Osteoporosis Management and the Nursing Home Patient

Dr Chie Wei FanForever Autumn & Bone Health Conference

30th September 2015

Mater MisericordiaeUniversity Hospital

Where I practice

• Community Geriatrician

• The MCMOP team– Catchment -

Service provided– Scope of practice

– assessment, prevention, investigation, end of life care

Objectives

• Osteoporosis in the nursing home residents

• Diagnosis and management (bone health and falls prevention

• Treatment of Osteoporosis• Medication Use review

A growing problem …

Central Statistics Office, Profile 2: Older and Younger, May 2012

Ageing population

• In 2011 census, there were 535,393 population age 65+

• 14.4% increase > national average– Fingal ↑ 38%– Kildare ↑ 30.3%– South Dublin ↑ 29.1%

Central Statistics Office, Profile 2: Older and Younger, May 2012

65 years and Older

• 6%, 65+ in communal establishment• Nursing homes• 80 and over

Central Statistics Office, Profile 2: Older and Younger, May 2012

Incidence

Prevalence of Osteoporosis by age

Richy F, Gourlay M, Ross PD, et al. Validation and comparative evaluation of osteoporosis self-assessment tool (OST) in a Caucasian population from Belgium. QJM 2003, 97(1):39-

46

Consequence

• Low bone mass and microarchitectural deterioration→ bone fragility

• WHO definition• Silent until fracture• Kyphosis, height loss, fractures• Morbidity and Mortality

Osteoporosis in the nursing home

• It is estimated that 86% of NH residents have osteoporosis 1.

• Rate of fracture 2.5-10 times higher 2.• Multiple co-morbidity, polypharmacy,

frailty, advanced dementia, mobility issues, chronic kidney disease, GI problems, medication adherence

1. Zimmerman SI, Girman CJ, Custis Buie V, et al. The prevalence of osteoporosis in nursing home residents. Osteoporosis International. 1999;9(2):151–157.

2. 2. Parikh S, Mogun H, Avorn J, Solomon DH. Osteoporosis medication use in nursing home patients with fractures in 1 US State. Archives of Internal Medicine. 2008;168(10):1111–1115

Diagnosis• Clinical – low fragility

fracture• FRAX1

• At risk – long term glucocorticoids, anticonvulsants, SSRI’s, Malabsorption syndrome, low weight, hyperthyroid

• Specific tests• DXA – mobility,

cognition• Thoraco-lumbar spine

(plain film)

1. www.shef.ac.uk/FRAX

Treatment options• Good general nutrition• Vitamin D3 – cholecalciferol 1 ± 1.2 g calcium supplementation 1

• Guidelines from the American Association of Clinical Endocrinologists recommendations for treatment of osteoporosis:

• First-line agents: Alendronate, risedronate, zoledronic acid, denosumab

• Second-line agent: Ibandronate • Second- or third-line agent: Raloxifene • Last-line agent: Calcitonin • Treatment for patients with very high fracture risk or in whom

bisphosphonate therapy has failed: teriparatide

1 Chapuy MC, Arlot ME, Duboeuf F, et al. Vitamin D3 and calcium to prevent hip fractures in elderly women. The New England Journal of Medicine. 1992;327(23):1637–1642

Date of download: 3/10/2015

From: Systematic Review: Comparative Effectiveness of Treatments to Prevent Fractures in Men and Women with Low Bone Density or Osteoporosis

Ann Intern Med. 2008;148(3):197-213. doi:10.7326/0003-4819-148-3-200802050-00198

Risk for vertebral fractures relative to placebo for participants who are at high risk for fracture, by agent.PTH = parathyroid hormone; SERM = selective estrogen receptor modulator. *Pooled risk estimate from cited meta-analysis or systematic review. †Pooled risk estimate calculated by authors; restricted to studies with >12 months of follow-up. ‡Risk estimate calculated from cited individual studies. §Insufficient data to calculate risk.

Figure Legend:

Copyright © American College of Physicians. All rights reserved.

Date of download: 3/10/2015

From: Systematic Review: Comparative Effectiveness of Treatments to Prevent Fractures in Men and Women with Low Bone Density or Osteoporosis

Ann Intern Med. 2008;148(3):197-213. doi:10.7326/0003-4819-148-3-200802050-00198

Risk for vertebral fracture relative to placebo for participants who are not at high risk for fracture, by agent.NR = not reported; PTH = parathyroid hormone; SERM = selective estrogen receptor modulator; WHI = Women's Health Initiative. *Pooled risk estimate from cited meta-analysis or systematic review. †Insufficient data to calculate risk. ‡Risk estimate calculated from cited individual studies.

Figure Legend:

Copyright © American College of Physicians. All rights reserved.

Over 80’s• Alendronate

– (FIT) – no over 80’s, Black 2000

– Pols 1999 include a few over 80’s mean age 62yo

• Risedronate– VERT New vertebral fracture

81%– HIP, 30%, McClung 2001

• Zoledronic acid– HORIZON-recurrent fracture

trial, 35% fracture, 50% >75 years, 28% mortality, Lyles 2007

• Teriparatide– No difference in

effectiveness, <75yo or 75+, Boonen 2006

• Denosumab– FREEDOM, 68%,

vertebral, hip and nonvertebral fractures 1/3 75+, Cummings 2009

Chua WM, Nandi N, Masud T. Pharmacological treatments for Osteoporosis in Very Elderly People. Ther Adv Dis 2011;2(4):279-286

Osteoporosis treatment in nursing home residents

• 67 nursing facilities in North Carolina and Arizona• High risk patients (previous fractures)• Calcium and Vit D 69%• Bisphosphonates 19%• Calcitonin 14%• Others 6%• Hip protectors 2%• Overall 36% receive some type of bone protection (0-85%)• Factors associated with treatment - Female (OR 2.4), suburban

location (OR 1.5). Residents with esophagitis, PUD or dysphagia (OR 0.6), alcohol abuse (OR 0.2).

• Suboptimal osteoporosis therapy

Colon-Emeric C, Lyles KW, Levine DA, et al. Prevalaence and predictors of osteoporosis Treatment in Nursing Home residents with known Osteoporosis or recent fracture. Osteoporos Int 2007,

18(4):553-559

Zoledronic Acid in Frail Elders to strengthen Bone (ZEST)

• 2 year double-blind, randomised trial

• 181 resident, mean age 85.4 years, Vitamin D replete

• Zoledronic acid 5 mg, daily calcium 1200mg and Vitamin D 800iu

• Treatment group had higher diabetes rate, falls history, anti-seizure meds and slow gait speed.

• 12-month absolute difference in BMD at hip (3.2%), spine (1.8%)

• No difference in adverse events or death

• “Although the single zoledronic acid infusion did improve BMD and bone turnover at 2 years in this cognitively challenged, less mobile osteoporotic group, it would be premature to recommend it for this population as a whole”

2 Greenspan SL, et al Efficacy and Safety of Single-Dose Zoledronic Acid for Osteoporosis in Frail Elderly Women:  A Randomized Clinical Trial, JAMA 2015, apr 13.

Calcium and Vitamin D• Start all residents on

Vitamin D therapy (800-1000iu daily). If there is inadequate dietary calcium intake consider adding 1.2g calcium supplementation.

• Check serum calcium level one month after commencing therapy. If corrected serum calcium is raised, look for cause.

Bisphosphonate• For mobile residents with

osteoporosis, consider oral bisphosphonates such as weekly alendronate, risedronate or monthly ibandronate.

• The residents should be able to sit upright and drink large volume of water when taking bisphosphonates.

Consider denosumab• If the residents who have

difficulty sitting up for 30min, difficulty drinking at least 300ml of water while taking bisphosphonate, have a history of esophagitis, have swallow impairment requiring crushed medications, consider denosumab subcutaneously.

Teriparatide• Residents on

parathyroid hormone therapy will be monitored by bone health specialists.

Renal impairment• Check renal function 3-

monthly. If eGFR is <33-35mL/min, stop all antiresorptive therapy and consult bone health specialists.

• Residents with eGFR <30mL/min on denosumab are at risk of significant hypocalcaemia.

Figure 1: Age-associated increase in the probability of any renal impairment (——) and renal impairment with albuminuria (– – –) in men (■) and women ( ) ♢with type 2 diabetes from the NEFRON study.

Thomas MC, MaclsaacRJ, Jerums G, et al Nonalbuminuric Renal Impairment in Type 2 Diabetic Patients and in the General Population (National Evaluation of the Frequency of Renal Impairment

cO-existing with NIDDM [NEFRON] . Diabetes Care 2009;32(8):1497-1502

End of life care

• Residents who is for end of life care, all bone health medications and other secondary prevention medications are stopped as part of the medication optimisation.