What are the recommended preventive measures for an 84-year-old female with a DEXA (Dual-Energy X-ray Absorptiometry) overall risk score of 3.9 for hip fracture in the next 10 years?

From the Guidelines

For an 84-year-old female with a DEXA risk score of 3.9 for hip fracture in the next 10 years, I strongly recommend implementing a comprehensive fracture prevention strategy, prioritizing bisphosphonate therapy, calcium and vitamin D supplementation, weight-bearing exercises, and fall prevention measures to minimize morbidity, mortality, and improve quality of life. This approach is supported by the most recent guidelines, including those from the American College of Rheumatology 1.

Key Components of the Prevention Strategy

• Bisphosphonate Therapy: Starting a bisphosphonate medication such as alendronate (Fosamax) 70mg once weekly or risedronate (Actonel) 35mg once weekly is crucial. These medications inhibit bone resorption, effectively slowing bone loss 1.
• Calcium and Vitamin D Supplementation: Daily supplementation with 1200mg of calcium and 800-1000 IU of vitamin D3 is essential to support ongoing bone mineralization 1.
• Weight-Bearing Exercises: Performing weight-bearing exercises 2-3 times weekly, focusing on balance training and gentle resistance exercises, helps maintain bone density and improves balance and muscle strength, reducing fall risk 1.
• Fall Prevention Measures: Home safety modifications, such as removing trip hazards, installing grab bars in bathrooms, ensuring adequate lighting, and using assistive devices if needed, are critical. Hip protectors may also provide additional protection during daily activities 1.

Considerations

• Given her advanced age, medication selection should consider renal function and overall health status.
• Monitoring for potential side effects of bisphosphonates, such as esophageal irritation, is necessary.
• The patient's high fracture risk, indicated by a DEXA score of 3.9, necessitates a proactive approach to prevent osteoporotic fractures and their associated morbidity and mortality 1.

From the FDA Drug Label

The incidence of hip fracture was 1.2% for placebo-treated women compared to 0.7% for Prolia-treated women at year 3. The age-adjusted absolute risk reduction of hip fractures was 0.3% with a relative risk reduction of 40% at 3 years (p = 0.04)

• Recommended preventive measures for an 84-year-old female with a DEXA overall risk score of 3.9 for hip fracture in the next 10 years may include:
  • Treatment with denosumab (Prolia) to reduce the risk of hip fractures, as it has been shown to have a relative risk reduction of 40% at 3 years
  • Ensuring adequate calcium and vitamin D supplementation daily, as all women in the study received at least 1000 mg calcium and 400 IU vitamin D supplementation daily 2
• It is essential to note that the study results are based on a population with a mean age of 72 years, and the patient in question is 84 years old, which may affect the applicability of the results.

From the Research

Preventive Measures for Hip Fracture

Given the DEXA overall risk score of 3.9 for hip fracture in the next 10 years for an 84-year-old female, several preventive measures can be considered:

• Pharmacological interventions:
  • Bisphosphonates have been shown to be effective in preventing hip fractures among older adults 3
  • Teriparatide, denosumab, and other bisphosphonates may also be effective in reducing the risk of fragility fractures 4
  • Antiresorptive medications, such as bisphosphonates and denosumab, may improve survival and reduce the risk of refracture in patients with hip fracture 5
• Non-pharmacological interventions:
  • Fall prevention strategies are crucial in preventing hip fractures, especially in frail older adults 3
  • Assessment of clinical risk factors, such as previous fracture and family history of fractures, can help identify patients at high risk of fracture 6
• Importance of DEXA scans:
  • DEXA scans can be useful in assessing fracture risk, especially in women aged 50-69 years without previous fracture 6
  • However, in women over 80 years old, clinical risk factors alone may be sufficient to make therapeutic decisions, and DEXA scans may not add significant value 6

Considerations for Treatment

When considering treatment for an 84-year-old female with a high risk of hip fracture:

• The US Preventative Services Task Force recommends consideration for screening for osteoporosis in women under age 65 who have an estimated 10-year major osteoporotic fracture risk of 9.3% or higher 7
• However, this threshold may have a low sensitivity to detect osteoporosis in women ages 50-64 years old 7
• A lower FRAX risk threshold may be considered to increase the sensitivity of detecting osteoporosis, but this may also reduce the specificity 7