Aging and bone health in individuals with developmental disabilities

Health Problems and Disabilities Among the Postmenopausal Saudi Women in Bisha City Receiving Home Care: A Descriptive Cross-Sectional Study

BACKGROUND

Postmenopausal women experience physical and psychological changes that may affect their health status. In Saudi Arabia, where the population of postmenopausal women is increasing, there is a need to examine the health problems and disabilities experienced by this group, particularly those who receive home care. This study aims to identify the common health problems and disabilities experienced by postmenopausal Saudi women in Bisha city who receive home care services.

METHODS

A cross-sectional study in Bisha city, Saudi Arabia, involved 155 postmenopausal women (age 60 years and above) receiving home care services. Data were collected using structured interviews and medical records.

RESULTS

The study found that the most common health problems among postmenopausal women receiving home care were cardiovascular diseases in 85 women (54.84%), diabetes in 85 women (54.84%), and musculoskeletal disorders in 56 women (36.13%). There was a significant association between the number of health problems and disabilities, indicating that women with more health problems were more likely to experience disabilities (p-value ≤ 0.05). The results showed that age (OR=1.56, 95% CI 1.23-1.99, p=0.001), chronic diseases (OR=2.34, 95% CI 1.43-3.84, p=0.001), and lower education level (OR=1.45, 95% CI 1.01-2.08, p=0.045) were significantly associated with the presence of health problems and disabilities among postmenopausal Saudi women receiving home care in Bisha city. However, marital status and employment status were not found to be significant predictors.

CONCLUSION

Postmenopausal women in Bisha city who receive home care services experience a range of health problems and disabilities, particularly related to hypertension, diabetes, and musculoskeletal disorders. The findings of this study can help healthcare providers develop effective interventions and strategies to improve the health outcomes of this population.

Medicine use in people with intellectual disabilities: a Finnish nationwide register study

BACKGROUND

People with intellectual disability (ID) are a vulnerable group in our society; many of them depend on other people for assistance in their everyday lives. Compared with the general population, people with ID have poorer general health and, therefore, need more healthcare services and use more medicines. The aim of this study is to define the population of all Finnish people with ID using administrative data and to compare their medicine use and expenditure on medicines to those of the age-matched and sex-matched controls.

METHODS

People with ID and their age-matched and sex-matched controls (1:1) were extracted from nationwide healthcare and social allowance registers. Administrative register data on all prescription medicine purchases in 2019 were used to determine the prevalence of medicine use in both groups on a general level and by medicine categories. The differences in the prevalence of medicine use between the two groups were analysed using the logistic regression model. In addition, we studied the total expenditure on reimbursable medicine purchases covered by the National Health Insurance between people with ID and control group.

RESULTS

The subpopulation of people with ID consisted 37 196 individuals, of whom 82.7% purchased prescription medicines in 2019. The corresponding share of individuals purchasing prescription medicines in the control group was 70.3%. The differences in the prevalence of medicine use between the two populations were highest in the younger age groups (0-6, 7-12 and 13-17). In the study population, 28.1% (OR = 12.28; 95% CI: 11.54-13.07) of the people used antipsychotics, making it the most used medicine category in people with ID. In the control group, 3.3% of people used antipsychotics. Compared with the control group, the use of antiepileptics, drugs for constipation, mineral supplements and anxiolytics was four to seven times higher among people with ID. Furthermore, the median expenditure on medicine use among people with ID was four times higher than in the control group.

CONCLUSIONS

Compared with the control group, people with ID used more medicines, especially psychotropics, and their expenditure on medicine use was higher.

Incidence of fractures in people with intellectual disabilities over the life course: a retrospective matched cohort study

BACKGROUND

Current osteoporosis guidelines do not identify individuals with intellectual disabilities (ID) as at risk of fracture, potentially missing opportunities for prevention. We aimed to assess the incidence of fractures in people with ID over the life course.

METHODS

Descriptive analysis of open cohort study using anonymised electronic health records from the UK Clinical Practice Research Datalink, linked to the Hospital Episode Statistics database (Jan 1, 1998-Dec 31, 2017). All individuals with ID were matched on age and sex to five individuals without ID.  We calculated the incidence rate (95% CI) per 10000 person-years (py) and incidence rate ratio (IRR, 95% CI) to compare fractures between individuals with and without ID (age 1-17 and ≥18 years) for any fracture, and in those aged 18-49 and ≥ 50 years for major osteoporotic fracture (vertebra, shoulder, wrist, hip), and for hip fracture.

FINDINGS

43176 individuals with ID (15470 children aged 1-17 years; 27706 adults aged ≥ 18 years) were identified and included (40.4% females) along with 215733 matched control individuals.  The median age at study entry was 24 (10th-90th centiles 3-54) years. Over a median (10th-90th centile) follow-up of 7.1 (0.9-17.6) and 6.5 (0.8-17.6) years, there were 5941 and 24363 incident fractures in the ID and non ID groups respectively. Incidence of any fracture was 143.5 (131.8-156.3) vs 120.7 (115.4-126.4)/10000 py (children), 174.2 (166.4-182.4)/10000 py vs 118.2 (115.3-121.2)/10000 py (adults) in females. In males it was 192.5 (182.4-203.2) vs 228.5 (223.0-234.1)/10000 py (children), 155.6 (149.3-162.1)/10000 py vs 128.4 (125.9-131.0)/10000 py (adults). IRR for major osteoporotic fracture was 1.81 (1.50-2.18) age 18-49 years, 1.69 (1.53-1.87) age ≥ 50 years in women. In men it was 1.56 (1.36-1.79) age 18-49 years, 2.45 (2.13-2.81) age ≥ 50 years. IRR for hip fracture was 7.79 (4.14-14.65) age 18-49 years, 2.28 (1.91-2.71) age ≥ 50 years in women. In men it was 6.04 (4.18-8.73) age 18-49 years, 3.91 (3.17-4.82) age ≥ 50 years. Comparable rates of major osteoporotic fracture and of hip fracture occurred approximately 15 and 20 years earlier respectively in women and 20 and 30 years earlier respectively in men with ID than without ID. Fracture distribution differed profoundly, hip fracture 9.9% vs 5.0% of any fracture in adults with ID vs without ID.

INTERPRETATION

The incidence, type, and distribution of fractures in people with intellectual disabilities suggest early onset osteoporosis. Prevention and management strategies are urgently required, particularly to reduce the incidence of hip fracture.

FUNDING

National Institute for Health and Care Research.

Prevalence and incidence of physical health conditions in people with intellectual disability - a systematic review

OBJECTIVE

To synthesize evidence on the prevalence and incidence of physical health conditions in people with intellectual disability (ID).

METHODS

We searched Medline, PsycInfo, and Embase for eligible studies and extracted the prevalence, incidence, and risk of physical health conditions in people with ID.

RESULTS

Of 131 eligible studies, we synthesized results from 77 moderate- to high-quality studies, which was mainly limited to high-income countries. The highest prevalence estimates were observed for epilepsy, ear and eye disorders, cerebral palsy, obesity, osteoporosis, congenital heart defects, and thyroid disorders. Some conditions were more common in people with a genetic syndrome. Compared with the general population, many health conditions occur more frequently among people with ID, including asthma and diabetes, while some conditions such as non-congenital circulatory diseases and solid cancers occur at the same or lower rate. The latter associations may reflect under-detection.

CONCLUSIONS

People with ID have a health profile more complex than previously known. There is a pressing need for targeted, evidence-informed population health initiatives including preventative programs for this population.

Oral bisphosphonates for osteoporosis in adult males with intellectual disabilities

INTRODUCTION

Oral bisphosphonates are first-line agents for treating osteoporosis in men, but there are no studies regarding efficacy of oral bisphosphonates for treatment of osteoporosis in ambulatory male adults with intellectual disability.

METHODS

Nine adult males with intellectual disability and increased fracture risk had been treated with weekly or monthly oral bisphosphonates, vitamin D and calcium for 1-3 years. Post-treatment bone mineral density (BMD), serum 25(OH)D, parathyroid hormone and C-telopeptide of type I collagen were then determined for the first time.

RESULTS

Weekly or monthly oral bisphosphonates were well tolerated and led to significant increases in BMD in all 9 individuals. Serum 25(OH)D level enhanced the "pecent increase of BMD" that occurred in response to bisphosphonate treatment (p < .05).

CONCLUSIONS

Weekly or monthly oral bisphosphonates are well tolerated by ambulatory adult males with ID and are effective in increasing BMD. Higher serum levels of vitamin D appear to improve the efficacy of bisphosphonates and therefore reduce fracture risk in adult males with intellectual disability.

Low Rates of Preventive Healthcare Service Utilization Among Adolescents and Adults With Down Syndrome

INTRODUCTION

People with Down syndrome have health risks that require specific lifelong preventive health care. With increasing life expectancy, people with Down syndrome also face health conditions typical of their unaffected peers and thus need coordinated health care. The purpose of this study is to describe rates of age/sex- and Down syndrome-specific preventive healthcare activities among adolescents and adults with Down syndrome.

METHODS

Using Medicaid claims (2006-2010) in California, Colorado, Michigan, and Pennsylvania, the cohort was defined as people with Down syndrome aged ≥12 years seen by primary care providers and enrolled in Medicaid for ≥45 of 60 months without dual Medicare enrollment (n=3,501). Age focus-consistent primary care providers were defined as having a focus concordant with a patient's age: 12-17 years, child or mixed-focus; ≥26 years, adult or mixed-focus; 18-25 years, any focus. Differences in healthcare activities were evaluated using Pearson's chi-square, Fisher's exact, and Kruskal-Wallis tests. Analyses were performed in 2015-2017.

RESULTS

Of the cohort, 79% had an age focus-consistent primary care provider. However, 40% of adults aged ≥26 years received care from a child-focused primary care provider. Only 43% with an age focus-consistent provider had ≥1 well examination (age focus-inconsistent primary care provider: 35%, p<0.001). Most preventive activities had poor rates (<50%) regardless of age focus consistency between provider and patient age or whether they were age/sex- or Down syndrome-specific (well examinations; vaccinations; sleep apnea; hearing; and breast, cervical, and colon cancer screenings). Lipids, vision, and thyroid screenings reached moderate levels (50% to <80%).

CONCLUSIONS

Rates of age/sex- and Down syndrome-specific preventive recommendations were low among adolescents and adults with Down syndrome, regardless of the age focus consistency of their primary care provider. This represents a significant opportunity to improve primary care in this vulnerable population.

Quantitative examination of the bone health status of older adults with intellectual and developmental disability in Ireland: a cross-sectional nationwide study

OBJECTIVES

(1) To investigate the prevalence of osteopenia and osteoporosis among adults with intellectual disabilities (IDs) and (2) to examine alternative optimal bone screening techniques.

DESIGN

Observational cross-sectional study.

SETTING

Wave 2 (2013-2106) of the Intellectual Disability Supplement to the Irish Longitudinal Study on Ageing.

PARTICIPANTS

A national representative sample of 604 male and female persons with ID aged 43 years and over. In total, 575 participants completed quantitative ultrasound (QUS) measurements for one or both feet.

OUTCOME MEASURES

Participants underwent health assessments consisting of eight objective health measures including the standardised QUS of the calcaneus bone using a GE Lunar Achilles. A preinterview questionnaire and face-to-face interview were also completed.

RESULTS

Objectively QUS identified poorer rates of bone health in people with ID overall with 74% indicating evidence of osteopenia (33.2%) or osteoporosis (41%). Females scored lower than males in the QUS t-scores -2.208 (±1.77) versus -1.78(±1.734). Bone status was stratified by gender (p=0.114), age (p=0.003), level of ID (p<0.0001) and living circumstance (p<0.0001).

CONCLUSIONS

This study has shown the prevalence of poor bone health in people with ID is substantial implying an increased risk of fracture due to reduced skeletal integrity. QUS screening has been shown to be useful when combined with clinical risk factors.

Bone quality in young adults with intellectual disability involved in adapted competitive football

The objective of this study was to analyse bone quality parameters of football players with intellectual disability (ID) participating in adapted competitive football. Sixty-seven male football players with ID were studied: 22 with Down syndrome (DS) and 45 without DS. The average age was 26 years (range: 16 ̶ 50 years). A group of 25 age-matched sedentary individuals with ID (11 DS and 14 non-DS) and another group of 20 healthy participants of the same age group not involved in competitive football were comparatively analysed. There were no differences in the bone quality parameters when the healthy sedentary individuals were compared with both the sedentary and the football players with ID. However, the speed of sound (SOS), T-score, and estimated bone mineral density (BMD) were of higher values in the football players with ID than in the sedentary ID group (p < 0.05). On comparing the football players with non-DS ID with the sedentary non-DS individuals, significant differences were noted in SOS (p < 0.01), T-scores (p < 0.01), and estimated BMD (p < 0.01). Four of the 45 non-DS (8.9%) and none of the football players with DS had T-scores less than -1.5. Two of the 14 sedentary non-DS participants (14.3%) had T-scores indicating osteoporosis. In summary, the ID population actively involved in football showed higher values of bone mass parameters than their sedentary ID and healthy peers. The participants with non-DS ID showed a higher prevalence of osteoporosis than the football players with DS. Participation in sports seems to prevent bone loss in individuals with ID.

Soins primaires aux adultes ayant des déficiences intellectuelles et développementales

Objectif

Mettre à jour les Lignes directrices consensuelles canadiennes 2011 en matière de soins primaires aux adultes ayant une déficience développementale.

Méthodes

Des médecins de famille et d’autres professionnels de la santé expérimentés dans les soins aux personnes ayant des DID ont examiné et synthétisé les récentes connaissances empiriques, d’écosystèmes, expertes et expérientielles. Un système a été conçu pour catégoriser la qualité des recommandations.

Recommandations

Les adultes ayant des DID sont un groupe hétérogène de patients qui présentent des affections médicales et des facteurs qui influent sur leur santé, qui diffèrent de ceux qui touchent les autres membres de la communauté de par leur nature, leurs manifestations, leur gravité ou leur complexité. Ces personnes nécessitent une approche de soins et des interventions adaptées à leurs besoins. Les présentes lignes directrices offrent des conseils en matière de normes de soins. Nous avons incorporé des références à des outils cliniques et à d’autres ressources pratiques. Les approches de soins décrites ici s’appliquent aussi à d’autres groupes de patients ayant un déficit cognitif ou de la communication, ou d’autres déficits des fonctions adaptatives.

Conclusion

À titre de fournisseurs de soins de première ligne, les médecins de famille jouent un rôle vital de promotion de la santé et de bien-être auprès des adultes ayant des DID. Ces lignes directrices peuvent les aider à prendre des décisions avec les patients et les aidants naturels.

Primary care of adults with intellectual and developmental disabilities: 2018 Canadian consensus guidelines

OBJECTIVE

To update the 2011 Canadian guidelines for primary care of adults with intellectual and developmental disabilities (IDD).

METHODS

Family physicians and other health professionals experienced in the care of people with IDD reviewed and synthesized recent empirical, ecosystem, expert, and experiential knowledge. A system was developed to grade the strength of recommendations.

RECOMMENDATIONS

Adults with IDD are a heterogeneous group of patients and have health conditions and factors affecting their health that can vary in kind, manifestation, severity, or complexity from those of others in the community. They require approaches to care and interventions that are adapted to their needs. These guidelines provide advice regarding standards of care. References to clinical tools and other practical resources are incorporated. The approaches to care that are outlined here can be applied to other groups of patients that have impairments in cognitive, communicative, or other adaptive functioning.

CONCLUSION

As primary care providers, family physicians play a vital role in promoting the health and well-being of adults with IDD. These guidelines can aid their decision making with patients and caregivers.

Low bone mineral density risk factors and testing patterns in institutionalized adults with intellectual and developmental disabilities

BACKGROUND

Adults with intellectual or developmental disability (ID/DD) have multiple risks for low bone mineral density (BMD) without formal guidelines to guide testing. We sought to identify risk factors and patterns of BMD testing among institutionalized adults with ID/DD.

METHODS

We evaluated risk factors for low BMD (Z-/T-score < -1) and patterns of BMD testing among adults with ID/DD receiving care at a state-run residential facility. Kruskal-Wallis, Fisher's exact and Pearson's chi-squared tests were used as appropriate.

RESULTS

Of the 140 eligible patients, only 44% ever had BMD testing of which 89% had low BMD. Median age at diagnosis was 42 years old. Individuals with low BMD were more likely to be older, non-weight bearing, Caucasian and have severe cognitive delay.

CONCLUSIONS

Adults with ID/DD in this facility had a high prevalence of low BMD. Further studies are needed to better characterize risk factors and inform screening within this high-risk population.

An exploration of the bone health of older adults with an intellectual disability in Ireland

BACKGROUND

Many risk factors have been confirmed for poor bone health among the general population including age, gender and corticosteroid use. There is a paucity of investigation among people with intellectual disability; however, research points to differing risks namely anti-epileptic medication use, Down syndrome and poor behaviour lifestyle.

METHODS

Data was extracted from the Intellectual Disability Supplement to the Irish Longitudinal Study on Ageing in Ireland. In total, 753 participants took part, and data was gathered on participants' health status, behavioural health, health screenings and activities of daily living. The prevalence of osteoporosis and related risk factors were specifically examined.

RESULTS

Overall, 8.1% reported a doctor's diagnosis of osteoporosis with over 20% reporting history of fracture. Risk identified included older age (P < 0.0001), female gender (P < 0.0001), difficulty walking (P < 0.0001) with older age and being female the stronger predictors for osteoporosis, odds ratio = 6.53; 95% confidence interval 2.82-15.11 and odds ratio = 4.58; 95% confidence interval 2.29-9.17, respectively. There was no gender difference regarding the level of fractures; however, epilepsy and anti-epileptic medication were strong predictors. Overall, 11.1% attended for bone screening diagnostics.

CONCLUSION

Despite low levels of reported doctor's diagnosis of osteoporosis risk factor prevalence was high. Considering the insidious nature of osteoporosis and the low levels of diagnostic screening, prevalence could be possibly higher.

Association of Protein Intake with Bone Mineral Density and Bone Mineral Content among Elderly Women: The OSTPRE Fracture Prevention Study

It has been hypothesized that high protein intakes are associated with lower bone mineral content (BMC). Previous studies yield conflicting results and thus far no studies have undertaken the interaction of body mass index (BMI) and physical activity with protein intakes in relation to BMC and bone mineral density (BMD).

OBJECTIVE

To evaluate the associations of dietary total protein (TP), animal protein (AP) and plant protein (PP) intakes with BMC and BMD and their changes. We tested also the interactions of protein intake with, obesity (BMI ≤30 vs. >30 kg/m2) and physical activity level (passive vs. active). Design/ Setting: Prospective cohort study (Osteoporosis Risk-Factor and Fracture-Prevention Study). Participants/measures: At the baseline, 554 women aged 65-72 years filled out a 3-day food record and a questionnaire covering data on lifestyle, physical activity, diseases, and medications. Intervention group received calcium 1000 mg/d and cholecalciferol 800 IU for 3 years. Control group received neither supplementation nor placebo. Bone density was measured at baseline and year 3, using dual energy x-ray absorptiometry. Multivariable regression analyses were conducted to examine the associations between protein intake and BMD and BMC.

RESULTS

In cross-sectional analyses energy-adjusted TP (P≤0·029) and AP (P≤0·045) but not PP (g/d) were negatively associated with femoral neck (FN) BMD and BMC. Women with TP≥1·2 g/kg/body weight (BW) (Ptrend≤0·009) had lower FN, lumbar spine (LS) and total BMD and BMC. In follow-up analysis, TP (g/kg/BW) was inversely associated with LS BMD and LS BMC. The detrimental associations were stronger in women with BMI<30 kg/m2. In active women, TP (g/kg/BW) was positively associated with LS BMD and FN BMC changes.

CONCLUSIONS

This study suggests detrimental associations between protein intake and bone health. However, these negative associations maybe counteracted by BMI>30 kg/m2 and physical activity.

Emphasizing the health benefits of vitamin D for those with neurodevelopmental disorders and intellectual disabilities

People with neurodevelopmental disorders and intellectual disabilities have much greater health care needs. Mainly staying indoors, such people generally have low 25-hydroxyvitamin D (25(OH)D) concentrations. The Vitamin D Task Force of the American Academy of Developmental Medicine and Dentistry (AADMD) reviewed the evidence of 25(OH)D concentrations that benefit the health of persons with developmental disabilities. Maintaining recommended optimal serum 25(OH)D concentrations year long will benefit skeletal development in infants, children, and adolescents, and benefit musculoskeletal health and neuromuscular coordination in adult patients, and decrease risk of falls. Maintaining optimal concentrations decreases risks and severities of autoimmune diseases, cardiovascular disease, many types of cancer, dementia, types 1 and 2 diabetes mellitus, and respiratory tract infections. Other benefits include improved dental and oral health and improved physical performance. The Task Force recommends that 25(OH)D concentrations for optimal health to be in the range of 75 to 125 nmol/L, which can be achieved using between 800 and 4000 IU/day vitamin D3 and sensible exposure to solar UVB radiation. The paper also discusses the potential risks of higher 25(OH)D concentrations, the evidence from and limitations of randomized controlled trials, and the recommendations by various groups and agencies.

The scope of pediatric physical therapy practice in health promotion and fitness for youth with disabilities

PURPOSE

The purpose of this report is to discuss the scope of pediatric physical therapy practice in health promotion and fitness for youth with disabilities.

SUMMARY OF KEY POINTS

Evidence is provided that supports integration of health promotion and fitness strategies in physical therapy clinical management. Physical therapists' roles in community-based adapted sports and fitness interventions and reimbursement considerations are discussed.

CONCLUSIONS

Physical therapists are in a unique position to provide expertise in the design and implementation of health promotion and fitness programs for youth with disabilities. These programs are important to promote active, healthy lifestyles and reduce comorbidities associated with sedentary behaviors and unhealthy weight, which are often seen in youth with disabilities.

RECOMMENDATIONS FOR CLINICAL PRACTICE

Pediatric physical therapists should incorporate health promotion and fitness strategies into practice.

Adaptation of the lateral distal femur DXA scan technique to adults with disabilities

The technique that best addresses the challenges of assessing bone mineral density in children with neuromuscular impairments is a dual-energy X-ray absorptiometry (DXA) scan of the lateral distal femur. The purpose of this study was to adapt this technique to adults with neuromuscular impairments and to assess the reproducibility of these measurements. Thirty-one adults with cerebral palsy had both distal femurs scanned twice, with the subject removed and then repositioned between each scan (62 distal femurs, 124 scans). Each scan was independently analyzed twice by 3 different technologists of varying experience with DXA (744 analyses). Precision of duplicate analyses of the same scan was good (range: 0.4%-2.3%) and depended on both the specific region of interest and the experience of the technologist. Precision was reduced when comparing duplicate scans, ranging from 7% in the metaphyseal (cancellous) region to 2.5% in the diaphyseal (cortical) region. The least significant change was determined as recommended by the International Society for Clinical Densitometry for each technologist and each region of interest. Obtaining reliable, reproducible, and clinically relevant assessments of bone mineral density in adults with neuromuscular impairments can be challenging. The technique of obtaining DXA scans of the lateral distal femur can be successfully applied to this population but requires a commitment to developing the necessary expertise.

Three non-ambulatory adults with multiple disabilities exercise foot-leg movements through microswitch-aided programs

This study assessed the use of microswitch-aided programs to help three non-ambulatory adults with multiple disabilities exercise foot-leg responses. Those responses served to activate a largely neglected part of the participants' body, with possibly positive physical implications (e.g., for blood circulation, swelling, and muscle strength). Intervention focused on the left and right foot-leg response, separately. Eventually, sessions with one response were alternated with sessions with the other response. Responses were monitored via microswitches and followed by 8s of preferred stimulation (e.g., music and vibrotactile stimulation), which was automatically delivered. The results showed that all three participants had high levels of foot-leg responses during the intervention phases and a 3-week post-intervention check. The participants also displayed expressions of positive involvement during those study periods (i.e., engaged in behaviors, such as music-related head movements, smiles, or touching the vibratory devices) that could be interpreted as forms of interest/pleasure and happiness. These results are in line with previous findings in this area and can be taken as an important confirmation of the strength and dependability of the approach in motivating non-ambulatory persons with multiple disabilities to engage in foot-leg movements. The practical implications of these findings are discussed.

Age-related changes in trabecular and cortical bone microstructure

The elderly population has substantially increased worldwide. Aging is a complex process, and the effects of aging are myriad and insidious, leading to progressive deterioration of various organs, including the skeleton. Age-related bone loss and resultant osteoporosis in the elderly population increase the risk for fractures and morbidity. Osteoporosis is one of the most common conditions associated with aging, and age is an independent risk factor for osteoporotic fractures. With the development of noninvasive imaging techniques such as computed tomography (CT), micro-CT, and high resolution peripheral quantitative CT (HR-pQCT), imaging of the bone architecture provides important information about age-related changes in bone microstructure and estimates of bone strength. In the past two decades, studies of human specimens using imaging techniques have revealed decreased bone strength in older adults compared with younger adults. The present paper addresses recently studied age-related changes in trabecular and cortical bone microstructure based primarily on HR-pQCT and micro-CT. We specifically focus on the three-dimensional microstructure of the vertebrae, femoral neck, and distal radius, which are common osteoporotic fracture sites.