What is the recommended treatment for osteoporosis in individuals over 80?

Treatment of Osteoporosis in Individuals Over Age 80

For individuals over 80 with osteoporosis, oral bisphosphonates (alendronate or risedronate) are the first-line pharmacological treatment, combined with calcium 1,000-1,200 mg daily and vitamin D 800 IU daily, plus weight-bearing exercise and fall prevention strategies. 1, 2

Risk Assessment and Monitoring

• Perform initial fracture risk assessment using bone mineral density (BMD) via dual-energy x-ray absorptiometry (DXA) with vertebral fracture assessment (VFA) or spinal x-rays 3
• Calculate 10-year fracture risk using FRAX for patients ≥40 years, though recognize this tool may underestimate risk in very elderly patients with multiple falls or frailty 3
• Reassess fracture risk clinically every 12 months and consider BMD testing every 1-3 years depending on risk factors 1
• Document history of prior fractures, falls, parental hip fracture, glucocorticoid use, smoking, alcohol consumption, and relevant comorbidities (inflammatory bowel disease, rheumatoid arthritis, chronic liver/kidney disease) 2

Non-Pharmacological Management

All patients over 80 should receive:

• Calcium supplementation: 1,000-1,200 mg elemental calcium daily through diet and supplements if dietary intake is insufficient 1, 2
• Vitamin D supplementation: 800 IU daily to maintain serum 25(OH)D levels ≥30 ng/mL (some guidelines suggest ≥20 ng/mL) 1, 2
• Exercise regimen: Regular weight-bearing exercises and resistance training (squats, push-ups) plus balance exercises (heel raises, standing on one foot) 1, 2
• Lifestyle modifications: Smoking cessation and limiting alcohol to 1-2 beverages daily 1

Important Caveats About Calcium and Vitamin D

While calcium and vitamin D are recommended, the evidence has important limitations. Calcium supplementation alone does not reduce fractures in community-dwelling older adults and may increase cardiovascular events by approximately 20% and kidney stone risk 4. High-dose vitamin D (>4,000 IU/day) has been associated with increased falls and fractures 4. Therefore, prioritize dietary calcium intake when possible and use the lowest effective supplemental doses 5, 4.

Pharmacological Treatment Algorithm

First-Line Therapy: Oral Bisphosphonates

For patients at high or very high fracture risk (T-score ≤-2.5, prior vertebral/hip fracture, or high FRAX score ≥20% for major osteoporotic fracture):

• Strongly recommend oral bisphosphonates (alendronate or risedronate) as initial therapy 1, 2
• Oral bisphosphonates reduce vertebral fractures by 52 per 1,000 person-years and hip fractures by 6 per 1,000 person-years 2
• These agents inhibit osteoclast activity, reduce bone resorption, and progressively increase bone mass 6

Second-Line Options (If Oral Bisphosphonates Not Appropriate)

If oral bisphosphonates are contraindicated, not tolerated, or compliance is problematic:

• Intravenous zoledronic acid (annual infusion) 1
• Denosumab (subcutaneous injection every 6 months) 1
  • Critical warning: Denosumab requires sequential therapy with bisphosphonates upon discontinuation to prevent rebound bone loss and vertebral fractures 3

Anabolic Agents for Very High-Risk Patients

For very high-risk individuals (recent vertebral fractures, hip fracture with T-score ≤-2.5, multiple fractures):

• Consider anabolic agents first: Teriparatide (PTH analog) or romosozumab 2, 7
• Teriparatide increases lumbar spine BMD by 5.9% and femoral neck BMD by 1.5% over median 10 months 8
• Teriparatide reduced vertebral fractures compared to alendronate in glucocorticoid-induced osteoporosis but not non-vertebral fractures 3
• Must follow anabolic therapy with antiresorptive agent (bisphosphonate or denosumab) to maintain gains 3, 7
• Anabolic effect is blunted if used after antiresorptive therapy, so sequence matters 3

Special Considerations for Patients Over 80

Frailty and Comorbidities

• Orthogeriatric co-management is recommended for frail elderly patients with multiple comorbidities and polypharmacy 1
• Medication choice may require adjustment in renal impairment 1
• Balance benefits of fracture prevention against potential medication side effects in very elderly patients 1

Fall Prevention

Fall risk increases dramatically with age and is a major contributor to fracture risk beyond BMD alone. Implement:

• Balance and gait training exercises 2
• Home safety assessment and modifications
• Review medications that increase fall risk (sedatives, antihypertensives)
• Vision and hearing assessment

Adherence and Monitoring

• Long-term adherence to osteoporosis medications is often poor, necessitating systematic follow-up 1
• Fracture liaison services (comprehensive management programs after fracture) increase medication initiation and adherence from 17% to 38% and may reduce subsequent fractures 2
• Regular monitoring for medication tolerance and adherence is essential 1
• Patient education about disease burden, risk factors, and treatment importance is critical 1

Post-Fracture Management

• Early rehabilitation is crucial to regain mobility and independence after fracture 1
• Patients with recent fracture should be considered very high-risk and may warrant anabolic therapy 2

Treatment Duration and Sequencing

• Bisphosphonates can be used for 3-5 years initially, with reassessment for drug holidays in lower-risk patients 7
• Anabolic agents (teriparatide, romosozumab) are typically used for 1-2 years, followed by transition to antiresorptive therapy 3, 7
• Denosumab and romosozumab require sequential antiresorptive therapy to prevent rebound bone loss 3