Yonago Acta medica 2014;57:45–52

Original Article

Bone Mineral Density in Residents of Care Facilities for the Aged and Effect ofPharmacotherapy
Takahiro Tokuda,*†§ Junichi Hasegawa,* Akiko Matsuda‡ and Hiroshi Hagino‡*Division of Pharmacotherapeutics, Department of Pathophysiological and Therapeutic Science, School of Medicine, Tottori University
Faculty of Medicine, Yonago 683-8503, Japan, †Kurayoshi Hospital, Kurayoshi, 682-0023, Japan and ‡Department of Fundamental
Nursing, School of Health Science, Tottori University Faculty of Medicine, Yonago 683-8503, Japan

ABSTRACT

fracture due to osteoporosis leads to serious disabilities
and a decrease in the quality of life, which may evenbe fatal,1 its management has emerged as an importantsocial as well as medical issue.2–4 Osteoporosis used to
be understood simply as aging of bone, but, in the late1980s, a few cohort studies involving local residents
were also carried out in Japan, evaluating the incidence
and effects of fracture due to osteoporosis, and indicating the importance of its prevention.1 Moreover, theconcept of evidence-based medicine proposed in the
1990s has also been adopted in the field of osteoporosis
as a basic position of clinical medicine, and successive
large-scale clinical trials with fracture as an endpoint
have been conducted in Western countries since 1994.
The spread of bone mineral analysis using a bone mineral analyzer and the availability of objective evaluationof the state of bone metabolism based on the measurements of bone metabolic markers have markedly contributed to this trend.3 As a result, in 1998, the Working
Group of the Osteoporosis Study Group, Ministry of
Health, Labour and Welfare Comprehensive Research
on Longevity evaluated and organized information
concerning anti-osteoporosis medications from objective viewpoints on the basis of the concept of evidencebased medicine and prepared the Japanese Guidelines
for the Prevention and Treatment of Osteoporosis.3, 4Thereafter, the necessity of the prevention and treatment of osteoporosis has become widely recognized,
and the guidelines have also been revised and widely
accepted.4
However, patients who can undergo bone mineralscreening or measurement are limited to those who
can visit departments such as the Departments of Orthopedics and Gynecology of a medical facility with

Background

Bone mineral densitometry has been
proven to be a powerful tool for the diagnosis and treatment of osteoporosis, which is increasing with aging of
the population, but opportunities to perform bone mineral densitometry in elderly facility residents, who areat a high risk of fracture, are scarce.
Methods We measured the bone mineral density in
315 residents of 5 care facilities for the aged in middle
Tottori Prefecture from 2002 to 2006. We also evaluated residents of an elderly nursing home with a historyof fragility fracture and those with osteoporosis who
were administered risedronate for its therapeutic effect.
Results
The bone mineral density was less than
70% of the young adult mean in 161 (51.1%) of the 315
subjects (aged 83.1 ± 7.8 years), 149 (57.8%) of the 258
women (83.9 ± 7.2 years), and 12 (21.1%) of the 57 men(79.8 ± 9.3 years). In the 13 subjects who were administered risedronate, the bone mineral density increased
from 65.8 to 67.2% of the young adult mean frombefore to after the beginning of administration, but it
decreased in the control group (n = 9). In those administered risedronate, the urinary level of N-telopeptide (amarker for bone resorption) began to decrease 3 months
after the beginning of the administration and showed asignificant decrease after 11 months (n = 8) comparedwith the control group. The mean pain score based on
the visual analogue scale showed significant reductionin the risedronate group compared with the control
group.
Conclusion The bone mineral density was low in thefacility residents and was less than 70% of the young
adult mean in 57.8% of women and in 21.1% of men,more frequently than expected. Bone resorption andosteoporotic pain were suppressed by risedronate in osteopenic patients in such care facility.

§Present address: Wellness Co., Ltd., 3-84, Kakuban-cho, Yonago
683-0812, Japan
Corresponding author: Junichi Hasegawa, MD
hasegawa@med.tottori-u.ac.jp
Received 2013 December 13
Accepted 2014 January 7
Abbreviations: BMD, bone mineral density; NTX, cross-linked
N telopeptide of type I collagen; VAS, visual analog scale; YAM,
young adult mean

Key words
bone mineral density; care facilities forthe aged; osteoporosis; risedronate; young adult mean

In Japan, patients with osteoporosis are increasing annually with the rapid aging of the population.1 Since
45

T. Tokuda et al.

a bone mineral analyzer. The bone mineral density(BMD) has been shown to increase even in osteoporotic
elderly people by making conscious efforts to walk,5and screening for osteoporosis is considered necessaryfor elderly care such as in long-term care facilities, inwhich many users are elderly people with a low activity level. The number of cases of hip fracture in Japanis estimated to exceed 120 thousand a year, about 10%of those who sustain the injury die within 1 year, andabout 30% show declines in activities of daily living.6
Also, skeletal deformities secondary to fracture cause abedridden state or chronic lumbar pain, hump back, anda decrease in height, which impair activities of dailyliving and increase the necessity for long-term care.7, 8
Many residents of care facilities are elderly people
at a constant risk of fracture associated with falling,etc., and its prevention is very important. The evaluationof factors related to the bone strength as well as lifestyleand living environment is necessary for the preventionof fracture. In this study, the prevalence of osteoporosis
was investigated in residents of long-term care facilities
in middle Tottori Prefecture and the effect of therapeutic intervention was evaluated in those who have few
chances to be prescribed.

Research proposed diagnostic criteria for osteoporosis
by taking the BMD into consideration, and set cutoff
values at < 70% of the mean BMD of those aged 20 to
44 years (the young adult mean; YAM) for osteoporosis
and 70 to 80% of the YAM for low BMD concerning
Japanese women.9 In the 2000 revision, the cutoff value
for the diagnosis of osteoporosis was also evaluated formen, and it was concluded that about 70% of the YAM
was appropriate for the discrimination of a high-risk
group for fracture in men as well as women.10 We adopted this criteria to detect the prevalence of osteoporosis in the residents of care facilities.
Effects of pharmacotherapy

The effects of pharmacotherapy were evaluated in
the residents of a nursing home for the aged in middle
Tottori Prefecture (Nursing Home B, one of 5 facilities). The BMD was measured using an ultrasound bonedensitometer (AOS-100NW, Hitachi-Aloka Medical)
in the right calcaneus. As a treatment, sodium risedronate (Benet, Takeda Pharmaceutical, Tokyo) was
administered at 2.5 mg (once daily) to those with a history of fragility fracture and those with a BMD < 70%
of YAM, and those who consented were followed up.
Residents in Nursing Home B with same conditions as
treated patients and those who consented to non-treatment were also followed up as the control. Risedronate
is expected to reduce bone resorption11, 12 and improve
low back pain even in residents without vertebral fractures.13
Biological indices that specifically reflect bonemetabolism have been confirmed to be useful as bonemetabolic markers for the evaluation of bone turnoverin bone remodeling, classification of disease types, andevaluation of therapeutic effects in metabolic bone disorders such as osteoporosis.14–16 The measurement of
the urinary levels of deoxypyridine and cross-linked N
telopeptide of type I collagen (NTX) for osteoporosis
began to be covered by insurance in December 1999. In
this study, the urinary excretion of the bone resorption
marker NTX was measured as an index of the therapeutic effect every 3 months for about 1 year. The measurement, commissioned to SRL (Tokyo, Japan), wascarried out by enzyme-linked immunosorbent assay.
For evaluation of the urinary NTX level, the value wascorrected for the creatinine level [creatinine-corrected
NTX level = (NTX concentration/creatinine concentration) × 11.3] in consideration of the effect of the renal
function.
The number of fracture cases was investigated by
preparing a check sheet and obtaining cooperation of
the staff of Nursing Home B. As for physical findings,

SUBJECTS AND METHODSThis study was carried out with approval (approval number 2301) by the Ethics Committee of Tottori University.
Prevalence of osteoporosis

The study was carried out between 2002 and 2006 in
315 who consented to cooperate in the study of 450 residents of 5 care facilities for the aged in middle Tottori
Prefecture. The total capacity of 8 facilities were 572 in
maximal number in the same district, residents of rest 3
facilities were not requested because of the lack of permission from the head of these facilities.
The BMD was measured using an ultrasound bonemineral densitometer (AOS-100NW, Hitachi-Aloka
Medical, Tokyo, Japan) in the right calcaneus. This densitometer was convenient to use at care facilities for theaged, because it required a short time for measurement,
permitted dry measurement without using water, andneeded no special facility as it emitted no radiation.
For comparison of the BMD with middle-aged toelderly residents of the same area in middle Tottori Prefecture, it was also measured in those who underwent
comprehensive health screening at Hospital A and consented to the measurement (using an ultrasound bonemineral densitometer, Benus III, Ishikawa Seisakusho,
Hakusan, Japan).
In 1996, the Japanese Society for Bone and Mineral
46

BMD of aged residents in care facilities

The difference between the BMD in facility residents
and in health screenees (control) is apparent even in thesame age groups.
Effects of pharmacotherapy

In the subjects at Nursing Home B, the administrationof sodium risedronate was recommended to 14 andinitiated in 13 (2 men and 11 women with a mean ageof 83.0 ± 5.3 years, range: 77–91 years). The patients’records showed that all patients had good compliancewith their prescribed regimen. Fourteen similar residents (1 men and 13 women with a mean age of 87.6 ± 5.5
years, range: 83–100 years) who consented were allocated to the control. The BMD in the patients in whom
it could be measured before and after the treatment (n =6) was 65.8 and 67.2% of the YAM, respectively (Fig. 3).
Its changing rate is +2.0 ± 2.0% in the treated subjects
and –3.5 ± 2.2% in the controls (n = 9) (P = 0.06).
Of the patients administered sodium risedronate,urine samples could be obtained during the treatment
period from 8. The urinary NTX level (creatininecorrected) decreased significantly 3 and 11 months after
the beginning of the administration compared with the
pre-administration value and was significantly lower
than in the control group after 11 months (Fig. 4).
During the observation period, no fracture occurredin the treated or control group. The mean pain scoreon the VAS decreased by 16.0 ± 5.8 mm in the treatedgroup but showed slight decrease by 2.3 ± 4.1 mm in
the control group. There is a significant difference between these values (P < 0.05).
The mean systolic blood pressure was 126.4 ± 4.1
mmHg before and 125.7 ± 4.5 mmHg after the administration in the treated group. In the control group,

Fig. 1. BMD in facility residents. The BMD of the right calcaneus in 315 residents of 5 care facilities for the aged is expressedas the percentage of the YAM (vertical axis) and plotted against
age (horizontal axis). In women ( ), the approximation line is y =–0.2762x + 92.69 (solid line). In men ( ), the approximation line
is y = –0.1321x + 87.667 (dashed line). BMD, bone mineral density; YAM, young adult mean.

changes in the blood pressure were investigated using
medical records. Pain was evaluated by quantification
using Huskisson’s visual analog scale17 (VAS; 0 mm =no pain, 100 mm = worst pain possible).
Statistics

Data of the 2 groups were compared using Student’s ttest.
RESULTS
Prevalence of osteoporosis

The 315 subjects consisted of 57 men (mean age: 79.8 ±9.3 years, range: 58–97 years) and 258 women (83.9 ± 7.2
years, range: 53–100 years). The approximation curveof the relationship between the BMD as the percentage of the YAM and age was y = –0.2762x + 92.69 in
women and y = –0.1321x + 87.667 in men (Fig. 1).
The BMD was < 70% of the YAM in 161 (51.5%)of the 315 subjects, 149 (57.8%) of the 258 women, and
12 (21.1%) of the 57 men. The percentage of those inwhom the BMD was < 70% of the YAM was about 2.4fold higher in women. As shown in the right of Fig. 2,
in those who underwent comprehensive health screening at Hospital A, it was < 70% of the YAM in only 1(1.1%) of all 91 subjects, 1 (1.3%) of the 78 women andnone (0%) of the 13 men. The relationship between the
BMD as the percentage of the YAM, the rate of BMD< 70% of the YAM and age are shown also in Table 1.

Fig. 2. Percentage of those with a BMD < 70% of the YAM in
facility residents and health screenees. The left graph shows
the percentages of those with a BMD < 70% of the YAM in all(51.1%, grey column), female (57.8%, white column) and male
(21.1%, black column) facility residents. The right graph shows
the percentages in all (1.1%), female (1.3%) and male (0%) healthscreenees. BMD, bone mineral density; YAM, young adult mean.

47

T. Tokuda et al.
Table 1. BMD and number of those < 70%YAM by age groupAge group (yr)
50–59
60–69

70–79

80–89

90–99

100–109

Total

Total number
BMD (%YAM)< 70% YAM2		
76 ± 12.7
1 (50%)

15		
77.8 ± 9.6*
2 (13.3%)

74		
73.3 ± 8.6*
26 (35.1%)

155		
69.9 ± 9.0
85 (54.8%)

68
68.9 ± 7.3
47 (69.1%)1		
70
0 (0%)

315

FemaleBMD (%YAM)< 70%YAM1		85		
0 (0%)

8		
75.1 ± 7.8*
2 (25%)

55		
71.8 ± 7.3
23 (41.8%)

133		
68.7 ± 7.5
81 (60.9%)

60		
68.1 ± 6.2
43 (71.7%)

1		
70
0 (0%)258

Male
BMD (%YAM)< 70%YAM1		67		
1 (100%)7		
80.9 ± 11
0 (0%)

19		
77.7 ± 10.7
3 (15.8%)

22		
76.9 ± 13.7
4 (18.2%)

8		
74.5 ± 11.9
4 (50%)

0		

57

Total number
BMD (%YAM)< 70% YAM40		
93.4 ± 12.9
1 (2.5%)4		
93.4 ± 11.6
0 (0%)

3 								88.6 ± 3.1
0 (0%)

47

FemaleBMD (%YAM)< 70% YAM

34		
92.6 ± 12.9
1 (2.9%)4		
93.4 ± 11.6
0 (0%)

1								88.40 (0%)

39

Male
BMD (%YAM)< 70% YAM6		
97.8 ± 13.3
0 (0%)

0 		
–		
–		

2 							88.8 ± 4.3
0 (0%)

8

Residents

0 (0%)

Controls

Residents: residents in 5 care facilities for the aged. Controls: health screenees at Hospital A.
< 70%YAM, number of subjects in whom the BMD is < 70% of the YAM; BMD (%YAM), bone mineral density as the percentage of the
YAM (%YAM); YAM, young adult mean (age: 20–44 years).
*P < 0.05 compared with the values in control.

DISCUSSION
There are many reports describing the BMD in the elderly patients or elderly community residents. However,We have little knowledge about BMD of the aged in
the care facilities especially in the Tottori Prefecture
due to lack of chances to measurement. It is the first report concerning the BMD for such facility residents in
Tottori prefecture. In the present study, we showed thatthe BMD was lower in older subjects, as was generally
expected in the residents of 5 care facilities for the aged.
Fujiwara et al. evaluated bone mineral densitometry
data of 3,248 persons among the subjects of an epidemiological study selected from citizens of Hiroshima
and Nagasaki Cities and reported, according to the diagnostic criteria of 1996, that the prevalence of osteoporosis was 24% (BMD in the lumbar vertebra) and 27%(BMD in the hip) in women aged 50 years and above.18
In males aged 50 years and above, also, they reported
that 3.2% were diagnosed with osteoporosis with a cutoff BMD of < 70% of the YAM (lumbar vertebra).18 It
was low in more women than men, showing a genderdifference. Since a gender difference similar to thatobserved in this study has been reported in many previous regular studies,19 and moreover, from the genderand age distribution of the prevalence of osteoporosis,

however, it had somewhat increased from 125.3 ± 4.6mmHg to 132.3 ± 4.0 mmHg at the end of the observation period, without significant difference in changes
between the 2 groups..

Fig. 3. Changes in the BMD as a percentage of the YAM between
before and after the administration of sodium risedronate. The left
bar graph shows the mean BMD as a percentage of the YAM in
the risedronate-treated group before (left) and after (right) the administration (n = 6). The right graph shows the mean values in thecontrol group before (left) and after (right) the same observation
period (n = 9). Data are expressed as mean ± SEM. BMD, bonemineral density; YAM, young adult mean.

48

BMD of aged residents in care facilities

acteristic of the facility residents or combined effects ofmultiple factors. Concerning Western populations resembling the subjects of our study, there is also a reportthat osteoporosis was observed in 47% of the postmenopausal women (mean age: 79 ± 10 years) admitted to anursing home who underwent BMD measurements.22
Compared with this value, also, the prevalence of osteoporosis in our subjects (57.8%) was high.
However, the prevalence of osteoporosis was markedly lower in the health screenees than in the facility
residents, probably because the health screenees weremore active and younger. Therefore, to detect osteoporosis, it is considered necessary to screen those consulting for medical services other than a comprehensive
health checkup. Also, as the subjects of this study were
facility residents, investigation of, and comparison with,the elderly living at home are considered necessary.
Recently, a nation-wide survey in Japan revealed
rapid increases in hip fracture over the last 10 years, andthe necessity of treatment for osteoporosis and measures
to prevent falls as well as appropriate treatment for hip
fracture has been suggested.23 In Japan, bisphosphonate
is most widely known and studied among drugs for thetreatment of osteoporosis.1 Risedronate is a bisphosphonate which reduces resorption and bone turnoverby inhibiting osteoclast activity. Risedronate has beenshown to increase BMD and inhibit vertebral and hip
fractures. Then, bisphosphonate preparations including
sodium risedronate have been administered to patientswith osteoporosis alone,24 those with osteoporosis andvertebral fracture,11, 12 and those after stroke,25, 26 andtheir effectiveness for fracture prevention and costeffectiveness have been evaluated. Among these studies, Ding et al.27 reported that the cost-effectivenessof risedronate was poor in Japanese women aged 55
years or above and even those aged 70 years or above ifthey have no history of vertebral fracture. However, on
the basis of the results of a survey of residents of various care facilities including homes for elderly people
with dementia in the United Kingdom, Aspray et al.28
contended that the risk of fracture at these facilities isignored and that treatment is necessary. As far as wesearched, effect of risedronate has not been examinedin the residents in care facilities except for hospitalized
disabled patients after stroke in Japan.25 In this regard,
it appears reasonable that patients who consented weretreated at our study in care facilities for prevention
against new fracture, and reduction of pain13 concerning low bone mass.
There is a report that bisphosphonate increases the
BMD but its preventive effect on postmenopausal fracture is insufficient without sufficient drug compliance,29

Fig. 4. Changes in the creatinine-corrected urinary cross-linked
N telopeptide of type I collagen (NTX) level. Changes in thecreatinine-corrected urinary NTX level after the administrationof sodium risedronate at 2.5 mg are shown as a ratio of the value
before administration (= 1). The values in the group administeredsodium risedronate ( ) showed significant decreases after 3 and11 months ( ) compared with the pre-administration value (n = 8).
The values in the control group ( ) also fluctuated but showed nosignificant change compared with the pre-administration value (n= 7). The urinary NTX concentration did not differ significantly
between the risedronate-treated and control groups before the administration but differed significantly after 11-month administration (†). Data are expressed as mean ± SEM.

Yamamoto reported that the prevalence of osteoporosis
was increasing with age in both men and women andthat it was about 3-fold higher in women than in men.20
In our study, also, the prevalence of osteoporosis in thefacility residents was about 2.4-fold higher in womenthan in men. In our subjects, women were predominant,accounting for 81.9%. This may be related to very low
bone mass of this study.
The percentage of those in whom the BMD of thelumbar vertebra was < 70% of the YAM among women
aged 50 years and above, calculated from the populationin 2000 estimated by the Ministry of Health, Labourand Welfare was reported to be 29.2%.3 The percentageof those in whom the BMD of the calcaneus was < 70%of the YAM in women aged 50 years and above among
the subjects of this study was about 57.8%, and this highfrequency is suspected to be due to the presence of underlying diseases and the consequent low activity level.
Yamazaki et al. reported that the BMD increases due tosuppression of bone turnover in postmenopausal women
regularly practicing outdoor walking compared withthose with no such habit.5 It has also been reported thatthe decrease in the BMD during a 10-year period wascorrelated with a decrease in activities of daily living inpeople aged 60 years and above.21 Considering these reports, the low bone mass observed in our subjects may
have been associated with a low activity level as a char49

T. Tokuda et al.

and a significant correlation between the compliancewith bisphosphonate therapy and risk of fracture has
been noted.30 Particularly, drug compliance is likely to
be poor when patients are asymptomatic, as in osteoporosis, and marked compliance has been reported to berelated to BMD measurement after the administration
and being nursing home residents,31 both of which applied to our subjects. In this study, as a result of checking the administration using a check sheet, compliancewith the risedronate therapy was satisfactory. Therefore,
while the BMD decreased by 3.5% of the YAM in thecontrol group, it increased by 2% in the treated group,
probably because of the effect of the administration.
A long time is needed to evaluate the fracturepreventive effect, which is the ultimate objective oftreatment for osteoporosis, and the BMD and bonemetabolic markers, which suggest the course of itschanges, are monitored as short-term indices. Bone
formation and bone resorption play key roles in maintaining the bone mass and quality. There are different
markers of bone formation and resorption, and they areuseful because their measurements by blood tests or
urinalysis permit simple evaluation of the state of bonemetabolism.16 If bone turnover is enhanced, aggressive
treatment is considered necessary, because not only is
the decrease in the BMD accelerated, but also the riskof fracture is increased regardless of the BMD.32 Human bone is composed primarily of calcium phosphate
and type I collagen, and if bone is decomposed byosteoclasts, NTX, a degradation product of type I collagen, is excreted into blood and, then, urine. Therefore,
the degree of bone decomposition can be evaluated bymeasuring urinary NTX, and the urinary NTX level isused for the diagnosis of osteoporosis and its responses
to treatment.15, 16 The urinary NTX level, which reflectsbone resorption, has been reported to be inversely correlated with the BMD, to be reduced by antiresorptive
therapies, and to be more sensitive than the serum NTX
level.33 While the BMD is an index representing theresults of past bone metabolism, the NTX level represents the present degree of bone resorption and predicts
decreases in the BMD in the near future.15 Thus, people
with a high NTX level are considered to reach a highrisk zone for fracture earlier than those with about thesame BMD but a low NTX level.15 Therefore, people
with a low bone mass and low NTX, in particular, may
require more aggressive treatment. In treating osteoporosis or reducing the risk of fracture, a bone turnovermarker is considered to be significant as an intermediate
endpoint in an early period of treatment before changes
in the BMD become clear.34 Eastel et al.35 reported not
only that early changes in the bone-turnover marker

level were predictive of changes in the BMD, but alsothat changes in the urinary NTX level 3 to 6 months
after the beginning of treatment with risedronate, etc.,
were correlated with decreases in the risk of vertebral
fracture. In this study, the creatinine-corrected urinary
NTX level decreased in the group treated with sodium
risedronate, suggesting that the drug suppressed boneturnover and reduced the risk of fracture.
Since the administration of sodium risedronate had
been reported to be useful for improving the qualityof life24 as well as preventing spinal fracture and therecurrence of femoral fracture,36 similar effects were
expected in this study. Indeed, the significant difference
between the decrease in the pain score in the control
group and in the treated group may have been due toimprovement of pain induced by osteoporosis or disorders associated with a low bone mass. However, no
fracture was observed during the observation period in
the treated or control group. This is considered to berelated to the small number of subjects and short observation period.
The systolic blood pressure was slightly increasedin the control group. This increase in the systolic bloodpressure may be related to a decrease in the BMD. Thisis because reports that a low Ca intake and decreasein the BMD associated with Ca loss were related to anelevation of the blood pressure37–39 and an increase in
the arterial stiffness was correlated with a decrease in
the BMD in hypertensive patients40 suggest a relationship between a decrease in the BMD and an elevationof the blood pressure. However, as there is also a reportthat the BMD was not associated with hypertension,41
further evaluation is necessary.
There are some limitations to our investigation.
First, in this study, we used the criteria proposed in the
diagnostic guideline 200010 to diagnose the osteoporosis because this survey had been planned and performed
between 2002 and 2006. In the 2012 revision of theguideline,42 for the definite diagnosis of osteoporosis,
ultrasound bone mineral densitometry determined to be
not appropriate. Second, the number of residents is too
small, and especially to detect a pharmacological effecton the prevention of the bone fracture, the observation
period is too short.
The authors declare no conflict of interest.
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