Osteoporosis in Older Adults - Fracture Prevention and Bisphosphonate Therapy

Key Points

• A fragility hip or vertebral fracture indicates high fracture risk even without a severely low T-score.
• DXA is important, but fracture history and clinical risk factors also drive treatment.
• Evaluate for secondary causes when disease is severe, atypical, or occurs in men or younger patients.
• Fall prevention is part of osteoporosis treatment.
• Bisphosphonates are first-line for many high-risk patients.
• Denosumab should not be stopped without an antiresorptive transition plan.
• Very-high-risk patients may benefit from anabolic therapy followed by antiresorptive therapy.
• Bisphosphonate holidays are individualized and are not equivalent to stopping denosumab.

Algorithm

1. Identify fragility fractures and clinical risk factors.
2. Obtain DXA when appropriate and calculate fracture probability when useful.
3. Check calcium, vitamin D, renal function, and targeted secondary-cause testing.
4. Address falls, exercise, nutrition, smoking, and alcohol.
5. Select antiresorptive or anabolic therapy according to fracture risk and contraindications.
6. Ensure calcium and vitamin D adequacy before potent therapy.
7. Reassess adherence, adverse effects, fractures, and BMD over time.
8. Plan transitions carefully when stopping denosumab or completing anabolic therapy.

Clinical Synopsis & Reasoning

Osteoporosis often remains silent until a low-trauma fracture occurs. A hip, vertebral, proximal humerus, or distal radius fracture after a fall from standing height should prompt evaluation for skeletal fragility even if osteoporosis was never previously diagnosed. Bone mineral density by DXA is central to diagnosis and risk stratification, but treatment decisions also incorporate age, prior fracture, glucocorticoid exposure, family history, smoking, alcohol, falls, secondary causes, and calculated fracture probability. A prior hip or vertebral fragility fracture generally indicates high risk regardless of the exact T-score.

Look for secondary contributors when clinical features suggest them: vitamin D deficiency, hyperparathyroidism, hyperthyroidism, hypogonadism, malabsorption, chronic kidney disease-mineral bone disorder, multiple myeloma, long-term glucocorticoids, anticonvulsants, aromatase inhibitors, and other conditions or therapies. Height loss or new back pain can represent an occult vertebral compression fracture. In men and in patients with unexpectedly severe or rapidly progressive disease, secondary-cause assessment is especially important.

Risk assessment should also include falls because fracture occurs when weak bone meets trauma. Strength and balance training, medication review, vision care, home-safety modification, and assistive devices can reduce fall exposure. Calcium intake should come primarily from diet when practical, with supplementation to meet but not greatly exceed recommended intake. Vitamin D sufficiency supports mineralization and treatment response but very high intermittent doses can increase falls in some populations.

Treatment Strategy & Disposition

Bisphosphonates are first-line therapy for many postmenopausal women and older men at high fracture risk when there is no contraindication. Oral alendronate or risedronate requires ability to follow administration instructions and consideration of significant esophageal disease. Intravenous zoledronic acid is useful when adherence or gastrointestinal tolerance is a concern but requires attention to kidney function and acute-phase reactions. Denosumab is a potent antiresorptive option, including in selected patients who cannot use bisphosphonates, but it should not be stopped or substantially delayed without a transition plan because rebound bone turnover and vertebral fractures can occur.

Patients at very high risk, such as those with multiple vertebral fractures or very low bone density plus recent fracture, may benefit from an anabolic strategy using teriparatide, abaloparatide, or romosozumab depending on clinical context and contraindications, followed by antiresorptive therapy to preserve gains. Romosozumab has cardiovascular warnings that require risk review. Therapy selection should consider kidney function, calcium status, dental health, cost, adherence, and prior treatment.

Reassess fracture risk after several years of bisphosphonate therapy. Some lower-risk patients can take a monitored drug holiday because bisphosphonates remain in bone, while high-risk patients often continue treatment. A drug holiday is not appropriate for denosumab. Repeat DXA timing is individualized based on risk and whether the result will change management. After a fragility fracture, fracture-liaison services can improve treatment initiation and reduce the common care gap between orthopedic repair and osteoporosis management.

Epidemiology / Risk Factors

• Osteoporosis prevalence and fracture incidence rise with age.
• Women are affected more often, but osteoporosis in older men is underdiagnosed and clinically important.
• Hip and vertebral fractures carry substantial morbidity and mortality.
• Many patients remain untreated after a fragility fracture despite clear future risk.

Investigations

When to Treat

Pharmacology

Prognosis / Complications

• Effective pharmacotherapy reduces vertebral and, for selected agents, hip and nonvertebral fractures.
• Risk remains elevated after a first fragility fracture, especially in the next several years.
• Functional recovery after hip fracture is strongly affected by baseline frailty and rehabilitation.
• Long-term outcomes improve when treatment adherence and fall prevention are sustained.

Patient Education / Counseling

• Explain that osteoporosis treatment aims to prevent the next fracture, not simply improve a number on DXA.
• Review the exact administration instructions for oral bisphosphonates.
• Tell patients receiving denosumab not to miss or stop injections without contacting the prescriber.
• Encourage weight-bearing and resistance exercise within mobility limits.
• Discuss adequate protein, calcium, vitamin D, smoking cessation, and moderation of alcohol.
• Report new thigh or groin pain and any interval fracture.

Notes

Osteoporosis care is frequently lost during transitions after fracture. A repaired hip fracture is not the end of treatment; it is evidence of skeletal fragility and a major opportunity for secondary prevention. Assign responsibility for medication initiation, monitoring, and follow-up before discharge. Fracture-liaison models are particularly valuable because they close this ownership gap.

References

1. Endocrine Society: Pharmacological Management of Osteoporosis in Postmenopausal Women — Link