Should a 78-year-old patient with a recent hip fracture undergo a Dual-Energy X-ray Absorptiometry (DEXA) scan and start bisphosphonate therapy, such as alendronate (alendronate) or risedronate (risedronate)?

Management of a 78-Year-Old Patient with Recent Hip Fracture: DEXA and Bisphosphonate Therapy

Yes, you should obtain a DEXA scan and start bisphosphonate therapy for your 78-year-old patient with a recent hip fracture. 1

Assessment and Diagnosis

• A hip fracture in a 78-year-old patient is considered a fragility fracture, which strongly indicates underlying osteoporosis and significantly increases the risk of subsequent fractures 1
• While a DEXA scan should be ordered to establish baseline bone mineral density (BMD), treatment with a bisphosphonate can be initiated without waiting for DEXA results in patients over 65 with fragility fractures, as the vast majority will have T-scores below -1.5 2
• The risk of subsequent fracture is highest immediately after the initial fracture and gradually decreases over time, making prompt intervention critical 1

Treatment Recommendations

Pharmacological Management

• Oral bisphosphonates are the first-line treatment for osteoporosis in patients with fragility fractures 2

  • Alendronate has demonstrated a 38% relative risk reduction in vertebral fractures over 3 years 3, 4
  • Risedronate has shown a 44% relative risk reduction in vertebral fractures and significant efficacy in elderly women 4, 5
  • Zoledronic acid (intravenous) is an alternative if oral medications are not tolerated 6

• Bisphosphonates have demonstrated efficacy in reducing fracture risk even in very elderly patients:

  • For patients ≥75 years, significant vertebral fracture risk reduction has been shown at 1 year for risedronate (81%), and at 3 years for alendronate (38%) 4

Calcium and Vitamin D Supplementation

• All patients should receive calcium (1200 mg/day) and vitamin D3 (800-1000 IU/day) supplementation along with bisphosphonate therapy 1
• Vitamin D levels should be checked at the same time as the DEXA scan to guide supplementation dosing 1

Monitoring and Follow-up

• A baseline DEXA scan should be obtained to assess initial BMD and to monitor treatment response 1
• Follow-up DEXA scan is recommended after 1-2 years of therapy to assess treatment effectiveness 1
• Monitoring for adverse effects of bisphosphonates is essential, particularly for:
  • Gastrointestinal side effects with oral formulations 1
  • Rare but serious complications like atypical femoral fractures with long-term use (typically after 3-5 years) 1

Important Considerations and Caveats

• Hip fractures carry a 20% mortality rate within the first year, making aggressive treatment essential 1
• Even if a patient experiences a decline in BMD while on bisphosphonate therapy, they may still benefit from a reduced fracture risk compared to no treatment 7
• For patients with advanced degenerative changes in the spine that may affect DEXA interpretation, quantitative CT may be considered as an alternative 1
• Fracture Liaison Services have been shown to significantly improve osteoporosis treatment after fragility fractures (45% vs 26% in control groups) 1

Conclusion

For your 78-year-old patient with a recent hip fracture, the evidence strongly supports obtaining a DEXA scan for baseline assessment and promptly initiating bisphosphonate therapy along with calcium and vitamin D supplementation. This approach will significantly reduce the risk of subsequent fractures and associated morbidity and mortality.