Pharmacological treatment of osteoporosis in the oldest old

Osteoporosis is a systemic skeletal disease characterized by low bone mass and microarchitectural deterioration of bone tissue, with a consequent increase in bone fragility and fracture risk.The incidence of osteoporotic fractures increases with age, and osteoporosis in old age is a challenge because of the extent of the problem and the significant burden in terms of morbidity, mortality, and economic cost.Age is one of the main determinants of not only the absolute risk of fracture but also the type of osteoporotic fracture. Between the ages of 55 and 75 years, postmenopausal women are at more risk of vertebral fractures than any other type of fracture, but at the age of >75 years, they become increasingly at a risk of hip fracture and other non-vertebral fractures. Nonpharmacological interventions such as fall prevention strategies play an essential role in the management of osteoporosis, also in the elderly.

The incidence of osteoporotic fractures increases with age and therefore global prevalence of osteoporotic fractures will increase with the aging of the population. In old age, osteoporosis is associated with a substantial burden in terms of morbidity and mortality. Nevertheless, osteoporosis in old age continues to be underdiagnosed and undertreated. This may, at least partly, be explained by the fact that evidence of the anti-fracture efficacy of osteoporosis treatments comes mainly from randomized controlled trials in postmenopausal women with a mean age of 70–75 years.

However, in the last years, subgroup analyses of these landmark trials have been published investigating the efficacy and safety of osteoporosis treatment in the very elderly. Based on this evidence, this narrative review discusses the pharmacological management of osteoporosis in the oldest old (≥80 years).

• There is high prevalence of calcium and/or vitamin D deficiency in old age, therefore these supplements are essential in the management of osteoporosis in the elderly people.Vitamin D deficiency is commonly defined as a serum level of 25-hydroxyvitamin D (25OHD) of <20 ng/mL, and although there is much controversy about this threshold, it is clear that low levels of 25OHD occur in all age-groups.The combined supplementation of calcium and vitamin D has become an essential component to reduce bone loss and fracture risk in elderly individuals.


• Adding antiresorptive or anabolic treatments or combinations, thereof, reduces the risk of vertebral fractures even more, at least in the elderly with documented osteoporosis.Data from the post hoc and preplanned analyses in the very elderly showed that currently, available osteoporosis therapies are relatively safe, with no significant differences in the incidence of most adverse events in the treated group compared with the placebo group.


• The reduction of hip fracture risk by antiresorptive treatments is less convincing, which may be explained by insufficient statistical power in some subanalyses and/or a higher impact of nonskeletal risk factors in the occurrence of hip fractures. Compared with younger individuals, a larger absolute risk reduction is observed in the elderly because of the higher baseline fracture risk. Therefore, the elderly will benefit more of treatment.


• In addition, current osteoporosis therapies also appear to be safe in the elderly. Although more research is required to further clarify the effect of osteoporosis drugs in the elderly, especially with respect to hip fractures, there is currently sufficient evidence to initiate appropriate treatment in the elderly with osteoporosis and osteoporotic fractures.