In an 84‑year‑old woman with dementia, osteopenia (T‑score –1.0 to –2.5) and high risk of falls and fractures, which oral bisphosphonate is preferred and what are its contraindications?

Recommended Oral Bisphosphonate and Contraindications

For this 84-year-old woman with dementia, osteopenia, and high fall risk, oral bisphosphonate therapy is NOT recommended due to poor adherence capability, dementia-related administration challenges, and the unfavorable benefit-harm balance in her specific context. 1

Critical Decision Framework

Why Treatment is NOT Recommended in This Case

The balance of benefits and harms does not favor bisphosphonate intervention for this patient. 1 Here's the algorithmic reasoning:

• Adherence barriers: Her dementia makes it nearly impossible to follow the stringent bisphosphonate administration requirements (take on empty stomach, remain upright 30 minutes, full glass of water) 1, 2
• Absolute risk reduction is small: With osteopenia (T-score -1.0 to -2.5), benefits would not begin until approximately 18 months of treatment, and the number needed to treat exceeds 100 1, 3
• Competing risks: At age 84 with dementia, life expectancy considerations and quality of life priorities outweigh modest fracture risk reduction 1
• Drug-disease interactions: Bisphosphonates can aggravate hiatal hernia and increase risks of atypical fractures and osteonecrosis 1

If Treatment Were Considered (Against Recommendation)

Should treatment be pursued despite the above concerns, risedronate would be the preferred oral bisphosphonate based on the following evidence hierarchy:

First-Line Agent: Risedronate

• Risedronate is specifically supported for osteopenic women ≥65 years at high fracture risk, reducing fragility fractures by 73% compared to placebo in post-hoc analyses 1
• Dosing: 35 mg orally once weekly (standard osteoporosis dosing) 4, 5
• Fracture risk reduction begins at 6-12 months for clinical vertebral fractures 5

Alternative: Alendronate

• Alendronate 70 mg orally once weekly is equally effective, reducing vertebral fractures by 50% and hip fractures by 40-50% over 3 years 6, 4, 5
• Clinical vertebral fracture risk reduced after just 1 year of treatment 5
• Both agents have similar efficacy; the choice between them is based on tolerability and cost 1, 4

Absolute Contraindications to Oral Bisphosphonates

Do not prescribe oral bisphosphonates if any of the following are present:

• Creatinine clearance <35 mL/min (alendronate is not recommended) 2
• Inability to stand or sit upright for at least 30 minutes after administration 2
• Esophageal abnormalities that delay esophageal emptying (stricture, achalasia) 2
• Hypocalcemia (must be corrected before initiating therapy) 2
• Known hypersensitivity to bisphosphonates 2

Relative Contraindications and Serious Warnings

Exercise extreme caution or avoid if:

• Active upper gastrointestinal disease (dysphagia, esophagitis, gastritis, duodenitis, ulcers, hiatal hernia) 1, 2
• Inability to follow administration instructions due to cognitive impairment 1
• Concurrent proton pump inhibitor use (decreases calcium absorption, increases fracture risk, may reduce bisphosphonate effectiveness) 1
• Concurrent SSRI use (doubles fracture risk through decreased osteoblast activity) 1
• Poor dental health or planned invasive dental procedures (risk of osteonecrosis of the jaw, though rare at <1 per 10,000 patient-years) 7, 2

Serious Adverse Events to Monitor

Rare but important complications include:

• Osteonecrosis of the jaw (ONJ): Risk increases with duration of exposure; complete dental work before starting therapy 7, 2
• Atypical femoral fractures: Low-energy fractures of femoral shaft; patients may report prodromal thigh pain weeks to months before complete fracture 2
• Severe musculoskeletal pain: Can occur from one day to several months after starting; discontinue if severe symptoms develop 2
• Esophageal complications: Esophagitis, esophageal ulcers, esophageal erosions if administration instructions not followed 2

Recommended Alternative Strategy for This Patient

Instead of bisphosphonates, optimize non-pharmacologic interventions: 1

• Calcium supplementation: 1,200 mg daily 1, 8
• Vitamin D supplementation: 800-1,000 IU daily, targeting serum 25(OH)D >32 ng/mL 8, 7
• Weight-bearing exercise: Daily walking as tolerated 1
• Fall prevention strategies: Home safety assessment, remove tripping hazards, adequate lighting 8
• Medication review: Discontinue or reduce medications that increase fall risk (sedatives, SSRIs if possible) 1

If Pharmacologic Treatment Becomes Necessary

Consider intravenous zoledronic acid (5 mg annually) as it eliminates adherence concerns with daily/weekly oral administration, though cost may be prohibitive and transportation to infusion appointments may be challenging 1, 7

Common Pitfalls to Avoid

• Never initiate bisphosphonates without correcting vitamin D deficiency first (increases hypocalcemia risk, particularly with IV formulations) 7
• Never allow patients to lie down within 30 minutes of oral bisphosphonate administration (dramatically increases esophageal complication risk) 8, 2
• Never assume osteopenia alone warrants treatment (T-score must be combined with clinical risk factors; most osteopenic patients do not require pharmacologic therapy) 1, 3
• Never prescribe oral bisphosphonates to patients who cannot reliably follow administration instructions due to cognitive impairment 1