What is the best approach to treating osteoporosis in a 91-year-old woman?

From the Guidelines

Treatment of osteoporosis in a 91-year-old woman should prioritize a comprehensive approach that includes calcium and vitamin D supplementation, fall prevention strategies, and consideration of bisphosphonates or denosumab, weighing the benefits against potential side effects and the patient's overall health status, as recommended by the American College of Physicians 1. The goal of treating osteoporosis in elderly patients is to reduce the risk of fractures, which can significantly impact morbidity, mortality, and quality of life.

Key Considerations

• Calcium supplementation (1000-1200 mg daily) and vitamin D (800-1000 IU daily) are essential components of osteoporosis treatment, as they support bone health and may help prevent fractures 1.
• Fall prevention strategies, including home safety assessments, vision checks, and appropriate assistive devices, are crucial in reducing the risk of falls and subsequent fractures.
• Bisphosphonates, such as alendronate or ibandronate, may be considered for patients with osteoporosis, but their use should be cautious due to potential side effects, including esophageal irritation and rare complications like atypical femur fractures 1.
• Denosumab offers an alternative for patients who cannot tolerate bisphosphonates, with the advantage of no renal clearance concerns 1.

Treatment Approach

The treatment approach should be individualized, taking into account the patient's fracture risk, comorbidities, life expectancy, and medication burden.

• Regular weight-bearing exercise within the patient's capabilities should be encouraged to maintain bone density and muscle strength.
• Monitoring should include periodic bone mineral density testing every 2-3 years and assessment of vitamin D levels. This balanced approach addresses the immediate fracture risk while considering the unique challenges of medication management in very elderly patients.

Evidence-Based Recommendations

The American College of Physicians recommends offering pharmacologic treatment with alendronate, risedronate, zoledronic acid, or denosumab to reduce the risk for hip and vertebral fractures in women with known osteoporosis 1. However, the decision to treat should be based on a discussion of patient preferences, fracture risk profile, and benefits, harms, and costs of medications, particularly in elderly patients with complex health needs 1.

From the FDA Drug Label

The safety of Prolia in the treatment of postmenopausal osteoporosis was assessed in a 3-year, randomized, double-blind, placebo-controlled, multinational study of 7808 postmenopausal women aged 60 to 91 years A total of 3876 women were exposed to placebo and 3886 women were exposed to Prolia administered subcutaneously once every 6 months as a single 60 mg dose.

The treatment of osteoporosis with denosumab (Prolia) can be helpful for a 91-year-old woman, as the drug label includes data from a study that involved women aged 60 to 91 years 2. However, it is essential to consider the potential adverse reactions and ensure that the patient is taking the recommended calcium and vitamin D supplementation to minimize the risk of hypocalcemia. The decision to treat osteoporosis in a 91-year-old woman should be made on a case-by-case basis, taking into account the individual's overall health and medical history. Key considerations include:

• The patient's renal function, as impaired renal function may increase the risk of hypocalcemia
• The patient's ability to tolerate the injections and potential side effects
• The potential benefits of treatment in preventing fractures and improving bone density

From the Research

Treatment Options for Osteoporosis in a 91-Year-Old Woman

• Bisphosphonates, such as alendronate and risedronate, are safe and effective agents for the treatment and prevention of osteoporosis, increasing bone mass and reducing the risk of vertebral and nonvertebral fractures 3.
• Antiresorptive drugs, including bisphosphonates and denosumab, are currently the most widely used osteoporosis medications, increasing bone mineral density and reducing the risk of fractures 4.
• Anabolic therapy with teriparatide has been shown to be superior to bisphosphonates in preventing vertebral and clinical fractures in postmenopausal women with vertebral fracture 4.
• Sequential treatment, starting with a bone-building drug followed by an antiresorptive, may provide better long-term fracture prevention for patients with severe osteoporosis and high fracture risk 4.

Considerations for Treatment

• The use of bisphosphonates has been limited to up to 10 years with oral bisphosphonates and 6 years with intravenous zoledronic acid due to the risk of rare side-effects 4.
• Lifestyle modification with nutritional counseling, exercise, and calcium and vitamin D supplementation is recommended as an adjunct to pharmacologic management of osteoporosis 5, 6.
• Improved household safety and the use of hip protectors can reduce the risk of falls and fractures 6.

Patient Selection and Monitoring

• Bone density testing is recommended for women aged 65 years and older, younger postmenopausal women with risk factors, or to follow therapy 5.
• The fracture risk assessment tool (FRAX) and Fracture Liaison Services can be used to identify patients at high risk of fracture and increase treatment rates 4.
• Monitoring and duration of treatment should be considered on an individual basis, taking into account the benefits and risks of treatment 7.