Endocrine Conditions in Older Adults: Osteoporosis

Osteoporosis management has undergone several paradigm shifts over the past 20 years because of emerging technologies and new treatments and decision support tools to guide risk assessment. Practice guidelines in the United States and abroad differ widely on recommendations for screening, prevention, and management. Screening has evolved, with improvements in bone mineral density testing, vertebral fracture assessment, trabecular bone scores, and decision support tools. All of these have improved the identification of patients at high risk of fractures. Prevention of osteoporosis should begin early in life, with adequate dietary calcium and vitamin D intake and exercise in childhood. At older ages, patients should undergo continuous reevaluation to minimize secondary risk factors (eg, comorbid conditions, drugs). Recommended management of osteoporosis includes exercise, bisphosphonates, denosumab, and parathyroid hormone analogs. Choice of optimal management depends on efficacy, potential adverse effects, patient and societal costs, and patient characteristics (eg, severity of disease, underlying etiologies, management preferences). The ideal duration of pharmacotherapy remains unclear. There is potential continued benefit with long-term management but increased risk of some adverse effects. These include atypical fractures and osteonecrosis of the jaw with bisphosphonates and denosumab, and osteosarcoma with parathyroid hormone analogs.