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Osteoporosis: the silent disease of aged care

Residential aged care facilities can be doing more to treat osteoporosis and can do better to prevent falls and osteoporosis-related fractures.

These are the conclusions from a new study looking at anti-osteoporosis medication use in aged care.

The study also found that reported diagnosis of osteoporosis in RACFs was lower than the international data, which suggests that up to 86 per cent of older adults have the disease.

In the RACFs studied, only a third of residents were reported as having osteoporosis. The authors suggested that this is unlikely to be an accurate figure and added that osteoporosis is likely to be under-diagnosed, which severely limits treatment.

One of the authors of the study, Macquarie University research fellow Kim Lind, spoke with Aged Care Insite to unpack the study and its results.

Currently, what does the literature tell us is the best course of action for osteoporosis treatment?

KL: It depends on the setting. For younger adults, we know that prevention is the best course, so the best thing we can all be doing right now to prevent osteoporosis is getting enough vitamin D, getting enough calcium in our diet, and doing weight-bearing exercise. Just twice a week. That’s the best thing we can all be doing. Then as adults get older, if their osteoporosis gets severe enough, they will want to be taking medication. For a lot of people, that just means taking a vitamin D supplement, and if osteoporosis gets more severe, taking an antiresorptive medication, of which there are two different classes.

Taking one of those medications is very, very effective for preventing fractures, and we hear a lot about preventing fractures because they do terrible things to people. For a lot of older adults, getting a fracture will mean losing their independence, it will mean a significant decline in their health, for some of them it can even mean early death. It’s really important to prevent that. For people in residential aged care, which was our population that we were studying, it’s especially important because they have a lot of the risk factors for falling and getting low impact fractures.

The morbidity rates among those in residential aged care with osteoporosis, and after falls, breaks and fractures, is quite high. So, what are you finding are the current trends of treatment in residential age care?

We had a very large study. We had over 10,000 residents who were in 68 facilities across New South Wales and the ACT, and one of the surprising things was that we found for only about a third of residents there was osteoporosis actually recorded in their electronic health record at the facility. That’s really surprising because based on other studies internationally, we expect that rate to be something closer to 80-90 per cent. So, only finding a third, we don’t think that’s actually an indication of a truly lower rate of disease in Australia. We think that it’s just not getting the attention it deserves, because we have people in residential aged care who are so medically complex, they have so many comorbidities, and osteoporosis is just this silent disease that may not cause symptoms for someone, so they might not tend to it until they get a fracture.

The good news was that the use of the vitamin D supplements is increasing a little bit, but after we adjust for a number of factors, it just stays kind of flat. Vitamin D use was, I’d say, relatively high. We’ll say in the ball park of 60 per cent of residents using them.

The thing that I was concerned about was that the use of the antiresorptive medications –which are for the more severe cases of osteoporosis in residential aged care – are not being used very often, and the rates are actually declining even after we account for a number of factors, and that’s concerning.

Why are antiresorptive medications underused?

In the early-to-mid 2000s, there were some concerns about these medications. There started to be these rare side effects that were reported. And they occur in people who have been treated with one of the medications. It’s called bisphosphonate. When people have been taking bisphosphonates for a long time, they are at risk of having these unusual, atypical femoral fractures. That’s the big bone in your thigh. They get these unusual fractures just from very low impact type of things. Things you wouldn’t expect to normally have a fracture from.

But, since that time, what we’ve found is there are newer medications that have a better side effect profile, and also, we’ve found that having what we call drug holidays, where basically you just take a break from the osteoporosis medications, for a while, and then restart, has helped.

Another conclusion was that fracture prevention should, and can, be improved. What measures would you suggest?

I’d really like to see residents being engaged in being more active, and just keeping people as active as possible. I think part of the issue is that if you look at say, the Aged Care Funding Instrument, we call it the ACFI, and we look at the incentives for funding things like exercise and those types of interactions are really not supported, but it’s so good for so many chronic diseases.

Ideally, we’d have less medication use, because we could have more physical activity, people being more active, people having better diets, and I think that would be the best case.

Could we also better identify those at risk of falls prior to the event? In your study, you recognised that females, people who are underweight, and people with a lower bone mass are more likely to have fractures. So, can we identify people and work on falls that way?

Yes, and there are plenty of screening tools that can identify those who are at higher risk of falls.

I think that’s something we can do very well – identify people. But I think what we see from the study is that osteoporosis is really not being identified or it’s just not getting the attention it needs, and I think that it just really is competing with all these other conditions that people have.

In an upcoming study that we’re working on right now, we’re looking at the complexity of all the conditions that residents have, and they are very, very complex, and they have a lot of other conditions, a lot of other medications they’re on, so I think they have to consider those factors.

How do we bring the diagnosis up for osteoporosis? It seems to be up to a third or two-thirds less than the rest of the world.

I think it is about awareness and making sure that for people who do need to be screened – and people who need dual-energy x-ray absorptiometry (DEXA) scans – to confirm how bad their osteoporosis is, that they have access to them. You can imagine, for someone who lives in a residential aged care facility, it could be more challenging to get them out of the facility, transport them to somewhere where they can get their DEXA scan.

I think making sure that we’re screening and diagnosing appropriately. And also, that when residents are incoming that they are getting a thorough review of all of their relevant health history, and their records are shared from their GP, or if they have any hospitalisation records, sharing information and making sure that care is integrated, I think is going to be one of those steps.

I know you’ve also done some work on antipsychotics, and we reported on a study in this last week that found that antipsychotics play a massive part in falls and fractures, with people up to 50 per cent more likely to fall or get a fracture. Do you think that plays a part in this?

That’s definitely a factor, and especially when we consider that antipsychotics are largely being used in people with dementia. So, that’s really important because people with dementia, when they have, say, a hip fracture, compared to people who don’t have dementia, they are much more likely to have a second hip fracture within three years, and they’re also more likely to die within 30 days of having that fracture. It’s really important that we also pay attention to folks with dementia, which is half of the residential aged care population.

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