What is the best management plan for a 79-year-old female with a history of compression fracture, osteopenia, normal current Dexa scan, and vitamin D level of 93, who is on Caltrate D (calcium and vitamin D) and recently experienced a fall?

Management of Compression Fracture in a 79-Year-Old Woman

This patient requires pharmacological osteoporosis treatment with a bisphosphonate (alendronate or risedronate) in addition to her current calcium and vitamin D supplementation, despite her "normal" current DEXA scan, because she has sustained a fragility fracture—the single most important indicator for treatment.

Why Treatment is Mandatory Despite Normal DEXA

• A compression fracture from a low-energy fall (falling from bed height) is definitionally a fragility fracture, which independently mandates osteoporosis treatment regardless of bone density measurements 1.
• The EULAR/EFORT guidelines explicitly state that patients over 50 years with a fragility fracture require pharmacological treatment to prevent subsequent fractures, which carry significantly higher morbidity and mortality 1.
• The "normal" current DEXA is misleading—her prior DEXA showed osteopenia (T-scores of -1.4 and -1.5), and she has now proven her bones are fragile through an actual fracture event 2.

Recommended Pharmacological Treatment

First-line therapy should be oral bisphosphonates: alendronate or risedronate 1, 3.

• These agents have demonstrated reduction in vertebral, non-vertebral, and hip fractures in high-quality randomized trials 1.
• They are well-tolerated, cost-effective (generics available), and have extensive clinical experience supporting their use 1.
• Treatment duration should be 3-5 years initially, with reassessment for continuation based on ongoing fracture risk 1.

Alternative Options if Oral Bisphosphonates Are Not Tolerated

• Intravenous zoledronic acid (annual infusion) for patients with gastrointestinal intolerance, malabsorption, or adherence concerns 1.
• Subcutaneous denosumab (every 6 months) as another alternative 1.
• Given this patient's age and fall history, ensuring adherence is critical—if oral medication compliance is questionable, IV or subcutaneous options may be preferable 1.

Continuation of Calcium and Vitamin D

Continue Caltrate D (calcium with vitamin D) as currently prescribed 1.

• Target calcium intake: 1000-1200 mg/day (dietary plus supplementation) 1, 4.
• Target vitamin D: 800 IU/day minimum 1, 4.
• Her vitamin D level of 93 ng/mL is excellent and well above the recommended threshold of ≥20 ng/mL 1, 2.
• All osteoporosis medication trials demonstrating fracture reduction included calcium and vitamin D supplementation as baseline therapy 1, 5.

Critical Non-Pharmacological Interventions

Fall Prevention (Highest Priority)

Implement a comprehensive fall prevention program immediately 1.

• This patient has already fallen once—her risk of subsequent falls and fractures is substantially elevated 1.
• Multidimensional fall prevention strategies reduce fall risk by 15-20% 1.
• Assess home safety: remove tripping hazards, improve lighting, install grab bars, consider bed rails or lowering bed height 1.
• Evaluate for orthostatic hypotension, vision problems, footwear issues, and medication side effects that increase fall risk 1.

Physical Rehabilitation and Exercise

Early initiation of physical therapy focusing on balance training and muscle strengthening 1.

• Weight-bearing and resistance exercises at least 3 times weekly 2, 4.
• Balance training has demonstrated reduction in both falls and fractures 1.
• The goal is to restore pre-fracture mobility and independence 1.

Lifestyle Modifications

• Ensure adequate protein intake (1.2-1.5 g/kg/day) to support muscle mass and bone health 4.
• Smoking cessation if applicable 1.
• Limit alcohol consumption 1.

Monitoring Plan

Repeat DEXA scan in 1-2 years to assess treatment response 1, 2.

• Earlier reassessment (1 year) is reasonable given her recent fracture and treatment initiation 1, 2.
• Monitor for medication tolerance and adherence at regular intervals 1.
• Assess for new fractures or height loss at each clinical visit 1.

Common Pitfalls to Avoid

• Do not be falsely reassured by a "normal" DEXA scan in the setting of a fragility fracture—the fracture itself proves bone fragility and overrides bone density measurements 1.
• Do not delay treatment while "watching and waiting"—the highest risk period for subsequent fractures is immediately after the first fracture 1.
• Do not prescribe calcium and vitamin D alone without bisphosphonate therapy—this is inadequate for a patient who has already fractured 1, 3.
• Do not overlook fall prevention—preventing the next fall is as important as strengthening bones 1.