by Flora Brahmbhatt, Pharm.D., CGP

Treatment of osteoporosis is a neglected subject in long term care. When a physician walks into a facility, no nurses run up to him/her and say “DOCTOR, Mrs. Smith has osteoporosis!” We are all busy taking care of more “emergent” problems (UTI’s, behavior issues, etc.) However, are we missing out on an opportunity to better serve our patients, and our facilities?

At the most basic level Osteoporosis is relatively easy to identify. If you walk through a facility and see a patient with kyphosis, they are likely to have Osteoporosis. Also, anyone who has suffered a “fragility fracture” (a fracture due to a fall from standing height or less, or other non-traumatic incidents, such as a rib fracture from coughing, a wrist fracture from a bed-turning, etc.) likely has a diagnosis of osteoporosis. And we underdiagnose, and therefore underserve these residents with our lack of treatment; one recent study by the National Osteoporosis Association has shown that 70% of residents in LTC facilities have osteoporosis, but only 10-20% have the diagnosis in their charts. Traditionally most nursing home residents are placed on Calcium and Vitamin D. But, studies have repeatedly shown that there is a limited amount of calcium can be absorbed, and with the present culture of overused PPIs, even less calcium is absorbed. Use of glucocorticoids is also a big risk facture in the development of osteoporosis; a 6 month course of treatment with a little as 5 mg/QD of Prednisone can lead to a many-fold increase in the incidence of osteoporosis.

Other treatment includes the bisphosphonates, both oral and IV, which often are contraindicated in our elderly population. These medications may aggravate existing GI conditions or may not be used due to reduced renal function. Regardless, the appropriateness of these drugs is questionable, as they require calcium supplementation to be effective. Also, these medications do nothing to build new bone. Instead they prevent continued break-down of already compromised bone.

This class has to be administered prior to the first food or drink of the day with a full 8 ounce glass of water. The resident has to remain sitting upright for a half hour after consumption of medication. Compliance with these administration instructions may be difficult when you have 30 other residents who are receiving medications, and who must be monitored.

One medication which is less often considered is Forteo, or teriparatide. This is the only FDA-approved anabolic treatment for building new bone. Its mechanism of action is unique, in that it augments the action of osteoclasts AND osteoblasts. Therefore, bone turnover (the breakdown of “old bone,” and the building of “new bone”) is increased, and the quantity AND quality of bone is improved.

There is a range of expense for treatment of osteoporosis . However, the cost of not treating to the “system” is much higher. If we consider all costs, the cost of a resident falling, surgery, rehab, etc…as well as the impact on the facility’s rating…all exceed the cost of any medication.

In any case, the most important lesson is: find the residents with osteoporosis, and assemble a treatment plan to address it. State surveyors will be increasingly vigilant in examining the MDS 3.0 to determine the residents who have the diagnosis “captured,” but no plan or inadequate plan in place for treatment. One thing is for certain, osteoporosis won’t kill a patient like uncontrolled hypertension. But, repeated fractures and falls will destroy the resident’s spirit and quality of life.