Diagnosis and management of osteoporosis in the older senior

Figures & data

Table 1 Suggested routine laboratory tests for the evaluation of secondary causes of osteoporosis in the older senior

Laboratory test	Secondary cause
Serum creatinine and blood urea nitrogen	Chronic kidney disease
Serum alkaline phosphatase	Paget’s disease; osteomalacia
Serum thyroid-stimulating hormone concentration	Hyperthyroidism or over-supplementation of thyroxine
Serum calcium and phosphorous concentrations	Vitamin D deficiency; malabsorption
24-hour urinary calcium	Excessive urinary excretion of calcium
Total serum testosterone (men)	Hypogonadism
25-hydroxy vitamin D	Vitamin D insufficiency/deficiency
Intact serum parathyroid hormone	Primary or secondary hyperparathyroidism
Serum protein electrophoresis	Multiple myeloma
Complete blood count	Leukemia
Liver function tests	Chronic liver disease

Table 2 Fall risk assessment in the older senior^58–60

Fall risk assessmenta
Basic fall history (eg, number and circumstances surrounding falls)
Medication review: eliminate unnecessary or inappropriate psychoactive medications including antipsychotics, anxiolytics, hypnotics, antidepressants, muscle relaxants, anticholinergics and narcotics, and medications such as diuretics or certain antihypertensives known to cause postural hypotension
Document alcohol consumption
Document acute or chronic medical conditions
Document orthostatic vitals (blood pressure and pulse)
Visual acuity testing
Basic gait, balance, and strength evaluation (eg, basic neurological exam to evaluate muscle strength, cerebellar function and peripheral sensory function; “Get Up and Go Test”b)
Cognitive status (eg, Mini-Mental State Exam)
Evaluation of home and personal safety

^aRecommended assessment for patients with two or more falls or one fall with injury within the past year.

^b“Get Up and Go Test”: patients are instructed to stand from a seated position without using their hands, walk 10 feet, turn around, return to the chair and sit down. Patients that take longer than 30 seconds are at a higher risk for falls.

Table 3 Recommendations for a bone-healthy lifestyle in the older senior

Intervention	Recommendations	Comments
Exercise^Citation61^–^Citation63	Moderate-intensity aerobic physical activity for ≥30 minutes for 5 days/week. 8–10 exercises using the major muscle groups for ≥2 days/week ≥ 10 minutes of activities to maintain or increase flexibility for ≥2 days/week Exercises to maintain/improve balance in older seniors with substantial fall risk	A physical examination should be performed prior to starting an exercise regimen. The exercise regimen should be tailored to each individual patient.
Fall prevention^Citation58^–^Citation60,Citation64^–^Citation66	Physical activity (as above) Home environment modifications Vision assessment Use of ambulation-assistive devices Treatment of cardiovascular causes of falls Eliminating unnecessary medications Vitamin D supplementation
Calcium^Citation5,Citation71,Citation72	1200–1500 mg calcium divided two to three times daily	Older seniors taking proton pump inhibitors may benefit from calcium citrate. Patients should be counseled regarding possible side effect of constipation.
Vitamin D^Citation5,Citation35	To avoid deficiency 800–1000 IU vitamin D3 daily OR 50,000 IU vitamin D2 every 2–4 weeks
	To treat deficiency 50,000 IU vitamin D2 every week for 8–16 weeks

Abbreviation: IU, international units.

Table 4 Pharmacologic therapy for osteoporosis in the older senior

Drug	Dosing	Efficacya antiresorptive agents (relative risk reduction)	Safety	Comments
Oral bisphosphonates
Alendronate^Citation81^–^Citation86	10 mg po once daily 70 mg po once weekly	VF: 47% HF: 51% NVF: 20% (NS)	GI side effects (eg, nausea, dyspepsia, esophagitis, GI ulceration); muscle pain; small risk for osteonecrosis of the jaw; Not recommended if CrCl < 30–35 ml/min (may be able to use risedronate in patients with CrCl between 15 and 30 ml/min)	Available in liquid form and in combination with cholecalciferol 2800 or 5600 units; Approved for use in men; Generic
Risedronate^Citation87^–^Citation89	5 mg po once daily 35 mg po once weekly 150 mg po once monthly	VF: 41%–49% HF: 30% NVF: 40%		Approved for use in men
Ibandronate^Citation90	2.5 mg po once daily 150 mg po once monthly	VF: 52% HF: NR NVF: NS
Intravenous bisphosphonates
Ibandronate^Citation82^–^Citation84,Citation91	3 mg iv injection over 3–5 seconds every 3 months	Antifracture efficacy demonstrated with oral ibandronate	Short-term flu-like symptoms (pyrexia, myalgias, arthralgias); muscle pain; small risk for osteonecrosis of the jaw; possible small increase in serum creatinine; Not recommended if CrCl < 30–35 mL/min
Zoledronic acid^Citation82^–^Citation84,Citation92,Citation93	5 mg iv infusion over 15 minutes once yearly	VF: 70% HF: 41% NVF: 25%–27% All cause mortality: 28%		Approved for use in men
Other
Raloxifene^Citation94^–^Citation96	60 mg po once daily	VF: 30% HF: NS NVF: 10% (NS)	Increased risk for VTE and fatal stroke	Approved to reduce the risk for invasive breast cancer
Calcitonin^Citation97,Citation98	200 IU (one puff) intranasally once daily alternating nostrils	VF: 33% HF: NS NVF: NS	Nasal effects (eg, irritation, congestion, discharge, sneezing)	Possible analgesic effects
Hormone replacement therapy^Citation104,Citation105	CEE 0.625 mg orally once daily with or without MPA 2.5 mg orally once daily	VF: 35%–38% HF: 33%–39% WF: 29%	Increased risk for cardiovascular disease, breast cancer, stroke, dementia and VTE	Only FDA indicated for the prevention of osteoporosis
Anabolic agents
Teriparatide (parathyroid hormone 1–34)^Citation99	20 mcg sc injection once daily	VF: 65% HF: NS NVF: 54%	Mild hypercalcemia, nausea, headache, dizziness, leg cramps; Contraindicated in patients with a history of prior radiation therapy to the skeleton and severe kidney dysfunction	Approved for use in men; Use approved for only 24 months
Parathyroid hormone (1–84)^Citation100	100 mcg sc injection once daily	VF: 61% HF: NS NVF: NS	Hypercalcemia, hypercalciuria, nausea, headache, dizziness, muscle cramps; Contraindicated in patients with a history of prior radiation therapy to the skeleton and severe kidney dysfunction	Approved outside the US; Use approved for only 24 months; need to monitor serum or urinary calcium at 1, 3 and 6 months
Antiresportive/anabolic agents
Strontium^Citation101^–^Citation103	2 g sachet dissolved in water orally one daily	VF: 41% HF: NS NVF: 10%(NS)	Nausea and diarrhea; possible increase risk for VTE and nervous system disorders; Not recommended if CrCl < 30 mL/min	Approved outside the US

^aEfficacy data from pivotal fracture trials in postmenopausal women.

Abbreviations: VF, new morphometric vertebral fracture; NVF, non-vertebral fracture; HF, hip fracture; RRR, relative risk reduction; GI, gastrointestinal; CrCl, creatinine clearance; NR, not reported; NS, not statistically significant; VTE, venous thromboembolism; CEE, conjugated equine estrogen; MPA, medroxyprogesterone acetate; WF, wrist fracture; FDA, Food and Drug Administration; sc, subcutaneous; IU, international units.

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