Screening for Osteoporosis in Women Aged 65-85 Years During Routine Visits
All women aged 65-85 years should receive routine screening for osteoporosis using dual-energy x-ray absorptiometry (DXA) of the hip and lumbar spine, as this reduces fracture risk and associated morbidity and mortality. 1
Screening Recommendations
- The U.S. Preventive Services Task Force (USPSTF) strongly recommends screening for osteoporosis in all women aged 65 years or older (Grade B recommendation) 1
- Screening should be performed using DXA of the hip and lumbar spine, which is the most widely accepted and validated method for assessing bone mineral density (BMD) 1
- Bone density measured at the femoral neck by DXA is the best predictor of hip fracture and is comparable to forearm measurements for predicting fractures at other sites 1
- No specific recommendations exist for when to stop screening, but clinical judgment should be used for women over 85 years of age, as there are few data on osteoporosis treatment in this population 1
Risk Assessment During Routine Visit
Assess for additional risk factors that may increase fracture risk, including: 1, 2
- Low body weight (weight < 70 kg)
- Smoking status
- Family history of osteoporosis
- Physical activity level
- Alcohol consumption
- Calcium and vitamin D intake
- History of fractures
- Medication use (especially glucocorticoids)
Consider using the FRAX fracture risk assessment tool (available at www.shef.ac.uk/FRAX/) to estimate 10-year fracture risk 1
- The 10-year fracture risk in a 65-year-old white woman without additional risk factors is 9.3% 1
Screening Intervals
- Evidence is lacking about optimal intervals for repeated screening 1
- A minimum of 2 years may be needed to reliably measure changes in BMD due to limitations in testing precision 1
- Longer intervals may be adequate for repeated screening to identify new cases of osteoporosis 1
- The yield of repeated screening will be higher in older women, those with lower BMD at baseline, and those with other risk factors for fracture 1
Management Following Screening
- For patients diagnosed with osteoporosis (T-score ≤ -2.5 or presence of fragility fracture): 3
- Recommend adequate calcium (1000-1200 mg daily) and vitamin D (800-1000 IU daily) intake 4
- Encourage weight-bearing and resistance exercises 4
- Recommend smoking cessation, as quitting smoking reduces osteoporosis risk 5
- Consider pharmacological treatment with FDA-approved therapies: 1
- Provide education about minimizing medication side effects 1
- Implement fall prevention strategies 4
Common Pitfalls and Caveats
- Failing to screen all eligible women aged 65-85 years; studies show adherence to screening guidelines varies widely among providers (33-100%) 7
- Not considering race/ethnicity in risk assessment; osteoporosis is common in all racial groups but most common in white women 1
- Overlooking the need for patient education about treatment options and their benefits/risks 1
- Neglecting to discuss lifestyle modifications alongside medication options 3
- Not addressing modifiable risk factors like smoking, which has proportionately higher risk in women than men 5
- Failing to monitor treatment adherence and effectiveness 4
Implementation in Practice
- Use electronic medical record systems to identify eligible women during routine visits 7
- Consider using the "Five As" approach for counseling on modifiable risk factors like smoking: ask, advise, assess, assist, and arrange follow-up 5
- When prescribing treatments, review the relative benefits and harms of available options to facilitate informed choice 1
- For women diagnosed with osteoporosis, schedule annual clinical assessments for treatment adherence, side effects, and new fractures 4
By implementing these evidence-based recommendations during routine visits, clinicians can effectively screen for osteoporosis in women aged 65-85 years and reduce the risk of osteoporotic fractures and their associated morbidity and mortality.