Osteoporosis: the emperor has no clothes

Area of Science:

• Gerontology
• Orthopedics
• Pharmacology

Background:

• Current strategies for preventing low-trauma fractures in older adults are based on the assumptions that osteoporosis is the primary cause, high-risk individuals can be identified, and bone-targeted treatments are effective.
• These foundational assumptions are increasingly being questioned by recent research.

Purpose of the Study:

• To critically evaluate the current paradigms in low-trauma fracture prevention among older persons.
• To examine the limitations of osteoporosis as the sole etiological factor, the efficacy of current screening methods, and the effectiveness and safety of bone-targeted pharmacotherapy.

Main Methods:

• Review and analysis of existing literature on fracture pathophysiology, risk prediction, and treatment efficacy in older adults.
• Examination of data regarding the role of falls, frailty, and age-related decline in physical functioning.
• Evaluation of the evidence for bone-targeted pharmacotherapy, including clinical trial data and real-world studies, and associated adverse events.

Main Results:

• Falls are common in fracture patients, but osteoporosis is often absent; aging-related decline and frailty contribute significantly to fall risk.
• Current fracture risk prediction tools, including bone densitometry, fail to accurately identify a substantial proportion of individuals who will fracture.
• Evidence for bone-targeted pharmacotherapy is limited, particularly for hip fracture prevention in women over 80 and men, with questionable real-world efficacy and potential for serious adverse events.

Conclusions:

• The current prevention strategies for low-trauma fractures in older adults, relying on osteoporosis, screening, and pharmacotherapy, are not fully supported by evidence.
• Alternative approaches considering multifactorial causes like falls and frailty, alongside more accurate risk assessment and targeted interventions, are needed.
• Further research is required to develop effective and safe strategies for fracture prevention in the aging population.