What preventative screening program is recommended for an elderly female with a history of fractures and high risk of developing osteoporosis, including vaccinations, cancer screenings, and medication management?

Preventative Screening for an Elderly Female with Fracture History and High Osteoporosis Risk

All women aged 65 years and older should undergo DEXA screening of the hip and lumbar spine for osteoporosis, regardless of risk factors, and given this patient's history of fractures and high risk, she requires immediate screening if not already done, along with consideration for pharmacologic treatment. 1

Osteoporosis Screening

Primary Screening Recommendation

• Women 65 years and older require routine DEXA screening of both the hip and lumbar spine, with no exceptions based on risk profile. 1, 2
• This patient's history of fractures places her in an even higher priority category, as previous fragility fractures are a strong indication for immediate DEXA screening regardless of age. 2
• The 10-year fracture risk for a 65-year-old white woman without additional risk factors is 9.3%, and this patient's prior fractures substantially elevate her risk beyond this baseline. 1

Vertebral Fracture Assessment (VFA)

• During the same DEXA session, VFA or standard radiography should be performed if the T-score is less than -1.0 and the patient meets any of these criteria: age ≥70 years, historical height loss >4 cm, self-reported prior vertebral fracture, or glucocorticoid therapy ≥5 mg prednisone daily for ≥3 months. 2
• Given this patient's fracture history, VFA is particularly important to identify asymptomatic vertebral compression fractures that may influence treatment decisions. 2

Screening Intervals

• For patients with osteoporosis or on treatment, repeat DEXA every 1-2 years to monitor treatment effectiveness. 2, 3
• For patients with normal bone density or mild osteopenia, repeat DEXA in 2-3 years. 2, 4
• A minimum of 2 years between scans is required to reliably measure BMD changes due to testing precision limitations. 1, 2
• Do not repeat DEXA scans more frequently than every 2 years in stable patients, as this provides no clinical benefit and exposes patients to unnecessary radiation. 3

Treatment Considerations

Pharmacologic Interventions

• Bisphosphonates and raloxifene have the strongest and most consistent evidence for reducing vertebral fractures in postmenopausal women with osteoporosis. 1
• Bisphosphonates reduce vertebral fractures with a relative risk of 0.66 (95% CI, 0.50 to 0.89) compared to placebo. 1
• Raloxifene reduces vertebral fractures with a combined relative risk of 0.61 (95% CI, 0.55 to 0.69) compared to placebo. 1
• To minimize gastrointestinal irritation from bisphosphonates, patients must take the medication with a full glass of water and remain upright for at least 30 minutes afterward. 1

Non-Pharmacologic Interventions

• Adequate calcium and vitamin D intake plus weight-bearing exercise form the foundation of osteoporosis management. 1
• Fall prevention strategies are critical, as hip fractures carry significant mortality risk—more than one-third of men and a substantial proportion of women who experience hip fractures die within one year. 1, 3

Additional Preventive Screenings for Elderly Women

Cancer Screening

• Breast cancer screening should continue in women with life expectancy greater than 5 years. 5
• Colorectal cancer screening should continue in women aged 50 and older with life expectancy greater than 5 years. 5
• Cancer screening decisions must account for life expectancy, functionality, and comorbidities, as survival benefit from screening is not seen unless life expectancy exceeds 5 years. 5

Vaccinations

• Annual influenza vaccination is recommended for all adults 65 years and older. 5, 6
• Pneumococcal vaccination is recommended for all adults 65 years and older. 5, 6
• Tetanus and diphtheria vaccination should be current. 5

Cardiovascular Prevention

• Aspirin therapy should be considered based on cardiovascular risk profile. 5
• Lipid management should be addressed according to cardiovascular risk. 5
• Blood pressure screening and management remain essential, as hypertension is a leading modifiable risk factor. 7

Other Important Screenings

• Visual and hearing impairment screening should be performed, as these contribute to fall risk and quality of life. 7
• Depression screening is recommended, as depression is common and often underdiagnosed in elderly populations. 7
• Abdominal aortic aneurysm screening is not indicated for women (this is specific to men aged 65-75 years with smoking history). 5

Medication Management Considerations

Medications That Increase Fracture Risk

• Review all current medications for agents that increase bone loss or fall risk: glucocorticoids, anticonvulsants, chronic heparin, aromatase inhibitors, and medications causing sedation or orthostatic hypotension. 2, 4
• Patients on glucocorticoid therapy for >3 months require DEXA screening regardless of age. 2, 4

Monitoring for Treatment Adherence

• Most patients who receive osteoporosis treatment do not remain on treatment for more than 1 year, making adherence monitoring and patient education critical. 8
• Develop strategies to improve treatment continuation rates, as long-term adherence is essential for fracture risk reduction. 8

Common Pitfalls to Avoid

• Do not delay DEXA screening in women 65 years and older based on perceived low risk—screening is universal at this age. 1
• Do not stop osteoporosis screening at an arbitrary age without considering individual factors such as treatment candidacy and life expectancy. 3
• Do not overlook that fracture risk increases with age, making screening potentially more valuable in older adults who remain treatment candidates. 3
• Do not fail to assess for new risk factors at each clinical encounter, including height loss >4 cm, new medications affecting bone metabolism, or development of conditions associated with bone loss. 2
• Do not use different DXA machines for serial measurements without cross-calibration, as this may lead to inaccurate assessment of BMD changes. 2