Screening Strategies for Treatment of Osteoporosis in Long‐Term Care Residents

Abstract

To the Editor: We appreciate the efforts of Greenspan et al.1 to examine screening and treatment strategies for osteoporosis of long-term care residents. The study results indicate that treatment eligibility for osteoporosis in long-term care residents vary widely depending on screening criteria. It is important to recognize that current standard sensitivity of the screening tools was not developed using this unique patient population. The study also excluded individuals receiving bisphosphonates, without reporting specific statistics on that subset. It is also not clear how many treatment-eligible individuals had received prior bisphosphonate therapy and for how long. One of the most important lessons to learn from this research is that, for optimum benefit, screening should take place at a much earlier stage, before individuals end up in long-term care facilities. The authors' suggestion to consider treatment for those with a clinical hip or spine fracture because most osteoporosis therapies have demonstrated fracture reduction in approximately 1 year raises questions. Osteoporosis is currently underdiagnosed and undertreated, but the relationship between degree of osteoporosis and its consequence—greater risk of fracture—is not straightforward.2 It varies considerably with advancing age. Thus, a similar extent of bone loss has a higher risk of fractures in older individuals than in younger ones. A published report3 indicates that the rate of bone mineral density decline at the hip after the age of 65 is significantly higher for white women than for nonwhite women. The comparative consequences need further investigation. Pooled data from two long-term extension trials4, 5 raise the question of whether continued bisphosphonate therapy imparts additional fracture-prevention benefit, relative to cessation of therapy after 5 years. Some epidemiological data6, 7 suggest that treatment with a bisphosphonate for more than 5 years is associated with greater risk of “atypical” subtrochanteric fractures and osteonecrosis of the jaw during prolonged bisphosphonate therapy. Modeling predicts that one atypical fracture occurs for every 100 femoral neck or intertrochanteric fractures prevented by the use of bisphosphonates. The individual efficacy of bisphosphonates in preventing future hip and vertebral fractures appears to be variable. Persistent effects of alendronate and zoledronic acid may be seen for several years; however, but there is greater bone loss after discontinuation of risedronate therapy. Randomized trials of other bisphosphonates, including ibandronate8 and etidronate,9 have shown that these drugs have efficacy in reducing the risk of new vertebral fractures, but the data do not show efficacy for treatment of hip fractures. Recent research data10 indicate that osteoporosis would develop in fewer than 10% of older women at rescreening intervals of approximately 1 year in those with advanced osteopenia. Therefore, treating elderly adults in long-term care facilities for suspected osteoporosis is challenging, especially when a majority of them have functional decline, dysphasia, poor oral health, and a limited prognosis. Conflict of Interest: None. Author Contributions: Both authors contributed equally. Sponsor's Role: None.