Overview of the Problem
When one thinks about common causes of morbidity and mortality in elderly, osteoporosis is probably not one of the first conditions to come to mind. Even though most physicians are aware of osteoporosis, it is generally considered a less important health matter. Because elderly patients often have several medical problems, these other diseases often attract the attention of the health care provider; as a result, osteoporosis frequently is not adequately addressed. Yet, osteoporosis is a serious, debilitating ailment with morbidity, mortality, and economic costs similar to many other chronic medical problems. The purpose of this article is to demonstrate the similarities between osteoporosis and other chronic diseases with regard to its personal and economic impact, and to highlight the measures to diagnose and treat this neglected but important disease.

Osteoporosis is a very common problem. According to World Health Organization criteria, it is estimated that 13-18% of women over the age of 50 have osteoporosis, and 40% will sustain an osteoporotic fracture (spine, hip, or wrist) in their remaining lifetime. The National Osteoporosis Risk Assessment, a longitudinal study in which more than 200,000 women in the United States over the age of 50 not known to have osteoporosis had a bone mineral density test performed, found that 40% of women had osteopenia, or low bone mass (T-Score between –1 and –2.5), while over 7% had osteoporosis (T-Score < -2.5).¹ Women over age 80 have a 93% chance of being osteopenic or osteoporotic (Figure).

Both spine and hip fractures are associated with increased morbidity and mortality.² The personal impact with regard to the disability that can result from fractures can be compared to the impact that a stroke or MI can have on an elderly person. Hip fractures are devastating for both genders, with about 34% excess mortality in the first year after a fracture for men, and 20-24% for women.³ In Sweden, the death rate for hip fracture per 100,000 elderly women has now exceeded the death rate from stroke.^4,5 Many physicians and most patients do not appreciate that a woman at age 50 is as likely to die of a hip fracture in her remaining lifetime (2.8%) as she is from breast cancer (2.8%).⁶

Those who survive a hip fracture are often unable to return to independent living, and 40% never return to pre-fracture function.⁷ A recent study to assess the excess mortality and institutionalization of community-dwelling people over age 60 found that after 2 years, 39.2% of the female hip fracture patients vs 19.7% of female controls were dead or institutionalized, compared with 52.1% of male hip fracture patients vs 12.4% of male controls.⁸ Nursing home residents who sustain a fracture are more than 15 times more likely to be hospitalized in the month following their fracture compared to those without a fracture, and their rate remains increased compared to controls for at least 12 months.⁹

Lippuner et al¹⁰ reported that women with fractures utilized more hospital days (568,000) compared to chronic obstructive pulmonary disease (353,000), stroke (352,000), or myocardial infarction (131,000). In the United States, the cost of fractures secondary to osteoporosis was $13.8 billion in 1995. This compares to asthma’s annual cost of $7.5 billion and congestive heart failure’s $20.3 billion. Hip fractures are expected to increase dramatically in the next several decades as “baby boomers” hit retirement age; therefore, inpatient costs for the year 2050 are projected to be greater than $130 billion.¹¹

Despite these staggering statistics, osteoporosis awareness in all age groups remains low. In a recent survey of recognition and treatment of osteoporosis-related vertebral fractures, a chart review of 934 hospitalized women over the age of 60 who had chest x-rays done during their admission was conducted. Study radiologists reviewed the radiographs, and records were examined for fractures, diagnosis of osteoporosis, and whether the patient received any treatment.¹²  Fewer than half of the patients who had fractures seen on chest x-ray had the fracture noted on the hospital record; even fewer had the fracture noted on the chart, and only 18% received treatment for their osteoporosis. Another study of community-dwelling women who sustained a hip fracture showed that after their fracture, only 13% received adequate treatment according to the guidelines set forth by the National Osteoporosis Foundation.¹³

Approach to Fracture Reduction in the Elderly Resident
It is important for those taking care of elderly residents not to become discouraged by these statistics, but to realize that, just as with other common diseases, osteoporosis can be successfully diagnosed and managed. Both the United States Preventive Services Task Force (USPSTF)¹⁴ and the National Osteoporosis Foundation (NOF)¹⁵ recommend bone mineral density (BMD) testing for all women over age 65, and for those under age 65 with other risks besides menopause. Bone mineral density has been shown to be an important predictor of fracture not only in community-dwelling white women but also in white female nursing home residents.¹⁶ If the patient has already sustained a low-trauma fracture, then that patient already has established osteoporosis, and BMD testing is not mandatory before starting therapy. In the long-term care population, it is more important to deem everyone at risk and consider appropriate interventions for all residents. If the elderly resident qualifies for prevention or treatment strategies for other medical conditions, then appropriate fracture prevention interventions should be considered for that resident as well. These include exercise and fall prevention, adequate calcium and vitamin D, and pharmacologic therapy.

Exercise/Hip Protectors/Fall Prevention
Physical inactivity is an independent risk factor for hip fracture in the elderly. It is estimated that 40-50% of institutionalized elderly fall each year.¹⁷ In this age group, 3-5% of falls result in fractures, with 1% of falls resulting in a hip fracture.¹⁸ Numerous studies have demonstrated the benefit of exercise in helping with balance and reducing falls.^19,20 Strength-training exercises can maintain or increase BMD and improve muscle mass, strength, and balance, thereby reducing falls and hip fracture risk. Although some studies of hip protectors showed no benefit,²¹ others have demonstrated reduction in hip fractures.²² Often the reduction is even more dramatic when evaluated for compliance. For example, in one study, all the fractures in the hip protector group occurred in patients not wearing the device at the time.²³ It is reasonable to utilize hip protectors in residents who fall frequently in a long-term care facility.

Calcium/Vitamin D
Calcium absorption decreases with age, and both men and women can benefit from calcium supplementation to ensure a total intake of 1200-1500 mg per day. Calcium carbonate is the most inexpensive form and should be taken with meals to enhance absorption. It is advisable to start with one supplement daily and build up gradually to the recommended 1200-1500-mg total intake to minimize the bloating, constipation, and other GI problems that can often occur with calcium supplementation. Some patients may better tolerate calcium citrate or calcium phosphate. If supplements are used, they should be divided into two or more doses since there is a limit to how much can be absorbed at one time. Administration at mealtime may help to enhance absorption, particularly of calcium carbonate. Calcium is known to interfere with the absorption and/or action of certain medications. Other drugs may also decrease the absorption or serum level of calcium. Ideally, the medications shown in the Table should be separated from the administration of calcium by several hours to ensure proper activity of each agent.

Vitamin D deficiency can be seen in a large percentage of elderly patients,²⁴ with up to 60% of patients with hip fractures having some deficiency of this vitamin.²⁵ Interestingly, Vitamin D deficiency can be associated with decreased muscle strength and weakness, which may further contribute to fractures by increasing falls. In a study of 122 patients in a geriatric institution who were given calcium, those who were additionally supplemented with 800 IU of cholecalciferol had a 49% decrease in falls.²⁶ Supplementation of calcium and vitamin D has also been shown to decrease the incidence of hip and other nonvertebral fractures.²⁷ Even if calcium and Vitamin D intake is considered adequate, additional supplementation in nursing home residents has been shown to produce an increase in BMD as measured by ultrasound.²⁸ Elderly patients should ingest between 600-800 IU of Vitamin D daily; chronic doses above 2000 IU daily should not be used.

Pharmacologic Therapy
Although the above measures are important, they often need to be combined with pharmacologic therapy to help reduce fractures in patients with osteoporosis. When determining whether to initiate drug therapy, one may be tempted to take into account the number of patients that need to be treated (NNT) to prevent a fracture over a defined period of time with the various drugs available, and apply this to the long-term care population. Unfortunately, one cannot compare NNTs from different trials, because each will vary depending on the incidence rate of fracture in that population (affected by age, BMD, and prior fracture history of the patients in each trial), as well as the drug’s treatment effect. Because fracture rates increase with age, these NNTs would actually underestimate the benefit to a higher risk long-term care resident. A more rational approach is to consider every patient susceptible to the devastation of osteoporosis and weigh the benefits and risks of treatment for each individual.

Several pharmacologic agents are presently available to treat osteoporosis, but some may not be as useful in the elderly/long-term care population. Hormone therapy, for example, once thought to be beneficial and recommended for all postmenopausal women, is no longer recommended for treatment because of the adverse events noted with estrogen/progestin combination in the Women’s Health Initiative²⁹ and because other therapies are available with fewer side effects. Raloxifene, a selective estrogen receptor modulator, is indicated for the prevention and treatment of osteoporosis and has been shown to decrease vertebral fractures by 30-50%. However, nonvertebral fractures are not reduced with raloxifene.³⁰ It is associated with an increased incidence of deep vein thrombosis, so should not be used in patients who are immobilized or otherwise at risk for thromboembolism.

Because of its effectiveness in reducing fractures, bisphosphonate therapy should be considered for all older patients, especially if they have low BMD and/or have already had a fracture.³¹ Alendronate and risedronate are two bisphosphonates presently indicated to prevent and treat osteoporosis, and both are available in a once-weekly formulation that simplifies their administration in a long-term care setting. A weekly suspension formulation of alendronate has also recently been approved. These agents have been shown to have significant effects on BMD within a few months and on fracture reduction within 12-18 months. Meta-analyses have demonstrated that both reduce vertebral and non-vertebral fractures.^32,33 Alendronate has been shown to increase BMD in women residing in long-term care facilities.³⁴ An analysis from the Fracture Intervention Trial³⁵ also demonstrated that alendronate treatment is associated with an early and sustained reduction in multiple symptomatic fractures in women over age 75. Contraindications to bisphosphonates include esophageal disorders and inability to sit upright for one-half hour after its weekly administration.

Calcitonin is another agent available for osteoporosis treatment. A recent meta-analysis concluded that calcitonin likely reduces vertebral fractures, but has unknown effects on nonvertebral fractures. Because of its more modest fracture reduction effects, it is generally used only if other agents are not tolerated.³⁶ 

A final agent that may have utility in the long-term care setting, especially if the patient is at high risk for fractures or if other agents are contraindicated or not tolerated, is teriparatide, a recombinant human parathyroid hormone formulation. This is the first anabolic agent available for osteoporosis and is administered as a daily injection. It has been shown to reduce vertebral, multiple vertebral, and nonvertebral fragility fractures within 20 months of treatment.³⁷ Although it has a warning about osteosarcomas seen in rat studies, its main contraindication in the elderly would be Paget’s disease of the bone, unexplained increase in alkaline phophatase, or prior radiation therapy involving the skeleton.

Conclusion
Osteoporosis is clearly an important condition that can affect the morbidity and mortality of an elderly patient in as devastating a fashion as a stroke, myocardial infarction, or breast cancer. Fortunately, as with other chronic medical problems, there are successful strategies to identify and treat this disease. The most important step in caring for those with fractures or at risk for fractures is to recognize the high risk present in these persons. Any resident who is felt to benefit from interventions to prevent other medical problems (eg, antihypertensive, cholesterol-lowering, or renal-sparing medications) should also receive appropriate treatment to prevent fractures and their damaging sequelae.