1. Schoen, Delores C.

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Vik, S. A., Jantzi, M., Poss, J., Hirdes, J., Hanley D. A., Hogan, D. B., et al. (2007). Factors associated with pharmacologic treatment of osteoporosis in an older home care population. The Journals of Gerontology, 62A(8), 872-878.


Individuals who experience osteoporotic fractures are at increased risk for further fractures. In the year following a hip fracture, the risk of institutionalization and mortality is significantly increased among older adults. In Canada, the current clinical practice guidelines for the diagnosis and treatment of osteoporosis highlight the importance of considering several risk factors, most notably, the presence of a past fragility fracture. However, it is believed that a large portion of those high-risk patients ($30%) are not receiving any of the recommended drug therapies.


Reasons for the lack of appropriate pharmacotherapy remain unclear. Lower treatment rates have been observed among men and patients attended by a general practitioner, but the findings regarding other potential correlates have been inconsistent. Previous investigations have been restricted by small sample sizes or use of administrative databases where data are usually limited to items submitted for billing purposes. The BMD measurement has become widely used in the diagnosis of osteoporosis. However, the authors believe that the increased reliance on BMD as a diagnostic tool may lead to a failure to treat persons at high risk and even lead to unnecessary treatment if diagnosis is based solely on the BMD.


A number of studies have shown low rates of osteoporosis treatment, but few, if any, have assessed a comprehensive range of functional and clinical correlates of treatment coverage. The objective of this study was to examine those sociodemographic, clinical, and functional characteristics that are associated with pharmacotherapy for osteoporosis among community-based seniors.


The sample included 48,689 home care clients 65 years or older from all 42 Community Care Access Centres (CCACs) across the province of Ontario, Canada. (CCACs are local agencies established to coordinate public access to government-funded home and community services and long-term care facilities.) Data for the study were taken from client health and functional records that are available from the comprehensive intake assessment, called the Resident Assessment Instrument for Home Care (RAI-HC), completed by trained home care managers between February and July of 2004. The RAI-HC tool provides a standardized assessment of clients' sociodemographic, physical, and cognitive status; psychologic and health conditions; formal and informal service use; and use of prescription and over-the-counter drugs. The reliability and validity of the tool have been previously established.


The RAI-HC included diagnostic items for assessing the presence of hip fracture, other fractures, and osteoporosis. Medication information included all prescribed and over-the-counter therapeutic products used by the client. Treatment coverage was examined for calcium and vitamin D and/or any of the antiosteoporotic prescription therapies approved for use in 2004. Patients taking one of the prescription therapies used primarily for osteoporosis, but without a recorded diagnosis of osteoporosis or prevalent fracture (n 5 2,138), were also included in the analyses. Sociodemographic, health, and functional variables assessed as potential correlates of treatment included age, sex, marital status, education, living arrangements, communication problems, confinement to wheelchair or bed, recent falls, comorbidity, prognosis of less than 6 months to live, and number of instances of nonadherence with prescribed medications.


Descriptive statistics were calculated and prevalence estimates of pharmacotherapy for osteoporosis among clients with a diagnosis of osteoporosis and/or fracture were reported. The associations between selected correlates and osteoporosis treatment were examined among two subgroups of clients: (i) those with a recorded diagnosis of osteoporosis (or without a diagnosis but receiving a bisphosphonate, raloxifene, or calcitonin) and no fractures and (ii) those with a prevalent fracture (with or without a recorded diagnosis of osteoporosis). Bivariate associations were examined using unadjusted odds ratios, 95% confidence intervals, and Fisher's exact test. Variables significant at p < .05 were considered as candidates for inclusion in multivariable analyses.


A total of 15,718 (32%) of home care clients had a recorded diagnosis of osteoporosis and/or a prevalent fracture. An estimated 20.5% had a diagnosis of osteoporosis but no fractures, 11.8% had a prevalent fracture, and 5.1% had a prevalent hip fracture. The mean age of all clients was 82.4 years (82.5 and 81.3 year for women and men, respectively). The majority of clients were women, widowed, and living in private homes. At least some level of cognitive and functional (activities of daily living) impairment was reported for 30% and 20% of the sample, respectively. Eleven percent had clinically significant depression. Almost two thirds had three or more comorbid conditions and some indication of health instability. Approximately 30% had experienced a fall in the past 90 days, more than 50% were using nine or more medications.


Many older adults with presumed osteoporosis in this study were not receiving drug therapy for that condition. Approximately 50% of the clients with a diagnosis of osteoporosis were receiving pharmacotherapy compared with 27% of those with a prevalent fracture. For both subgroups, treatment coverage was significantly lower among clients with at least three chronic conditions, health instability, fewer than nine medications, functional impairment, depressive symptoms, and among those clients who were widowed. Among clients with a diagnosis of osteoporosis, treatment was positively associated with cognitive impairment and negatively associated with confinement to a wheelchair or a bed. Men with a prevalent fracture were significantly less likely to receive treatment particularly in the absence of an osteoporosis diagnosis.


Limitations to the study are as follows: (i) the authors were unable to differentiate between fragility and traumatic fractures; (ii) BMD results were not available to the researchers; and (iii) there was a lack of data on weight-bearing activities of the clients.


Because the focus was on pharmacotherapy, and there were limited data on other therapies, additional efforts are needed to explore the prevalence and consequences of nonpharmacologic options for seniors at high risk for fragility fractures. Healthcare practitioners often face difficult treatment decisions among older populations with failing health and may not initiate osteoporosis therapy to minimize polypharmacy. However, this is no excuse when effective osteoporosis therapies are available and should be offered to persons at high risk for fractures.