What is the osteoporosis workup for elderly female patients?

From the Guidelines

The osteoporosis workup for elderly female patients should begin with a comprehensive assessment including a dual-energy X-ray absorptiometry (DXA) scan to measure bone mineral density at the hip and spine, as recommended by the American College of Physicians in their 2023 guideline 1. This assessment is crucial for identifying patients at high risk of fractures and for guiding treatment decisions. The workup should also include laboratory tests such as complete blood count, comprehensive metabolic panel, 25-hydroxyvitamin D level, thyroid-stimulating hormone, and calcium levels to rule out secondary causes of osteoporosis. A fracture risk assessment using the FRAX tool should be performed to estimate the 10-year probability of major osteoporotic fracture, as suggested by the 2017 American College of Physicians guideline 1. Additional testing may include parathyroid hormone levels, 24-hour urinary calcium, and bone turnover markers like serum C-telopeptide (CTX) or procollagen type 1 N-terminal propeptide (P1NP) in certain cases. Medical history should focus on risk factors such as previous fractures, family history, early menopause, smoking, alcohol use, and medications that affect bone health like glucocorticoids. Physical examination should include height measurement to detect vertebral compression fractures, assessment of fall risk, and evaluation of balance and gait. This comprehensive workup allows for appropriate treatment decisions, which may include calcium (1000-1200 mg daily) and vitamin D (800-1000 IU daily) supplementation, along with pharmacologic therapy such as bisphosphonates (alendronate 70 mg weekly), denosumab (60 mg subcutaneously every 6 months), or anabolic agents like teriparatide (20 mcg subcutaneously daily) for high-risk patients, as recommended by the 2023 American College of Physicians guideline 1. Early diagnosis and intervention are crucial as osteoporosis significantly increases fracture risk, leading to substantial morbidity and mortality in elderly women, highlighting the importance of a thorough workup and evidence-based treatment approach 1.

Some key points to consider in the workup and management of osteoporosis in elderly female patients include:

• The importance of individualized treatment selection based on comorbidities and concomitant medications associated with higher risk for falls/fractures, as noted in the 2023 American College of Physicians guideline 1.
• The need for regular assessment of baseline risk for fracture and adjustment of treatment accordingly, as recommended by the 2023 American College of Physicians guideline 1.
• The potential benefits of physical activity in preventing osteoporosis, as highlighted in the 2020 systematic review on physical activity and osteoporosis prevention in older people 1.
• The importance of considering the patient's overall health status, including risk factors for falls and fractures, when making treatment decisions, as emphasized in the 2017 American College of Physicians guideline 1.

By following a comprehensive and evidence-based approach to the workup and management of osteoporosis in elderly female patients, healthcare providers can help reduce the risk of fractures and improve outcomes for these patients.

From the Research

Osteoporosis Workup for Elderly Female Patients

The osteoporosis workup for elderly female patients typically involves a combination of clinical risk factors, bone mineral density (BMD) testing, and fracture risk assessment tools.

• The World Health Organization (WHO) FRAX algorithm is a widely used tool for assessing 10-year fracture risk in postmenopausal women and older men 2.
• FRAX uses clinical risk factors such as age, gender, body mass index, ethnicity, smoking, alcohol use, glucocorticoid use, rheumatoid arthritis, and secondary osteoporosis, as well as BMD testing, to quantify a patient's 10-year probability of a hip or major osteoporotic fracture 2.
• The National Osteoporosis Foundation Clinician's Guide recommends treating patients with FRAX 10-year risk scores of ≥3% for hip fracture or ≥20% for major osteoporotic fracture to reduce their fracture risk 2.
• Other fracture risk assessment tools, such as the Osteoporosis Self-assessment Tool, Osteoporosis Risk Assessment Instrument, and Simple Calculated Osteoporosis Risk Estimation, have also been validated for use in postmenopausal women 3.
• The FRACTURE Index is another assessment tool that can be used to predict hip fracture risk in postmenopausal women, and is comprised of seven variables including age, BMD T-score, fracture after age 50, maternal hip fracture after age 50, weight, smoking status, and use of arms to stand up from a chair 4.

Treatment Options

Treatment options for osteoporosis in elderly female patients may include:

• Bisphosphonates, such as alendronate and risedronate, which have been shown to prevent bone loss and reduce fractures in postmenopausal women 5.
• Estrogens and selective estrogen receptor modulators (SERMs), such as raloxifene, which can help prevent bone loss and reduce fracture risk in postmenopausal women 5.
• Calcitonin, which can increase bone mineral density and reduce fracture risk in postmenopausal women 5.
• Teriparatide, which can increase bone formation and reduce fracture risk in postmenopausal women 5.

Monitoring and Follow-up

Regular monitoring and follow-up are important for elderly female patients with osteoporosis, and may include:

• Regular BMD testing to monitor changes in bone density 6.
• FRAX assessments to monitor changes in fracture risk 6.
• Regular review of medication adherence and potential side effects 6.