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LEARNING OBJECTIVES

Learning Objectives

  • 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

  1. Both older men and women are at risk of osteoporotic fractures.

  2. Fracture risk assessment, including clinical factors, should be performed in every person older than 65.

  3. Calcium and vitamin D should be an essential component of any osteoporosis treatment.

  4. Antiresorptives (bisphosphonates and denosumab) and anabolics (teriparatide and romosozumab) 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 (a fracture resulting from a fall from standing height or less) 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 fracture risk approximately doubles. As seen in Table 51-1, a T-score less than −2.5 defines osteoporosis; osteopenia (low bone mass) and normal bone mass are also defined.

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TABLE 51-1 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 confirm the diagnosis of osteoporosis and indicates that interventions are needed prior to fracture in older adults. In addition, individuals with osteopenia could be still at risk of fractures. They, therefore, should be followed carefully for further bone loss while also promoting nonpharmacologic interventions that maintain bone health. 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 occurs in women between 51 and 75 years. It is related to estrogen deficiency seen with ...

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