Treating the Very Old for Low Bone Density Highly Beneficial


NEW ORLEANS — Very elderly Americans are rarely assessed and treated for low bone density and osteoporosis despite significant potential benefits, experts said at the annual meeting of the International Society for Clinical Densitometry.

“It's the oldest old, those over age 85,” whose numbers are increasing most dramatically. “In fact, people over 100—the centenarians—are the fastest growing group of Americans,” said Neil Binkley, M.D., of the University of Wisconsin, Madison.

Bone loss happens faster in the very elderly than it does in the less elderly, resulting in higher prevalence rates of osteoporosis, hip fractures, and other serious fractures, said Michael McClung, M.D., of the Oregon Osteoporosis Center, Portland.

Yet despite these risks, the rates of bone density screening go down as age increases, Dr. Binkley said.

“We aren't doing a very good job of paying attention to elderly patients,” Dr. McClung agreed.

One possible explanation is that physicians may be overwhelmed by the problem and incorrectly assume that everyone over a certain age has osteoporosis when in fact about half of the patients over age 85 have osteoporosis.

As a result, physicians miss the opportunity to obtain the significant benefits they could reap from targeted interventions, Dr. McClung said.

The very elderly tend to fall into two groups: the ambulatory and reasonably healthy and nursing home residents, who tend to be in poor health and not ambulatory.

Virtually all nursing home residents have osteoporosis or low bone density and a very high risk of fractures. Yet these patients rarely receive even calcium and vitamin D supplementation.

The cost of withholding such basic interventions is huge. For the current population of approximately 1,600,000 nursing home residents, the cost of hip fractures is about $700 million per year, assuming an annual hip fracture rate of 2.3% and a cost of $18,500 per hip fracture.

In deciding how to care for these patients, it's helpful to divide them into three groups, Dr. Binkley said.

Some patients come to nursing homes for terminal care and these patients probably won't benefit from osteoporosis treatment. A number of patients come to nursing homes for rehabilitation following a hip fracture and these people should be treated for low bone density and osteoporosis, Dr. Binkley said.

The third group poses the real treatment challenge: long-term care patients who are in nursing homes because of cognitive decline or the need for help with daily living tasks. There are no data on the effectiveness of treatments for this type of patient.

“The easy answer might be that we ensure that they have adequate calcium intake and give them vitamin D,” Dr. Binkley proposed.

Vitamin D supplementation, in particular, “is an incredibly cost-effective way to intervene,” Dr. McClung agreed. Vitamin D deficiency is very common in the elderly, even in those who still have good mobility.

“The older we get, the more dependent we are on higher levels of vitamin D to maintain calcium homeostasis,” Dr. McClung said.

Vitamin D deficiency not only has skeletal consequences, but is also associated with muscle weakness, an increased risk of falls and, as a result, an increased risk of fractures.

A number of studies have demonstrated a reduced fracture risk in elderly patients who use vitamin D supplementation. In particular, results of these studies have suggested that 400 IU of vitamin D per day may not be adequate for many older individuals.

Dr. McClung added that in his own clinic, individuals over the age of 70 are given a 50,000-U dose of vitamin D taken once a month.

Although a number of drugs have been shown to reduce fracture risk in osteoporotic patients, most of the trials have not involved patients over the age of 80. Several studies have shown that bisphosphonates are effective in reducing the risk of hip fracture in patients between 70 and 80 years old, but only a few have shown effectiveness in patients older than age 80.

Yet “there is no evidence that age is a factor in limiting any of the treatment effects of the drugs that we currently use,” Dr. McClung said.

Given the lack of supportive data, deciding whether or not to use bisphosphonates in nursing home residents, however, is tricky.

“My approach, in the absence of data, is to utilize cognition,” Dr. Binkley said. He asks his patients if this type of treatment is feasible in their living situation, and he inquires about their desire to take the drug and how their family feels about the approach. If the responses are favorable, he prescribes a bisphosphonate.


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