How common, and how often treated
The report of a US trial in long-term care cites osteoporosis in 85% of institutionalised older people and fracture rates eight to nine times those of older people living in the community. It also notes that most are left untreated and that frail residents were excluded from the pivotal osteoporosis trials 29.
That last point shapes everything on this page. Most of what is known about bone medicines comes from women in their sixties and seventies living at home.
The options
Calcium and protein from food
Promising, not yet provenExtra dairy on the menu reduced fractures within months in one large Australian aged care trial.
The evidence
In 60 Australian facilities with 7,195 residents, raising intake to about 1,142 mg of calcium and 1.1 g of protein per kilogram of body weight a day reduced all fractures by 33% and hip fractures by 46% over two years. The reduction in hip fractures reached significance at five months. Residents in the comparison facilities were eating about 700 mg of calcium and 0.9 g of protein per kilogram a day 8.
In practice
A single trial, in residents who already had adequate vitamin D 8. It needs no tablets and is a change the facility makes to the menu.
Vitamin D with calcium
Supported by trial evidenceDaily vitamin D with calcium reduced hip fractures in very old women in a large trial.
The evidence
In 3,270 ambulatory French women with a mean age of 84, vitamin D3 800 IU with 1.2 g of calcium daily for 18 months was followed by 43% fewer hip fractures and 32% fewer non-vertebral fractures among those who completed the study, with similar results by intention to treat 11. In an Australian residential care trial in which everyone received calcium, adding vitamin D reduced falls, but the effect on fractures was not statistically significant (odds ratio 0.69, 95% CI 0.40 to 1.18) 10.
Bisphosphonates after a fracture
Supported by trial evidenceAfter a hip fracture, a yearly zoledronic acid infusion reduced further fractures and deaths. The benefit of bisphosphonates takes about a year to appear.
The evidence
In 2,127 people who had a hip fracture repaired (mean age 74.5), zoledronic acid started within 90 days and given yearly reduced new clinical fractures from 13.9% to 8.6% and deaths from 13.3% to 9.6% over a median of 1.9 years 31. A meta-analysis of ten trials in 23,384 postmenopausal women with osteoporosis estimated that 12.4 months of bisphosphonate treatment were needed to prevent one non-vertebral fracture per 100 women treated, and 20.3 months to prevent one hip fracture per 200 30.
In practice
The authors of the time-to-benefit analysis conclude that treatment is most likely to help women with a life expectancy of more than about a year 30. Participants in these trials were younger and fitter than most aged care residents.
Zoledronic acid in very frail residents
Uncertain / conflictingIn the one trial in frail women in long-term care, bone density improved but fractures did not fall.
The evidence
In 181 women aged 65 and over with osteoporosis living in nursing homes and assisted living, including women with cognitive impairment and immobility, a single 5 mg dose improved hip and spine bone density over two years. Fracture rates were 20% with treatment and 16% with placebo (odds ratio 1.30, 95% CI 0.61 to 2.78), and mortality 16% and 13%, neither difference being statistically significant. More treated women had multiple falls, a difference that disappeared after adjusting for frailty at baseline 29.
In practice
The trial was too small to settle the question of fractures. Its authors wrote that any change in nursing home practice should wait for larger trials 29.
Time to benefit and life expectancy
A treatment that takes a year to prevent a fracture can only help someone who lives that long 30. For a resident in the last months of life, starting a bone medicine adds a tablet or an infusion with little chance of benefit. For a resident who is walking, has just had a fracture and may live for several years, treatment is likely to be worthwhile. Most residents sit somewhere between, and the decision is a judgement made with them and their family.
PBS criteria for osteoporosis medicines depend on age, fracture history and bone density, and they change. Check the current listing before prescribing.
Questions a family can reasonably ask
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Has my relative had a fracture after a minor fall or bump, and has their bone health been looked at since?
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Are they getting enough calcium and protein from the food they are eating?
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Are they taking vitamin D, and how often?
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If they are on denosumab, when is the next injection due and who is making sure it happens?
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Given their health overall, is a bone medicine likely to help them?
Sources cited on this page
- 1 Australian Commission on Safety and Quality in Health Care. Preventing Falls and Harm from Falls in Older People: Best Practice Guidelines for Australian Residential Aged Care Services. Sydney: ACSQHC; 2025. View source
- 8 Iuliano S, Poon S, Robbins J, et al. Effect of dietary sources of calcium and protein on hip fractures and falls in older adults in residential care: cluster randomised controlled trial. BMJ. 2021;375:n2364. View source
- 9 Baek Y, Iuliano S, Robbins J, Poon S, Seeman E, Ademi Z. Reducing hip and non-vertebral fractures in institutionalised older adults by restoring inadequate intakes of protein and calcium is cost-saving. Age Ageing. 2023;52(6):afad114. View source
- 10 Flicker L, MacInnis RJ, Stein MS, et al. Should older people in residential care receive vitamin D to prevent falls? Results of a randomized trial. J Am Geriatr Soc. 2005;53:1881–8. View source
- 11 Chapuy MC, Arlot ME, Duboeuf F, et al. Vitamin D3 and calcium to prevent hip fractures in elderly women. N Engl J Med. 1992;327:1637–42. View source
- 12 Sanders KM, Stuart AL, Williamson EJ, et al. Annual high-dose oral vitamin D and falls and fractures in older women: a randomized controlled trial. JAMA. 2010;303:1815–22. View source
- 13 Bischoff-Ferrari HA, Dawson-Hughes B, Orav EJ, et al. Monthly high-dose vitamin D treatment for the prevention of functional decline: a randomized clinical trial. JAMA Intern Med. 2016;176:175–83. View source
- 29 Greenspan SL, Perera S, Ferchak MA, Nace DA, Resnick NM. Efficacy and safety of single-dose zoledronic acid for osteoporosis in frail elderly women: a randomized clinical trial. JAMA Intern Med. 2015;175:913–21. View source
- 30 Deardorff WJ, Cenzer I, Nguyen B, Lee SJ. Time to benefit of bisphosphonate therapy for the prevention of fractures among postmenopausal women with osteoporosis: a meta-analysis of randomized clinical trials. JAMA Intern Med. 2022;182:33–41. View source
- 31 Lyles KW, Colón-Emeric CS, Magaziner JS, et al. Zoledronic acid and clinical fractures and mortality after hip fracture. N Engl J Med. 2007;357:1799–809. View source
- 32 Cummings SR, Ferrari S, Eastell R, et al. Vertebral fractures after discontinuation of denosumab: a post hoc analysis of the randomized placebo-controlled FREEDOM trial and its extension. J Bone Miner Res. 2018;33:190–8. View source
See every source cited across the falls and frailty section →
Written by Dr Josh Hatch, FRACGP. General information only, reflecting his reading of the published evidence as at October 2026. It is not individual medical advice, does not create a doctor–patient relationship, and must not be used to start, stop or change any treatment. Evidence and Australian regulatory and PBS arrangements change — always confirm current advice with the treating GP, pharmacist or specialist.
This is general education, not a clinical protocol. The doctors who practise with Umbrella Aged Care are independent general practitioners, and each makes their own clinical decisions with the resident and family. Your GP’s advice for an individual may differ from what is written here. If it does, please ask them to talk it through with you.