Osteoporosis in aged care

• Assess aged care residents for bone health and fracture risk.
  Assess residents admitted to aged care facilities for fracture risk to ensure effective fracture prevention measures are implemented.
• Consider falls prevention measures for all aged care residents.
  Work with aged care facilities to introduce measures to reduce the risks of falls for residents.
• Regularly review medicines for aged care residents to minimise falls risk.
  Consider common adverse effects and polypharmacy when reviewing risk.
• Refer to the NPS MedicineWise decision pathway for PBS-listed treatment selection for management of confirmed osteoporosis and corticosteroid-induced osteoporosis.
  

Osteoporosis is increasingly prevalent in an ageing population and may affect a large proportion of aged care residents. Minimal trauma fractures (commonly of vertebrae, wrist and hip)^1,5 are a major health burden in ageing populations.¹

They cause pain, severe disability and reduced quality of life⁵ and are associated with increased risk of repeat fracture and excess mortality.^3,5 Fracture of the hip is considered the most serious, requiring hospitalisation and surgery, and is associated with the most complications.¹

In 2012, Australians experienced more than 140,800 fractures related to osteoporosis or osteopenia (the precursor to osteoporosis). This number is predicted to increase by 30% over the next decade.⁵ In 2006–07, approximately 1 in 9 patients hospitalised for osteoporotic hip fracture were discharged to an aged care facility.⁶

People who sustain a hip, vertebral or non-hip major fracture have reduced survival compared with the general population.⁷ This elevated risk of death persists for 10 years after an initial fracture, but is greatest for the first 5 years. Despite this, fewer than 20% of patients presenting with minimal trauma fracture are investigated or treated for osteoporosis.^3,4,8

Australian consensus guidelines recommend that patients admitted to aged care facilities be assessed for fracture risk, to ensure early implementation of effective fracture prevention measures.⁹

Risk factors for osteoporotic-related fractures in this population include those applicable for community-dwelling individuals (eg, female gender, low BMD, older age, previous fracture, postural instability) as well as the following:^9,10

• male gender
  
• low serum vitamin D
  
• bowel or bladder incontinence
  
• cognitive impairment
  
• use of anxiolytics
  
• high serum phosphate.
  

Patients aged ≥ 70 years are eligible for MBS-subsidised bone densitometry.¹⁰ 

Preventing falls is one of the most important strategies for reducing fracture risk among aged care residents.⁹

Factors that increase the risk of falls in older patients include poor eyesight, poor muscle strength and balance, and unsafe flooring/steps.¹¹ Some common medicines can also have adverse effects that lead to falls (see below).

The risk of falling in older people increases with the number of medications prescribed.^12,13 Regular medicines review and the maintenance of an up-to-date medicines list may help identify potential medicine-related issues and support appropriate prescribing in aged care.

Common classes of medicines used in aged care and their adverse effects

• anticholinergics:  blurred vision, dizziness, drowsiness
  
• antidepressants:  blurred vision, dizziness, drowsiness, hypotension, sedation
  
• antihypertensives:  dizziness, hypotension
  
• antipsychotics:  blurred vision, hypotension, sedation
  
• benzodiazepines: drowsiness, light-headedness, sedation
  

There is limited evidence to guide the choice of osteoporosis medicines in aged care residents. Medication choice should therefore be based on gender, age, medical history, comorbidities and personal preference.

In Australia, osteoporosis medicines are PBS-subsidised for men and women after minimal trauma fracture as well as for those at high risk without prior fracture, on the basis of age (≥ 70 years) and BMD T-score (≤ –2.5 or ≤ –3.0^a). Some osteoporosis medicines are also available through the PBS for treatment of corticosteroid-induced osteoporosis.

Before starting pharmacological treatment for osteoporosis, clinicians should exclude other conditions that may be associated with low BMD, and correct vitamin D and calcium levels if they are deficient.¹⁴

For further guidance on treatment selection of PBS-listed osteoporosis medicines please refer to the NPS MedicineWise decision pathway. You can also download a medicines table (including safety considerations) for PBS-listed osteoporosis medicines.

The health professional-mediated Bone Health Action Plan helps promote adherence and facilitate discussions with patients and carers about the benefits and safety issues of osteoporosis medicines.

^aUse of zoledronic acid in patients with minimal trauma fracture or those who are ≥ 70 years with T-score ≤ –3.0.