Osteoporosis prevention, diagnosis and management in postmenopausal women and men over 50 years of age

Recommendations

Identifying patients to investigate for osteoporosis

Evidence statement

In patients who have sustained a recent minimal trauma fracture, there is a high prevalence of risk factors for osteoporosis that are independent of BMD.5 This suggests that all postmenopausal women and men older than 50 years of age should undergo an assessment of their risk factors for osteoporosis, and all patients who sustain a minimal trauma fracture should be screened for risk factors, regardless of BMD, so that action may be taken to reduce the risk of subsequent fractures.

There is strong multinational randomised controlled trial (RCT) evidence that mild (Grade 1: 20–25% vertebral height loss) vertebral fractures are a significant risk factor for future vertebral fractures.6 The risk of new vertebral fracture increases progressively with the grade of the initial vertebral fracture; a severe initial fracture is associated with a six-fold increase in the risk of new vertebral fractures in the following three years.6 A moderate increase in the risk of non-vertebral fractures is also seen following moderate to severe vertebral fracture, a finding that is independent of BMD.6 The Dubbo Osteoporosis Epidemiology Study found that all fracture types, except ankle and rib fractures, are associated with increased subsequent fracture risk, with even a minor initial fracture resulting in an increased risk of major or hip fracture.7 Approximately half of re-fractures occurred in the first two years, and the risk persists for up to 10 years.7

Grade: A

Recommendation 1
All individuals over the age of 50 who sustain a fracture following minimal trauma (such as a fall from standing height or less) should be considered to have a presumptive diagnosis of osteoporosis.

Grade: B

Recommendation 2
A presumptive diagnosis of osteoporosis can be made in a patient with a spinal compression fracture in whom there is no history of significant trauma and/or the patient is deemed to be at high risk of osteoporotic fracture. Caution regarding diagnosis and treatment should be exercised if only a single mild deformity is detected, especially in a patient under the age of 60.

Grade: B

Recommendation 3
Conduct a clinical risk-factor assessment in postmenopausal women and men over the age of 50 with one or more major risk factors for minimal trauma fracture. Individual risk-factor profile should determine the need for assessment.

International guidelines recommend fracture risk assessment in postmenopausal women and men older than 50 years of age.1,2,3,4

  • History of minimal trauma fracture
  • Height loss ≥3 cm and/or back pain suggestive of vertebral fracture
  • Female
  • Older than 70 years of age
  • History of falls
  • Parental history of hip fracture
  • Premature menopause or hypogonadism
  • Prolonged use of glucocorticoids (at least three months cumulative prednisone or equivalent ≥7.5 mg per day)
  • Use of other medications that cause bone loss
  • Conditions or diseases that lead to bone loss
  • Low body weight
  • Low muscle mass and strength
  • Low physical activity or prolonged immobility
  • Poor balance
  • Smoking
  • High alcohol intake
  • Energy, protein or calcium undernutrition
  • Vitamin D insufficiency

Presence of existing minimal trauma fractures

The single most easily recognised risk factor for osteoporotic fracture is the presence of any spinal or non-spinal minimal trauma fracture (a fracture occurring as a result of a fall from standing height or less). This also applies to vertebral fractures that are coincidentally detected on radiographs. It should be noted that not all vertebral deformities result from minimal trauma. A review of trauma history may guide interpretation of vertebral deformities. Dual energy X-ray absorptiometry (DXA) may be useful to determine if the patient has reduced bone mineral density (BMD) with a higher likelihood of sustaining an osteoporotic vertebral fracture.

Low BMD

Relative fracture risk approximately doubles for each unit (standard deviation) decrease in T-score, as measured by DXA. Postmenopausal women and men older than 50 years of age with osteoporosis (T-score ≤–2.5) are already at increased risk of minimal trauma fracture. Absolute fracture risk increases with both increasing age and decreasing BMD. The absolute risk for fracture is therefore high in postmenopausal women and men aged 70 years or older with a T-score ≤–2.5 (without fracture) and even higher in those with T-score ≤–3.0.

Age

Fracture risk is strongly affected by age for both sexes. With each decade the risk of minimal trauma fracture approximately doubles. Age as a fracture risk is independent of both BMD and clinical risk factors, such as risk of falling, which also increase with age and contribute to fracture risk.

Calcium and vitamin D status

Suboptimal dietary calcium intake and vitamin D deficiency are important public health problems in Australia. Vitamin D deficiency is associated with a higher risk of falling as well as with a lower BMD. Routine screening of vitamin D levels should not be carried out. Testing should be restricted to those with suspected or proven osteoporosis, conditions or medications known to decrease vitamin D levels, deeply pigmented skin, or severe lack of sun exposure due to cultural, medical, occupational or residential reasons.

Paternal or maternal history of hip fractures

Paternal or maternal history of hip fractures is regarded as the most reliable indicator of genetic risk of minimal trauma fracture. However, family history of other types of minimal trauma fracture should also be considered.

Sex

At each age group, men are at approximately 50% lower fracture risk than women: for every three fractures, two will occur in women and one in a man. However, once a man has experienced a fracture, his risk of a subsequent fracture is equivalent to that of a woman of comparable age who has also experienced a fracture.

Falls

A history of falls increases the risk of peripheral minimal trauma fractures for postmenopausal women and men of comparable age. This applies to falls without external cause that have occurred more than once in the past 12 months. Risk factors for falling include poor quadriceps strength, body sway, vitamin D deficiency, medications, visual impairment and environmental hazards.

Smoking

For both women and men, smoking is a moderate risk factor for vertebral and non-vertebral (including hip) minimal trauma fractures. The determination of a gradation of risk depending on the number of cigarettes is still inaccurate. However, smokers generally have a higher fracture risk than non-smokers.

Low levels of physical activity or prolonged immobility

Lack of physical activity is a risk factor for hip fractures and vertebral fractures. Immobility (ie mobility limited to such a degree that the person cannot leave their home or cannot do any housework) may be associated with, and compounded by, low or no exposure to sunlight and subsequent vitamin D deficiency. The inability of a patient to rise from a chair without using their arms (a marker of loss of lower extremity strength and power) is associated with increased risk of minimal trauma fracture.

Low body weight and weight loss

Low body weight (body mass index <20) doubles the relative risk of a hip fracture for both women and men. An increased risk has also been demonstrated for spine and peripheral fractures. Unintentional weight loss is also associated with an increased risk of minimal trauma fracture. Anorexia nervosa is associated with increased risk of developing osteoporosis.

Loss of height

Some loss of height is typical with advancing age and can be due to disc degeneration and/or scoliosis. Accurate measurement and recording of height is important; loss of 3 cm or more, as measured by stadiometer, requires exclusion of vertebral deformity or fractures by X-ray. The greater the height loss, in the absence of obvious scoliosis, the greater the likelihood of vertebral fractures.

High alcohol intake

In this context, high alcohol intake is considered to be greater than two standard drinks per day for both men and women. For more information, refer to the evidence statement for Recommendation 8.

Medications

Medications associated with increased risk of minimal trauma fracture include, but are not limited to, glucocorticoids, excessive thyroid hormone replacement, anti-androgen therapy, anti-oestrogen treatments (aromatase inhibitors), selective serotonin reuptake inhibitors, thiazolidenediones, proton pump inhibitors, certain anti-epileptic drugs and certain anti-psychotics. However, it is not always possible to distinguish the effects on bone health of the drug treatments from the effect of the underlying condition that required their use.

Medical conditions that increase fracture risk (secondary osteoporosis)

Medical conditions that increase bone loss or lead to lower BMD at an earlier age include, but are not limited to, rheumatoid arthritis, Cushing syndrome (endogenous or exogenous), hyperparathyroidism, hyperthyroidism or thyroxine excess, chronic kidney disease, chronic liver disease, premature menopause, male hypogonadism, coeliac disease or other malabsorption disorder, depression, organ or bone marrow transplantation, myeloma or monoclonal gammopathies, human immunodeficiency virus (HIV) infection and diabetes mellitus. These conditions are associated with an increase in the age-specific risk for osteoporosis and minimal trauma fractures. Multiple myeloma may also present with pathologic fractures.

There is strong multinational randomised controlled trial (RCT) evidence that mild (Grade 1: 20–25% vertebral height loss) vertebral fractures are a significant risk factor for future vertebral fractures.6 The risk of new vertebral fracture increases progressively with the grade of the initial vertebral fracture; a severe initial fracture is associated with a six-fold increase in the risk of new vertebral fractures in the following three years.6 A moderate increase in the risk of non-vertebral fractures is also seen following moderate to severe vertebral fracture, a finding that is independent of BMD.6 The Dubbo Osteoporosis Epidemiology Study found that all fracture types, except ankle and rib fractures, are associated with increased subsequent fracture risk, with even a minor initial fracture resulting in an increased risk of major or hip fracture.7 Approximately half of re-fractures occurred in the first two years, and the risk persists for up to 10 years.7

  • Any postmenopausal woman or man older than 50 years of age should be considered to have osteoporosis if they suffer a fracture after minimal trauma, such as after a fall from standing height or less. Although bone densitometry is not always required, it can exclude non-fragility causes of fracture.
  • Patients should be assessed for possible vertebral wedge or crush fractures if there is well-documented height loss of ≥3 cm (measured by stadiometer), kyphosis or unexplained episodes of back pain. A standard spine X-ray should be performed. If vertebral wedge or crush fractures are detected, bone densitometry should be performed to determine BMD at the hip and spine.
  1. Cosman F, de Beur SJ, LeBoff MS, et al. Clinician’s guide to prevention and treatment of osteoporosis. Osteoporos Int 2014;25(10);2359–81.
  2. National Osteoporosis Guideline Group. Guideline for the diagnosis and management of osteoporosis in postmenopausal women and men from the age of 50 years in the UK. Sheffield, UK: NOGG, 2014.
  3. Scottish Intercollegiate Guidelines Network. Management of osteoporosis and the prevention of fragility fractures. SIGN publication no. 142. Edinburgh, UK: SIGN, 2015.
  4. Kanis JA, McCloskey EV, Johansson H, et al. European guidance for the diagnosis and management of osteoporosis in postmenopausal women. Osteoporos Int 2013;24(1):23–57.
  5. Malgo F, Appelman-Dijsktra NM, Termaat MF, et al. High prevalence of secondary factors for bone fragility in patients with a recent fracture independently of BMD. Arch Osteoporos 2016;11;12. doi:10.1007/s11657-016-0258-3.
  6. Johansson H, Odén A, McCloskey EV, Kanis JA. Mild morphometric vertebral fractures predict vertebral fractures but not nonvertebral fractures. Osteoporos Int 2014;25(1):235–41.
  7. Center JR, Bliuc D, Nguyen TV, Eisman JA. Risk of subsequent fracture after low-trauma fracture in men and women. JAMA 2007;297(4):387–94.

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