How Pharmacists Can Better Serve Older Female Veterans

Totaling more than 2 million, women comprise the fastest-growing group within the veteran population.

Pharmacists in Texas, California, Virginia, and Georgia may be more likely to encounter female veterans in their practice settings, given that these states have the highest numbers of women veterans, according to the US Department of Veterans Affairs (VA).

Joanne LaFleur, PharmD, MSPH, assistant professor in the Department of Pharmacotherapy at the University of Utah, told Pharmacy Times about 1 important risk factor among veterans that pharmacists should be aware of: hip fractures. Knowing this could help pharmacists identify those at risk and help them prevent osteoporosis or educate them on treatment and adverse effects.

Dr. LaFleur, who is affiliated with the VA Salt Lake City Healthcare System, and her fellow researchers recently examined Women’s Health Initiative data on patients aged 50 to 79 years. Of a cohort of about 145,000 women, 3719 self-reported as veterans and 141,802 self-reported as non-veterans.

Because the VA has to prioritize who receives care, patients who obtain their health care through the VA may be of a lower socioeconomic strata, which is relevant because of the health risks associated with being unemployed or not having the means to pay for health insurance.

These patients are more likely to be smokers and to have higher alcohol intake, which are 2 risk factors for fractures. Therefore, Dr. LaFleur and her colleagues hypothesized that this was the reason why veterans had higher rates of fractures.

However, veterans still had a higher fracture rate even when controlling for these important clinical risk factors. Veterans faced 25% greater odds of a hip fracture than civilians, and they also had higher 10-year probabilities for any major fracture compared with civilians.

Basically, female veterans have increased hip fracture rates that are not explained by differences in well-recognized fracture risk factors.

“We’re not totally positive why women veterans have higher risks,” Dr. LaFleur told Pharmacy Times.

However, she did believe it had something to do with activities or exposures during service years, perhaps related to heavy lifting.

Pharmacists can be helpful resources for this patient population across many platforms, including smoking cessation and weight-loss counseling, Dr. LaFleur said. She also added that in the VA setting, pharmacists play more of a clinical role than what is typically seen in other health care systems.

For example, there is a bone health team within the VA where a clinical pharmacist helps screen patients who are at high risk for fractures. This pharmacist identifies patients and helps them initiate treatment.

“So, in addition to things like managing smoking and weight loss, pharmacists can also be on a health care team that focuses particularly on osteoporosis risk,” Dr. LaFleur said.

Knowing that an individual is a veteran can help pharmacists orient that patient on what it means to be at risk for hip fracture and offer some ways to safeguard against it. Thus, pharmacists can think of veteran status as a risk factor for fractures, just like low body mass index or a history of smoking or falls.

Pharmacists can also educate younger women on how they can reduce their risk for fractures. Some of these tips include getting enough vitamin D and calcium, doing weight-bearing exercises, working on muscle tone, and maintaining proper gait.

In addition, community pharmacies could hold a bone screening day and conduct tests on peripheral bone density for patients with risk factors, including older female veterans.

Yet another area where pharmacists can help is supplementation. Dr. LaFleur mentioned that primary care providers are asking about vitamin D and calcium as a matter of routine care now, and pharmacists can help deficient patients increase their intake. According to LaFleur, deficient vitamin D levels have been associated with many health risks, not just those related to bones.

One helpful counseling point that pharmacists can make is to educate patients on osteonecrosis of the jaw. This is 1 potential adverse event of bisphosphonates that Dr. LaFleur thinks has received a lot of undue attention.

Dr. LaFleur said she has never seen anyone with osteonecrosis of the jaw from bisphosphonates for osteoporosis treatment. The cases she does know about were related to high doses for oncology treatment.

“I think the fear of osteonecrosis of the jaw is a bit overblown,” Dr. LaFleur said. “…That said, they [pharmacists] do need to talk to patients about the potential risk factors with bisphosphonates.

And sometimes, patients can’t tolerate them, so they need to be looking at other treatment options.”

Dr. LaFleur also stressed that osteoporosis isn’t just a women’s health issue. She started studying male osteoporosis in the VA before she took on this research related to older female veterans.

“Male osteoporosis is another huge problem that is really being overlooked,” she said. “Right now, it hasn’t really reached a crisis point, but it’s going to soon.”

With an aging population, and as male veterans in particular get older, osteoporotic fractures will become more of an issue, she said.

A woman at age 50 has about a 60% chance of experiencing an osteoporotic fracture in her lifetime, while a man at age 50 has a 25% chance.

“While their risk is not as high, it is still substantial,” Dr. LaFleur said.

In addition, men have worse fracture outcomes. For instance, they tend to have higher rates of morbidity and mortality, and they are much less likely to regain functionality after a fracture.

“Osteoporosis is a concern in men, and nobody’s paying attention,” Dr. LaFleur said.