Breaking Bone: Vulnerability, Assessment, and Prevention

Fragile Balance: Managing Bone Health in People with Intellectual Disability and Epilepsy, an English Multi-Site Study Menon R, Young C, Dale M, Allen M, McCabe J, Badger S, Appleyard M, Mousailidis G, Newman R, Jory C, Hammett J, Swift A, Jones C, Sawhney I, Winterhalder R, Watkins L, Shankar R. Seizure . 2025;133:189-194. doi:10.1016/j.seizure.2025.10.018. Epub ahead of print. PMID: 41183451. Background: People with intellectual disability (ID) experience poorer health outcomes than the general population, with epilepsy and polypharmacy contributing to further risks. Bone health is a neglected area, despite the established association between antiseizure medications (ASMs) (especially those cautioned by the UK Medicines and Healthcare products Regulatory Agency [MHRA]), and reduced bone mineral density. We aimed to evaluate prescribing practices, fracture risk, and bone health management in adults with ID and epilepsy attending specialist ID services. Methods: A cross-sectional study was conducted across 3 English specialist ID epilepsy services between August 2021 and August 2022. Data were collected from case-note review, including ASM prescribing, falls and fracture history, bone health monitoring, and protective treatments. Descriptive statistics, Chi-square, and Mann-Whitney U tests were conducted. Logistic regression was used to examine associations between ASM use and fracture risk. Results: Of 484 adults analyzed, almost all (97%) were prescribed ≥1 ASM, with 18% receiving 4 or more and 63% receiving at least one MHRA-cautioned ASM. Over 25% on MHRA-cautioned ASMs had a history of fractures, yet 38% received no bone-protective treatment. Patients with severe-profound ID were prescribed significantly more ASMs than those with mild-moderate ID. Each additional ASM increased fracture risk by 37%, and each additional MHRA-cautioned ASM by 43%. Conclusions: Adults with ID and epilepsy are frequently exposed to polypharmacy, including bone health–compromising ASMs, yet bone health monitoring and treatment remain suboptimal. Targeted strategies and ID-specific guidance are urgently required to reduce fracture risk and improve outcomes in this vulnerable group.