Aged Care Insite Issue 114 | Aug-Sep 2019 | Page 37

clinical focus after we account for a number of factors, and that’s concerning. Why are antiresorptive medications underused? In the early to mid-2000s, there were some concerns about these medications. There started to be these rare side effects that were reported. The side effects occur in people who have been treated with one of the medications. It’s called bisphosphonate. When people have been taking bisphosphonates for a long time, they are at risk of having these unusual, atypical femoral fractures. That’s the big bone in your thigh. They get these unusual fractures just from very low impact type of things. Things you wouldn’t expect to normally have a fracture from. But, since that time, what we’ve found is there are newer medications that have a better side-effect profile. Also, we’ve found that having what we call ‘drug holidays’, where you basically take a break from the osteoporosis medications for a while and then restart, has helped. Another conclusion was that fracture prevention should, and can, be improved. What measures would you suggest? That’s really surprising because based on other studies internationally, we expect that rate to be something closer to 80–90 per cent. So, only finding a third, we don’t think that’s actually an indication of a truly lower rate of disease in Australia. We think that it’s just not getting the attention it deserves, because we have people in residential aged care who are so medically complex, they have so many comorbidities, and osteoporosis is just this silent disease that may not cause symptoms for someone, so they might not tend to it until they get a fracture. The good news was that the use of the vitamin D supplements is increasing a little bit, but after we adjust for a number of factors, it just stays kind of flat. Vitamin D use was, I’d say, relatively high. We’ll say in the ball park of 60 per cent of residents using them. The thing that I was concerned about was that the use of the antiresorptive medications – which are for the more severe cases of osteoporosis in residential aged care – are not being used very often, and the rates are actually declining, even I’d like to see residents being engaged in being more active, and just keeping people as active as possible. I think part of the issue is that if you look at, say, the Aged Care Funding Instrument (ACFI), the incentives for funding things like exercise and those types of interactions are really not supported, but it’s so good for so many chronic diseases. Ideally, we’d have less medication use, because we could have more physical activity, people being more active, people having better diets, and I think that would be the best case. In your study, you recognised that females, people who are underweight, and people with a lower bone mass are more likely to have fractures. So, could we better identify those at risk of falls prior to the event? Yes, and there are plenty of screening tools that can identify those who are at higher risk of falls. I think that’s something we can do very well – identify people. But I think what we see from the study is that osteoporosis is really not being identified, or it’s just not getting the attention it needs, and I think it’s competing with all these other conditions that people have. In an upcoming study that we’re working on right now, we’re looking at the complexity of all the conditions that residents have, and they are very complex, and they have a lot of other conditions, a lot of other medications they’re on, so I think they have to consider those factors. How do we increase osteoporosis diagnosis in Australia? I think it’s about awareness, and making sure that people who need to be screened, and people who need dual-energy x-ray absorptiometry (DEXA) scans to confirm how bad their osteoporosis is, that they have access to them. You can imagine, for someone who lives in a residential aged care facility, it could be more challenging to get them out of the facility and transport them to somewhere where they can get their DEXA scan. We need to make sure we’re screening and diagnosing appropriately, and that when residents are incoming they get a thorough review of all their relevant health history, and that their records are shared from their GP, or if they have any hospitalisation records, sharing information and making sure that care is integrated. I know you’ve also done some work on antipsychotics. We recently reported on a study that found antipsychotics can play a big part in falls and fractures – people on antipsychotics are up to 50 per cent more likely to fall or get a fracture. Do you think that plays a part in this? That’s definitely a factor, and especially when we consider that antipsychotics are largely being used in people with dementia. So, that’s really important because people with dementia, when they have, say, a hip What we see from the study is that osteoporosis is really not being identified. fracture, compared to people who don’t have dementia, they are much more likely to have a second hip fracture within three years, and they’re also more likely to die within 30 days of having that fracture. It’s really important that we also pay attention to folks with dementia, which is half of the residential aged care population. ■ agedcareinsite.com.au 33