deprescribing, frailty and bone health

what is appropriate polypharmacy

medicines use has been optimised and medicines are prescribed according to best evidence.”

what is problematic polypharmacy

the prescribing of multiple [medicines] inappropriately, or where the intended benefit of the [medicines are] not realised.”

what is under prescribing

ommission of medications required to treat a condition, without a valid reason it is not prescribed, under STOPP START criteria. More likely in polypharmacy.

what is overprescribing

–Not needed/wanted, potential harm outweighs benefit, not prescribing better available alternatives, medicine appropriate for condition but not patient or harmful combinations

–A change in condition making medicine inappropriate

what are consequences of problematic polypharmacy

Increased cost, pill burden and medicines waste

Leads to prescribing cascade

Hospitalisations

Increased frailty, falls and mortality

Increased clinical workload

what are solutions to problematic polypharmacy

aim to reduce ADRs, increase appropriateness, reduced falls, improve adherence, maintain quality of life, reducing readmissions, cost benefits

what are interventions to address the consequence of polypharmacy

Medication reviews, clinical decision support tools, checklists, audit, feedback, patient education & training

Deprescribing tools – ACB, Opioid deprescribing, Medicines overuse in dementia and people living with learning disabilities, Medichec, STOPP/START tool, STOPPFrail tool, ThinkCascades tool, PrescQIPP

what is the mechanism of anticholinergic medication

Anticholinergics function by blocking the neurotransmitter acetylcholine

Systemic effects impact smooth muscle function in the lungs, gastrointestinal system, and urinary tract

Prescribed for various medical conditions including Parkinson’s disease, allergies, COPD, depression, and urinary incontinence

what are adverse drug reactions associated with anticholinergics

Dry eyes, urinary retention, dizziness, cognitive impairment, and falls

Anticholinergic effects intensify with stronger medications or combinations

Older patients, due to multiple medications and age-related changes, are more susceptible to ADRs

what is the association between anticholinergics and cognitive impairment and dementia

Longitudinal studies show a link between anticholinergic use and the risk of developing cognitive impairment and death

Dose-dependent association found between long-term anticholinergic use and dementia risk

what is person-centred deprescribing

Assess the patient - what are their priorities and perspectives

Agree goals

Identify potentially inappropriate medicines

Assess risks and benefits

Agree actions

Communicate with others

Monitor, review and adjust regularly

what is the definition of frailty

– gradual decreased physiological reserve with increased vulnerability to stressors, a multisystem decline

10% of >65’s and 25-50% of >85’s

Linked with multimorbidity, LTCs [75% of >75s have more than one LTC], 20-50% of older people with CVD are frail

Prevention of frailty is around modifiable influences such as physical activity, resistance exercise, obesity

what risk assessments can be used to assess frailty

Fried Frailty Phenotype (Physical Frailty Criteria)

Clinical Frailty Scale (CFS)

FRAIL Scale

Edmonton Frail Scale (EFS)

Rockwood Frailty Index (FI)

Comprehensive Geriatric Assessment (CGA) is the Gold Standard

Geriatric G8 screening tool

what does the G8 screening tool assess

1.Age

2.Declining food intake?

3.Recent weight loss?

4.Mobility level

5.Neuropsychological conditions?

6.BMI

7.>3 prescription drugs daily

8.Self-rated health status

• the higher the score the better

what are common bone conditions in the elderly

Osteoporosis

•Characterised by low bone density and structural deterioration.

•Often undiagnosed until a fragility fracture occurs.

•Key sites: Hip, vertebrae, distal radius.

Osteomalacia

•Often due to vitamin D deficiency; presents with bone pain and muscle weakness.

•Paget’s Disease (less common but relevant in some populations

what is the pathophysiology of bone ageing

•Aging - decreased bone mass, increased and structural deterioration of bone tissue, increased fragility fracture risk

•Decreased bone formation and increased resorption, trabecular thinning and loss of connectivity, Reduced osteoblast activity and hormonal changes (e.g., ↓ oestrogen, ↓ testosterone, ↓ IGF-1).

what is the problem with fractures

• significant morbidity, loss of independence, mortality

• total annual cost of 4.4 billion

what increases the risk of sarcopenia and frailty

• muscle weakness

• further increases fall risk and fracture likelihood

what is sacropenia

age-related loss of muscle mass and functioning – signs include falls, feeling weak, walking slowly, difficulty rising from a chair etc=

what is the presence of osteoporosis

• 1 in 2 women

• 1 in 5 men over 50

what are non modifiable risk factors for poor bone health in the elderly

Age, female sex, menopause, family history, white or Asian ethnicity, previous fragility fracture, rheumatological conditions, parent with hip fracture

what are modifiable risk factors

Vitamin D deficiency

Inadequate calcium intake

Sedentary lifestyle

Smoking and alcohol use

Polypharmacy (i.e. corticosteroids, anticonvulsants, SSRIs)

Falls

Low BMI <18.5

how does cancer effect bone health

• cancer and cancer treatments significantly increase the risk of bone loss and skeletal complications

• the bone is the third most common site for metastasis

• bone fragility can lead to pain, fractures, immobility and reduced qol

what cancers commonly affect the bone

• breast

• prostate

• lung

• multiple myeloma

• primary bone cancers which are less common

what are the mechanisms of bone involvement in cancer

Bone Metastasis

•Osteolytic or Osteoblastic lesions: Cancer cells disrupt the balance of osteoclast and osteoblast activity via signalling pathways

•Treatment-Related Bone Loss

•Hormonal therapies - aromatase inhibitors decrease oestrogen and increase bone resorption, androgen deprivation therapies decrease testosterone and decrease bone mass

•Chemotherapy

•Direct toxic effects on bone remodelling

•Induced premature menopause or hypogonadism

•Steroids: Glucocorticoid-induced osteoporosis (e.g., in lymphoma or multiple myeloma

what are risk factors for increased falls

Muscle weakness

Poor balance or gait disorders

Cognitive impairment

Polypharmacy

Vision impairment

Urinary incontinence

Environmental hazards (loose rugs, poor lighting)

Inappropriate footwear

Assistive device misuse

what are the best risk assessment tools for falls

• FRAX

• Q fracture

who should be assessed for fragility fractures

•All women > 65 years, and all men > 75 years.

•All women aged < 65 years and all men aged < 75 years with

•A previous osteoporotic fragility fracture.

•Current use or frequent recent use of oral corticosteroids.

•History of falls.

•Family history of hip fracture. 

•Low body mass index (less than 18.5 kg/m²).

•Smoking.

•Alcohol intake of more than 14 units per week.

•A secondary cause of osteoporosis

what is a fragility fracture

is defined as a fracture following a fall from standing height or less, although vertebral fractures may occur spontaneously, or as a result of routine activities such as bending or lifting.

how to assess fragility fracture risk

FRAX or Qfracture (preferred) AND clinical judgement

absolute risk of hip and major osteoporotic fractures (spine, wrist, shoulder) over 10 years

FRAX assigns green, amber or red zone score for fracture, but underestimates some risk factors (high alcohol, heavy smoking, regular corticosteroid use)

Qfracture – developed for the UK population Qfracture, can be updated annually, validated tool, includes additional risk factors

10% threshold

what tools are used to diagnose/ screen

• BMD T score <2.5 osteporosis

• Frax tool - 10 year probability of fracture with/ without BMD

• Consider vit d levels, serum calcium, phosphate, TSH, renal function, markers of bone turnover

• Baseline BMD for all patients on aromtase inhibitors or androgen deprivation therapy, long term corticosteroid use, metastatic bone disease

• Lab tests - serum calcium, phosphate, vit d, PTH, ALP

• Imagine - bone scans, PET-CT, MRI for bone metastais

falls prevention strategies

Exercise

•Weight-bearing (walking, dancing), resistance/strength training, balance and flexibility exercises (Tai Chi, yoga)

Lifestyle

•Smoking cessation

•Alcohol moderation

•Home safety interventions

•Medication review (deprescribing high-risk drugs)

•Vision correction

•Footwear and orthotics

•Nutrition

Calcium and Vit D

•Calcium: at least 1g daily with Vitamin D: 400–1,000 IU/day (higher if deficient)

•Adequate protein intake, caution in CKD2-3B, avoid in CKD4-5

Frailty Management:

•G8/Comprehensive Geriatric Assessment (CGA), Multidisciplinary interventions, Nutrition optimisation (especially protein and Vitamin D), Resistance and aerobic exercise, Social support and caregiver involvement

what are first line treatments for poor bone health

• bisphosphonates (alendronate, risedronate, zolendronic acid)

• inhibitors of bone resorption

what are alternative treatment for poor bone health

•Denosumab (especially in renal impairment)

•Teriparatide or abaloparatide (anabolic agents), Romosozumab (dual action; newer specialist option)

•Hormone replacement therapy (select postmenopausal women; assess risk-benefit)

what are consequences of falls

• hip fracture 20% mortality at one year

• immediate orthapaedic and geriatric co-management improves outcomes

• post fracture osteporosis treatment should be begun in hospital or shortly after

what is the impact of a fall

•Physical injuries: fractures, head trauma

•Psychological: fear of falling (FoF), depression, loss of confidence

•Functional decline

•Increased institutionalization and healthcare costs

•Higher mortality

what monitoring and follow up needs to be done after a fall

•Tolerance to treatment after 12-16 weeks (ADRs such as upper GI effects)

•Check  adherence after 12 weeks

•Reassess need for continued bisphosphonate after 5 years

•Maintain good oral hygiene

•Attend routine dental check ups & inform dentist of treatment

•Report signs/symptoms of osteonecrosis of the jaw

•Follow up on FoF and psychosocial impact, depression