Supplements in falls patients

Dr Nick JohnDeepak Jadon (SHO)

Older People’s Unit

October 2007

Overview

Background Objective Standards Methods Results Conclusion Recommendations Discussion

Background - Osteoporosis

Progressive skeletal disease characterised by low bone mass micro-architectural deterioration

Resulting in ↑ bone fragility ↑ susceptibility to fracture

2 types of osteoporosis

1. Involutional / senile ↓ cortical & trabecular bone

2. Post-menopausal & steroid-induced ↓ trabecular bone mainly

Fracture burden

>50y presenting with fragility # have a ↑ incidence of osteoporosis

Fragility # = fracture from standing height / less– These patients are readily identifiable & should be prioritised for treatment

Osteoporotic # affects 1:2 women and 1:5 men >50y – 1/3 of adult women will sustain >1 osteoporotic # in their lifetime– Patients with previous # are x 2 - 8 more likely to have a # at any skeletal site– 1/3 have a hip # by age of 80y

Hip fracture patients– 50% no longer able to live independently – 20% die within 6 months – 25 % require long term care

5y mortality after hip / vertebral # is 20% greater than expected

Cost– 200,000 fractures each year – £1 – 1.9 billion

Targeting therapy

It is possible to target 3 groups – though there is often much overlap

1. at risk of osteoporosis

2. at risk of falling

3. at risk of fragility fractures

The Audit

Standards

RCP working party report 2001 suggests – consideration of Calcium + Vit D supplementation in patients

with– Incident / prevalent falls– Housebound with limited sun exposure– Poor mobility– Potential for malnutrition– Frail

VERY MUCH THE COHORT ON OPU !

Working Party Reports 2001. Osteoporosis. Clinical guidelines for prevention and treatmentUpdate on pharmacological interventions and an algorithm for management

Royal College of Physicians

Scottish guidelines

Treating frail housebound patients with Calcium & Vit D can – ↓ hip # by 35% – ↓ non-vertebral # by 26%

Calcium 1 – 1.2 g + 800 iu Vit D (per day)

Not necessary to measure [Vit D] before Tx

Scottish Intercollegiate Guidelines Network. Management of Osteoporosis. A National Clinical Guideline. No. 71.

Objectives

To ensure that all geriatric patients – with a history of falls – are on bone protective agents – in the form of Calcium & Vitamin D – to reduce the incidence of future osteoporotic

fragility fractures

Methodology

Retrospective audit Patients admitted to Victoria Ward 6 months (1st February - 31st July 2007) Admitted under Acute Geriatric intake via

A&E MAU

Analysis of discharge summaries Case notes if more elaboration needed

Methodology – Key parameters

Age & Gender Reason for admission

– Incident fall– Other (CP, SOB, confusion, CVA etc.)

History of previous falls (Prevalent fall) Calcium / Vit D prescribed on discharge

– Agent– Dose

If not prescribed, reason– Intolerant (severe dyspepsia)– Palliative– Hypercalcaemia– Declined– No contraindication

Concurrent use of bisphosphonate– Agent– Dose

Results - The sample

Total admissions 296

No discharge summary 27

Patients analysed 259

Female

Male

Reason for admission

197 (76%)

62 (24%)

Incident fall

Other

Reason for admission

21 (24%)

41

17 (9%)

180

0

50

100

150

200

Incident Fall Other

No previous falls

Previous falls

Use of supplements

18

3 (14%)30

11 (27%)

12

5 (29%)

0

10

20

30

40

50

IF + prev falls

IF + noprev fall

other + prev fall

No supplementSupplement

Incident fall group (previous fall & no previous fall)

4

115

21

PalliativeSevere DyspepsiaDeclinedNo contraindicationNo notesNo fall

Compliance with guidelines in incident falls group

2 (3% )5 (8% )

55 (89% )

On supplement if appropriateNon-compliant with guidelinesNo Notes

Other group (non-incident fall gp, but with previous fall)

1

1

1

1

1

No CIxHypercalcaemiaToo grittyNo notesNo fall

Non-incident (‘other’) fall group compliance with guidelines

1 (5%)

17 (90%)

1 (5% )

On supplement if appropriateNon-compliant with guidelineNo notes

Overall compliance with guidelines

6 (7%)

76 (93%)

Compliant

Non-compliant

Conclusion

93% compliance with guidelines is excellent ! But always room for improvement

We are excellent at targeting incident fallers– As it jogs our memory

Need to keep this issue at forefront of mind in those presenting with other complaints

– Asking ‘Have you ever had a fall before?’ takes a few secs

Suggested recommendations

↑ awareness amongst allied health professionals Implementation of ‘Falls Passport’

“All older people presenting with an injurious fall should be offered a multifactorial risk assessment” - NICE guidance 2005 -

– Currently used in ED– Assesses

Hx of falls Preciptating factors Exacerbating factors Vulnerability

– Triages further referral & investigation– Formally documents this assessment

Re-audit in 1year

Pharmacological agents

Choice of supplement

85%

15%

Calcichew D3 Forte

Adcal D3 forte

Choice of bone protecting agent

12%

6%

82%

2%

AledronateRisedronateStrontium ranealateNone

NICE committee recommendations

Elderly population can’t be assumed to have an adequate dietary intake of calcium & vit D

Normal serum concentrations of calcium & vitamin D are needed to ensure optimum effects of the treatments for osteoporosis

Thus calcium + vitamin D prescribed unless clinicians are confident that levels are normal

Evidence for Calcium & Vit D supplementation

Reviewed in the 2001 RCP Osteoporosis Guidelines Guidelines unclear if the benefits of Tx due to

– vitamin D– calcium – combination of both

Calcium 1g/day – ↓ bone loss in women with osteoporosis (level Ia)– ↓ the risk of vertebral fracture (leveI Ib)– effects on hip fracture are less certain (Level II)

Vitamin D 800 iu/day– ↓ hip & other # in the institutionalised frail elderly (level Ib)– beneficial effects in the general community have not been demonstrated.

Vitamin D & calcium in elderly female patients – saves great resources & low marginal costs– is recommended that these individuals be offered such treatment (grade A)

Intervention Bone mineral Vertebral Hipdensity fracture fracture

Exercise A B BCalcium + vit D A B BDietary calcium B B BSmoking cessation B B BReduced alcohol C C BOestrogen A B BRaloxifene A A –Etidronate A – –Alendronate A – –

Preventive approaches[meta-analysis by RCP 2001]

Intervention Bone mineral Vertebral Hipdensity fracture fracture

Calcium + vit D A A BOestrogen A A BAlendronate A A AEtidronate A A BCalcitonin A A BFluoride A A –Anabolic steroids A – BCalcitriol A A C

Treatment approaches [meta-analysis by RCP 2001]

Older men with osteoporosis

Study results are conflicting Calcium & vitamin D supplementation may

be useful Grade C

Dietary Sources

Dietary Calcium

Intake of calcium is essential – throughout life – childhood & adolescence when bone most actively formed

Groups where calcium intake may be ↓– Adolescents

Skeletal length & density changes considerably Dieting teenage girls

– Sports people ↓ calcium intake is well documented among

– women athletes – sports where weight is important eg. jockeys, rowers, boxers, ballet dancers, gymnasts etc

– Vegans Soya milk (fortified with calcium & B12) good alternative to cows milk

– Malabsorption IBD, coeliacs & lactose intolerants = reduction in nutrient intake / calcium absorption

Dietary Vit D

Consider supplementation of vitamin D Older people

– Ageing ↓ the permeability of skin to sunlight, ↑the reliance on foods– Supplements are particularly recommended if

ill housebound resident in institution

Care Home. – WARNING: fish oil supplements are a rich source of vit D – avoid overdose

Pureed diets Ethnic attire

– Sunlight is the most important source of vitamin D. – In UK, sunlight most effective between approximately the April – Oct

Predictors of Vit D deficiency

A British study of 467 patients In 129 patients with hypovitaminosis D

– normal ALP 76%, – normal calcium 90%– normal phosphate 95%

In the 50 patients with the most severe hypovitaminosis D– 66% vegetarian / vegan– 72% clothing partially / completely occlusive of sunlight – 60% went outdoors < 5 times / week

Conclusion routine measurement of ALP, calcium & phosphate

– is of no use in predicting hypovitaminosis D risk factors for vitamin D deficiency

– Good predictors of hypovitaminosis D[ASSESSMENT OF VITAMIN D DEFICIENCY: USEFULNESS OF RISK FACTORS, SYMPTOMS AND ROUTINE BIOCHEMICAL TESTS GR Smith1, PO Collinson2, PDW Kiely]

Falls assessment

Reducing the impact of falls

Using external hip protectors incorporated into specially designed underwear

1yr Danish study randomised 665 elderly NH residents external hip protectors controls (no hip protector)

Result– 50% reduction in hip # in hip protectors group. – Problems

bulky uncomfortable

(Lauritzen et al 1993)

Thank you for listening !

Any questions?