Osteoporosis is characterized by low bone mineral density and associated with low impact skeletal fractures most often involving the spine, hip, pelvis, proximal humerus and forearm. It is predominantly a disease of ageing, affecting primarily postmenopausal women, but also older men. Both hip and non-hip fractures are associated with excess mortality post-fracture. Fragility fractures can be acutely and subacutely life threatening for many older patients. Postmenopausal osteoporosis has a big impact on health care expenses, with associated spending expected to double for osteoporosis by the year 2050. Despite the severe medical and socioeconomic consequences of fragility fractures, treatment and prevention efforts remain inadequate, particularly in the oldest and highest-risk patients. Osteoporosis is still viewed as an inevitable consequence of aging, rather than an opportunity for treatment and prevention. Multiple factors contribute to the failure of initiating appropriate treatment for osteoporosis, even in patients with fragility fractures. Our review offers an overview of the current literature and offers answers common issues in the management of osteoporosis in older adults.