Supplements in falls patients

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Supplements in falls patients

• Dr Nick John
• Deepak Jadon (SHO)
• Older Peoples Unit
• October 2007

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Overview

• Background
• Objective
• Standards
• Methods
• Results
• Conclusion
• Recommendations
• Discussion

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Background - Osteoporosis

• Progressive skeletal disease characterised by
• low bone mass
• micro-architectural deterioration
• Resulting in
• ? bone fragility
• ? susceptibility to fracture

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2 types of osteoporosis

• Involutional / senile
• ? cortical trabecular bone
• Post-menopausal steroid-induced
• ? trabecular bone mainly

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Fracture burden

• gt50y 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 12 women and 15 men
  gt50y
• 1/3 of adult women will sustain gt1 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

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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

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The Audit
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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

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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.

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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

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Methodology

• Retrospective audit
• Patients admitted to Victoria Ward
• 6 months (1st February - 31st July 2007)
• Admitted under Acute Geriatric intake via
• AE
• MAU
• Analysis of discharge summaries
• Case notes if more elaboration needed

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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

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Results - The sample
Total admissions 296
No discharge summary 27
Patients analysed 259
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Reason for admission
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Reason for admission
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Use of supplements
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Incident fall group
(previous fall no previous fall)
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Compliance with guidelines in incident falls group
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Other group (non-incident
fall gp, but with previous fall)
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Non-incident (other) fall group compliance with
guidelines
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Overall compliance with guidelines
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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

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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

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Pharmacological agents
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Choice of supplement
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Choice of bone protecting agent
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NICE committee recommendations

• Elderly population cant 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

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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)

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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
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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
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Older men with osteoporosis

• Study results are conflicting
• Calcium vitamin D supplementation may be useful
• Grade C

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Dietary Sources
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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

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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

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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 lt 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

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Falls assessment
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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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Thank you for listening !

• Any questions?