Prevention of Fractures in the Elderly

A fragility (osteoporotic) fracture results from low-energy trauma — typically a fall from standing height or less. It is the product of two independent factors: the fall (impact) and bone made fragile by ageing (osteoporosis). Prevention must therefore address both.

The commonest sites are hip, forearm (distal radius) and vertebrae; humerus and ribs follow. Maintenance of musculoskeletal health during ageing is a key determinant of functional ability.

In elderly patients, only 3% of hip fractures are pathological (metastasis, myeloma, bone cysts, Paget's disease); over half of patients are osteoporotic and almost all have osteopenia.

After a proximal femoral fracture, in the first year: 56% fall again, 28% have repeated falls, 12% sustain a new fracture, and 5% fracture the opposite hip — making secondary prevention mandatory.

Three pillars of fracture prevention:

Assessing fall risk and delivering preventive interventions

Protecting the trochanteric region (hip protectors)

Assessing and treating osteoporosis B. Fracture Risk Assessment

FRAX integrates clinical risk factors with or without BMD to compute the 10-year probability of hip fracture and of major osteoporotic fracture. It can be modulated by BMD, trabecular bone score (TBS), glucocorticoid therapy, fall history, type 2 diabetes and hip axis length.

Major risk factors: age, female sex, low BMI, prior fragility fracture, parental hip fracture, height loss >4 cm, secondary osteoporosis, glucocorticoid therapy, excess alcohol and smoking.

Diagnosis: osteoporosis can be diagnosed clinically in a patient with a minimal-trauma fracture without any other test. Otherwise DXA T-score ≤ −2.5. Note that after age 80 a woman with BMD normal for her age already has a T-score of −2.5, so DXA for diagnostic purposes alone is chiefly indicated in women under 75.

Exclude secondary osteoporosis in every fragility fracture: full history of corticosteroids and alcohol, plus complete blood count, liver and kidney function, serum calcium and phosphorus (mg/dL), 25(OH) vitamin D (ng/mL) and TSH. In the elderly the dominant secondary cause is hyperthyroidism; also consider malnutrition, low body weight, hypogonadism and hyperparathyroidism.

For all patients, regardless of risk category:

Calcium 800–1000 mg/day (diet preferred)

Protein ≥1 g/kg body weight/day

Vitamin D ~800 IU/day, with adequate sun exposure

Daily weight-bearing physical activity

Fall-prevention measures

Education on osteoporosis, medication, diet and exercise

A structured exercise programme should run for at least 50 hours, be progressive, and include strength and balance components. It reduces falls, but the effect on fracture risk itself remains uncertain.

Calcium + vitamin D combined had a clear benefit in elderly women living in nursing homes. However, a meta-analysis of 33 randomised trials with 51,145 participants (Zhao et al., JAMA 2017) showed no reduction in fracture risk in community-dwelling older adults with calcium, vitamin D, or both.

Hip protectors: most upper-femoral fractures follow a sideways fall directly onto the greater trochanter. Two rigid shells or foam pads held over the trochanters absorb the shock and disperse energy into soft tissue.

Cochrane Review (2014, 19 studies, ~17,000 people): in nursing/residential care, RR 0.82 (95% CI 0.67–1.00) — a small reduction in hip fracture risk (moderate quality). In the community, RR 1.15 (0.84–1.58) — little or no effect. Poor acceptance and adherence is the major barrier, particularly in the cognitively impaired.

Multifactorial fall risk assessment and intervention — exercise, medication review, home hazard modification, vision correction, cardiac pacing for carotid sinus hypersensitivity — is inseparable from fracture prevention. Minimum work-up in a faller: lying/standing BP and a 12-lead ECG.

Treatment pathway by risk category:

Low risk: reassurance, lifestyle advice; consider menopausal hormone therapy (MHT) or SERMs

High risk: oral bisphosphonate or another inhibitor of bone resorption (denosumab)

Very high risk: anabolic agent (teriparatide, abaloparatide, romosozumab) followed by an inhibitor of bone resorption; consider local osteo-enhancement procedure (LOEP) if hip fracture risk is very high

Bisphosphonates — first line. Reduced hip fractures demonstrated with risedronate, pamidronate and zoledronic acid. NNT ≈ 200 to prevent one hip fracture. Zoledronic acid 5 mg IV once yearly reduces clinical fracture by 33%, vertebral fracture by 77% and peripheral fracture by 25% — vitamin D must be given beforehand. Adverse effects: flu-like syndrome after the first infusion (1 in 3), higher incidence of atrial fibrillation, GI upset with oral forms, and rare osteonecrosis of the jaw. Gastro-resistant risedronate improves adherence.

Other agents:

Denosumab — fully human monoclonal antibody to RANKL; blocks RANK binding, inhibits osteoclast development and activity; subcutaneously twice yearly; reduces vertebral, non-vertebral and hip fractures (FREEDOM). Discontinuation may cause multiple vertebral fractures — follow with a bisphosphonate for 1–2 years.

Teriparatide — reduces new vertebral and non-vertebral fracture independent of initial T-score, age and number of fractures; bone mass gain is dose-dependent.

Romosozumab — monoclonal antibody to sclerostin; increases formation and decreases resorption. 12 months of romosozumab followed by alendronate gave significantly lower fracture risk than alendronate alone (ARCH; Saag et al.); FDA-approved April 2019 for high-risk postmenopausal women.

Limited in the elderly: raloxifene does not reduce femoral neck fracture; SERMs must be avoided after femoral neck fracture (thromboembolic risk); HRT carries breast cancer, thromboembolic, stroke and coronary risks; strontium ranelate caused fatal DRESS and thromboembolism; calcitonin has weak efficacy.

Duration and monitoring:

Check bone turnover markers at 3–6 months to verify compliance with resorption inhibitors

Reassess after 3 years of IV or 5 years of oral bisphosphonate: low-risk patients may discontinue for 2 years (reconsider yearly); high-risk patients continue

Whatever the drug, it must be combined with adequate calcium and vitamin D intake

Life expectancy and systems of care:

Unlike cancer screening, the effectiveness of fracture prevention INCREASES with advancing age — a 90-year-old has a higher lifetime fracture risk and a lower NNT than a 70-year-old. Economic models suggest treatment is cost-effective even with a life expectancy as short as two years.

Drug benefit appears at 6–12 months; the benefit of effective fall prevention may be immediate.

Fracture Liaison Services (FLS) provide routine, coordinator-based assessment and management of all postmenopausal women and all men with a fragility fracture; the IOF "Capture the Fracture" campaign sets internationally endorsed best-practice standards to break the fragility fracture cycle. Orthogeriatric co-management models improve outcomes after hip fracture.

ACP Living Clinical Guideline (Annals of Internal Medicine, 2023) — bisphosphonates confirmed as first line. Bisphosphonates are strongly recommended as initial pharmacologic treatment in postmenopausal women (high-certainty evidence) and conditionally suggested in men. Denosumab is second line for those with contraindications or adverse effects. Romosozumab or teriparatide followed by a bisphosphonate is suggested only in women at very high fracture risk. For women over 65 with osteopenia, an individualised decision on starting a bisphosphonate is advised. The 2023 update removed the earlier 2017 ambiguity that allowed either bisphosphonates or denosumab as first choice, and as a "living guideline" it is revised as new data emerge.

NOGG UK guideline 2024 — HRT returns as first-line in a defined group. Specific 2024 updates include fracture risk assessment by ethnicity, and in Parkinson's disease, Down's syndrome and lower-limb amputation; the definition of very high fracture risk has been clarified; and HRT is now recommended as a first-line option in younger postmenopausal women with high fracture risk and low baseline risk of adverse events. Three anabolic agents — teriparatide, abaloparatide and romosozumab — are now available, with teriparatide licensed for a once-only treatment course; no evidence yet supports one specific sequence, so specialist input is essential.

RACGP / Healthy Bones Australia 2024. Widespread population-based screening is not recommended; FRAX-based absolute risk assessment is encouraged. It is essential to identify patients at "imminent" or "very high" fracture risk — the group in whom early osteoanabolic therapy should be considered. Critically, calcium and vitamin D supplementation reduces fracture risk only in individuals who are actually deficient, not in healthy non-institutionalised people. The guideline also addresses rebound vertebral fracture after denosumab cessation and formally removes strontium as a therapy.

ASBMR/BHOF goal-directed treatment position statement (JBMR, 2024). Major guideline bodies (AACE, Endocrine Society, The Menopause Society, BHOF, ESCEO/IOF, NOGG) have all now adopted a new "very high fracture risk" category. A subset of these patients is at imminent risk for the two years following an incident fracture or after multiple prior fractures — the rationale for treat-to-target, anabolic-first therapy.

USPSTF draft statement (December 2024) — vitamin D and calcium downgraded. A Grade D (recommend against) was proposed for vitamin D, with or without calcium, to prevent fractures in postmenopausal women and men ≥60 years, and a Grade D for vitamin D to prevent falls in the same group. This applies only to community-dwelling individuals and does not apply to those with diagnosed osteoporosis, vitamin D deficiency, or malabsorption.

Cochrane Review 2025 (care facilities, CD016064) — the institutional exception holds. In care facilities, vitamin D supplementation, exercise, and staff-engaged individually tailored multifactorial interventions probably reduce falls — reinforcing that nursing-home residents remain a group who benefit from vitamin D, in contrast to community dwellers.

Short-course sequential therapy after hip fracture (2025). Current guidelines recommend anabolic agents first-line in very-high-risk patients including recent hip fracture, followed by antiresorptive therapy, but real-world implementation is limited and the optimal anabolic duration is uncertain. A study of 113 osteoporotic hip fracture patients evaluated 3–6 months of teriparatide or romosozumab followed by denosumab versus anabolic monotherapy, since shorter anabolic courses may be more feasible in frail elderly patients than the conventional 18–24 months.

Indian guidance — ISBMR position statement. Osteoporotic fractures occur at an earlier age in Indians than in the West, so screening should begin earlier. FRAX may underestimate future fracture risk in the Indian population and still requires validation. Maintaining optimal serum 25(OH) vitamin D usually requires regular supplementation, and bisphosphonates remain the first choice in most cases. For vertebral fractures, teriparatide is recommended as initial anabolic treatment for 24 months followed by an antiresorptive; zoledronic acid or denosumab are alternatives, with zoledronic acid preferred. A Markov microsimulation cost-effectiveness analysis of FRAX-based intervention thresholds in Indian women (Osteoporosis International, 2025) has now been published, and FRAX without DXA is highlighted as usable where densitometry is unavailable. Maintenance vitamin D3 of 1000–2000 IU daily is typically required.

Indian service gaps. DXA availability is concentrated in urban tertiary centres; Fracture Liaison Services are few and reimbursement is limited. Practical Indian strategy: clinical diagnosis on a minimal-trauma fracture, FRAX without BMD, generic alendronate or annual zoledronic acid, calcium and vitamin D correction, and fall prevention through NPHCE geriatric clinics and district-level rehabilitation units.

NICE NG249 (April 2025). Vitamin D supplements are not recommended specifically to reduce falls, though people are encouraged to follow standard advice on vitamin D to maintain bone and muscle health — separating the bone indication from the falls indication.

Fragility fracture = fall + fragile bone. Prevent both.

Three pillars: fall risk intervention, hip protectors, osteoporosis treatment.

Commonest sites: hip, forearm, vertebra.

Only 3% of elderly hip fractures are pathological.

After hip fracture, in 1 year: 56% fall, 28% recurrent falls, 12% new fracture, 5% fracture the other hip.

FRAX = 10-year probability of hip and major osteoporotic fracture.

T-score ≤ −2.5 = osteoporosis; but a minimal-trauma fracture is diagnostic on its own.

DXA for diagnosis alone is mainly indicated in women <75.

Commonest secondary cause of osteoporosis in the elderly = hyperthyroidism.

Universal measures: calcium 800–1000 mg/day, protein ≥1 g/kg/day, vitamin D ~800 IU/day, weight-bearing exercise.

Exercise programme should be ≥50 hours, progressive, strength + balance.

Zoledronic acid 5 mg IV yearly: ↓ clinical fracture 33%, vertebral 77%, peripheral 25% — correct vitamin D first.

NNT ≈ 200 with oral bisphosphonate to prevent one hip fracture.

Denosumab = anti-RANKL, 6-monthly SC; never stop without bisphosphonate cover.

Romosozumab = anti-sclerostin; 12 months then alendronate (ARCH).

Raloxifene does not reduce hip fracture; SERMs contraindicated after femoral neck fracture.

Bisphosphonate holiday after 3 years IV / 5 years oral in low-risk patients only.

Hip protectors: RR 0.82 in care homes; no benefit in the community.

Fracture prevention becomes MORE effective with advancing age — cost-effective with life expectancy as short as 2 years.

Fracture Liaison Service + "Capture the Fracture" = secondary prevention model.