Abstract
This prospective study assessed the effectiveness of screening older long-term care residents (LTCRs) for fracture risk and osteoporosis in Taiwan. Fracture risk screening was done using the Fracture Risk Assessment Tool (FRAX), and those with high or moderate risk were offered osteoporosis workup and treatment at the hospital. Among 785 LTCRs screened, 338 men (mean age 75.6) and 447 women (mean age 81.2) were included. Only 5.2% of women and no men were using anti-osteoporosis medication. Based on the Bone Health and Osteoporosis Foundation (BHOF) recommendations, 69.2% of men and 92.6% of women were classified as high fracture risk. In 110 participants willing to receive bone mineral density examination, osteoporosis was diagnosed in 86.2% of women and half of men. FRAX could effectively differentiate fracture risk in 648 LTCRs who completed 2-year follow-ups; no fracture occurred in the low-risk group. The study emphasizes the importance of fracture risk screening to enhance osteoporosis diagnosis and treatment among LTCRs.
Key words: Fracture risk, long-term care resident, long-term care institution, osteoporosis, bone mineral density
Introduction
Osteoporosis is a serious problem worldwide, especially in developed countries with aging populations. The global burden of osteoporosis-related issues have doubled in the past two decades, with a continuous increase in recent years (1). Additionally, osteoporosis and related osteoporotic fractures increase morbidity, mortality, and economic burden, decreasing health-related quality of life (2). Also, a greater use of long-term care services is expected because of the decreasing number of family caregivers and the increasing number of women entering the workforce.
Residents of long-term care institutions (LTCIs) are generally old, and age is inversely related to lower bone mass (3). The prevalence of osteoporosis in long-term care residents (LTCRs) is as high as 70% in men and 92% in women (4). A recent study revealed that hip fracture rates could be 10-fold in the LTCRs than in the general population (5). Hip fractures could cause infection and pressure ulcers, functional decline, diminished quality of life, high risk of hospitalization, substantial physical and financial burden to patients and society, and an extremely high mortality rate of 50% within one year (5, 6, 7). However, the “diagnosis rate” of osteoporosis in this population remained low (8, 9), just as the treatment rates (9, 10). Information on the condition's prevalence and diagnosis rate is limited, and the need for treatment for osteoporosis among LTCRs has not been adequately evaluated. Moreover, it is not known whether osteoporosis screening in the LTCIs leads to a better prognosis.
We aimed to investigate the proportion of LTCRs at risk of fractures and affected by osteoporosis through screening, as well as tracking the short-term incidence of falls, fractures, and mortality in this population.
Material and Methods
Study Design
This study was a prospective cohort study to evaluate the prevalence of osteoporosis and treatment and the effectiveness of the Fracture Risk Assessment Tool (FRAX) in predicting fracture risk among LTCRs. The Research Ethics Committee of the National Taiwan University Hospital has approved the study protocol (NTUH-REC-201812152RINB).
Study Participants
We performed convenience sampling among LTCRs from 20 LTCIs in Yunlin County. Residents aged ≥50 years and living in the LTCIs, including nursing homes and assisted living facilities, were invited to join our study. Those at the terminal stage of life or who were comatose were excluded. Following administrative meetings with LTCIs, letters or messages about the study program and invitations to participate were sent out to family members. Recruitment was done in cooperation with the directors, nurses, and social workers at each LTCI. After obtaining informed consent from the residents and their families, face-to-face interviews and screening for fracture risk and osteoporosis were conducted.
Procedure and Treatment
We collected the baseline characteristics information, including age, sex, body mass index (BMI), activities of daily living (Barthel index), frailty (11), alcohol and smoking status, comorbidities, previous fracture history, parental history of fracture, age at menopause, and fall history by interviewing LTCRs and their caregivers, or from checking residents' medical records. Residents who needed assistance, such as walkers or crutches, to walk were categorized as having an unsteady gait. Further, if their Transfer, Mobility, and Stairs scores in the Barthel index were all 0, we categorized them as bedridden. In the LTCIs in Taiwan, medications, health supplements, and food for LTCRs are typically distributed by the LTCI personnel. We collected and recorded the daily calcium, vitamin D, milk, and protein intake to assess their nutrition status. Further, we surveyed their medical records to check whether osteoporosis had been diagnosed and whether they were currently on anti-osteoporosis medication.
After obtaining the information above, we screened the fracture risk of the study participants using the FRAX (12). FRAX uses eleven clinical risk factors, such as age, sex, and fracture history, to predict a 10-year probability of major osteoporotic fractures (including clinical spine, hip, distal forearm, and proximal humerus fractures) and hip fractures, and can be used with or without bone mineral density (BMD) examination. It has been used to screen fracture risk and subsequently suggests BMD examination and osteoporosis treatment in a large community randomized controlled trial (13) and to successfully reduce hip fractures. Greenspan et al. (14) also used FRAX as a screening tool for LTCRs considering its ease of use and ability to be employed without BMD. This is an excellent benefit for LTCRs who find it challenging to access BMD testing by dual-energy x-ray absorptiometry (DXA). After fracture risk without BMD was calculated, we categorized LTCRs as high, moderate, and low fracture risk based on the guidelines of the Bone Health and Osteoporosis Foundation (BHOF) (15). The LTCRs with major osteoporotic fracture (MOF) risk ≥20% or hip fracture (HF) risk ≥3% were classified as high fracture risk; those with 10% ≤ MOF risk < 20% or 1.5% ≤ HF risk < 3% as moderate risk, and those with MOF risk <10% or HF risk <1.5% as low risk.
We then invited those with high and moderate fracture risk to our hospital to complete the osteoporosis workup and continue further treatment whenever necessary. The evaluation typically takes 1–2 hours, including BMD examination, X-rays of the pelvis anterior-posterior view and thoracolumbar spine anterior-posterior/lateral views, and blood tests. The blood tests include complete blood count, calcium, phosphate, albumin, creatinine, and parathyroid hormone level to investigate secondary causes of osteoporosis. Vertebral fractures were identified by Genant's semi-quantitative method (16). BMD of the hip (total hip, femoral neck) and PA spine (L1–L4) were measured by Hologic Discovery Wi Bone Densitometer (Hologic Inc, Bedford, MA). The precision error of DXA scanning conducted on the participants was 1.2% for the total hip, 1.9% for the femoral neck, and 1.5% for the PA spine (17).
Treatment was recommended for those who fulfilled BHOF guidelines (15), including those with hip or vertebral fractures, BMD T-score ≤−2.5, and persistent high FRAX fracture risk after adjustment of BMD with T-score to between −1.0 and −2.5. However, our National Health Insurance (NHI) covers only those who have fulfilled the reimbursement criteria to initiate anti-osteoporosis medications (AOMs) (18) due to a global budget policy. Therefore, we either prescribed vitamin D and calcium for those who did not fulfill our NHI criteria or suggested that they pay out of pocket.
Outcome Ascertainment
During the treatment period, we monitored the adherence to medication, side effects of the treatment, and the incidence of falls, fractures, and mortality using X-rays, medical records, or phone calls. We also presented the initial findings of BMD changes in non-bedridden and bedridden residents following one year of treatment.
Statistical Analyses
The demographic and clinical characteristics of the study population are illustrated in Table 1. We estimated the FRAX risk status of our study population, and FRAX scores were categorized according to BHOF recommendations. Patients evaluated as FRAX moderate or high risk were transferred to the hospital for BMD examination. This study summarized continuous variables as the mean and standard deviation for those with normal distribution. Analysis of Variance (ANOVA) was employed to compare the means between different groups. For continuous variables with non-normal distribution, Kruskal-Wallis Test was utilized to assess the differences in medians across various groups. Categorical variables were presented as counts and percentages. The Chi-square test or Fisher exact test was applied to evaluate the differences in the distribution of these categorical variables among different groups. All statistical analyses were conducted using SAS software, Version 9.4 (SAS Institute, Cary, NC, USA), with an a-significance level of 0.05.
Table 1.
Baseline characteristics of the enrolled study participants
| Male (n=338) | Female (n=447) | Total (n=785) | |
|---|---|---|---|
| Age (mean, SD), years | 75.6±10.4 | 81.2±9.4 | 78.8±10.2 |
| Body weight (mean, SD), kg | 57.6±10.8 | 50.8± 10.1 | 53.7±10.9 |
| BMI (mean, SD), kg/m2 | 21.9±3.7 | 22.5±4.3 | 22.2±4.0 |
| Barthel index (mean, SD) | 30.7±31.8 | 27.1±31.9 | 28.6±31.9 |
| -Bed ridden* (n, %) | 113 (39.9) | 173 (47.4) | 286 (44.1) |
| Frail (n, %) | 172 (55.1) | 251 (61.4) | 423 (58.7) |
| Current smoker (n, %) | 11 (3.3) | 3 (0.7) | 14 (1.8) |
| Alcohol consumption 3 or more units /day (n, %) | 1 (0.3) | 0 (0.0) | 1 (0.1) |
| No. of selected comorbidities ≥3 (n, %) | 76 (22.5) | 110 (24.6) | 186 (23.7) |
| Hypertension (n, %) | 168 (49.7) | 232 (51.9) | 400 (51.0) |
| Diabetes mellitus (n, %) | 82 (24.3) | 132 (29.5) | 214 (27.3) |
| Cardiovascular disease* (n, %) | 125 (37.1) | 137 (30.9) | 262 (33.6) |
| Dementia* (n, %) | 83 (24.6) | 146 (32.7) | 229 (29.2) |
| Parkinsonism (n, %) | 53 (15.7) | 53 (11.9) | 106 (13.5) |
| Previous fracture history (n, %) | 36 (10.7) | 116 (26.0) | 152 (19.4) |
| Unsteady gait (n, %) | 253 (80.1) | 340 (84.2) | 593 (82.4) |
| Fall in the past year (n, %) | 56 (17.4) | 81 (18.8) | 137 (18.2) |
| -Fall & fracture in the past year (n, %) | 16 (4.8) | 25 (5.6) | 41 (5.3) |
| Milk intake ≥ 1 glass /day (n, %) | 147 (44.5) | 222 (49.7) | 369 (47.5) |
| Protein intake ≥60g (n, %) | 266 (81.1) | 354 (80.1) | 620 (80.5) |
| Ca supplement intake (n, %) | 15 (4.5) | 33 (7.5) | 48 (6.2) |
| Vit D supplement intake (n, %) | 3 (0.9) | 15 (3.4) | 18 (2.3) |
| Diagnosed osteoporosis (n, %) | 7 (2.1) | 39 (8.8) | 46 (5.9) |
| Current AOM use (n, %) | 0 (0.0) | 23 (5.2) | 23 (2.9) |
| FRAX-Major (mean, SD) | 8.8±4.7 | 19.0±7.0 | 14.6±7.9 |
| FRAX-Hip (mean, SD) | 5.3±4.4 | 10.7±5.5 | 8.4±5.7 |
| FRAX (n, %Y)^ | |||
| High risk | 234 (69.2) | 414 (92.6) | 648 (82.6) |
| Moderate risk | 58 (17.2) | 16 (3.6) | 74 (9.4) |
| Low risk | 46 (13.6) | 17 (3.8) | 63 (8.0) |
*Bedridden: the score of Transfer, Mobility, and Stairs in the Barthel index were all 0; #Cardiovascular disease: including coronary heart disease and cerebrovascular disease; &Dementia: including Alzheimer's disease and vascular dementia; ^According to Bone Health and Osteoporosis Foundation (BHOF) recommendations: High risk: Major osteoporotic fracture risk ≥20% or Hip fracture risk ≥3%; Moderate risk: 20%≥Major osteoporotic fracture risk ≥10% or 3% ≥Hip fracture risk ≥1.5%; Low risk: 10%≥Major osteoporotic fracture risk or 1.5% ≥Hip fracture risk; Ca: calcium, Vit D: vitamin D, AOM: anti-osteoporosis medication, FRAX: Fracture Risk Assessment Tool
Results
Seven hundred eighty-five LTCRs consented to screening from October 2018 to November 2019 in Yunlin County, Taiwan (Table 1). There were 338 men and 447 women with mean ages of 75.6 and 81.2 years, respectively. The mean BMI was 21.9 kg/m2 for men and 22.5 kg/m2 for women. Most participants were severely dependent on their everyday physical activity, with a mean Barthel index of 28. There were 44.1% categorized as bedridden, and 58% of the participants were classified as frail by the Study of Osteoporotic Fracture (SOF) criteria. A few participants consumed alcohol (0.1%) or currently smoked (1.8%). Many had multiple comorbidities, and 23.7% had greater than or equal to three comorbidities. The five most common comorbidities were hypertension (51.0%), cardiovascular disease (33.6%), dementia (29.2%), diabetes mellitus (27.3%), and Parkinsonism (13.5%). Most (82.4%) participants had an unsteady gait requiring some walking assistance. Previous fractures were more common in women (26.0%) than men (10.7%). Some (18.2%) had experienced a fall the last year, following which a few (5.3%) had fractures. Around half of them (47.5%) drank greater or equal to one glass of milk daily, and most of them (80.5%) took sufficient protein every day. However, only 6.2% and 2.3% of LTCRs regularly took calcium and vitamin D supplements. The diagnosed rate of osteoporosis was as low as 8.8% in women and 2.1% in men, and current AOM use was even uncommon — 5.2% in women and 0.0% in men.
The distribution of the FRAX score for both men and women are presented in Table 1. The mean MOF and HF risk was 8.8% and 5.3% in men, lower than the corresponding risks (19.0% and 10.7%) for women. Based on BHOF recommendations, 69.2% of men and 92.6% of women were classified as high fracture risk. Some men were classified as moderate (17.2%) or low fracture risk (13.6%). In contrast, only a few women were classified as moderate (3.6%) or low fracture risk (3.8%).
After screening with FRAX, those with moderate and high fracture risk and not taking active osteoporosis treatment were invited to the hospital for further examination. One hundred and ten LTCRs were willing and suitable for transfer and completed the osteoporosis workup, including a BMD examination, plain radiography, and blood tests. These LTCRs were slightly older and had more comorbidities. They also had a higher prevalence of fall history, fracture risk, and calcium and vitamin D usage than the whole study participants. Plain radiography revealed that 83.6% had osteoporotic fractures, mainly vertebral (76.4%). Women had more hip fractures than men (35.2% vs. 15.4%). Half the men and 86.2% of the women were diagnosed with osteoporosis with a BMD T-score at any site ≤−2.5. After our process of screening and BMD examination, the overall diagnosed rate of osteoporosis increased from 5.9% (46/785) to 17.6% (138/785). Osteoporosis treatment was recommended for 98 LTCRs. Most (98%) also fulfilled our National Health Insurance reimbursement criteria, and 93 LTCRs were willing to receive treatment. For practical reasons, a subcutaneous injection of Denosumab 60 mg every six months was prescribed for those who agreed to receive treatment. This would help this fragile population avoid prolonged waiting times and stagger side effects. After our suggestion for anti-osteoporosis medication, the osteoporosis treatment rate increased from 2.9% (23/785) to 14.8% (116/785). Also, the percentage of individuals receiving calcium rose from 6.2% (48/785) to 20.1% (158/785), and vitamin D supplementation increased from 2.3% (18/785) to 16.3% (128/785) at the very least.
In this two-year follow-up study involving 648 LTCRs (82.5% follow-up rate), the overall fall incidence was 17.7 per 1000 PYs (Table 2). Female LTCRs had a higher fall incidence (22.8 per 1000 PYs) than males (10.9 per 1000 PYs). Fall incidence was highest in LTCRs aged between 70 and 85 (23.4 per 1000 PYs). Bedridden LTCRs has lower fall incidence (1.8 per 1000 PYs) than non-bedridden LTCRs (27.0 per 1000 PYs). Those with high FRAX risk had the highest fall incidence (21.0 per 1000 PYs).
Table 2.
Incidence of falls, fractures, and mortality, per 1000 Person-Years
| Fall | p-value | All Fractures | Hip | Vertebra | Others | p-value | Mortality | p-value | |
|---|---|---|---|---|---|---|---|---|---|
| Overall (N=648) | 17.7 | 13.1 | 6.5 | 1.9 | 4.7 | 172.7 | |||
| Gender | 0.116 | 0.100 | 0.004 | ||||||
| - Female | 22.8 | 18.1 | 9.9 | 1.6 | 6.6 | 141.5 | |||
| - Male | 10.9 | 6.6 | 2.2 | 2.2 | 2.2 | 214.8 | |||
| Age, years | 0.263 | 0.156 | ≤ 0.001 | ||||||
| - < 70 | 10.1 | 0.0 | 0.0 | 0.0 | 0.0 | 115.3 | |||
| - 70 - < 85 | 23.4 | 18.2 | 7.3 | 3.6 | 7.3 | 148.8 | |||
| - >= 85 | 12.5 | 12.7 | 9.5 | 0.0 | 3.2 | 250.6 | |||
| Bedridden | 0.110 | 0.007 | 0.001 | ||||||
| - Yes | 1.8 | 2.2 | 0.0 | 0.0 | 2.2 | 234.8 | |||
| - No | 27.0 | 21.1 | 11.4 | 3.2 | 6.5 | 128.2 | |||
| FRAX^ | 0.646 | 0.542 | 0.035 | ||||||
| - Low | 14.3 | 0.0 | 0.0 | 0.0 | 0.0 | 128.9 | |||
| - Medium | 11.9 | 8.8 | 8.8 | 0.0 | 0.0 | 87.0 | |||
| - High | 21.0 | 14.7 | 6.8 | 2.3 | 5.6 | 187.0 | |||
FRAX: Fracture Risk Assessment Tool; ^According to Bone Health and Osteoporosis Foundation (BHOF) recommendations: High risk: Major osteoporotic fracture risk ≥20% or Hip fracture risk ≥3%; Moderate risk: 20%>Major osteoporotic fracture risk ≥10% or 3% >Hip fracture risk ≥1.5%; Low risk: 10%>Major osteoporotic fracture risk or 1.5% >Hip fracture risk
The overall incidence of fractures was 13.1 per 1000 PYs, with hip fractures accounting for 6.56 per 1000 PYs. Females had a higher fracture incidence (18.1 per 1000 PYs) than males (6.6 per 1000 PYs). No fracture occurred in LTCRs under 70; the highest fracture incidence was observed in LTCRs aged between 70 and 85 years. The fracture incidence is significantly lower in bedridden LTCRs at 2.2 per 1000 PYs compared to 21.1 per 1000 PYs in non-bedridden LTCRs. Despite lacking statistical significance, a discernible dose-dependent association emerged between fracture incidence and FRAX fracture risk. LTCRs with high FRAX fracture risk had the highest fracture incidence (14.7 per 1000 PYs). LTCRs with low FRAX fracture risk had no instances of fracture during the follow-up period.
The overall mortality rate was 172.7 per 1000 PYs, with males, older age, and bedridden being identified as significant risk factors for mortality. LTCRs categorized as high fracture risk by FRAX exhibited significantly higher mortality rates.
We conducted a comparative analysis of fall incidence, fractures, and mortality between two groups: individuals who underwent evaluation and treatment and those who did not. We carefully matched these two groups based on gender, age, and FRAX scores (supplementary table 1). After matching, we observed that while there were no significant differences in falls and fractures, the non-treated group exhibited significantly higher mortality rates, with a hazard ratio of 3.498 (95% CI, 1.578–7.758) (supplementary table 2).
Additionally, we conducted a one-year follow-up on BMD after treatment. In the group of residents who were not bedridden, we noted increased BMD in the lumbar spine, femoral neck, and total hip regions (supplementary table 3). By contrast, in the bedridden group, we mainly observed increased BMD in the lumbar spine but not as much in the femoral neck or total hip.
Discussion
Discussion of the results
This study highlights the concerning issue of underdiagnosis and inadequate management of osteoporosis in LTCRs. Despite a high prevalence of osteoporosis in this population, irrespective of gender, the rates of diagnosis, treatment, and nutrition supplementation remain alarmingly low. In addition, LTCRs experience high rates of falls, fractures, and mortality. The fracture risk is particularly elevated in a high-risk group identified through FRAX stratification, whereas no fractures were observed in the FRAX low-risk group. Utilizing FRAX as a screening tool for fracture risk assessment and comprehensive osteoporosis workup can increase awareness and improve osteoporosis diagnosis and treatment rates in LTCRs.
The calcium supplementation rate remained low among general LTCRs at 5% (9), showing concordance between our study and the literature. This phenomenon is similar but more severe when considering AOM use in LTCRs. AOM use remained low in the general LTCR population (9) and among those diagnosed with osteoporosis (8) and osteoporotic fractures (10). There is a massive gap between the prevalence and treatment rates of osteoporosis among LTCRs. Several reasons could be responsible for this unmet need, including lack of evidence on the approaches that can effectively prevent fractures among LTCRs, the likelihood of LTCRs not surviving long enough to obtain the benefits of AOM therapies, increased polypharmacy, concern over side effects of treatment, lack of staff time to administer medications (19). Before adopting Denosumab and injectable bisphosphonate, oral bisphosphonate posed a challenge for bedridden patients. Moreover, older residents with multiple comorbidities in LTCIs were less likely to participate in clinical trials. Only two randomized controlled trials (19, 20) had been conducted among LTCRs, which revealed BMD improvement after bisphosphonates treatment. Two population-based studies (21, 22) also showed some anti-fracture effectiveness after AOM treatment.
Although life expectancy is a concern, the mean life expectancy is 3 to 5 years in assisted living facilities (14) and 2.8 years (23) in nursing homes, which is sufficient for some potent drugs to deliver their effect (24) and potentially prevent the decline in quality of life (6). These findings highlight the pressing necessity for implementing more proactive screening strategies to improve the diagnosis rate of osteoporosis. Moreover, the current body of research underscores the need for further investigation into this matter within the studied population.
Whether FRAX is suitable for screening in LTCRs is debatable. Although FRAX is commonly used and externally validated worldwide, it has not been validated in LTCRs. Further, its prediction for a 10-year fracture probability is not pragmatic for LTCRs, who generally have a shorter life expectancy. Our results revealed that 92.6% of women and 69.2% of men were categorized as high fracture risk by FRAX, consistent with the data reported in a previous study (25). Although statistical significance was not achieved, a discernible dose-dependent relationship between fracture incidence and FRAX fracture risk became evident. This indicates that FRAX might still be appropriately applied in this population. Future validation and modification are warranted for imminent fracture risk predictions by including other factors related to this population, such as dementia and mobility, or by developing a new one. On the other hand, high FRAX fracture risk is significantly associated with increased mortality. Considering that bedridden LTCRs have low fracture risk and an increase in mortality, AOM treatment may not be warranted for bedridden LTCRs with a limited life expectancy, even if they present a high FRAX fracture risk. An effective fall prevention strategy is more suitable for them, as the effect of AOM treatment takes at least one year to manifest (24).
In our study, although the high rates of participants were classified as moderate or high risk using FRAX (722/785, 92%), the number of participants willing to visit the hospital for further evaluation and treatment was relatively low (110/722, 15.2%). There are several factors contributing to the low rate of evaluation and treatment. Firstly, there is a lack of awareness about the disease. Despite providing FRAX evaluations and informing individuals about their fracture risk, there is still a low willingness of the long-term care residents and families to undergo evaluation and treatment. Additionally, transportation poses a significant challenge. Some long-term care facilities in Taiwan are situated in rural areas that are distant from hospitals, and the frailty of older residents makes it difficult for them to visit hospitals for examinations or treatment. This requires special personnel and vehicles equipped for wheelchairs, which not only increases the logistical obstacles but also diminishes the willingness of individuals to follow up on their healthcare needs.
The treatment strategy for LTCRs with high risk in FRAX but unwilling to visit the hospital for further evaluation is a multifaceted challenge, encompassing factors such as disease awareness, risk perception, transportation logistics, treatment adherence, cost-effectiveness, and tangible therapeutic benefits. It's crucial that well-designed studies in the future address these complex issues to provide valuable insights.
Considering the low rate of evaluation and treatment, we conducted a more in-depth analysis by comparing age-, sex-, and FRAX-matched groups—one receiving treatment and the other not. The non-treatment group had a significantly higher hazard ratio for mortality, reaching 3.498. We believe that this might be attributed to participation bias. Many individuals unwilling to undergo further examination and treatment after the FRAX assessment were bedridden, potentially explaining the higher mortality rates.
In the preliminary analysis regarding changes in BMD after one year of Denosumab treatment, we observed an increase in BMD in both the spine and hip for non-bedridden individuals and exclusively in the spine for bedridden individuals. Although these changes did not reach statistical significance, we noted a lack of hip BMD increase in the bedridden group. The distinction may be attributed to promoting bone construction through mechanical stress. The lumbar spine bears the body's weight when sitting up, while the hip does not bear body weight in bedridden individuals. These findings suggest a hypothesis that mobility and mechanical stress significantly influence BMD changes. Further study is warranted, potentially leading to tailored treatment approaches for individuals with varying levels of mobility.
Strengths
This is the first prospective study to conduct active fracture risk screening and link it to short-term outcomes in LTCRs. There is very limited, if any, literature that reports the fracture risk of men in LTCIs. Further, no fracture risk data among LTCRs in Asia are available in the literature, despite the continent being home to the fastest-aging population in the world.
Limitations
First, this study may have potential biases considering it is not a randomized controlled trial. For example, those willing to transport themselves for further examination might be healthier, less frail, and relatively physically robust. Nonetheless, a previous study (25) revealed that LTCRs with dependence on activity of daily living or transfer likely do not have the occasion to fall and are at a much lower risk for hip fractures. Those examined and treated are the only targets for urgent fracture prevention. Second, we do not have a control group that has not been screened and has gone without treatment following their BMD assessment. However, persistent decrements of BMD are expected (7) and possibly increase the fracture risk. Third, because of the budget, sample size, and study design, we did not have the proper sample to perform subgroup analysis to determine those who could benefit most from the screening strategy. Finally, external validation of our results is needed for better generalizability.
Conclusions
Osteoporosis is highly prevalent among both men and women LTCRs. As such, they are expected to have a high risk of fractures. AOM treatment rate, calcium, and vitamin D supplementation rates remained low among the general LTCR population due to low osteoporosis diagnosis rates. Screening for fracture risk among LTCRs helps increase osteoporosis diagnosis and treatment rates. Our study demonstrates that FRAX is associated with high fracture incidence, high fall occurrence, and elevated mortality. Therefore, further research is warranted when utilizing FRAX-based fracture risk assessment for selecting appropriate osteoporosis treatment in patients. More comprehensive information on screening and treatment effectiveness and costs is needed to identify the most appropriate candidates for AOM treatment and assess the cost-effectiveness of interventions.
Key Points
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•
High FRAX fracture risk is associated with high fracture incidence, high fall occurrence, and elevated mortality.
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There was no fracture in long-term care residents with low FRAX scores during the 2-year follow-up.
Why Does this Paper Matter?
Fracture risk and osteoporosis screening could be effective among long-term care residents.
Authors' Contributions:
Study design: SHF, CYW, FYH, and CY Li; Conducting the experiments: SHF, CYW; Data analysis: CYW, HKY; Contributed to new methods or models: RSY, FYH, and CY Li; Manuscript writing and review: SHF, CY Lai, CYW, and CYLi.
Other Contributors:
We sincerely thank Hsin-Yi Tsai, Syun-Ping Fu, Wen-Yen Hsu, Horng-Ai Elderly Long-term Care Center, Yunlin Elder Welfare Protection Association, Yunlin County Private Stone Turtle Nursing Center for the Elderly, Santa Elderly Long-term Care Center, JINGDE NURSING HOME, Wei Chun Long-Term Care Center, Department of Pharmacy, Department of Laboratory Medicine, and Department of Medical Imaging in National Taiwan University Hospital Yun-Lin Branch for the assistance of this project.
Funding/Support:
This study was supported by the Research Assistantships funded by the Ministry of Science and Technology, Taiwan (grant number MOST 108-2314-B-002-100-MY3, to SHF); National Taiwan University Hospital Yun-Lin Branch ([grant number NTUHYL 111.X009 & NTUHYL 111.F008, to SHF)]; National Health Research Institutes ([grant number CG-111-GP-0S, to CYW).
Data Access, Responsibility, and Analysis:
CY Li and SHF had full access to all data obtained in this study and took full responsibility for the integrity of the data and the accuracy of the data analysis.
Role of Funder(s)/Sponsor(s):
The funders/Sponsors had no role in study design, data collection, analysis, publication decision, or manuscript preparation.
Conflicts of Interest disclosures:
The authors of this study declare no conflicts of interest.
Impact statement:
In this prospective cohort study, long-term care residents exhibit a high prevalence of undiagnosed or untreated osteoporosis. FRAX scores correlate with fracture incidence, effectively predicting the risk of fractures in long-term care residents.
Electronic Supplementary Material
Supplementary material is available in the online version of this article at https://doi.org/10.1007/s12603-023-2045-3.
Supplementary material, approximately 19.2 KB.
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