Barry Goldlist, MD, FRCPC, FACP
The last several years have seen an explosion in both theoretical and practical knowledge in osteoporosis. Currently, there are several safe and effective treatments available that increase bone density. From a geriatrician's point of view, what is particularly promising, is the growing recognition that age alone is not a contraindication to treatment. In fact, evidence from other disease processes (e.g. myocardial infarction) suggests that those who are at highest risk, such as the elderly, also can potentially realize the greatest absolute benefit from effective treatments.
There is still some doubt about what is(are) the treatment(s) of choice. Most experts feel that calcium and vitamin D intake should be optimized regardless of which primary therapy is initiated. Until recently it was 'common knowledge' that estrogen was the drug of choice, because of beneficial effects on coronary artery disease and possibly cognition. These benefits were felt to outweigh any risks of endometrial cancer (assuming progesterone accompanied the therapy), and breast cancer. Unfortunately, these conclusions were based on observational or epidemiological studies, not randomized trials. The first generation of randomized trials does not substantiate a beneficial effect of estrogens on cardiac disease or cognition, and more information is still required.
In the 'old' old, another factor is operational as well: the tendency to fall. In fact, for those over 75, the real issue is not treatment of osteoporosis, but fracture prevention. Preventing fractures depends upon building stronger bones and preventing injurious falls. There is now excellent literature on the value and feasibility of assessing falls, and even one excellent paper by Tinetti and her group at Yale demonstrating the feasibility of falls prevention in primary care. One of the key interventions that Tinetti recommends is physical therapy and exercise for patients with impaired function of upper and/or lower extremities. Thus exercise has a dual purpose in fracture prevention; it helps to build bone and it prevents injurious falls. It is possible that introduction of strenuous exercise before the development of osteoporosis and overt motor dysfunction would be even more beneficial.
In summary, there seems to be a strong consensus, based on good evidence, that treatment of osteoporosis is warranted. The issues at the current time relate to population screening (who, when, how), and how to integrate the treatment with programs of falls prevention so that the ultimate goal of fracture prevention can be realized.
