Feature Article
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Osteoporosis in Very Elderly Nursing Home Patients Objective: To describe the prevalence of osteoporosis in frail elderly nursing home patients who are at the highest risk of falls and fractures.
Subjects/Setting: Case series of 22 frail, very elderly patients from the authors' practice in a predominantly white Jewish urban nursing home in Philadelphia, PA.
Methods: Portable dual-energy x-ray absorptiometry (DEXA) bone mineral density (BMD) scans were done on the wrist (radius and ulna, RU) in 22 consecutive patients, and medical records were reviewed for concomitant conditions.
Results: The median age of the patients was 87 years; 86% were female; 77% had dementia; 78% had atherosclerotic cardiovascular disease; 59% were ambulatory; and most (68%) had already suffered fractures. The median DEXA T score (for the distal RU) was -2.9, for the proximal RU - 6.7, and for the proximal radius -6.49. All subjects met the criteria for the diagnosis of osteoporosis, with the great majority (77%) judged to have severe osteoporosis, Stage IV.
Conclusions: This study, although small, demonstrates that most frail women in the nursing home have osteoporosis, usually severe, and may benefit from more aggressive treatment for osteoporosis. Further studies are needed, particularly concerning the efficacy of treatment for reducing fractures in this most vulnerable population. (Annals of Long-Term Care 2000;8[3]:83-87)
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Introduction The incidence and severity of osteoporotic fractures increases dramatically with age. At least 30% of postmenopausal white women in the United States have osteoporosis of the hip, spine, or forearm, according to epidemiologic studies, and more than 1 million Americans have fractures related to osteoporosis each year.1,2 Up to 20% of patients with fractures die, and 33% to 50% become institutionalized.3 The economic impact of osteoporosis and osteoporotic fractures is also tremendous; the costs to the U.S. health care system are estimated at $6 billion to $10 billion.1,2
The impact of osteoporosis would appear to be greatest in nursing home residents, who may receive suboptimal care and may not have been the subjects of sufficient research. The very elderly and frail nursing home population has a particularly high risk of falls, fractures, mobility problems, pain, and disability. Testing and treatment are difficult in this population because of financial and logistic factors as well as a high risk of polypharmacy and adverse drug reactions.
Bone mineral density (BMD) testing for osteoporosis is now widely recommended for postmenopausal women to determine the need for treatment, which is more available and effective than in the past. BMD testing is now covered by Medicare under the Balanced Budget Act of 1997. However, widespread BMD testing of nursing home patients would be an expensive, problematic proposition in this era of limited prospective payment for long-term care. Further, the efficacy of treatments aimed at improving bone density are not defined in the very elderly, whose bone density may be so far below the fracture threshold that only other measures aimed at reducing falls and fractures might really be helpful.4,5
To clarify the prevalence of the problem of osteoporosis in the nursing home setting, the authors conducted the present study, performing bone density scans on a series of patients in their nursing home practice.
Methods The authors evaluated a population of frail, very elderly patients from The Golden Slipper Uptown Home for the Aged, a predominantly white Jewish urban nursing home in Philadelphia, PA. All available female patients in the authors' practice at the facility were tested during a one-month period, along with several male patients judged to be frail and likely to have osteoporosis.
The BMD test available in the nursing home, through a private portable radiology company, was a Norland Dual Energy Bone Densitometry unit scanning the wrist and forearm. BMD measurements were provided for the distal radius and ulna (RU), the proximal RU, and the proximal radius alone. T scores were reported as standard deviations below the BMD of normal young subjects. Z scores for age-matched controls were also provided but were not analyzed separately.
Demographics, including age and sex, and associated conditions—including ambulation status, history of falls, concomitant diseases, and medications—were evaluated via systematic review of medical records. Additionally, all patients had basic laboratory evaluations (comprehensive metabolic panel, thyroid-stimulating hormone) to exclude major secondary causes of osteoporosis, such as hyperthyroidism, hyperparathyroidism, and other metabolic abnormalities.
The scans and reports were reviewed again by an independent radiologist, who rated each study for quality and severity of osteoporosis, classified as grades I to IV. Data were recorded and tabulated and statistics were calculated using the Microsoft Excel microcomputer spreadsheet program.
Results This section covers the demographics and concurrent conditions of the patients, the bone mineral density test results, and follow-up.
Demographics and Concurrent Conditions Twenty-two patients were enrolled in the study. The median age was 87 years (range, 80-100 years), and 19 (86%) were female.
Seventy-seven percent of the patients had dementia; 78% had atherosclerotic heart disease; 23% had hypothyroidism; 19% had tremor or Parkinson's disease; 17% had cerebrovascular disease; 5% had seizures; and 6% were judged to be taking medications that could contribute to osteoporosis (eg, thyroid medications, steroids). Most subjects (68%) had already suffered falls and fractures, and 59% were still ambulatory, indicating continued risk of falls and fractures. Few were on any previous therapy for osteoporosis except for vitamins and calcium.
Bone Mineral Density Test Results The median dual-energy x-ray absorptiometry (DEXA) T score (for the distal RU) was - 2.9, for the proximal RU -6.7, and for the proximal radius -6.49. According to current criteria, osteoporosis is diagnosed when the DEXA score is > 2.5 standard deviations below the mean for normal younger subjects. All subjects (100%), including both males and females, met this criterion for the diagnosis of osteoporosis. There was a correlation of age with decreased BMD.
In evaluating the DEXA studies for quality and severity, in order to add discriminatory value, an independent staff radiologist graded the bone densities based on an arbitrary grading scale of I to IV, defined as follows:
Osteopenia, Stage I, T score ~< 2.5 Mild osteoporosis, Stage II, T score ~ 2.5-3.5 Moderate osteoporosis, Stage III, T score ~3.5-4.5 Severe osteoporosis, Stage IV, T score >~ 4.5
The majority (77%) of the cases were judged to have severe osteoporosis, Stage IV (Figure).
Follow-up Based on these results, all patients were provided with individualized treatment. All were placed on calcium and vitamin D. Patients who, in the judgment of their physicians, were able to take alendronate appropriately and safely were started on 10 mg every morning. Other patients were prescribed estrogens or calcitonin, depending on their individual preferences and medical history. Most patients have been able to tolerate the ordered therapies, but several have had to discontinue alendronate due to gastrointestinal (GI) side effects or difficulty in administering the drug as specified by the manufacturer (ie, 1 tablet qAM, 30-60 minutes before other medications or food, with 8 oz of water, with the patient remaining upright after taking the medication). The authors are continuing to monitor medication compliance and effectiveness.
Discussion This is one of the few studies of the prevalence of osteoporosis in frail nursing home patients, who would appear most at risk from the disease and its sequelae. The authors' study indicates that all elderly female nursing home patients have significant osteoporosis, and many male patients do as well. At least one previous report supports a very high prevalence of osteoporosis in nursing home patients.6 There is little reason to think that the population studied here is not representative of elderly white female nursing home residents, but these results may not be generalizable to other groups. Other caveats regarding this study include the relatively small numbers and the use of portable wrist DEXA, which is not as widely accepted or standardized a procedure as hip and spine studies.
These results suggest that most frail elderly women in nursing homes may benefit from treatment for osteoporosis. Most if not all of the elderly patients in these facilities—at least those who are female—may be safely assumed to have significant osteoporosis or to be at high risk, even if they cannot have a BMD scan performed. Current guidelines for osteoporosis suggest performing bone mineral density studies on patients who are at risk and are being considered for treatment,7,8 but it may not always be feasible or necessary to perform such testing on nursing facility patients.9 Patients may have to be sent to a fixed radiology facility. However, even if portable tests are available, they may be expensive and less reliable. In the authors' facility, the only diagnostic modality easily available was portable DEXA scanning of the wrist, which is probably sufficiently accurate for general osteoporosis screening, although measurements at the wrist are reportedly more predictive of wrist fractures than hip or spinal fractures.10-12
However, based on the frequency of osteoporosis demonstrated in this study, the prevalence is so high that empiric treatment may be reasonable, especially given that reimbursement for testing is limited by managed care and the Prospective Payment System. The feasibility and cost-effectiveness of treatment must always be carefully considered in today's medical economic environment.
It is certainly reasonable to recommend that all elderly patients at risk for osteoporosis should at minimum be placed on multivitamin/mineral supplements plus a calcium supplement; such a regimen has indeed been reported to reduce hip fractures in elderly patients.13,14 The authors' general preference is to routinely order a common over-the-counter therapeutic multivitamin/mineral preparation to be taken once a day, plus a calcium or calcium/vitamin D supplement to be taken two to three times daily, for all at-risk patients. This supplementation would seem to be an inexpensive, prudent, and probably efficacious routine measure.
More aggressive pharmacologic therapy for osteoporosis is problematic, however. Alendronate, while proven very effective for osteoporosis,15 is expensive and is labor-intensive due to its method of administration as described above; it also produces a significant incidence of GI toxicity. Alendronate is even approved for prevention as well as treatment of osteoporosis,16 so theoretically all postmenopausal women could be candidates for this agent. However, it must be realistically acknowledged that alendronate and other medications for osteoporosis remain of unclear benefit and cost-effectiveness in the very elderly nursing home population. Further research is needed to determine whether its use is safe, reasonable, and cost-effective for widespread use in long-term care facilities, especially under a Prospective Payment System.
Estrogens are also proven to improve bone density;17 estrogen plus alendronate has additive benefit.18 Estrogens may in fact be recommended to all postmenopausal females due to multiple potential benefits (for osteoporosis, cardiovascular disease, Alzheimer's disease), but they are underutilized due to fear of side effects, particularly breast cancer. The true risks and benefits of estrogens in very elderly women have been little studied or understood. It seems advisable to use estrogens only when patients and families can understand and accept the controversial risk-benefit profile.
Raloxifene is another new agent, a selective estrogen receptor modulator, which improves bone mass in postmenopausal women and has been demonstrated to reduce vertebral fractures,19 although its efficacy in the treatment of severe osteoporosis in very elderly patients has not been studied. Similarly, calcitonin—although it has been reported to improve bone density and to reduce pain, particularly in the spine—has not been proven effective in reducing the more important hip fractures.20 Putting patients on multiple supplements and drugs for prevention, even if somewhat efficacious, poses problems of increased cost, burdensome medication administration time and effort, and the risk of polypharmacy, side effects, and interactions.
Additionally, Resnick4 and Greenspan5 have theorized that very elderly patients are so far below the fracture threshold that any treatment aimed at bone density may be futile. Therefore, emphasis needs to be placed not on pharmacologic therapy but rather on strategies to reduce falls and injuries, such as exercise, protective padding, and environmental modifications.
Conclusions The authors' study, although small, shows that osteoporosis—usually severe—is present in most if not all frail elderly female nursing home patients. This finding suggests the need for essentially universal therapy. It is not clear that testing is necessary if the prevalence of the disorder approaches 100%, and present medications for osteoporosis can be used preventively as well as therapeutically. However, further studies are needed concerning the true costs, risks, and benefits of medical treatment for osteoporosis in the frail very elderly nursing home population.
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From Albert Einstein Medical Center, Division of Geriatric Medicine, Departments of Medicine and Radiology, Philadelphia, PA. Dr. Goldberg is Geriatrics Fellowship Program Director and Medical Director, Willowcrest Center for Subacute Care, Dr. Tran is Director of Nuclear Medicine, and Dr. Restrepo was a Medical Resident at the time these studies were performed. Address for correspondence: Todd H. Goldberg, MD, CMD, FACP, Albert Einstein Medical Center, 5501 Old York Rd, Philadelphia, PA 19141.
Annals of Long-Term Care - ISSN: 1524-7929 - Volume 8 - Issue 03 - March 2000 |