Overcoming barriers to osteoporosis care in vulnerable elderly patients with hip fractures.

Indications for and benefits of providing osteoporosis (OP) care for hip fracture patients have become widely understood. The hip fracture patient is frequently over age 80 years, minimally ambulatory, has multiple medical comorbidities, and has cognitive impairment. Patient barriers to initiation of effective OP treatment include: age, dementia, medical comorbidities, polypharmacy, lack of adherence with treatment, alcohol abuse, postoperative delirium, language barriers, inadequate social support, and socioeconomic status. In a large teaching hospital, 244 patients presented with hip fracture over 2 years: 72% were female and 64% were over age 80. Forty percent had been diagnosed with dementia; another 29% had other severe medical comorbidities.Opportunities for OP diagnosis and treatment are numerous. In acute care hospitals, coordinator facilitated programs are effective for identification, education, assessment, referral, and treatment of underlying OP in fracture patients. System modifications may include an automated care path or automatic specialist referral for hip fracture patients. In the rehabilitation hospital, the patients are in a more stable condition, there is a focus on the recent fracture, and there are opportunities to initiate OP treatment and to promote adherence. In long-term care, dietary intake including calcium and vitamin D supplementation and persistence with pharmacotherapy can be monitored. Patient education and referral to the family physician for osteoporosis investigation and treatment have improved patient knowledge and diagnosis, but the reported impact on treatment has been limited.Effective OP care for the vulnerable hip fracture patient should be initiated early but may be complex and require coordination. In addition to calcium and vitamin D supplementation, most patients in this category have an indication for aminobisphosphonate therapy. Liaison between the orthopaedic team and the discharge destination caregivers, an established discharge diagnosis of osteoporosis, and ensuring patients are discharged on supplements and medication will promote patient, caregiver, and primary care physician awareness of the patient's OP care needs. Education programs may provide benefits at later stages, to improve adherence with treatment.