Osteoporosis

Metabolic bone disease encompasses disorders characterised by:

Reduced bone mass and
Disruption of bone microarchitecture
→ leading to increased bone fragility and higher fracture risk

Epidemiology and Under-treatment

Underdiagnosis and undertreatment are common.
Only:
- ~10% of men with osteoporosis
- ~30% of postmenopausal women with fragility fractures
  → receive appropriate treatment.

Common Fragility Fracture Sites

Hip
Spine (vertebral compression fractures)
Distal forearm (Colles’ fracture)
→ Typically following low trauma or minimal force events.

Natural History of Bone Mass

Age Range	Bone Mass Trends
20–35 years	Peak bone mass attained
>35–50 years	Gradual bone loss begins (~1%/year)
Post-menopause / Hypogonadism	Accelerated loss (3–4%/year)
Age 50	Osteopenia in men: 33–47% Osteoporosis in men: 4–6%
Age 65	Bone loss rates similar in men and women
Age 75	Sharp rise in hip fractures in men
Age 80	Osteoporosis: Women: 90% (15% hip fracture risk) Men: 50%
Age 90	Hip fracture incidence: Women: 33% Men: 17%

Types of Osteoporosis

Type	Population	Pathophysiology	Common Fracture Sites
Type I (Postmenopausal)	Women, post-menopause	↓ Estrogen → ↑ bone resorption → ↓ trabecular bone	Vertebral (T7–T9), distal forearm
Type II (Senile)	Both sexes >60 years	Age-related loss of cortical & trabecular bone	Femoral neck, pelvis, proximal humerus, proximal tibia

Secondary Causes of Osteoporosis

Endocrine Disorders

Primary hyperparathyroidism
Hyperthyroidism (e.g. Graves’ disease)
Cushing’s syndrome
Hyperprolactinemia (prolactinoma)
Hypogonadism (e.g. menopause, orchiectomy)
Diabetes mellitus type 1
Growth hormone deficiency

Chronic Medical Conditions

Chronic kidney or liver disease (CKD, CLD)
Rheumatoid arthritis, SLE
Malnutrition
Mastocytosis
Vitamin D deficiency
Spinal cord injury
Malabsorption syndromes (e.g. coeliac, Crohn’s, post-bariatric surgery)
Alcoholism
Organ or bone marrow transplant

Malignancy

Multiple myeloma
Lymphoma
Leukemia
Ectopic ACTH syndrome

Medications Contributing to Bone Loss

Drug Class	Examples / Notes
Glucocorticoids	Systemic and inhaled
Thiazolidinediones	Pioglitazone, rosiglitazone
Excess thyroxine	TSH suppression
Hormone suppression	Aromatase inhibitors, GnRH agonists, Depo-Provera
Antiepileptics	↑ Vitamin D metabolism, ↑ bone turnover
Heparin (long-term)	Interferes with osteoblasts
Methotrexate	High dose, long duration
Vitamin A excess	>10,000 IU/day
Loop diuretics	↑ Renal calcium loss
PPIs	↓ Calcium absorption

Risk Factors

Non-modifiable

Age >70 years
Female age >50, Male >60
Family history of minimal trauma fracture
Caucasian or Asian ethnicity

Modifiable

Smoking
Alcohol >2 standard drinks/day
Low dietary calcium or vitamin D
Low body weight (BMI <20)
Physical inactivity
Recurrent falls
Chronic systemic inflammation

Comorbid Conditions

Endocrine: Cushing’s, hypogonadism, thyroid/parathyroid disorders
Inflammatory: RA, SLE, ankylosing spondylitis
GI: Crohn’s, coeliac, UC, post-gastric bypass
Psychiatric: Anorexia nervosa, schizophrenia
Chronic organ disease: CKD, CLD
Haematological: Multiple myeloma
Long-term corticosteroid use
Suboptimal transgender hormone therapy

Osteoporosis Evaluation

Osteoporosis – Diagnosis Criteria

Clinical Scenario	Population	Diagnostic?	Notes
Fragility fracture (hip or vertebra)	Any age	✅ Yes	Diagnostic of osteoporosis regardless of BMD
Fragility fracture (non-hip/vertebra) + T-score ≤ –1.5	Adults ≥50 years	✅ Yes	Supports diagnosis per Australian guidelines
T-score ≤ –2.5	Postmenopausal women or men ≥50	✅ Yes	WHO diagnostic threshold
Z-score ≤ –2.0 + fragility fracture or risk factors	Premenopausal women, men <50	✅ Suggestive	Suggests secondary osteoporosis; not diagnostic alone
T-score between –1.0 and –2.5 (osteopenia)	Postmenopausal women or men ≥50	❌ No	Requires fracture risk assessment (FRAX or Garvan)
Normal BMD (T-score ≥ –1.0)	All	❌ No	No diagnosis; continue monitoring

MBS Criteria for DXA Scan Eligibility

Eligibility Criterion	MBS-Funded DXA?	Notes
Age ≥70 years	✅ Yes	No additional risk factor required
Minimal trauma fracture at any age	✅ Yes	Includes vertebral, hip, and most non-vertebral fractures (not fingers/toes)
Glucocorticoid therapy (≥7.5 mg/day for ≥3 months)	✅ Yes	Includes prednisone or equivalent
Primary hyperparathyroidism	✅ Yes	MBS item 12323
Chronic liver or kidney disease	✅ Yes	Must be clinically significant
Conditions causing malabsorption (e.g. coeliac disease)	✅ Yes	Includes IBD, bariatric surgery
Hypogonadism (e.g. premature menopause <45 years, androgen deficiency)	✅ Yes	May also be secondary to cancer therapy
Multiple falls or immobility	✅ Yes	Clinical documentation needed
Parental history of hip fracture	✅ Yes	Family history of osteoporosis not enough—must be hip fracture
Vitamin D deficiency, smoking, alcohol use, or osteoarthritis only	❌ No	Do not qualify unless combined with other listed MBS criteria
Osteopenia or low BMD on previous scan	❌ No	Not a standalone MBS indication for repe

Osteoporosis – Treatment Criteria

Clinical Scenario	Treatment Indicated?
Hip or vertebral fragility fracture (any age)	✅ Yes Treat regardless of BMD
Non-hip fragility fracture + T-score ≤ –1.5	✅ Yes Supports treatment
T-score ≤ –2.5 (without fracture)	✅ Yes WHO treatment threshold
Osteopenia (T-score –1.0 to –2.5) + FRAX or Garvan high risk	✅ Yes FRAX: Hip >5%, Major >20%; Garvan: High 5- or 10-year risk
Z-score ≤ –2.0 with fracture or secondary cause	✅ Consider – Especially if risk factors present; often requires specialist input
T-score > –2.5 and low FRAX/Garvan risk	❌ No – Recommend lifestyle modification monitor with follow-up DXA
Normal BMD	❌ No – No treatment required; repeat DXA in 10–15 years based on clinical risk

1. Diagnosis of Osteoporosis

Osteoporosis may be diagnosed by any of the following:

A. Minimal Trauma (Fragility) Fracture

Definition: A fracture resulting from low-energy trauma that would not normally fracture healthy bone. Examples:
- Fall from standing height or less
- Minor bumps/collisions
- Routine activities (e.g. coughing, bending)

Fracture Site	Interpretation
Hip or vertebral fracture	Diagnostic of osteoporosis at any age. DXA not essential
Non-hip/vertebral fracture (e.g. wrist, humerus)	Assess with DXA: T-score ≤ –1.5 supports diagnosis and treatment

❗ Note: Fragility fracture overrides age and BMD as a diagnostic and treatment trigger – Osteoporosis is diagnosed, even without DXA. and can initiate treatment

B. Bone Mineral Density (BMD) by DXA Scan

assume No history of minimal trauma fracture

Sites: Lumbar spine, femoral neck (Grade A recommendation)
Criteria based on WHO definitions (for postmenopausal women and men ≥50 years):

T-score	Interpretation	Clinical Implication
≥ –1.0	Normal	Reassess lifestyle; monitor risk
–1.0 to –2.5	Osteopenia (low bone mass)	Requires fracture risk stratification (FRAX)
≤ –2.5	Osteoporosis	Initiate treatment

C. Z-score (for <50 years)

Used in premenopausal women, men <50, and children
Z-score ≤ –2.0 = “below expected range for age” → prompts further investigation but not sufficient alone for diagnosis

MBS Eligibility for DXA Scan

Eligible for Medicare-funded DXA if:
Age ≥70 years (no risk factors needed)
OR any age with qualifying risk factors:

MBS Qualifying Risk Factors (if <70 years)

Non-modifiable: Parental hip fracture
Modifiable/Lifestyle:
- Premature menopause
- Hypogonadism
- Multiple falls, immobility
- Low body weight or muscle mass
- Smoking, alcohol >2 drinks/day
- Vitamin D deficiency
Medical conditions:
- Rheumatoid arthritis, diabetes
- CKD, CLD, coeliac disease
- Hyperthyroidism, hyperparathyroidism
- Myeloma, MGUS, HIV, depression
- Organ or bone marrow transplant
Medications:
- High risk: Glucocorticoids ≥7.5 mg/day >3 months, aromatase inhibitors, anti-androgens, excess thyroxine
- Moderate risk: SSRIs, antipsychotics, thiazolidinediones, PPIs, antiepileptics

General Clinical or Lifestyle Factors (Non-MBS-Eligible Alone)

do not by themselves qualify for Medicare-funded BMD testing if the patient is <70 years of age:

Age 50–69 without a fragility fracture or MBS-listed risk factor
Postmenopause (without additional MBS risk factors)
Sedentary lifestyle or office-based occupation
Poor dietary intake (unless calcium/protein deficiency is formally diagnosed)
Family history of osteoporosis (if no parental hip fracture)
Mild vitamin D insufficiency (without documented deficiency or fracture)
BMI <25 (unless significantly low weight or sarcopenia)
Smoking or alcohol use without meeting specific thresholds
- e.g. <2 standard drinks/day or <20 pack-year smoking history

Conditions/Medications Not Explicitly Covered by MBS

These may increase risk but are not MBS-listed for rebate purposes:

Risk Factor	Notes
Polycystic ovarian syndrome (PCOS)	Not directly included
Osteoarthritis	May affect scan accuracy, not an indication
Mild depression or anxiety	Only severe or with psychotropic use (e.g. SSRIs) may qualify
Proton pump inhibitors (PPIs) — occasional use	Must be long-term/chronic use to be considered
Anti-hypertensives (e.g. thiazides)	Not listed by MBS
Statins	Not MBS-listed unless related to CKD/liver disease
Migraine medications (e.g. topiramate)	Not MBS-listed

Others – Commonly Misinterpreted

Misunderstood Factor	MBS Status
Osteopenia on previous scan	❌ Not eligible alone
Previous low trauma fracture at finger/toe	❌ Not considered fragility fracture
History of falls — single episode	❌ Needs to be multiple or recurrent
Family history of osteoporosis	❌ Must be parental hip fracture to qualify
Use of calcium or vitamin D supplements	❌ Not a qualifying factor

🧮 Fracture Risk Assessment Tools

🔹 FRAX (TOOL (Australia)

Calculates 10-year probability of:
- Hip fracture probability >5% 🡪 need to start treatment
- Major osteoporotic fracture probability >20% 🡪 need to start treatment
Uses age, sex, BMI, risk factors, femoral neck T-score
Age range: 40–90 years
Limitations: Doesn’t include falls history; may over/underestimate in some groups

🔹 Garvan Fracture Risk Calculator (Garvan Institute, Australia)

Estimates 5- and 10-year risk of hip and total fracture
Includes number of prior fractures and history of falls
Can be used with or without BMD
Limitations: Doesn’t include smoking, alcohol, or secondary osteoporosis

racgp-osteoporosis-clinical-guidelines-summary-ver2018 Download

DEXA Scan

Anatomical Sites for BMD Measurement

Site	Clinical Use
Lumbar Spine	– Most sensitive for early bone loss (especially trabecular bone) – Best for younger patients without osteoarthritis – Preferred for assessing risk of vertebral compression fractures
Femoral Neck	– High predictor of hip fracture risk – Preferred site for older adults, especially with lumbar degenerative disease
Other Sites	– Wrist or calcaneus may be used if spine/hip cannot be assessed (e.g. deformity, prosthesis) – Less commonly used in standard practice

Advantages of DEXA

Very low radiation dose (~4 microsieverts; less than a chest X-ray)
High precision and reproducibility
Gold standard for fracture risk estimation
Used in international diagnostic criteria (WHO)

Limitations of DEXA

Accuracy may be affected by:
- Spinal osteoarthritis or sclerosis
- Old fractures
- Obesity or patient positioning
- Calcified aorta or degenerative changes
Scores are not interchangeable between anatomical sites or scan types

Scoring & Interpretation

T-Score (WHO standard for adults ≥50 years)

Measures SD deviation from young healthy adult mean
Used for diagnosing osteopenia/osteoporosis in postmenopausal women and men ≥50

T-Score Range	Interpretation
≥ –1.0	Normal
–1.0 to –2.5	Osteopenia (low bone mass)
≤ –2.5	Osteoporosis

Z-Score (for <50 years or premenopausal women)

Compares BMD to age-, sex-, and ethnicity-matched population
Helps identify secondary causes in younger adults
Z-scores are primarily used in the following groups:
- Premenopausal women
- Men <50 years
- Children/adolescents
- Patients with suspected secondary osteoporosis

Z-Score Range	Interpretation
> –2.0	Within expected range for age
≤ –2.0	Below expected range for age — may indicate underlying pathology

T-score vs Z-score – Comparison

Feature	T-score	Z-score
Reference group	Young healthy adults (age ~30)	Age-, sex-, and ethnicity-matched population
Used for	Postmenopausal women, men ≥50	Premenopausal women, men <50, children
Diagnostic use	WHO osteoporosis/osteopenia criteria	Not diagnostic; flags unusual bone loss
Threshold of concern	≤ –2.5 = osteoporosis	≤ –2.0 = below expected range for age
Purpose	Fracture risk and treatment thresholds	Screening for secondary causes

Bloods – Further Investigations

FBE/CMP/eLFT/Vit D/PTH/ testosterone in males/coeliac serology/urinary/serum immunophoresis/24 hour urinary cortisol
- evaluating for Osteoporosis Secondary Causes
  - Complete Blood Count : Multiple Myeloma
  - Alkaline Phosphatase increased : Paget’s Disease
  - Hepatic Aminotransferase levels (AST, ALT) increased: Hepatic disease
  - Serum Albumin decreased: Malnutrition
  - Serum Creatinine increased: Renal disease
  - Increased Ionized Serum Calcium:
    - Hyperparathyroidism. Cancer
  - Decreased Calcium:
    - Vitamin D Deficiency. Malabsorption
  - Thyroid Stimulating Hormone (TSH) decreased: Hyperthyroidism
  - Hypogonadism: Men: Total Serum Testosterone – Testicular Failure
  - Women: Estradiol: Consider in pre- or peri-menopausal women
    - Unnecessary in post-menopausal women
- High risk for secondary cause
  - Hypercalciuria
    - 24 hour Urine Calcium excretion >250 mg
  - Vitamin D Deficiency
    - Serum 1,25-Hydroxy Vitamin D decreased
  - Hyperparathyroidism
    - Intact Parathyroid Hormone (PTH) increased
  - Cushing’s Disease
    - 24 hour Urine Cortisol
  - Multiple Myeloma evaluation
    - Serum Protein Electrophoresis (SPEP)
  - Hemochromatosis
    - Serum Iron increased
    - Ferritin level increased
  - Celiac Sprue
    - Tissue transglutaminase and Endomysial antibodies

Management

Recommended First-Line Pharmacological Therapy

Treatment	Strength of Recommendation
Bisphosphonates (e.g. alendronate, risedronate)	Grade A
Denosumab	Grade A (women) Grade B (men)
Estrogen therapy (in postmenopausal women)	Grade A

Non-Pharmacological Management

Intervention	Grade of Recommendation
Falls prevention strategies	A
Resistance and balance training	A
Modify smoking, alcohol, and nutrition	C
Psychosocial support and patient education	D

Lifestyle

**weak evidence of decreased fracture from only lifestyle Mx
Quit smoking
Appropriate weight
Falls prevention
Adequate weight bearing exercise (skipping, jumping better than swimming, walking, riding)
Decrease EtOH
Limit PPI

Vitamin D

Primarily formed in skin from sunlight exposure.
Small dietary amounts in oily fish, liver, and eggs.
Production depends on skin color, location, and time of year.
Does not effect Bone Mineral Density, Muscle Strength, fall risk or function
Mixed evidence on vitamin D supplementation preventing bone loss and fractures
- Increases bone density 1% per year
Beneficial for high-risk groups
- aged care residents
- housebound people
No benefit from Vitamin D supplement
- Postmenopausal women in community
- age <75
measurement only recommended for high risk groups
aim levels >50 before bisphosphonate commencement
levels > 75 recommended

Calcium

Meta-analyses show no correlation between dietary calcium intake and fracture risk.
Best dietary sources:
- milk, hard cheeses, yoghurt.
Moderate sources:
- firm tofu, almonds, sesame seeds, tinned fish, some green leafy vegetables, calcium-enriched soy milk.
Advise adequate dietary calcium intake:
- 1300 mg/day for women >50 and men >70 years of age
- 1000 mg/day for men 50–70 years of age
Does not increase bone density (but slows loss)
Overdosage above 1500 mg daily weakens bone
Mixed evidence on dietary calcium and fracture risk.
Meta-analyses show no correlation between dietary calcium intake and fracture risk.
Harm with supplemental calcium; supplements not generally recommended.
Calcium supplementation may be needed when starting medication if dietary intake is insufficient.

Calcium and vitamin D supplementation are not recommended for routine use in non-institutionalised older people

Bisphosphonates

decrease rate of bone loss and decrease fracture rates
Increases bone density 5-6% per year
Consider stopping oral Bisphosphonates after 5 years (and reclast after 3 years)

Generic name	Route	Dose	Frequency
Alendronate	orally	70mg	Weekly for 5-7 years
Alendronate	orally	10mg	Daily for 5-7 years
Risendronate (actonel)	orally	35mg	Weekly for 5-7 years
Risendronate	orally	150mg	Monthly for 5-7 years
Zoledronic acid	IV	5mg	yearly for 3 years

Zoledronic acid infusion (Aclasta) criteria
- Must have Vit D level > 50 nmol/L
- Serum calcium 2.10-2.60 mmol/L
- eGFR > 35ml/min/1.73m2
SE:
- Oesophagitis
- Gastritis
- nausea
- dyspepsia
- Osteonecrosis of jaw is a rare complication
  - Consider patient risk of MRONJ before starting osteoporosis therapy.
  - Ensure high-risk patients receive a dental review prior to therapy initiation.
  - mainly occurs with IV treatments and have had dental surgery
  - Little benefit to cessation prior to dental extraction.

To minimise upper GI side effects advise patients to take first thing in morning (empty stomach) and remain upright for ≥ 30mins
not to be taken with calcium or antacids

BMD response r/v 2 yearly
- Oral therapy continued for up to 5 years and iv therapy for 3 years
- After 5 years of oral bisphosphonates or 3 years of intravenous bisphosphonates, a “drug holiday” can be considered in patients at low-to-moderate fracture risk.
- Patients at high fracture risk may continue therapy for up to 10 years.
Keep treatment going if:
- Femoral neck T-score lower than -2.5 w/o vertebral fractures
- Femoral neck T-score lower than -2.0 with vertebral fractures
- A recent fracture has occurred

Raloxifene

Selective oestrogen receptor modulator (SERM)
prevents post menopausal bone loss
not shown to prevent non-vertebral fractures
increased incidence hot flushes, risk DVT, stroke
Reduces risk of breast cancer, but increase risk DVT/Stroke
Raloxifene 60mg orally daily
PBS streamlined authority –minimal trauma fracture and diagnosis with CT or MRI

HRT

long term management >5yrs rarely indicated for treatment of OP
Benefits may not outweigh risks of CVA, VTE, CAD, Breast Cancer
shown to decrease fracture rates

Strontium

decreased bone resorption
decreases fractures
only registered for female use
2g orally daily

Teriparatide

-synthetic PTH, increases bone formation
-must be specialist initiated
-daily 20mcg subcut

Denosumab(Prolia)

monoclonal antibody inhibits osteoclast activity
Correct vitamin D prior to initiation as may exacerbate hypocalcemia
60mg subcut injection q 6 monthly
PBS streamlined authority
Well tolerated by patients
Stopping denosumab after long-term use can lead to a rebound effect with rapid bone loss and increased risk of vertebral fractures.
- Evidence suggests a significant increase in fracture risk within 12-24 months after stopping
- Current guidelines recommend continuing denosumab as long as the patient is at high risk of fracture.Transition to another anti-resorptive therapy (e.g., bisphosphonates) is suggested if denosumab is stopped.
Assess dental hygiene
- rarely cx osteonecrosis of jaw
- Invasive dental procedures should be performed just prior to the next six-monthly injection.
- The in vivo effect on bone suppression will be waning at this time

Denosumab	Bisphosphonates
pros: – More significant increase in BMD compared to bisphosphonates. – Rapid onset of action and potent antiresorptive effects. – Effective in patients with renal impairment.	pros: – Long-term data on fracture prevention. – Oral and intravenous administration options. – Accumulate in bone, providing a residual effect after stopping.
cons: – Increased risk of hypocalcemia. – Rebound bone loss and increased fracture risk upon discontinuation. – Possible increased risk of serious infections and skin reactions.	cons: – Gastrointestinal side effects (with oral forms) – Risk of osteonecrosis of the jaw and atypical femoral fractures (with long-term use). – Renal toxicity (particularly with intravenous forms)

Denosumab generally shows a greater efficacy in increasing BMD and reducing fracture risk compared to bisphosphonates, especially in the short to medium term.
Denosumab might be preferable in patients with renal impairment.
Bisphosphonates remain a viable option due to their long-term safety data and residual effect, especially in patients who require or prefer oral medication.
The choice between denosumab and bisphosphonates should be individualized, considering patient-specific factors like renal function, risk of adherence issues, and long-term treatment planning.

Children

-usually secondary to long term steroid use
-also caused by malignancy, malabsorption, poor nutrition, anorexia, hypogonadism

Men

-1/3 >60yo will have OP fracture, of which 60% are due to secondary OP
-need investigations and endocrinology referral

Considerations

eGFR <35 bisphosphonates and <30 strontium and teripartide contraindicated
Steroids fracture risk increased 75% in first 3 months use, BMD should be assessed prior to long term initiation
-discontinuation: half patients stop taking in 6 months, two thirds by 12 months

Monitoring Recommendations

Bone Status	Recommended Interval for Repeat DEXA
Normal or mild osteopenia (T > –1.5)	Every 10–15 years
Moderate osteopenia (T –1.5 to –2.0)	Every 5 years
Severe osteopenia (T –2.0 to –2.4)	Every 1–2 years
Osteoporosis (T ≤ –2.5 or under active treatment)	Every 2 years or less, guided by clinical context

Prevention

Activity

Regular, high-intensity weight-bearing exercise slows bone density loss in postmenopausal women and older men.
- Effective activities: jogging, dancing, tennis, step aerobics.
- Strength and resistance training (e.g., weight lifting) recommended.
- Exercise should be progressive, varied, 30 minutes, 2-3 times per week.
- Short, intense sessions are better than prolonged, less intense exercise.
- High-intensity balance training decreases fall and fracture risk.
- Modify activity recommendations for people with osteoporosis.
- Avoid high-impact activities for those with established osteoporosis.
- Supervision by a physiotherapist or trained professional recommended.

Smoking Cessation

Associated with higher rates of fragility fracture but interventions have not shown to reduce fractures.
Highly recommended for other health reasons.

Avoid Underweight

Low body weight may lead to lower muscle and bone mass.
Exercise and diet are important for maintaining healthy weight and bone density.

Hypogonadism

Should be managed in its own right.
Not generally treated pharmacologically just for fracture prevention.

Minimize Steroid Use

>3 months on oral steroids increases fracture risk.
High-dose inhaled steroids can impact bone mass in children.

Detect and Manage Malabsorption and Chronic Inflammatory Conditions

Important for vitamin D and calcium absorption.
Conditions to consider: inflammatory bowel disease, coeliac disease, surgical short gut, chronic arthritis.

Recurrent Falls

Multimodal falls prevention interventions have good evidence and may reduce fractures.
- Exercise Programs:
  - Strength and Resistance Training:
    - Focus on building muscle strength and improving balance.
    - Recommended activities: weight lifting, resistance bands, body-weight exercises.
    - High-intensity balance training can reduce fall risk.
  - Balance and Flexibility Exercises:
    - Tai Chi and yoga to improve balance and flexibility.
    - Activities that challenge balance, such as standing on one leg.
  - Weight-Bearing Activities:
    - Walking, dancing, and low-impact aerobics to improve bone density and overall mobility.
- Home Hazard Assessment and Modification:
  - Identify and mitigate fall hazards in the home environment.
  - Install grab rails in bathrooms and stairways.
  - Ensure adequate lighting throughout the home.
  - Use non-slip mats and remove loose rugs.
  - Arrange furniture to create clear pathways.
- Medication Review:
  - Regularly review medications to identify those that may increase fall risk (e.g., sedatives, antihypertensives).
  - Adjust dosages or discontinue unnecessary medications under medical supervision.
- Vision Correction:
  - Regular eye exams to ensure proper vision.
  - Update eyeglasses prescriptions as needed.
  - Consider wearing single-lens glasses instead of bifocals or multifocals when walking outside.
- Footwear and Foot Care:
  - Wear supportive, well-fitting shoes with non-slip soles.
  - Address foot problems such as bunions or calluses that can affect balance.
- Education and Training:
  - Provide education on fall prevention strategies.
  - Encourage awareness of individual risk factors and proactive management.
  - Training in how to get up safely after a fall.
- Assistive Devices:
  - Use of canes, walkers, or other assistive devices for those with mobility issues.
  - Ensure proper fitting and training in the use of these devices.
- Community-Based Programs:
  - Participation in local fall prevention programs and classes.
  - Access to resources and support groups for fall prevention.

Adequate Vitamin D

Expect lower levels at the end of winter.
Safe sun exposure and supplements are recommended where feasible or adequate.

High Alcohol Intake

Associated with higher fracture rates similar to smoking.
Reduction recommended for overall health reasons.

Hip Protectors

Foam pads (soft) or plastic shields (hard) worn over hips in special underwear.
Reduce hip fracture risk in older people in aged care facilities.
Number needed to treat (NNT) for one year to prevent one fracture is 91.
Not effective in community settings due to low usage.