Do we order a DEXA (Dual-Energy X-ray Absorptiometry) scan for a 65-year-old male?

DEXA Scan Recommendations for 65-Year-Old Men

A DEXA scan is not routinely recommended for all 65-year-old men but should be performed only for those with risk factors for osteoporosis. 1

Risk Assessment for Men at Age 65

• By age 65, approximately 6% of men have DEXA-determined osteoporosis, making risk factor assessment before this age reasonable 1
• Men should undergo individualized risk factor assessment before ordering a DEXA scan 1
• The American College of Physicians recommends DEXA scans only for men at increased risk for osteoporosis who are candidates for drug therapy 1
• The National Osteoporosis Foundation recommends routine DEXA screening for men starting at age 70, not 65 1, 2, 3

Risk Factors That Warrant DEXA Screening in 65-Year-Old Men

• Age over 70 years (not applicable to this 65-year-old patient) 1, 3
• Low body weight (BMI <20-25 kg/m²) 1
• Weight loss >10% compared to usual adult weight 1
• Physical inactivity (no regular physical activities like walking, climbing stairs, carrying weights) 1
• Previous fragility fracture 1
• Systemic corticosteroid therapy 1
• Androgen deprivation therapy for prostate cancer 1
• Spinal cord injury 1
• Family history of osteoporotic fractures 1

Screening Approach for 65-Year-Old Men

1. Perform risk factor assessment first 1
2. Order DEXA scan only if risk factors are present 1
3. If on androgen deprivation therapy for prostate cancer, DEXA scan is specifically recommended 1
4. Consider using FRAX tool to calculate 10-year fracture risk if uncertain 1

Interpreting DEXA Results

• Normal: T-score ≥ -1.0 1
• Osteopenia: T-score between -1.0 and -2.5 1
• Osteoporosis: T-score ≤ -2.5 1

Common Pitfalls to Avoid

• Ordering DEXA scans for all men at age 65 without risk assessment is not cost-effective 1
• Using peripheral bone measurement tests (like calcaneal ultrasonography) instead of DXA is not recommended as they are not sufficiently sensitive or specific 1
• Failing to consider medication effects, particularly androgen deprivation therapy, which significantly increases fracture risk 1, 4
• Not repeating DEXA scans at appropriate intervals for monitoring (every 1-2 years for those with osteoporosis or on treatment; every 2-3 years for those with normal BMD) 2, 3

Special Considerations

• For men with spinal deformity, consider obtaining forearm DEXA in addition to hip measurements, as spinal measurements may be inaccurate 5
• In men with prostate cancer on androgen deprivation therapy, select "secondary osteoporosis" when using the FRAX algorithm 1
• For men with abnormal DEXA results, ensure adequate calcium intake (1200 mg/day) and vitamin D supplementation (800-1000 IU/day) 1