLUSIONS

LWDH pills may upregulate the Wnt/β-catenin signaling pathway to elevate the expression of osteogenic differentiation proteins, including collagen Ⅰ and RUNX2, and to increase the ALP activity in MC3T3-E1 cells for the treatment of OP.

Prescriber Perspectives and Experiences with Deprescribing Versus Continuing Bisphosphonates in Older Nursing Home Residents with Dementia

BACKGROUND

Few guidelines address fracture prevention medication use in nursing home (NH) residents with dementia.

OBJECTIVE

We sought to identify factors that influence prescriber decision-making for deprescribing of bisphosphonates for older NH residents with dementia.

METHODS

We conducted 12 semi-structured interviews with prescribers who care for older adults with dementia in NHs.

MAIN MEASURES

Interview prompts addressed experiences treating fractures, benefits, and harms of bisphosphonates, and experiences with deprescribing. Coding was guided by the social-ecological framework including patient-level (intrapersonal) and external (interpersonal, system, community, and policy) influences.

RESULTS

Most prescribers were physicians (83%); 75% were female and 75% were White. Most (75%) spent less than half of their clinical effort in NHs and half were in the first decade of practice. Among patient-level influences, prescribers uniformly agreed that a prior bisphosphonate treatment course of several years, emergence of adverse effects, and changing goals of care or limited life expectancy were compelling reasons to deprescribe. External influences were frequently discussed as barriers to deprescribing. At the interpersonal level, prescribers noted that family/informal caregivers are diverse in their involvement in decision-making, and frequently concerned about the adverse effects of bisphosphonates, but perceive deprescribing as "withdrawing care." At the health system level, prescribers felt that frequent transitions make it difficult to determine duration of prior treatment and to implement deprescribing. At the policy level, prescribers highlighted the lack of guidelines addressing residents with limited mobility and dementia or criteria for deprescribing, including uncertainty in the setting of prior fractures and lack of bone densitometry in NHs.

CONCLUSION

Systems-level barriers to evaluating bone densitometry and treatment history in NHs may impede person-centered decision-making for fracture prevention. Further research is needed to evaluate the residual benefits of bisphosphonates in medically complex residents with limited mobility and dementia to inform recommendations for deprescribing versus continued use.