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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
conclusion
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
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
nice committee recommendations
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
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)
slide34

Preventive approaches

[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 – –

slide35

Treatment approaches

[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
  • Study results are conflicting
  • Calcium & vitamin D supplementation may be useful
  • Grade C
dietary calcium
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
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
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]

reducing the impact of falls
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)

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