New research from the Australian Institute of Health Innovation (AIHI) at Macquarie University shows that doses of the most widely used osteoporosis medication in residential aged care (RAC) are being frequently missed or delayed, leading to rapid weakening of bones in the spine and increased fracture risk for older Australians.

The study published in the British Journal of Clinical Pharmacology analysed medication administration data (2018–2022) from more than 10,600 RAC residents across Australia and found that:

• one in five people prescribed denosumab experienced doses that were delayed beyond recommended timeframes
• almost all residents who stopped denosumab treatment (more than 98 per cent) were not given follow-on bisphosphonate therapy which clinical guidelines recommend should be given for 12 to 24 months as protection against bone loss.

Denosumab is used by 86.9 per cent of older adults on osteoporosis treatment in RAC. Denosumab must be given strictly every six months. Missing or delaying a dose or stopping without appropriate replacement therapy can lead to vertebral fractures due to rapid bone resorption, even with delays as short as 30 days.

Senior author Associate Professor Magda Raban said while there is a belief that once a medicine is prescribed in an aged care home, it will be given correctly and safely, the data challenges this assumption.

“Denosumab works very well when given correctly. But our research shows that in aged care settings, 20 per cent of people prescribed denosumab experienced delayed or missed doses, and when treatment is stopped, residents are almost never given the recommended replacement therapy. This creates a serious and avoidable risk of fractures in a very vulnerable population,” Associate Professor Raban said.

Fractures in older people are associated with pain, loss of mobility, hospitalisation and increased mortality, making osteoporosis management in aged care a critical patient safety issue.

Lead author Marea O’Donnell, a pharmacist and researcher at AIHI, said the problem is not with the medication but with the health system that supports its use.

“Denosumab treatment requires a six-monthly injection, and the logistics of timely ordering and supply can be complex in residential aged care,” O’Donnell said.

The authors note that improved use of electronic medication systems could help prevent errors and ensure the timely supply and availability of injections.

Better coordination across RAC and hospitals, and a stronger role for aged care pharmacists, could help ensure injections are given on time and that safe replacement therapy is initiated if treatment stops, Associate Professor Raban said.

O’Donnell said the findings also highlight the importance of residents and families in medication management.

“Understanding that missed or delayed injections carries real risks empowers residents and families to ask the right questions about medication schedules, transitions to and from hospital and what happens if treatment is interrupted,” O’Donnell said.