The global prevalence of osteoporotic fractures and the socioeconomic burden is increasing with aging of the population. Frailty, sarcopenia, malnutrition and a propensity to falls are contributing to osteoporotic fractures in old age with an estimated 750 000 fragility fractures per year in Germany. Despite this increasing number of fractures, osteoporosis remains underdiagnosed and undertreated in the geriatric population. In order to estimate fracture risk in elderly patients, it is important to combine bone mineral density measurement by dual-energy X-ray absorptiometry (DXA) with a problem-oriented geriatric assessment. This includes evaluation of muscle strength, walking speed, nutritional status, risk of falls, as well as cognitive function. Since age per se is the dominant fracture risk factor in women over 70 and men over 80, it is possible to omit DXA measurement in this age group, especially after an incident fragility fracture. The cornerstones of an effective fall and fracture prevention include a targeted training of strength, endurance, coordination and balance in addition to a healthy and active lifestyle. Because of the high prevalence of calcium and/or vitamin D deficiency in old age, close monitoring and appropriate substitution are essential in the management of osteoporosis in the elderly. Anti-osteoporotic drugs are effective and well tolerated in the geriatric population and should be initiated to prevent fractures in high risk cohorts and for secondary prevention. Recently, coordinator-based fracture liaison services have been shown to effectively reduce fracture risk in the high risk geriatric population.