Senior Vit-D Final and Falls

8/22/2019 Senior Vit-D Final and Falls

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The role of Vitamin D andCalcium in preventing falls in

the older population

John SeniorCNC Clinical Practice

Auburn Hospital


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Guidebook forPreventing Falls

and Harm FromFalls in OlderPeople: AustralianHospitals(short version; in the fullversion it is section 18)

Section 5.2

Vitamin D andCalciumsupplementation


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This lady typifies manypeople's conception of oldshe is

in pain,

unsteady on her feetshorter and kyphotichas multiple chronichealth care problems

Image on www.beat-menopause-weight-gain.com


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The aim of this talkis to challenge

perceptions showinghow, through agreaterunderstanding of our

environment,nutrition andlifestyle changes wecan improve ourwellbeing.


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Objectives:

To understand why vitaminD and calcium deficiencyare important Public

Health issues

Discuss the recommendations specifiedin this guidebook
http://www.google.com/imgres?imgurl=http://jerseyshorecremation.com/Images/sun%20rays.jpg&imgrefurl=http://jerseyshorecremation.com/&usg=___qT_f3A0-1Kbc3C8nLDPlryJu_Y=&h=768&w=1024&sz=69&hl=en&start=50&zoom=1&itbs=1&tbnid=Ku9QUbwvpCZjtM:&tbnh=113&tbnw=150&pr


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25(OH)DIs the most accurate blood test to determine vitamin DstatusIs the main storage of vitamin D

Is a fat soluble pro-hormone that is essential for theproduction of 1,25(OH)2D3 (the activated form ofvitamin D)

Some definitions:

Vitamin D supplements come in two distinct forms, the

strength is usually given as International Units (IU)

Vitamin D2 (ergocalciferol) is synthesised from yeastVitamin D3 (cholecalciferol) is synthesised from lanolin


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Recommendations

Patient assessment

hospitalisation should be viewed as anopportunity to identify and address falls risk

factors, including adequacy of calcium andvitamin D.


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Recommendations

Intervention

Vitamin D and calcium supplementation shouldbe recommended as an intervention strategy

to prevent falls in older people

Benefits are most likely to be seen when25(OH)D is:

< 50 nmol/L (Insufficiency)< 25 nmol/L (Deficiency)


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Low vitamin D levels have been associated withreduced bone mineral density, high bone

turnover and increased risk of hip fracture.

It is unlikely that patient benefits from vitamin D and calciumsupplementation will be seen in hospital - but there is evidence tosupport dietary supplementation in the longer term


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Discharge Planning

Continuing careAny introduction of vitamin D and calciumsupplementation should be conveyed to thepersons general practitioner or healthprovider.

Patient education

Why they are taking vitamin D and orcalcium supplementation.Foods rich in calciumFoods that contain vitamin D


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5.2.1 Assessing vitamin D adequacy

vitamin D may prevent falls byimproving muscle strength andpsychomotor performance, independently

of any role in maintaining bone mineraldensity.


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Bone continually remodels itself through a process of breaking down(or resorption) by osteoclasts and rebuilding (or formation) byosteoblasts

NB: Calcium and vitamin D need to be replete in patients prior tocommencing osteoporosis treatment (eg bisphosphonates)

References:www.coe-stemcell.keio.ac.jp/member/matsuo.html

ACI. The Orthogeriatric Model of Care. Clinical Practice Guide 2010

PhysiologyrevisionBone remodeling

Bone resorptionby osteoclasts

Bone formation

by osteoblasts

SAP


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Low vitamin D slows the reformation of bone resulting inosteomalacia (lack of bone hardening) and/or

osteoporosis (loss of bone formation)

www.iofbonehealth.org/newsroom/resources/imag...

Normal bone matrix Osteoporotic bone


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Approximately 50% of persons 65 years and

older in North America and 66% of personsinternationally (all ages) failed to maintainhealthy bone density

Reference Cited Bordelon P. et al American Family Physician October2009

Separations from Australian hospitals 2005-6due to falls was 145,340

(Ref:http://www.aihw.gov.au/publications/index.cfm/title/10715)

Prevalence of osteoporosis


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Fall in ECFcalcium

Insufficientcalciumabsorption

IncreasedPTH

1,25(OH)2D3by synthesising more[from 25(OH)D] in the kidney

Absorptionof calcium inthe small intestine

i.e., Vitamin Denables calciumabsorption

Relationshipbetween calciumand vitamin D

Raised PTH is anindicator ofVitamin D

deficiency


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5.2.2 Ensure minimum sun exposure toprevent vitamin D deficiency

5 - 15 minutes exposure of the face and upperlimbs to sunlight four to six times a week, althoughdeliberate sunlight exposure between 10am and 3pmin the summer months for more than 15 minutes isnot advised

If this modest sunlightexposure is not possible, a

vitamin D supplement of atleast 800 IU per day isrecommended


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Why is vitamin D deficiency an issue forthe older adult?

As we age our skin looses its ability tosynthesize vitamin D

Elderly people may not like, or have theability, to receive adequate UVB radiation(ie sunlight)

Malnourishment is common in the elderly

Concern about developing skin cancers


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5.2.3 Assessing the need for vitaminD and calcium supplementation

For confirmed cases of vitamin Ddeficiency, supplementation with 3,000 -5,000 IU per day for at least a month isrequired to replenish body stores.

For most older adults in long-term care in

Australia, it is appropriate to supplementwith 1,000 IU vitamin D withoutmeasuring 25(OH)D


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Effect of dose and duration of vitamin D supplementation on the meanserum 25-hydroxyvitamin D [25(OH)D] concentration achieved

Ref: Lee, J. H. et al. J Am Coll Cardiol 2008;52:1949-1956

Response of Serum Vitamin D Levels toSupplementation

100 nmol/L

140 nmol/L

40 nmol/L


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5.2.4 Encourage patients to include high-calcium foods in their diet

Referral to a dietitian may be appropriate if a personis having trouble consuming adequate calcium, haslactose intolerance, does not include calcium as anormal part of their diet...

Recommendation for calcium800mg per day for men1,000mg per day for women

However, this level may be too low, with othersources recommending daily intake of 1,500mg forboth men and women.


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5.2.5 Discourage patients from consuming

foods that prevent calcium adsorption

Patients should be discouraged from consuming toomany foodstuffs that lower or prevent calcium

adsorption

caffeinesoft drinks containing phosphoric acid


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People at a higher risk of vitamin D deficiency:

People who spend most time indoors getting little sun

Have dark skin

Wear clothing that covers most of the body

Use sunscreen whenever they go outside

Elderly

Overweight

Take anticonvulsants


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Vitamin D deficiency is significantlymore common among people withdementia and people from culturally andlinguistically diverse groups

Furthermore, vitamin D deficiency hasbeen associated with osteoporosis,

cognitive decline and maculardegeneration


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...Vitamin D supplementation is effective inreducing the rate of falls in nursing carefacilities...

Reference: The Cochrane Collaboration 2010

Lets consider some of the reasons why this is so


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Maintenance of: BALANCE

25(OH)D receptors are present in skeletal muscle,

deficiency leads to:

Reference: Bordelon P. et al Recognition and Management of Vitamin D Deficiency.

American Family Physician volume 80, Issue 8 (October 2009)

Proximalmuscleweakness


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Because in the event of tripping or suddenmovement people with proximal muscle weakness

are not able to correct their sudden balancedisturbance


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Other musculoskeletal factors to

consider

The global bone discomfort and muscle

aches of vitamin D deficiency often leadto a misdiagnosis of:

Fibromyalgia

Chronic fatigue syndromeArthritis

Reference Cited Bordelon P. et al American Family Physician October 2009


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We have concentrated on the

musculskeletal aspects of vitamin D &calcium deficiency and falls in theolder adult now let us consider someother issues

Firstly cardiovascular effects


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Multivariate adjusted hazard ratios for major adverse CVevents

Ref: Lee, J. H. et al. J Am Coll Cardiol 2008;52:1949-1956

> 45nmol/L 25 -


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Reference: Dr. Samuel Badalian and Paula Rosenbaum Obstetrics andGynecology, April 2010

23% of American women (n=1,961) over 20 years old had apelvic floor disorder, often leading to urinary incontinence

Low vitamin D levels predicted pelvic floor disorders;urinary incontinence was twice as likely in vitamin D

deficient women

The authors concluded:Our findings suggest that treatment ofvitamin D insufficiency and deficiency inboth premenopausal and postmenopausalwomen could improve pelvic musclestrength, with a possible reduction in theprevalence of pelvic floor disorders,including urinary incontinence.


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Can excessive vitamin D be toxic?


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Adverse events from vitamin D3

plotted against 25(OH)D status anddaily intake


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Contraindications to vitamin Dsupplementation:

Granulomatous diseases (e.g.,tuberculosis)

Metastatic bone disease

Sarcoidosis

h h d h


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Intermittent high dose therapy, 2 studies

Among older community-dwelling women, annual oraladministration (500,000 IU) of high-dose cholecalciferolresulted in an increased risk of falls and fractures

Reference: Saunders et al Annual High-Dose Oral Vitamin D and Falls andFractures in Older Women. JAMA, May 12, 2010

A study in South Australia (Royal Adelaide Hospital) gave

elderly residents of aged care vitamin D3 every threemonths, there were no cases of toxicity. Concluded, VitaminD3 100,000 IU given orally 3 monthly is a practical, safe,effective and inexpensive way to meet the vitamin D3requirements of aged-care residents

Reference: Wigg A et al. A System for Improving Vitamin D Nutrition inResidential Care MJA 2006; 185(4): 195-198


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Suggested recommendations:

People identified as higher risk of vitamin Ddeficiency should have a baseline serum25(OH)D, the best time to test is in lateWinter or early Spring.

Hospitalisation of an older person providesan opportunity to screen for vitamin D

status as part of a comprehensive healthcare assessment.


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Thank you

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Senior Vit-D Final and Falls