Guidelines Recommend Interventions to Prevent Fractures in Long-Term Care

New guidelines for the prevention of fractures in older adults who live in long-term care facilities were recently published in the Canadian Medical Association Journal. The information builds on guidelines published in 2010 that focus on community-dwelling older adults.

“What is different about these guidelines is that we involved long-term care facility residents and family members in developing the recommendations,” said Alexandra Papaioannou, MD, professor of medicine, McMaster University, and a geriatrician with Hamilton Health Sciences, Hamilton, Ontario. “It is important that residents are involved in decision making around fracture management, and that these decisions consider a person’s health conditions and life expectancy.”

The new guidelines address older residents with a high risk of fracture as well as older residents with a lower risk. A prior fracture of the hip or spine; more than one previous fracture (not including fractures of the hands, feet, or ankles); or the recent use of systemic glucocorticoids and a prior fracture are each factors that place residents at high risk. In addition, residents identified as high-risk before admission to long-term care as well as residents who received osteoporosis treatment before admission are considered at high risk of fracture.

The guidelines include the following interventions to reduce fracture risk:

Calcium supplements for residents not getting the daily recommended intake. For high-risk residents, the guidelines recommend up to 500 mg of supplemental calcium per day. For residents not at high risk, the guidelines suggest 500 mg per day.

Daily vitamin D3 supplements of 800 IU to 2000 IU are recommended for all long-term care residents, regardless of risk level.

For residents at high risk, weekly alendronate or weekly or monthly risedronate is recommended. For high-risk residents with difficulty taking oral medications, zoledronic acid or denosumab are recommended. It is suggested that raloxifene and etidronate be avoided.

Hip protectors are recommended for mobile residents at high risk and are suggested for residents not at high risk.

In addition, balance, strength, and functional training exercises are suggested for residents not at high risk. For residents at high risk, such exercises are suggested only as part of a multifactorial intervention to prevent falls. In fact, individually tailored multifactorial interventions—such as assistive devices, assessment of environmental hazards, and management of urinary incontinence—are suggested for all residents to reduce the risk of falls and fractures.—Jolynn Tumolo