All elderly patients should receive Calcium and Vitamin D

1. All elderly patients should receive Calcium and Vitamin D Latana Munang

2. Calcium Structure Bones & teeth Cell signalling Vasoconstriction & vasodilation Nerve impulse Muscle contraction Co-factor enzyme Coagulation cascade Vitamin D Calcium metabolism Cell differentiation Immune system modulator T Cells Macrophages Blood pressure regulation Function

3. Calcium homeostasis PTH ↑ Bone resorption Serum calcium Vitamin D ↑Calcium & phosphate absorption Vitamin D 25-hydroxylase 25 OH Vitamin D 1-α-hydroxylase 1,25 (OH)2 Vit D3 (active) 25 OH Vit D (inactive)

6. Calcium content • 8-ounce glass of milk 300 mg • 2 ounces of Swiss cheese 530 mg • 6 ounces of yogurt 300 mg • 2 ounces of sardines with bones 240 mg • 6 ounces of cooked turnip greens 220 mg • 3 ounces of almonds 210 mg

7. Should all elderly people be given Calcium and Vitamin D supplements?

8. Non-supplement users Supplement users Diet only Diet only Combined intakes2 mg mg NHANES III Ervine RB, Kennedy-Stephenson J. Mineral Intakes of Elderly Adult Supplement and Non-Supplement Users in the Third National Health and Nutrition Examination Survey. J Nutr 2002; 132 (11): 3422-7

9. Vitamin D insufficiency • Systematic review of post-menopausal women with & without osteoporosis • 30 studies Jan 1994 – Apr 2004 • Community living 1.6% • Institutionalised 86% • Osteoporotic women 12.5% - 76% • History of fracture(s) 50% - 70% Gaugris S, Heaney RP, Boonen S, Kurth H, Bentkover JD, Sen SS. Vitamin D inadequacy among post-menopausal women: a systematic review. QJM 2005; 98(9): 667-76

10. Calcium & Vit D supplementation Cumulative hazard for falls Cumulative hazard for fractures Flicker L, MacInnis RJ, Stein MS, et al. Should older people in residential care receive vitamin D to prevent falls? Results of a randomized trial. Journal of the American Geriatrics Society 2005; 53(11): 1881-8

11. RECORD Trial Grant AM, Anderson FH, Avenell A, et al. Oral vitamin D3 and calcium for secondary prevention of low-trauma fractures in elderly people (Randomised Evaluation of Calcium or Vitamin D, RECORD): a randomised, placebo-controlled trial. Lancet 2005; 365 (9471): 1621-1628

12. Cochrane Systematic Review • 38 trials • Vit D vs. placebo/no treatment • No evidence for annual injection of vit D in preventing hip or other osteoporotic fractures • No evidence for oral vit D either as a 4-monthly bolus dose of 100,000 IU or daily doses up to 830 IU • Further studies indicated with doses of ≥800 IU daily in very high risk populations with low sunlight exposure, such as people in nursing homes Avenell A, Gillespie WJ, Gillespie LD, O'Connell DL. Vitamin D and vitamin D analogues for preventing fractures associated with involutional and post-menopausal osteoporosis. Cochrane Database of Systematic Reviews 2005, Issue 3

13. Vit D + calcium vs. placebo/no treatment • 700-800 IU vit D3 + 1000 mg calcium reduces the incidence of hip fractures and all non-vertebral fractures • Statistically significant effect seen in pooled data from institutionalised participants, but not in those living in the community. • No evidence that people with a prior fracture history, irrespective of age, benefit in respect of hip fracture incidence from vitamin D and calcium • Alfacalcidol • 3 small trials, same author, evidence inconclusive • Calcitriol • Benefit unclear, increased risk of hypercalcaemia

14. SIGN Guidelines • In frail, elderly women (aged 80+ years) with a diagnosis of osteoporosis, with or without previous osteoporotic fractures • To reduce hip fracture risk, frail elderly women who are housebound should receive oral calcium (1000-1200 IU daily + 800 IU Vitamin D)