Osteoporosis Care Staff Guide: Fracture Risk and Bone Health

Osteoporosis is a condition that weakens the bones, making them fragile and more likely to break. It develops slowly over several years and is often only discovered after a fracture. Because older residents are at the highest risk, and because a broken hip or spine can change a person's life, care staff have an important role in prevention, in recognising when something is wrong, and in making sure treatment is taken correctly.

This guide summarises what the NHS says about osteoporosis, the medicines used, and what that means for everyday care. It does not replace the advice of the resident's GP, pharmacist or specialist team.

What osteoporosis is

The NHS describes osteoporosis as a condition where bones become weak and fragile. The bones most commonly affected are the wrist, hip and spine, though ribs, arms and the pelvis can also break, sometimes after something as minor as a cough or a sneeze. There are usually no symptoms until a bone breaks. Broken bones in the spine are a common cause of long-term pain, and some older people develop a stooped, forward-bent posture.

Who is at risk

The NHS lists several groups at higher risk, including:

• women, especially after an early menopause (before 45) or removal of the ovaries
• people taking high-dose steroid tablets for more than three months
• people with inflammatory, hormone-related or malabsorption conditions
• people with a family history, particularly a parent who broke a hip
• people with a low body weight, a current or past eating disorder, or very little exercise
• heavy drinkers and smokers

Men, younger women and children can be affected too. In care settings, long-term steroid use, poor nutrition and limited mobility often combine, so it is worth asking whether a resident's bone health has ever been assessed.

How osteoporosis is diagnosed

A doctor may estimate future fracture risk using tools such as FRAX or Q-Fracture. The NHS explains that a DEXA scan, a painless bone density scan taking 10 to 20 minutes, produces a T score. A score above -1 is normal, between -1 and -2.5 indicates osteopenia (lower than average bone density, which does not always progress), and below -2.5 indicates osteoporosis. Treatment decisions depend on age, sex, scan results and overall fracture risk, so a resident's care plan should reflect the clinician's advice.

Medicines for osteoporosis

The NHS describes several types of medicine:

• Bisphosphonates (alendronic acid, ibandronic acid, risedronate and zoledronic acid), given as tablets, a liquid or an injection.
• Raloxifene, a daily tablet recommended only for women after the menopause.
• Teriparatide, a daily injection used for a small number of people with very low bone density.
• Denosumab and romosozumab, injections given every month or every few months, used when other medicines cannot be taken or osteoporosis is severe.
• HRT, which can help keep bones strong, with benefits and risks to be discussed with the GP.

The NHS says bisphosphonates usually take 6 to 12 months to work and may be taken for five years or longer.

Giving bisphosphonate tablets safely

The NHS advises that bisphosphonates should always be taken on an empty stomach with a full glass of water. The person must stay upright for 30 minutes afterwards and wait 30 minutes to 2 hours before eating or drinking anything else. Side effects can include irritation of the food pipe, swallowing problems and stomach pain. For care staff, this means building the timing into the medicines round, making sure the resident can sit or stand upright afterwards, and reporting any pain on swallowing, heartburn or chest discomfort. Residents with swallowing difficulties need particular care, so see our guide to dysphagia and choking risk. Check the specific instructions on the resident's medicine record and with the pharmacist, because products differ.

Calcium and vitamin D

The NHS says most healthy adults need 700 mg of calcium a day, usually from a varied diet, but people with osteoporosis may need more, usually as supplements, as advised by the GP. All adults need 10 micrograms of vitamin D a day. Most people get enough from sunlight on the skin between about late March or early April and the end of September, so everyone should consider a daily 10-microgram supplement in autumn and winter. Many care home residents spend little time outdoors, so supplements are an important conversation with the GP. Our guide to nutrition and hydration in care homes explains how to offer calcium-rich foods within a balanced diet.

Preventing falls and fractures

Osteoporosis makes the consequences of a fall more serious. The NHS recommends regular exercise, stopping smoking, reducing alcohol, removing home hazards and keeping up with sight and hearing tests. In a care home, that translates into good lighting, uncluttered walkways, suitable footwear, regular vision and hearing checks and encouraging safe movement. Our guide to falls prevention in care homes sets out a practical approach.

Recognising a possible fracture

Because osteoporosis is painless until a bone breaks, new pain deserves attention. Sudden back pain, new difficulty weight-bearing, a shortened or rotated leg after a fall, or pain that is out of proportion to an apparent injury should be reported at once and escalated using the home's procedures. In an emergency, call 999. Never assume that a resident without obvious injury has not been hurt, particularly if they are living with dementia and cannot describe their pain.

Handling residents with fragile bones

Follow the moving and handling plan for each resident exactly, use the correct equipment and technique, and avoid pulling on limbs. Explain what you are doing, move slowly and ask for help when needed. A resident with osteoporosis should still be supported to be as active as is safe, since movement helps maintain bone strength.

Frequently asked questions

Can osteoporosis be cured?

No, but medicines, nutrition and an active lifestyle can strengthen bones and lower the risk of breaks.

Why do bisphosphonates have such strict instructions?

The NHS explains they need an empty stomach and plenty of water, and the person must stay upright, to help prevent irritation of the food pipe.

Does a normal-looking posture mean healthy bones?

Not necessarily. Osteoporosis is often silent until a fracture occurs, which is why risk assessment matters.

Further learning

Bone health links closely with falls, nutrition, medicines and moving and handling. Our CPD learning for care staff can help you deepen your knowledge. This article draws on NHS osteoporosis information (last reviewed October 2022), so always check the current guidance and the resident's own care plan.