Osteoporosis is a chronic, progressive skeletal disease characterized by low bone mass, microarchitecture deterioration of bone tissue, bone fragility, and a consequent increase in fracture risk.

1. Ahmed Khairi Mshari
Consultant Family Physician
in
Elderly People

2. Define osteoporosis and identify its
classes.
Discuss the prevalence and impact
of osteoporosis in the elderly.
Identify key risk factors contributing
to osteoporosis development in the
elderly.
Recognize and describe clinical
features associated with
osteoporosis.
Understand the significance of
measuring bone mineral density in
diagnosing and assessing
osteoporosis risk.
Apply recommended guidelines for
assessing osteoporosis risk in the
elderly.
Discuss strategies for preventing
osteoporosis and fractures.
Discuss established treatment
strategies.
Explain the mechanism of action,
role, benefits, and risks of
Bisphosphonates in osteoporosis
treatment.
Understand the importance of
regular patient monitoring during
osteoporosis treatment.

3. Osteoporosis is a chronic, progressive
skeletal disease characterized by low bone
mass, microarchitecture deterioration of
bone tissue, bone fragility, and a
consequent increase in fracture risk.
The National Osteoporosis Foundation

4.  There are 44 million Americans have low
bone mass, and 10 million have
osteoporosis.
 Osteoporosis affects about 50% of women
and 20% of men older than 50 years.
 Its prevalence increases from 8% in the
seventh decade to 47.5% in the ninth
decade.
 Two million osteoporotic fractures occur
each year.
 The overall prevalence of fragility
fractures is higher in women.
 Vertebral fractures are the most
prevalent of all fragility fractures.
 Only 1/3 of vertebral fractures receive
medical attention.
 There are almost 300,000 hip fractures
annually.
 Hip fractures are associated with the
most serious outcomes:
 > 20% of patients dying during the first
year.
 > 40% of them are unable to return to
their previous ambulatory state.
 > 20% of them are placed in long-term
care facilities.
 Hip fractures contribute more to
significant health care expenditure.

5.  Bone is continuously undergoing a remodeling
process called Bone Turnover.
 This involves both bone formation and
resorption.
 Osteoblasts are responsible for bone
formation, synthesizing new bone tissue by
depositing collagen and minerals.
 Osteoclasts are responsible for bone
resorption, breaking down old or damaged
bone tissue and releasing calcium and minerals
into the bloodstream.
 Remodeling allows bones to adapt to changing
mechanical demands, repair micro-damage,
and maintain mineral balance in the body.

6.  Bone remodeling is a dynamic process
influenced by mechanical stress on
bones and hormonal regulation.
 It is tightly regulated by Parathyroid
hormone and Calcitonin.
 PTH stimulates bone resorption to
release calcium into the bloodstream.
 Calcitonin inhibits bone resorption,
promoting calcium deposition in bones.
 Sex hormones (Estrogen and
Testosterone) have a protective role in
maintaining bone density.

7.  Postmenopausal.
 Involutional or Senile
Osteoporosis.
 Secondary to
various causes and
risk factors.
Secondary
Osteoporosis
Primary
Osteoporosis

8.  Age
 Gender
 Family history and
genetics
 Race and ethnicity
 Previous fractures
 Body size
Non-Modifiable
 Nutrition (Calcium,
Vitamin D Intake)
 Physical activity and
exercise
 Smoking and excessive
alcohol consumption
 Medications
 Hormonal imbalance
Modifiable

9.  Eating disorders (anorexia
nervosa)
 Malabsorption syndrome (coeliac
disease)
 Connective tissue disorders (RA)
 Chronic organ failure (kidney,
liver, heart, lungs)
 Endocrine disorders
(Cushing syndrome, DM,
hyperparathyroidism,
thyrotoxicosis, hypogonadism)
Medical causes
 Corticosteroids
 Anticonvulsants
 Thiazolidinediones
 Long-term heparin
 Excessive thyroid hormone
 Proton pump inhibitors
 SSRIs
 Anticoagulants
 Methotrexate
 Depo-Provera
Medications

10.  Fragility fractures have a
significant impact on the quality
of life and functionality of
Patients.
 These fractures often occur as a
result of minimal trauma or falls,
and their consequences can be
severe and long-lasting.
 They are commonly affected the
hip, spine (vertebral
compression fractures), and
wrist (distal radius fractures).
Complications of Osteoporosis

11.  Hip fractures: They can lead to a significant
loss of independence and mobility. Many
require surgical intervention and
rehabilitation, and some may never regain
previous level of function.
 Vertebral compression fractures: They can
cause chronic back pain and a decrease in
height, kyphosis which can further impact
mobility and balance.
 Wrist fractures: They can result in impaired
upper limb function and limit an individual's
ability to perform daily tasks independently.

12.  Osteoporosis is generally asymptomatic until
fractures occur.
 Fractures of the forearm and hip are usually easy to
diagnose, but vertebral fractures are difficult to
detect clinically.
 About 90% of hip fractures occur after a fall.
 2/3 of vertebral fractures are silent and occur with
minimal stress, such as lifting, sneezing, or bending.
 Vertebral fractures may cause an acute episode of
back pain lasting for 6-8 weeks before settling to a
more chronic backache.
 Vertebral fractures cause height loss, kyphosis, and
severe cervical lordosis.

13.  Clinical findings can significantly increase the
suspicion of osteoporosis or spinal fracture and
identify individuals may benefit from earlier
screening, including:
 Low body weight (<51 kg).
 Inability to place the back of the head against a
wall when standing upright (humped back).
 Low tooth count (<20).
 Rib-pelvis distance ≤2 fingerbreadths.
 Loss of height >3 cm.
 Physical exam should also focus on secondary
causes of osteoporosis.

14.  Dual energy X-ray
absorptiometry (DXA) is the
gold standard for the diagnosis
of osteoporosis.
 It assesses the bone mass at
lumbar spine, hip and wrist.
 Bone mass is measured as bone
mineral density (BMD) in g/cm2.
 The BMD ‘T-Score’ is the number
of SD away from the mean BMD
of a 30-year-old adult of the
same sex.
 Each SD change of BMD
increases fracture risk by 2-3
times.

15. 1. Determine BMD.
2. Estimate fracture risk.
3. Identify candidates
for intervention.
4. Assess changes in
bone mass over time
in treated and
untreated patients.
DXA scan
Benefits

16. T-Score
Category Definition by Bone Density
Normal T-Score is greater than −1.0
Osteopenia T-Score is −1 to −2.5
Osteoporosis T-Score is less than −2.5
Severe
osteoporosis
T-Score is less than −2.5
with 1 or more fragility fractures

17. Normal Bone Osteopenia Osteoporosis
T-Score > −1.0 T-Score −1 to −2.5 T-Score < −2.5

18. All men ≥ 70-year-old
Younger men with
clinical risk factors
for fracture.
Screening Guidelines for
Assessing Osteoporosis Risk
All women ≥ 65-year-old.
Younger and
perimenopausal women
with risk factors for
fragility fractures.

19.  FRAX is an accessible online
algorithm developed by WHO.
 It aimed to calculate a patient’s
10-year probability of a fragility
fracture.
 It uses some of the clinical risk
factors and BMD measurements.
 It also uses country-specific
fracture data.
 It is used for untreated
patients only.
 It is applicable to both women
and men ages 40-90 years.
About the Risk Factors

20. About the Risk Factors

21.  All older patients should
have a S. Ca level, 25-
hydroxy vitamin D, and
PTH assessment.
 Basic chemistry panel;
CBC; RFT and LFT.
 Rule out common
secondary causes of
osteoporosis.

22.  Modify secondary causes of osteoporosis
 Adequate Calcium and vitamin D intake
 Regular weight-bearing, muscle
strengthening exercise
 Prevent falls
 Correct vision and hearing
 Evaluate gait and balance
 Assess medication side effects
 Evaluate home safety
 Hip protectors if high fall risk
 Quit smoking and limit alcohol and caffeine
intake
Prevention of Osteoporosis
and Fractures

23.  NOF and IOM recommended:
 Men age 50-70 consume 1000 mg/day
 Women ≥ 51 years and men ≥ 71 years
consume 1200 mg/day of calcium.
 Intakes in excess of 1200-1500 mg/day
increase the risk of kidney stones and
CVD.
 The average daily dietary calcium intake
in adults ≥ 50 years is 600-700 mg/day.
 Calcium supplements should be used
when an adequate dietary intake cannot
be achieved.

24.  Vitamin D plays a major role in
calcium absorption, bone
health, muscle performance,
balance, and risk of falling.
 Vitamin D deficiency is associated
with muscle weakness and falls.
 Vitamin D status can be evaluated
by measuring serum 25-hydroxy
vitamin D.
30
0
10
20
40
50
60
70
80
90
100
Deficient
Ideal
Risk of Toxicity
Blood Level of Vitamin D (ng/ml)
Insufficient

25.  IOM recommends a dietary allowance of
vitamin D:
 600 IU/day for people ≤ 70 years old.
 800 IU/day for those >70 years old.
 NOF recommends an intake of 800-1000
IU/day of vitamin D for adults ≥50 years
old.
 Supplementation with vitamin D2
(Ergocalciferol) or vitamin D3
(Cholecalciferol) may be used.
 Patients receiving treatment for
osteoporosis are offered concomitant
Calcium and Vitamin D supplementation.

26. Many older patients are at high risk for Vitamin D
deficiency:
 Patients with malabsorption (celiac disease) or
other intestinal diseases (IBD, gastric bypass
surgery).
 Chronic renal insufficiency.
 Patients on medications that increase the
breakdown of Vitamin D (some antiseizure drugs).
 People with limited sun exposure, housebound
patients, individuals with very dark skin.
 Chronically ill patients.
 Obese individuals.

27. Treatment of vitamin D
deficiency may be done with
50,000 IU of Vit. D2 or vit. D3
once a week or the equivalent
daily dose for 8-12 weeks to
achieve a S. 25(OH)D level of
approximately 30 ng/ml.
This regimen should be followed
by maintenance therapy of 1000-
2000 IU/day to maintain the
target blood level (30 ng/ml).
5
20
30
10

28.  Calcium Homeostasis explaining how
the body maintains calcium levels.
 When blood calcium levels are low,
the Parathyroid hormone promotes:
 Absorption of calcium in the
intestine.
 Conservation of calcium by the
kidneys.
 Release of calcium from bone
tissue.
 When blood calcium levels are high,
the Calcitonin hormone promotes:
 Elimination of calcium by the
kidneys.
 Storage of calcium in bone tissue.

29. 1. An adult hip or vertebral fragility
fracture.
2. T-score ≤ −2.5 for lumbar spine, total
hip, or femoral neck after
appropriate evaluation to exclude
secondary causes.
3. T-scores between (−1.0 and −2.5) at
the lumbar spine or femoral neck
and a FRAX 10-year probability of a
hip fracture ≥3% or a 10-year
probability of major osteoporosis-
related fractures ≥20%.

30.  A number of pharmacological agents have been developed to treat
osteoporosis.
 There are a number of side effects and potential long-term risks that
dictate the need for proper selection and individualized treatment.
 Treatment guidelines recommend using BISPHOSPHONATES as first
line of treatment.
 The other drugs are used to individuals who are not responding or
cannot tolerate bisphosphonate.
 All patients who are started on treatment for osteoporosis should
also receive adequate intake of Calcium and Vitamin D
supplementation.

31.  Current osteoporosis therapy are
divided into Antiresorptive and
Anabolic agents.
 Antiresorptive therapy available now:
 Bisphosphonates.
 Hormone replacement therapy.
 Raloxifene.
 Denosumab.
 Calcitonin.
 Parathyroid hormone is the only
anabolic agent available now.

32.  Bisphosphonates (BPs) are the mainstay of
osteoporosis prevention and treatment.
 They have a proven antifracture efficacy
and good safety profile.
 They reduce risk of vertebral, hip, and
other fractures.
 They are potent antiresorptive agents by
inhibiting osteoclastic activity.
 They are contraindicated with eGFR below
30 ml/min.
 Prior to initiating therapy, Calcium and
Vitamin D must be adequately replenished
due to avoid possibility of hypocalcemia.
BISPHOSPHONATES
for strong bones

33.  Following administration, BPs
target bone surfaces and are
ingested by osteoclasts during
the process of bone resorption.
 Then BPs are released within
the osteoclasts and impairs
bone resorption.
 The skeletal benefits may be
preserved for at least 1–2 years
after cessation of treatment.
Mechanism of Action
of Bisphosphonates

34.  FDA approved the following agents:
Alendronate, Risedronate,
Ibandronate and Zoledronic acid.
 BPs may be given as:
 Orally:
 Daily (Alendronate, Risedronate).
 Weekly (Alendronate, Risedronate).
 Monthly (Risedronate, Ibandronate).
 Intravenously:
 Every 3 months (Ibandronate).
 Once yearly (Zoledronic acid).
 It is recommended that
patients be reevaluated after
5 years of oral or 3 years of
intravenous BPs therapy.
 If they are osteopenic and
without fracture risk, they
can begin a BPs holiday, and
reevaluation in 1-2 years.
 Oral BPs may be continued
for up to 10 years in patients
whose BMD levels remain in
the osteoporotic range after 5
years.

35.  Alendronate can increase BMD by about
8% at the spine and 4% at the hip over 3
years.
 It reduces the incidence of spine, hip, and
forearm fractures by about 50 % over 3
years.
 It is the most commonly used because it
is the least expensive.
 It is prescribed as:
 5 mg daily, 35 mg weekly tablets, for
the prevention of osteoporosis.
 10 mg daily tablet, 70 mg weekly tablet,
for the treatment of osteoporosis.

36.  Oral BPs must be taken first thing
in the morning on an empty
stomach with a full glass of water
because of their poor absorption.
 Patients must sit upright for 30
minutes (with alendronate and
risedronate), to 60 minutes (with
ibandronate) ingesting other
medication or food and must not lie
down.

37.  Common:
 Upper GI intolerance (oral).
 Flu-like symptoms (IV).
 Less common:
 Atrial fibrillation (IV Zoledronic
acid).
 Hypocalcemia (IV).
 Atypical femoral shaft fractures.
 Rare:
 Osteonecrosis of the jaw.
 Esophageal ulceration.
Adverse Effects of
Bisphosphonates

38.  HRT (Estrogen and Progestogen) is
primarily indicated for the treatment of
moderate-severe menopausal
symptoms.
 It is also approved for the prevention of
osteoporosis in postmenopausal
women.
 It prevents bone loss and reduces the
risk of fragility fractures in post-
menopausal women.
 The Women’s Health Initiative Study
recommended NOT to be used above
the age of 60 because of an increased
risk of breast cancer, CVD and venous
thromboembolic disease.
Hormone
Replacement
Therapy

39.  It is a selective estrogen receptor modulator.
 It has estrogen agonist actions on the
skeleton BUT estrogen antagonist actions on
the breast and endometrium.
 It is effective at reducing vertebral fractures
only.
 It is generally used in postmenopausal women
with osteoporosis who are unable to tolerate
BPs and have a high breast cancer risk.
 It increases risk of venous thromboembolism.
 It can be given orally in dose of 60 mg/day.
 Bazedoxifene is a selective estrogen receptor
modulator more recently approved for use in
the prevention of osteoporosis.

40.  Teriparatide is a recombinant human (synthetic) PTH.
 It has anabolic actions on the skeleton if given as daily
S/C injection.
 It decreases fragility fractures.
 It is given in dosage of 20 mcg/day for up to 2 years.
 It is approved for the treatment of:
Postmenopausal women with severe bone loss.
Men with osteoporosis who have high risk of fracture.
Individuals whose condition has not improved with Bps
therapy.
 One study suggests to follow Teriparatide therapy with
Bps to maintain BMD gains.

41.  It is a human monoclonal antibody
that inhibits the activity of osteoclasts.
 It has been shown to decrease fragility
fractures.
 It significantly increased BMD in
postmenopausal women.
 It is also given to persons who doesn’t
improve with BPs.
 It is given S/C in a dose of 60 mg every
6 months for 3 years.
 It may cause hypocalcemia, that can
be mitigated by calcium and vitamin D
supplements.

42.  It has a direct inhibitory effects on osteoclastic
bone resorption.
 It reduces the occurrence of vertebral
compression fractures only.
 It is approved for the treatment of osteoporosis
in women who are at least 5 years
postmenopausal.
 It is an option for women who cannot tolerate
BPs or SERMs.
 It may reduce pain following an acute vertebral
compression fracture.
 Calcitonin nasal spray is generally administered
once per day.

43.  Osteoporosis is a chronic disease and
requires lifelong management and follow-up.
 No pharmacologic therapy should be
considered indefinite in duration.
 Duration decisions need to be individualized.
 Evidence of efficacy beyond 5 years is
limited.
 Osteonecrosis of the jaw and atypical femur
fractures are more common beyond 5 years.
 All non-bisphosphonate medications produce
temporary effects that wane upon
discontinuation.
 BPs may allow residual effects even after
treatment discontinuation.
Panoramic radiograph:
Patient: 48 years old, female, metastatic
breast cancer on zoledronic acid (Zometa).

44.  Osteoporosis medications
should be reviewed annually.
 Encourage the followings:
 Appropriate treatment
compliance.
 Appropriate calcium and
vitamin D intakes.
 Exercise, fall prevention, and
other lifestyle measures.
 Reevaluation of the patient.
Reevaluation includes:
 Interval clinical history
(intercurrent fracture history
and new chronic diseases or
medications use).
 Height measurement is a critical
determination of osteoporosis
treatment efficacy.
 Serial DXA testing.
 Vertebral imaging if there has
been any documented height
loss during the treatment
period.
 Testing biochemical markers.

45.  Serial DXA testing is an important
component of osteoporosis
management.
 Perform BMD testing 1-2 years after
initiating therapy and every 2 years
thereafter.
 More frequent BMD testing may be
warranted in patients at higher risk
of bone loss.
 The interval may be longer for
patients without major risk factors
and who have an initial T-score in
the normal or upper low bone mass
range.

46.  Biochemical markers of bone
remodeling include:
Resorption markers: serum
C-telopeptide (CTX) and urinary
N-telopeptide (NTX).
Formation markers: serum
bone-specific alkaline
phosphatase (BSAP), osteocalcin
(OC), and aminoterminal
propeptide of type I procollagen
(PINP).
 Samples obtained in the early
morning after an overnight fast.
Biochemical markers are helpful in:
 Predict risk of fracture in
untreated patients.
 Predict rapidity of bone loss in
untreated patients
 Predict extent of fracture risk
reduction when repeated after 3-6
months of treatment.
 Predict magnitude of BMD
increases with therapies.
 Determine adequacy of patient
compliance with osteoporosis
therapy.
 Determine duration of “drug
holiday” and when and if
medication should be restarted.

47.  Integrate osteoporosis awareness into
geriatric practice for comprehensive
patient care.
 Prioritize timely osteoporosis diagnosis
through risk assessment and bone
density evaluations.
 Make treatment decisions based on
evidence and patient-specific factors
for optimal outcomes.
 Educate patients about adherence,
lifestyle adjustments, and fall
prevention for active participation in
bone health.
 Consider future research opportunities
to advance geriatric osteoporosis
management and enhance patient
well-being.

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