What is the recommended management plan for osteoporosis in geriatric patients?

Management of Osteoporosis in Geriatric Patients

All geriatric patients aged 50 years and older with a recent fragility fracture should be systematically evaluated for fracture risk and managed through a multidisciplinary fracture liaison service (FLS), with oral bisphosphonates (alendronate 70 mg weekly or risedronate 35 mg weekly) plus calcium (1,000-1,200 mg/day) and vitamin D (800-1,000 IU/day) as first-line pharmacologic therapy for those at high fracture risk. 1, 2

Identification and Risk Assessment

Who Should Be Evaluated

• Every patient aged ≥50 years with a recent fragility fracture requires systematic fracture risk evaluation 1
• Women >70 years and men >80 years should undergo clinical risk assessment even without prior fracture 3
• Risk assessment includes: clinical risk factors review, DXA of spine and hip, spine imaging for vertebral fractures, falls risk evaluation, and screening for secondary osteoporosis 1

Fracture Risk Thresholds for Treatment

• T-score ≤-2.5 at femoral neck, total hip, or lumbar spine 1, 2
• 10-year fracture probability ≥20% for major osteoporotic fractures or ≥3% for hip fractures using FRAX 1
• In patients >75 years (women) or >85 years (men) with 10-year fracture risk >30%, bone density measurement can be omitted and treatment initiated based on clinical assessment alone 3

Pharmacologic Management

First-Line Therapy: Oral Bisphosphonates

Oral bisphosphonates are the initial treatment of choice because they reduce vertebral, non-vertebral, and hip fractures by approximately 50% over 3 years, are well-tolerated, cost-effective, and have extensive clinical experience 1, 2, 4

Dosing options: 2

• Alendronate: 70 mg weekly or 10 mg daily
• Risedronate: 35 mg weekly, 150 mg monthly, or 5 mg daily

Pre-treatment requirements: 2

• Mandatory dental screening to identify and address dental issues before starting therapy (bisphosphonates increase osteonecrosis of jaw risk, particularly with invasive dental procedures)
• Check serum calcium to exclude hypocalcemia (contraindication)
• Assess renal function (creatinine clearance <35 mL/min contraindicates zoledronic acid)

Important caveats: 1

• Bisphosphonates require stringent administration instructions (take on empty stomach, remain upright for 30-60 minutes)
• Can aggravate hiatal hernia and GERD
• Consider adherence challenges in cognitively impaired or frail elderly patients

Alternative Antiresorptive: Denosumab

• Subcutaneous denosumab at osteoporosis-indicated dosage is an alternative for patients who cannot tolerate or have contraindications to bisphosphonates 1, 4
• Particularly useful in patients with renal impairment or GI intolerance to oral bisphosphonates 5

Anabolic Agents for Very High-Risk Patients

Consider teriparatide, abaloparatide, or romosozumab as initial therapy (followed by transition to antiresorptive) for very high-risk patients with: 2, 4, 5

• Recent vertebral fracture
• Multiple fractures
• T-score ≤-3.5
• Hip fracture with T-score ≤-2.5

Evidence for elderly: Teriparatide reduces vertebral fractures (ARR 6.4%, p<0.05) and new nonvertebral fragility fractures (ARR 9.9%, p<0.05) in women ≥75 years 6

Non-Pharmacologic Interventions (Essential for All Patients)

Calcium and Vitamin D

• Calcium: 1,000-1,200 mg/day (dietary plus supplementation if needed) 1, 2
• Vitamin D: 800-1,000 IU/day, targeting serum 25-OH vitamin D ≥20 ng/mL 1, 2
• Higher vitamin D doses may be necessary in patients with risk factors for bone loss 1

Exercise and Fall Prevention

Combination exercise program including: 1

• Balance training
• Flexibility/stretching exercises
• Endurance exercise
• Resistance/progressive strengthening exercises
• Muscle resistance exercises (squats, push-ups) and balance exercises (heel raises, standing on one foot) 4

For high fall-risk patients (e.g., chemotherapy-induced peripheral neuropathy, cognitive impairment): individually tailored, supervised exercise program until safe independent performance 1

Multimodal fall prevention requires addressing underlying cardiovascular, pulmonary, and neurological diseases while critically evaluating medications that increase fall risk 3

Lifestyle Modifications

• Smoking cessation 1, 2
• Limit alcohol consumption 1, 2
• Weight-bearing exercise 1

Multidisciplinary Care Structure

Fracture Liaison Service (FLS)

Implementation of FLS increases medication initiation and adherence from 17% to 38% (risk difference 20%, 95% CI 16-25%) and reduces subsequent fracture rates 1, 4

FLS components: 1

• Designated local responsible lead coordinating care
• Liaison between surgeons, rheumatologists/endocrinologists, geriatricians, and general practitioners
• Systematic invitation and follow-up of all fracture patients
• Adherence rates up to 90% in FLS (vs. lower rates in usual care)

Orthogeriatric Comanagement

For elderly patients with hip fracture, orthogeriatric comanagement (joint care model between geriatrician and orthopedic surgeon on dedicated ward) achieves: 1

• Shortest time to surgery
• Shortest length of inpatient stay
• Lowest inpatient and 1-year mortality rates

Key elements: 1

• Surgery within 48 hours of injury
• Adequate preoperative assessment including pain relief, fluid management
• Comprehensive geriatric assessment
• Appropriate postoperative care: pain management, antibiotic prophylaxis, correction of anemia, cognitive function assessment, pressure sore prevention, nutritional support, early mobilization

Rehabilitation

Appropriate rehabilitation program should include: 1

• Early postfracture physical training and muscle strengthening
• Long-term continuation of balance training
• Multidimensional fall prevention

Monitoring and Follow-Up

Treatment Monitoring

• Repeat DXA scan in 1-2 years to assess treatment response 2
• Continue monitoring every 1-2 years during treatment 2
• Significant BMD change is ≥1.1% 2
• Assess adherence and tolerance at regular intervals 1, 2

Patient Education

Patients should be educated about: 1

• Burden of disease
• Risk factors for fractures
• Follow-up requirements
• Duration of therapy

Risk communication and shared decision-making positively influences adherence 1

Special Considerations in Geriatric Population

Frail Elderly and Comorbidities

• Frail elderly with major fractures warrant orthogeriatric and multidisciplinary approach 1
• For elderly patients with immobility and comorbidities (e.g., hip or pelvic insufficiency fracture) who cannot attend FLS, anti-osteoporotic treatment can be started even without DXA scan 1
• Limited data exist for patients ≥80 years and those with significant comorbidities, requiring careful consideration of agent properties, efficacy, tolerability, and contraindications 6, 3

Adherence Challenges

• Poor adherence is common in geriatric patients with polypharmacy and cognitive impairment 1
• Complex administration requirements (e.g., bisphosphonates) may be challenging 1
• Consider simpler regimens (weekly vs. daily dosing, IV vs. oral routes) or alternative agents (denosumab) in patients with adherence concerns 5

Drug Interactions

• Monitor for digitalis toxicity when using teriparatide in patients on digoxin (hypercalcemia may predispose to toxicity) 7
• Evaluate medication burden and potential drug-disease interactions in multimorbid patients 1

Treatment Duration and Sequencing

• Pharmacological treatment should use drugs demonstrated to reduce vertebral, non-vertebral, and hip fractures 1
• Regular monitoring for tolerance and adherence is essential 1
• For anabolic agents: transition to antiresorptive agent after completing anabolic therapy to maintain gains 2, 4, 5
• Treatment duration decisions should balance fracture risk reduction against potential adverse effects (atypical fractures, osteonecrosis) with long-term bisphosphonate use 1