Trends in mortality with osteoporosis recorded as the underlying cause of death among adults aged 65 years and older in the United States, 1999–2024

Objective Osteoporosis coded as the underlying cause of death increases mortality risk in older adults. This study aimed to examine temporal trends and demographic disparities in mortality with osteoporosis as the underlying cause of death among U.S. adults aged 65 years and older from 1999 to 2024, and to identify recent mortality plateauing patterns. Methods A population-based retrospective ecological analysis was performed using the CDC WONDER national mortality database. All eligible decedents were restricted to adults ≥65 years with ICD-10 M80/M81 recorded as the underlying cause of death. Mortality counts, age-adjusted mortality rates (AAMR), crude mortality rates (CMR for age subgroups), and average annual percent change (AAPC) with 95% confidence intervals (CIs) were stratified by sex, census region, race/ethnicity, urbanization (limited to 1999–2020), and age group. Annual cells with death counts <10 were suppressed and excluded from continuous trend plotting. Joinpoint regression with pairwise AAPC Z -tests was applied to quantify and compare subgroup trends. Results Total deaths with osteoporosis as the underlying cause decreased from 1,622 in 1999 to 484 in 2024 (−70.16%). The overall AAMR declined from 4.78 (95% CI: 4.54–5.01) to 0.92 (95% CI: 0.84–1.00), with an overall AAPC of −6.26 (95% CI: −7.37–−5.14; P < 0.05). Statistically significant full-period downward AAPCs were observed across all demographic subgroups. However, segmented APC 95% CIs crossed zero in recent years for most groups, indicating widespread mortality plateauing after long-term decline. Formal pairwise comparisons confirmed faster annual mortality reduction in Southern census regions and metropolitan areas. For Hispanic adults aged ≥65 years, annual osteoporosis-related death counts were consistently less than 10 from 1999 to 2024, resulting in massive suppressed annual data that cannot support a continuous trend curve, though valid aggregate cross-sectional mortality metrics for this subgroup are fully available. Females, individuals aged ≥85 years, and nonmetropolitan residents sustained higher mortality burden. Conclusions Mortality with osteoporosis documented as the underlying cause of death presented a significant overall downward trend among U.S. adults aged 65 and older over 1999–2024, yet most subgroups exhibited plateauing mortality in recent calendar years. Continuous annual trend visualization for Hispanic populations is unfeasible due to CDC WONDER privacy suppression rules that hide records with fewer than 10 annual deaths, while complete aggregate summary statistics for Hispanic participants are reported. Females, the oldest-old population, and rural residents carried persistent excess mortality burden. These stratified nationwide epidemiological findings support targeted bone health public interventions for high-risk elderly subgroups