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Q In older persons, is prophylactic use of vitamin D effective for preventing falls?
Clinical impact ratings GP/FP/Primary care ★★★★★★☆ IM/Ambulatory care ★★★★★★☆ Geriatrics ★★★★★☆☆
Medline and the Cochrane Controlled Trials Register (January 1960 to February 2004), EMBASE/Excerpta Medica (January 1991 to February 2004), and the American Society for Bone and Mineral Research conference abstracts (1995–2002). Bibliographies of relevant studies were reviewed and experts in the field were contacted for unpublished studies.
Study selection and assessment:
randomised controlled trials (RCTs) that compared prophylactic use of any type of vitamin D with a control condition in community dwelling or institutionalised older persons (mean age of study participants had to be ⩾60 y). Studies were also required to have a methods section that stated how falls (the outcome) were defined and ascertained. After the selection process, study quality was further assessed against specified criteria that included allocation concealment, blinding, and withdrawals.
low trauma falls defined as unintentionally coming to rest on the ground, floor, or other lower level.
5 RCTs (n = 1237) (mean age 70y, 81% women) met the selection criteria. Comparisons included cholecalciferol, 800 IU/day plus calcium, 1200 mg/day with calcium, 1200 mg/day (2 RCTs); cholecalciferol, 400 IU/day plus calcium, 800 to 1000 mg/day from diary products with placebo (1 RCT); calcitriol, 0.5 μg/day with placebo (1 RCT); and 1α-calcidiol, 1 μg/day with placebo (1 RCT). Meta-analyses were done using fixed and random effects models. Both analyses showed that fewer patients in the vitamin D group than in the control group had ⩾1 fall (table). Furthermore, a sensitivity meta-analysis of the 10 “potentially appropriate for inclusion RCTs” (10 001 participants) showed that fewer patients in the vitamin D group than in the control group had ⩾1 fall (relative risk reduction 13%, 95% CI 4 to 20).
In older persons, prophylactic use of vitamin D is effective for reducing falls.
Abstract and commentary also appear in ACP Journal Club.
Falls are a serious concern in older persons because of their high prevalence and potential to lead to severe morbidity or mortality. Any intervention to decrease this epidemic would be welcome. The meta-analysis of 5 RCTs by Bischoff-Ferrari et al suggests that a daily supplement of vitamin D can reduce falls in older persons by 19%. A number needed to treat of 15 is impressive and the inexpensive cost of vitamin D supplementation makes this recommendation even more compelling.
Are there any cautions to a program of vitamin D supplementation in older adults? Perhaps if one is reluctant to treat while a mechanism of action is yet to be determined. The authors cite a plausible argument that vitamin D enhances muscular strength, noting evidence for muscle cell growth after stimulation of the “highly specific nuclear vitamin D receptor” in human muscle. Indeed, the rapid onset of benefit (in 2–3 mo in 2 of the selected 5 RCTs) parallels results seen in studies emphasising exercise intervention,1 which has a somewhat more easily understood mechanism of action on muscle.
3 of the 5 RCTs stipulated calcium supplementation along with vitamin D. Hypercalcaemia was not reported, and of the 4 trials that measured postintervention concentrations of vitamin D, no cases of hypervitaminosis D occurred. However, use of calcium supplementation and the optimal dose of either calcium or vitamin D are unclear.
A recent Cochrane review of falls in the elderly2 lists risk factor intervention, muscle strengthening and balance training, and withdrawal of psychotrophic medications as interventions “likely to be beneficial.” Such steps should certainly be continued. Now, healthcare providers should consider routine vitamin D supplementation for older persons as recommended by Bischoff-Ferrari et al in this review.
For correspondence: Dr H A Bischoff-Ferrari, Brigham and Women’s Hospital, Boston, MA, USA.
Sources of funding: Harvard/Harford Foundation; Charles A. King Trust Fellowship Award; Irene and Fredrick Stare Nutrition Education Fund; Swiss Foundation for Nutrition Research; International Foundation for the Promotion of Nutrition Research and Nutrition Education.