What is the best treatment approach for an 85-year-old female with a current right humerus fracture due to a fall and diagnosed with osteoporosis based on a Dual-Energy X-ray Absorptiometry (DEXA) scan?

Treatment of Osteoporosis in an 85-Year-Old Female with Humerus Fracture

The optimal treatment approach for this 85-year-old female with a right humerus fracture and osteoporosis should include immediate fracture management followed by oral bisphosphonate therapy, along with calcium and vitamin D supplementation.

Acute Fracture Management

Initial Management

• Appropriate immobilization of the right humerus fracture
• Pain management with multimodal analgesia
• Early mobilization as tolerated to prevent complications of immobility 1
• Consider orthopedic consultation for fracture stabilization if indicated

Osteoporosis Treatment

First-Line Pharmacologic Therapy

• Oral bisphosphonate therapy is the recommended first-line treatment for this patient with osteoporosis and a recent fragility fracture 1
  • Options include:
    • Alendronate 70 mg weekly
    • Risedronate 35 mg weekly
    • Ibandronate 150 mg monthly

Calcium and Vitamin D Supplementation

• Calcium: 1,000-1,200 mg daily 1, 2
• Vitamin D: 600-800 IU daily (target serum level ≥20 ng/ml) 1, 2

Alternative Therapies (if oral bisphosphonates are contraindicated)

In order of preference:

1. Intravenous bisphosphonates (zoledronic acid 5 mg annually) 1
2. Denosumab 60 mg subcutaneously every 6 months 1, 3
   • Particularly beneficial for patients with renal insufficiency
3. Teriparatide 20 mcg subcutaneously daily 4
   • Consider for very high-risk patients with severe osteoporosis

Comprehensive Care Approach

Fall Prevention

• Home safety assessment and modification
• Balance and strength training exercises
• Review of medications that may increase fall risk
• Vision assessment
• Appropriate footwear

Lifestyle Modifications

• Weight-bearing and resistance exercises as tolerated
• Smoking cessation if applicable
• Limiting alcohol consumption to 1-2 drinks per day
• Balanced diet rich in calcium 5

Follow-up Care

• Bone mineral density (BMD) testing to monitor treatment response
  • First follow-up DXA scan 1-2 years after initiating therapy 1
• Regular assessment of medication adherence and side effects
• Periodic reassessment of fracture risk

Important Considerations

Age-Specific Factors

• At 85 years of age, this patient is at very high risk for subsequent fractures
• The presence of a fragility fracture alone is sufficient to diagnose osteoporosis and initiate treatment, even without DXA confirmation 1

Treatment Duration

• Initial treatment duration of 3-5 years
• Reassess fracture risk after this period to determine need for continued therapy

Monitoring for Adverse Effects

• Monitor for potential side effects of bisphosphonates:
  • Gastrointestinal issues with oral formulations
  • Atypical femoral fractures (rare but serious)
  • Osteonecrosis of the jaw (rare, primarily with IV formulations)

Pitfalls to Avoid

• Do not delay osteoporosis treatment while waiting for fracture healing
• Do not rely solely on calcium and vitamin D without pharmacologic therapy in a patient with established osteoporosis and fracture 5
• Do not overlook the need for a comprehensive approach including fall prevention
• Avoid assuming that age alone is a contraindication to pharmacologic therapy 6

By implementing this treatment approach, the patient's risk of subsequent fractures can be significantly reduced, improving her morbidity, mortality, and quality of life outcomes.