Fractures, mostly of the hip and pelvis, wrist, and sometimes of the vertebra, account for nearly half of emergency department treatments for elderly individuals seen because of a fall. Bone density measurements show that more than half of these patients have osteoporosis. The notion that it is too late to start treatment in a late stage of the disease forms a barrier to treatment. The aim of this article is to evaluate the effectiveness of therapeutic options for osteoporosis in the elderly, with a view to reducing the incidence of fractures. Although most studies of fracture reduction with medical treatment were not designed for the “geriatric” population, the average age of participants in most clinical trials was about 70 years. Nowadays, clinicians can choose from several effective treatments for the prevention of osteoporotic fractures in high- risk postmenopausal women. Data on the antifracture potential of calcium/vitamin D, raloxifene, bisphosphonates, strontium ralenate, and parathyroid hormone are now available. In all major studies patients also received calcium and vitamin D supplements. Bisphosphonates and strontium ranelate are good choices for first- or second- line treatment, while for the time being parathyroid hormone should only be used for the second- line treatment of osteoporosis in the elderly. The ease of use of bisphosphonates, with once weekly, once monthly, or intravenous administration, may be advantageous for elderly patients already taking multiple medications.
This is a preview of subscription content, access via your institution.
Buy single article
Instant access to the full article PDF.
Price excludes VAT (USA)
Tax calculation will be finalised during checkout.
Hegeman JH, Willemsen G, van Nieuwpoort J et al. Effective tracing of osteoporosis at a fracture and osteoporosis clinic in Groningen; an analysis of the first 100 patients. Ned Tijdschr Geneeskd 2004; 148: 2180–5.
Christiansen C. Consensus development conference: diagnosis, prophylaxis and treatment of osteoporosis. Am J Med 1993; 94: 646–50.
Lips P, Courpron P, Meunier PJ. Mean wall thickness in trabecular bone packets in the human iliac crest: changes with age. Calcif Tissue Res 1978; 26: 13–7.
Kanis JA, Johnell O, Oden A, Johansson H, McCloskey E. FRAX and the assessment of fracture probability in men and women. Osteoporos Int 2008; 19: 385–97.
Grossman J, Maclean CH. Quality indicators for the care of osteoporosis in vulnerable elders. J Am Geriatr Soc 2007; 55 (Suppl 2): S392–402.
Boonen S, Vanderschueren D, Haentjens P, Lips P. Calcium and vitamin D in the prevention and treatment of osteoporosis — a clinical update. J Intern Med 2006; 259: 539–52.
Tang BMP, Eslick GD, Nowson C et al. Use of calcium or calcium in combination with vitamin D supplementation to prevent fractures and bone loss in people aged 50 years and older: a meta-analysis. Lancet 2007; 370: 657–66.
Boonen S, Lips P, Bouillon R, Bischoff-Ferrari HA, Vanderschueren D, Haentjens P. Need for additional calcium to reduce the risk of hip fracture with vitamin D supplementation: evidence from a comparative metaanalysis of randomized controlled trials. J Clin Endocrinol Metab 2007; 92: 1415–23.
Bolland MJ, Barber PA, Doughty RN et al. Vascular events in healthy older women receiving calcium supplementation: randomised controlled trial. BMJ 2008; 336: 262–6.
Bischoff-Ferrari HA, Dawson-Hughes B, Willett WC et al. Effect of Vitamin D on falls: a meta-analysis. JAMA 2004; 291: 1999–2006.
Bischoff-Ferrari HA, Willett WC, Wong JB et al. Fracture prevention with vitamin D supplementation: a meta-analysis of randomized controlled trials. JAMA 2005; 293: 2257–64.
Chapuy MC, Arlot ME, Duboeuf F et al. Vitamin D3 and calcium to prevent hip fractures in the elderly women. N Engl J Med 1992; 327: 1637–42.
Lips P, Graafmans WC, Ooms ME et al. Vitamin D supplementation and fracture incidence in elderly persons. A randomized, placebo-controlled clinical trial. Ann Intern Med 1996; 124: 400–6.
Zarowitz BJ, Stefanicci R, Hollenack K et al. The application of evidence-based principles of care in older persons (issue 1): management of osteoporosis. J Am Med Dir Assoc 2006; 7: 102–8.
Alvarez MJM, Diaz-Curiel M. Pharmacological treatment of osteoporosis for people over 70. Aging Clin Exp Res 2007; 19: 246–54.
Black DM, Cummings SR, Karpf DB et al. Randomised trial of effect of alendronate on risk of fracture in women with existing vertebral fractures. Fracture Intervention Trial Research Group. Lancet 1996; 348: 1535–41.
Cummings SR, Black DM, Thompson DE. Effect of alendronate on risk of fracture in women with low bone density but without vertebral fractures: results from the Fracture Intervention Trial. JAMA 1998; 280: 2077–82.
Harris ST, Watts NB, Genant HK et al. Effects of risedronate treatment on vertebral and nonvertebral fractures in women with postmenopausal osteoporosis: a randomized controlled trial. Vertebral Efficacy With Risedronate Therapy (VERT) Study Group. JAMA 1999; 282: 1344–52.
McClung MR, Geusens P, Miller PD et al. Effect of risedronate on the risk of hip fracture in elderly women. Hip Intervention Program Study Group. N Engl J Med 2001; 344: 333–40.
Cranney A, Guyatt G, Griffith L et al. IX: Summary of meta-analyses of therapies for postmenopausal osteoporosis. Endocr Rev 2002; 23: 570–8.
Boonen S, Laan RF, Barton IP, Watts NB. Effect of osteoporosis treatments on risk of non-vertebral fractures: review and meta-analysis of intention-to-treat studies. Osteoporos Int 2005; 16: 1291–8.
Hochberg MC, Thompson DE, Black D. The effect of alendronate on age-specific incidence of key osteoporotic fractures (Joint meeting of the International Bone and Mineral Society and the European Calcified Tissue Society, June 2001, Madrid, Spain.). Bone 2001; 28: (Suppl 5): P576S.
Boonen S, McClung MR, Eastel R et al. Safety and efficacy of risedronate in reducing fracture risk in osteoporotic women aged 80 and older: Implications for use of antiresorptive agents in the old and oldest old. J Am Geriatr Soc 2004; 52: 1832–9.
Sato Y, Kanoko K, Satoh K, Iwamoto J. The prevention of hip fracture with risedronate and ergocalciferol plus calcium supplementation in elderly women with Alzheimer disease: a randomized controlled trial. Arch Intern Med 2005; 165: 1737–42.
Sato Y, Kanoko K, Satoh K, Iwamoto J. Risedronate sodium therapy for prevention of hip fracture after stroke in elderly women. Neurol 2005; 64: 811–6.
Sato Y, Kanoko K, Satoh K, Iwamoto J. Risedronate sodium therapy for prevention of hip fracture in men 65 years or older after stroke. Arch Intern Med 2005; 165: 1743–8.
Sato Y, Honda Y, Iwamoto J. Risedronate and ergocaldferol prevent hip fracture in elderly men with Parkinson disease. Neurol 2007; 68: 911–5.
Fleurence RL, Iglesias CP, Johnson JM. The cost effectiveness of bisphosphonates for the prevention and treatment of osteoporosis. A structured review of the literature. Pharmacoeconomics 2007; 25: 913–33.
Schousboe JT, Taylor BC, Fink HA et al. Cost-effectiveness of bone densitometry followed by treatment of osteoporosis in older men. JAMA 2007; 298: 629–37.
ChesnutIII CH, Skag A, Christiansen C et al. Effects of oral ibandronate administered daily or intermittently on fracture risk in postmenopausal osteoporosis. J Bone Miner Res 2004; 19: 1241–9.
Stakkestad JA, Benevolenskaya LI, Stepan JJ et al. Intravenous ibandronate injections given every three months: a new treatment option to prevent bone loss in postmenopausal women. Ibandronate Intravenous Study Group. Ann Rheum Dis 2003; 62: 969–75.
Chesnut CH, Ettinger MP, Miller PD et al. Ibandronate produces significant, similar antifracture efficacy in North American and European women: new clinical findings from BONE. Curr Med Res Opin 2005; 21: 391–401.
Delmas PD, Recker RR, Chesnut CH 3rd et al. Daily and intermittent oral ibandronate normalize bone turnover and provide significant reduction in vertebral fracture risk: results from the BONE study. Osteoporos Int 2004; 15: 792–8.
Compston J. Treatments for osteoporosis — looking beyond the HORIZON. N Engl J Med 2007; 356: 1878–80.
Black DM, Delmas PD, Eastell R et al. Once-yearly zoledronic acid for treatment of postmenopausal osteoporosis. HORIZON Pivotal Fracture Trial. N Engl J Med 2007; 356: 1809–22.
Lyles KW, Colón-Emeric CS, Jay S et al. Zoledronic acid and clinical fractures and mortality after hip fracture. N Engl J Med 2007; 357: 1799–809.
Rizzoli R, Burlet N, Cahall D et al. Osteonecrosis of the jaw and bisphosphonate treatment for osteoporosis. Bone 2008; 42: 841–7.
Meunier PJ, Roux C, Seeman E et al. The effects of strontium ranelate on the risk of vertebral fractures in women with postmenopausal osteoporosis. N Engl J Med 2004; 350: 459–68.
Reginster JY, Seeman E, De Vernejoul MC et al. Strontium ranelate reduces the risk of nonvertebral fractures in postmenopausal women with osteoporosis: Treatment of Periferal Osteoporosis (TROPOS) study. J Clin End Metab 2005; 90: 2816–22.
Seeman E, Vellas B, Benhamou C et al. Strontium ranelate reduces the risk of vertebral and nonvertebral fractures in women eighty years of age and older. J Bone Miner Res 2006; 21: 1113–20.
Neer RM, Arnoud CD, Zanchetti JR et al. Effect of parathyroid hormone (1–34) on fractures and bone mineral density in postmenopausal women with osteoporosis. N Engl J Med 2001; 344: 1434–41.
Reginster J-Y, Felsenberg D, Boonen S et al. Effects of long-term strontium ranelate treatment on the risk of non vertebral and vertebral fractures in postmenopausal osteoporosis. Results of a five-year, randomized, placebo-controlled trial. Arthritis Rheum 2008; 58: 1687–95.
Greenspan SL, Bone HG, Ettinger MP et al. Effect of recombinant human parathyroid hormone (1–84) on vertebral fracture and bone mineral density in postmenopausal women with osteoporosis. Ann Intern Med 2007; 146: 326–39.
Marcus R, Wang O, Satterwhite J et al. The skeletal response to teriparatide is largely independent of age, initial bone mineral density, and prevalent vertebral fractures in postmenopausal women with osteoporosis. J Bone Miner Res 2003; 18: 18–23.
Boonen S, Marin F, Mellstrom D et al. Safety and efficacy of teriparatide in elderly women with established osteoporosis: bone anabolic therapy from a geriatric perspective. J Am Geriatr Soc 2006; 54: 782–9.
Ettinger B, Black DM, Mitlak BH et al. Reduction of vertebral fracture risk in postmenopausal women with osteoporosis treated with raloxifene: results from a 3-year randomized clinical trial. Multiple Outcomes of Raloxifene Evaluation (MORE) Investigators. JAMA 1999; 282: 637–45.
Miller RG. Osteoporosis in postmenopausal women. Therapy options across a wide range of risk for fracture. Geriatrics 2006; 61: 24–30.