American Academy of Family Physicians (AAFP) 2011 Scientific Assembly
October 14-17, 2011; Orlando, FL
During the AAFP meeting, more than 300 continuing medical education (CME) courses and plenary sessions were held. Clinical Geriatrics (CG) had the opportunity to interview two presenters regarding their CME sessions, one of which focused on osteoporosis and fracture risk in the elderly, and the other on preventing and treating diabetic and pressure ulcers. You can find the latter interview in the December issue of the Journal.
Geriatric Hip Fracture and Osteoporosis
In the United States, approximately 10 million people have osteoporosis and another 18 million people have low bone mass, increasing their risk of developing osteoporosis. Of people aged >50 years, one in two women (50%) and one in eight men (12.5%) are predicted to sustain an osteoporosis-related fracture in their lifetime. CG discussed screening and management of osteoporosis and prevention of hip fractures with Alvin Lin, MD, FAAFP, clinical assistant professor, Department of Family and Community Medicine, University of Nevada School of Medicine, Las Vegas, and adjunct assistant professor of family medicine and geriatrics, Touro University Nevada College of Medicine, Henderson, NV. Slides for Lin’s session, “Geriatric Hip Fracture and Osteoporosis: Update on Diagnosis and Management,” can be viewed at http://bit.ly/AAFPosteoporosis.
CG: What risk factors should clinicians consider when evaluating a patient for osteoporosis, and do all risk factors bear equal weight or do some confer greater risk than others?
Dr. Lin: The strongest risk factors for osteoporosis and fracture include age (>40 years), sex (female), weight (body mass index <20), height (≤5 ft), previous personal fracture, parent with a hip fracture, current smoking, use of corticosteroids, presence of rheumatoid (but not osteo-) arthritis, and excess alcohol consumption. Risk factors for secondary osteoporosis include type 1 diabetes mellitus, osteogenesis imperfecta, untreated hyperthyroidism, hypogonadism or premature menopause (<45 years), chronic malnutrition, malabsorption, and chronic liver disease.
Observational data have also suggested a link between osteoporosis and an acidic diet, androgen deprivation therapy, and use of aromatase inhibitors, proton pump inhibitors, rosiglitazone, and selective serotonin reuptake inhibitors. When osteoporosis is diagnosed, one of the most useful fracture risk assessment tools is FRAX (Fracture Risk Assessment Tool), developed by the World Health Organization and available at www.shef.ac.uk/FRAX. The FRAX online osteoporotic fracture risk calculator is specific to country and ethnicity. For example, if selecting the United States, one can choose from Caucasian, Black, Hispanic, and Asian databases; for Singapore, one can choose from Chinese, Malay, and Indian; and for China, there is a difference between the mainland and Hong Kong.
When should treatment for osteoporosis be initiated, and is drug treatment contraindicated in any geriatric patients?
In the United States, it is suggested that we consider FDA-approved drug therapy in those who have sustained a hip or vertebral fracture, have a T-score ≤-2.5 at the femoral neck or spine, or have osteopenia (T-score between -1 and -2.5 at the femoral neck or spine) and a 10-year probability of a hip fracture ≥3% or a 10-year probability of a major osteoporotic fracture ≥20%, as identified on FRAX. Contraindications to drug therapy are similar to those for other conditions, such as previous adverse reactions or a known drug allergy. Untreated hypocalcemia and hypovitaminosis D need to be addressed first, although I wouldn’t necessarily call these contraindications. However, due to the difficulties associated with taking oral bisphosphonates, I would reconsider this option in someone who can’t remain upright for at least 30 to 60 minutes at a time. I would also question treating someone with a life expectancy of <10 years.
Can you describe the most common drug treatments for osteoporosis and briefly outline their efficacy?
FDA-approved drug therapy can be thought of as either anabolic or anticatabolic. In other words, they either cause bone growth or slow down its loss. Unfortunately, we don’t have too many of the former. In fact, only daily injectable teriparatide and recombinant parathyroid hormone qualify as such. All others are anti-catabolic or antiresorptive agents. Bisphosphonates are the most well known of this class, which also includes estrogens, a selective estrogen receptor modulator (SERM), and calcitonin. The newest kid on the block is semiannually injected denosumab, which also slows down bone loss, but by preventing RANK ligand from activating its receptor, RANK.
What about nondrug interventions?
Calcium and vitamin D are the most well-known nondrug interventions, aside from exercise. There is some debate—despite the Institute of Medicine’s recommendations last year—over just how much vitamin D is required for optimal bone health (as opposed to other effects). Calcium carbonate is the most easily found form of calcium; however, recent studies have demonstrated an increased risk of osteoporotic fractures in patients who chronically suppress their gastric acid production with proton pump inhibitors (PPI). It is thought that suppression of gastric acid by PPI decreases calcium carbonate absorption; thus, some clinicians recommend supplementing with calcium citrate if a patient is concurrently taking a PPI. Other vitamins and minerals thought to play a role in bone health include vitamin K, magnesium, and strontium. One systematic review and meta-analysis noted some benefit from whole body vibration, but concluded that we need large-scale, long-term studies to make stronger recommendations.
What are some obstacles and side effects geriatricians may encounter with regard to drug treatments?
Cost is a major issue with teriparatide, aside from being a daily injection. Bisphosphonates can cause esophagitis if not taken properly. Thus, it is important to continuously review the proper directions with patients: bisphosphonates must be taken on an empty stomach, washed down with 8 ounces of water (no other types of liquids), and the patient must remain upright for 30 to 60 minutes. Bisphosphonates are also known to increase the risk for osteonecrosis of the jaw, a rare but debilitating condition. The debate over estrogens continues and would offer enough information for an interview just on this topic. Raloxifene, the only FDA-approved SERM for osteoporosis, increases the risk of venous thromboembolism and vasomotor instability. On the other hand, it also has a second FDA-approved indication as a prophylactic to reduce the risk of invasive breast cancer in high-risk women who are past menopause. The side effects of calcitonin, which may include symptoms such as runny nose, nasal discomfort, and nosebleeds, are due mainly to its nasal route of administration. With denosumab, we worry about hypocalcemia (prior to initiation), constipation, bone pain, various infections, and skin issues (eg, dermatitis); however, as it is so new, we still don’t know the full extent of its potential effects.
Studies have shown that longterm bisphosponate use (≥5 years) can increase a patient’s risk of certain fractures. Can you briefly outline these risks and how they may impact treatment?
Atypical femur fractures of the shaft have been noted in several large studies since 2010. However, while the relative risk of these atypical fractures is increased, the absolute risk remains small, such that the use of bisphosphonates is still associated with a decrease in all-cause mortality. Nevertheless, due to the real risk of complications and uncertainty from the currently available data, two FDA advisory panels recommended in September 2011 that time limits be set for bisphosphonate use, but they did not come to a consensus regarding duration of use.
What risk factors increase a patient’s propensity to fall?
Falls are considered multifactorial. The strongest risk in predicting a future fall is a history of previous falls. Gait and balance impairment obviously make a difference in fall risk, along with sarcopenia, visual impairment, medications, and one’s environment. Depression, dizziness, orthostatic hypotension, age >80 years, being female, and other functional limitations have all been associated with a greater risk of falls, as have urinary incontinence, cognitive impairment, arthritis, diabetes complications, and pain.
How can clinicians screen patients for fall risk?
The Timed Up & Go (TUG) test can be easily and quickly performed in the clinician’s office with just a chair. It consists of timing how long it takes a patient to get up out of a chair, walk approximately 10 feet, turn around, walk back, and sit down safely. In a low-risk patient, it should take no more than 9 seconds. Anything over 10 seconds is worrisome for osteoporotic fracture and fall risk. Use of TUG was recently shown to better stratify risk than assessment of bone mineral density alone. Poor visual acuity and polypharmacy, especially the use of central nervous system agents and cardiac medications, are useful in screening; however, the latter qualification includes the vast majority of geriatric patients. A home visit would most definitely be helpful in screening for fall risk by evaluating the environment for issues such as slick flooring, loose wiring, and poor lighting, among many other hazards.
What interventions can be taken to reduce the risk of falls?
Several interventions come to mind and should be performed concurrently. For instance, a home safety evaluation with appropriate modifications is key. Addressing polypharmacy by eliminating duplicate and unnecessary medications is also essential, as is reevaluating the use of centrally acting and cardiac drugs that can affect cognition and blood pressure. Fall risk intervention is a team effort; in addition to the physician, it requires the input of a skilled physical therapist to determine the type and amount of exercise necessary to address sarcopenia and balance and gait issues, input of the ophthalmologist to correct visual acuity issues, and input of the podiatrist to address foot and shoe concerns.
Wound Care in Geriatric Patients: From Diabetic Ulcers to Pressure Sores
Because of their comorbidities and limited physiological reserve, elderly individuals are susceptible to sustaining wounds and experience greater difficulty healing. When skin breakdown occurs, such as with diabetic foot ulcers and pressure sores, the risk of morbidity and mortality increases while quality of life decreases. CG discussed wound management in geriatric patients with Joseph Mazziotta, MD, Family Practice Physician, Tallahassee Memorial Healthcare, Tallahassee, FL. Slides for Mazziotta’s session, “Pressure Sores and Ulcers: Wound Care: From Diabetic Ulcers to Pressure Sores,” can be found online at http://bit.ly/AAFP-Mazziotta.
CG: How can clinicians tell whether a wound is healing normally in a geriatric patient?
Dr. Mazziotta: Wounds that are healing normally should initially have a healthy beefy red granulation tissue base. With time, epithelial cells will migrate inward from the edges. This typically appears as a thin, light pink tissue that will wrinkle if gently squeezed. As the tissue matures over 6 to 12 months, it will become thicker and have more elasticity.
What are the risk factors for diabetic foot ulcers, and are the risks increased in elders?
The risks for diabetic foot ulcers are based on several factors, including Charcot foot deformities, impaired microvascular and macrovascular circulation, edema, sensation loss from neuropathy, and an impaired immune response. These factors are also present in the geriatric patient, but may be compounded by increased limitations in mobility, plantar fat pad atrophy, impairment of other senses, polypharmacy, and other comorbidities.
How should clinicians manage diabetic foot ulcers? Are there any gold standards of care?
The ideal management of diabetic foot ulcers should focus on prevention and early identification of risk factors, such as neuropathy, impaired circulation, and proper offloading of boney prominences. Teaching the patient the importance of conducting daily foot inspections will identify problems at their earliest stage. If circulatory compromise is suspected, early referral to vascular surgery is recommended. Likewise, early referral for orthotic fitting is essential to offload pressure from the area. If ulceration is noted, the wound should be assessed for infection in the soft tissue as well as the underlying boney structures. Many topical dressing can be used to treat the ulcer bed; however, iodine and peroxide solutions should be avoided because they can impair healing. Standards of care recommend a goal of reducing the size of the wound by 50% in the first 4 weeks. If this goal is not met, then wound-healing times can be severely delayed. Any patients with diabetic foot ulcers that are not promptly healing should be referred to a wound center for advanced treatment modalities.
Which patients are at greatest risk for pressure sores?
Patients at most risk for pressure sores generally have impaired mobility, such as from a spinal cord injury, stroke, or any other condition leading to a prolonged bed-ridden state. Patients with boney abnormalities, such as kyphosis, are unable to adequately distribute pressure evenly, placing them at risk. In addition, poor nutritional states with low protein stores increase the risk for pressure sores. Ensuring proper skin integrity is an important preventive measure. Skin exposed to excessive moisture (eg, urine) can become irritated and macerated. Likewise, excessively dry skin can fissure and lose elasticity, making it susceptible to tearing or ulceration. Medications are another important consideration. For example, chronic steroids and chemotherapeutic agents can cause thinning of the skin, which increases the risk for skin tears and shear injuries.
Which preventive strategies can be employed to reduce the risk for pressure sore development?
Proper identification of the at-risk patient and early intervention is crucial to prevent pressure ulcers. Proper offloading of boney prominences, such as the heels, sacrum, and any spinal prominences is a key element of prevention. Many offloading devices, such as air-shifting mattresses and wheelchair seat cushions, are essential for patients who are chronically nonambulatory. Likewise, many other products are available to offload elbows, ankles, and heels. Keeping the patient clean and dry is also a key element of prevention and treatment of pressure ulcers. Finally, a nutritional assessment should be considered for all patients at high risk for pressure sores.
Why should patients with pressure sores receive nutritional assessments, and which measures should be assessed?
Many patients who are at risk for pressure ulcers are malnourished. Likewise, a majority of patients with chronic open wounds have malnutrition. This may be due to poor appetite, impaired swallowing, lack of availability of nutritious foods, or substance abuse. Many patients can also be in chronic protein–losing states from accelerated catabolism, enteropathies, nephropathies, or directly from wound surface secretions. Typically, this manifests as protein malnutrition, but patients can also lack other micronutrients, such as vitamin C, vitamin D, and zinc. A nutritional assessment should be considered for all patients with chronic wounds of any type. At a minimum, this should include measuring prealbumin levels and C-reactive protein. Unless contraindicated, patients should be encouraged to increase their protein intake and eat a well-balanced diet. When warranted, appetite stimulants (megestrol, mirtazapine, dronabinol) should be considered. In rare cases, when prealbumin levels cannot be improved with adequate protein supplementation, the provider should consider use of anabolic steroids for a brief period of time to get wound closure.