Falls and Fractures: A Podcast with Sarah Berry

Eric 00:01

Welcome to the GeriPal Podcast. This is Eric Widera.

Alex 00:03

This is Alex Smith.

Eric 00:04

And Alex, who do we have with us today?

Alex 00:06

In studio, visiting professor coming to us from Boston. She is a returning GeriPal guest. This is Sarah Berry, who is at the Hebrew Senior Life and Beth Israel Deaconess Medical center and Harvard Medical School. And she is a practicing geriatrician and researcher. Sarah, welcome back to the GeriPal Podcast.

Sarah 00:28

Thanks so much. Happy to be here.

Eric 00:30

So we’re going to be talking about falls and fractures. We’ve got a lot to talk about. I have a lot of questions. But before we do, Sarah, do you have a song request for Alex?

Sarah 00:37

Ooh, how about Free Fallin’?

Alex 00:41

Free Fallin’?

Alex 00:45

We did this, like one of our first podcasts, I remember, and second verse, I kind of went for it. But today I’m not because it is November 6th and I’m feeling subdued.

Eric 00:57

Subdued. We won’t talk about what happened on November 5th.

Alex 01:00

November 5th. So here’s a little bit of subdued. Free Fallin’.

Alex 01:11

(singing)

Eric 02:33

Sarah, excellent song.

Sarah 02:35

That was nice choice.

Eric 02:37

Is there any other reason you picked that song besides, are you a Tom Petty fan?

Sarah 02:42

I am a Tom Petty fan, yeah. But it was just the first thing that came to mind when you asked me to talk about falls.

Eric 02:48

Well, I want to thank you for joining us because you’ve done a lot of the studies around falls and fractures and like, how we think about, especially like in, in frailer older adults, those in nursing homes. I wonder how did you get interested in this as like a research, academic focus of yours?

Sarah 03:08

Yeah, you know, when I went into my geriatric fellowship or even during residency, I think that I thought that I was going to be interested in dementia and that maybe that would be my line of focus. But I was really struck early on in my training by the number of patients that had these serious falls, fractures, sort of this feeling that they were never going to get back home or they weren’t going to get back home in the same shape that they were before. And I had a good mentor in residency that really encouraged me. You know, if you want to think about the problem, think about clinical research. And was really fortunate to have great mentorship throughout my career.

Eric 03:49

Great. And when you think about like back then, I guess now too, like how big of a problem is falls?

Sarah 03:57

Yeah, it’s a pretty big problem for older adults, I’d say in community dwellers. About one out of every three older adults falls each year in the nursing home that’s higher. It’s one out of two.

Alex 04:10

Wow.

Sarah 04:11

I think the CDC estimates that every 20 minutes an older adult dies from a fall. A fall related injury.

Alex 04:19

Wow.

Sarah 04:20

And many more are injured.

Eric 04:22

Yeah. And the big things that we think about as far as complications, so there, obviously the thing that comes to everybody’s mind is like fractures. But there’s other things too, like increased social isolation because there’s a fear of falling. Is that right?

Sarah 04:36

Yeah, absolutely. Even the falls that don’t result in a major injury, like the fracture, the head traumas, even the falls without those, tend to result in an increase in fear of falling. Anxiety and institutionalization.

Eric 04:51

Yeah. You know, I wonder how much, because it’s probably not brought up a lot in primary care settings. People don’t ask about it, they don’t screen about it. I’m guessing older adults don’t bring it up frequently that they’ve fallen. So it’s a silent, I don’t want to say silent epidemic that’s used too often. But there’s silence around these falls and there’s probably some nihilism about kind of, oh, what can we do about falls anyways?

Sarah 05:17

No, I think all of that is true. I think there’s just sort of this feeling that maybe it’s because it happens so often. I think both the patients feel that. I think providers feel that way. Right. You see this in people’s notes. You know, it was a mechanical fall and people kind of stop getting curious about why it happened or how they can prevent it.

Eric 05:38

So is nihilism the right approach here? Like there’s nothing we can do or do you feel like and we can talk about if so there are things that we can do to prevent falls and prevent the complications of those falls.

Sarah 05:53

Yeah, there are absolutely things we can do to prevent falls and prevent the complications. Maybe not all falls, but we can certainly reduce the frequency of falls and reduce serious injuries in the setting of a fall.

Eric 06:06

All right, before we get to that, I got some other important questions. Interrupt me anytime, Alex, if you got something. Okay, so if I were to believe you that we’re going to get to like, what interventions we can do to decreased risk for falls, how does Sarah screen? Do you just ask people like, have you had a fall lately? How do you screen or assess for risk for falls?

Sarah 06:30

Yeah, that’s honestly the best way to screen for falls is, have you had a fall in the past year or are you worried about falling? And if the answer is yes, then the patient’s at risk.

Eric 06:41

Yeah, that’s like the. One of the biggest risk factors, is that right?

Sarah 06:44

Absolutely.

Eric 06:45

Any other risk factors that we should be worried about?

Sarah 06:47

Well, there’s lots of risk factors for falls. You know, some of the major ones, things like dementia, cognitive impairment, Parkinson’s disease, you know, abnormalities with gait, balance, frailty, you know, low high body mass index. I mean, there’s a lot, you know, medications that goes on and on.

Eric 07:09

Yeah.

Sarah 07:09

But I do think consistently across studies, across settings, sort of the number one predictor of falls is, have you had a fall in the past year?

Eric 07:18

So if there’s one question our audience should ask.

Sarah 07:21

Absolutely.

Eric 07:21

Older adults, have you had a fall.

Alex 07:22

In the last year or are you worried about falling?

Sarah 07:25

Yeah, yeah.

Alex 07:27

Are there professional society recommendations or U.S. preventive services task Force recommendations to screen certain groups, all older adults, for falls?

Sarah 07:37

Yeah. The CDC has nice recommendations, the steady guidelines, and honestly, it follows pretty close with the American Geriatrics, British Geriatric Society guidelines for screening for falls. But really, they recommend that annually that you ask adults 65 years and older if you’ve had a fall or if you’re worried about falling.

Eric 07:59

Okay, you have somebody who says, yes, I have fallen. Alex. I know Alex has fallen. He’s broken in the last year. You have.

Alex 08:08

On a bike, I’m always. Yeah, I don’t know if that counts. Fall from bike.

Eric 08:13

Okay. Actually, the last bike accident, you didn’t even fall. You stayed on the bike.

Alex 08:18

Broke my hand while on the bike.

Eric 08:20

Okay, you have somebody who’s screened positive. What do you do? What’s the next step?

Sarah 08:28

Yeah, so it’s probably assessing their gait and balance is the next step. So, you know, in community dwellers, I do the get up and go test. You know, ask them to stand, ideally, without using their arms, walk about 10ft, turn around, sit down, and they should be able to do that if you’re timing them in 12 to 15 seconds or less, you know, if you don’t have the capabilities or, you know, to do a timed up and go test. You know, don’t let perfect get in the way of good. You know, just have them do that test and see if you’re not worried. You’re a little bit worried. Or you’re a lot worried. If you’re a lot worried, you’ve got your answer. If you’re a little bit worried or unsure, then maybe you move on to another test of balance.

Eric 09:17

So again, you’re at this point, you’re trying to assess for risk for falls, using the time to go. Are you also doing an assessment? Assessment? Like Sarah’s doing a timed up and go. Like, are you actually watching their gate and thinking about what, what do I think I can maybe intervene on?

Sarah 09:34

You know, I, I do. I, you know, I pay attention to. Arm swing is a big one. You pay attention to their assisted device and how comfortable that feels with them, how stable that feels with them. But, you know, honestly, even just a, a gut gestalt, you know, I’m a little worried about this patient. I’m, I’m, I’m not worried about this. Pat, I think is better than nothing when screening patients for gait.

Eric 10:01

Great. And so you’re getting the sense now you’re worried that this patient’s moderate to high risk. Timed up and go was long.

Alex 10:12

What’s long?

Sarah 10:14

More than 12 or 15 seconds.

Alex 10:15

More than 12 or 15 seconds.

Eric 10:17

What does Sarah do next?

Sarah 10:19

Yeah. So, I mean, again, if you’re really worried, you’ve probably got your answer. And you knew in somebody who’s had a fall and they’ve got gait abnormalities, they probably need to talk with them about falls and about, you know, sort of multifactorial interventions, you know, targeting their greatest risk factors to reduce the risk of falls. If they’re somewhere in between, you know, where you are a little worried or you’re unsure, you might do a balance test. So that is asking them to stand with their feet together, you know, for 10 seconds, and then the semi tandem stance where one foot is halfway in front of the other, and then the full tandem stance, one foot in front or the other, for 10 seconds. And if they have trouble with that, then again, I would consider them high risk and move on to this multifactorial intervention.

Eric 11:10

And tell me, what is a multifactorial intervention?

Sarah 11:14

So it’s really assessing patients for their individual risk factors for falls. So gait is one we’ve already talked about. Vision is another obvious one. Hearing is one. Looking at medications, I think is a really big one. And highly modifiable. Orthostatic vital signs I think can be appropriate. Just a good footwear, maybe another one, again, that’s highly modifiable. But just looking at their risk factors and trying to target those that you can intervene on.

Eric 11:56

So Potentially some of these intrinsic issues, including kind of their vision. Are they having orthostasis? Is that why they’re falling? Do they have some other medical condition like Parkinson’s disease that may be contributing to it? Medications. Which medications are you most worried about?

Sarah 12:16

Yeah, medications in general have been shown to increase the risk of fall. So persons that are taking more than five, seven, you know, there’s been a number of different thresholds that have been proposed, sort of irregardless of what medication it is.

Eric 12:30

So just the sheer number.

Sarah 12:32

Yeah, just the sheer number. But certainly psychotropic medications, you know, and there’s really no evidence when it comes to falls that some of the newer psychotropic medications are any safer than the older ones. Right. We might choose a newer antipsychotic over an older antipsychotic because it has less of the motor side effects. But we really shouldn’t kid ourselves into thinking that it’s safer when it comes to falls.

Eric 13:00

So antipsychotics, benzos, I’m guessing on there. All the sleep medicines potentially on there.

Sarah 13:07

Correct. Correct. Gabapentin is another one that I’m concerned about. I think there’s a few studies in dialysis patients and in hospitalized patients suggesting that gabapentin and pregabalin is associated with an increased risk of falls.

Eric 13:24

Yeah.

Alex 13:25

How about opioids?

Sarah 13:26

Yeah, that’s another one. And it’s tough, Right, because, you know, the pain, you were often giving these, you know, medications to patients. You know, there’s some intractable confounding there. Nonetheless, they probably do increase the risk of falls.

Alex 13:42

Yeah. And marijuana or Marinol or cannabinoids.

Sarah 13:48

Yeah, great question. I don’t think we’ve got really solid data on that. And I think in particular, there’s interest sometimes in the nursing home and using that in place of other drugs. And I think it’s something we need more data on.

Alex 14:06

Came up on our recent podcast about update on cannabis and marijuana, and one of our guests mentioned that you can use cannabis products for treatment of behavioral symptoms and people with dementia in nursing homes, which was news to us. So, interested about the potential side effects of that?

Sarah 14:29

Yeah, My suspicion is it’s like a lot of these others, like gabapentin, that it maybe, you know, have a better profile for other things, but perhaps when it comes to falls, it’s no better.

Eric 14:41

Yeah. Anything that’s potentially somewhat sedating.

Sarah 14:44

Correct. Yeah.

Eric 14:46

How do you think about blood pressure medicines?

Alex 14:48

Right.

Sarah 14:49

Yeah, that’s a great question, too. You know, the studies are mixed where some studies suggesting that Blood pressure medicines are associated with an increased risk of falls. Some studies even saying that maybe they’re associated with a decreased risk of falls. I like there was some work from Mary Tonetti’s group looking at a large sample of hospitalized patients with injurious falls and their antihypertensive use. And really what I took away from that study was it matters whether you have a history of falls. So they did a subgroup analysis, and in particular, in adults who had reported a fall in the past year, they seem to be at greater risk of injurious falls with antihypertensives. So, again, going back to that, if you just have one question to ask your patients or when you’re thinking about what that blood pressure target should be, maybe it’s if I’ve had a fall in the past year.

Alex 15:48

Did you do a study where you looked at the falls around the time of initiation of antihypertensives?

Sarah 15:55

Yeah. Yeah. Great memory. It’s been a little while. But we looked at a number of classes of medications and found that when you increase the dose or start the medication, patients were at a particularly high risk of falls. And that’s true not only for antihypertensives, but for the diuretics. It was true for meds like benzos, antipsychotics, and for antidepressants. And that. That included. The most common antidepressant in that study was. Was trazodone, something that we sort of, you know, typically consider to be a safer geriatric drug.

Alex 16:34

Hmm.

Eric 16:35

Okay. I got another. My last fall med’s question doesn’t increase risk for falls, but may increase risk for complications of falls. How do you think about anticoagulants and falls? Specifically doacs?

Sarah 16:49

Yes. I think that’s also an area where we could probably use some more research. We looked at it in nursing home residents, and we looked at sort of standard dosing of DOAC. So that would be, like, for apixaban, the 5mg bid versus anything lower than that, we called reduced dose of DOACs. And we found that, at least in nursing home residents, there was no difference in the efficacy of the drugs when you got the lower dose. But there was certainly an increased risk of bleeding. And a lot of this is, as you say, it’s bleeding in the setting of. Some of this is bleeding bleeding, and some of this is bleeding in the setting of a fall.

Eric 17:32

Okay. So we have these intrinsic issues, but there’s also, like, extrinsic issues that contribute to falls, including in people’s Homes.

Sarah 17:42

Yeah.

Eric 17:43

How do you think about that? And, and as you’re seeing patients or potentially in nursing homes, like you also work in a nursing home, is that right?

Sarah 17:51

Yeah, I work in long term care and ask to see a lot of fallers.

Eric 17:54

How do you think about those extrinsic factors?

Sarah 17:57

Yeah, I love it that you asked those question because I think that that’s something that we don’t often think about. I go back to at the beginning of the podcast I mentioned there’s this tendency you’ll see in the chart. Oh, it was a mechanical fall and people just stopped. But if you ask people, people have these chronic risk factors that you mentioned, the Parkinson, Parkinson’s disease, the cognitive impairment, the visual impairment, they have them every day. But there’s generally some trigger something that happened that they fell last Tuesday. Right. And you’ve got to really ask about the situational factors to learn about those.

So you know, it could be things like, you know, the throw rugs people talk about or poor lighting. You mentioned, you know, starting a new medication I think is sort of falls into that area as well. Risk takers is another thing. You know, the people that, you know are climbing up on ladders or on washing machines to get things down, they may not volunteer that information, but you know, if you ask them kind of what was happening with the fall, you, you may be surprised and learned.

Eric 19:02

Yeah. And if I remember correctly there, I think there was one, it was from BMJ or land. I think it was a UK study. They looked at eyesight, they saw like ophthalmologists, a bunch of people got glasses. And what happened is there was an increased risk for falls. And I think it turned out the most common prescription was like a bifocal lens.

Sarah 19:23

Yeah, I think with. You’re right. So cataract removal first. Cataract has been shown to reduce the risk of falls. But you’re right, I mean I think giving people proper eyewear is good care, but hasn’t necessarily proved to be effective or at least by itself in reducing falls.

Eric 19:40

And I think the interesting thing about bifocals, if you look straight, every everything’s in focus, you look down now you’re look, you’re using your reading glasses basically. So you’re not seeing any of those things that could potentially make you slip fall.

Sarah 19:54

Right.

Eric 19:54

Okay, what are the evidence based interventions that we could do to reduce falls?

Sarah 20:02

Yeah, so in the community dwellers, I would say the strongest evidence base is for exercise. Right. So it needs to be exercise that includes some gait balance and strengthening it’s been shown to be effective when done in groups. It’s been shown to be effective when you give patients home exercise. I mean, exercise, I think there’s no question is effective in preventing falls and fall related injuries. Getting people to exercise. Right now, that’s the challenge.

Eric 20:35

Is Tai Chi part of that? I see a lot of Tai Chi falls articles out there.

Sarah 20:39

Yeah, Tai Chi is one type of exercise that certainly combines some strengthening and core strengthening and balance. So it’s nice. And yes, there’s good evidence in community dwellers that Tai Chi prevents falls.

Alex 20:55

How about in nursing home or long term care settings?

Sarah 20:59

Yeah, nursing homes it is a little bit more complicated. You know, the evidence that exercise prevents falls, or particularly that it prevents falls in persons with dementia, which is the majority of nursing home residents, I think it’s a little less clear. What seems to be effective in nursing homes is again, doing a multifunction assessment of all the patient’s risk factors and then honing in on the ones that are modifiable and trying to address them. That’s certainly what I do in the nursing home.

I often find, again, you’re looking and asked to see somebody after a fall and they’re wearing slippers without a back and no tread. Right. Again, we may not prevent all of the falls that that person has, but we can reduce the number of falls by targeting risk factors like that.

Eric 21:53

What if, if there was a simple vitamin everybody could take that would reduce their risk for falls? Vitamin, let’s call it D, Vitamin D. I love vitamins because, like, we get really into them until we realize that they don’t really work. Where are we in that cycle with vitamin D? How? There was a lot of talk about vitamin D about a decade ago, decreasing falls and fractures. Did that hold up?

Sarah 22:21

Yeah, you’re right. The pendulum really swung pro vitamin D. Then it kind of swung the other way and you’ve got these meta analysis, maybe more meta analysis sometimes than individual studies on vitamin D and often with conflicting results. So it’s hard. What’s a clinician supposed to do? You know, I think some of the uncertainty and the discrepancies in the meta analysis depends on which patient population you’re enrolling.

And in general, I would say that the evidence does not support that vitamin D prevents falls for your average, you know, community dweller, you know, persons that are probably replete with vitamin D. But in nursing home residents, there is actually evidence that vital vitamin D reduces falls and in particular that calcium and vitamin D can prevent fractures in nursing home residents.

Eric 23:15

And for those studies, did they include, did it matter what your vitamin D level or did everybody have low vitamin D level?

Sarah 23:23

Yeah, it didn’t matter in those studies. So they were, you know, randomized trials and one they didn’t check the vitamin D level and the other they did, but it was fairly comparable across, across the groups.

Alex 23:35

So nursing home long term care. Vitamin D prevents not just falls, but fractures. And it’s interesting to try to think like, what’s the mechanism by which it might. Vitamin D and calcium might prevent falls. Like the fracture part I can get, but the mechanistically, the fall part I have trouble with.

Sarah 23:55

Yeah, I mean, I am certainly not an expert on this. There’s been a lot of, you know, speculation. I mean, there are vitamin D receptors with muscles, you know, the way that it’s metabolized and with the kidneys, I think there’s a lot of speculation, but I also think there’s a lot of unknowns.

Eric 24:13

Yeah. In some ways it’s like it’s a hormone too, because they’ve also done studies on vitamin D at really high levels, which actually shows a higher risk for falls.

Alex 24:23

Oh, U shape.

Eric 24:25

Yeah, yeah. So right there is this recommended. Like for most people it’s get it through your diet in sufficient quantities. But for the people that you are going to supplement, you don’t want to give too much and you don’t want to give too little, is that right?

Sarah 24:42

Correct. It’s one time in nursing homes it’s so tempting, I think, to give the higher doses just to reduce the pill burden, which is real and problematic in the nursing home. But I do think it’s one area where we have, have pretty strong evidence that the higher doses of 50,000 international units, for whatever reason, does seem to be associated with an increased risk of falls.

Eric 25:07

What does Sarah Berry Do? 800, is that your target?

Sarah 25:11

800 international units, whatever’s available. 800 or 1,000 maybe. If I’m particularly worried about somebody and they have some risk factors, they’re obese, dark skin, maybe I’d go with 2000.

Alex 25:25

I know we want to get to the fractures part and I have two more questions from my perspective about the falls part. All right, so in the long term care setting or the hospital setting, our first podcast was about bed alarms. First GeriPal podcast.

Eric 25:41

Yeah.

Alex 25:42

So there’s this tension, right, between safety and fall risk and autonomy and allowing people to take risks.

Eric 25:52

And if you just restrain them in bed, Alex, they won’t fall.

Alex 25:55

Right. You will reduce your. Well, maybe, maybe you would think that it would reduce the Fall risk. I don’t know whether it actually does, but how do you think about that tension in the long term care setting?

Sarah 26:07

Yeah, that’s a great question. I’m definitely a believer that fall rates, we can improve them in nursing homes, but they cannot and should not be zero. Right. If we’ve really suppressed them that far, then we probably are restricted people too much. It is a challenge. I’m delighted. Our facility made the decision years ago to be alarm free.

Eric 26:33

Oh, really? No bed alarms.

Sarah 26:34

No bed alarms.

Alex 26:35

No bed alarms.

Sarah 26:36

And we did kind of. It was relatively crude, but analysis looking at rates of falls before and after the bed alarms and didn’t find any difference. And again, it made the nurses happy to get rid of them. They were responding to the, to these false alarms that were going off, particularly in our really thin patients. And also I’m not sure that they were really preventing falls. Right, you were just finding the fall after it occurred.

Eric 27:04

Because it is interesting because like you said, one of the most important interventions is exercise mobility, like moving around, which also increases your risk for falls, potentially because you’re moving around, but in the long term it may decrease your risk. But bed alarms is the opposite. It nudges people never to get out of their bed or their chair that the alarm is on because you’re going to have this really annoying sound.

Sarah 27:26

Yeah, I think you said that. Well, and the nurses, they drive them crazy.

Alex 27:31

Okay, my second question is in the outpatient setting, we had a podcast with Tom Gill about that stride study published in New Journal. And my general recollection not having reviewed it recently is that that it was a multi component intervention and that the primary outcome was prevention of injurious falls. And that was not a significant difference and that it did, in a secondary outcome, prevent falls in general. Any thoughts about that study in the outpatient setting and whether that affected your practice?

Sarah 28:07

Yeah, that’s great. And I think it was discouraged for a lot of us that believe in false prevention strategies. And the way that I interpret it, no, I’m still a big believer in false prevention strategies. What was different about that trial in some of the individual trials that used exercise or visual changes, is that this was a pragmatic trial. People didn’t sign consent. They didn’t say, like, hey, I’m looking to prevent falls. Right. They took primary care practice and they randomize them to get their prevention.

So instead of in the trials. Right. You’ve got a highly motivated group that wants to prevent falls, whereas in the pragmatic studies you don’t. And Again, I don’t see that as, that falls prevention doesn’t work. I think it’s just a reminder for us as physicians that you can’t give somebody a multimodal intervention just because they’re at risk of falls. You’ve got to talk to your patients about falls and, and see where they are. We talk a lot about with smoking cessation or weight loss. Right. About readiness and sort of patient activation. Right. You know, if you’ve got a patient and they may have a lot of risk factors for falls. Right. And they may have even had a fall with a bad injury. But if they’re in this pre contemplative stage and they tell you that, you know, I’m never going to fall again, it was just the silly mistake.

Don’t worry about me. Right. You know, trying to give them, you know, a multifactorial intervention and a lot. Right. It’s not going to work. Right. We need to instead talk to the patients about how serious these falls are, move them from a pre contemplative state into a state of action, and then just, you know, give them one intervention at a time along the way. And, you know, to me, that was the difference between. It’s not that the stride approach was wrong, but to me that’s why they didn’t find an effect.

Eric 30:10

Okay, so we have the falls. We’re doing everything that we can do to reduce the risk of falls, but we also should think about how do we reduce the risk of the complications of falls, in particular fractures. How do you assess for the, like, the risk of fractures, especially like in your population, nursing home patients, or frail older adults or older adults with multimorbidity. Like these people are not part of clinical studies generally. How do you think about that?

Sarah 30:40

Yeah, you know, I think in general, you know, probably bone mineral density screening isn’t, isn’t going to fully capture risk in sort of your frail older population. So if you have it, great. I’m not discouraging or saying there’s not value in that, but really considering their clinical characteristics. So, you know, in the community, probably the best studied model is, is the FRAX model, you know, which is available. It works up to age 90, beyond age 90, you know, they didn’t have data. And so you’re, you’re sort of on your, on your own or just sort of assume the age of 90.

Eric 31:23

And is that just postmenopausal women or men too?

Sarah 31:27

No, the FRAX works in men too. And you can calculate it with or without bone mineral density and Honestly, it does pretty well even without bone mineral density. And so that’s often what I would recommend in community dwellers that are a little bit more frail. Maybe you’ve got a bone mineral density test, maybe it’s five years old, 10 years, you know, an older test still. Put it in, put in what you have, right. And get kind of a risk and then I kind of take that risk and it’s like, you know, anything in geriatric medicine. There’s a little bit of interpretation with it. You know, I think if you have somebody and they have, they’re kind of on the fence, but they’ve also got Parkinson’s disease and cognitive impairment and they’re on a number of medications that make you nervous, round up and assume that their risk is a little higher than it is. Conversely, if you’ve got a patient and they’re bed bound and immobile or more near the end of their life, you might round that risk down. I recognize that that’s not highly scientific, but I think it’s just of a, anyway, kind of what, what we have for frail older adults in the community.

Alex 32:40

And we’ll include a link to the FRAX model in the show notes associated with this podcast. And just for our listeners though, it’s spelled F R A X, correct, right?

Sarah 32:49

Yeah, correct.

Eric 32:50

Okay, what about in a nursing home setting, does FRAX apply or are there better ones?

Sarah 32:55

Yeah, I would say FRAX is probably not the one to use in nursing homes because again, FRAX gives you a 10 year risk and you know, calculating a 10 year risk and I mean I recognize that it takes into account the competing risk of death. It also doesn’t consider a lot of, you know, the characteristics of nursing home residents. So yeah, we’ve developed a model, it’s called the frail model, the fracture risk assessment in long term care that predicts the two year absolute risk of hip fracture. We’ve got a website, it’s not nearly as pretty as the FRACS website, but you can put in the patient characteristics and get a two year risk of fracture.

I would say short of the website though, in sort of an absolute tool. The real drivers in the nursing home tend to be patients having a history of falls. Right. Having a history of fractures and patients mobility or independence. Right. So the patients that are independent in their activities of daily living and they’re independent in transferring those patients are at highest risk of falls in the nursing home. And then as residents become more dependent, their risk actually goes down. So it’s a little different, right, than in the community dwellers where we usually think of impairment increasing the risk.

Eric 34:15

Yeah, kind of. Also that U shaped curve. So like somebody with advanced dementia who is now bed bound, their risk for having a fall is correct. A lot lower.

Sarah 34:25

A lot lower.

Eric 34:27

Then the question is, is there a role for potential medications to help reduce that risk for fracture? So, you know, the ones that we think about, like bisphosphonates, how do you think about bisphosphonates and reducing that risk?

Sarah 34:43

Yeah. So are we back in the community or nursing?

Eric 34:46

Let’s go back in the community briefly. Then we’ll focus probably most of our energy on this. Frail, older, multimorbid.

Sarah 34:53

Yeah, yeah. Well, even in, I would say even in community dwellers, you know, there’s good evidence that bisphosphonates reduce the risk of fracture. The time to benefit too, for men too, and probably the time to benefit is about 13 months, a little every year. So in general, my rule of thumb has been if somebody, if I think somebody has about a two year life expectancy, then it probably makes sense to at least consider these drugs. Right. It may not be consistent with their goals of care, it may not be appropriate, but at least to consider them. Right. Somebody that’s got a life expectancy, I think they’re probably going to pass away in the next two years.

I probably wouldn’t, but I would say that there’s, you know, post hoc analysis of randomized controlled trials in patients with hip fracture, men and women that got zolendronic acid versus not. And they looked in again in a subgroup analysis of those with cognitive impairment, and it didn’t look like the fracture benefit was really much. You know, it still reduced fractures in people with cognitive impairment. We’ve also done a large observational study where we looked at patients who are hospitalized with a fracture and then to see who got a bisphosphonate after or not. And we did subgroup analysis. People were either frail at the time of their fracture or not using the frailty index. And again, it looked like the bisphosphonates, you know, that the beneficial effect was pretty similar. So I think we actually do have growing evidence that the bisphosphonates are reasonably effective even in patients with cognitive impairment and with frailty.

Alex 36:41

And for more on that, also consider listening to our prior podcast with James Deardorff and say, Lee, about the lag time to benefit for bisphosphates. I remember themselves saying they were surprised when the lag time to benefit was 13 months, you know, was about a year.

Eric 36:56

Well, let’s ask about that. So in James Derridor study we’ll have a link to in the show notes. I have it written down here because I looked it up. 10 RCTs, they combined nearly 23,000 patients. Included in these 10 RCTs, all were women with osteoporosis. Women with osteoporosis, the lag time to benefit. So it took 12 months to avoid one non vertebral fracture per 100 women and to avoid one hip fracture, the numbing treat was 200 at 20 months. So nearly two years. Does that ring true to you?

Sarah 37:34

Yeah, that seems reasonable. And again, I think we have that meta analysis was focused on the clinical trials that as you say, they were postmenopausal women, they weren’t necessarily frail, they weren’t the patients that were taken care of and they weren’t men. That being said, I think increased observational data supports that the benefits of the drugs are probably similar, you know, in subgroups. So, you know, if somebody has, I would say a two year life expectancy is sort of what I have in my mind is sort of, you know, for these drugs.

Eric 38:14

And why two year? What’s.

Alex 38:16

Why not one? Because on eprognosis I think we put it at 13 months or one year or something like that, which is interesting.

Eric 38:22

Because that’s also for any non vertebral fracture. And again, hip fracture obviously is longer than that. It’s closer to two years. Yeah, I mean, and the number to treat is 200. Got it. 200.

Alex 38:31

Maybe we should move the needle on the.

Eric 38:33

How do you think about needle?

Alex 38:34

That reminds me of last night. Okay, wait, back, back to now. The present.

Eric 38:38

The present two years versus one year. Sarah, why, why are you thinking more two?

Sarah 38:44

Yeah, hard to pin me down. So I, I think as you said, sort of 13 months. Right. So somebody’s got to live 13 months before they get a benefit in any fracture. And then hip fractures, which are the more serious ones, are about two years. So I mean, and let’s be honest, I mean, I’m not sure that our prognosis tools are so fine that we can release, you know, but if I would not be surprised that somebody passed away in the next two years, then, you know, I probably wouldn’t be using them. But otherwise I think we should least have a conversation and consider.

Eric 39:17

Yeah, I love this because I was, I was reading one of your articles I have a link to. It was, it was controversies in nursing homes about like falls and fractures and osteoporosis meds. And one of the things was not just when to consider starting it and incorporating some of these things that you’re talking about, like life expectancy, Are they bed bound? Like, are they getting up and walking around? Those types of things. But also. So when do we stop these drugs? And importantly, like, we think about this all the time, like in our hospice unit. Should we continue these medications or should we stop? How do you think about stopping these medicines?

Sarah 39:54

Yeah, it’s tough. But the good thing we know about the bisphosphonates is they have this very long half life. Right. There are randomized control trials, the flex trials, where they looked at women who had taken alendronate for five years and then randomized them to continue for versus stop. And in general, there was not a lot of difference in fractures in those that got the five years versus those. And so we know too that these drugs do are associated with a rare but serious risk of atypical femur fractures that almost never happens until you’ve been on them until five, you know, five years or more. And so, yes, so for all of those reasons, it makes sense to consider, you know, a drug holiday or stopping. I think in my patients, if somebody’s been treated for five years and they’re within, I think they’re within the last few years of their life, right. You’re probably talking about stopping the drug. It’s not a drug holiday. There’s no need to do additional screening or consideration. Right. Similarly, I think, you know, patients who have been treated and they’re, as you said, they’re no longer at risk, are not at the same risk of falls. Right.

They’ve become, become not ambulatory, they’re more sedentary, they’re, you know, or bed bound, requiring a lift. Right. That’s probably another time when, you know, if somebody’s been treated, it makes sense to stop. And then I guess what can become a little gray, right, Is, you know, well, somebody’s been treated three years or somebody’s been, you know, a little bit less. And in general, I do try to think, you know, if somebody’s not ambulatory and I think their life expectancy expectancy is two years are left, it is probably appropriate to stop bisphosphonates.

Alex 41:45

Can I ask how you, how you have that conversation? Like, what do you say to patients or their family members?

Sarah 41:51

Yeah, you know, I think sort of reminding them that this drug is still in your system, that you’re probably still benefiting from this drug, but if you were to continue taking this drug, it might have some adverse side effects. Right. And that your risk is not the same as it was before. It is a tough. That is a tough conversation. You know, just to mention because I think sometimes it’s confusing. This recommendation is really specific for the bisphosphonates. Denosumab is a little different.

Eric 42:27

How so?

Sarah 42:28

Yeah, so denosumab is a drug that it works by blocking the osteoclast activity. And as soon as you take the drug away, there’s this increased activation of osteoclast. You break down bone and there’s an increased risk of vertebral fractures in particular and probably other fractures. So denosumab, I mean, the good news is it’s only given every six months. But in general. But the notion of holidays. Right. Don’t apply to it. It’s a short acting drug. I still think it’s reasonable. Stop it. If you think that somebody’s life expectancy, if you think they’re within the last year of life again or they’ve become really immobile.

Eric 43:12

Okay, I got last question for you. Unless Alex has another question.

Alex 43:16

Well, can I ask my head first so that I can put on my guitar? Returning to the outpatient setting or maybe inpatient or long term care setting as well. Exercise we talked about for falls for fractures, specific types of exercise that you encourage your patients, patients like fracture to prevent. Yeah, fractures improve bone health is tough question.

Sarah 43:39

Do you know?

Alex 43:40

I don’t know. I think of like weight bearing. Like isn’t the mantra. You gotta grind the bones.

Sarah 43:45

Yes. So I mean definitely weight bearing exercise is best for the bones. So something like swimming, for instance, is great cardiovascular but doesn’t stimulate bones. But you know, I do think there’s a lot of uncertainty for our more frail older patients, particularly those who’ve had vertebral fractures. They have a lot of kyphosis of like exactly what types of exercises strength and conditioning we should be recommending for them. So love to get PT’s input on that and yeah, thanks, Sarah.

Eric 44:18

Last question for me. If you had a magic wand, you can make one thing different around how we either screen, assess or treat falls and fractures for our listeners, what would that be?

Sarah 44:28

I’d like physicians, particularly young physicians, to get curious about falls. I think they’re just so common in older adults that we sort of lost our curiosity. But if you’re curious and you ask about them, you can prevent them. Not all of them, but some.

Eric 44:45

Love it. Alex. A little bit more free falling. Tom Petty.

Sarah 44:50

What a treat.

Alex 44:56

(singing)

Eric 45:47

Sarah, thank you very much. If there was a song that could capture the mood that I’m in on November 6th, that is a song. So thank you for that and thank you to all of our listeners for your continued support.

Sarah 46:02

Thank you. That was fun.

This episode is not CME eligible.