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AbuAlrob H, Ioannidis G, Jaglal S, Costa A, Grifith LE, Thabane L, Adachi JD, Cameron C, Hillier L, Lau A, Papaioannou A. Hip fracture rate and osteoporosis treatment in Ontario: A population-based retrospective cohort study. Arch Osteoporos 2024; 19:53. [PMID: 38918265 PMCID: PMC11199290 DOI: 10.1007/s11657-024-01402-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 04/24/2024] [Indexed: 06/27/2024]
Abstract
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.
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Affiliation(s)
- Hajar AbuAlrob
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada.
| | | | - Susan Jaglal
- Department of Physical Therapy, University of Toronto, Toronto, Canada
| | - Andrew Costa
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
- Department of Medicine, McMaster University, Hamilton, Canada
| | - Lauren E Grifith
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Lehana Thabane
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
- Department of Pediatrics and Anesthesia, McMaster University, Hamilton, Canada
| | | | - Cathy Cameron
- Institute for Clinical Evaluative Sciences, Toronto, Canada
| | | | - Arthur Lau
- Department of Medicine, McMaster University, Hamilton, Canada
| | - Alexandra Papaioannou
- Department of Medicine, McMaster University, Hamilton, Canada
- Geras Centre for Aging Research, Hamilton, Canada
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Niznik JD, Kelley CJ, Fasth L, Colón-Emeric C, Thorpe CT, Gilliam MA, Lund JL, Hanson LC. Deprescribing bisphosphonates for older adults with dementia: perspectives of caregivers. Osteoporos Int 2024; 35:589-598. [PMID: 37980284 PMCID: PMC11145563 DOI: 10.1007/s00198-023-06967-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 11/01/2023] [Indexed: 11/20/2023]
Abstract
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.
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Affiliation(s)
- Joshua D Niznik
- Division of Geriatric Medicine, University of North Carolina at Chapel Hill, School of Medicine, Chapel Hill, NC, USA.
- Center for Aging and Health, University of North Carolina at Chapel Hill, School of Medicine, 5003 Old Clinic CB#7550, Chapel Hill, NC, 27599, 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.
| | - Casey J Kelley
- Center for Aging and Health, University of North Carolina at Chapel Hill, School of Medicine, 5003 Old Clinic CB#7550, Chapel Hill, NC, 27599, USA
| | - Lauren Fasth
- Division of Pharmaceutical Outcomes and Policy, University of North Carolina at Chapel Hill, Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - 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
| | - 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
| | - Meredith A Gilliam
- Division of Geriatric Medicine, University of North Carolina at Chapel Hill, School of Medicine, Chapel Hill, NC, USA
- Center for Aging and Health, University of North Carolina at Chapel Hill, School of Medicine, 5003 Old Clinic CB#7550, Chapel Hill, NC, 27599, USA
| | - Jennifer L Lund
- Department of Epidemiology, University of North Carolina at Chapel Hill Gillings School of Global Public Health, Chapel Hill, NC, USA
| | - Laura C Hanson
- Division of Geriatric Medicine, University of North Carolina at Chapel Hill, School of Medicine, Chapel Hill, NC, USA
- Center for Aging and Health, University of North Carolina at Chapel Hill, School of Medicine, 5003 Old Clinic CB#7550, Chapel Hill, NC, 27599, USA
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Niznik J, Colón-Emeric C, Thorpe CT, Kelley CJ, Gilliam M, Lund JL, Hanson LC. Prescriber Perspectives and Experiences with Deprescribing Versus Continuing Bisphosphonates in Older Nursing Home Residents with Dementia. J Gen Intern Med 2023; 38:3372-3380. [PMID: 37369891 PMCID: PMC10682438 DOI: 10.1007/s11606-023-08275-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 06/09/2023] [Indexed: 06/29/2023]
Abstract
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.
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Affiliation(s)
- Joshua Niznik
- Division of Geriatric Medicine, University of North Carolina at Chapel Hill, School of Medicine, Chapel Hill, NC, USA.
- 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.
- Department of Epidemiology, University of North Carolina at Chapel Hill Gillings School of Global Public Health, Durham, NC, USA.
| | - Cathleen Colón-Emeric
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Department of Epidemiology, University of North Carolina at Chapel Hill Gillings School of Global Public Health, Durham, NC, USA
- Division of Geriatrics, Duke University School of Medicine,, Durham, NC, USA
| | - 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
- Department of Epidemiology, University of North Carolina at Chapel Hill Gillings School of Global Public Health, Durham, NC, USA
| | - Casey J Kelley
- Center for Aging and Health, University of North Carolina at Chapel Hill, School of Medicine, Chapel Hill, NC, USA
- Department of Epidemiology, University of North Carolina at Chapel Hill Gillings School of Global Public Health, Durham, NC, USA
| | - Meredith Gilliam
- Division of Geriatric Medicine, University of North Carolina at Chapel Hill, School of Medicine, Chapel Hill, NC, USA
- Center for Aging and Health, University of North Carolina at Chapel Hill, School of Medicine, Chapel Hill, NC, USA
- Department of Epidemiology, University of North Carolina at Chapel Hill Gillings School of Global Public Health, Durham, NC, USA
| | - Jennifer L Lund
- Department of Epidemiology, University of North Carolina at Chapel Hill Gillings School of Global Public Health, Durham, NC, USA
- Durham VA Geriatric Research Education and Clinical Center, Durham, NC, USA
| | - Laura C Hanson
- Division of Geriatric Medicine, University of North Carolina at Chapel Hill, School of Medicine, Chapel Hill, NC, USA
- Center for Aging and Health, University of North Carolina at Chapel Hill, School of Medicine, Chapel Hill, NC, USA
- Department of Epidemiology, University of North Carolina at Chapel Hill Gillings School of Global Public Health, Durham, NC, USA
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Niznik JD, Gilliam MA, Colón-Emeric C, Thorpe CT, Lund JL, Berry SD, Hanson LC. Controversies in Osteoporosis Treatment of Nursing Home Residents. J Am Med Dir Assoc 2022; 23:1928-1934. [PMID: 36335990 PMCID: PMC9885478 DOI: 10.1016/j.jamda.2022.09.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 09/26/2022] [Accepted: 09/30/2022] [Indexed: 11/06/2022]
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.
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Affiliation(s)
- Joshua D Niznik
- 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.
| | - 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
| | - 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
| | - 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
| | - Jennifer L Lund
- Department of Epidemiology, University of North Carolina at Chapel Hill Gillings School of Global Public Health, Chapel Hill, NC, USA
| | - 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
| | - 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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Niznik JD, Aspinall SL, Hanson LC, Gilliam MA, Li X, Kelley CJ, Thorpe CT. Patterns of oral bisphosphonate deprescribing in older nursing home residents with dementia. Osteoporos Int 2022; 33:379-390. [PMID: 34480586 PMCID: PMC8813888 DOI: 10.1007/s00198-021-06141-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 08/28/2021] [Indexed: 02/03/2023]
Abstract
UNLABELLED In a national sample of Medicare nursing home residents with dementia treated with bisphosphonates, 20% had bisphosphonates deprescribed. Residents with clinical characteristics representing decreased likelihood for long-term benefit were more likely to have bisphosphonates deprescribed. Future studies are needed to evaluate outcomes of deprescribing bisphosphonates in this population. INTRODUCTION To determine incidence of deprescribing bisphosphonates among nursing home (NH) residents with dementia and identify factors associated with deprescribing. METHODS 2015-2016 Medicare claims, Part D prescriptions, Minimum Data Set (MDS) 3.0, and Nursing Home Compare for non-skilled NH residents aged 65 + with dementia and prescriptions for oral bisphosphonates overlapping the first 14 days of the stay. Our primary definition for deprescribing was a 90-day gap in medication supply; we also explored the reliability of different deprescribing definitions (30-, 90-, 180-day gaps). We estimated associations of NH, provider, and resident characteristics with deprescribing bisphosphonates using competing risks regression models. RESULTS Most NH residents with dementia treated with bisphosphonates (n = 5312) were ≥ 80 years old (72%), white (81%), and female (90%); about half were dependent for transfers (50%) or mobility (45%). Using a 90-day gap in supply, the 180-day cumulative incidence of deprescribing bisphosphonates was 14.8%. This increased to 32.1% using a 30-day gap and decreased to 11.7% using a 180-day gap. Factors associated with increased likelihood for bisphosphonate deprescribing were age ≥ 90 years, newly admitted (vs. prevalent stay), dependent for mobility, swallowing difficulty, > 1 hospitalization in the prior year, CCRC facility, and nurse practitioner primary provider (vs. physician). Cancer and western geographic region were associated with reduced likelihood for deprescribing. CONCLUSION In a national sample of NH residents with dementia, bisphosphonate deprescribing was uncommon, and associated with clinical characteristics signifying poor prognosis and decreased likelihood for long-term benefit. Future studies should evaluate clinical outcomes of deprescribing bisphosphonates in this population.
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Affiliation(s)
- Joshua D Niznik
- Division of Geriatric Medicine, Center for Aging and Health, School of Medicine, University of North Carolina At Chapel Hill, 5003 Old Clinic, CB# 7550, Chapel Hill, NC, 27599, 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.
| | - Sherrie L Aspinall
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, PA, USA
- VA Center for Medication Safety, Hines, IL, USA
- University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA
| | - Laura C Hanson
- Division of Geriatric Medicine, Center for Aging and Health, School of Medicine, University of North Carolina At Chapel Hill, 5003 Old Clinic, CB# 7550, Chapel Hill, NC, 27599, USA
| | - Meredith A Gilliam
- Division of Geriatric Medicine, Center for Aging and Health, School of Medicine, University of North Carolina At Chapel Hill, 5003 Old Clinic, CB# 7550, Chapel Hill, NC, 27599, USA
| | - Xintong Li
- Division of Pharmaceutical Outcomes and Policy, University of North Carolina At Chapel Hill, Eshelman School of Pharmacy, Chapel Hill, NC, USA
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDROMS), University of Oxford, Oxford, UK
| | - Casey J Kelley
- Division of Geriatric Medicine, Center for Aging and Health, School of Medicine, University of North Carolina At Chapel Hill, 5003 Old Clinic, CB# 7550, Chapel Hill, NC, 27599, USA
| | - 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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Colón-Emeric CS, Hecker EJ, McConnell E, Herndon L, Little M, Xue T, Berry S. Improving shared decision-making for osteoporosis pharmacologic therapy in nursing homes: a qualitative analysis. Arch Osteoporos 2022; 17:11. [PMID: 34981246 PMCID: PMC9479090 DOI: 10.1007/s11657-021-01050-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 12/16/2021] [Indexed: 02/03/2023]
Abstract
Decisions on whether to use pharmacologic osteoporosis therapy in skilled nursing facility residents are complex and require shared decision-making. Residents, proxies, and staff desire individualized fracture risk estimates that consider advanced age, dementia, and mobility. They want options for reducing administration burden, monitoring instructions, and periodic reassessment of risk vs. benefit. PURPOSE Decisions about pharmacologic osteoporosis treatment in nursing home (NH) residents with advanced age and multimorbidity are complex and should occur using shared decision-making. Our objective was to identify processes and tools to improve shared decision-making about pharmacologic osteoporosis treatment in NHs. METHODS Qualitative analysis of data collected in three NHs from residents at high fracture risk, their proxies, nursing assistants, nurses, and one nurse practitioner (n = 28). Interviews explored participants' stories, attitudes, and experiences with oral osteoporosis medication management. Framework analysis was used to identify barriers to shared decision-making regarding osteoporosis treatment in this setting. RESULTS Participants wanted individualized fracture risk estimates that consider immobility, advanced age, and comorbid dementia. Residents and proxies expected nursing staff to be involved in the decision-making; nursing staff wished to be informed on the relative risks vs. benefits of medications and given monitoring instructions. Two important competing demands to address during the shared decision-making process were burdensome administration requirements and polypharmacy. Participants wanted to reassess pharmacologic treatment appropriateness over time as clinical status or goals of care change. CONCLUSIONS Shared decision-making using strategies and tools identified in this analysis may move osteoporosis pharmacologic treatment in NHs and for other older adults with multimorbidity from inappropriate inertia to appropriate prescribing or appropriate inaction.
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Affiliation(s)
- Cathleen S Colón-Emeric
- Duke University, Box 3003 DUMC, Durham, NC, 27710, USA. .,Durham VA Geriatric Research Education and Clinical Center, Durham, NC, 27705, USA.
| | | | - Eleanor McConnell
- Duke University, Box 3003 DUMC, Durham, NC, 27710, USA.,Durham VA Geriatric Research Education and Clinical Center, Durham, NC, 27705, USA
| | | | - Milta Little
- Duke University, Box 3003 DUMC, Durham, NC, 27710, USA
| | - Tingzhong Xue
- Duke University, Box 3003 DUMC, Durham, NC, 27710, USA
| | - Sarah Berry
- Hebrew Center for Senior Life, Boston, MA, USA
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McArthur C, Hillier L, Ioannidis G, Adachi JD, Giangregorio L, Hirdes J, Papaioannou A. Developing a Fracture Risk Clinical Assessment Protocol for Long-Term Care: A Modified Delphi Consensus Process. J Am Med Dir Assoc 2021; 22:1726-1734.e8. [PMID: 32972869 DOI: 10.1016/j.jamda.2020.08.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 07/21/2020] [Accepted: 08/13/2020] [Indexed: 01/07/2023]
Abstract
OBJECTIVES To develop a fracture risk Clinical Assessment Protocol (CAP) based on long-term care (LTC) fracture prevention recommendations and an embedded fracture risk assessment tool. DESIGN A modified Delphi consensus approach including 2 survey rounds and a face-to-face meeting was implemented to reach consensus on matching of LTC fracture prevention guideline statements to Fracture Risk Scale (FRS) risk levels. SETTING AND PARTICIPANTS A national panel of recognized experts in osteoporosis, fractures, and long-term care, including an LTC resident and family members. METHODS Round 1 survey respondents (n = 24) were provided the LTC fracture prevention guidelines matched to FRS risk levels and were asked whether they agreed the guideline was appropriate for the risk level (yes, no, I don't know, I agree with some but not all of it) and to provide comments. In round 2, guideline statements that did not achieve consensus (≥80% agreement) were revised consistent with comments provided in round 1 and respondents were asked again if they agreed with the guideline statement. Statements that did not achieve consensus were to be discussed and resolved in an in-person meeting (n = 17). RESULTS In round 1 (75% response rate), consensus was achieved in 7/14 guideline statements. In round 2 (56% response rate), 5 statements were revised based on round 1 feedback and for 2 statements additional information was provided. Consensus was achieved in all but one statement related to the inappropriateness of pharmacologic therapy for residents with life expectancy less than 1 year. Following facilitated meeting discussions, consensus was obtained to revise the guideline statement to reflect that life expectancy was but one of several criteria that should be used to inform medication decisions. CONCLUSIONS AND IMPLICATIONS An evidence-based fracture risk CAP was developed that will be embedded in international routine clinical assessment tools to guide fracture prevention in LTC.
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Affiliation(s)
- Caitlin McArthur
- McMaster University, Hamilton, Ontario, Canada; GERAS Centre for Aging Research, Hamilton, Ontario, Canada.
| | | | - George Ioannidis
- McMaster University, Hamilton, Ontario, Canada; GERAS Centre for Aging Research, Hamilton, Ontario, Canada
| | | | - Lora Giangregorio
- University of Waterloo, Waterloo, Ontario, Canada; Schlegel-UW Research Institute for Aging, Hamilton, Ontario, Canada
| | - John Hirdes
- University of Waterloo, Waterloo, Ontario, Canada
| | - Alexandra Papaioannou
- McMaster University, Hamilton, Ontario, Canada; GERAS Centre for Aging Research, Hamilton, Ontario, Canada
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Niznik JD, Li X, Gilliam MA, Hanson LC, Aspinall SL, Colon-Emeric C, Thorpe CT. Are Nursing Home Residents With Dementia Appropriately Treated for Fracture Prevention? J Am Med Dir Assoc 2021; 22:28-35.e3. [PMID: 33321079 PMCID: PMC8358966 DOI: 10.1016/j.jamda.2020.11.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 11/12/2020] [Accepted: 11/13/2020] [Indexed: 12/21/2022]
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.
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Affiliation(s)
- Joshua D Niznik
- Division of Geriatric Medicine, 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.
| | - Xintong Li
- Division of Pharmaceutical Outcomes and Policy, University of North Carolina at Chapel Hill, Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Meredith A Gilliam
- Division of Geriatric Medicine, University of North Carolina at Chapel Hill, School of Medicine, Chapel Hill, NC, USA
| | - Laura C Hanson
- Division of Geriatric Medicine, University of North Carolina at Chapel Hill, School of Medicine, Chapel Hill, NC, USA
| | - Sherrie L Aspinall
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, PA, USA; VA Center for Medication Safety, Hines, IL, USA; Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA
| | | | - 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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Lind KE, Jorgensen ML, Gray LC, Georgiou A, Westbrook JI. Anti-osteoporosis Medication Use in a High Fracture-Risk Population: Contemporary Trends in Australian Residential Aged Care Facilities. Health Serv Insights 2019; 12:1178632919852111. [PMID: 31210731 PMCID: PMC6547170 DOI: 10.1177/1178632919852111] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 04/25/2019] [Indexed: 12/15/2022] Open
Abstract
Osteoporotic fractures impose substantial morbidity and mortality among older adults. Undertreatment is an ongoing concern; treatment rates declined following reports of adverse effects of guideline-recommended bisphosphonates, but new antiresorptives have since become available. Our goal was to identify contemporary trends in osteoporosis treatment guideline adherence in a high fracture-risk population. We conducted a secondary data analysis using electronic health record data of adults aged ⩾65 years from 68 residential aged care facilities in Australia during 2014-2017 (n = 9094). Using medication administration data, we identified antiresorptive (bisphosphonates and denosumab) and vitamin D supplement use among residents with osteoporosis. Regression was used to evaluate temporal trends, and resident and facility characteristics associated with antiresorptive use and vitamin D use. In 2014, 34% of women and 42% of men with osteoporosis used antiresorptives; this decreased 8 percentage points by 2017. Antiresorptive use was higher among those with a history of fracture and lower in the last year of life. Denosumab use increased but did not substitute for the continued decline in bisphosphonate use. Vitamin D was consistently used by more than 60% of residents and was higher among those with fracture history. Greater attention to the treatment of osteoporosis treatment rates among this high fracture-risk population is warranted.
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Affiliation(s)
- Kimberly E Lind
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, NSW, Australia
| | - Mikaela L Jorgensen
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, NSW, Australia
| | - Leonard C Gray
- Centre for Health Services Research, Faculty of Medicine, The University of Queensland, Woolloongabba, QLD, Australia
| | - Andrew Georgiou
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, NSW, Australia
| | - Johanna I Westbrook
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, NSW, Australia
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Abstract
OBJECTIVE To evaluate the cost-effectiveness of routine administration of single-dose zoledronic acid for nursing home residents with osteoporosis in the USA. DESIGN Markov cohort simulation model based on published literature from a healthcare sector perspective over a lifetime horizon. SETTING Nursing homes. PARTICIPANTS A hypothetical cohort of nursing home residents aged 85 years with osteoporosis. INTERVENTIONS Two strategies were compared: (1) a single intravenous dose of zoledronic acid 5 mg and (2) usual care (supplementation of calcium and vitamin D only). PRIMARY AND SECONDARY OUTCOME MEASURES Incremental cost-effectiveness ratio (ICER), as measured by cost per quality-adjusted life year (QALY) gained. RESULTS Compared with usual care, zoledronic acid had an ICER of $207 400 per QALY gained and was not cost-effective at a conventional willingness-to-pay threshold of $100 000 per QALY gained. The results were robust to a reasonable range of assumptions about incidence, mortality, quality-of-life effects and the cost of hip fracture and the cost of zoledronic acid. Zoledronic acid had a potential to become cost-effective if a fracture risk reduction with zoledronic acid was higher than 23% or if 6-month mortality in nursing home residents was lower than 16%. Probabilistic sensitivity analysis showed that the zoledronic acid would be cost-effective in 14%, 27% and 44% of simulations at willingness-to-pay thresholds of $50 000, $100 000 or $200 000 per QALY gained, respectively. CONCLUSIONS Routine administration of single-dose zoledronic acid in nursing home residents with osteoporosis is not a cost-effective use of resources in the USA but could be justifiable in those with a favourable life expectancy.
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Affiliation(s)
- Kouta Ito
- Department of Medicine, Hebrew SeniorLife, Roslindale, Massachusetts, USA
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
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Factors associated with receiving anti-osteoporosis treatment among older persons with minimal trauma hip fracture presenting to an acute orthogeriatric service. Injury 2016; 47:2149-2154. [PMID: 27496719 DOI: 10.1016/j.injury.2016.07.034] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Revised: 07/21/2016] [Accepted: 07/21/2016] [Indexed: 02/02/2023]
Abstract
BACKGROUND/AIM The aim of this study was to investigate factors that were associated with receiving anti-osteoporosis treatment (AOT) among patients with minimal trauma hip fracture admitted to an Australian tertiary trauma centre under the Acute Orthogeriatric Service (AOS) over a 6 month period. DESIGN Observational study using prospectively collected data. METHODS Demographic and clinical characteristics of 211 patients were extracted from the local hip fracture registry and electronic medical records. The outcome measure was receipt of AOT before separation from the AOS. Binary logistic regression was used to identify factors independently associated with treatment. RESULTS 91 (45%) patients received AOT, including 51 (25.2%) treatment-naive patients. Factors significantly associated with receiving treatment included higher serum vitamin D level (OR 1.44, 95% CI 1.23-1.70, p<0.001) and trochanteric vs. cervical fracture (OR 2.67, 95% CI 1.30-5.49, p=0.007). Living in a residential aged care facility (RACF) prior to the index fracture (OR 0.2, 95% CI 0.08-0.54, p=0.001) and higher American Society of Anaesthesiologists (ASA) physical status score (OR 0.5, 95% CI 0.25-0.98, p=0.04) significantly lowered the likelihood of treatment. Age, gender, cognitive impairment, premorbid walking ability, previous fragility fracture and renal impairment did not correlate with treatment. CONCLUSION A significant proportion (55%) of hip fracture patients did not receive AOT in hospital. The probability of receiving treatment appears to be significantly associated with serum vitamin D level, fracture type, place of residence and comorbidity burden.
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Niimi R, Kono T, Nishihara A, Hasegawa M, Matsumine A, Kono T, Sudo A. Teriparatide Treatment in Nursing Home Residents: A Retrospective Case-Control Study. J Am Geriatr Soc 2016; 64:911-2. [PMID: 27100602 DOI: 10.1111/jgs.14073] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Rui Niimi
- Department of Orthopedic Surgery, Tomidahama Hospital, Tomidahama-cho, Yokkaichi City, Mie, Japan
| | - Toshibumi Kono
- Department of Orthopedic Surgery, Tomidahama Hospital, Tomidahama-cho, Yokkaichi City, Mie, Japan
| | - Atsushi Nishihara
- Department of Orthopedic Surgery, Tomidahama Hospital, Tomidahama-cho, Yokkaichi City, Mie, Japan
| | - Masahiro Hasegawa
- Department of Orthopedic Surgery, Graduate School of Medicine, Mie University, Edobashi, Tsu City, Mie, Japan
| | - Akihiko Matsumine
- Department of Orthopedic Surgery, Graduate School of Medicine, Mie University, Edobashi, Tsu City, Mie, Japan
| | - Toshihiko Kono
- Department of Orthopedic Surgery, Tomidahama Hospital, Tomidahama-cho, Yokkaichi City, Mie, Japan
| | - Akihiro Sudo
- Department of Orthopedic Surgery, Graduate School of Medicine, Mie University, Edobashi, Tsu City, Mie, Japan
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Kennedy CC, Ioannidis G, Thabane L, Adachi JD, O’Donnell D, Giangregorio LM, Pickard LE, Papaioannou A. Osteoporosis prescribing in long-term care: impact of a provincial knowledge translation strategy. Can J Aging 2015; 34:137-48. [PMID: 25850439 PMCID: PMC5104546 DOI: 10.1017/s0714980815000057] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
This study described prescribing trends before and after implementing a provincial strategy aimed at improving osteoporosis and fracture prevention in Ontario long-term care (LTC) homes. Data were obtained from a pharmacy provider for 10 LTC homes in 2007 and 166 homes in 2012. We used weighted, multiple linear regression analyses to examine facility-level changes in vitamin D, calcium, and osteoporosis medication prescribing rates between 2007 and 2012. After five years, the estimated increase in vitamin D, calcium, and osteoporosis medication prescribing rates, respectively, was 38.2 per cent (95% confidence interval [CI]: 29.0, 47.3; p < .001), 4.0 per cent (95% CI: -3.9, 12.0; p = .318), and 0.2 per cent (95% CI: -3.3, 3.7; p = .91). Although the study could not assess causality, findings suggest that wide-scale knowledge translation activities successfully improved vitamin D prescribing rates, although ongoing efforts are needed to target homes with low uptake.
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Affiliation(s)
- Courtney C. Kennedy
- Department of Medicine, McMaster University
- St. Peter’s Hospital, GERAS Centre
| | - George Ioannidis
- Department of Medicine, McMaster University
- St. Peter’s Hospital, GERAS Centre
| | - Lehana Thabane
- Clinical Epidemiology and Biostatistics, McMaster University
- St Joseph’s Healthcare – Hamilton
| | - Jonathan D. Adachi
- Department of Medicine, McMaster University
- St Joseph’s Healthcare – Hamilton
- Alliance for Better Bone Health Chair in Rheumatology
| | | | | | - Laura E. Pickard
- Department of Medicine, McMaster University
- St. Peter’s Hospital, GERAS Centre
| | - Alexandra Papaioannou
- Department of Medicine, McMaster University
- St. Peter’s Hospital, GERAS Centre
- Eli Lilly Canada Chair in Osteoporosis
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Affiliation(s)
| | - Kate E Poland
- Sir Charles Gairdner Hospital; Nedlands Western Australia
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Zarowitz BJ, Cheng LI, Allen C, O'Shea T, Stolshek B. Osteoporosis prevalence and characteristics of treated and untreated nursing home residents with osteoporosis. J Am Med Dir Assoc 2015; 16:341-8. [PMID: 25726417 DOI: 10.1016/j.jamda.2015.01.073] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2014] [Revised: 12/22/2014] [Accepted: 01/06/2015] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Our primary objective was to describe the prevalence of osteoporosis (OP) diagnosis in nursing home residents (NHRs). Secondary objectives included assessment of pharmacologic therapies and risk of fracture in NHRs with OP, as well as differentiating clinical characteristics of treated versus untreated male and female NHR with OP. Finally, we sought to evaluate persistence and compliance rates in NHRs treated with OP and determine the prevalence of severe renal impairment in NHRs with OP treated with a bisphosphonate. DESIGN Retrospective cohort analysis. SETTING US NH. PARTICIPANTS NHRs with a Minimum Data Set (MDS) 3.0 record in the Omnicare Senior Health Outcomes (OSHO) data repository during the time period of October 1, 2011, to September 30, 2012. MEASUREMENTS A patient was considered to have an OP diagnosis if MDS item I3800 indicated the NHR had OP or if the MDS record contained ICD-9-CM codes 733.0x. An expanded definition of OP diagnosis was explored, in which an NHR with a previous fracture (MDS items I3900, I4000, J1700C=1) was also considered to have OP. OP pharmacologic therapies were extracted from the pharmacy claims data and included alendronate, calcitonin salmon, denosumab, ibandronate, raloxifene, risedronate, and teriparatide. Using MDS items, cognitive impairment (Brief Instrument for Mental Status, Cognitive Performance Scale) and functional impairment (composite activities of daily living) were assessed. Using MDS and prescription claims data, high risk of fracture (at least 2 of the following: age ≥75 years, female gender, previous fracture, history of falls, and use of a bisphosphonate) was assessed. Persistence was indicated by continuous use of therapy without a gap of more than 60 days, compliance was calculated using the medication possession ratio, and creatinine clearance (Clcr) was calculated using a modified Cockcroft-Gault equation. RESULTS The prevalence of OP in NHRs was 13.5%. Using the expanded OP definition, the prevalence of OP increased to 24.2%. Among NHRs with OP (n = 23,666), the mean age was 82.5 and 85.1% were female; 36.8% had gastroesophageal reflux disease or ulcer. Per the definition of high risk for fracture based on older age, female gender, prior fracture, fall history, and use of bisphosphonates, 89.0% of NHRs with OP met the criteria. Additionally, 10.8% had hip fracture, and 15.8% had other fracture. Overall, few NHRs with OP received active treatment: one-third received pharmacologic therapy, of which 73.5% received an oral bisphosphonate. Those with a history of hip fracture had similar treatment rates (31.7%) to those without (32.0%) (P = .804), whereas those with a history of other fracture were more likely to be treated (35.9%) than those without (31.2%) (P = .001). Two-thirds of residents with OP had moderate/severe cognitive impairment, and these residents were less likely to receive OP therapy than those without (P = .001). Persistence with pharmacologic therapy in NHR with a full year of pharmacy data (n = 1399) was higher for raloxifene (82.9%), with calcitonin salmon and bisphosphonates being similar, and the few NHRs who received teriparatide and denosumab were lower. Of the NHRs who received bisphosphonates for whom there was creatinine clearance data, 57% had a Clcr lower than 35 mL/min. CONCLUSION The recognized prevalence of OP in NHRs using MDS records was low, but consistent with previous reports. Among those with a documented diagnosis of OP, approximately 89% of NHRs with OP were at high risk of fracture and only one-third were treated with active pharmacologic therapy. For those treated, persistence and compliance was suboptimal, but higher with oral therapies. More than half of NHRs with OP treated with bisphosphonates had Clcr of less than 35 mL/min, suggesting alternative forms of therapy should be considered. For all of these reasons, the opportunity exists to improve the care and medication use of residents with OP who are at high risk of fracture.
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Affiliation(s)
- Barbara J Zarowitz
- Health Economics and Outcomes Research, Omnicare Senior Health Outcomes, Livonia, MI.
| | - Lung-I Cheng
- Health Economics and Outcomes Research, Amgen, Inc, Thousand Oaks, CA
| | - Carrie Allen
- Health Economics and Outcomes Research, Omnicare Senior Health Outcomes, Livonia, MI
| | - Terrence O'Shea
- Health Economics and Outcomes Research, Omnicare Senior Health Outcomes, Livonia, MI
| | - Bradley Stolshek
- Health Economics and Outcomes Research, Amgen, Inc, Thousand Oaks, CA
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Wall M, Lohfeld L, Giangregorio L, Ioannidis G, Kennedy CC, Moser A, Papaioannou A, Morin SN. Fracture risk assessment in long-term care: a survey of long-term care physicians. BMC Geriatr 2013; 13:109. [PMID: 24138565 PMCID: PMC3853074 DOI: 10.1186/1471-2318-13-109] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2013] [Accepted: 09/19/2013] [Indexed: 11/21/2022] Open
Abstract
Background The majority of frail elderly who live in long-term care (LTC) are not treated for osteoporosis despite their high risk for fragility fractures. Clinical Practice Guidelines for the diagnosis and management of osteoporosis provide guidance for the management of individuals 50 years and older at risk for fractures, however, they cannot benefit LTC residents if physicians perceive barriers to their application. Our objectives are to explore current practices to fracture risk assessment by LTC physicians and describe barriers to applying the recently published Osteoporosis Canada practice guidelines for fracture assessment and prevention in LTC. Methods A cross-sectional survey was conducted with the Ontario Long-Term Care Physicians Association using an online questionnaire. The survey included questions that addressed members’ attitudes, knowledge, and behaviour with respect to fracture risk assessment in LTC. Closed-ended responses were analyzed using descriptive statistics and thematic framework analysis for open-ended responses. Results We contacted 347 LTC physicians; 25% submitted completed surveys (81% men, mean age 60 (Standard Deviation [SD] 11) years, average 32 [SD 11] years in practice). Of the surveyed physicians, 87% considered prevention of fragility fractures to be important, but a minority (34%) reported using validated fracture risk assessment tools, while 33% did not use any. Clinical risk factors recommended by the OC guidelines for assessing fracture risk considered applicable included; glucocorticoid use (99%), fall history (93%), age (92%), and fracture history (91%). Recommended clinical measurements considered applicable included: weight (84%), thyroid-stimulating hormone (78%) and creatinine (73%) measurements, height (61%), and Get-Up-and-Go test (60%). Perceived barriers to assessing fracture risk included difficulty acquiring necessary information, lack of access to tests (bone mineral density, x-rays) or obtaining medical history; resource constraints, and a sentiment that assessing fracture risk is futile in this population because of short life expectancy and polypharmacy. Conclusion Perceived barriers to fracture risk assessment and osteoporosis management in LTC have not changed recently, contributing in part to the ongoing care gap in osteoporosis management. Our findings highlight the importance to adapt guidelines to be applicable to the LTC environment, and to develop partnerships with stakeholders to facilitate their use in clinical practice.
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Affiliation(s)
- Michelle Wall
- McGill University Health Center Research Institute, Montreal, Canada.
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Abstract
Large numbers of frail elderly people spend some time of their lives in care homes. Increasing age is associated with altered physiology, multiple diagnoses and complex comorbidity, and polypharmacy. Those living in care homes often take larger numbers of medications than those who live in the community and the risk of morbidity as a direct or indirect result of medications is high. Many methods have been suggested to revise the number and type of medications prescribed for individuals at risk of adverse drug reactions (ADRs), both in the community and in hospital with variable success and implementation. Assessment of prescribed and nonprescribed medications by pharmacists, nurses and general practitioners all have a role in optimizing therapeutics with evidence that improved prescribing can reduce the risk of ADRs. In conjunction with these professionals, community geriatricians undertaking a comprehensive geriatric assessment can reduce the number of medications prescribed or optimize therapy where there may be underprescribing (e.g. in depression), thereby reducing the overall risk of hospital admission ADRs.
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Rodondi A, Chevalley T, Rizzoli R. Prevalence of vertebral fracture in oldest old nursing home residents. Osteoporos Int 2012; 23:2601-6. [PMID: 22302103 DOI: 10.1007/s00198-012-1900-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2011] [Accepted: 11/08/2011] [Indexed: 01/09/2023]
Abstract
UNLABELLED We evaluated vertebral fracture prevalence using DXA-based vertebral fracture assessment and its influence on the Fracture Risk Assessment (FRAX) tool-determined 10-year fracture probability in a cohort of oldest old nursing home residents. More than one third of the subjects had prevalent vertebral fracture and 50% osteoporosis. Probably in relation with the prevailing influence of age and medical history of fracture, adding these information into FRAX did not markedly modify fracture probability. INTRODUCTION Oldest old nursing home residents are at very high risk of fracture. The prevalence of vertebral fracture in this specific population and its influence on fracture probability using the FRAX tool are not known. METHODS Using a mobile DXA osteodensitometer, we studied the prevalence of vertebral fracture, as assessed by vertebral fracture assessment program, of osteoporosis and of sarcopenia in 151 nursing home residents. Ten-year fracture probability was calculated using appropriately calibrated FRAX tool. RESULTS Vertebral fractures were detected in 36% of oldest old nursing home residents (mean age, 85.9 ± 0.6 years). The prevalence of osteoporosis and sarcopenia was 52% and 22%, respectively. Ten-year fracture probability as assessed by FRAX tool was 27% and 15% for major fracture and hip fracture, respectively. Adding BMD or VFA values did not significantly modify it. CONCLUSION In oldest old nursing home residents, osteoporosis and vertebral fracture were frequently detected. Ten-year fracture probability appeared to be mainly determined by age and clinical risk factors obtained by medical history, rather than by BMD or vertebral fracture.
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Affiliation(s)
- A Rodondi
- Division of Bone Diseases, Department of Medical Specialties, Geneva University Hospitals and Faculty of Medicine, CH–1211 Geneva 14, Switzerland
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Abstract
Osteoporosis is a highly prevalent chronic disease in the US and worldwide. The most serious consequence of this disorder is fractures, which have a serious negative impact on quality of life and are often the trigger for accelerated deterioration, ultimately ending in death. Despite the availability of effective preventive treatments, osteoporosis is frequently underdiagnosed and/or undertreated, particularly among the elderly, who are also at greatest risk. In addition, the presence of co-morbid medical conditions may be both a barrier to osteoporosis care and a risk factor for falls; thus individuals with multiple co-morbid conditions may be a particularly high-risk group. The management of osteoporosis involves improving bone health via adequate nutrition, calcium and vitamin D supplements, and fall prevention strategies. Although these measures are important in the management of all patients, most elderly patients are likely to need additional pharmacological therapy to adequately reduce their fracture risk. Several pharmacological treatments have been shown to significantly reduce the risk of fracture, including bisphosphonates (e.g. alendronate, risedronate, ibandronate, zoledronic acid), denosumab, raloxifene, calcitonin and teriparatide. Despite recent advances in osteoporosis care, additional action is urgently needed to improve the quality of life of osteoporotic patients in general and of elderly patients in particular, since fracture outcomes are typically poorer in older than in younger patients. This article reviews the current status of osteoporosis management, emphasizing the need to improve osteoporosis care, with a particular focus on the US, by the use of quality-improvement measures and incentives, which might result in an increased awareness and improved treatment for this debilitating disease.
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Affiliation(s)
- Jeffrey R Curtis
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, AL 35294, USA.
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Bonjour JP, Benoit V, Pourchaire O, Rousseau B, Souberbielle JC. Nutritional approach for inhibiting bone resorption in institutionalized elderly women with vitamin D insufficiency and high prevalence of fracture. J Nutr Health Aging 2011; 15:404-9. [PMID: 21528169 DOI: 10.1007/s12603-011-0003-y] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Nutritional approach to the deterioration of bone integrity and increased fracture risk appears to be particularly appropriate in elderly women living in nursing homes. OBJECTIVE To investigate the beneficial effect of the consumption of soft plain cheese on bone resorption markers in institutionalized elderly women. DESIGN Prospective, randomized crossover controlled study. SETTING Six French nursing homes or other institutions for elderly. PARTICIPANTS Institutionalized women ≥ 65 years old with low vitamin D status and calcium intake below 700 mg/day. INTERVENTION Consumption of soft plain cheese made of semi-skimmed milk which was fortified by both vitamin D3 (+1.25 µg/100g) and milk extracted Ca, thus achieving a total Ca content of 151 mg/100g as compared to about 118 mg/100g for standard fresh cheese. Two servings were taken every day during the 6 weeks that preceded or followed a period of 6 weeks without soft plain cheese consumption. MEASUREMENTS The primary end point was the change in serum carboxy terminal cross-linked telopeptide of type I collagen (CTX) selected as a marker of bone resorption. RESULTS 29 women aged 73-94 yr were selected, 21 of them with mean age 87.2±6.1 years remained compliant. The intervention increased calcium and protein intakes by 51% (904±228 vs. 599±122 mg/d) and 33 % (74.2±17.1 vs. 55.6±12.7 g/d, mean±SD), respectively. The dietary intervention was associated with a statistically significant increase in serum levels of both 25OHD and IGF-I, while those of [corrected] CTX and TRAP5b were significantly reduced. Compliance was 93,4 %. The daily consumption of two servings of soft plain cheese was well accepted in terms of tastiness and appetite suited portion size. CONCLUSION This randomized crossover controlled trial demonstrates that in elderly women living in nursing homes, the consumption of soft plain cheese increasing the supply of vitamin D, calcium and proteins, could reduce bone resorption and thereby reduce the risk of incidental fragility fractures in the long term.
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Affiliation(s)
- J-P Bonjour
- Division of Bone Diseases, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland.
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Abstract
SummaryThe prevalence of falls and associated injuries increases with age and dependency. The highest occurs among individuals living in long-term care institutions. Preventing falls results in reduced physical and psychological morbidity as well as having cost-saving implications. This review explores both uni- and multifactorial approaches to reducing fall rates and risk in individuals in long-term care, as well as highlighting the differences in this group from community-dwelling individuals.
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Demontiero O, Herrmann M, Duque G. Supplementation With Vitamin D and Calcium in Long-Term Care Residents. J Am Med Dir Assoc 2011; 12:190-4. [DOI: 10.1016/j.jamda.2010.09.013] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2010] [Revised: 09/30/2010] [Accepted: 09/30/2010] [Indexed: 10/18/2022]
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Duque G, Close JJ, Jager JP, Ebeling PR, Inderjeeth C, Lord S, McLachlan AJ, Reid IR, Troen BR, Sambrook PN. Treatment for osteoporosis in Australian residential aged care facilities: consensus recommendations for fracture prevention. Med J Aust 2010; 193:173-9. [DOI: 10.5694/j.1326-5377.2010.tb03839.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2009] [Accepted: 03/30/2010] [Indexed: 11/17/2022]
Affiliation(s)
- Gustavo Duque
- Ageing Bone Research Program, Sydney Medical School – Nepean Campus, University of Sydney, Sydney, NSW
| | - Jacqueline J Close
- Prince of Wales Medical Research Institute, University of New South Wales, Sydney, NSW
| | | | - Peter R Ebeling
- Department of Medicine, Western Hospital, University of Melbourne, Melbourne, VIC
| | - Charles Inderjeeth
- Area Rehabilitation and Aged Care, National Institute of Clinical Studies and University of Western Australia, Perth, WA
| | - Stephen Lord
- Prince of Wales Medical Research Institute, University of New South Wales, Sydney, NSW
| | - Andrew J McLachlan
- Faculty of Pharmacy, University of Sydney and Centre for Education and Research in Ageing, Sydney, NSW
| | - Ian R Reid
- Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Bruce R Troen
- Department of Geriatric Medicine, Miller School of Medicine, University of Miami, Miami, Fla, USA
| | - Philip N Sambrook
- Kolling Institute for Medical Research, Sydney Medical School – Northern Campus, University of Sydney, Sydney, NSW
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