Osteoporosis in over 50s - clinical fact sheet and MCQ

Overview

Osteoporosis is a systemic skeletal disease defined by reduced bone mineral density (BMD) and microarchitectural deterioration, increasing the risk of fractures.^1,2 It is a major public health issue, affecting millions of Australians over 50 years of age. The condition is largely asymptomatic until a fracture occurs, leading to underdiagnosis and undertreatment.¹

Fractures related to osteoporosis, particularly hip and vertebral fractures, are associated with increased mortality and morbidity, loss of independence and quality of life. There is insufficient evidence to recommend population-based systematic screening with BMD measurement for reduction of osteoporotic fractures in Australia, and case-finding is recommended, including with the use of  a fracture risk assessment tool, particularly the Fracture Risk Assessment Tool, FRAX®. 

Assessing risk

A comprehensive list of non-modifiable and modifiable risk factors for osteoporosis can be found here.

• Risk factors^1,2

• • All postmenopausal women and men > 50 years old should undergo a risk factor assessment for osteoporosis even in the absence of fracture

  • Risk factors include:

    • non-modifiable factors, eg age ≥70 years, parent with hip fracture or other types of minimal trauma fracture

    • lifestyle factors, eg smoking, low muscle mass, immobility

    • certain comorbid conditions, eg early menopause, rheumatoid arthritis, hypogonadism, coeliac disease

    • medications that cause bone loss, eg glucocorticoids, aromatase inhibitors

  • Patients at very high risk include those with DXA T-score ≤ -3.0 and:

    • recent fracture within 2 years, and/or

    • history of 2 or more minimal trauma fractures, and/or

    • clinical risk factors (see above), and/or

    • FRAX risk of major osteoporotic fracture (MOF) ≥30% (ie involving vertebra, hip, humerus, and forearm) or hip risk ≥4.5%

Case-finding and investigations¹

Bone mineral density (BMD) assessment should be measured at a minimum of two sites, including the lumbar spine and hip¹

• DXA is the gold standard for diagnosis of osteoporosis and is used to guide treatment

• WHO definitions for postmenopausal women and men >50 years old:

• normal BMD: T-score ≥ -1.0

• osteopenia: T-score between -1.0 and -2.5

• osteoporosis: T-score ≤ -2.5 at the femoral neck

• severe osteoporosis as defined by the International Osteoporosis Foundation: T-score ≤ -2.5 and history of at least one fragility fracture³

Patients at very high risk: refer to bone specialist for treatment.

Patients who have sustained a minimal trauma fracture:

• at hip or vertebra: commence treatment with a provisional diagnosis of osteoporosis; DXA may be performed to monitor BMD but not necessary for initiating treatment

• at site other than hip or vertebra: refer for DXA

• if T-score ≤ -1.5, commence treatment

• if T-score > -1.5, investigate other causes of fracture

Patients at risk with no history of fracture:

• with non-modifiable or lifestyle factors: 

• perform FRAX assessment and refer for DXA if ≥10%

• if DXA T-score ≤ -2.5, commence treatment

• if DXA T-score between -1.5 and -2.5, recalculate FRAX to account for T-score and treat only if MOF risk ≥20% or hip fracture risk ≥3%

• with comorbidities or medications known to increase osteoporosis risk:

• perform DXA and treat or calculate FRAX as per algorithm for non-modifiable or lifestyle factors above

Management

Review the flowchart for osteoporosis risk assessment, diagnosis, and management here.

1. Non-pharmacological management

• Calcium and vitamin D:¹

  • 1300 mg/day for women >50 years

  • 1000 mg/day for men 50-70 years

  • 1300 mg/day for men >70 years

• adequate calcium intake should be ensured, preferably through diet.:

• consider calcium supplementation for all frail older patients, and in patients on osteoporosis treatment with inadequate dietary calcium

• vitamin D supplementation (800-1000 IU/day) is recommended in frail older patients, and for individuals with serum 25 hydroxyvitamin D < 50 nmol/L

• Protein intake of 1.0-1.2 g/kg body weight can improve bone and muscle health¹

• Exercise can reduce fracture risk:¹

• weight-bearing impact exercises (eg, walking, dancing) should be done most days

• resistance training (at least twice per week) is crucial for maintaining muscle strength and reducing falls

• Proactive falls risk assessment and fall prevention strategies based on risk, including:¹

• physiotherapy referral for tailored exercises targeting balance, gait, and strength

• education on falls prevention

• medication review

• foot health and footwear

• appropriate vision correction

2. Pharmacological treatment

• Bisphosphonates (oral alendronate, risedronate, or IV zoledronic acid):¹

• for primary prevention of vertebral fractures from osteopenia in women >10 years postmenopause

• to reduce fractures in postmenopausal women and men >50 years at high fracture risk

• most common adverse effects are gastrointestinal; atypical fracture of the femur is rare, as is medication-related osteonecrosis of the jaw; consider dental review prior to treatment 

• upper GIT disorders (eg, Barrett’s oesophagus or ulcers) are contraindications 

• reassess need for therapy after 5–10 years if T-score ≥ -2.5 and no recent fractures

• Denosumab:¹

• alternative to bisphosphonates in men and postmenopausal women at high fracture risk

• administered as subcutaneous injection

• avoids gastrointestinal adverse effects found with biphosphonates

• therapy should not be abruptly stopped - transition to a bisphosphonate is necessary to prevent rebound fractures

• Romosozumab:¹

• an osteoanabolic agent recommended for very high-risk patients as first-line therapy

• administered with monthly subcutaneous injection

• contraindicated in patients with history of stroke or myocardial infarction due to increased cardiovascular risk

• note this is the most recent addition to pharmacological therapies for osteoporosis (PBS listed in 2021), so evidence is limited

• conditional PBS approval requires a consultant physician to initiate this medication

• Menopausal hormone therapy (MHT):¹

• consider oestrogen replacement therapy  in women within 10 years of menopause for osteoporosis prevention but requires careful risk-benefit assessment 

• selective oestrogen receptor modulators may be considered, if at risk of vertebral fracture and other agents not tolerated, particularly  in younger postmenopausal women with personal or family history of breast cancer 

• Recombinant human parathyroid hormone (teriparatide) is reserved for patients with very high fracture risk or those experiencing fractures despite antiresorptive therapy¹

3. Consider specialist referral if:

• recurrent or multiple fractures despite adequate treatment (may require first-line osteoanabolic therapy)¹

• BMD T-score ≤ -3 and patient is taking glucocorticoids, or has multiple risk factors indicating imminent or very high fracture risk¹

• atypical femoral fractures in patients on long-term bisphosphonates (may require reassessment of biphosphonate therapy)¹

• symptoms suggestive of secondary osteoporosis, such as unintentional weight loss, gastrointestinal disorders (e.g., coeliac disease), or hormonal disorders (e.g., hyperthyroidism).

• concurrent chronic kidney disease²

• osteoporosis post-transplant²

4. Monitoring and follow-up¹

• Adjust monitoring frequency depending on fracture risk or other risk factors

• Reassess fracture risk, medication side effects, and therapy adherence every 6–12 months for patients on pharmacological therapy

• Repeat DXA to reevaluate risk and/or monitor response to treatment:

• for patients with osteoporosis, prior to modifying pharmacological therapy or if a new minimal trauma fracture is sustained while on treatment

• aim to use the same instrument to enhance comparability of results

• regular DXA scans may help to improve patient compliance with therapy

• for patients not on pharmacotherapy, consider repeating scans after minimum 2 years to reliably detect BMD change; however, in high-risk patients, consider annual scans

• Bone turnover markers may be used in specialist settings to assess treatment efficacy
  

References

1. RACGP, Healthy Bones Australia. Osteoporosis management and fracture prevention in postmenopausal women and men over 50 years of age. 2024. (last accessed March 2025). 

2. Therapeutic Guidelines. Osteoporosis and minimal-trauma fracture. 2024. (last accessed March 2025).

3. International Osteoporosis Foundation. Diagnosis. 2025. (last accessed April 2025).

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