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Supplements in falls patients. Dr Nick John Deepak Jadon (SHO) Older People’s Unit October 2007. Overview. Background Objective Standards Methods Results Conclusion Recommendations Discussion. Background - Osteoporosis. Progressive skeletal disease characterised by

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Supplements in falls patients

Supplements in falls patients

Dr Nick John

Deepak Jadon (SHO)

Older People’s Unit

October 2007


Overview
Overview

  • Background

  • Objective

  • Standards

  • Methods

  • Results

  • Conclusion

  • Recommendations

  • Discussion


Background osteoporosis
Background - Osteoporosis

Progressive skeletal disease characterised by

  • low bone mass

  • micro-architectural deterioration

    Resulting in

  • ↑ bone fragility

  • ↑ susceptibility to fracture


2 types of osteoporosis
2 types of osteoporosis

  • Involutional / senile

    • ↓ cortical & trabecular bone

  • Post-menopausal & steroid-induced

    • ↓ trabecular bone mainly


  • Fracture burden
    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
    Targeting therapy

    It is possible to target 3 groups

    • though there is often much overlap

  • at risk of osteoporosis

  • at risk of falling

  • at risk of fragility fractures



  • Standards
    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 managementRoyal College of Physicians


    Scottish guidelines
    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
    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
    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
    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






  • Incident fall group previous fall no previous fall
    Incident fall group (previous fall & no previous fall)



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




    Conclusion
    Conclusion guidelines

    • 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
    Suggested recommendations guidelines

    • ↑ 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





  • Nice committee recommendations
    NICE committee recommendations guidelines

    • 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
    Evidence for Calcium & Vit D supplementation guidelines

    • 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)


  • Preventive approaches guidelines

    [meta-analysis by RCP 2001]

    Intervention Bone mineral Vertebral Hip

    density fracture fracture

    Exercise A B B

    Calcium + vit D A B B

    Dietary calcium B B B

    Smoking cessation B B B

    Reduced alcohol C C B

    Oestrogen A B B

    Raloxifene A A –

    Etidronate A – –

    Alendronate A – –


    Treatment approaches guidelines

    [meta-analysis by RCP 2001]

    Intervention Bone mineral Vertebral Hip

    density fracture fracture

    Calcium + vit D A A B

    Oestrogen A A B

    Alendronate A A A

    Etidronate A A B

    Calcitonin A A B

    Fluoride A A –

    Anabolic steroids A – B

    Calcitriol A A C


    Older men with osteoporosis
    Older men with osteoporosis guidelines

    • Study results are conflicting

    • Calcium & vitamin D supplementation may be useful

    • Grade C


    Dietary sources

    Dietary Sources guidelines


    Dietary calcium
    Dietary Calcium guidelines

    • 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
    Dietary Vit D guidelines

    • 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
    Predictors of Vit D deficiency guidelines

    • 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

    Falls assessment guidelines


    Reducing the impact of falls
    Reducing the impact of falls guidelines

    • 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

    Thank you for listening ! guidelines

    Any questions?


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