This chapter addresses the following Geriatric Fellowship Curriculum Milestones: #18, #53
To understand the features of osteoporosis in older persons.
To identify fracture risk in older persons.
To learn fracture prevention strategies in older persons.
Key Clinical Points
Both older men and women are at risk of osteoporotic fractures.
Fracture risk assessment, including clinical factors, should be performed in every person older than 65.
Calcium and vitamin D should be an essential component of any osteoporosis treatment.
Antiresorptives (bisphosphonates and denosumab) and anabolics (teriparatide) are effective and safe treatments for osteoporosis in older persons.
DEFINITION OF OSTEOPOROSIS
The term osteoporosis was first introduced in the nineteenth century based on histologic diagnosis (“porous bone”). Osteoporosis is a “disease characterized by low bone mass and microarchitectural deterioration of bone tissue leading to enhanced bone fragility and a consequent increase in fracture incidence.” Osteoporosis may also be defined either by the presence of a fragility fracture or by bone mineral density (BMD) measurement. In defining BMD criteria for osteoporosis, the World Health Organization (WHO) used as the standard the BMD of young adult women who were at the age of peak bone mass. For each standard deviation below peak bone mass (or 1 unit decrease in T-score), a woman’s risk of fracture approximately doubles. As seen in Table 118-1, a T-score less than −2.5 defines osteoporosis; osteopenia (low bone mass) and normal bone mass are also defined.
TABLE 118-1WORLD HEALTH ORGANIZATION CRITERIA FOR OSTEOPOROSIS |Favorite Table|Download (.pdf) TABLE 118-1 WORLD HEALTH ORGANIZATION CRITERIA FOR OSTEOPOROSIS
|WHO CLASSIFICATION ||BMD T-SCORE |
|Normal ||> −1 |
|Osteopenia ||≤ 1 but > −2.5 |
|Osteoporosis ||≤ −2.5 |
|Severe osteoporosis ||≤ −2.5 + fragility fracture |
A BMD measurement may permit early diagnosis of osteoporosis and intervention prior to fracture in older adults. In addition, subjects with osteopenia could be still at risk of fractures and therefore should be followed carefully for further bone loss. Although the original standards for definitions of osteoporosis were determined in white women, the standards for men and Hispanic women are similar to those of white and African-American women. However, defining osteoporosis solely by T-score does not effectively capture all patients at risk of a fracture. Greater than 50% of all hip fractures occur in those with T-scores that are better than −2.5. Failure to evaluate and treat such patients adds to the individual and societal cost and consequences of osteoporosis. Therefore, we are still faced with the challenge of improving the identification of the individual patient at risk of fracture and subsequently optimizing both prevention and treatment for older adults.
Primary or idiopathic osteoporosis has been historically classified as postmenopausal or senile osteoporosis. Postmenopausal osteoporosis, formerly known as type I, occurs in women between 51 and 75 years of ...