According to the 2008 National Osteoporosis Foundation recommendations, treatment of osteoporosis should be considered for:
- (1) patients with a history of hip or vertebral fracture,
- (2) patients with a T-score of -2.5 or lower at the femoral neck or spine,
- (3) patients who have a T-score of between -1.0 and -2.5 at the femoral neck or spine and a 10-year hip fracture risk of ≥3% or a 10-year risk of a major osteoporosis-related fracture of ≥20% as assessed with the FRAX tool (Kanis et al., 2010).
It is important to ensure the sufficient calcium intake through a balanced diet. It appears that an intake of more than 1,000 mg/day is sufficient for bone health (Moyer et al., 2013). However, the average daily dietary calcium intake in adults age 50 and older is 600 to 700 mg/day. Increasing dietary calcium is the first-line approach, but calcium supplements should be used when an adequate dietary intake cannot be achieved. There is no evidence that calcium intake in excess of these amounts confers additional bone strength. Intakes in excess of 1,200 to 1,500 mg/day may increase the risk of developing kidney stones, cardiovascular disease, and stroke. However, a review of the literature indicates this is a controversial issue (Reid et al., 2015).
Vitamin D plays an essential role in the maintenance of bone strength because it is necessary for intestinal absorption of calcium. Vitamin D is synthesized in skin during sun exposure as well as ingested as part of a balanced diet. Older individuals synthesize less vitamin D in skin (they also tend to expose their skin less than younger adults) and they frequently have nutritionally deficient diets. Thus, many older people may suffer from low vitamin D (Reid, 2017). A recommendation of daily vitamin D supplementation at a dose of 800 IU/day (20 μg/day) in older adults (>70 years) has been adopted by International Osteoporosis Foundation and the Institute of Medicine (Rizzoli et al., 2013).
The most commonly prescribed medications used to treat osteoporosis are oral bisphosphonates. Bisphosphonates reduce osteoclast-mediated bone resorption by suppressing osteoclast activity. Adequate calcium and vitamin D supplements are necessary for optimal effect of bisphosphonate. Maximal reduction in bone resorption typically occurs within 3 months of initiating oral bisphosphonate therapy and remains approximately constant thereafter with bisphosphonate continuance. Suppression of resorption occurs even more rapidly after intravenous bisphosphonate therapy (Fazil et al., 2015). However, studies have reported that the majority of postmenopausal women discontinue bisphosphonate therapy within 1 year of initiation, indicating that adherence to long-term bisphosphonate treatment is often inadequate (Imaz et al., 2010). Patients should be advised to maintain an upright posture for 30 to 60 minutes after ingesting medication with a full glass of water. Nonspecific gastrointestinal symptoms, such as nausea, dyspepsia, and gastritis, are common reasons for oral bisphosphonate discontinuation. Severe musculoskeletal pain has been reported as well as ocular inflammation, esophageal cancer, osteonecrosis of the jaw, and subtrochanteric fractures of the femur (Kennel & Drake, 2009). Bisphosphonates include: Alendronate (Fosamax); Risedronate (Actonel); Etidronate (Didronel); and Ibandronate (Boniva) among others.
Selective estrogen receptor modulators exhibit estrogen receptor agonist or antagonist activity based on the target tissue. Raloxifene (Evista) acts like an estrogen agonist at bone, preserving the integrity and strength without stimulating the breast or endometrial tissue. Raloxifene has been shown to reduce the risk of vertebral fractures by about 30% in patients with a prior vertebral fracture and by about 55% in patients without a prior vertebral fracture over 3 years (Ettinger et al., 1999). Raloxifene is also indicated for the reduction in risk of invasive breast cancer in postmenopausal women with osteoporosis. Adverse effects include increased risk of venous thromboembolism and hot flashes (Hadji, 2012).
Teriparatide is a parathyroid hormone analog that stimulates osteoblastic activity in bone. Parathyroid hormone can cause bone resorption or bone synthesis depending on how it is used. Intermittent parathyroid hormone stimulation of bone, rather than prolonged receptor stimulation, enhances bone formation (Frolik et al., 2003). When used properly, teriparatide increases hip and spine BMD and reduces the risk of vertebral and nonvertebral fractures in postmenopausal osteoporotic women.
Combination therapy with antiresorptive medications and teriparatide simultaneously promotes bone synthesis. Studies have shown that the combination of teriparatide and denosumab increases bone density and estimated strength more than monotherapy and more than any currently available regimen. Teriparatide provides maximal benefit when its use is followed by or combined with an antiresorptive medication (Tsai et al., 2017). However, when individuals established on potent bisphosphonates are switched to teriparatide, hip BMD declines below baseline for at least the first 12 months after the switch to teriparatide. This transient hip BMD loss is more prominent when the antiresorptive agent is denosumab. Hip BMD remains below baseline for almost a full 24 months (Cosman et al., 2017).
Calcitonin is a bone resorption inhibitor derived from salmon and FDA-approved for the treatment of osteoporosis in women who are at least 5 years postmenopausal when alternative treatments are not suitable. Miacalcin nasal spray has not been shown to increase BMD in early postmenopausal women. However, calcitonin is known for its ability to relieve back pain due to vertebral compression fracture (Blau & Hoehns, 2003).
Antibody-Mediated Antiresorptive Therapy: Denosumab
Denosumab is a human monoclonal antibody that is genetically engineered to bind to cytokines that act as osteoclastic cell stimulants. The drug ultimately blocks osteoclastic activity and inhibits reabsorption of bone. Current data show that with up to 8 years of continued use, there is continued improvement in bone density with reduced fracture risk (Zaheer et al., 2015). To optimize treatment, denosumab should be used in combination with vitamin D and calcium. It has the potential to cause hypocalcemia and increased parathyroid hormone if used alone. Potential adverse effects include hypocalcemia, immunosuppression, osteonecrosis of the jaw, and possible increased fracture risk following discontinuation of the medication (Zanchetta et al., 2018). Based on current data, denosumab should not be stopped without continuing an alternative treatment in order to prevent rapid BMD loss.
How Long Should Osteoporosis Medications Be Used?
All nonbisphosphonate medications produce temporary effects that wane upon discontinuation. If these treatments are stopped, benefits rapidly disappear. In contrast, it may be possible to discontinue bisphosphonates and retain residual benefits against fracture at least for several years (Cosman et al., 2014). Evidence of efficacy beyond 5 years is limited, whereas rare safety concerns such as osteonecrosis of the jaw and atypical femur fractures become more common beyond 5 years.
Home Healthcare for Patients With Osteoporosis and/or Fragility Fracture
Home healthcare clinicians are in a key position to assess patients with a fracture history, initiate a care plan, inform physicians of patient risk status, coordinate multidisciplinary care, and provide patient and family education (Outman et al., 2012). Rehabilitation at home after a fragility fracture is preferred by the majority of older adults. However, approximately, 20% of persons who suffer hip fracture require long-term care (Salkeld et al., 2000). Comprehensive home healthcare after a fragility fracture includes fall prevention, family and patient education, pharmacologic management, physical therapy, and occupational therapy as well as pain management and thromboprophylaxis.
Postfracture Physical Rehabilitation
The goal of physical rehabilitation after a fragility fracture is to restore patients to their preinjury status, although 50% of older adults who sustain a hip fracture never regain prefall level of function and 40% never recover their prefracture walking ability (Haentjens et al., 2010). Many investigators question whether the current physical rehabilitation programs are sufficiently rigorous and prescribed for enough length of time. In general, a therapeutic exercise program needs to address flexibility, muscle strength, weight-bearing, core stability, cardiovascular fitness, and gait steadiness. Exercises that enhance the patient's proprioception and balance contribute to postural stability.
Typically, home healthcare rehabilitation is provided 1 to 3 times per week for 3 to 6 weeks and one-half hour to 1 hour at a time. However, regular exercise for several days a week for 6 months to a year improves mobility, increases walking speed, and improves quadriceps strength (Turunen et al., 2017).
A home safety assessment, alcohol cessation, evaluation of vision, review of medications (specifically psychoactive medications), and orthostatic blood pressure assessment are important in mitigating patient falls. Studies of community dwellers have shown significant reduction of falls and fractures following exercise intervention, with the benefit increasing with escalating intensity of the exercise (Li et al., 2016). Foot problems and inappropriate footwear in older adults are associated with impaired balance and performance. Recommendations for use of appropriate shoes are indicated. Environmental hazards are any objects (throw rugs, furniture) or circumstances in the home environment that increase an individual's risk of falling, such as poor lighting, clutter, and lack of handrails in bathrooms.
Pain management in older adults can be complicated after a fragility fracture. According to Aubrun and Marmion (2007), given the likely comorbidities and increased sensitivities to opioids, the usage of multiple approaches to treating pain should be utilized. Acetaminophen, ibuprofen, and naproxen are commonly used for mild to moderate back pain due to compression fracture. Back bracing and back strengthening exercises are also recommended. For severe pain, opioids are used. Clinicians should use the World Health Organization (2007) pain ladder when treating pain in vertebral compression fracture. Opioids may induce sedation, cognitive impairment, delirium, and falls in older adults due to increased cerebral sensitivity to them. There is no difference in cognitive effects for fentanyl, morphine, or hydromorphone. If pain does not subside, studies show that calcitonin added to the regimen assists in pain relief (Blau & Hoehns, 2003). Kyphoplasty is also effective in relieving vertebral compression fracture pain.
Pharmacologic prophylaxis for venous thromboembolism should be undertaken postoperatively for all patients with a hip fracture. Presently there is no consensus on the best agent to use. Studies have shown that fondaparinux or low-molecular weight heparin for 28 to 35 days after surgery are effective (Fisher et al., 2013). Warfarin is an alternative reasonable choice for therapy and is often used in patients who were taking warfarin prior to fracture. Direct thrombin inhibitors (dabigatran) and factor Xa inhibitors (rivaroxaban) are newer oral anticoagulants. However, there is no strong evidence with regard to their use in patients with fragility fractures around the hip. They do not require laboratory monitoring and can be administered in a fixed dose, but their disadvantage is that they do not have an antagonist to reverse their pharmacologic effect (Ktistakis et al., 2017). Pneumatic compression devices or foot impulse technology and thromboembolic stockings are recommended as mechanical means of thromboprophylaxis.
Home healthcare providers care for an aging patient population with diverse conditions and multiple medications that can increase their risk of osteoporosis. BMD in addition to an evaluation of clinical risk factors are necessary to diagnose osteoporosis; DEXA and FRAX are the tools available. Undertreatment of osteoporosis is common among community dwelling older adults. Lack of patient adherence and insufficient physician prescription of medications are common. There are a wide array of osteoporosis medications and patients need education about their use. With the growing number of older adults in the population, increasing numbers will be vulnerable to osteoporosis and fragility fracture. Home healthcare providers need to be proactive to assess the aging population and assist in their treatment of this common disorder. Home healthcare clinicians are key members of the interdisciplinary care team in the recovery of patients with fragility fracture.
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Antoniadou E., Kouzelis A., Diamantakis G., Bavelou A., Panagiotopoulos E. (2017). Characteristics and diagnostic workup of the patient at risk to sustain fragility fracture. Injury
. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/28855082
Aubrun F., Marmion F. (2007). The elderly patient and postoperative pain treatment. Best Practice and Research. Clinical Anaesthesiology
, 21(1), 109–127.
Blau L. A., Hoehns J. D. (2003). Analgesic efficacy of calcitonin for vertebral fracture pain. Annals of Pharmacotherapy
, 37(4), 564–570.
Brauer C. A., Coca-Perraillon M., Cutler D. M., Rosen A. B. (2009). Incidence and mortality of hip fractures in the United States. Journal of the American Medical Association
, 302(14), 1573–1579.
Burge R., Dawson-Hughes B., Solomon D. H., Wong J. B., King A., Tosteson A. (2007). Incidence and economic burden of osteoporosis-related fractures in the United States, 2005-2025. Journal of Bone and Mineral Research
, 22(3), 465–475.
Chesnut C. H. 3rd, Silverman S., Andriano K., Genant H., Gimona A., Harris S., ..., Baylink D. (2000). A randomized trial of nasal spray salmon calcitonin in postmenopausal women with established osteoporosis: The prevent recurrence of osteoporotic fractures study. PROOF Study Group. American Journal of Medicine
, 109(4), 267–276.
Cosman F., de Beur S. J., LeBoff M. S., Lewiecki E. M., Tanner B., Randall S., ...National Osteoporosis Foundation. (2014). Clinician's Guide to Prevention and Treatment of Osteoporosis. Osteoporosis International
, 25(10), 2359–2381.
Cosman F., Nieves J. W., Dempster D. W. (2017). Treatment sequence matters: Anabolic and antiresorptive therapy for osteoporosis. Journal of Bone and Mineral Research
, 32(2), 198–202.
Ettinger B., Black D. M., Mitlak B. H., Knickerbocker R. K., Nickelsen T., Genant H. K, ..., Cummings S. R. (1999). Reduction of vertebral fracture risk in postmenopausal women with osteoporosis treated with raloxifene: Results from a 3-year randomized clinical trial. Multiple Outcomes of Raloxifene Evaluation (MORE) Investigators. Journal of the American Medical Association
, 282(7), 637–645.
Fazil M., Baboota S., Sahni J. K., Ameeduzzafar, Ali J. (2015). Bisphosphonates: Therapeutics potential and recent advances in drug delivery. Drug Delivery
, 22(1), 1–9.
Fisher W. D., Agnelli G., George D. J., Kakkar A. K., Lassen M. R., Mismetti P., ..., Turpie A. G. (2013). Extended venous thromboembolism prophylaxis in patients undergoing hip fracture surgery—The SAVE-HIP3 study. Bone & Joint Journal, 95-B
Frolik C. A., Black E. C., Cain R. L., Satterwhite J. H., Brown-Augsburger P. L., Sato M., Hock J. M. (2003). Anabolic and catabolic bone effects of human parathyroid hormone (1–34) are predicted by duration of hormone exposure. Bone
, 33(3), 372–379.
Hadji P. (2012). The evolution of selective estrogen receptor modulators in osteoporosis therapy. Climacteric
, 15(6), 513–523.
Haentjens P., Magaziner J., Colón-Emeric C. S., Vanderschueren D., Milisen K., Velkeniers B., Boonen S. (2010). Meta-analysis: Excess mortality after hip fracture among older women and men. Annals of Internal Medicine
, 152(6), 380–390.
Hamann C., Kirschner S., Günther K. P., Hofbauer L. C. (2012). Bone, sweet bone--osteoporotic fractures in diabetes mellitus. Nature Reviews. Endocrinology
, 8(5), 297–305.
Hong A. R., Kim J. H., Lee K. H., Kim T. Y., Im S. A., Kim T. Y., ..., Shin C. S. (2017). Long-term effect of aromatase inhibitors on bone microarchitecture and macroarchitecture in non-osteoporotic postmenopausal women with breast cancer. Osteoporosis International
, 28(4), 1413–1422.
Imaz I., Zegarra P., González-Enríquez J., Rubio B., Alcazar R., Amate J. M. (2010). Poor bisphosphonate adherence for treatment of osteoporosis increases fracture risk: Systematic review and meta-analysis. Osteoporosis International
, 21(11), 1943–1951.
Kanis J. A., McCloskey E. V., Johansson H., Oden A., Melton L. J. 3rd, Khaltaev N. (2008). A reference standard for the description of osteoporosis. Bone
, 42(3), 467–475.
Kanis J. A., McCloskey E. V., Johansson H., Oden A., Ström O., Borgström F. (2010). Development and use of FRAX in osteoporosis. Osteoporosis International
, 21(Suppl. 2), S407–S413.
Kennel K. A., Drake M. T. (2009). Adverse effects of bisphosphonates: Implications for osteoporosis management. Mayo Clinic Proceedings
, 84(7), 632–637.
Ktistakis I., Giannoudis V., Giannoudis P. V. (2017). Anticoagulation therapy and proximal femoral fracture treatment: An update. European Federation of National Associations of Orthopaedics and Traumatology (EFFORT) Open Reviews
, 1(8), 310–315.
Li F., Harmer P., Fitzgerald K. (2016). Implementing an evidence-based fall prevention intervention in community senior centers. American Journal of Public Health
, 106(11), 2026–2031.
Maes M. L., Fixen D. R., Linnebur S. A. (2017). Adverse effects of proton-pump inhibitor use in older adults: A review of the evidence. Therapeutic Advances in Drug Safety
, 8(9), 273–297.
Miller P. D. (2014). Chronic kidney disease and osteoporosis: Evaluation and management. BoneKEy Reports
, 3, 542.
Miller P. D. (2016). Underdiagnosis and undertreatment of osteoporosis: The battle to be won. Journal of Clinical Endocrinology and Metabolism
, 101(3), 852–859.
Moyer V. A., LeFevre M. L., Siu A. L. (2013). Vitamin D and calcium supplementation to prevent fractures in adults. Annals of Internal Medicine
, 159(12), 856–857.
O'Connor K. M. (2016). Evaluation and treatment of osteoporosis. Medical Clinics of North America
, 100(4), 807–826.
Outman R. C., Curtis J. R., Locher J. L., Allison J. J., Saag K. G., Kilgore M. L. (2012). Improving osteoporosis care in high-risk home health patients through a high-intensity intervention. Contemporary Clinical Trials
, 33(1), 206–212.
Rachner T. D., Khosla S., Hofbauer L. C. (2011). Osteoporosis: Now and the future. Lancet
, 377 (9773). 1276–1287.
Reid I. R. (2017). Vitamin D effect on bone mineral density and fractures. Endocrinology & Metabolism Clinics of North America
, 46(4), 935–945.
Reid I. R., Bristow S. M., Bolland M. J. (2015). Calcium supplements: Benefits and risks. Journal of Internal Medicine
, 278(4), 354–368.
Rizzoli R., Boonen S., Brandi M. L., Bruyère O., Cooper C., Kanis J. A., ..., Reginster J. Y. (2013). Vitamin D supplementation in elderly or postmenopausal women: A 2013 update of the 2008 recommendations from the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO). Current Medical Research and Opinion
, 29(4), 305–313.
Salkeld G., Cameron I. D., Cumming R. G., Easter S., Seymour J., Kurrle S. E, Quine S. (2000). Quality of life related to fear of falling and hip fracture in older women: A time trade off study. British Medical Journal
, 320 (7231). 341–346.
Tsai J. N., Burnett-Bowie S. M., Lee H., Leder B. Z. (2017). Relationship between bone turnover and density with teriparatide, denosumab or both in women in the DATA study. Bone
, 95, 20–25.
Turunen K., Salpakoski A., Edgren J., Törmäkangas T., Arkela M., Kallinen M., ..., Sipilä S. (2017). Physical activity after a hip fracture: Effect of a multicomponent home-based rehabilitation program—A secondary analysis of a randomized controlled trial. Archives of Physical Medicine and Rehabilitation
, 98(5), 981–988.
World Health Organization. (2007). Assessment of Osteoporosis at the Primary Health Care Level. Summary Report of a WHO Scientific Group
. Geneva: Author.
Wright N. C., Saag K. G., Dawson-Hughes B., Khosla S., Siris E. S. (2017). The impact of the new National Bone Health Alliance (NBHA) diagnostic criteria on the prevalence of osteoporosis in the United States: Supplementary presentation. Osteoporosis International
, 28(11), 3283–3284. doi:10.1007/s00198-017-4207-9
Zaheer S., LeBoff M., Lewiecki E. M. (2015). Denosumab for the treatment of osteoporosis. Expert Opinions in Drug and Metabolic Toxicology
, 11(3), 461–470.
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Zanchetta M. B., Boailchuk J., Massari F., Silveira F., Bogado C., Zanchetta J. R. (2018). Significant bone loss after stopping long-term denosumab treatment: A post FREEDOM study. Osteoporosis International
, 29(1), 41–47. doi:10.1007/s00198-017-4242-6