Preventing Fractures in Nursing Home Residents

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Preventing Fractures in Nursing Home Residents

• Cathleen Colon-Emeric, MD, MHSC
• and Kenneth Lyles, MD Duke University

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Osteoporosis in Maryland SNFs
Zimmerman SI, Osteoporos Int 1999
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Epidemiology of Fractures in SNF

• 1.5 falls/bed/year
• 4-10 result in a fracture
• 1/3 of all hip fracture cases in Australia
  admitted from SNF1
• Risk of fracture 3-6 times higher than community
  dwellers1,2

1Cumming, 1996 2Ooms, 1994
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Fracture rates, Wisconsin SNFs
Kane et al. 1995
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From Cummings SR, Nevitt MC, Browner WS et al.
NEJM 1995332767-73.
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Which SNF Residents are at highest risk to
fracture?
Ambulatory
Visual impairment
More independent and active
Female
Faller
Wanderer
Prior fracture
Cognitively impaired
Anxiolytic user
Colón-Emeric, 2003
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DEXA scans

• Gives T score standard deviations above/below
  mean for healthy young adults
• T score lt -2.5 indicates osteoporosis
• T score lt -1.0 indicates osteopenia

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Lessons from the Risedronate-HIP Trial

• Women aged 70-79 with osteoporosis benefit from
  risedronate
• (RR hip fracture 0.6, NNT 77)
• Women over 80 with risk factors, but unknown BMD,
  did not benefit
• Bottom line Need BMD measurements before
  starting therapy unless resident has a previous
  fracture

McClung, 2001
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Risk of subsequent fractures in patients with
low-trauma fractures

• After vertebral fracture 2 x increase1
• After hip fracture 2.5 x increase, gt10/year2
• BMD declines nearly 5 in year after hip
  fracture3

3Fox, 2000
2Colón-Emeric, 2003
1Klotzbuecher, 2000
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Osteoporosis Treatment Options
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Calcium and Vitamin D

• Given to all residents regardless of BMD,
  decreases risk of all non-vertebral fractures by
  251
• If you treat 21 residents for 18 months, you will
  prevent 1 fracture
• Effect rapidly lost when discontinued2,3

1. Chapuy et al, NEJM 1993 2. Dawson-Hughes et
al, NEJM 1997 3. Dawson-Hughes et al, Am J Clin
Nutr 2000
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Bisphosphonates

• Given to women with osteoporosis1
• Decreases fracture risk 50
• Treat 30 women for 2 years, prevent 1 fracture
• Usually given weekly
• Can cause hypocalcemia in vitamin D deficient
  patients2
• Safety and efficacy demonstrated in nursing homes3

1. Cranney, 2002 2. Rosen, 2003 3.
Greenspan, 2002
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Safe administration of bisphosphonates

• Must give fasting with full glass of water
• Have resident sit upright for 1 hour after dose
  to prevent esophageal irritation
• GERD (reflux) is NOT a contraindication
• IV preparations on the way

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Calcitonin

• Given to women with osteoporosis1
• Decrease spine fractures 30-40
• Treat 12 women for 2 years to prevent 1 spine
  fracture
• Does not reduce non-spine fractures
• Generally well tolerated
• May have analgesic properties in acute spine
  fractures2
• Side effect is nasal congestion

1. Chestnut, 2000 2. Silverman, 2002
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Raloxifene

• In women with osteoporosis
• Reduces spine fractures 30-40
• Treat 16-50 women for 2 years to prevent 1
  fracture
• Does not reduce non-spine fractures
• Increased risk of venous thromboemolism
• May reduce breast cancer risk

Ettinger, 1999
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Parathyroid hormone

• In men and women with osteoporosis
• Decreases spine and non-spine fracture risk
  30-60
• Treat 11-29 subjects for 18 months to prevent 1
  fracture
• Given as subcutaneous injection
• Osteosarcoma risk?
• Hypercalcemia, nausea, dizziness, cramps

Neer, 2001
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Combination Therapy

• Combining alendronate and parathyroid hormone
  does not improve BMD over either alone
• Alendronate may attenuate the effect of PTH
• Other combinations of medications may increase
  BMD but have not been shown to be effective in
  reducing fractures

Black, 2003
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Fracture Prevention Summary
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KPH Hip Protector
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External Hip Protectors

• Meta-analysis suggests 60 decreased risk of hip
  fracture
• In patients who are fully compliant, decreases
  risk by 90
• If you have 24 residents wear hip protectors for
  1-2 years you will prevent 1 hip fracture
• Staff and resident education interventions
  greatly increase compliance

1. Kannus et al. NEJM 2000 2. Cochrane
Collaboration, 2000
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Summary and Recommendations

• Osteoporosis is highly prevalent in nursing home
  residents
• Adequate Calcium and vitamin D supplementation is
  very important for all residents
• Residents with prior osteoporotic fractures need
  effective anti-osteoporosis medications and/or
  hip protectors
• Consider screening others who are at high risk