Make no bones about it; pharmacists play an important role in reducing people’s risk of falls and bone fractures through targeted advice and interventions
Falls are common causes of unintended injury among Australia’s ageing population. In fact, the number of cases of unintentional bodily harm and injury-related deaths as a result of a fall is rising. An Australian study found 8% of women in their forties, 14% in their fifties, 25% in their sixties and 40% in their seventies had experienced a fall in the previous 12 months.
According to the Australian Institute of Health and Welfare (AIHW), falls account for 37% of all injury-related deaths and are considered a major cause of hospitalised injuries. Indeed, in 2016-17 alone more than 100,000 people were hospitalised due to a fall. That equates to 273 people every day!
While fractures (predominantly to the hip, wrist, arm and leg) are the most common fall-related injury, head injuries are also widespread. The common causes of falls are slipping, tripping and stumbling, however, poor bone health also comes into play.
Indeed, 4.74 million Australians over the age of 50 have osteoporosis, osteopenia or poor bone health. By 2022 it is expected there will be a 30% increase in the number of annual fractures occurring as a result of poor bone health. It’s estimated there will be one fracture every 2.9 minutes. This compares to one fracture every 8.1 minutes in 2001.
The impact of falls and fractures
Women account for the majority of the hospitalisations for falls, making up 65% of cases. Even so, bone health awareness messages should not be solely targeted at women.
Osteoporosis Australia CEO Mr Greg Lyubomirsky, explains, “Currently 66% of Australians aged over 50 are estimated to have poor bone health. Hip fractures remain the costliest type of fracture related to osteoporosis. Other types of fractures that are widespread include wrist, spinal, arm and leg fractures. While osteoporosis mainly affects women, men also need to check their bone health with 25% of cases occurring in males.
“Certainly, men generally have a lower tendency of developing osteoporosis than women, but by the age of 65 to 70 years men lose bone density at the same rate as women. So while women are typically considered to be at higher risk of developing osteoporosis compared to their male counterparts, this is a disease affecting an increasing number of males as life expectancy increases.”
Mr Lyubomirsky says the issue is that people do not take their bone health seriously. “Fractures can result in pain, surgery, hospital stays, not to mention the disruption to work and family life. In extreme cases, fractures can lead to premature death or an inability to continue living in your own home. This is an important message pharmacists can convey effectively; early investigation can prevent serious fractures.”
Aside from the physical impact of a fall, it’s also important to recognise the psychological effect and how this can impact daily life. According to the Australian and New Zealand Falls Prevention Society (ANZFPS). ‘Falls can also result in restriction of activity and fear of falling, reduced quality of life and independence.’
Even in cases where there are no physical injuries, there is the risk of post-fall syndrome. This is described as ‘a loss of confidence, hesitancy, tentativeness with resultant loss of mobility and independence.’
The ANZFPS states that following a fall, 48% of older people report a fear of falling and 25% report curtailing activities. There is also the associated risk of disability and poor mobility, which can lead to increased dependency on others and a higher likelihood of being admitted to a care institution.
Discussing bone health
Mr Lyubomirsky says, “Currently there are over 165,000 fractures due to poor bone health. Risk factors for poor bone health should be investigated and pharmacists are ideally placed to raise the issue of poor bone health with patients and encourage people to also speak to their doctor.
“This is specifically important for patients with certain conditions or who are taking medications that may be impacting bone health. For example, in cases where there is prolonged use of corticosteroids and in patients who are taking certain medications for prostate or breast cancer, as well as epilepsy.”
According to the Australian Institute of Health and Welfare (Australia’s health 2020; data insights), certain medicines that act on the central nervous system can be problematic for older people. In particular, anti-dementia, antidepressant, antipsychotic, benzodiazepine and opioid medicines are mentioned, as they are all associated with dizziness or drowsiness and this brings an increased risk of falls.
“For older Australians, falls can also lead to fractures and up to half of all falls occur in the home. Discussing any recent falls and recommending changes in the home to reduce fall hazards (such as bad lighting, uneven rugs, loose chords and any treatments causing dizziness) can assist patients and raise the issue directly,” says Mr Lyubomirsky.
“For anyone aged 50 years and above pharmacists should raise the issuer of osteoporosis risk factors and recommend a visit to the Know Your Bones online self-assessment to review common risk factors for osteoporosis and poor bone health. The national awareness program developed by Osteoporosis Australia and the Garvan Institute of Medical Research has been utilised by nearly 80,000 Australians. Simply advise people to visit www.knowyourbones.org.au. Michelle Bridges has recently been announced as the Know Your Bones Ambassador to help expand the reach of this important prevention initiative,” he adds.
Unfortunately, osteoporosis is referred to as the ‘silent disease’, as often there are no symptoms; suffering a fracture is the first signal that bone health is an issue. Therefore, having the conversation and encouraging people to consider their bone health and know the risk factors is important.
According to Osteoporosis Australia, those people most at risk of osteoporosis include:
- Post-menopausal women or women who have gone through early menopause
- Men and women aged over 50
- Anyone with a family history of osteoporosis
- People with low calcium or vitamin D levels
- People with chronic diseases such as rheumatoid arthritis, liver or kidney disease
- People who are overweight or obese
Three factors in optimal bone health
Mr Lyubomirsky tells The AJP, “Pharmacists and their staff can offer their customers practical advice on ways in which to support their bone health. This includes getting enough daily calcium, exercising regularly and sufficient vitamin D.
“The best way to achieve this is by sustaining a healthy lifestyle by avoiding lifestyle risk factors such as smoking, alcohol and low levels of physical activity.
“Calcium is the major building block for bones; it gives them their strength. The recommended amount of calcium is dependent on your age and gender, however, the most recommended dietary levels are between 1000 – 1300mg per day. When dietary intake is not sufficient a supplement in the range of 500-600 mg per day may be required to boost calcium levels.
“It is difficult to get vitamin D that is required from diet. Vitamin D increases the amount of calcium that is absorbed in the body and the best way to absorb this is through getting enough sunshine. For people who do not get adequate incidental sun exposure, again, a supplement may be required.
“When it comes to exercise, weight bearing activities, including jogging, running, tennis, basketball or volleyball, are great for bone health. Other exercises that create an impact for your bones are resistance training and balance training, which assist in falls prevention.”
Bone health in the era of COVID-19
While COVID-19 has disrupted the lives of many Australians, those people who are recovering from a bone fracture or living with osteoporosis require ongoing treatment.
Medical director of Osteoporosis Australia Professor Peter Ebeling says, “We need to ensure patients are taking medication as advised and getting prescriptions filled on time. However, we also know patients may be reluctant to attend GPs in person for parenteral osteoporosis therapy due to fear of COVID-19, and so are choosing telemedicine consultations instead.”
Pharmacists may be in a position to reassure these patients and offer key recommendations relating to their treatment. Osteoporosis Australia provides the following advice points:
- It’s important that 6-monthly denosumab injections are not delayed by more than 4 weeks.
- If patients will not or cannot attend their GP for injections, two alternatives exist; firstly, any nurse can safely administer the injection; secondly, for patients unable to receive an injection then the patient can be sent a prescription for an oral bisphosphonate, which can be taken until they feel comfortable about re-attending their GP to restart denosumab injections.
- For those people who have changed to an oral bisphosphonate (either alendronate 70mg weekly or risedronate 35mg weekly or risedronate 150mg monthly), the first dose should be taken around the time of the ‘missed’ denosumab dose or as soon as practical after that.
Mr Lyubomirsky adds that pharmacists can support osteoporosis patients during the COVID-19 crisis by providing a clear and consistent message that promotes medication compliance. “We know by keeping patients up to date with their medication we can manage their condition and reduce fractures, thereby avoiding pressure on our already stretched hospital system.
“Pharmacists can also help reduce concerns in people delaying a visit to the doctor due to concerns relating to the coronavirus.”
Furthermore, COVID-related restrictions and social distancing may impact people’s ability to participate in regular exercise or falls-related rehabilitation programs. Indeed, a growing body of evidence supports strength and balance exercise, in particular Tai Chi, to reduce the risk of falls. Yet, Government advice to avoid large gatherings, such as community centres and gyms, may result in people with osteoporosis or at risk missing out on necessary exercise.
Pharmacists can play a vital role in discussing appropriate balance and strength exercises to do at home. In fact, a Cochrane review found that while group-based exercise reduced the rate of falls by 29%, home-based exercise reduced the rate of falls by 32%, with Tai Chi identified as a suitable activity.
Key points regarding falls prevention exercise include:
- Exercise must offer a moderate to high-level challenge to balance;
- The exercise must be of a sufficient dose to have an effect (at least 2 hours per week);
- The benefits of exercise are lost when exercise is ceased, thus ongoing exercise is necessary.
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Australian Institute of Health and Welfare. Australia’s health 2020: data insights. Australia’s health series no. 17. Cat. no. AUS 231. Canberra:
Osteoporosis Australia. Osteoporosis management during COVID-19. Osteoblast Medical Issue. Autumn 2020. Accessed online Sept 2020 via osteoporosis.org.au
Buchbinder R, Haines T et al. Case for Action proposal: Falls and fracture prevention. Submitted by the NHMRC Research Translation Faculty Arthritis and Musculoskeletal Steering Group and the Injury Prevention and Control Steering Group. February 2015. Available here