What is the recommended management for a 75-year-old patient with a history of fracture, osteopenia (Bone Mineral Density (BMD) T scores of -1.3 at the lumbar spine and -1.4 at the hip), and increased risk of falls?

Management of a 75-Year-Old with Fragility Fracture and Osteopenia

This patient requires immediate pharmacological treatment with bisphosphonates (alendronate or risedronate) despite having osteopenic T-scores, because the presence of a fragility fracture at age 75 automatically upgrades the diagnosis to osteoporosis and mandates treatment regardless of BMD values. 1, 2

Why This Patient Needs Treatment Now

A fragility fracture supersedes any DXA measurement—patients in the osteopenic range who have sustained a fragility fracture should be upgraded to the diagnosis of osteoporosis. 1 This is a critical clinical principle that many providers miss: the T-scores of -1.3 and -1.4 are misleading in this context because:

• Any patient over 50 years who develops a fracture from minimal trauma (including falls from standing height) meets criteria for osteoporosis treatment 1
• The combination of age 75 + fragility fracture + fall risk creates extremely high subsequent fracture risk 1
• Most fractures actually occur in osteopenic individuals due to their greater numbers, despite lower individual risk 3

First-Line Pharmacological Treatment

Start oral bisphosphonates immediately—alendronate or risedronate are the preferred first-choice agents. 1, 4 These drugs:

• Reduce vertebral fractures by 65-68% 1, 4
• Reduce non-vertebral fractures by 40-53% 1, 5
• Reduce hip fractures by 40% 6, 5
• Are well-tolerated, low-cost (generics available), and physicians have extensive experience with them 1
• Should be prescribed for 3-5 years initially, with longer duration for patients who remain at high risk 1, 4

Alternative bisphosphonates if oral intolerance, dementia, malabsorption, or non-compliance: 1

• Zoledronic acid (intravenous annually)
• Denosumab (subcutaneous every 6 months)

Essential Baseline Interventions Before Starting Bisphosphonates

Correct vitamin D deficiency before initiating bisphosphonates to prevent hypocalcemia: 2

• Check 25-hydroxyvitamin D level (target ≥20 ng/mL)
• Prescribe vitamin D 800 IU daily 1, 2
• Ensure calcium intake 1000-1200 mg daily (diet plus supplementation if needed) 1, 2

Critical caveat: Vitamin D supplementation at 800 IU daily reduces non-vertebral fractures by 15-20% and falls by 20%, but high pulse doses of vitamin D increase fall risk—avoid bolus dosing. 1

Non-Pharmacological Interventions (Mandatory, Not Optional)

Fall prevention is paramount in this patient with documented fall history: 1

• Balance training and multidimensional fall prevention programs must be implemented immediately and continued long-term 1
• Physical training and muscle strengthening should begin early post-fracture 1
• Weight-bearing exercise 30 minutes at least 3 times weekly (walking, resistance exercises) 2

Lifestyle modifications: 1, 2

• Stop smoking immediately (accelerates bone loss and increases fall risk)
• Limit alcohol intake (negative effects on BMD and fall risk)

Why FRAX Calculation Is Irrelevant Here

Many providers mistakenly calculate FRAX scores in patients with existing fragility fractures. Do not waste time with FRAX in this patient—the presence of a fragility fracture alone mandates treatment. 1, 2 FRAX is only useful for osteopenic patients WITHOUT prior fractures to determine if they meet treatment thresholds (≥20% 10-year major osteoporotic fracture risk or ≥3% hip fracture risk). 1, 2

Monitoring and Follow-Up

Systematic follow-up is essential because long-term adherence to bisphosphonates is poor (often <50% in routine practice, though up to 90% in fracture liaison services). 1 Implement a structured five-step plan: 1

1. Identify the patient with recent fracture (already done)
2. Invite for fracture risk evaluation (completed)
3. Differential diagnosis (rule out secondary causes if Z-score <-2.0)
4. Initiate therapy (bisphosphonates + calcium/vitamin D + fall prevention)
5. Regular follow-up for adherence and tolerance monitoring

Risk communication and shared decision-making improve adherence—explain that without treatment, this patient faces a 40-70% risk of another fracture within 3-5 years. 1

Rehabilitation Goals

The primary goal is to regain pre-fracture mobility and independence. 1 Early identification of individual functional goals and needs is essential before developing the rehabilitation plan. 1 An orthogeriatric and multidisciplinary approach is warranted for elderly patients with major fractures. 1