Osteoporosis and risk of falls

Background (age, sex, occupation, baseline function)

• 81-year-old female
• Retired shop assistant
• Lives alone (widowed 12 years ago)
• Has largely been independent, driving until two years ago
• Rarely leaves the house unless accompanied due to her fear of falls

History of presentation/reason for review

• Falls clinic review after recent fall in kitchen at home (with no fractures)

Current medical history and relevant co-morbidities

• Further falls around the home with no fractures
• Non-valvular atrial fibrillation – seven years ago
• Fractured wrist after fall on ice - eight years ago
• Osteoporosis – 11 years ago
• COPD – 15 years ago
• Osteoarthritis (OA) – 16 years ago
• Hypertension – 24 years ago
• Dyspepsia – 24 years ago

Current medication and drug allergies (include over the counter (OTC) preparation, traditional medicines and herbal remedies)

Allergies or adverse drug reactions (ADRs): nil

Currently prescribed:  

• Alendronic acid 70mg tablets: one tablet weekly
• Anoro Ellipta® dry powder inhaler (DPI): one dose each morning
• Atorvastatin 40mg tablets: one tablet daily
• Calcium 1.5g and vitamin D 400iu chewable tablets: two tablets daily
• Diclofenac gel: apply as needed
• Indapamide 2.5mg tablets: one tablet daily
• Lansoprazole 15mg capsule: one capsule daily
• Paracetamol 500mg tablets: take two tablets when required for pain
• Peptac® liquid: 20ml twice daily
• Ramipril 10mg tablet: one tablet daily
• Salbutamol metered dose inhaler (MDI) 100 micrograms: two puffs when required for breathlessness
• Warfarin tablets 1mg tablets: three tablets daily (target INR 2.5)
• Zopiclone 7.5mg tablet: one tablet at night

Over the counter medicines: Devil’s claw herbal remedy

Lifestyle and current function

• Previously very fit and independent (golfing) and likes to do chair-based exercises daily (watching online)
• Mobile around the house using a walking frame
• Used to cook regularly but now relies on deliveries of ready-made meals
• Gave up smoking 22 years ago (40 pack-year smoking history)
• Drinks alcohol occasionally
• Clinical Frailty Score (Rockwood) 5 (mildly frail)

“What matters to me” (ideas, concerns and expectations of treatment)

• Wants to stay at home and live independently for as long as possible without falls or pain
• Doesn’t find the diclofenac gel useful but is unsure what else she could use for sore knees after falling

Observations, examinations and results 

Note: local laboratory ranges may vary

• Weight 44.9kg, Height 152cm, BMI 19kg/m²
• BP 130/72mmHg, no postural change
• Urea and Electrolytes within normal range
• Creatinine 77micromol/L (60-120micromol/L), calculated creatinine clearance 36ml/min
• FBC within normal range
• INR: 2.5 (target 2.0-3.0)
• HbA1c 54mmol/mol (7.1%)
• Cholesterol 4.9mmol/L (<5.0mmol/L)
• LFTs within normal range
• TSH within normal range
• DXA (Dual-energy X-ray absorptiometry) scan T-score of –2.5 spine and –3 hip (11 years ago)
• QFracture score 36.2

Most recent relevant consultations

• The Advanced Nurse Practitioner visited last week to check urea and electrolytes and blood pressure after recent fall - all observations and results were within normal range
• An occupational therapist has assessed her living accommodation and there are rails, a raised toilet seat and the walking frame is suitable

Person specific issues to address

• Reducing risk of falls and associated fractures
• Provide adequate analgesia

 

Person specific issues to address

• No essential drugs

 

Person specific issues to address

• Check adherence with all therapy as substantial polypharmacy load
• Osteoporosis: alendronic acid taken for over 10 years, could assess the possibility of a treatment pause for two years given the volume of medication and possible GI side effects. Thereafter review again for most suitable bone protection treatment (e.g. parenteral). Establish whether there has been considerable height loss recently to indicate possibility of vertebral fracture and requirement for spinal imaging
• AF: warfarin should be reviewed considering falls risk. A DOAC may be a more suitable option and reduce monitoring requirements
• Hypertension: consider stopping indapamide. May reduce dose of ramipril based on BP target to minimise falls risk. No issues with statin
• Dyspepsia: may benefit from reduction and withdrawal of lansoprazole, use Peptac® symptomatically. Dyspepsia symptoms may be helped by pausing alendronic acid
• Continue calcium and vitamin D supplementation, especially as limited time outdoors
• Review need for zopiclone as this may cause drowsiness the next day, affecting mobility

 

Person specific issues to address

• Analgesia: use paracetamol regularly for pain rather than when required. Reduce the dose to 500mg four times a day, as weight less than 50kg
• Ensure chair-based programme of exercises appropriate to need (physiotherapy input) and look at feasibility of weight bearing exercise
• Review diet with potential for dietitian input

 

Person specific issues to address

• Risk of bleeds when falling – review warfarin choice for AF
• Hypertension target may need to be reviewed to reduce risk of falls. Stop indapamide and review. May also be able to reduce or stop ramipril
• Stop zopiclone as increased risk of sedation and falls risk (phased reduction suggested: reduce to 3.75mg tablets for two weeks then alternate nights for two weeks)
• Potential for interactions (warfarin, lansoprazole, ramipril) with the herbal remedy devil’s claw as interferes with cytochrome p450 metabolism. Advise to stop taking as no known benefit in OA

 

Person specific issues to address

• Salbutamol MDI could be changed to a dry powder inhaler (DPI) to streamline devices. She has sufficient inspiratory flow to manage DPI and this reduces environmental impact
• Diclofenac gel is one of the most polluting pharmaceutical agents and has the potential to interact/interfere with other medication. Discuss continued need or use paracetamol regularly instead
• Ramipril capsules are more cost-effective than tablets
• Advised to dispose of medicines through the community pharmacy
• Advised to only order what is needed, do not stockpile medicines  

 

Agreed plan

• Conduct falls risk assessment (including vision, cognitive function, balance, muscle strength and footwear)
• Exercise plan and dietitian input to encourage muscle bulk and nutrition
• Pause alendronic acid for two years. After two years, review risk and potential benefit of bone protection, where IV bisphosphonate or denosumab may be options
• Change warfarin to a DOAC (refer to local guidance for management of change and formulary choice)
• Stop indapamide and review BP in four weeks. May subsequently be able to reduce ramipril to 5mg daily, monitor BP
• Change ramipril tablets to capsules
• Stop diclofenac gel and take 500mg paracetamol four times a day regularly
• Phased reduction of zopiclone and advise on sleep hygiene methods and resources
• Stop Devil’s claw (herbal remedy)
• Change salbutamol to a DPI (Salbutamol Easyhaler®) for use when needed