Age and Ageing Advance Access originally published online on June 8, 2006
Age and Ageing 2006 35(5):455-456; doi:10.1093/ageing/afl043
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Fracture prevention in care home residents: is vitamin D supplementation enough?
Most low trauma fractures occur in older people, where they are associated with excess mortality, morbidity and health and social service expenditure. The incidence of fractures is highest in elderly care home residents, with hip fracture rates of up to 5% per year [1]. Care home residents have a 3- to 4-fold higher incidence of fractures than people of the same age living in the community [1], reflecting their lower bone mineral density (BMD) and greater risk of falls [2, 3]. Falls prevention is an intuitive way to prevent fractures, but studies have not shown a consistent benefit in this group of vulnerable elderly people. In a randomised controlled trial in elderly people with cognitive impairment who had fallen, three-quarters of whom were care home residents, multifactorial intervention failed to decrease the incidence of falls [4]. An alternative strategy to prevent fractures is to improve bone health. Vitamin D insufficiency is a potentially reversible cause of falls and fractures in older people [5]. The National Diet and Nutrition Survey reported that over one-third of care home residents above the age of 65 years had evidence of vitamin D insufficiency, using the relatively conservative threshold of a serum 25 hydroxyvitamin D (25OHD) below 25 nmol/l [6].The strongest evidence for the benefit of vitamin D supplementation is provided by a trial in 3,270 women living in French nursing homes or apartment blocks for the elderly, who were randomised to receive 1,200 mg of calcium and 800 IU of vitamin D3 or placebo daily [7]. At 18 months, calcium and vitamin D decreased the risk of hip and other non-vertebral fractures by 43 and 32%, respectively. In a small subgroup of subjects who underwent venepuncture, serum 25OHD increased from 40 to 100 nmol/l with calcium and vitamin D.
Because compliance with daily calcium and vitamin D supplementation may be poor and add to the burden of medication in care home residents, there has been interest in alternative methods of correcting vitamin D insufficiency. This issue contains an article reporting the results of a cluster randomised controlled trial of oral vitamin D2 100,000 IU every 3 months in 3,717 care home residents [8]. The authors report no reduction in all non-vertebral fractures, hip fractures or falls in the vitamin D-treated group. The short median duration of follow-up of 10 months and the lower than expected fracture rates may have limited the power of the study to detect a meaningful reduction in fracture risk. The ascertainment of falls in the study may have also been sub-optimal. Although venepuncture was only performed in a small sample of study participants, mean serum 25OHD increased from 59 nmol/l at baseline to 99 nmol/l 1 month after the first dose of vitamin D. This raises the intriguing possibility that the negative results in this study may reflect a lower prevalence of vitamin D insufficiency than in the earlier study by Chapuy et al. [7]. Nevertheless, one should be circumspect about drawing conclusions when serum 25OHD was only measured in small subgroups of participants of these studies, particularly when there are systematic differences in the results generated with different assay methods [5].
Other studies of vitamin D supplementation in care home residents have yielded conflicting results. In a study from Finland, intramuscular vitamin D2 (150,000–300,000 IU) was administered annually to older people living either in the community or in residential care. This resulted in a reduction in fractures of 25% in both groups, but this was only statistically significant after pooling the data [9]. A Norwegian study examined the use of 5 ml of cod liver oil (
400 IU vitamin D3) in nursing home residents [10]. Although active treatment increased serum 25OHD from 47 to 64 nmol/l, there was no significant difference in the incidence of hip fracture or non-vertebral fractures compared with placebo. This disappointing result may reflect the low dose of vitamin D in the cod liver oil, as a meta-analysis suggested that vitamin D 400–500 IU daily was ineffective in fracture prevention [11].
Other recent articles have cast doubt on the role of vitamin D supplementation, with and without calcium, in the prevention of low trauma fractures in older people [12–14]. The latest Cochrane Systematic Review concluded that vitamin D alone was not associated with any reduction in fractures [15]. Combined calcium and vitamin D supplementation decreased the incidence of hip fractures [relative risk (RR) 0.81, 95% confidence intervals (CI) 0.68–0.96] and non-vertebral fractures (RR 0.87, 95% CI 0.78–0.97), but this effect appeared to be restricted to those living in institutionalised care.
What then should we advise about the prevention of fractures in care home residents? Combined calcium and vitamin D should certainly be considered but may be ineffective in those who are chair- or bed-bound because their risk factor profile for falls and fractures may be very different from that of more ambulant residents [5]. In women above the age of 75 years who already have a history of fracture, National Institute for Health and Clinical Excellence guidance advocates bisphosphonate treatment without the need for BMD measurement [16]. Although bisphosphonates have not been shown to reduce fracture risk in care home residents, alendronate with calcium and vitamin D supplementation increases BMD more than calcium and vitamin D alone [17]. As elderly care home residents with a previous low trauma fracture are at the highest risk of further fractures, this opportunity for secondary prevention should not be ignored.
As geriatricians, we are used to arguments suggesting that we should not inflict treatments on frail elderly patients. Meanwhile, those most likely to benefit from intervention are often systematically excluded from appropriately designed clinical trials. Overall, the evidence for fracture prevention in older people with osteoporosis is compelling. Care home residents with the highest risk of fracture present logistical problems regarding consent to treatment, polypharmacy and doubt about the health economic benefits. For those of us caring for the victims of preventable fractures, many of whom are frail, cognitively impaired and suffering from delirium post-fracture, inertia is not an option.
1 Sunderland Royal Hospital, Kayll Road, Sunderland, UK
2 School of Clinical Medical Sciences, University of Newcastle upon Tyne, UK
* To whom correspondence should be addressed: Consultant Physician, Musculoskeletal Unit, Freeman Hospital, Newcastle upon Tyne NE7 7DN, UK Tel: (+44) 191 223 1160 Fax: (+44) 191 223 1161 Email: rmfrancis{at}compuserve.com
References
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- Aspray TJ, Stevenson P, Abdy SE, Rawlings DJ, Holland T, Francis RM. Low bone mineral density measurements in care home residents—a treatable cause of fractures. Age Ageing 2006; 35: 37–41.
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- Finch S, Doyle W, Lowe C et al. National Diet and Nutrition Survey: People Aged 65 Years and Over. Volume 1: Report of the Diet and nutrition Survey. London: The Stationary Office, 1998.
- Chapuy MC, Arlot ME, Duboeuf F et al. Vitamin D3 and calcium to prevent hip fractures in elderly women. N Engl J Med 1992; 327: 1637–42.[Abstract]
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[Abstract/Free Full Text] - Grant AM, Avenell A, Campbell MK et al. Record Trial Group. 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: 1621–8.[CrossRef][ISI][Medline]
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[Abstract/Free Full Text] - Avenell A, Gillespie W, Gillespie L, O’Connell D. Vitamin D and vitamin D analogues for preventing fractures associated with involutional and post-menopausal osteoporosis. Cochrane Database Syst Rev 2005: issue 3, CD000227. DOI: 10.1002/14651858.CD000227.pub2.
- NICE. Bisphosphonates (alendronate, etidronate, risedronate), selective oestrogen receptor modulators (raloxifene) and parathyroid hormone (teriparatide) for the secondary prevention of osteoporotic fragility fractures in postmenopausal women. NICE Technology Appraisal 87, January 2005.
- Greenspan SL, Schneider DL, McClung MR et al. Alendronate improves bone mineral density in elderly women with osteoporosis residing in long-term care facilities. Ann Intern Med 2002; 136: 742–6.
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