COMMENTARIES

A Practical Approach to Osteoporosis

Management in the Geriatric Population
Dan Liberman, MD, MScCH, FRCPC, Angela Cheung, MD, PhD, FRCPC
University Health Network, Toronto Rehabilitation Institute, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
DOI:http://dx.doi.org/10.5770/cgj.18.129

ABSTRACT The purpose of this article is to supply primary healthcare

providers with a reference on how to manage osteoporosis
Osteoporosis is a medical condition that is seen commonly in patients 65 years or older in Canada. The information
in elderly patients, and it is associated with a large burden presented is in keeping with the 2010 recommendations by
of morbidity and mortality. This article provides a practical Osteoporosis Canada.(2)
approach to the workup and management of osteoporosis in
patients 65 years or older. WHO TO SCREEN

Key words: osteoporosis, fracture, bisphosphonate, vitamin D, The clinical recommendations are that every patient over the
CAROC age of 50 should be assessed. Thus, every patient 65 years
of age and older should be regularly screened for risk factors
INTRODUCTION for osteoporosis and fragility fractures. This applies for both
women and men. In the younger population, there are several
It is estimated that osteoporosis may cost as much as $3.9 bil- risk factors that prompt consideration for bone mineral density
lion a year in Canada alone.(1) These include costs associated testing; these factors do not play a role in the geriatric popula-
with acute care admissions, rehabilitation, long-term care, tion. Our recommendation is that all patients aged 65 and over
drug costs, and productivity losses, among others.(1) There should have a bone mineral density test. This differs slightly
is no longer a belief that osteoporosis is simply a matter of from the United States Preventive Services Task Force and the
treating bone mineral density values; the priority now is to United Kingdom—National Osteoporosis Guideline Group,
prevent fragility fractures and their immediate and long-term who recommend bone mineral density testing in women over
sequelae.(2) It is now well known that, aside from the pain, the age of 65 and men over the age of 70.(11,12)
morbidity, and financial costs of fragility fractures, there is
also an increased risk of mortality due to fractures,(3) and CLINICAL ASSESSMENT AND TESTING
current antiresorptive therapies reduce this risk.(4)
In the United States, it is estimated that 44 million History taking is especially important for our target popula-
people have osteopenia or osteoporosis.(5) In Canada, by tion. The purpose of taking a proper history is to identify the
the year 2036, due to rapid ageing of the population, the factors that increase the risk for low bone mineral density,
number of citizens aged over 65 may outnumber children. falls and resultant fractures. This includes a history of falls,
(6) A previous systematic review revealed that the major- the number of falls in the past year, gait, balance difficulties
ity of patients who sustained fragility fractures were not and fragility fractures. Other risk factors that apply to any
receiving adequate osteoporosis workup and management. age group include current glucocorticoid use, excessive
(7) In 2007, Bessette et al.(8) found that 81% of fractures alcohol (three or more units per day) and smoking status,
sustained by women over age 50 would be considered rheumatoid arthritis, and a history of a parental hip fracture.
fragility fractures. Among these women, 79% had either The association of caffeine consumption and the risk of
not been prescribed treatment to prevent further fractures osteoporosis has been inconsistent, though one study has
or had not been investigated for osteoporosis. A fragility shown that a daily caffeine intake of 330 mg (equivalent to
fracture results from a fall from standing height or less; four cups of coffee) may increase the risk of osteoporotic
this increases the risk for subsequent fractures by up to fractures in women.(13)
9.5 fold.(9) The strongest association is between a prior There are a number of non-glucocorticoid medications
and subsequent vertebral fracture, with the risk increasing that are suspected of inducing osteoporosis and/or increasing
with the number of vertebral fractures.(10) fracture risk. These include antiepileptic drugs, suppressive

© 2015 Author(s). Published by the Canadian Geriatrics Society. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial
No-Derivative license (http://creativecommons.org/licenses/by-nc-nd/2.5/ca/), which permits unrestricted non-commercial use and distribution, provided the original work is properly cited.

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dose thyroid hormones, aromatase inhibitors, gonadotropin- HOW TO INTERPRET BMD RESULTS
releasing hormone agonists, antipsychotics, selective sero-
tonin reuptake inhibitors, and proton pump inhibitors.(14) For simplicity and convenience, we prefer using the Cana-
There is also literature that certain co-morbidities increase dian Association of Radiologists and Osteoporosis Canada
osteoporosis severity, particularly Crohn’s disease.(15) The (CAROC) system.(19,20) The CAROC system is an easy-to-use
increased osteoporosis severity among other diseases, such scoring system that plots a patient’s femoral neck bone mineral
as depression, breast cancer, and prostate cancer, may be due density T-score against a curve that divides patients into low
to the medications used to treat the disease.(15) Parkinson’s (< 10%), moderate or high (> 20%) ten-year fracture risk. The
disease was found to have an age-adjusted hazard ratio of 2.2 2010 version of the CAROC tool has been validated in Canada
for incident fracture.(16) (grade A) and is the preferred national risk assessment system
The appropriate physical examination maneuvers serve for reporting bone mineral density results (grade D).(2) These
two purposes: to assess risk factors for future fragility fractures scoring systems are sex-specific. For a woman over the age
and to screen for possible undiagnosed vertebral fractures. of 65, a femoral neck T-score -1.9 or lower places her in the
The elements of the physical exam that are most pertinent moderate-risk category, while a value lower than -3.5 makes
to the elderly population include weight measurement, the her a high ten-year fracture risk patient.
Get-Up-and-Go Test (which helps assess for proximal muscle There are certain caveats when plotting the femoral neck
weakness, gait, and risk of falls), and screening for vertebral T-score on the CAROC curve. Any fragility fracture after the
fractures (height loss of > 2 cm, rib to pelvis distance < or age of 40, or recent prolonged glucocorticoid use (defined as
equal to 2 fingers’ breadth, and an occiput-to-wall distance daily prednisone ≥ 7.5 mg for a cumulative duration of three
of > 5 cm). Assessing for vertebral fractures is supported by months or longer over the past year), increases the ten-year
Grade A evidence.(2) While the guidelines do not necessarily fracture risk by one category. If both features are present,
mention performing a cognitive screen, a 2005 study revealed the patient becomes high-risk, even with a normal T-score.
that patients with dementia have a relative risk of 10.1 for Any patient who has more than one fragility fracture, or a
having at least one fall in the next year.(17) fragility fracture of the hip or vertebra, is considered at high
The etiology of falls is generally multifactorial. There are ten-year fracture risk. If the T-score for the lumbar spine or
many risk factors that have been identified for falls. These in- total hip is -2.5 or less, the patient is at least at moderate ten-
clude psychotropic medications, gait and balance impairment, year fracture risk.
functional limitation, home hazards, advanced age, cognitive Certain situations regarding moderate risk patients com-
impairment, and visual impairment.(18) pel us to treat. These factors include a lumbar spine T-score
Baseline biochemical tests are not mandatory unless that is at least one standard deviation less than the femoral
the patient is found to have lower than normal bone mineral neck score, older than age 65 with a prior history of wrist frac-
density results. In the event that osteoporosis or osteopenia ture, history of wrist fracture with a T-score lower than -2.5,
is diagnosed, then the recommended blood tests include cor- recurrent falls, low-dose glucocorticoid therapy, and current
rected calcium, alkaline phosphatase, creatinine, complete use of aromatase inhibitors or androgen deprivation therapy.
blood count, thyroid stimulating hormone, and a serum protein
electrophoresis (only for patients with vertebral fractures). HOW TO TREAT
A serum 25-hydroxy vitamin D level is also recommended
after the patient has been supplemented with vitamin D for a The goals of treatment for patients with osteoporosis include
minimum of three months. bone strengthening, optimizing physical function, prevention of
If there is clinical worry about a possible vertebral fracture, new fractures, and decreasing symptoms of prior fractures.(21)
lateral thoracic and lumbar spine x-rays should be ordered. Non-pharmacologic interventions should be advised to
The final step in the workup of a geriatric patient is bone all patients who have osteoporosis. Inactivity and immobility
mineral density testing. To facilitate testing for frail individu- promotes reduced bone mass, and even moderate (or more
als who are unfit to be screened with a bone mineral density vigorous) walking programs help reduce the risk of hip frac-
test, the 2010 Osteoporosis Canada guidelines highlight four tures.(22) Those who are at high-risk of falls may benefit from a
categories of patients who are considered high-risk (and don’t home occupational therapy safety assessment. Smoking cessa-
necessarily require testing for risk assessment). These include tion and moderation of alcohol intake are also recommended.
patients with It is estimated that one-third of falls can be prevented with
falls prevention strategies.(18) Among the particular exercise
1. hip fractures programs, challenging balance training (particularly tai chi)
2. vertebral fractures may help to reduce the risk, fear, and number of falls,(23,24)
3. more than one fragility fracture core stability exercises are recommended for those with a
4. one fragility fracture and who are on glucocorticoids prior vertebral fracture, and resistance training (appropri-
(equivalent to prednisone of equal to or greater than 7.5 ate for functional capacity) is recommended even for those
mg per day for greater than three months in the past year). who are at-risk for osteoporosis. Combining weight bearing

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exercises with strength training will help prevent bone loss. Most trials that examine high doses of vitamin D are not
(24) A Bayesian approach revealed that hip protectors decrease properly designed to assess long-term harms.(32) The studies
the risk of incident hip fractures in elderly nursing home that investigated whether vitamin D and/or calcium supple-
residents,(25) and these protectors should be considered in mentation led to an increased risk of certain malignancies were
patients at high-risk for falls. either inconsistent or not relevant to our patient population.(33)
The recommendations regarding calcium and vitamin The purported association between calcium supple-
D supplementation may cause confusion. With reference to mentation and cardiovascular disease is controversial. One
vitamin D, most of the circulating vitamin comes from expo- reanalysis of the Women’s Health Initiative database revealed
sure to sunlight, not from diet. Certain factors, such as use of an increased hazard ratio for those patients who were assigned
sunscreen, darker skin colour, and being elderly, decrease the to calcium supplementation (and were not taking calcium
efficiency of vitamin D production in the skin. We aim for a supplements at the time of randomization).(34) It is important
serum 25-hydroxyvitamin D level of 75 nmol/L, which likely to determine how much calcium a patient is receiving in their
cannot be maintained during the Canadian winter without diet before deciding on the supplementation dose. For women
supplementation.(26) The American Geriatrics Society Work- over the age of 50, and men over 70 years of age, an appropri-
group on Vitamin D Supplementation for Older Adults also ate recommended dietary intake is 1,200 to 2,000 mg/day of
concluded that a serum 25-hydroxyvitamin level of 75 nmol/L elemental calcium.(35) Dietary calcium intake may have less
should be a minimum goal for elderly adults (particularly frail adverse cardiovascular effects than supplements because they
ones).(27) For every 1,000 IU of vitamin D3, the average serum are taken in less concentrated boluses and are absorbed more
25-hydroxyvitamin D level will rise by approximately 20 slowly since they are eaten with fat and protein.(36)
nmol/L.(28) In elderly patients at moderate risk for vitamin D
deficiency, we typically supplement with 1,000 IU of vitamin ANTIRESORPTIVE MEDICATION
D3 daily. Higher doses may be required, and doses up to 2,000
IU a day are considered safe. For elderly patients who would The decision to initiate antiresorptive therapy depends on the
be at risk for fractures due to vitamin D deficiency (typically patient’s overall risk. Those who are at high ten-year fracture
those with comorbid conditions that inhibit absorption of the risk should be treated. Those who fall into the moderate-risk
vitamin D supplement or patients with ongoing bone loss or category should be managed on a case-by-case basis. They
recurrent fractures despite adequate treatment), higher supple- should undergo a comprehensive evaluation to determine if
mental doses may be required, and serum 25-hydroxyvitamin there are any other factors that might lead the physician to
D levels can be used to guide dosing. consider therapy (for example, repeated falls, disorders associ-
There is extensive discussion regarding the timing and ne- ated with osteoporosis, women receiving aromatase-inhibitor
cessity of measuring serum vitamin D levels. Testing should be therapy). Patients who are in the low-risk category generally
conducted three months after initiating therapy and should not do not require any further therapy, aside from lifestyle modi-
be repeated once the recommended level of 75 nmol/L is reached fications (exercise, smoking cessation, falls prevention) in
(unless there is a change in clinical status). Ongoing bone loss addition to optimization of their calcium and vitamin D intake
or new fragility fractures would be considered a change in (diet and supplemental).
clinical status. The American Geriatrics Society Workgroup Bisphosphonates, the most commonly used antiresorp-
recommends monitoring of serum 25-hydroxyvitamin D tive therapy, are generally well tolerated and, for most patients
levels in individuals who take medications that bind vitamin who suffer from osteoporosis, the treatment benefits outweigh
D, who are obese, who have malabsorption syndromes, or the risks.(37) The bisphosphonates reduce the incidence of
who limit their overall vitamin D intake.(27) new vertebral fractures by up to 50%, non-vertebral fractures
The daily total intake of elemental calcium should be by 20%, and hip fractures by 40%.(38) The time to onset of
1,200 mg. When possible, we try to encourage patients to benefit for the bisphosphonates is around six months for
achieve their daily target through calcium-rich foods, but clinical vertebral fracture prevention, and 18 months for hip
acknowledge that not all geriatric individuals can, or want fracture prevention.(39)
to, change their diet. In post-menopausal women, alendronate, risedronate, and
The evidence behind vitamin D and calcium supplemen- zoledronic acid are all appropriate first-line therapies for the
tation is strong. It increases bone mineral density, reduces prevention of vertebral and non-vertebral fractures (including
falls, and decreases the risk of hip and non-vertebral fractures hip). The choice of which particular medication to use can be
in elderly, institutionalized individuals.(29) Community-based determined by patient preference. Risedronate and alendronate
clinical trials with calcium and vitamin D supplementation are available orally; they both can be taken daily or weekly,
have poor compliance and tend to be negative,(30) though with risedronate also having a once-monthly pill. Risedronate
a 2005 meta-analysis on vitamin D supplementation of also has a once-weekly pill that can be taken with food. Zole-
700–800 international units a day did reduce the risk of hip dronic acid is available as a once-yearly intravenous infusion.
and non-vertebral fractures in both ambulatory and institu- An important topic is the long-term safety profile of
tionalized individuals.(31) bisphosphonates. Bisphosphonate binding to skeletal bone

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is unsaturable, so that the medication accumulates over time, ANABOLIC (BONE FORMATION) AGENTS
and may be released even after therapy has been stopped.(40)
The likelihood of atypical femur fractures is low, even in Teriparatide is a recombinant parathyroid hormone amino
women who have received treatment for up to a decade.(37) acid 1 to 34 and is effective at increasing bone mineral
Nonetheless, these concerns have led to the idea of a drug density and decreasing vertebral and non-vertebral frac-
holiday after several years of therapy. tures in post-menopausal women.(45,46) Therapy may be
Not much data exist to guide decisions regarding duration inconvenient because teriparatide has to be injected sub-
of drug holidays. For those who have moderate ten-year risk cutaneously daily.
of fracture, it may be reasonable to discontinue intravenous
bisphosphonate use after three years and oral bisphosphonate WHEN TO REPEAT BMD
use after five years. So long as there has not been a significant
loss of bone mineral density (or fracture) on subsequent test- The response to therapy with any osteoporosis medication
ing, the holiday may be continued for up to five years. The is often examined by repeating bone mineral density tests,
FLEX trial showed that ten years of alendronate therapy did although the bone density response may vary with different
not significantly reduce the risk of non-vertebral fractures, therapies. The optimal time to repeat bone density tests is one
compared to five years of alendronate therapy. The benefit to three years initially. Ideally, testing should be performed
in continuing alendronate therapy for ten years occurs in the at the same laboratory for each visit, to decrease variability
population whose femoral neck T-scores are -2.5 or less, who between machines.
have a lower incidence of novel vertebral fractures.(41) Patients Once bone mineral density is stable, the testing interval
who are at high-risk for future fractures should be treated for can lengthen, allowing for five to ten years for those who are
up to ten years before a shorter drug holiday can be offered low-risk and do not have a reason for potential fast bone loss.
(typically two years at the most). Patients should be monitored
for significant bone loss or novel fractures. The other option is REFERRAL TO OSTEOPOROSIS SPECIALIST
for those at high-risk for future fractures and who are receiv-
ing antiresorptive therapy to switch to bone formation therapy The decision for a primary-care physician to refer a patient with
after five to ten years of use. For all patients, regardless of osteoporosis should be made on a case-by-case basis. Certain
risk, the decision of when to hold bisphosphonates and for patients would likely benefit from referral. These include
how long should be made on a case-by-case basis. patients with continuing bone loss or fracture despite taking
Denosumab is a fully human monoclonal antibody first-line therapy, intolerance to medication, secondary causes
RANKL inhibitor. This ultimately prevents the differentiation of osteoporosis, and extremely low bone mineral density values.
and function of osteoclasts, and leads to increased bone mass.
(42,43) It is administered as a subcutaneous injection every six
CONCLUSION
months. For patients who cannot take oral bisphosphonates
(typically due to gastrointestinal side effects or the need to take This article touches on the workup and treatment of elderly
on an empty stomach), denosumab has been shown to have patients with osteoporosis. It is aimed at Canadian primary-
similar bone mineral density improvements as alendronate.(44) care providers, and uses the CAROC guidelines (as opposed
Unlike bisphosphonates, which incorporates into bone, deno- to US or UK guidelines) to assess ten-year fracture risk.
sumab does not, and cessation of therapy may lead to a more This was not meant to be an in-depth review of the mecha-
rapid decline of bone mineral density compared to bisphos- nisms of bone loss in the elderly. The desire is to provide an
phonates. A 2012 review shows that denosumab is efficacious easy-to-follow practical guide to the office-based treatment of
and safe as a first-line treatment for postmenopausal women, osteoporosis. The expectation is to decrease the risk of fragility
particularly those who cannot take bisphosphonates.(21) While fractures and its consequences in the frail, elderly population.
rare, cellulitis was significantly more common in patients re-
ceiving denosumab compared to placebo; it occurred in 12 out CONFLICT OF INTEREST DISCLOSURES
of 3,886 patients in the FREEDOM trial, compared to one in
3,876 patients in the placebo arm.(42) Atypical femur fractures, The authors declare that no conflicts of interest exist.
although rare, have also been observed with denosumab therapy.
In July 2013, Health Canada decided to withdraw calci-
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