Adults older than age eighty-five are the fastest growing segment of our population. You may have a parent or loved one who is fortunate enough to be part of this long-lived group. Along with this population boom, senior residential living communities and facilities are growing in number by leaps and bounds. Many of these communities offer a range of options from independent living through skilled-care nursing homes. In addition, “boomerang seniors” are another growing phenomenon; that is, aging parents moving in with their adult children.
Residents in assisted living and nursing homes have the highest risk for fracture of anyone. Unfortunately, this risk is frequently not addressed even if your parent changed residence to one of these facilities specifically because of a fracture. The bone connection is often overlooked. It may be up to you to bring up the topic and work with the staff and your parent's doctor to reduce the risk of falls and fractures.
ASSISTED LIVING
Assisted living is “housing with supportive services” that fills the niche between living in your own home and living in a nursing home. These facilities can be an attractive option for people who no longer are able to live independently but do not need the medical care provided in a nursing home. The average assisted living resident walks with the assistance of a cane or walker and receives help with some of their daily activities, such as bathing and dressing.
Residents in the assisted living facilities usually require additional assistance and services over time. In all likelihood, with a lower level of physical or mental functioning, the resident would no longer meet the facilities' entry criteria. But most facilities try to keep their residents as long as possible before moving them to a higher level of support—the skilled nursing home. Plus, the staff bonds with your parent, and their goal is to have 100 percent occupancy.
One of the common reasons for discharge from the assisted living facility is a fall with injury. The most common serious injury is hip fracture. Surveys of residents in assisted living show that they do not perceive osteoporosis to be as important or urgent as other health concerns. In the context of their overall health, they see osteoporosis as neither disabling nor immediately life threatening.
From a national survey, three-quarters of women older than eighty are estimated to have osteoporosis. These high numbers refer to women living independently in the community. Since women residing in assisted living tend to be frailer, the percentage is probably even higher. No matter how you look at it, residents in assisted living are at extremely high risk of devastating, life-altering or fatal fractures.
Assisted living residents maintain their regular doctors and leave the facility to go to their doctor visits. They need to talk with their doctor about lowering their risk of falls and fractures. Vitamin D blood levels may need to be checked to ensure that supplementation is adequate to maintain a level above 30 ng/ml. This simple measure may help reduce falls and fractures and improve muscle strength.
The facility itself should have a protocol in place for fall prevention. At the present time, assisted living facilities are not federally regulated but are under state law. It is up to each facility or its parent company to set up and implement procedures to decrease falls and fractures. Find out about the fall prevention measures in place at the facility your loved one resides in or may be considering. The facility staff members want to keep everyone safe and minimize their liability as well.
NURSING HOMES: SKILLED NURSING FACILITIES
With aging, maintenance of independence is a major goal. Sometimes, due to unforeseen circumstances or multiple problems of aging, independence is not possible. Injuries from falls account for 40 percent of all nursing home admissions. Nursing homes provide the medical care and support needed for those with physical and mental limitations.
Osteoporosis is common. Osteoporosis is estimated to be present in approximately 90 percent of women and 50 percent of men living in nursing homes. Fractures are all too common. In a study of nearly 1,500 Caucasian women living in nursing homes in Maryland, about one in nine residents had a fracture each year. They happen more often among those who are able to walk or move from bed to chair and are not common among bed-bound residents. If one is up and moving, the risk of falls with injury is high. Hip fractures are the most common fracture.
About one-fifth of all hip fractures in the US occur in women residing in nursing homes. Low bone mass predicts osteoporotic fracture. However, among frail nursing home residents, association of low bone mass to fracture risk is less clear. Nursing home residents have many additional risk factors for fracture in addition to low bone density, such as unsteady walking, poor memory and confusion, and the use of multiple medicines, all of which lead to an increased risk of falls.
Osteoporosis is often ignored. Nursing home residents may have other competing illnesses and more “immediate” problems. Adding to an already long list of medicines, osteoporosis medicines, which require special dosing instructions, can prove cumbersome. Even adding calcium and vitamin D is challenging. History of falls and fractures is not correlated with who is diagnosed and treated in nursing homes.
Nursing home residents are provided with medical care in the facility. Doctors and often their staff, a nurse practitioner or physician assistant, may oversee the residents' care. In addition to complex and competing problems, doctors cite short stays at facilities, medicine costs, and reimbursement issues as barriers to treating high-risk patients, even those who have already fractured.
Another common reason for not treating osteoporosis in the nursing home is the perception that “it is no use,” due to the limited amount of time a frail, older person may have to live. However, high-risk patients do benefit from treatment. In addition, the osteoporosis medicines decrease fracture risk quickly, with significant reductions within the first year of therapy.
It is never too late to treat osteoporosis in order to decrease fracture risk and improve quality of life. However, few nursing home residents are currently receiving treatment for osteoporosis despite elevated fracture risk or even a recent fracture. Many patients slip between the cracks after sustaining a major fracture. The continuity of their care is often lost amid transfers from hospital care to rehabilitation to a new permanent residence. Even though a fracture may have started the cascade of events, an “osteoporosis” diagnosis does not end up on their list of problems. Therefore, it is not appropriately addressed and treated.
OSTEOPOROSIS TREATMENT
Treatment in this high-risk group encompasses the same general measures and medicines as in younger adults with an emphasis on fall prevention.
Fall Prevention
Strategies to prevent falls are a critical part of osteoporosis management. All nursing homes should have programs in place for fall and fracture prevention. Research shows that the simple strategy of identifying those at high risk for falls may decrease the number of falls per person by nearly half. An evaluation of thigh muscle (quadriceps) strength, which is an independent risk factor for falls and fracture, is essential. These muscles are key for standing up, sitting, making transfers from bed to chair, and walking. Therapy to strengthen quadriceps muscle and training to safely transfer and walk are helpful.
Evidence from randomized clinical trials shows that up to half of falls in older people can be prevented. The trials used either a single intervention strategy (such as exercise) or programs that focus on reducing risk factors. Based on the consistency of results, the most effective interventions for the prevention of falls and fractures include the use of strength and balance training, followed by reducing the number and dosage of medicines, and adding supplementation of vitamin D and calcium.
Hip Protectors
In theory, wearing an external hip protector that absorbs the energy of a fall or diverts it away from the bone makes sense as a way to prevent a broken hip during falls. It is as if you have an air bag on your hip to cushion the blow. Unfortunately, hip protectors have not been effective in practice. Residents find they are difficult to put on and are bulky under their clothes, so they do not wear them.
Results from the latest well-designed clinical trial in nursing home residents showed that the specific protector it tested failed to prevent hip fractures. The study subjects did wear the hip protector; they just did not work. More research is needed in this area before recommending the use of hip protectors.
Calcium and Vitamin D
Previously, the moderate protective effect of vitamin D on fracture risk was attributed primarily to changes in bone mineral density. However, vitamin D may directly improve muscle strength and reduce fracture risk through fall prevention.
There is some dispute as to whether the effects are the result of vitamin D alone or only vitamin D in combination with calcium. Usually, one of the nine or more medicines on the resident's daily list is a calcium tablet combined with vitamin D. This adequately supplies daily calcium. Additional vitamin D is usually in the daily multivitamin. However, those two sources together are usually not enough to support a vitamin D blood level over 30 ng/ml.
In this population, adequate vitamin D supplementation decreases falls and fractures and improves muscle strength. Vitamin D is important. Make sure that your parent's vitamin D level is checked and that appropriate amounts of supplement are given to maintain levels above 30 ng/ml.
Medicines
Ideally, the medicines for osteoporosis treatment should be tested for safety and effectiveness in this older population of individuals who reside in long-term care facilities. However, clinical trials with high-risk patients are challenging in this setting. Reclast is the only osteoporosis medication for which a large fracture trial has been done with individuals who sustained a hip fracture. These individuals usually received rehabilitation services in a nursing home after hospital discharge. Fosamax was evaluated for bone density changes and safety among female residents of long-term care facilities.
Beyond Reclast, Fosamax, calcium, and vitamin D, no other studies have been designed to look at older individuals in this living situation. Little data is available from similar age groups who are healthier and living in the community setting. Actonel was evaluated in a large fracture trial of high-risk older individuals. Other large pivotal fracture trials recruited “healthy” women who met entry criteria up to age cutoffs of eighty, eighty-five, and more recently ninety years old.
Several medicines may be easier to use in these settings. Administration by shots under the skin or infusions by vein may have appeal for residents on multiple oral medicines, or those with digestive diseases or concern about intolerability or absorption. These methods guarantee delivery to the bone.
The extended release formulation of Actonel, called Atelvia, which is given after breakfast once weekly, avoids the fasting requirements of Fosamax, Actonel, and Boniva. However, Atelvia still requires remaining upright for thirty minutes after taking the medicine.
The once-a-year dosing of Reclast has a distinct advantage over other medicines. The intravenous administration bypasses any concerns about digestive side effects from pills or cumbersome dosing. Use of Reclast ensures that individuals are actually getting the medicine. The most common limitation on use of Reclast in this high-risk group is reduced kidney function.
The advantage of Prolia, a shot given once every six months, is that it can be used in those with reduced kidney function. Because of its unique mechanism of action, Prolia is a potent alternative to other antiresorptives. Forteo is also an effective option, since it causes bone formation and improvement of the microstructure of bone. Sometimes the staff of a long-term care facility will be a little reticent to use this medicine because it is a daily injection. However, the prefilled syringe is easy to use and lasts twenty-eight days.
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The Bare Bones
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