Osteoporosis screening



The U.S. Preventive Services Task Force (USPSTF) recommend that all women 65 years of age or older be screened by bone densitometry.


Screening for and treating osteoporosis is to prevent osteoporotic fractures and the functional decline that often accompanies these fractures.


Osteoporosis screening should be performed using dual energy X-ray absorptiometry (DXA) to measure BMD of the hip and spine. 


BMD is usually measured at the lumbar spine and hip with dual-energy x-ray absorbtiometry (DXA) and is used to diagnose osteoporosis when the measurement is 2.5 or more standard deviations below peak bone mass.

One cannot reliably compare DEXA measurements overtime from repeat testing unless the measurements are performed on the same the x-ray machine used for the earlier test.


Low BMD contributes to elevated fracture risk, but is also influenced by age, prior fracture history, and other factors.


Most fractures occur in individuals with a bone mineral density that is above the osteoporotic threshold.



Screening is recommended for younger women with risk factors.



Insufficient evidence exists to make recommendations about the intervals for repeated screening and the appropriate age to stop screening.



Osteoporosis is a metabolic bone disorder that affects more than 200 million people worldwide. 



Osteoporosis is characterized by low bone mass, which makes bones fragile 


and susceptible to fractures. 



Osteoporotic fractures are more common in the elderly.



Osteoporosis is a systemic bone disorder typified by low bone mineral density (BMD). 



Reduced bone mass is a hallmark of osteoporosis, but microarchitectural deterioration of bone and increased bone fragility are also present. 



The prevalence of osteoporosis is more common among white women, persons with low body mass.



Osteoporosis is seen in all racial and ethnic groups. 



Osteoporosis is present in all weight categories, and both genders.



For residents in skilled nursing facilities,  osteoporosis prevalence exceeds 50%.



Age-related change in bone mass occurs when there is an imbalance in bone formation and bone resorption: decreased bone formation, osteoblastic activity, and increased bone resorption, osteoclastic activity.



Bones remodeling changes usually begins in the third decade of life and continues with aging. 



Increased osteoclastic activity is significantly exacerbated by estrogen loss, especially during menopause in women.



Osteoporosis is typified by low bone mineral density (BMD), reduced bone mass, microarchitectural deterioration of bone and increased bone fragility.



It is seen in all racial and ethnic groups, all weight categories, and in both men and women. 



For residents in nursing facilities, the prevalence of osteoporosis exceeds 50% regardless of race or gender.



Osteoporosis results in  fractures that significantly increase with age. 



Age-related change in bone mass occurs when there is an imbalance in bone formation and bone resorption. 



With osteoporosis there is decreased bone formation with decreased osteoblastic activity and increased bone resorption by osteoclastic activity.



This imbalance in bone formation and bone resorption results in bone remodeling that’s usually begins in the third decade of life and continues with aging.



With osteoporosis  increased osteoclastic activity is significantly exacerbated by estrogen loss, especially during menopause in women.



Due to a higher peak bone mass and no substantial loss in estrogen men are likely to develop osteoporosis approximately 10 years after women. 



Reduced bone density is a major risk factor for fractures.



Falling in older adults contributes substantially to osteoporotic fractures, especially nonvertebral fractures. 



Vertebral fractures are the most common osteoporotic fractures.



Vertebral fractures account for 70% of all fractures. 



One in 5 women with an asymptomatic or symptomatic vertebral fracture will experience another vertebral fracture within one year.



The presence of a vertebral fracture also increases risk of nonvertebral fractures.



The National Osteoporosis Foundation recommendation: that all men and women over age 65 have a BMD test. 



Younger postmenopausal women with 1 additional risk factor should also have a BMD test. 



Patients  with hyperthyroidism, hyperparathyroidism and those on chronic glucocorticoid therapy should also be screened for reduced bone density.



The lowest score should be used to determine whether the patient is normal, has osteopenia or osteoporosis. 



With a normal BMD, repeat testing should occur in 3-5 years and in those with osteopenia, tests should be repeated in 2 years.



Bone turnover markers predict bone resorption and can be used to predict fracture risk and monitor treatment but 


should not be used to diagnose osteoporosis. 



Bone turnover marker monitoring include diseases with rapid and severe bone loss such as persons using chronic glucocorticoid therapy, with hyperparathyroidism or hypogonadism.



Calcium carbonate and calcium citrate may be used as dietary supplements. 



Calcium should be taken in divided doses to improve absorption.



A meta-analysis of randomized clinical trials in older women finds that a 


vitamin D dose of 700-800 units/day is associated with decreased risk of hip fractures.



Other studies suggests vitamin D decreases fall risk, and improves muscle strength and balance. 



Phosphorus intake is essential to normal bone development and mineralization. 



Vegetarians are at increased risk for phosphorus deficiency. 



In individuals with low phosphorus intake who also use calcium carbonate/ citrate supplements may bind phosphorus and create a negative phosphorus balance. 



Excessive phosphorus intake may disrupt skeletal homeostasis.



Bisphosphonates inhibit osteoclast activity and reduces bone turnover, increases bone density and prevents both vertebral and nonvertebral fractures.



Relatively small increases in BMD may reduce fracture risk by 20 to 50%. 



Most osteoporosis screening trials have excluded patients over age 80, so the benefit in this population is unclear: In astudy of women over age 80, risedronate had no effect on hip fractures, but there was an 80% reduction in new vertebral fractures at one year.



Bisphosphonates are associated with esophagitis and esophageal/gastric ulcers.



The  relatively long half-life of bisphosphonates and evidence that bone turnover may remain suppressed after discontinuation of the drug, some consideration is  to stop the drug after 5 years.



Raloxifene has been shown to increase BMD in both the spine and hip and to decrease vertebral fracture risk by up to 60%. 



Hormone replacement therapy (HRT)



Estrogen therapy has been shown in several studies to increase BMD from 2% to 7% at all sites and to prevent both vertebral and hip fractures (PEPI 1996; Lindsay et al 2005). 



HRT in some studies has been associated with an increased risk of myocardial infarction, stroke, thromboembolism and breast cancer. 



Low dose oral estrogen or transdermal estrogen may minimize or even reduce cardiovascular and stroke.



HRT should be reserved for women with significant symptoms of menopause and should be limited to the shortest possible duration.



Teriparatide, a recombinant human PTH, is an anabolic agent that stimulates osteoblastic bone formation. 



Calcitonin inhibits bone resorption and may increase BMD in the spine by up to 3%. 



It has been shown to decrease vertebral fractures to a lesser degree the other osteoporosis medications and has no benefit in preventing hip fractures.



Calcitonin is generally reserved for persons who cannot tolerate other medications. 



Calcitonin has also been found to reduce bone pain from vertebral compression fractures.



Determination of vitamin D status is important in all older adults. 



Serum 25-hydroxyvitamin D measurement is recommended since the half-life is longer and there are fewer fluctuations that seen in 1,25- dihydroxyvitamin D, the biologically active form of vitamin D. 


The goal torn 25-hydroxyvitamin D level is to be greater than 30 ng/ml with a PTH of less than 42 pg/ml. 


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