Osteoporosis: An Underdiagnosed Threat to Healthy Aging

Osteoporosis is a systemic skeletal disorder characterised by low bone mass and microarchitectural deterioration of bone tissue, leading to increased bone fragility and susceptibility to fractures. It is a major public health concern, particularly in aging populations, due to its association with morbidity, mortality, and significant healthcare costs.

In Ireland, it is estimated that over 300,000 people are affected by osteoporosis. Globally, one in three women and one in five men over the age of 50 will experience an osteoporotic fracture in their lifetime. Despite its high prevalence and consequences, osteoporosis remains underdiagnosed and undertreated, especially in primary care.

Risk Factors

Non-modifiable risk factors:

• Age >65 years
• Female sex
• Caucasian or Asian ethnicity
• Family history of osteoporosis or fragility fractures

Modifiable and secondary causes:

• Low body mass index
• Smoking and excessive alcohol use
• Prolonged corticosteroid use
• Vitamin D deficiency
• Sedentary lifestyle
• Certain medical conditions (e.g., rheumatoid arthritis, hyperthyroidism)

Diagnosis

Diagnosis is based on measurement of bone mineral density (BMD) using dual-energy X-ray absorptiometry (DXA). The World Health Organization defines osteoporosis as a T-score ≤ -2.5 at the lumbar spine, femoral neck, or total hip.

Fracture risk can also be assessed using tools like FRAX, which estimates the 10-year probability of hip and major osteoporotic fractures.

Clinical Impact

Osteoporotic fractures, particularly of the hip and vertebrae, are associated with:

• Increased morbidity and long-term disability
• Reduced independence and quality of life
• Increased mortality, especially in the first year post-hip fracture

In Ireland, approximately 4,000 hip fractures occur annually, and one in five patients dies within 12 months of such an event.

Management

Lifestyle and non-pharmacological strategies:

• Weight-bearing and resistance exercise
• Smoking cessation and alcohol moderation
• Adequate intake of calcium (1000–1200 mg/day) and vitamin D (800–1000 IU/day)

Pharmacological treatment:

• First-line: bisphosphonates (e.g., alendronate, risedronate)
• Alternatives: denosumab, selective oestrogen receptor modulators, teriparatide (in severe cases)

Treatment decisions should be based on BMD, fracture risk assessment, and clinical judgement.

Gaps in Primary Care

• Inconsistent screening, especially in men and those without prior fracture
• Underuse of DXA scanning
• Low initiation and adherence to osteoporosis treatment
• Missed opportunities for secondary prevention following initial fractures

Fracture Liaison Services (FLS) have been shown to improve secondary prevention but are not universally implemented.

Conclusion

Osteoporosis is a highly prevalent, yet frequently overlooked, condition that contributes significantly to avoidable disability and healthcare burden. Primary care plays a crucial role in identifying at-risk individuals, initiating appropriate investigations, and coordinating long-term management. Enhanced screening and intervention protocols are essential for reducing fracture incidence and supporting healthy aging.

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