Recommendations for preventing fracture in long-term care.

The 2010 clinical practice guideline for the diagnosis and management of osteoporosis in Canada1 focused on the care of adults living in the community. However, the fracture rate for adults living in long-term care (residents) is two to four times that of adults of similar age living in the community, and one-third of older adults who experience hip fracture are residents in long-term care.2 Hip fracture is one of the most serious consequences of osteoporosis and also one of the leading causes of admission to hospital.3 When residents return to long-term care after a hospital stay, they need additional hours of specialized care.4,5 In addition, fracture pain and delirium frequently associated with analgesia are distressing for residents and their families. Vertebral fractures are also a concern for residents, and the reported prevalence is up to 30% (for at least one moderate to severe fracture).6 Multiple vertebral fractures can be a substantial cause of pain, anxiety, depression, reduced pulmonary function7 and agitation.

Frail older adults at high risk of fracture in long-term care face other challenges. More than 40% have dementia,8 a similar percentage experience swallowing difficulties,9,10 and over 20% may have renal insufficiency.11,12

It may be difficult to identify residents at high risk of fracture, as the current fracture risk assessment tools (the Canadian Association of Radiologists and Osteoporosis Canada tool13 [CAROC; www.osteoporosis.ca/multimedia/pdf/CAROC.pdf] and the Canadian WHO Fracture Risk Assessment Tool [FRAX; www.shef.ac.uk/FRAX/]) provide 10-year fracture risk and have not been validated in long-term care, where over 20% of residents may die within one year of admission.14,15 Most research regarding risk assessment and pharmacologic therapies has not included those with multiple comorbidities.16,17