Osteoporosis is a systemic skeletal disease that makes the bones weak, increasing the risk of fractures. Approximately 10 million adults in the United States have osteoporosis. Another 44 million have low bone density (osteopenia), putting them at increased risk of breaking a bone. In all, half of all adults over the age of 50 have concerns about bone health. Approximately 30% of all postmenopausal women in the U.S. have osteoporosis. The incidence of osteoporotic fractures increases with advancing age. That is why it is important to treat osteoporosis in postmenopausal women and elderly women. 

Please keep reading to learn more about osteoporosis treatment in the elderly who have a high fracture risk. Diet, calcium and vitamin D, exercise, and drug therapy can benefit the elderly, especially elderly women over the age of 80 with a diagnosis of osteoporosis.

What is osteoporosis? How is it diagnosed?

Osteoporosis is a silent disease of the bones that affects millions of Americans. It is responsible for about 2 million broken bones each year. Yet, 80% of elderly patients who suffer fractures are not tested for osteoporosis.

Doctors diagnose osteoporosis, assess fracture risk, and determine the need for treatment of osteoporosis by ordering a test called a bone density scan or bone densitometry. This is an X-ray exam that measures bone mineral density (BMD). It is commonly performed using a DXA or DEXA machine at the femoral neck (neck of the thigh bone), total hip, lumbar spine, and radius (wrist). These are the most common locations where postmenopausal osteoporosis fractures occur. 

A person is diagnosed with osteoporosis based on criteria developed by the World Health Organization (WHO). Anyone with a BMD value (T-score) less than or equal to -2.5 is classified as having osteoporosis. A diagnosis of osteoporosis may also be made if a patient has suffered a fragility fracture independent of BMD and no other causes for the fracture can be identified.

Gender disparities in osteoporosis in the elderly

Both elderly women and elderly men are at risk of osteoporosis. However, women start experiencing bone loss at an earlier age and faster than men. Women over the age of 50 are four times more likely to suffer from osteoporosis and tend to have fractures 5-10 years earlier than men. On the other hand, elderly men tend to have fractures at a higher bone density, usually in the lumbar spine. They also have a higher risk of death from hip fractures. Additionally, men are under-screened and under-treated for osteoporosis even after experiencing a fracture.

How do doctors assess hip fracture risk?

To determine the risk of hip fractures and other osteoporotic fractures, doctors use FRAX (Fracture Risk Assessment Tool). The FRAX score is reported as a percentage and indicates a person’s risk of having vertebral and nonvertebral fractures (hip, spine, and wrist fractures) in the next 10 years. A higher value indicates a greater risk of osteoporotic fractures. The formula for FRAX takes into account a patient’s age, gender, weight, alcohol intake, smoking history, and fracture history to calculate the overall fracture risk.

What is the oldest treatment for osteoporosis?

When it comes to osteoporosis, prevention is better than cure and is the best strategy for fracture risk reduction. The National Osteoporosis Foundation (NOF) recommends the following for all adults over the age of 50 to reduce fracture risk:

• Calcium 1200 mg every day through diet and/or calcium supplements
• Vitamin  800-1000 IU every day
• Regular weight-bearing and muscle-strengthening exercise
• Avoidance of cigarette smoking and excessive alcohol intake 
• Prevention of falls

Should bone loss occur and low bone mineral density develop despite these preventive measures, osteoporosis treatment with drugs can help.

What is the usual treatment for osteoporosis?

Doctors can prescribe medications to treat osteoporosis in elderly patients. Osteoporosis treatment can slow down bone loss; reduce the risk of hip fractures, vertebral fractures (spine fractures), and wrist fractures. These drugs can also lower the risk of falls and control symptoms like pain. 

Treatment with drugs is usually considered in elderly women and men who have already suffered a hip fracture or vertebral fracture, have a BMD T-score of less than -2.5, or have a BMD T-score between -1 and -2.5 (osteopenia). 

How is osteoporosis treated in postmenopausal women and very elderly women?

The National Osteoporosis Foundation has outlined recommendations for the management of osteoporosis. However, in clinical practice, the decision to treat osteoporosis in the elderly is complicated by the role of frailty and fall risk on health outcomes. These risk factors are not included in the FRAX fracture risk calculation. 

Once the decision has been made to treat osteoporosis with a drug, the most appropriate drug is selected, keeping in mind patient preferences, previous experience with osteoporosis medications, and the efficacy and safety of a particular drug in elderly women and very elderly women and men. Various drugs are available for treating osteoporosis. The most common osteoporosis drugs are described below.

Bisphosphonates

These medications slow down bone loss, decrease bone turnover, and preserve or increase bone density. They can significantly reduce the risk of fractures in both younger patients and postmenopausal women. Bisphosphonates have been studied for safety and efficacy in very elderly women (over the age of 80) and were found to reduce vertebral and nonvertebral fracture risk.

Bisphosphonates approved by the U.S. Food and Drug Administration (FDA) include alendronate (Fosamax), ibandronate (Boniva), risedronate (Actonel), and zoledronic acid (Reclast). They are available as pills and intravenous injections. Potential side effects of bisphosphonates include nausea, stomach pain, swallowing problems, and irritation or ulceration of the esophagus (food pipe). Taking the medication on an empty stomach first thing in the morning and staying upright for half an hour without eating can reduce the side effects.

Denosumab

This is a monoclonal antibody that is usually given by injection once every 6 months. Denosumab slows bone breakdown and increases cortical bone mass to strengthen bones. Side effects can include injection site reactions, eczema, and low calcium levels. Very rarely, this medication can cause osteonecrosis of the jaw or thigh fracture.

Parathyroid Hormone Analogues

Some forms of the parathyroid hormone can be used to treat people with a high risk of vertebral and nonvertebral fractures due to osteoporosis. These drugs include teriparatide (Forteo) and abaloparatide (Tymlos). They are injected under the skin daily for a maximum of 2 years and work by encouraging new bone growth. Some studies and clinical trials have shown that these drugs result in a greater increase in bone mineral density compared to bisphosphonates. They have been studied for safety and efficacy in younger women, younger postmenopausal women, and elderly women, ranging from 22 to 89 years. Potential side effects of these medications include nausea, fatigue, injection site reaction, and high calcium levels.

Selective Estrogen Receptor Modulators (SERMs)

Medications such as raloxifene (Evista) mimic estrogen, a female hormone that is a key regulator of bone metabolism in men and women. This class of drugs is used to treat certain types of cancers like breast cancer and endometrial cancer. It is also an FDA-approved treatment for postmenopausal osteoporosis. The medication is available as a tablet and is taken by mouth every day. Possible side effects can include hot flashes, leg cramps, leg swelling, blood clots, and stroke (rare).

Calcitonin

This is a hormone that is naturally produced by the thyroid gland in the body. It is sometimes used for the treatment of osteoporosis in postmenopausal women. Calcitonin is available as a nasal spray under the brand names Fortical and Miacalcin and also as a shot. However, it is not as effective as other osteoporosis treatments like bisphosphonates or denosumab.

In general, raloxifene and calcitonin are not the first choices of osteoporosis treatment in elderly patients because of the lack of proven effectiveness. They have not been found to reduce the risk of nonvertebral fractures (non-spine fractures), which are a major concern in the elderly patient population. Also, these drugs can increase the risk of thromboembolic events (blood clots) in elderly patients who are at a high risk of heart disease and stroke. 

References:

1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5505539/
2. https://www.medpagetoday.com/endocrinology/osteoporosis/80637
3. https://www.hmpgloballearningnetwork.com/site/altc/content/management-of-osteoporosis-in-elderly-women
4. https://www.bonehealthandosteoporosis.org/preventing-fractures/general-facts/
5. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5380170