Management of osteoporosis in the elderly

ABSTRACT

Background: Osteoporosis is predominantly a condition of the elderly, and the median age for hip fracture in women is approximately 83 years. Osteoporotic fracture risk is multifactorial, and often involves the balance between bone strength and propensity for falling.

Objective: To present an overview of the available evidence, located primarily by Medline searches up to April, 2009, for the different management strategies aimed at reducing the risk of falls and osteoporotic fractures in the elderly.

Results: Frailty is an independent predictor of falls, hip fractures, hospitalisation, disability and death in the elderly that is receiving increasing attention. Non-pharmacological strategies to reduce fall risk can prevent osteoporotic fractures. Exercise programmes, especially those involving high doses of exercise and incorporating balance training, have been shown to be effective. Many older people, especially the very elderly and those living in care institutions, have vitamin D inadequacy. In appropriate patients and given in sufficient doses, vitamin D and calcium supplementation is effective in reducing both falls and osteoporotic fractures, including hip fractures. Specific anti-osteoporosis drugs are underused, even in those most at risk of osteoporotic fracture. The evidence base for the efficacy of most such drugs in the elderly is incomplete, particularly with regard to nonvertebral and hip fractures. The evidence base is perhaps most complete for the relatively recently introduced drug, strontium ranelate. Non-adherence to treatment is a substantial problem, and may be exacerbated by the requirements for safe oral administration of bisphosphonates.

Conclusion: Evidence-based strategies are available for reducing osteoporotic fracture risk in the elderly, and include exercise training, vitamin D and calcium supplementation, and use of evidence-based anti-osteoporotic drugs. A positive and determined approach to optimising the use of such strategies could reduce the burden of osteoporotic fractures in this high-risk group.     

Management of chronic constipation in the elderly

Constipation is a significant healthcare problem in the elderly. However, while undoubtedly common in the elderly, data on the prevalence of constipation in general and of its subtypes vary considerably, depending on the nature of the study population and their location. Furthermore, the complexity of the pathophysiology of constipation in this age group is little appreciated. Assumptions regarding 'age-related changes in colorectal physiology' are, for the most part, not supported by scientific evidence and may serve to distract the clinician from uncovering the contributions of co-morbid diseases and the impact of iatrogenic factors. The evidence base from which one can develop recommendations on the management of constipation in the elderly is, for the most part, slim. This becomes most starkly apparent when one attempts to critically assess specific approaches to management. There is insufficient evidence to support the use of many commonly used laxatives both in the general population and in the elderly. Lifestyle interventions have value for some patients but data are lacking on the benefits of these interventions for patients with chronic constipation. Data in the elderly do not exist for most new pharmacological approaches to constipation. Pending the availability of good data, management of constipation in the elderly should be tailored to each individual's needs and expectations, regardless of age or place of residence. In certain situations, constipation may be complicated by the development of impaction; preventive strategies are important in this context. We urge enrolment of many more elderly individuals with chronic constipation in clinical trials designed to address their particular needs.     

Management of insomnia in patients with chronic pain conditions

The management of insomnia in patients experiencing chronic pain requires careful evaluation, good diagnostic skills, familiarity with cognitive-behavioural interventions and a sound knowledge of pharmacological treatments. Sleep disorders are characterised by a circular interrelationship with chronic pain such that pain leads to sleep disorders and sleep disorders increase the perception of pain. Sleep disorders in individuals with chronic pain remain under-reported, under-diagnosed and under-treated, which may lead--together with the individual's emotional, cognitive and behavioural maladaptive responses--to the frequent development of chronic sleep disorders. The moderately positive relationship between pain severity and sleep complaints, and the specificity of pain-related arousal and mediating variables such as depression, illustrate that insomnia in relation to chronic pain is multifaceted and poorly understood. This may explain the limited success of the available treatments. This article discusses the evaluation of patients with chronic pain and insomnia and the available pharmacological and nonpharmacological interventions to manage the sleep disorder. Non-pharmacological interventions should not be considered as single interventions, but in association with one another. Some non-pharmacological interventions especially the cognitive and behavioural approaches, can be easily implemented in general practice (e.g. stimulus control, sleep restriction, imagery training and progressive muscle relaxation). Hypnotics are routinely prescribed in the medically ill, regardless of their adverse effects; however, their long-term efficacy is not supported by robust evidence. Antidepressants provide an interesting alternative to hypnotics, since they can improve pain perception as well as sleep disorders in selected patients. Sedative antipsychotics can be considered for sleep disturbances in those patients exhibiting psychotic features, or for those with contraindications to benzodiazepines. Low doses of sedative antipsychotics may improve chronic insomnia in the elderly. However, no intervention is likely to be effective unless a good physician-patient relationship is developed.     

Comparison of drug adherence rates among patients with seven different medical conditions

STUDY OBJECTIVE: To compare drug adherence rates among patients with gout, hypercholesterolemia, hypertension, hypothyroidism, osteoporosis, seizure disorders, and type 2 diabetes mellitus by using a standardized approach. DESIGN: Longitudinal study. DATA SOURCE: Health care claims data from 2001-2004. PATIENTS: A total of 706,032 adults aged 18 years or older with at least one of the seven medical conditions and with incident use of drug therapy for that condition. MEASUREMENTS AND MAIN RESULTS: Drug adherence was measured as the sum of the days' supply of drug therapy over the first year observed. Covariates were age, sex, geographic residence, type of health plan, and a comorbidity score calculated by using the Hierarchical Condition Categories risk adjuster. Bivariate statistics and stratification analyses were used to assess unadjusted means and frequency distributions. Sample sizes ranged from 4984 subjects for seizure disorders to 457,395 for hypertension. During the first year of drug therapy, 72.3% of individuals with hypertension achieved adherence rates of 80% or better compared with 68.4%, 65.4%, 60.8%, 54.6%, 51.2%, or 36.8% for those with hypothyroidism, type 2 diabetes, seizure disorders, hypercholesterolemia, osteoporosis, or gout, respectively. Age younger than 60 years was associated with lower adherence across all diseases except seizure disorders. Comorbidity burden and adherence varied by disease. As comorbidity increased, adherence among subjects with osteoporosis decreased, whereas adherence among those with hypertension, hypercholesterolemia, or gout increased. Add-on drug therapies and previous experience with taking drugs for the condition increased adherence among subjects with hypertension, type 2 diabetes, hypothyroidism, or seizure disorders but not the other conditions. CONCLUSION: This uniform comparison of drug adherence revealed modest variation across six of seven diseases, with the outlier condition being gout.     

Factors associated with alcohol consumption among medical cannabis patients with chronic pain

IntroductionChronic pain is the most common reason for medical cannabis certification. Data regarding alcohol use and risky drinking among medical cannabis patients with pain is largely unknown. Therefore, we examined the prevalence and correlates of alcohol use and risky drinking in this population.MethodsParticipants completed surveys regarding demographics, pain-related variables, anxiety, cannabis use, and past six-month alcohol consumption. Alcohol use groups were defined using the AUDIT-C [i.e., non-drinkers, low-risk drinkers, and high-risk drinkers (≥ 4 for men and ≥ 3 for women)] and compared on demographic characteristics, pain measures, anxiety, and cannabis use.ResultsOverall, 42% (n = 330/780) were non-drinkers, 32% (n = 251/780) were low-risk drinkers, and 26% (n = 199/780) were high-risk drinkers. Compared to non-drinkers, low- and high-risk drinkers were significantly younger whereas a larger proportion of low-risk drinkers reported being African-American compared to non- or high-risk drinkers. High-risk drinkers reported significantly lower pain severity/interference compared to the other groups; high-risk drinkers were also less likely to be on disability compared to other groups. A multinomial logistic regression showed that patients reporting lower pain severity and less disability had greater odds of being classified a high-risk drinker.ConclusionsHigh-risk drinking appears common among medical cannabis patients. Future research should examine whether such use is concurrent or consecutive, and the relationship of such co-use patterns to consequences. Nevertheless, individuals treating patients reporting medical cannabis use for pain should consider alcohol consumption, with data needed regarding the efficacy of brief alcohol interventions among medical cannabis patients.     

Travellers with pre-existing medical conditions

Medical conditions that influence travel include those that compromise the immunity of the traveller and chronic underlying diseases or infirmities. The former includes HIV, transplantation, malignancy and its treatment, IgA deficiency, asplenia and use of immunocompromising drugs like corticosteroids. Chronic conditions include diabetes mellitus, end stage renal disease, diseases associated with compromised cardiac or pulmonary function and certain gastrointestinal diseases including cirrhosis. This review includes practical approaches to each of these conditions with attention to risk assessment and avoidance, vaccination when appropriate and not a risk to the compromised host, and arming the traveller with self-therapy and chemoprophylaxis. Since travellers with underlying conditions are often taking various medications the travel health practitioner must be alert for possible drug/drug interactions and must adjust dosages depending on the level of compromised renal or hepatic function. Finally, education of such travellers is paramount; they must understand that risk avoidance is critical and preventative modalities such as vaccination and chemoprophylaxis are never 100% efficacious.     

Medication adherence and barriers among low-income,uninsured patients with multiple chronic conditions

BackgroundPoor adherence to long-term therapies is a public health concern that affects all populations. Little is known about the context of adherence in chronic diseases for the uninsured population in the United States.ObjectiveTo evaluate medication adherence and barriers among low-income, uninsured adults recently initiating new therapy for a chronic disease.MethodsA cross-sectional study in two Community Health Centers located in Chatham County, Georgia, was performed between September and December 2015. Patients, randomly selected for inclusion in the study, were eligible if they had been prescribed medication for 2 or more chronic conditions and had recently started a new medication regimen. The Morisky-Green-Levine questionnaire was used to assess adherence. Potential barriers were analyzed using the Multidimensional Model proposed by the World Health Organization—social and economic, healthcare team and system-related, condition-related, therapy-related, and patient-related factors. Multivariate logistic regression models were used to analyze factors associated with non-adherence.ResultsA total of 150 participants were interviewed at 6 months after treatment initiation. Non-adherence was reported by 52% of the participants. Higher adjusted odds of non-adherence were observed in participants who did not receive information about their medications (adjusted odds ratio [AOR] = 2.40, 95% confidence interval [CI] = 1.01–5.74), did not regularly visit a primary health-care provider (AOR = 2.74, 95% CI = 1.09–6.88), and had changes in their treatment (AOR = 3.75, 95% CI = 1.62–8.70). Alternatively, adjusted odds of non-adherence were lower for patients who reported using pillboxes (AOR = 0.31, 95% CI = 0.10–0.95), having help from a caregiver (AOR = 0.15, 95% CI = 0.04–0.60), and integrating medication dosing into daily routines (AOR = 0.18, 95% CI = 0.06–0.59).ConclusionsMedication non-adherence was common among low-income, uninsured patients initiating therapy for chronic conditions. Several modifiable barriers highlight opportunities to address medication non-adherence through multidisciplinary interventions.     

Management of severe osteoporosis

Introduction: Severe osteoporosis represents a disease of high mortality and morbidity. Recognition of what constitutes and causes severe osteoporosis and aggressive intervention with pharmacological agents with evidence to reduce fracture risk are outlined in this review.

Areas Covered: This review is a blend of evidence obtained from literature searches from PubMed and The National Library of Medicine (USA), clinical experience and the author’s opinions. The review covers the recognition of what constitutes severe osteoporosis, and provides up-to-date references on this sub-set of high risk patients.

Expert Opinion: Severe osteoporosis can be classified by using measurements of bone densitometry, identification of prevalent fractures, and, knowledge of what additional risk factors contribute to high fracture risk. Once recognized, the potential consequences of severe osteoporosis can be mitigated by appropriate selection of pharmacological therapies and modalities to reduce the risk for falling.     

药师个体化干预在社区老年慢性病服务模式的建立与探讨

目的通过对社区老年慢性病患者开展药师个体化干预实践,探讨药师对患者合理用药的影响和干预模式的评价。方法从社区老年慢性病患者中筛选出100例进行干预,6月后评价患者在用药数量、用药依从性、日常生活能力以及再次入院率等方面的变化。结果干预后,患者用药数量和再次入院率显著下降(Z=0.91,P <0.05;χ~2=5.827,P <0.05);患者用药依从性和日常生活自理能力较干预前显著提高(Z=4.002,P <0.001;Z=6.84,P <0.001)。结论通过对温江地区社区老年慢性病患者进行药师个体化干预,患者的用药依从性和日常生活自理能力得到提高,患者的用药数量和再次入院率显著降低,本研究为建立适用于社区老年慢性病患者的标准化药师个体化干预流程提供参考。     

Management of osteoporosis in adults with cystic fibrosis

Cystic fibrosis (CF) is the most common genetic disease that causes respiratory failure within the Caucasian population. The life span of patients with CF has gradually increased from a median of 2 years of age to >30 years. Concurrent with this increased lifespan, a variety of other nutritional, endocrine and bone issues have been recognised. Decreased absorption of fat-soluble vitamins (D and K in particular) because of pancreatic insufficiency, altered sex hormone production, chronic inflammation, a lack of physical activity, glucocorticoid treatment and an intrinsic hyper-resorptive bone physiology are some of the factors that contribute to the prominence of bone disease within the CF population. In some series, three-quarters of adult patients with CF have osteopenia or osteoporosis. Lung transplantation is one viable treatment for patients with end-stage CF, which requires a lifetime of antirejection medication. Immunosuppressant therapies have a detrimental effect on bone mineral density (BMD). To combat the multifactorial nature of CF-related bone disease, advances in nutritional and vitamin supplementation, and anti-resorptive and anabolic therapies have evolved. Chronic vitamin D depletion contributes to bone disease in the CF population. The isoform of vitamin D that is the best and safest supplement, with the lowest cost, has yet to be identified. However, it is clear that many patients with CF who receive the standard of care (i.e. two daily combination vitamin A, D, E and K tablets [ADEKs]) may still be vitamin D-deficient. More aggressive supplementation needs to be individualised, with close monitoring of serum 25-hydroxyvitamin D levels. Similarly, routine calcium supplementation may be important, and evidence is accumulating that vitamin K also plays an important role in maximising and maintaining BMD. Early recognition and treatment of delayed puberty in adolescents and hypogonadism in adults with hormone replacement therapy is recommended to maintain BMD in patients with CF. Bisphosphonates, including pamidronic acid, etidronic acid and alendronic acid, reduce bone resorption by inhibiting the recruitment and function of osteoclasts. Pamidronic acid is beneficial in improving BMD in CF patients before and after transplantation. Bisphosphonate therapy and minimisation of glucocorticoid dosage have been shown to be efficacious in glucocorticoid-induced osteoporosis. Teriparatide is the first US FDA-approved anabolic growth agent for bone, and has been shown to increase BMD and decrease fracture incidence in postmenopausal women. Teriparatide may offer a new avenue for treating bone disease in CF since many patients may have poor bone formation as well as accelerated bone breakdown. Numerous clinical trials are underway to optimise treatment of CF osteoporosis.     

鲑鱼降钙素在老年糖尿病并发骨质疏松中的疗效观察

目的应用鲑鱼降钙素对患有糖尿病骨质疏松症的老年患者进行治疗,研究分析临床效果。方法抽取88例糖尿病骨质疏松症老年患者,将其分为对照组和治疗组。对照组采用钙尔奇D进行治疗;治疗组采用钙尔奇D与鲑鱼降钙素联合进行治疗。结果治疗组患者的症状改善效果明显优于对照组,相关指标在治疗前后的改善幅度明显大于对照组,差异均有统计学意义(P<0.05)。结论应用鲑鱼降钙素对患有糖尿病骨质疏松症的老年患者进行治疗的临床效果较明显。     

Continuation with apixaban treatment is associated with lower risk for hospitalization and medical costs among elderly patients

Objective: To compare the risk of hospitalization and costs associated with major bleeding (MB) or stroke/systemic embolism (SE) among elderly patients with nonvalvular atrial fibrillation (NVAF) who initiated apixaban then switched to another oral anticoagulant (OAC) vs. those who continued with apixaban treatment.

Methods: NVAF patients (≥65?years) initiating apixaban were identified from the Humana database (1 January 2013–30 September 2017) and grouped into switcher and continuer cohorts. For switchers, the earliest switch from apixaban to another OAC was defined as the index event/date. A random date during apixaban treatment was selected as the index date for continuers. Patients were followed from index date to health plan disenrollment or 31 December 2017, whichever was earlier. Multivariable regression analyses were used to examine the association of switchers vs. continuers with risk of MB-related or stroke/SE-related hospitalization and healthcare costs during follow-up.

Results: Of 7858 elderly NVAF patients included in the study, 14% (N?=?1110; mean age: 78?years) were switchers; 86% (N?=?6748; mean age: 79?years) were continuers. Apixaban switchers vs. continuers had significantly greater risk of MB-related hospitalization (hazard ratio [HR]: 2.00; 95% CI: 1.52–2.64; p?<?.001) during follow-up; risk of stroke/SE hospitalization did not differ significantly (HR: 1.36, 95% CI: 0.89–2.06, p?=?.154). MB- and stroke/SE-related medical costs were higher for switchers vs. continuers, although total all-cause healthcare costs were similar.

Conclusion: Elderly patients with NVAF in the US who continued with apixaban treatment had a lower risk of MB-related hospitalization and lower MB- and stroke/SE-related medical costs compared to patients who switched to another OAC.     

Pharmacotherapeutics knowledge of some nonemergency and emergency conditions among medical undergraduates in an Indian medical college

Objectives:To assess pharmacotherapeutics (PT) knowledge of second professional medical undergraduates.Results:MCQs related with PT of nonemergency conditions were responded correctly by 9.8–77.7% of participants. MCQs related with PT of some emergency conditions were responded correctly by 17–66.1% of participants. No statistically significant association was observed in PT knowledge with respect to mode of admission.Conclusion:Gross deficiency in the PT knowledge can potentially and adversely affect future rational prescribing skills. PT knowledge about common medical conditions should be emphasized during undergraduate training program.KEY WORDS: Knowledge, medical, pharmacotherapeutics, undergraduates     

社区多病种慢性病老年患者用药依从性调查及影响因素分析

目的:调查上海市嘉定区真新地区多病种慢性病老年患者用药依从性及影响因素.方法:采取整群抽样的方法对上海市嘉定区真新地区15个社区中60～75岁的398例患多种慢性病的老人的用药依从性进行调查.结果:398例老年患者用药依从率仅为37.19％.性别、年龄、文化程度、对疾病重视程度、对用药的重要性及对不按医嘱用药的危害性了解程度、药品类别数、用药剂型数、用药方式数和药品不良事件等因素对患者用药依从性有一定影响.结论:影响罹患慢性病老年患者用药依从性的因素较多,有必要构建相应的药学干预模式,为社区患者开展合理用药宣教、指导患者用药及为其建立药历等提高患者用药依从性,促进合理用药,改善药物治疗效果,使患者获得满意的治疗.     

高龄骨质疏松症病人骨折术后的治疗

目的：探讨高龄骨质疏松致粗隆骨折术后的继续治疗,以提高对内固定的疗效。方法：20例高龄粗隆骨折术后的病人,年龄78～96岁,平均84岁,随机分为A、B两组。A组使用密盖息、骨化三醇、活力钙治疗;B组使用骨化三醇、活力钙治疗。观察两组症状及血钙、血磷、碱性磷酸酶、尿羟脯氨酸／肌酐的变化。结果：A组治疗8wk后疼痛缓解,B组无明显改变。碱性磷酸酶在8wk后差别不明显;尿羟脯氨酸／肌酐比值,A组有所降低,B组下降不明显。结论：密盖息能提高中枢痛阈与β-内啡肽水平,起到快速缓解骨痛的作用,并有抑制骨吸收的作用。对高龄粗隆骨折术后病人利用密盖息进行综合治疗是提高手术疗效的重要方法之一。