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Summary: This consensus article reviews the diagnosis and treatment of osteoporosis in geriatric populations. Specifically, it reviews the risk assessment and intervention thresholds, the impact of nutritional deficiencies, fall prevention strategies, pharmacological treatments and their safety considerations, the risks of sub-optimal treatment adherence and strategies for its improvement. Introduction: This consensus article reviews the therapeutic strategies and management options for the treatment of osteoporosis of the oldest old. This vulnerable segment (persons over 80years of age) stands to gain substantially from effective anti-osteoporosis treatment, but the under-prescription of these treatments is frequent. Methods: This report is the result of an ESCEO (European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis) expert working group, which explores some of the reasons for this and presents the arguments to counter these beliefs. The risk assessment of older individuals is briefly reviewed along with the differences between some intervention guidelines. The current evidence on the impact of nutritional deficiencies (i.e. calcium, protein and vitamin D) is presented, as are strategies to prevent falls. One possible reason for the under-prescription of pharmacological treatments for osteoporosis in the oldest old is the perception that anti-fracture efficacy requires long-term treatment. However, a review of the data shows convincing anti-fracture efficacy already by 12months. Results: The safety profiles of these pharmacological agents are generally satisfactory in this patient segment provided a few precautions are followed. Conclusion: These patients should be considered for particular consultation/follow-up procedures in the effort to convince on the benefits of treatment and to allay fears of adverse drug reactions, since poor adherence is a major problem for the success of a strategy for osteoporosis and limits cost-effectiveness.

Several disorders of increased bone turnover and low bone mineral density (BMD) are associated with severe pain that is refractory to treatment with conventional and even opioid analgesics. Because of their ability to effectively improve the underlying pathogenesis of these disorders (i.e., reduce bone resorption and increase BMD), bisphosphonates are considered part of the palliative care of malignant bone-related pain and also appear to have some analgesic efficacy in other, non-malignant conditions. Ibandronate, a potent, nitrogen-containing bisphosphonate that can be given orally and intravenously, has demonstrated robust effects in relieving the pain associated with several malignant disorders. Unlike other available intravenous (i.v.) bisphosphonates, i.v. ibandronate is not associated with renal side effects, even at high doses such as 6 mg every 3 weeks. In addition, oral ibandronate (50 mg daily) is currently the only oral bisphosphonate proven to reduce and maintain bone pain scores below baseline for 2 years in patients with metastatic bone disease. Lower dose, less intense dosing regimens of ibandronate relieve bone pain in non-malignant conditions: i.v. ibandronate (2 mg every 3 months with or without an initial 4 mg injection) provides pain relief for patients with corticosteroid-induced osteoporosis, localised transient osteoporosis (bone marrow oedema) and sternocostoclavicular hyperostosis. Both oral and i.v. ibandronate are well tolerated. In conclusion, ibandronate offers an effective and convenient choice for the relief of bone pain in a wide variety of underlying bone conditions.

We investigated how calcium channel blocking agents modify the known decrease of QT time with increasing heart rate and calcium level. Furthermore, we examined how the influence of calcium channel blocking agents is modulated by atrial stimulation. To answer these questions, we measured the QT time both at a spontaneous heart rate and during atrial stimulation with 90 and 110 beats/min before and after intravenous administration of 5 mg verapamil in 23 patients with primary hyperparathyroidism, pre- and postoperatively. Atrial stimulation increased the frequency-related standard values of QT time. The spontaneous heart rate (HR) was influenced by neither the calcium level nor verapamil. The statistically significant correlations QT vs. HR and QT vs. Ca were reduced by verapamil, which indicated its influence. However, this effect did not achieve statistical significance.

In 75 operatively proved cases of primary hyperparathyroidism (PH) mean systolic and diastolic blood pressure (BP) values were significantly higher pre- than postoperatively. There were 27 patients (36%) who showed hypertension before operation (systolic BP greater than or equal to 150 mm Hg, mean 169 +/- 20 mm Hg). In 20 of these the hypertension was reversible after successful treatment of PH, in seven cases elevated values persisted. The mean age of patients with persisting hypertension was significantly higher than the group with normalization of BP after operation (P less than 0.01). As far as clinical presentation of PH was concerned it were those cases with hypercalcaemic syndrome and with accidentally discovered hypercalcaemia who most often showed hypertension. In cases with recurrent urolithiasis and with osteitis fibrosa as leading symptoms there was no significant increase of hypertension as compared to the whole group. Because of the relatively high incidence of hypertension in PH this possibility should be taken into consideration in each diagnostic clarification of hypertensive patients.

A reference group (252 males, 436 females) and a group of patients with primary hyperparathyroidism (34 males, 67 females) and cirrhosis of the liver (33 males) were subjected to a multivariate data assessment; the analyses were performed on the Technicon autoanalyzer SMA 12/60 (sodium, potassium, chloride, total protein, albumin, inorganic phosphorus, cholesterol, urea nitrogen, calcium, creatinine, bilirubin, uric acid) and the SMA 6 plus (iron, copper, magnesium, alkaline phosphatase, acid phosphatase, glucose). A multivariate test statistic containing age as a regressor variable was used, thus correcting for age. Derivation of the test statistic required multivariate normality of the distributions of the clinical-chemical values, a condition which is generally not fulfilled in the data of patients. In order to arrive at the multivariate normality of the distributions, we applied the X-transformation of van der Waerden [1965) Mathematische Statistik, Springer Verlag, Berlin--Gottingen-Heidelberg) to the marginal values. We introduced the concept of group-conformity behaviour of the patient data. According to our definition, a patient behaves in conformity with a given group of patients with respect to a clinical-chemical value, if the patients' value deviates from the estimated age-specific expected value of the reference group and the deviation lies in the same direction as that of the mean value of the respective group of patients. Using this procedure, disease-specific deviation patterns were determined from the data, thus enabling us to make clear separations of the patient groups from the reference group and from each other. Furthermore, the computed deviation patterns throw light upon the pathobiochemical modifications of the parameters in the examined diseases.