What are the recommendations for bone density screening and osteoporosis management in a 78-year-old female?

Bone Density Screening for a 78-Year-Old Female

A 78-year-old woman should undergo bone density screening with DXA of the hip and lumbar spine, as the USPSTF strongly recommends routine screening for all women aged 65 years or older regardless of risk factors. 1

Screening Recommendation

• All women aged 65 years or older should receive routine DXA screening for osteoporosis (Grade B recommendation). 1, 2
• At age 78, this patient is well within the age range where screening provides clear benefits in reducing fracture-related morbidity and mortality. 2
• DXA measurement of the femoral neck is the best predictor of hip fracture risk and is comparable to forearm measurements for predicting fractures at other sites. 1, 2
• The screening should include both hip and lumbar spine measurements, as this is the most widely accepted and validated method for assessing bone mineral density. 2

Risk Assessment at This Visit

Beyond the routine screening, assess for additional risk factors that increase fracture risk:

• Low body weight (< 70 kg) is the single best predictor of low bone mineral density. 1, 3
• Previous fragility fractures at any age significantly increase future fracture risk. 3, 4
• Glucocorticoid use (equivalent to ≥5 mg prednisone daily for ≥3 months) substantially increases bone loss. 5, 4
• Height loss > 4 cm or development of kyphosis suggests possible vertebral fractures. 5
• Family history of hip fracture in a parent increases risk. 4
• Smoking, excess alcohol consumption, and low physical activity are modifiable risk factors. 4, 6

Fracture Risk Calculation

• Use the FRAX tool to estimate 10-year absolute fracture risk for hip, spine, shoulder, and forearm fractures, combining clinical risk factors with BMD measurement. 2, 4
• For a 65-year-old white woman without additional risk factors, the 10-year fracture risk is 9.3%; at age 78, this baseline risk is substantially higher. 2
• Treatment is recommended for patients with ≥20% 10-year risk of major osteoporotic fracture or ≥3% 10-year risk of hip fracture. 4

Management Based on Screening Results

If Osteoporosis is Diagnosed (T-score ≤ -2.5 or fragility fracture present):

Pharmacological Treatment:

• First-line therapy: Oral bisphosphonates (alendronate) reduce vertebral fractures by 52 per 1000 person-years and hip fractures by 6 per 1000 person-years. 4
• Alendronate 70 mg once weekly is therapeutically equivalent to 10 mg daily and reduces vertebral fractures by 47-48% and multiple vertebral fractures by 78-90%. 7
• If bisphosphonates are contraindicated or not tolerated, denosumab is the alternative antiresorptive agent. 4, 8
• For very high-risk patients (recent vertebral fractures, hip fracture with T-score ≤ -2.5, or multiple fractures), consider anabolic agents first (teriparatide, abaloparatide, or romosozumab), followed by an antiresorptive agent. 4, 9

Non-Pharmacological Management:

• Calcium 1000-1200 mg daily and vitamin D 600-800 IU daily (some sources recommend 800-1000 IU). 2, 4
• Weight-bearing and muscle resistance exercises (squats, push-ups) combined with balance exercises (heel raises, standing on one foot). 4
• Fall prevention strategies are critical at this age. 2
• Smoking cessation and alcohol moderation. 4, 9

If Results Show Normal BMD or Osteopenia:

• Repeat DXA in 2-3 years for normal bone density or mild osteopenia. 5
• For osteopenia with T-score < -2.0, consider shorter intervals or treatment based on FRAX score. 5
• A minimum of 2 years is needed to reliably measure changes in BMD due to testing precision limitations. 1, 3

Screening Intervals Going Forward

• For patients with osteoporosis or on treatment, repeat DXA in 1-2 years to monitor treatment effectiveness. 5, 3
• For those with normal BMD or mild osteopenia, repeat in 2-3 years. 5
• The yield of repeated screening is higher in older women, those with lower baseline BMD, and those with other risk factors. 1
• Longer intervals may be adequate for repeated screening to identify new cases, though evidence on optimal intervals is limited. 1

Common Pitfalls to Avoid

• Do not delay screening based on the assumption that treatment options are limited in older adults; evidence supports treatment benefits in this age group. 1
• Do not overlook vertebral fractures; consider vertebral fracture assessment (VFA) if T-score < -1.0 and patient is ≥70 years old, as some patients above the treatment threshold may still qualify for treatment based on vertebral fractures. 5, 3
• Do not repeat DXA scans too frequently (less than 2 years apart) in patients with normal BMD, as this provides no clinical benefit and increases radiation exposure. 5
• Do not assume African-American women don't need screening; while they have higher average BMD than white women at the same age, osteoporosis affects all racial groups. 1, 2
• Do not forget to assess medication adherence at follow-up visits, as adherence is critical for fracture prevention. 2

Special Considerations for This Age Group

• There is no upper age limit for screening, though data on treatment in women older than 85 years is limited. 1
• At age 78, the absolute benefit of screening and treatment is substantial due to the high baseline fracture risk. 1
• Fracture liaison services (comprehensive management programs after a fracture) increase medication initiation and adherence by 38% compared to 17% without such services, reducing subsequent fracture rates. 4