Osteoporosis in Older Persons by Gustavo Duque & Douglas P. Kiel

Author:Gustavo Duque & Douglas P. Kiel
Language: eng
Format: epub
Publisher: Springer International Publishing, Cham

Implications for Prevention and Treatment

Conceptualizing osteoporotic fracture as a geriatric syndrome strongly implies a need for a multi-modal approach to prevention and treatment, since “optimal clinical care cannot be based entirely on a biological framework” [2] but must address multiple etiology and pathogenetic pathways. Clinicians are accustomed to considering multiple pathways to improve bone strength, including providing calcium and vitamin D supplements, identifying and treating secondary causes of osteoporosis, minimizing corticosteroids or antiepileptic medications, prescribing osteoporosis pharmacotherapies, and counseling about smoking, alcohol use, and physical activity.

Increasingly, clinical practice guidelines also recommend interventions to reduce fall risk [41]. Because falls are themselves multifactorial, this may be best accomplished in a dedicated fall clinic or prevention program, which are described in greater detail elsewhere in this book. Weight bearing exercise has been widely studied as a means to improve both muscle strength and bone density [42] although studies are heterogeneous and compliance rates generally low [43]. Advocacy efforts around fall prevention have led to more widespread availability of balance and exercise classes such as Tai Chi or Otago for older adults in the U.S., and such classes are generally covered by Medicare through the Silver Sneakers program [44]. As noted above, addressing other related geriatric syndromes identified during screening such as incontinence and depression may have both direct and indirect effects on bone strength and fall risk; comprehensive geriatric assessment programs may be helpful in managing these overlapping geriatric syndromes.

A multi-factorial approach is also required to prevent post-fracture complications and their resulting spiral of decline. Multi-component prevention strategies have been shown to reduce the incidence of post-fracture delirium by one third, and are likely cost effective [45]. Nutritional supplements have not been found to improve mortality or disability, but show a trend toward reduction in a composite outcome of mortality or medical complications after hip fracture and deserve additional study [46]. Extended physical therapy to improve muscle strength, improve physical function, and reduce falls has been demonstrated to be effective after an osteoporotic fracture [47, 48], but frequently is not covered by payers.

Treatment decisions are also influenced by the fact that osteoporotic fractures have the greatest impact in older adults who commonly have other geriatric syndromes, multiple medical co-morbidities, frailty, and limited life expectancy. The decision to prescribe a bone active medication may be relatively straightforward in an otherwise healthy postmenopausal woman, but becomes much more challenging in a frail older adult who already takes an average of eight medications [49] and has an average of five chronic conditions [50]. For example, a hypothetical patient with co-morbid osteoporosis, osteoarthritis, diabetes, hypertension and COPD who is treated according to clinical practice guidelines would be taking 19 doses of 12 unique medications a day, requiring five different administration times, at a cost of more than $400 per month [51]. Moreover, frail older patients may have limited life expectancy which impacts the effectiveness of osteoporosis medications; in fact for patients with incident hip, vertebral or forearm fracture, the 5-year mortality risk exceeds the 5-year fracture risk by about 40 % [52].

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