What is the best treatment approach for an elderly patient with osteopenia, considering potential comorbidities and risk of fractures?

Treatment of Osteopenia in Elderly Patients

For elderly patients with osteopenia, treatment decisions must be based on individualized fracture risk assessment using FRAX scores, with pharmacologic therapy initiated only when 10-year risk reaches ≥20% for major osteoporotic fracture or ≥3% for hip fracture—otherwise, focus on calcium, vitamin D, and lifestyle modifications alone. 1, 2

Risk Stratification: The Critical First Step

Osteopenia (T-score between -1.0 and -2.5) is not a disease diagnosis but rather a risk factor that must be contextualized 3, 4. The key is calculating absolute fracture risk:

• Calculate FRAX score incorporating age, BMD, prior fractures, family history, smoking, alcohol use, and glucocorticoid use 2
• Treatment thresholds: Initiate bisphosphonates if 10-year major osteoporotic fracture risk ≥20% OR hip fracture risk ≥3% 1, 2
• Automatic treatment indication: Any history of fragility fracture regardless of FRAX score 2

Important caveat: Most fractures occur in osteopenic individuals simply because this population is so large, but the number needed to treat (NNT) is >100 in osteopenia versus 10-20 in osteoporosis 5. This makes risk stratification essential to avoid overtreatment.

Universal Non-Pharmacologic Interventions (All Elderly Patients with Osteopenia)

These foundational measures apply regardless of whether pharmacologic treatment is initiated:

Calcium and Vitamin D Optimization

• Calcium: 1,000-1,200 mg daily from diet plus supplements 1, 2
• Vitamin D: 800 IU daily (avoid high pulse doses which increase fall risk) 1
• Critical: Check and correct vitamin D deficiency (target ≥20-30 ng/mL) before starting any bisphosphonate to prevent hypocalcemia 2

Exercise and Fall Prevention

• Weight-bearing exercise: 30 minutes at least 3 times weekly (walking, jogging) 2
• Balance exercises: Reduce fall risk, which is the proximate cause of most fractures 1
• Moderate evidence exists for improvement in walking speed with active physical therapy 1

Lifestyle Modifications

• Smoking cessation and alcohol limitation: Both accelerate bone loss 2
• Fall risk assessment: Address polypharmacy, vision problems, home hazards 1

Pharmacologic Treatment Algorithm

When FRAX Thresholds Are Met

First-line: Oral bisphosphonates (alendronate or risedronate) 1

• Strong recommendation with high-certainty evidence for postmenopausal women 1
• Generic formulations strongly preferred due to significantly lower cost with equivalent efficacy 1, 6
• Post-hoc analysis shows risedronate reduces fragility fractures by 73% in women with advanced osteopenia (T-score near -2.5) 1
• Duration: Typically 3-5 years initially 1

Alternative bisphosphonates:

• Zoledronic acid (IV): For patients with oral intolerance, dementia, malabsorption, or non-compliance 1
• Risedronate: Equally effective alternative to alendronate 2

Second-line: Denosumab (subcutaneous)

• Reserved for patients with contraindications to bisphosphonates or who experience adverse effects 1, 6
• Moderate-certainty evidence for postmenopausal women 1
• Critical warning: Risk of multiple vertebral fractures upon discontinuation—requires transition to bisphosphonate if stopped 7

Special Considerations for the "Oldest Old" (>80 years)

• Anti-fracture efficacy demonstrated by 12 months, countering the misconception that long-term treatment is required 8
• This age group has the highest absolute fracture risk and stands to gain substantially from treatment 8
• However, increased risk for falls and adverse events from polypharmacy requires careful drug selection 1

Treatment Duration and Monitoring

• Bisphosphonate holiday: Consider stopping after 5 years unless patient remains at very high risk 1
• Decision should be based on baseline fracture risk, medication type, half-life in bone, and ongoing risk-benefit assessment 1
• Systematic follow-up is essential as long-term adherence is poor (improves to 90% in fracture liaison services) 1

When NOT to Treat Pharmacologically

Do not initiate bisphosphonates in elderly patients with osteopenia when:

• FRAX scores below treatment thresholds (10-year major osteoporotic fracture risk <20% AND hip fracture risk <3%) 1, 2
• Mild osteopenia (T-score between -1.0 and -1.5) in patients <65 years 1
• No history of fragility fractures 1

In these cases, focus exclusively on calcium, vitamin D, exercise, and fall prevention 3, 4.

Common Pitfalls to Avoid

• Do not treat based on T-score alone: Osteopenia diagnosis does not equal treatment indication 3, 5
• Avoid high-dose vitamin D pulses: Associated with increased fall risk 1
• Do not use raloxifene or ibandronate as first-line: Evidence limited to vertebral fractures only, not hip or non-vertebral fractures 1
• Never use menopausal estrogen therapy: Strong recommendation against use for osteoporosis treatment 1
• Assess renal function: Severe hypocalcemia risk in advanced kidney disease with denosumab 7