1. Beyond the Break - Part 2: Clinical Application of the 2015 Long-Term Care Fracture Prevention Guidelines Sid Feldman MD, CCFP (COE), FCFP, CMD Medical Director, Jewish Home for the Aged (Apotex Centre) Executive Medical Director LTC and Residential Program and Chief, Department of Family and Community Medicine, Baycrest Health Sciences Associate Professor, Department of Family and Community Medicine, University of Toronto sfeldman@baycrest.org July 8, 2016

2. RELATIONSHIPS WITH COMMERCIAL INTERESTS: -Grants/Research support: None -Speakers Bureau/Honoraria: None -Other: Employee of Baycrest Health Sciences Potential for conflict(s) of interest: None Disclosure: Presenter 2

3. This program has received financial support from The Canadian Institute for Health Research and the Ontario Ministry of Health and Long-Term Care in the form of an unrestricted educational/research grant. This program has not received in-kind support from any commercial/for profit organization Potential for conflict(s) of interest: None Disclosure: Program 3

4. On behalf of Osteoporosis Canada’s Scientific Advisory Committee, we acknowledge: Alexandra Papaioannou, MD MSc FRCP(C) FACP Nancy Santesso, PhD MLIS BASc RD Suzanne Morin, MD MSc FRCP FACP Sid Feldman, MD CCFP FCFP Jonathan Adachi, MD FRCPC Richard Crilly, MD MRCP(UK) FRCPC Lora Giangregorio, PhD Susan Jaglal, BSc MSc PhD Robert Josse, MD BS BSc Sharon Kaasalainen, BScN MSc PhD Paul Katz, MD CMD Andrea Moser, MD MSc CCFP FCFP Hope Weiler, RD PhD Susan Whiting, PhD Angela Cheung, MD PhD FRCPC CCD Papaioannou A et al. CMAJ. 2015 4

5. Objectives: By the end of this session, participants will be able to: 1.Identify LTC residents who are at high risk for fracture 2.Apply new LTC Fracture Prevention guideline recommendations 3.Stop pharmacotherapy when appropriate 5

6. How were the recommendations developed?

7. Using the GRADE Approach Balance of Benefits & Harms Recommendation Values & Preferences Quality of the Evidence Resources Balshem H et al. J Clin Epidemiol. 2011 7

8. How can the recommendations be interpreted?

9. www.gradeworkinggroup.org Interpreting the Recommendations 9

10. Fractures are bad At least 10 % of LTC residents re-fracture within one year Substantial decline in function after fracture across all ADL domains 1-year mortality over 40% for residents living in long-term care Papaioannou A et al. J Soc Obstetr Gynecaol Can. 2000 Neuman M et al. JAMA Intern Medicine. 2014 10

11. What is the Goal of the Fracture Prevention Recommendations? Immobility Pain Transfers to hospital Improve quality of life for residents of LTC Reduce:

12. Case 1: On admission Mrs. A is an 87 year old woman with moderate dementia, who had been living with her husband. He unfortunately died 6 months ago. She was unable to care for herself at home. How should we assess her risk for fractures? 12

13. More history… Never been told in the past that she had osteoporosis Never on medication for osteoporosis Fractured wrist 8 years ago while walking on sidewalk Daughter says she used to be 5’5”, now 5”2” 13

14. Height loss prompted a lateral thoracolumbar x-ray to be ordered Found a significant vertebral fracture 14

15. Is she at high risk for fracture?

16. Papaioannou A et al. CMAJ. 2010 Ask the following questions on admission Determine…How to assess?... Prior hip fracture“Have you ever broken your hip?” Prior vertebral fractureHave you lost height?” If YES and >6 cm historically, order lateral thoracic and lumbar spine More than one prior fracture (excluding fractures of the hands/feet/ankle) “Have you had a broken bone after 50?” If recently used systemic glucocorticoids and have had one prior fracture Are you using medications such as steroids or prednisone? If identified as high risk and/or on osteoporosis treatment prior to admission “Have you been on osteoporosis medications? BMD is not required to identify residents at high risk of fracture 16

17. Answer YES to any of these questions, then consider at HIGH RISK of fracture Bone density NOT required to assess fracture risk in this population. 17

18. Case 1, continued Diet at home has been limited, losing weight in the last few months (one of the reasons prompting admission) Now that she is in a LTC home, her appetite seems good and she is willing to eat food without difficulty At home, not taking calcium or vitamin D (though bottles of both were at home) No significant dysphagia noted by staff 18

19. What are the recommendations for calcium and vitamin D?

20. For all residents, we recommend dietary interventions to meet the recommended dietary allowance (RDA) for calcium – The RDA for people >70 years for calcium is 1200 mg daily (3 servings of dairy or dairy equivalents) Calcium Remember, this means a strong recommendation Papaioannou A et al. CMAJ. 2015 20

21. For residents at high risk who cannot meet the RDA for calcium through dietary intake, we recommend daily supplements of calcium up to 500 mg For residents who are not at high risk of fractures and who cannot meet the RDA for calcium through dietary intake, we suggest daily supplements of calcium up to 500 mg, depending on resources and their values and preferences Calcium Papaioannou A et al. CMAJ. 2015 21

22. For residents at high risk of fractures, we recommend daily supplements of 800 – 2000 UNITS vitamin D 3 For residents not at high risk, we suggest daily supplements of 800 – 2000 UNITS vitamin D 3, depending on resources and their (or their caregiver’s) values and preferences Vitamin D Papaioannou A et al. CMAJ. 2015 22

23. Would you give supplemental calcium or vitamin D?

24. Able to get sufficient calcium from her diet, so no supplement required Added 1000 IU vitamin D daily 24

25. Case 2: Focus on Exercise Mr. B is at low risk for fracture based on admission questions. Should he participate in an exercise program? Ms. C is at high risk for fracture. Should she participate in an exercise program? 25

26. Case 2 Sorry, exercise is complicated… Most studies did not measure fractures, pain, quality of life or mobility, they measured falls For those at lower risk, exercise tended to reduce the number of falls For those at high risk, exercise tended to increase the number of falls But in high risk, when combined with multifactorial fall prevention interventions, number of falls seems to have been modestly reduced Type of exercises varied, including tai chi, strength training and functional exercise (simulate “real”, common movements) 26

27. For residents at high risk of fractures, we suggest balance, strength and functional training exercises only when part of a multifactorial intervention to prevent falls – This recommendation places a high value on avoiding the small increase in falls which may occur among individuals at high risk of falls who participate in exercises, such as balance, strength and functional training For residents not at high risk, we suggest balance, strength and functional training exercises to prevent falls – This recommendation places a high value on the probably small reduction in falls that is achieved with exercise, as falls may lead to serious injuries. It also places high value on the other benefits that exercise could provide. Exercise Remember, this means a weaker recommendation Papaioannou A et al. CMAJ. 2015 27

28. Worth considering… From video evidence: ~ 1/3 of individuals who fall in LTC hit their heads 74% have some hand contact first but not of sufficient strength to prevent falling Exercise focusing on arm resistance, reaction time and strength training may be of benefit for higher risk individuals Robinovitch S et al. Lancet. 2013 http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(12)61263-X/references http://www.sfu.ca/tips.html 28

29. Any combination of interventions that are tailored to an individual’s risk to reduce falls. Such interventions may include: – medication reviews, assessment of environmental hazards, use of assistive devices, exercise, management of urinary incontinence and educational interventions directed to staff Multifactorial interventions For all residents, we suggest multifactorial interventions that are individually tailored to reduce the risk of falls and fractures Papaioannou A et al. CMAJ. 2015 29

30. 30 https://effectivepractice.org/resources/academic-detailing-service/

31. Case 3 Mrs D has severe dementia and likes to wander aimlessly. She has fallen before and is at high risk for fracture Would she benefit from hip protectors? 31

32. For residents who are mobile and at high risk of fractures, we recommend hip protectors For residents who are not at high risk of fracture but are mobile, we suggest hip protectors depending on resources available and the residents’ values and preferences. Hip protectors Papaioannou A et al. CMAJ. 2015 32

33. Case 4: Mr. E. has just sustained a fall and fractured his hip. Prior to this, he was ambulating with a cane Since he has returned to the LTC Home following surgery, he now needs a walker (or wheelchair for longer distances) He is able to swallow well and has normal kidney function Despite his fracture he is otherwise reasonably well, except, for his underlying Alzheimer’s Disease and you think he has a reasonable life expectancy His goals of care have always been towards active treatment and his SDM wants therapy if it will help prevent future fractures. 33

34. Case 4 Would he benefit from pharmacotherapy to prevent future fractures? Which medications are first line? 34

35. For HIGH RISK residents, we recommend.. Recommended Administration: Not to be crushed In the morning, on an empty stomach If resident can remain upright for 30 min after administration Alendronate 70 mg weekly 35 mg weekly or 150 mg monthly Risedronate 1 st line therapy NOTE Risedronate DR can be taken immediately after breakfast and is not required to be taken first thing in the morning on an empty stomach. Papaioannou A et al. CMAJ. 2015 35

36. Alendronate and risedronate are not recommended for older persons with severe renal insufficiency (creatinine clearance <35 mL/min or <30 mL/min, respectively) Contraindications Papaioannou A et al. CMAJ. 2015 36

37. Case 5 Mrs. F has had prior fractures and is at high risk for fracture. She has moderate to severe dementia but you think her life expectancy is at least 2 years. She has choking episodes and is on a thickened puree diet. What pharmacotherapy would you recommend for her? 37

38. For HIGH RISK Residents + Difficulty Taking Oral Medications, we recommend.. 1 st line therapy Denosumab* (60 mg subcut twice yearly) Zoledronic Acid (5mg IV yearly) *This recommendation applies to the older persons who have difficulty taking oral medications due to dysphagia, an inability to sit up for 30 min, cognitive impairment or intolerance LU code 428, 429-women only Papaioannou A et al. CMAJ. 2015 38

39. Denosumab: While denosumab can be prescribed to residents with renal impairment, they are at higher risk of developing hypocalcemia Zoledronic Acid: Health Canada advises that caution is necessary for people who receive other medications that could affect renal function; CrCl should be monitored before and periodically after treatment. Appropriate hydration (500 mL of water) is necessary before and after treatment. This medication should not be administered in people with severe renal impairment (CrCl <30 mL/min) Contraindications 39

40. For HIGH RISK residents, we suggest... Teriparatide (20 mcg subcut daily) Teriparatide (20 mcg subcut daily) Although the benefits of teriparatide (in particular on vertebral fracture) probably outweigh harms of treatment, the cost of therapy restricts its access, and there may be a higher burden due to daily injections Papaioannou A et al. CMAJ. 2015 40

41. For HIGH RISK Residents, we suggest not to use… Etidronate Raloxifene There is moderate quality evidence for little to no reduction in fractures (in particular hip fractures) with etidronate. The cost is also high given the lack of important benefits. The harms of raloxifene (e.g. venous thromboembolism and musculoskeletal events – arthralgia, myalgia) probably outweigh the probable reduction in vertebral fractures and small reductions in hip and non-vertebral fractures Papaioannou A et al. CMAJ. 2015 41

42. Case 6 Mrs. G. has end-stage CHF, COPD and Parkinson’s Disease. She has sustained multiple fractures and is at high risk for future fractures You would not be surprised if she dies within the year Would she benefit from pharmacotherapy? 42

43. Pharmacotherapy is not appropriate in the final year of life.

44. For access to the recommendations and other tools and resources, please visit Osteoporosis Canada at www.osteoporosis.ca www.osteoporosis.ca Papaioannou A et al. CMAJ. 2015

45. Determine risk of fracture on resident’s admission Calcium and vitamin D supplementation Exercise, hip protectors and multifactorial interventions Pharmacological therapy for residents at high risk Summary Papaioannou A et al. CMAJ. 2015 45

46. Immobility Pain Transfers to hospital Improve quality of life for residents of LTC Reduce: Papaioannou A et al. CMAJ. 2015