Should a 92-year-old woman with osteoporosis be treated?

Treatment of Osteoporosis in a 92-Year-Old Woman

Treatment for osteoporosis should be offered to a 92-year-old woman with osteoporosis, focusing on calcium and vitamin D supplementation, fall prevention, and considering individualized pharmacotherapy based on fracture risk assessment. 1

Risk Assessment

Before initiating treatment, a thorough assessment of fracture risk is essential:

• Use FRAX (Fracture Risk Assessment Tool) to determine 10-year fracture probability 1
• Consider the patient's estimated life expectancy
• Evaluate the presence of prior fractures, which significantly increase future fracture risk
• Assess fall risk factors specific to this age group

First-Line Interventions

Non-Pharmacological Approaches

• Calcium and vitamin D supplementation:
  • Calcium: 1,000-1,200 mg daily (diet plus supplements) 1
  • Vitamin D: 800-1,000 IU daily with a target serum level ≥20 ng/ml 1
• Fall prevention strategies are crucial in this age group:
  • Home safety assessment
  • Review of medications that may increase fall risk
  • Vision assessment
  • Appropriate footwear
  • Use of assistive devices if needed

Lifestyle Modifications

• Weight-bearing and resistance exercises as tolerated (at least 30 minutes, 3 days/week) 1
• Smoking cessation if applicable
• Limiting alcohol consumption

Pharmacological Treatment Decision

The decision to use pharmacological therapy should consider:

1. Fracture risk: Higher risk justifies more aggressive intervention
2. Life expectancy: Benefits of treatment may take 9-18 months to manifest 2
3. Medication adherence capability: Past adherence predicts future compliance
4. Comorbidities: Especially those affecting medication metabolism or absorption

Treatment Algorithm Based on Risk Assessment:

1. For high fracture risk (FRAX score showing 10-year risk of hip fracture ≥3% or major osteoporotic fracture ≥20%):

   • Consider oral bisphosphonates as first-line therapy 1
   • If oral administration is problematic due to adherence issues or hiatal hernia (common in elderly), consider:
     • IV bisphosphonate (zoledronic acid) 3
     • Denosumab (subcutaneous injection every 6 months) 4, 5

2. For very high fracture risk (recent fractures, T-score ≤-3.5):

   • Consider anabolic agents like teriparatide 1, 6
   • Follow with an antiresorptive agent to maintain bone gains 7

Special Considerations for the 92-Year-Old Patient

• Medication administration: Weekly or monthly oral bisphosphonates may be difficult for this patient to take correctly, especially with a history of irregular adherence 2
• Renal function: Decreased renal function in elderly patients may increase risk of hypocalcemia with certain medications 4
• Polypharmacy concerns: Consider potential drug interactions with existing medications 2
• Time to benefit: The American Geriatrics Society notes that for bisphosphonates, the NNT to prevent any fracture is 18 at 4 years, with some benefit beginning at approximately 18 months 2

Monitoring and Follow-up

• BMD testing every 2 years to assess treatment efficacy 1
• Regular assessment of calcium levels, particularly if using denosumab 4
• Ongoing evaluation of fall risk
• Medication adherence assessment

Potential Pitfalls and Caveats

• Hypocalcemia risk: Patients with impaired renal function are more likely to experience hypocalcemia with certain osteoporosis medications 4
• Osteonecrosis of the jaw: Rare but serious complication of antiresorptive therapy 4
• Atypical femoral fractures: Associated with long-term bisphosphonate use 4
• Multiple vertebral fractures following discontinuation: Can occur after stopping denosumab 4
• Adherence challenges: The stringent administration requirements for bisphosphonates may be particularly difficult for elderly patients 2

In this 92-year-old woman, the balance of benefits versus risks favors at minimum calcium and vitamin D supplementation with fall prevention strategies. If her estimated life expectancy exceeds 1-2 years and she has high fracture risk, pharmacological intervention should be considered, with preference for medications that minimize adherence challenges, such as denosumab or yearly IV bisphosphonate administration.