DEXA Screening Guidelines for Older Adults

Primary Screening Recommendation

The American College of Radiology recommends routine DEXA screening for all women aged 65 years and older, regardless of risk factors 1, 2

For an 86-year-old woman who has never had a DEXA scan, baseline screening is recommended due to the high risk of fragility fractures and increasing prevalence of osteoporosis with age 1
If she had a previous normal DEXA, the decision to screen again depends on when it was performed and whether new risk factors have emerged, with evidence suggesting extended screening intervals in women with normal baseline bone density, but her advanced age warrants reassessment 1
For a woman with known osteoporosis or on treatment, repeat DEXA every 1-2 years is recommended to monitor treatment effectiveness 1, 3

A history of fragility fractures confirms osteoporosis diagnosis, superseding DEXA results 4
Height loss >4 cm suggests possible vertebral compression fractures and warrants both DEXA and vertebral fracture assessment (VFA) 1
Medications affecting bone, such as glucocorticoids, aromatase inhibitors, androgen deprivation therapy, or anticonvulsants, should be considered 1, 5
Medical conditions like chronic kidney disease, rheumatoid arthritis, malabsorption disorders, hyperparathyroidism, or hyperthyroidism should be evaluated 5
Lifestyle factors, including smoking, excessive alcohol use, inadequate calcium/vitamin D intake, or sedentary lifestyle, should be assessed 6

If her T-score is ≤-1.0, VFA should be performed concurrently with DEXA, given her age over 70 years 1

Spinal degenerative changes can falsely elevate lumbar spine BMD measurements, making hip measurement the primary diagnostic site in this scenario 3, 4, 5
There is no upper age limit for screening, though data on treatment efficacy in women over 85 is limited, and screening remains valuable for fracture prevention if she has reasonable life expectancy and functional status 7

Order DEXA of both lumbar spine and hip, with the understanding that hip measurements will be more reliable given her age, and request VFA if T-score is ≤-1.0 or if she has height loss or kyphosis 1, 4, 5
The scan should assess lumbar spine (L1-L4), total hip and femoral neck bilaterally, and consider forearm if hip and spine cannot be measured 1, 4, 7
Follow-up intervals will depend on results, with every 1-2 years if osteoporosis is present or she's on treatment, or every 2-3 years if bone density is normal or shows mild osteopenia 1