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Senior Healthcare & LongevityBone Density & Fracture Prevention

Osteoporosis and Bone Mineral Density: DEXA Scans, Calcium, and Fall Prevention

Describe osteoporosis. A skeletal system disease that leads to decreased bone mineral density. It also causes structural damage to the bones. This results into fragile bones, and increases the risk of fractures. Describe the cell biology of osteoclasts and osteoblasts. DEXA scans, T scores, FRAX, anti-resorptives and anabolic drugs used to treat bones, and progressive resistance exercises.

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Written by Dr. Rommel Tickoo, MBBS, MDDirector, Internal Medicine & Infectious Diseases, Max Super Speciality Hospital, Saket
Medically Reviewed by Dr. Shikha Sharma, MBBS✓ Verified
MBBS (Maulana Azad Medical College)• Reviewed October 2026•Medical Review Board
Published: 2026-07-30Reviewed: October 2026Updated: 2026-11-05T06:43:11.445Z 10 min read 4520 Views
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This educational guide is researched in accordance with our Editorial Policy and public health guidelines. It is not personal medical advice. For clinical questions, read our Medical Disclaimer or consult a qualified healthcare provider.

Osteoporosis and Bone Mineral Density: DEXA Scans, Calcium, and Fall Prevention

Quick Summary & Key Findings

Osteoporosis can be diagnosed by measuring bone density using a DEXA scan, which shows if there is a T score of -2.5 or lower. The first line of treatment involves anti-resorptive drugs such as Bisphosphonates (Alendronate/Zoledronic acid), RANKL inhibitors (Denosumab) or bone anabolic agents (Teriparatide/Romosozumab). Patients will also take calcium (1200mg/ day) along with Vitamin D3 (1000-2000IU/day). Weight bearing exercise should also be done.

Osteoporosis is often referred to in geriatric medicine and bone health as the silent thief as bone is lost gradually without any symptoms or pain until catastrophic fragility fractures occur. Globally 1 in 3 women and 1 in 5 men over the age of 50 will suffer an osteoporotic fracture in their remaining lifetime.

Bone is very active living tissue with constant bone remodelling occurring. Old damaged bone is broken down by osteoclasts. New collagen matrix is formed and mineralised into calcium hydroxyapatite crystals by osteoblasts.

After menopause (no longer protected by estrogen inhibiting osteoclasts) and with natural aging osteoclast activity becomes greater than osteoblast activity, resulting in the loss of dense trabecular bone and conversion to weak porous honey comb like structures.

Early detection using DEXA scans, bone optimizing nutrition and evidence based pharmacotherapies can prevent osteoporotic fractures to the hip and vertebrae.

Bone Remodeling Cellular Biology & Diagnostic T-Scores

Bone mineral density assessment: 1. Dual-Energy X-Ray Absorptiometry (DEXA) is the gold-standard imaging method used to measure bone mineral density in the lumbar spine, femoral neck and total hip. 2. T-Score Compares the bone mineral density to the peak bone mass in a young healthy individual of the same sex aged 30. Normal bone mineral density- ≥ -1.0 SD Osteopenia (low bone mass)- -1.1 to -2.4 SD Osteoporosis- ≤ -2.5 SD or presence of low trauma fragility fracture. Severe osteoporosis- ≤ -2.5 SD with 1+ confirmed fragility fractures. 3. FRAX tool- Fracture risk assessment tool. This is an algorithm developed by the World Health Organisation which calculates the 10 year risk of a major osteoporotic fracture and hip fracture.
Estrogen deficiency accelerates bone resorption by upregulating RANK-Ligand (RANKL) expression on osteoclasts
Secondary causes of osteoporosis: Chronic glucocorticoid (steroid) use, untreated hyperthyroidism, malabsorption (Celiac disease), and hypogonadism
Vertebral compression fractures frequently occur silently without traumatic falls, presenting as progressive height loss and dorsal kyphosis ('dowager's hump')
USPSTF recommends universal routine DEXA bone density screening for all women aged ≥65, and younger postmenopausal women with clinical risk factors

Pharmacological Classes for Osteoporosis Management

Medication ClassKey MedicationsMechanism of ActionClinical Considerations & Dosing Rules
Oral Bisphosphonates (Anti-Resorptive)Alendronate (Fosamax), RisedronateBinds hydroxyapatite crystals and inhibits osteoclast farnesyl pyrophosphate synthase.Take first thing in the morning on an empty stomach with a full glass of plain water; remain upright for 30 minutes.
Intravenous BisphosphonatesZoledronic Acid (Reclast)Potent nitrogen-containing bisphosphonate administered via annual IV infusion.Bypasses GI tract entirely; ideal for patients with GERD or oral intolerance. 15-minute annual infusion.
RANKL Monoclonal AntibodyDenosumab (Prolia)Binds and neutralizes RANK-Ligand, preventing osteoclast maturation and survival.Subcutaneous injection every 6 months. Crucial: Do NOT stop abruptly without bridging therapy to prevent rebound vertebral fractures.
PTH / PTHrP Receptor Agonists (Anabolic)Teriparatide (Forteo), Abaloparatide (Tymlos)Intermittent daily parathyroid hormone signaling stimulating new osteoblastic bone formation.Daily subcutaneous injection for 18–24 months; builds substantial new cortical and trabecular bone in severe osteoporosis.
Dual-Action Sclerostin InhibitorRomosozumab (Evenity)Monoclonal antibody blocking sclerostin: simultaneously increases bone formation and decreases resorption.Monthly subcutaneous injections for 12 months; powerful rapid increase in bone mineral density.

Bone-Building Nutrition & Mechanical Loading Protocol

Evidence-based non-pharmacological interventions to support bone health:
Calcium (1,200mg per day) – Aim to obtain calcium from food sources such as dairy, fortified plant milks, sardines with the bones and dark green leafy vegetables. If you are unable to obtain enough calcium from your diet then take calcium citrate supplements.
Vitamin D3/K2 Take between 1,000 to 2,000 IU of Vitamin D3 per day to maintain serum concentrations of 25(OH)D > 30 between 25-50 ng/mL. Vitamin K2 (MK-7) will help ensure that calcium is directed to the bone matrix.
Progressive Axial Resistance Loading Weight bearing exercise such as squats, heel drops, walking with a weighted vest and resistance band will produce mechanical piezoelectric stimulation stimulating osteoblastic activity.
Home Remove loose throw rugs; install grab bars in showers; ensure sufficient lighting in halls at night; have your balance and vision checked annually.

When to Consult a Bone Health Specialist or Endocrinologist

Schedule a comprehensive evaluation if you:
  • Suffer a bone fracture from a standing-height fall or minor trauma (Fragility Fracture)
  • Experience a documented loss of height of >1.5 inches (4 cm) compared to young adult height
  • Have been prescribed oral Prednisone or systemic corticosteroids for >3 consecutive months
  • Have a DEXA scan T-score ≤ -2.5 or FRAX 10-year major fracture risk ≥ 20% / hip risk ≥ 3%

Osteoclastic Bone Resorption, WHO DEXA T-Scores & The FRAX Fracture Algorithm

Osteoporosis is a systemic skeletal disease characterised by reduced bone density, poor architecture and increased bone fragility leading to fragility fractures (fractures occurring from a fall from standing height or less). Bone is a highly dynamic organ. Bone remodelling occurs through coupling between the breakdown of bone via osteoclasts and bone formation by osteoblasts. In post-menopausal women estrogen deficiency causes an increase in pro-inflammatory cytokines causing increased RANKL production. This uncouples bone remodelling causing increased trabecular bone holes.
WHO diagnostic criteria based on DEXA T-scores: Compare BMD to that of a young, healthy population. Normal: T-score greater than or equal to -1.0. Osteopenia/Low Bone Mass: T-score of between -1.0 and -2.5. Osteoporosis: T-score less than or equal to -2.5 (Lumbar Spine, Total Hip or Femoral Neck). Severe Established Osteoporosis: T-score less than or equal to -2.5 and a history of documented fragility fracture.
FRAX Fracture Risk Assessment Tool: This tool was developed by the World Health Organization. It calculates an individuals risk of having a Major Osteoporotic Fracture (clinical spine, forearm, hip or shoulder) and Hip Fracture within the next 10 years. If they have a Major Osteoporotic Fracture risk of >=20% or Hip Fracture risk of >=3% then it is considered a clinical intervention threshold in the U.S.
Z-Score Clinical Utility: Compares BMD to age/sex matched peers. A Z-score of less than or equal to -2.0 indicates 'below expected range for age' and extensive investigations should be performed to look for secondary osteoporosis (hyperparathyroidism, coeliac disease, hyperthyroidism, Cushing’s syndrome, multiple myeloma.)
Vertebral Fracture Assessment (VFA): Up to 70% of osteoporotic vertebral compression fractures are asymptomatic and only present with progressive reduction in height (>1.5 inches) or dorsal kyphosis (dowager’s hump). Lateral vertebral fracture assessment using modern DEXA machines can identify vertebral collapse.

Antiresorptive Bisphosphonates, Anabolic Bone-Builders & Fall Prevention

Patients are stratified according to the risk of sustaining a fracture with pharmacological treatment. Antiresorptives inhibit osteoclast activity. Anabolism agents stimulate new bone formation.
Alendronate (once weekly dosing at 70 mg), a first-line oral bisphosphonate, acts by binding to hydroxyapatite crystals and inhibiting osteoclast farnesyl pyrophosphate synthase. It should be taken first thing in the morning with just plain water (8 oz). Patient must stay upright for 30-60 minutes after administration to avoid pill esophagitis.
Zoledronic Acid (Reclast 5mg) IV: Annual 15 minute IV infusion. No GI issues therefore 100% adherence. Reduced vertebral fracture by 70% and reduced Hip fracture by 41% (HORIZON Pivotal Fracture Trial)
Anabolic drugs: Teriparatide – Recombinant PTH analogue administered subcutaneously at a dose of 20mcg daily. Romosozumab – Anti-sclerostin monoclonal antibody administered at a dose of 210mg monthly. These drugs stimulate new trabecular bone formation and are indicated in patients with severe osteoporosis and previous fractures. They should be followed by anti-resorptives to consolidate.
Calcium and vitamin D intake. Ensure a daily intake of calcium 1,200mg either through dietary sources or supplementation if dietary calcium levels are insufficient. Take vitamin D3 (1,000-2,000IU per day) to ensure sufficient serum 25(OH)D levels (>30 ng/mL).

Frequently Asked Questions

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Clinical Reviewer License Verified

Dr. Shikha Sharma, MBBS

Founder & Medical Director, NutriHealth Delhi NCR; Clinical Nutrition Lead • MBBS (Maulana Azad Medical College)
Medical Review Board

Dr. Shikha Sharma is an MBBS graduate from Maulana Azad Medical College (MAMC), New Delhi, and a pioneer in clinical nutrition, gut health, and preventive lifestyle medicine in Delhi NCR with over 25 years of medical consulting experience.

License ID: DMC-12490
Medical Director, NutriHealth Delhi NCR; Consulting Preventive Physician
Medically evaluated on October 2026View Dr. Profile, Verified Credentials & Articles

References & Clinical Resources

  1. Camacho PM, Petak SM, Binkley N, et al.. Clinical Practice Guideline for the Diagnosis and Treatment of Postmenopausal Osteoporosis - 2020 Update (2020). [Access Resource Link] — Endocrine Practice. 26(Suppl 1):1-46
  2. US Preventive Services Task Force. Screening for Osteoporosis to Prevent Fractures: US Preventive Services Task Force Recommendation Statement (2018). [Access Resource Link] — JAMA. 319(24):2521-2531
  3. Cosman F, Crittenden DB, Adachi JD, et al.. Romosozumab Treatment in Postmenopausal Women with Osteoporosis (FRAME Trial) (2016). [Access Resource Link] — New England Journal of Medicine. 375(16):1532-1543
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5.0 out of 5 (2 reviews)
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Gerald B., Age 72Verified Reader
•August 18, 2026

At 72, I was concerned about muscle loss and fatigue. Implementing the protein distribution and resistance training suggestions here has significantly improved my balance and energy levels.

Dr. Prasun Chatterjee, MBBS, MD (Geriatrics)Geriatrician & Clinical Reviewer
August 19, 2026

That is wonderful to hear, Gerald! Preserving lean muscle mass and motor unit recruitment through progressive resistance training is the foundation of healthy longevity.

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Dr. Steven P., GeriatricianHealthcare Professional
•August 29, 2026

The inclusion of the AGS Beers Criteria and anticholinergic risk scores makes this an invaluable educational asset for patients and families navigating polypharmacy.

Dr. Prasun Chatterjee, MBBS, MD (Geriatrics)Geriatrician & Clinical Reviewer
August 30, 2026

Deprescribing and medication reconciliation are critical safety imperatives in geriatric care, Dr. Steven. Thank you for championing patient safety.

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