Supplements in falls patients Dr Nick John Deepak Jadon (SHO) Older People’s Unit October 2007.
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Transcript of Supplements in falls patients Dr Nick John Deepak Jadon (SHO) Older People’s Unit October 2007.
Supplements in falls patients
Dr Nick JohnDeepak Jadon (SHO)
Older People’s Unit
October 2007
Overview
Background Objective Standards Methods Results Conclusion Recommendations Discussion
Background - Osteoporosis
Progressive skeletal disease characterised by low bone mass micro-architectural deterioration
Resulting in ↑ bone fragility ↑ susceptibility to fracture
2 types of osteoporosis
1. Involutional / senile ↓ cortical & trabecular bone
2. Post-menopausal & steroid-induced ↓ trabecular bone mainly
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
It is possible to target 3 groups – though there is often much overlap
1. at risk of osteoporosis
2. at risk of falling
3. at risk of fragility fractures
The Audit
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 management
Royal College of Physicians
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
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
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
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
Results - The sample
Total admissions 296
No discharge summary 27
Patients analysed 259
Female
Male
Reason for admission
197 (76%)
62 (24%)
Incident fall
Other
Reason for admission
21 (24%)
41
17 (9%)
180
0
50
100
150
200
Incident Fall Other
No previous falls
Previous falls
Use of supplements
18
3 (14%)30
11 (27%)
12
5 (29%)
0
10
20
30
40
50
IF + prev falls
IF + noprev fall
other + prev fall
No supplementSupplement
Incident fall group (previous fall & no previous fall)
4
115
21
PalliativeSevere DyspepsiaDeclinedNo contraindicationNo notesNo fall
Compliance with guidelines in incident falls group
2 (3% )5 (8% )
55 (89% )
On supplement if appropriateNon-compliant with guidelinesNo Notes
Other group (non-incident fall gp, but with previous fall)
1
1
1
1
1
No CIxHypercalcaemiaToo grittyNo notesNo fall
Non-incident (‘other’) fall group compliance with guidelines
1 (5%)
17 (90%)
1 (5% )
On supplement if appropriateNon-compliant with guidelineNo notes
Overall compliance with guidelines
6 (7%)
76 (93%)
Compliant
Non-compliant
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
↑ 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
Pharmacological agents
Choice of supplement
85%
15%
Calcichew D3 Forte
Adcal D3 forte
Choice of bone protecting agent
12%
6%
82%
2%
AledronateRisedronateStrontium ranealateNone
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
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)
Intervention Bone mineral Vertebral Hipdensity fracture fracture
Exercise A B BCalcium + vit D A B BDietary calcium B B BSmoking cessation B B BReduced alcohol C C BOestrogen A B BRaloxifene A A –Etidronate A – –Alendronate A – –
Preventive approaches[meta-analysis by RCP 2001]
Intervention Bone mineral Vertebral Hipdensity fracture fracture
Calcium + vit D A A BOestrogen A A BAlendronate A A AEtidronate A A BCalcitonin A A BFluoride A A –Anabolic steroids A – BCalcitriol A A C
Treatment approaches [meta-analysis by RCP 2001]
Older men with osteoporosis
Study results are conflicting Calcium & vitamin D supplementation may
be useful Grade C
Dietary Sources
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
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
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
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)
Thank you for listening !
Any questions?