Vitamin D status and falls and fractures in elderly : An evidence based review

Dr Y Premchandra *

Aged persons enjoying a local sports meet in the outskirts of Imphal :: Pix - Hueiyen Lanpao

The elderly population is comprised of men and woman who are 60 years old or over. This population suffers from a high incidence of falls and the study goes on to report that 32% has experienced a fall in the last 12 months and that 19% had suffered from fractures as a result of the fall. Factors such as old age, female gender and recent diagnosis of osteoporosis were said to be contributing factors to fall frequency.

Family history, sun exposure, intake of dairy products and vitamin D intake are identified as additional clinical risk factors. It is highlighted by Binkley in 2010 that vitamin D can be obtained from the skin when 7-dehydrocholesterol is converted to vitamin D3 (cholecalciferol) by ultraviolet B radiation or by oral vitamin D2 (ergocalciferol) and D3. The 25-hydroxyvitamin D levels in the blood stream provide an accurate determination of vitamin D. A daily intake of 1000 IU or more of vitamin D is recommended for optimal health.

Vitamin D Status in Elderly : Trémezaygues (2010) identifies that although Vitamin D deficiency affects persons of all ages, elderly population is at more risk as they have limited outdoor activities, less exposure to the sunlight as well as their aging skin become less efficient to synthesize vitamin D.

Many international studies looked at the status of vitamin D levels in elderly. Hirani and Primatesta (2005) made a national survey in England and found the prevalence of vitamin D deficiency among persons aged over 65 years living in institutions as 30.2% in men and 32.5% in women. In Germany a study by Hintzpeter and Reichrath (2008) found that 75% of elderly women aged between 65 and 79 years had a level below 20 ng/ml.

According to Nakamura (2006) the prevalence of vitamin D insufficiency in Japan was up to 50% in inactive elderly people than in active elderly people. In Canada Rucker et al (2002) observed vitamin D deficiency in 34% of elderly Calgary residents. Jakobsen (2013) found very high prevalence of vitamin D deficiency among elderly in Greenland. It is established that at least 20% senior in USA are vitamin D deficient. It has been agreed about the following levels of 25(OH) D (Holick, 2009 Table: 1)

Table 1: level of 25(OH) D and its significance
Less than 20 ng/ml indicate vitamin D deficiency
21-29 ng/ml indicate vitamin D insufficiency
30–100 ng/ml indicate sufficient vitamin D

Screening and replacement of Vitamin D : Endocrine society guidelines (2011) states that Vitamin D screening should be restricted to patient at high risk for deficiency which would include patients with osteoporosis, those with malabsorption, patients taking medicine interfering with vit d metabolism and with chronic kidney disease. Adults who are vitamin D deficient or insufficient should be treated with 50,000 IU of vitamin D2( d3) weekly for 8 weeks with a goal of achieving 25( OH )D level of 30 ng/ ml or above.

Falls and fractures in elderly, Prevalence and Risk factors:

Alexander BH (1992) gives the distribution of history of fall among elderly people over 60 years and shows that, out of the total sample population, 51.5% subjects had fallen. Fracture was reported in 21.3%, and other injuries occurred in 79.6% of those who had fallen. The most common were fractures of the spine, hip, forearm, leg, ankle, pelvis, upper arm, and hand. Fractures among females (26.4%) were reported more frequently than males (16%) and fracture was seen more in urban subjects (29.4%) than in rural subjects (13.4%). Hausdroff (2001) says that one out of three adults age 65 and older falls each year in which falls are the leading cause of injury and death.

They are also the most common cause of nonfatal injuries and hospital admissions for trauma. Falls and fractures are more common in females (2:1). Most fractures among older adults are caused by falls. Hornbrook (1994) states that men are 34% more likely than women to die from a fall. In 2009, about 20,400 older adults died from unintentional fall injuries.

In 2010, 2.3 million nonfatal fall injuries among older adults were treated in emergency departments and more than 662,000 of these patients were hospitalized. Stevens (2006) gives that in 2010, the direct medical cost of falls, adjusted for inflation, was $30.0 billion. The death rates from falls among older men and women have risen sharply over the past decade (WISQARS 2010). White and non-hispanics have higher fall rates than blacks and Hispanics respectively. (Vellas 1997)

Table 2: Risk factors for falls and causes of vertigo

Risk factors for falls
* Lower limb weakness
* Postural hypotension
* History of falls
* Polypharmacy i.e. > 4 drugs
* Gait/balance problem
* Cognitive impairment
* Visual impairment
* Incontinence
* Arthritis of lower limb joints
* Age over 65

Causes of vertigo

* Benign positional vertigo
* Ménière’s disease
* Viral labyrinthitis
* Brainstem stroke

Anderson (2008) gives causes of falls. Of the medical conditions predisposing to falls, (table 2) musculoskeletal problems rank first, followed by visual defect, neurological illness, syncope, vestibular causes, vertigo, hypertension, postural hypotension (table 4) and dementia. Drug induced falls (table 3) were commonly associated with sedatives and hypnotics usage. The sedentary group fell more frequently than exercising group due to lack of stability.

Campbell (1995) identifies fall as an event caused by age associated diseases like Parkinson’s disease, cognitive decline and musculoskeletal problems in association with physiological changes like impairment of sensory system, impairment of righting reflex and decrease in lean body mass. The incidence of falls increases with advancing age.

Johnson (2006) & Joshi K (2003) studied Indian population and found hip fracture associated with falls as one of the leading causes of death in elderly. The morbidity due to falls included serious injuries and fractures, restricted mobility and loss of independence leading to functional decline, psychological fear of falling (post fall syndrome) and permanent disability.

Table 3: Drugs linked to falls by causing postural hypotension or leading to sedation / confusion
* Nitrates Benzodiazepines
* Codeine-based analgesics
* ACE inhibitors
* L-Dopa
* Antipsychotics, e.g. haloperidol
* Anticonvulsants
* Diuretics
* Anti-platelet agents
* Opiates * Digoxin
* Anticholinergics
* Antidepressants, (TCA & SSRIs)

Hausdorff (2001) study reports, 35% had at least one fall in the preceding year. Although the overall ratio of female fallers to male fallers was 2.7:1, this ratio approached unity with advancing age. Schuffam (2003) reports that falls impose a substantial burden on health and social service. Mobility was significantly impaired in those reporting falls (Blake 1988).

Table 4: Common causes of postural hypotension
* Drugs
* Prolonged bed rest following illness
* Dehydration
* Carotid sinus disease
* Anaemia
* Autonomic failure
* Sepsis
* Adrenal insufficiency
* Alcohol

The elderCranney et al (2007) carried out a comprehensive study of association of health outcomes with different Vitamin D levels in multiple RCTs on prevention of falls and/or fractures in elderly adults. The study showed that there was fair evidence that 1) vitamin D level was inversely proportional to falls, 2) Positive association with BMD was present and 3) there was inconsistent evidence for an association with fractures. They noted that Vitamin D assay imprecision led to different thresholds for different events.

Broe (2007) concluded that there is a dose response effect on serum vitamin D levels with dose of > 400 IU daily vs 400 IU daily. In 2 trials on fractures primarily in elderly institutionalized women, benefit was present at vitamin D doses of 700 – 800 IU/d and calcium 500 – 1200 mg/d. They pointed out poor compliance with vitamin D supplementation, incomplete assessment of vitamin D status and large losses to follow – up as limitations.

Effects of vitamin D and calcium could not be separated. Burleigh (2007) noted Vitamin D > 700 IU/d with calcium supplementation had a small beneficial effect on BMD and reduced the risk of fractures and falls, only in specific subgroups. No harmful effect was noted with these doses.

A meta-analysis was performed including 11 double-blind RCTs of oral vitamin D supplementation at all doses in persons 65 years or older. The vitamin D doses were divided into quartiles and the data analyzed according to these. It was found that at the highest intake level of vitamin D – average of 800 IU/d – there was a 30 % reduction in risk of hip fracture and a 14 % reduction in the risk of any non-vertebral fracture. This benefit was seen irrespective of age group, type of dwelling, baseline vitamin D levels and additional calcium supplementation. (Bischoff-Ferrari, 2012)

Conclusion:

The rationale behind vitamin D supplementation in elderly population in order to prevent fractures and falls is discussed here. Falls in elderly people and falls related outcomes like fractures allows a very marked increase in the morbidity and mortality in this high risk group. Majority of the international data over the last decade including the data presented in this review demonstrates the beneficial effects of calcium and vitamin D supplementation in the over 65 years of age.

Evidence indicates that supplementation with calcium and vitamin D improves muscle strength, functional ability, bone density and walking distance which leads to fewer fractures and falls respectively in frail and homebound elderly people. Furthermore, Yaffe et al (1999) supported the hypothesis of improvement in the cognitive function, especially attention, with vitamin D supplementation.

To conclude supplementation with vitamin D and calcium in elderly population with vitamin D deficiency improves muscle performance, bone strength and lower risk of falling and fractures, increases BMD. However, evidence to suggest improvement in muscle strength and decrease incidence of falls and fracture in elderly population with normal levels of vitamin D does not exist.