Primary prevention

Prevention of hip fractures includes appropriate identification and treatment of those at risk for osteoporosis, as well as identifying those at risk for falls.[41][42]

There is some evidence that multifaceted interventions in hospital inpatients may reduce the relative risk for number of falls; this may be more likely in a subacute setting.[43][44]​​​​​ [ Cochrane Clinical Answers logo ] [Evidence C] [ Cochrane Clinical Answers logo ] These interventions included risk assessment, risk factor assessment, care planning, medical/diagnostic approaches, changes in the physical environment, education programs, medication review, hip protectors, removal of physical restraints, and exercise.[43] Hip protectors have been used in an attempt to reduce the risk of fracture with a fall; however, there may only be a marginal benefit to their use.[45][46]

UK National Institute for Health and Care Excellence (NICE) guidelines on the prevention of falls in older people recommend that older people who present for medical attention because of a fall, or report recurrent falls in the past year, or demonstrate abnormalities of gait and/or balance should be offered a multifactorial risk assessment; NICE further recommends that this assessment should be part of an individualized, multifactorial intervention.[47]

In postmenopausal women, regular low-intensity physical activity, such as walking, bowling, and golf, has been shown to lower hip fracture risk.[48] Prior other low-energy fractures such as previous distal radius fractures have a significant impact on the risk of subsequent hip fracture.[49] Diagnosing osteopenia or osteoporosis in these patients is an important measure to prevent a future hip fracture.[50] The benefit-risk ratio of hormone therapy appears favorable for the prevention of bone loss or fracture among women (without contraindications) who are ages under 60 years or are within 10 years of menopause onset.[31] Women with an intact uterus should receive combined estrogen/progestin therapy to protect against endometrial hyperplasia and cancer, whereas women without a uterus should receive estrogen alone.[31] Bisphosphonates may be appropriate to prevent bone loss in women with early menopause when estrogen is contraindicated, or when hormone therapy is discontinued. See Menopause.

Interventions to preserve bone strength that are recommended for the general population include:[42]

  • weight-bearing exercises (in which bones and muscles work against gravity with feet and legs bearing body weight), for example walking, jogging, tai chi, stair climbing, dancing, tennis

  • muscle-strengthening exercises, for example weight training, resistive exercises including yoga, pilates, boot camp calisthenics.

The table that follows summarizes recommendations on prevention of osteoporotic fractures from the Bone Health and Osteoporosis Foundation (BHOF).[42]

Note that an individual patient may fall into more than one group, and so interventions might be additive; please review all population and subpopulation groups to assess all that apply.

Man ages ≥50 years or postmenopausal woman

All

Intervention
Goal
Intervention

Advice on balance training, muscle-strengthening exercise, and safe movement strategies

Counsel or refer patients for advice and instruction on:

  • Balance training

  • Muscle-strengthening exercise, for example weight training and resistive exercises, such as yoga, Pilates, and boot camp calisthenics

  • Safe movement strategies

Supervision is recommended to ensure physical activities are safe and sustainable given an individual’s health status and overall fitness. To avoid injury, it is recommended that patients are evaluated before initiating a new exercise program, particularly one involving compressive or contractile stressors (such as running or weightlifting).

Consultation with a trained physical therapist and/or participation in group exercise led by certified fitness personnel may help ensure patient safety, motivate daily participation, and promote social engagement.

Providing principles of safe movement are followed, walking and daily activities such as housework and gardening are practical ways to contribute to maintenance of fitness and bone mass.

Goal

Prevention of fracture(s) in the activities of daily life

Maintaining independence by preventing an injury that could lead to nursing home admission is likely to be a priority for many individuals.

Adherence with a recommended lifestyle change may be challenging; linking the change to something of value to an individual may help to improve motivation.

With osteoporosis or osteopenia meeting criteria for treatment

Intervention
Goal
Intervention

Treatment of osteoporosis or osteopenia

Offer treatment for osteoporosis or osteopenia using lifestyle interventions with or without medication in line with published clinical guidance on management of osteoporosis/osteopenia.

Medication for osteoporosis/osteopenia:

Management plans are highly individualized and recommendations differ according to sex, investigation findings, personalized fracture risk assessment results, and whether or not glucocorticoid use is a contributing factor to bone mineral density loss.

It is recommended that treatment is stratified according to fracture risk; combination or sequential treatment with different classes of medication may be required to lower risk to acceptable levels in people at particularly high risk of future fracture.

Patient adherence to prescribed treatment is key. An estimated 25–30% of people with osteoporosis do not start taking their prescribed medication and 50% or more do not continue treatment after 1 year; nonadherence to treatment is associated with higher morbidity and mortality. Ensure a good foundation for treatment is in place, including focused support and monitoring early in treatment, which may help improve a patient’s long-term adherence with prescribed treatment and, consequently, fracture outcomes.

Ask questions about patient preferences and address fears and misconceptions as part of the medication selection process, as this can not only promote better adherence to prescribed treatment but also lead to better outcomes in terms of prevention of fractures and disability.

Lifestyle interventions for osteoporosis:

A multicomponent program is recommended, encompassing:

  • Progressive resistance training

  • Balance training

  • Back extensor strengthening

  • Core stabilizers

  • Cardiovascular conditioning

  • Impact or ground-reaction forces to stimulate bone

Note that recreational pursuits and athletic activities that exert intense forces on weakened bone and/or involve abrupt or high-impact loading can break bones in people with osteoporosis. For safety, it is recommended that any program of physical activity is developed and supervised by certified fitness personnel experienced with skeletal fragility in older adults.

See: Osteoporosis

Goal

Increased bone mineral density; improved falls outcomes; reduced fracture risk

Like any lifelong chronic disease, osteoporosis is most successfully managed with continued therapy and monitoring.

Recommended duration of treatment varies according to patient characteristics and the type of medication used.

Periodically review pharmacotherapy to determine whether treatment should be continued, changed, stopped, or resumed. It is reasonable to evaluate patients every 1 to 2 years during any hiatus from active bisphosphonate treatment.

For patients on pharmacological therapy, a reasonable 3-year target outcome could be to increase the T-score from − 2.8 to > − 2.5 and have no fractures.

Stable bone mineral density and a year with no new fractures could be a measurable goal for someone with low bone mineral density and prior fragility fractures.

If the patient is not on track to reach their target or does not reach their target, consider clinical reassessment and possibly a change in therapy.

With insufficient intake of calcium

Intervention
Goal
Intervention

Advice on increased calcium intake ± calcium supplementation

Adequate total calcium intake is defined as:

  • 1000 mg/day for men ages 50-70 years and women ages 50 years.

  • 1200 mg/day for women ages ≥51 years and men ages ≥71 years.

Increasing dietary calcium is the first-line approach when there is inadequate calcium intake.

Advise people to eat a balanced diet rich in foods that provide calcium as well as numerous nutrients needed for good health:

  • Low-fat dairy products

  • Select dark greens

  • Fish with bones

  • Fruits

  • Vegetables

  • Fortified foods (e.g. nondairy supplemented beverages including orange juice, or soy and almond milk)

Calcium supplements are recommended when an adequate dietary intake cannot be achieved.

Supplemental calcium is most widely available as calcium carbonate and calcium citrate:

  • Calcium citrate is useful for people with achlorhydria, inflammatory bowel disease, absorption disorders, and those on proton-pump inhibitors that reduce gastric acid as it doesn't require stomach acid for absorption and can be taken on an empty stomach.

Doses may need to be split to ensure optimal absorption.

Goal

Achieve targets for recommended calcium intake according to sex and age; fracture prevention

Goals are the following:

  • 1000 mg/day for men ages 50-70 years and women ages 50 years.

  • 1200 mg/day for women ages ≥51 years and men ages ≥71 years.

There is no evidence that calcium intake in excess of recommended amounts confers additional bone benefit. Supplemental calcium intake above 1200-1500 mg/day can increase risk for developing kidney stones in at-risk individuals.

With vitamin D deficiency or insufficiency

Intervention
Goal
Intervention

Vitamin D supplementation

Vitamin D sufficiency is defined as 30-50 ng/mL.

Prescribe supplemental vitamin D as needed for individuals ages 50 years and older to achieve a sufficient vitamin D level.

Higher doses may be necessary in some adults, especially those with malabsorption.

See: Vitamin D deficiency.

Goal

Maintenance of serum vitamin D sufficiency; fracture prevention

Maintain serum vitamin D sufficiency (30-50 ng/mL).

In healthy individuals a serum 25(OH) vitamin D level ≥20 ng/mL may be sufficient, but in the setting of known or suspected metabolic bone disease ≥30 ng/mL is appropriate.

With tobacco use

Intervention
Goal
Intervention

Smoking cessation advice ± referral

Provide guidance for smoking cessation; advise the patient that use of tobacco products is detrimental to the skeleton as well as to overall health.

Refer for smoking cessation care as appropriate.

See: Smoking cessation.

Goal

Cessation of smoking; fracture prevention

With alcohol intake＞two drinks/day (in women) or＞three drinks/day (in men)

Intervention
Goal
Intervention

Advice on avoidance of excessive alcohol intake ± substance use referral

Provide guidance for avoidance of excessive alcohol intake; advise the patient that alcohol intake of more than two drinks a day for women or three drinks a day for men may be detrimental to bone health, and that it has been associated with reduced calcium absorption and increased risk for falls.

Identify patients at risk for chronic heavy drinking and/or binge drinking who require further evaluation and treatment.

See: Alcohol use disorder.

Goal

Alcohol intake within safe drinking limits; fracture prevention

In women: ≤ two drinks/day is recommended.

In men: ≤ three drinks/day is recommended.

With major risk factors for falls

Intervention
Goal
Intervention

Falls prevention strategies

Identify and address modifiable risk factors associated with falls, such as:

  • Sedating medications

  • Polypharmacy

  • Hypotension

  • Gait or vision disorders

  • Out-of-date prescription glasses

In community-dwelling patients, refer for at-home fall hazard evaluation and remediation.

Many risk factors for falls are modifiable: muscle strength and balance can be improved through targeted exercise; visual impairment can be addressed; fall hazards in the home and work environment can be remediated; medications that induce dizziness and disorientation can be replaced or reduced.

See: Optimizing functional status in the elderly.

Goal

Reduced risk of future falls and fractures

Secondary prevention

Preventive actions include management of osteoporotic conditions using optimization of nutrition (particularly dietary calcium and vitamin D), reduction in alcohol intake, and smoking cessation.[8][41]​ Pharmacologic measures may include bisphosphonates and parathyroid hormone analogs.[8][31][41][146][147]​ Further measures include removing trip hazards in the home and re-evaluating the need for medications that may cause syncopal episodes.

There is some evidence that multifaceted interventions in hospital inpatients may reduce the relative risk for number of falls; this may be more likely in a subacute setting.[43][44]​​​​ [ Cochrane Clinical Answers logo ] [Evidence C] [ Cochrane Clinical Answers logo ] ​ These interventions include risk assessment, risk factor assessment, care planning, medical/diagnostic approaches, changes in the physical environment, education programs, medication review, nutritional risk screening, hip protectors, removal of physical restraints, and exercise.[43] Patients who are at high risk of falls may need to also wear hip protectors.[45][46][148]

Guidelines and care pathways have been established by the US Preventive Services Task Force, as well as NHS England, Public Health England, and the UK National Institute for Health and Care Excellence (NICE), for the prevention of falls in older people.[47][149]​​[150][151] The NICE guidelines recommend that older people who present for medical attention because of a fall, or report recurrent falls in the past year, or demonstrate abnormalities of gait and/or balance should be offered a multifactorial risk assessment; NICE further recommends that this assessment should be part of an individualized, multifactorial intervention.[47]

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