What is the recommended evaluation and treatment for a 77-year-old male at risk for osteoporosis and hyperparathyroidism?

BMD Screening Recommendation for a 77-Year-Old Male

This 77-year-old man should undergo DXA scanning of the lumbar spine and bilateral hips immediately, as he exceeds the age threshold for routine screening and has potential hyperparathyroidism as a secondary cause requiring evaluation. 1, 2

Age-Based Screening Mandate

• All men aged 70 years or older should undergo screening DXA scans regardless of other risk factors, making this patient clearly eligible based on age alone 1, 2
• By age 65, at least 6% of men have DXA-determined osteoporosis, and this prevalence increases substantially after age 70 1, 3
• A 60-year-old white man has a 25% lifetime risk for osteoporotic fracture, with 1-year mortality after hip fracture being twice that of women 3

Optimal DXA Protocol

Both lumbar spine and bilateral hip measurements should be obtained during the same examination to ensure accurate diagnosis even when one site is unreadable or artificially elevated by degenerative disease, which is common in elderly men 3, 2

• DXA is the accepted reference standard for diagnosing osteoporosis in men and remains the only test validated for guiding treatment decisions 3
• DXA has proven ability to predict fracture risk, with approximately doubling of vertebral and hip fracture incidence for every standard deviation decrease in bone mineral density 1
• A female reference database should be used for the densitometric diagnosis of osteoporosis in men 1

Critical Evaluation for Hyperparathyroidism

Given the concern for hyperparathyroidism, obtain serum ionized calcium and intact parathyroid hormone (iPTH) levels in addition to DXA, as these are significantly more sensitive than total calcium for detecting primary hyperparathyroidism in patients with osteoporosis 4

• Screening patients with osteoporosis for hyperparathyroidism using only total serum calcium will fail to diagnose hyperparathyroidism in patients with intermittent or no elevation of total calcium 4
• In patients with osteoporosis and hyperparathyroidism, 95% had elevated ionized calcium values even when total calcium was normal, and 87% had elevated intact PTH 4
• Secondary hyperparathyroidism is specifically listed as a significant osteoporosis risk factor requiring evaluation 1
• Primary hyperparathyroidism causes increased bone remodeling with bone resorption prevailing, leading to reduced BMD, deterioration of bone microarchitecture, and increased fracture risk even in mild cases 5

Additional Laboratory Assessment

Obtain the following baseline laboratory tests to identify secondary causes of osteoporosis and guide treatment decisions:

• Serum 25-hydroxyvitamin D level (to assess for vitamin D deficiency) 1
• Serum total testosterone (as part of pre-treatment assessment, given that 38% of men over 75 have low testosterone) 1, 6
• Complete metabolic panel including serum calcium, phosphate, and creatinine 1
• Thyroid function tests (TSH) to exclude thyroid disease as a secondary cause 1

Risk Factor Documentation

Perform a comprehensive clinical fracture risk assessment including:

• History of previous fragility fractures 1
• Falls assessment and frailty evaluation 1
• Medication history, particularly glucocorticoid use, anticonvulsants, or chronic heparin 1, 2
• Measurement of height (without shoes) to assess for height loss >4 cm 2
• Body weight and BMI assessment (low body weight <20-25 kg/m² is a risk factor) 1, 2
• Family history of hip fracture 1
• Alcohol use (≥3 units/day) and smoking history 1
• Assessment for hypogonadism symptoms 1

FRAX Calculation

Calculate 10-year fracture risk using the FRAX tool with BMD results once available, as this is the appropriate tool for fracture risk assessment and setting intervention thresholds in men with osteoporosis 1

• FRAX-based intervention thresholds should be age-dependent in men with osteoporosis 1
• Trabecular bone score, used with BMD and FRAX probability, provides useful information for fracture risk assessment in men 1

Common Pitfalls to Avoid

• Do not rely solely on lumbar spine DXA in elderly men, as degenerative changes can falsely elevate BMD readings and mask true osteoporosis 3, 2
• Do not use peripheral bone measurement tests (like calcaneal ultrasonography) instead of DXA, as they are not sufficiently sensitive or specific 1, 7
• Do not screen for hyperparathyroidism with total calcium alone, as this will miss many cases; always include ionized calcium and intact PTH 4
• Do not delay DXA testing while pursuing alternative screening methods, as this patient already meets age criteria for immediate screening 3, 2

Interpretation of Results

Use T-scores with the following diagnostic thresholds (same as in women):

• Normal: T-score ≥ -1.0 7
• Osteopenia: T-score between -1.0 and -2.5 7
• Osteoporosis: T-score ≤ -2.5 7

Follow-Up DXA Timing

If osteoporosis is diagnosed or treatment is initiated, repeat DXA in 1-2 years to monitor treatment effectiveness 3, 2

If results show osteopenia, repeat DXA in 2-3 years 3, 2

Baseline Supplementation

Ensure vitamin D and calcium repletion in this patient above age 65:

• All men above age 65 should receive calcium 1000-1200 mg daily and vitamin D 800-1000 IU daily 1, 8
• This should be initiated regardless of DXA results 1