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. ■
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