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Preventing Fractures in Nursing Home Residents

Preventing Fractures in Nursing Home Residents. Cathleen Colon-Emeric, MD, MHSC and Kenneth Lyles, MD: Duke University. Osteoporosis in Maryland SNFs. Zimmerman SI, Osteoporos Int 1999. Epidemiology of Fractures in SNF. 1.5 falls/bed/year 4-10% result in a fracture

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Preventing Fractures in Nursing Home Residents

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  1. Preventing Fractures in Nursing Home Residents Cathleen Colon-Emeric, MD, MHSC and Kenneth Lyles, MD: Duke University

  2. Osteoporosis in Maryland SNFs Zimmerman SI, Osteoporos Int 1999

  3. 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

  4. Fracture rates, Wisconsin SNFs Kane et al. 1995

  5. From Cummings SR, Nevitt MC, Browner WS et al. NEJM 1995;332:767-73.

  6. 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

  7. DEXA scans • Gives T score = standard deviations above/below mean for healthy young adults • T score < -2.5 indicates osteoporosis • T score < -1.0 indicates osteopenia

  8. 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

  9. Risk of subsequent fractures in patients with low-trauma fractures • After vertebral fracture: 2 x increase1 • After hip fracture: 2.5 x increase, >10%/year2 • BMD declines nearly 5% in year after hip fracture3 1Klotzbuecher, 2000 2Colón-Emeric, 2003 3Fox, 2000

  10. Osteoporosis Treatment Options

  11. Calcium and Vitamin D • Given to all residents regardless of BMD, decreases risk of all non-vertebral fractures by 25%1 • 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

  12. 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

  13. 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

  14. 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

  15. 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

  16. 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

  17. 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

  18. Fracture Prevention Summary

  19. KPH Hip Protector

  20. 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

  21. 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

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