A randomised, double-blind, placebo-controlled trial assessing the effect of zoledronic acid on osteopenia in 2000 women aged 65 years and older over a 6-year treatment period has revealed a statistically significant reduction of fracture incidence. Although the treatment effect seen in this study may have been somewhat overestimated due to selection, the implications for clinical practice could be considerable, as half of all women aged over 65 years are osteopenic and most fractures in the general population occur in this group. However, treatment with zoledronic acid is relatively expensive and the impact on health care costs of treating all older women with osteopenia would be dramatic. Additionally, the decision to treat should be based primarily on fracture risk, which is not only dependent on bone density, but also on other factors such as genetic susceptibility, risk of falling and previous fracture. Zoledronic acid should be reserved for osteopenic women who have an evidently high fracture risk due to these other factors.