Fracture Risk in Nursing Home Residents Initiating Antipsychotic Medications

Objectives To determine whether antipsychotic medication initiation is associated with subsequent fracture in nursing home residents, whether fracture rates differ between users of first- and second-generation antipsychotics, and whether fracture rates differ between users of haloperidol, risperidone, olanzapine, and quetiapine. Design Time-to-event analyses were conducted in a retrospective cohort using linked Medicaid; Medicare; Minimum Data Set; and Online Survey, Certification, and Reporting data sets. Setting Nursing homes in California, Florida, Missouri, New Jersey, and Pennsylvania. Participants Nursing home residents aged 65. Measurements Fracture outcomes (any fracture; hip fracture) in users of first- and second-generation anti-psychotic and specifically users of haloperidol, risperidone, olanzapine, and quetiapine. Comparisons incorporated propensity scores that included individual- (demographic characteristics, comorbidity, diagnoses, weight, fall history, concomitant medications, cognitive performance, physical function, aggressive behavior) and facility- (nursing home size, ownership factors, staffing levels) level variables. Results Of 8,262 subjects (in 4,131 pairs), 4.3% suffered any fracture during observation, with 1% having a hip fracture during an average follow-up period of 93 +/- 71days (range 1293days). Antipsychotic initiation was associated with any fracture (hazard ratio (HR)=1.39, P=.004) and hip fracture (HR=1.76, P=.02). The highest risk was found for hip fracture when antipsychotic use was adjusted for dose (HR=2.96, P=.008), but no differences in time to fracture were found between first- and second-generation agents or between individual drugs. Conclusion Antipsychotic initiation is associated with fracture in nursing home residents, but risk does not differ between commonly used antipsychotics.