Falls prevention for older people: vitamin D, calcium or both?
ABSTRACT Falls and fall-related fractures increase with age and affect skeletal and muscle health negatively. Insufficient vitamin D and calcium intake is a contributing factor to fall-related fractures in older people (aged ≥65 years). The use of vitamin D and calcium supplements by the general public has increased, especially among older people in nursing homes, under long-term care, or with prolonged hospitalisation. However, there is controversy regarding the actual clinical benefits of taking vitamin D with and without calcium. This article reviews the current evidence on the use of vitamin D supplements with and without calcium in older people, as a means of reducing falls and related fractures.
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ABSTRACT: Vitamin D supplements have been used to prevent fractures. The effect may be mediated through increased bone mass, but also through reduced falling propensity. The aim of this study was to evaluate the association between 25-hydroxy vitamin D levels (25OHD), fall-associated variables (including tests of functional performance), and fracture in ambulatory women. At baseline 25OHD was measured in 986 women. Fall-associated variables were investigated at baseline. Fractures were recorded during a 3-year follow-up. Four percent of the women had 25OHD levels below 20 ng/ml (50 nmol/l), and 26% had 25OHD levels below 30 ng/ml (75 nmol/l). 25OHD correlated with gait speed (r =0.17, P <0.001), the Romberg balance test (r =0.14, P <0.001), self-estimated activity level (r =0.15, P <0.001), and thigh muscle strength (r =0.08, P =0.02). During the 3-year follow-up, 119 out of the 986 women sustained at least one fracture. The Cox proportional hazard ratio (HR) (95% confidence interval) for sustaining a fracture during the follow-up was 2.04 (1.04-4.04) for the group of women with 25OHD below 20 ng/ml, in which 9 out of 43 women sustained a fracture. Thirty-two of the 256 women with 25OHD levels below 30 ng/ml sustained a fracture during the follow-up, with a non-significant HR of 1.07 (1.07-1.61). This cohort of elderly, ambulatory women had a high mean 25OHD. A low 25OHD was associated with inferior physical activity level, gait speed and balance. A 25OHD level below 30 ng/ml was not associated with an increased risk of fractures in this study. However, a subgroup of women with 25OHD levels below 20 ng/ml had a tendency to an increased risk of fractures, which may be associated with an inferior physical activity and postural stability.Osteoporosis International 11/2005; 16(11):1425-31. · 4.04 Impact Factor
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ABSTRACT: Vitamin D deficiency is common among older people and can cause mineralization defects, bone loss, and muscle weakness. The aim of this study was to investigate the association of serum 25-hydroxyvitamin D (25-OHD) concentration with current physical performance and its decline over 3 yr among elderly. The study consisted of a cross-sectional and longitudinal design (3-yr follow-up) within the Longitudinal Aging Study Amsterdam. An age- and sex-stratified random sample of the Dutch older population was used. Subjects included 1234 men and women (aged 65 yr and older) for cross-sectional analysis and 979 (79%) persons for longitudinal analysis. Physical performance (sum score of the walking test, chair stands, and tandem stand) and decline in physical performance were measured. Serum 25-OHD was associated with physical performance after adjustment for age, gender, chronic diseases, degree of urbanization, body mass index, and alcohol consumption. Compared with individuals with serum 25-OHD levels above 30 ng/ml, physical performance was poorer in participants with serum 25-OHD less than 10 ng/ml [regression coefficient (B) = -1.69; 95% confidence interval (CI) = -2.28; -1.10], and with serum 25-OHD of 10-20 ng/ml (B = -0.46; 95% CI = -0.90; -0.03). After adjustment for confounding variables, participants with 25-OHD less than 10 ng/ml and 25-OHD between 10 and 20 ng/ml had significantly higher odds ratios (OR) for 3-yr decline in physical performance (OR = 2.21; 95% CI = 1.00-4.87; and OR = 2.01; 95% CI = 1.06-3.81), compared with participants with 25-OHD of at least 30 ng/ml. The results were consistent for each individual performance test. Serum 25-OHD concentrations below 20 ng/ml are associated with poorer physical performance and a greater decline in physical performance in older men and women. Because almost 50% of the population had serum 25-OHD below 20 ng/ml, public health strategies should be aimed at this group.Journal of Clinical Endocrinology & Metabolism 07/2007; 92(6):2058-65. · 6.43 Impact Factor
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ABSTRACT: Our objective was to determine international estimates of the economic burden of falls in older people living in the community. Our systematic review emphasized the need for a consensus on methodology for cost of falls studies to enable more accurate comparisons and subgroup-specific estimates among different countries. The purpose of this study was to determine international estimates of the economic burden of falls in older people living in the community. This is a systematic review of peer-reviewed journal articles reporting estimates for the cost of falls in people aged > or =60 years living in the community. We searched for papers published between 1945 and December 2008 in MEDLINE, PUBMED, EMBASE, CINAHL, Cochrane Collaboration, and NHS EED databases that identified cost of falls in older adults. We extracted the cost of falls in the reported currency and converted them to US dollars at 2008 prices, cost items measured, perspective, time horizon, and sensitivity analysis. We assessed the quality of the studies using a selection of questions from Drummond's checklist. Seventeen studies met our inclusion criteria. Studies varied with respect to viewpoint of the analysis, definition of falls, identification of important and relevant cost items, and time horizon. Only two studies reported a sensitivity analysis and only four studies identified the viewpoint of their economic analysis. In the USA, non-fatal and fatal falls cost US $23.3 billion (2008 prices) annually and US $1.6 billion in the UK. The economic cost of falls is likely greater than policy makers appreciate. The mean cost of falls was dependent on the denominator used and ranged from US $3,476 per faller to US $10,749 per injurious fall and US $26,483 per fall requiring hospitalization. A consensus on methodology for cost of falls studies would enable more accurate comparisons and subgroup-specific estimates among different countries.Osteoporosis International 02/2010; 21(8):1295-306. · 4.04 Impact Factor
Asian J Gerontol Geriatr 2011; 6: 107–9
Asian Journal of Gerontology & Geriatrics Vol 6 No 2 December 2011
Falls prevention for older people:
vitamin D, calcium or both?
J Kotecha1,2,3, MPA, PhD Candidate, L Leung2,3 MBBChir, MFM(Clin), FRACGP, FRCGP
1 School of Rehabilitation Therapy, Queen’s University, Kingston, Ontario, Canada
2 Centre of Studies in Primary Care, Queen’s University, Kingston, Ontario, Canada
3 Department of Family Medicine, Queen’s University, Kingston, Ontario, Canada
Correspondence to: Dr Lawrence Leung, Centre of Studies in Primary Care, Queen’s University, 220 Bagot Street, Kingston, Ontario, K7L 5E9,
Canada. E-mail: firstname.lastname@example.org
Key words: Accidental falls; Aged; Calcium; Vitamin D
56%6 of falls in older people lead to fractures; 26%
of those who sustained hip fractures die within 12
months.8 A viscous cycle ensues when a fall leads
to fear of falling and reduction in physical activity,
which in turn contributes to decline in health and
vulnerability to future falls.9,10
FALLS PREVENTION STRATEGIES
Falls prevention strategies include regular physical
activity,11 environmental adaptations minimising
home hazards (e.g. hand rails, uncluttered
surroundings, etc),12 improved nutrition and vitamin
D and/or calcium supplements to enhance bone
and muscle health. The best preventive approach
is interdisciplinary,13 with emphasis on regular
exercise,14 which is often deficient in older people.15,16
VITAMIN D FOR BONE AND MUSCLE
Vitamin D is fat soluble and synthesised from
cholesterol. It exists in 2 forms: ergocalciferol
(D2) and cholecalciferol (D3). D2 is produced by
conversion of dietary provitamin D via ultraviolet
radiation through the skin, whereas D3 comes from
food and conversion via ultraviolet radiation. Vitamin
D regulates calcium and phosphate metabolism
through intestinal absorption, mediated through
the enzyme 25-hydroxyvitamin D-1α-hydroxylase
(CYP27B1) found in kidney tubules.17 An extra
autocrine/paracrine function of vitamin D can affect
cell differentiation and proliferation, which maintains
bone health and prevents osteoporosis (Figure).17
Vitamin D is crucial for normal functioning of the
muscle18 and nervous system.19 Deficiency of vitamin
Falls and fall-related fractures increase with age
and affect skeletal and muscle health negatively.1,2
Insufficient vitamin D and calcium intake is a
contributing factor to fall-related fractures in older
people (aged ≥65 years). The use of vitamin D and
calcium supplements by the general public has
increased, especially among older people in nursing
homes, under long-term care, or with prolonged
hospitalisation. However, there is controversy
regarding the actual clinical benefits of taking
vitamin D with and without calcium. This article
reviews the current evidence on the use of vitamin
D supplements with and without calcium in older
people, as a means of reducing falls and related
FALLS IN OLDER PEOPLE
Falls in older people are caused by intrinsic (medical
conditions, impaired vision and hearing, age-related
changes, and risk-taking behaviours) and extrinsic
(medications, improper use of assistive devices, and
environment [e.g. poor lighting, uneven surfaces,
bulky furniture, etc]) factors acting alone or in
combination. In Canada, persons aged over 65 years
account for 40% of all injury-related hospitalisations;
85% of such hospitalisations were caused by falls.3
The mean cost of falls in older people escalated
abruptly from US$3476 per fall without injury to
US$10 749 with injury and to US$26 483 needing
hospitalisation.4 The incidence of falls in older people
has been reported to be 30% in the USA,4 46% in
Spain,5 and 89% among villagers in Warsaw.6 5%7 to
108 Asian Journal of Gerontology & Geriatrics Vol 6 No 2 December 2011
Kotecha and Leung
D is linked to myopathy, rickets in children, and
osteomalacia in adults.20-22 Older people are more
predisposed to vitamin D deficiency,22 which can
be as a result of low dietary intake, reduced sun
exposure, and impaired conversion mechanism in
BENEFITS OF VITAMIN D
In community older people, decreased levels of
serum hydroxyl vitamin D is associated with muscle
weakness, which leads to poor balance and gait,
predisposing to increased falls and fractures.1,20,23
Vitamin D also has a role in neuromuscular or
neuroprotective function.24 In a randomised, double-
blind placebo-controlled trial,24 a single intramuscular
injection of 600 000 IU ergocalciferol significantly
improves aggregate functional performance time
in the following 6 months, compared to placebo
injection. Vitamin D supplementation improves
neuromuscular or neuroprotective function and thus
reduces falls and fractures. In a meta-analysis with a
total of 1237 subjects, vitamin D supplementation in
the older people reduced the likelihood of falling by
22% (corrected odds ratio [OR], 0.78; 95% confidence
interval [CI], 0.64-0.92), compared to patients
receiving calcium or placebo.25 The calculated
number needed to treat was 15 (95% CI, 8-53), i.e. 15
subjects need to be treated with vitamin D to prevent
one fall. In another meta-analysis,26 daily intake
of 200 to 1000 IU of vitamin D reduces falls in the
older people by 14%, compared to calcium alone or
placebo (relative risk [RR], 0.86; 95% CI, 0.79-0.93).
BENEFITS OF VITAMIN D WITH
Calcium is the essential component for bones.
Addition of vitamin D to calcium is beneficial in
reduction of the risk of falls and or related fractures
in older people.27,28 A single intervention with
vitamin D plus calcium over a 3-month period
reduces the risk of falling by 49%, compared to
calcium alone.27 However, other studies reported
much smaller or no effects on falls and fracture
reduction following treatment with vitamin D in
combination with calcium.28-32 In a pooled analysis,
no benefit from treatment with Vitamin D alone in
preventing fractures was found,32 but when given
with calcium, the combination reduced hip and total
fractures, irrespective of age, gender or history of
fractures. Nonetheless, this analysis targeted women
at high risk for hip fracture and not the general
older population. The mean age group in the pooled
analysis was 69.9 years.
NEITHER VITAMIN D NOR CALCIUM
The best strategies for falls and fracture prevention
in the older people should include regular physical
activities, environmental adaptations, good nutrition,
Figure. Vitamin D pathway to bone and muscle health
Vitamin D through dietary intake,
supplements, and ultraviolet exposure
Intermediate outcomes: bone mass
density and prevention of bone loss
Other outcomes: beneficial effects on
muscles and nerves
Clinical outcomes related to low serum
25 hydroxy vitamin D levels: fractures
from falls, rickets, and osteoporosis
Serum 25 hydroxy vitamin D
sun, body mass
Asian Journal of Gerontology & Geriatrics Vol 6 No 2 December 2011
Falls prevention for older people
nutritional education, and intake of vitamin D and/
or calcium supplements. Consensus on the major
contributors to reducing falls and fractures in the
older people is lacking, be it vitamin D alone or in
combination with calcium, regular physical activity,
or change in dietary habits.
The role of vitamin D and calcium in maintaining
bone and muscle health remains undisputed. Older
people are predisposed to vitamin D deficiency. A
multi-factorial prevention strategy (calcium and/
or vitamin D supplementation, adequate exercises,
and good nutrition) is preferred. Current evidence is
still inconclusive regarding the efficacy of vitamin D
alone or in combination with calcium. More rigorous
double-blind, randomised, placebo-controlled trials
with multiple arms are needed.
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between 25-hydroxy vitamin D levels, physical activity, muscle
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