Supplements in falls patients

1. Supplements in falls patients Dr Nick John Deepak Jadon (SHO) Older People’s Unit October 2007

2. Overview • Background • Objective • Standards • Methods • Results • Conclusion • Recommendations • Discussion

3. Background - Osteoporosis Progressive skeletal disease characterised by • low bone mass • micro-architectural deterioration Resulting in • ↑ bone fragility • ↑ susceptibility to fracture

5. 2 types of osteoporosis • Involutional / senile • ↓ cortical & trabecular bone • Post-menopausal & steroid-induced • ↓ trabecular bone mainly

9. 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

10. 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

11. The Audit

12. 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

14. 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.

15. 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

16. 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

17. 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

18. Results - The sample

19. Reason for admission

20. Reason for admission

21. Use of supplements

22. Incident fall group (previous fall & no previous fall)

23. Compliance with guidelines in incident falls group

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

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

26. Overall compliance with guidelines

27. 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

28. 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

29. Pharmacological agents

30. Choice of supplement

31. Choice of bone protecting agent

32. 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

33. 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)

34. 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 – –

35. 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

36. Older men with osteoporosis • Study results are conflicting • Calcium & vitamin D supplementation may be useful • Grade C

38. Dietary Sources

39. 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

40. 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

42. 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]

43. Falls assessment

46. 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)

47. Thank you for listening ! Any questions?