AGS Releases Consensus Statement on Vitamin D and Calcium

Falls are a significant cause of injury and death among older adults in long-term care facilities. More than half of nursing home residents fall at least once in any given year, with as many as 6% sustaining fractures, according to the Centers for Disease Control and Prevention. All told, roughly 1,800 nursing home residents aged 65 years and older die of complications due to fall-related injuries yearly.¹

Insufficient intake of vitamin D, as well as calcium, are leading contributors to falls and potentially debilitating and fatal fractures. Vitamin D plays a key role in calcium absorption and in maintaining healthy bone density and physical function. Consequently, low vitamin D levels are associated with muscle weakness, loss of bone strength and density, and both falls and fractures.

Increased vitamin D intake and adequate calcium, however, can significantly reduce the incidence of these fractures, notes an important new consensus statement from the American Geriatrics Society (AGS). An abridged version of the statement is published in the January issue of the Journal of the American Geriatrics Society, and the full consensus statement is available at the AGS products portal, www.GeriatricsCareOnline.org.

“The goal of the consensus statement is to help primary healthcare providers help older patients—both those living in communities and those in long-term care—get adequate vitamin D from all available sources,” says James Judge, MD, Chair of the AGS Consensus Statement on Vitamin D Supplementation for Older Adults Work Group. “The statement is based on up-to-date, high-quality research and incorporates the review and comments of multiple medical organizations.”

The work group’s report concludes that older people should have sufficient vitamin D intake from all sources—diet, sunlight, and supplements—to establish older adults’ vitamin D levels of 30 ng/mL or 75 nmol/L. These levels, research shows, are associated with reduced risks of falls-related injuries.

With the exception of “fatty fish,” such as salmon, and milk and other drinks and foods fortified with vitamin D, there are relatively few dietary sources of this important nutrient. And while skin can produce vitamin D when exposed to sunlight, this ability declines significantly with age, while risk of skin cancer due to sun exposure remains. For these reasons, supplemental vitamin D is particularly important in later life, the consensus statement notes.

“The bottom line is that this is a terrific guideline,” says Barbara Resnick, PhD, CRNP, past president of the AGS who has conducted research on exercise interventions for older adults that are designed to reduce risks of fractures due to falls and other causes. “It provides useful information for healthcare providers, making them feel comfortable making vitamin D recommendations that clearly offer more benefit that harm.”

The AGS’ consensus statement recommends that clinicians take the following steps to ensure that their older patients get adequate vitamin D supplementation:

1.    Review older patients’ vitamin D intake from all sources (diet, sunlight exposure, and supplements) and discuss strategies to achieve a total vitamin D input of 4000 international units daily (IU/day), which will achieve recommended vitamin D levels in 90% of patients, and will assure that all patients will minimize their risks of falls and fall-related injuries—without toxicity. Note: The statement notes that lower dose supplementation (1000 IU daily) will achieve recommended vitamin D levels in about half of all older adults, and that substantially higher doses are needed to achieve recommended levels in 90% of patients.

2.    Talk to older patients (and their caregivers, if needed) about how to ensure that they get adequate vitamin D and calcium supplementation. Note: There is insufficient data to support a recommendation for increased vitamin D supplementation without calcium for older people. In most studies, calcium doses range between 500 and 1200 mg daily.

3.    Discuss different vitamin D and calcium supplementation schedules with older adults and their caregivers, and help them choose the one they are most likely to follow. For example, vitamin D supplements can be formulated so they can be taken daily, weekly, or monthly, and there are different combinations of calcium and vitamin D supplements available.

“When developing these recommendations we took into consideration that the depth of the evidence in this area will expand over the next 5 to 10 years,” notes Michael Gloth, MD, and Douglas Kiel, MD, members of the work group. “In the meantime, it’s important that in the next 3 to 5 years, the oldest adults who are at the highest risk for falls and related injuries gain the benefits of sufficient vitamin D supplementation.” u

A Word of Caution to Long-Term Care Providers…

In addition to ensuring that older adults get sufficient vitamin D and calcium, clinicians and other long-term care staff should make sure that residents are not taking medications that might increase their risks of falls, notes Barbara Resnick, PhD, CRNP, who suggests that clinicians consult the AGS Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults to lower risks of medication-related falls when prescribing. Facility staff should also encourage residents to get regular exercise, under close supervision, to further lower their risks of falling and suffering fractures.

Reference

1. Falls in nursing homes. Centers for Disease Control and Prevention Website. Updated February 29, 2012. Accessed January 9, 2014.