An innovative bone health quality improvement for older patients with falls and fractures

Introduction

Fragility fractures are a major cause of morbidity, mortality and loss of independence in frail older adults. Early identification and management of osteoporosis and poor bone health can reduce fracture risk and improve quality of life. NICE and National Osteoporosis Guideline Group (NOGG) guidance recommend osteoporosis risk assessment as part of multifactorial falls assessment and advise bone health assessment for frail older inpatients. We undertook a quality improvement (QI) project at Glangwili Hospital to improve the assessment and management of bone health in older patients at risk of falls and fractures.

Methods

This prospective ongoing QI project was conducted on a Care of the Elderly ward and during consultant-led frailty ward rounds. Consultant in Care of the Elderly (COTE) and Registrar performed bone health assessments and provided recommendations regarding calcium supplementation, vitamin D replacement and antiresorptive treatment. FRAX was not routinely used because of recognised limitations in this patient group, including difficulties obtaining accurate height measurements. All patients underwent clinical risk assessment, renal function testing and bone profile analysis. Serum vitamin D measurements were obtained only when antiresorptive treatment was being considered. Patients presenting with falls were prescribed vitamin D with or without calcium. Those with a history of fragility fracture were considered for antiresorptive therapy where appropriate. Patients with severe dementia or terminal illness were excluded from the analysis.

Results

A total of 131 patients were included between January and July 2026 (66 male, 65 female; age range 65-100 years). Six patients were excluded because of severe illness or contraindications to treatment. Five patients were referred for DEXA scanning.

History of Falls

• Vitamin D treatment increased from 2 patients on admission to 11 on discharge.
• Calcium & Vitamin D remained relatively stable, increasing slightly from 19 to 20 patients.
• Calcium, Vitamin D & AA/RA treatment increased from 4 to 10 patients.
• Prolia was initiated in 7 patients (0 on admission).
• Zoledronic Acid was initiated in 8 patients (0 on admission).

History of Fracture

• Vitamin D treatment increased slightly from 2 to 3 patients.
• Calcium, Vitamin D & AA/RA increased from 5 to 8 patients.
• Prolia use increased from 1 to 4 patients.
• Zoledronic Acid use increased from 1 to 4 patients.

Clinical Frailty Score of 5-8 started on Calcium and Vitamin D- 49 patients

Conclusion

This senior led bone health QI initiative improved assessment and management of osteoporosis risk in frail older inpatients. Increased prescribing of vitamin D, calcium supplementation and antiresorptive therapies demonstrated improved adherence to national guidance and greater recognition of osteoporosis risk factors. Continued education of doctors and ANPs will support sustainability of the project, with the aim of expanding this model to other wards and hospitals to improve bone health outcomes and reduce future falls and fragility fractures.