Osteoporosis is characterized by reduced bone mass, deterioration of bone matrix, and diminished bone architectural strength. The rate of bone resorption is greater than the rate of bone formation. The bones become progressively porous, brittle, and fragile, and they fracture easily. Multiple compression fractures of the vertebrae result in skeletal deformity (kyphosis). This kyphosis is associated with loss of height. Patients at risk include postmenopausal women and small-framed, nonobese Caucasian women.

Risk factors include inadequate nutrition, inadequate vitamin D and calcium, and lifestyle choices (e.g., smoking, caffeine intake, and alcohol consumption); genetics; and lack of physical activity. Age-related bone loss begins soon after peak bone mass is achieved (in the fourth decade). Withdrawal of estrogens at menopause (or oophorectomy) causes decreased calcitonin and accelerated bone resorption, which continues during menopausal years. Immobility contributes to the development of osteoporosis. Secondary osteoporosis is the result of medications or other conditions and diseases that affect bone metabolism. Specific diseases (e.g., celiac disease, hypogonadism) and medications (e.g., corticosteroids, anticonvulsant medications) that place patients at risk need to be identified and therapies instituted to reverse the development of osteoporosis.

Baseline dual-energy x-ray absorptiometry (DEXA, DXA) testing is recommended for all women older than 65 years, for postmenopausal women older than 50 years with osteoporosis risk factors, and for all people who have had a fracture thought to occur as a consequence of osteoporosis.

• Osteoporosis is identified on routine x-ray images when there has been 25% to 40% demineralization.
• DEXA, DXA provides information about spine and hip bone mass and bone mineral density (BMD).
• Laboratory studies (e.g., serum calcium, serum phosphate, serum alkaline phosphatase, urine calcium excretion, urinary hydroxyproline excretion, hematocrit, erythrocyte sedimentation rate [ESR]) and x-ray studies are used to exclude other diagnoses.

• Adequate, balanced diet rich in calcium and vitamin D. The recommended adequate intake level of calcium for men 50 to 70 years is 1,000 mg daily, and for women ages 51 and older and men ages 71 and older is 1,200 mg daily.
• Increased calcium intake during adolescence, young adulthood, and middle age, or a prescribed calcium supplement with meals or beverages high in vitamin C
• Regular, weight-bearing exercise to promote bone formation (20 to 30 minutes of aerobic exercise 3 days per week)
• Other medications: alendronate (Fosamax), risedronate (Actonel), ibandronate (Boniva), and zoledronic acid (Reclast); calcitonin (Miacalcin); selective estrogen receptor modulators (SERMs) such as raloxifene (Evista); teriparatide (Forteo)
• Conservative management of osteoporotic compression fractures of the vertebrae; for patients nonresponsive to first-line approaches to vertebral compression fracture treatment, possibly percutaneous vertebroplasty or kyphoplasty (injection of polymethyl methacrylate bone cement into the fractured vertebra, followed by inflation of a pressurized balloon to restore the shape of the affected vertebra)

Gerontologic Considerations

Older adults fall frequently as a result of environmental hazards, neuromuscular disorders, diminished senses, diminished cardiovascular responses, and responses to medications. The patient and family need to be included in planning for care and preventive management regimens. For example, the home environment should be assessed for safety and elimination of potential hazards (e.g., scatter rugs, cluttered rooms and stairwells, toys on the floor, pets underfoot). A safe environment can then be created (e.g., well-lit staircases with secure hand rails, grab bars in the bathroom, properly fitting footwear).