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Special issues

Management of osteoporosis in frail and older people (over 75 years of age)

Management of osteoporosis in frail and older people (over 75 years of age)

Recommendation 36


Consider a multifactorial approach (environment, pharmacological treatments, exercise, nutrition) to reduce falls and fracture risk.


Despite the high absolute fracture risk in the older adult population, there is limited evidence-based literature, RCTs, and studies with fractures as an outcome in frail and older people (defined as aged >75 years for the purpose of this document). This group is at the highest risk of fracture, with hip fracture the most common fracture type.1,2

Few studies include patients aged >75 years and, if they do, the numbers are often small and they are infrequently analysed as subgroups. Most of the evidence is based on a systematic review.3 Reassuringly, a review of the published literature on the clinical efficacy and safety of specific osteoporosis treatments in reducing fracture risk in women aged ≥75 years confirms the benefit of treatment.4–15 A consensus statement has recommended there is sufficient evidence for pharmacological treatments for the prevention of osteoporotic fracture in residential aged care.16 (Refer to Sections 3.1, 3.2, 3.3, and 3.5 for evidence updates on bisphosphonates, denosumab, romosozumab, and teriparatide, respectively).

Denosumab is the only agent for which RCTs have been specifically designed and powered to demonstrate a benefit in the reduction of hip fracture risk in women aged >75 years.11–13,15 Risedronate has been demonstrated to be beneficial in a mixed cohort of patients aged between 70 and 100 years with osteoporosis, but not in those aged >80 years with risk factors only.5–7

For non-vertebral fracture, there is evidence for fracture risk reduction with zoledronic acid in those aged ≥75 years,10 and with risedronate in those aged 70–79 years.5 There are inadequate conclusive data for most other agents in terms of non-vertebral fracture risk reduction in older populations because this subgroup is not specifically reported.14,15

Antiresorptives and osteoanabolic agents (romosozumab and teriparatide) are considered effective for vertebral fracture risk reduction in older female populations.3–16

Studies of the osteoanabolic agent romosozumab (compared with placebo or active comparators) have included a large proportion (30–50%) of patients aged >75 years. Although there is evidence for benefit in the total cohort (age 55–90 years) in improving BMD,17–20 vertebral fracture risk,17,18 clinical fracture risk19,20 and non-vertebral fracture risk,19 the benefit in those specifically over 75 years was not reported. However, there is no reason to doubt its efficacy in older people.

A Cochrane review of data pooled from 14 studies (11,808 participants) conducted in residential care settings found moderate-quality evidence for a small reduction in hip fracture risk (RR 0.82; 95% CI: 0.67–1.00) for hip protectors.21 The absolute effect was 11 fewer people (95% CI: from fewer than 20 to 0) per 1000 having a hip fracture when provided with hip protectors. There was moderate-quality evidence when pooling data from five trials in the community (5614 participants) that showed little or no effect on hip fracture risk (RR 1.15; 95% CI: 0.84–1.58) with hip protectors.21

  • Frail and older people aged >75 years are at the highest risk of minimal trauma fracture. It is essential to assess bone health and BMD, if indicated. (Note: BMD testing is Medicare subsidised for those with risk factors, those aged >70 years and those with a fragility fracture. See Appendix C.)
  • Frail and older people have unique needs and differ from younger populations in fragility fracture risk.
  • It is important that clinicians apply a multifactorial and multidisciplinary approach for effective fracture reduction in frail and older people, rather than just relying on bone-protective medications.22
  • It is essential to address the triad of osteoporosis, falls risk and reducing the impact of falls in frail and older people15 (refer to Sections 2.2 and 2.3).
  • A safe environment (extrinsic) and minimising intrinsic factors (comorbidity, medications and polypharmacy) are critical to reducing falls risk.
  • Encourage safe mobility and exercise under appropriate supervision15 (refer to Section 2.3).
  • Optimise nutrition, particularly protein, calcium and vitamin D status, because frail and older people are more likely to be deficient due to poor dietary intake, malabsorption or inadequate sun exposure (vitamin D). Supplementation can be considered. Refer to Sections 2.1 and 2.2.
  • Choose anti-osteoporosis medications based on patient factors, including medication adherence and persistence factors15 (refer to Section 3).
  • FLSs and early, multidisciplinary intervention after fracture are cost-effective strategies to reduce recurrent fracture risk.22
  1. Sanders KM, Seeman E, Ugoni AM, et al. Age- and gender-specific rate of fractures in Australia: A population-based study. Osteoporos Int 1999;10(3):240–47.
  2. Jones G, Nguyen T, Sambrook PN, Kelly PJ, Gilbert C, Eisman JA. Symptomatic fracture incidence in elderly men and women: The Dubbo Osteoporosis Epidemiology Study (DOES). Osteoporos Int 1994;4(5):277–82.
  3. Inderjeeth CA, Foo AC, Lai MM, Glendenning P. Efficacy and safety of pharmacological agents in managing osteoporosis in the old old: Review of the evidence. Bone 2009;44(5):744–51.
  4. Ensrud KE, Black DM, Palermo L, et al. Treatment with alendronate prevents fractures in women at highest risk: Results from the Fracture Intervention Trial. Arch Intern Med 1997;157(22):2617–24.
  5. Boonen S, McClung MR, Eastell R, et al. Safety and efficacy of risedronate in reducing fracture risk in osteoporotic women aged 80 and older: Implications for the use of antiresorptive agents in the old and oldest old. J Am Geriatr Soc 2004;52(11):1832–39.
  6. McClung MR, Geusens P, Miller PD, et al. Effect of risedronate on the risk of hip fracture in elderly women. N Engl J Med 2001;344(5):333–40.
  7. Masud T, McClung M, Geusens P. Reducing hip fracture risk with risedronate in elderly women with established osteoporosis. Clin Interv Aging 2009;4:445–49.
  8. Boonen S, Black DM, Colón-Emeric CS, et al. Efficacy and safety of a once-yearly intravenous zoledronic acid 5 mg for fracture prevention in elderly postmenopausal women with osteoporosis aged 75 and older. J Am Geriatr Soc 2010;58(2):292–99.
  9. Black DM, Delmas PD, Eastell R, et al. Once-yearly zoledronic acid for treatment of postmenopausal osteoporosis. N Engl J Med 2007;356(18):1809–22.
  10. Lyles KW, Colón-Emeric CS, Magaziner JS, et al. Zoledronic acid and clinical fractures and mortality after hip fracture. N Engl J Med 2007;357(18):1799–809.
  11. Boonen S, Adachi JD, Man Z, et al. Treatment with denosumab reduces the incidence of new vertebral and hip fractures in postmenopausal women at high risk. J Clin Endocrinol Metab 2011;96(6):1727–36.
  12. McClung MR, Boonen S, Törring O, et al. Effect of denosumab treatment on the risk of fractures in subgroups of women with postmenopausal osteoporosis. J Bone Miner Res 2012;27(1):211–18.
  13. 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(5):782–89.
  14. Greenspan SL, Schneider DL, McClung MR, et al. Alendronate improves bone mineral density in elderly women with osteoporosis residing in long-term care facilities. A randomized, double-blind, placebo-controlled trial. Ann Intern Med 2002;136(10):742–46.
  15. Inderjeeth CA, Inderjeeth KA. Osteoporosis in older people. J Pharm Pract Res 2021;51(3):265–74.
  16. Duque G, Iuliano S, Close JCT, et al. Prevention of osteoporotic fractures in residential aged care: Updated consensus recommendations. J Am Med Dir Assoc 2022;23(5):756–63.
  17. Saag KG, Petersen J, Brandi ML, et al. Romosozumab or alendronate for fracture prevention in women with osteoporosis. N Engl J Med 2017;377(15):1417–27.
  18. Cosman F, Crittenden DB, Adachi JD, et al. Romosozumab treatment in postmenopausal women with osteoporosis. N Engl J Med 2016;375(16):1532–43.
  19. Tian A, Jia H, Zhu S, et al. Romosozumab versus teriparatide for the treatment of postmenopausal osteoporosis: A systematic review and meta-analysis through a grade analysis of evidence. Orthop Surg 2021;13(7):1941–50.
  20. Lewiecki EM, Blicharski T, Goemaere S, et al. A Phase III randomized placebo-controlled trial to evaluate efficacy and safety of romosozumab in men with osteoporosis. J Clin Endocrinol Metab 2018;103(9):3183–93.
  21. Santesso N, Carrasco-Labra A, Brignardello-Petersen R. Hip protectors for preventing hip fractures in older people. Cochrane Database Syst Rev 2014;(3):CD001255.
  22. Inderjeeth CA, Raymond WD, Geelhoed E, Briggs AM, Oldham D, Mountain D. Fracture liaison service utilising an emergency department information system to identify patients effectively reduce re-fracture rate is cost-effective and cost saving in Western Australia. Australas J Ageing 2022;41(3):e266–75.
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