What is the best management approach for an elderly female patient with osteopenia?

Management of Osteopenia in an Elderly Female

For an elderly female with osteopenia, the decision to initiate pharmacologic treatment depends on her 10-year fracture risk calculated using FRAX: treat with bisphosphonates if her risk is ≥20% for major osteoporotic fracture OR ≥3% for hip fracture; otherwise, focus on calcium/vitamin D supplementation and lifestyle modifications. 1, 2

Risk Stratification Algorithm

First, confirm osteopenia with DEXA scan showing T-score between -1.0 and -2.5 at the femoral neck, total hip, or lumbar spine 2. The diagnosis of osteopenia alone is not an indication for treatment—it must be combined with fracture risk assessment 3.

Calculate 10-year fracture risk using FRAX, which incorporates age, BMD, prior fractures, family history, smoking, alcohol use, and other risk factors 1, 2. This tool has been validated in large U.S. cohorts and reliably guides treatment decisions 2.

Treatment thresholds for pharmacologic intervention:

• Major osteoporotic fracture risk ≥20% OR hip fracture risk ≥3% 1, 2
• History of low-trauma fracture, even without meeting FRAX thresholds 4, 2
• Age ≥65 years with severe osteopenia (T-score < -2.0) places patients at higher risk than younger women or those with mild osteopenia 1

Universal Non-Pharmacologic Management

All elderly women with osteopenia require these interventions regardless of fracture risk:

Calcium and vitamin D supplementation:

• Calcium 1,000-1,500 mg daily 4, 2
• Vitamin D 800-1,000 IU daily, targeting serum levels ≥20 ng/mL 4, 2
• These reverse secondary hyperparathyroidism, improve BMD, reduce body sway, and strengthen lower extremities 5, 6

Exercise prescription:

• Weight-bearing impact exercise (walking, dancing) 30 minutes at least 3 days per week 1, 2
• Multicomponent programs incorporating progressive resistance training, balance exercises, and functional training 2-3 days weekly 1
• Evidence shows this reduces fall rate and positively influences BMD when sustained >1 year 1

Lifestyle modifications:

• Smoking cessation—smoking increases fracture risk across all populations 1, 2
• Limit alcohol to <2 units daily, as higher intake increases fracture risk 1, 2
• Fall prevention strategies including home hazard modification 1, 2

Pharmacologic Treatment for High-Risk Patients

For women ≥65 years meeting treatment thresholds, initiate oral bisphosphonates as first-line therapy 1, 4, 2. Post-hoc analysis of large RCTs demonstrates risedronate reduces fragility fractures by 73% in women with advanced osteopenia near the osteoporosis threshold 1. This benefit is similar across all bisphosphonates based on data in osteoporotic women 1.

Specific bisphosphonate options:

• Alendronate 70 mg once weekly 4
• Risedronate 35 mg once weekly 4, 2

Critical administration instructions to maximize absorption and minimize GI adverse effects:

• Take on empty stomach with full glass of water 4
• Remain upright for 30-60 minutes after dosing 4
• Wait 30 minutes before eating or taking other medications 4

Treatment duration and monitoring:

• Initial treatment period of 5 years 4, 2
• Do NOT monitor bone density during the initial 5-year treatment period 4, 2
• After 5 years, reassess fracture risk to determine if continuation is warranted 4, 2

Monitoring Strategy for Untreated Patients

For women not meeting treatment thresholds, repeat DEXA every 2 years to monitor bone density progression 2. Earlier reassessment is warranted if new risk factors develop (e.g., glucocorticoid initiation, new fracture) 2.

Do not perform bone density scans more frequently than annually 2.

Common Pitfalls to Avoid

Do not treat based on T-score alone—the number needed to treat in osteopenia without high fracture risk exceeds 100, compared to 10-20 in established osteoporosis 3. Most fractures occur in osteopenic individuals due to their greater numbers, but individual risk varies widely 7, 3.

Never skip calcium and vitamin D supplementation—pharmacologic therapy is significantly less effective without adequate supplementation 4, 5. Community-dwelling elderly in northern regions are particularly deficient in vitamin D during winter 6.

Avoid overtreatment of low-risk patients and undertreatment of high-risk patients—use FRAX systematically rather than clinical gestalt alone 2.

If denosumab is ever used (not first-line), never discontinue abruptly without transitioning to a bisphosphonate, as this causes rebound fractures 4.

Adverse Effects to Monitor

Short-term bisphosphonate effects: upper GI symptoms (esophagitis, dyspepsia), influenza-like symptoms with first dose 4

Long-term bisphosphonate effects (rare): atypical femoral fractures, osteonecrosis of the jaw 4. These risks increase with prolonged use beyond 5 years, which is why reassessment at 5 years is critical 1, 4.