Transcript Supplements in falls patients

Supplements in falls patients
Dr Nick John
Deepak Jadon
Older People’s Unit
October 2007
(SHO)
Overview
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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
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2.
↓ cortical & trabecular bone
Post-menopausal & steroid-induced
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↓ trabecular bone mainly
Fracture burden
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>50y presenting with fragility # have a ↑ incidence of osteoporosis
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Fragility # = fracture from standing height / less
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Osteoporotic # affects 1:2 women and 1:5 men >50y
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These patients are readily identifiable & should be prioritised for treatment
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
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50% no longer able to live independently
20% die within 6 months
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25 % require long term care
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5y mortality after hip / vertebral # is 20% greater than expected
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Cost
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200,000 fractures each year
£1 – 1.9 billion
Targeting therapy
It is possible to target 3 groups
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1.
2.
3.
though there is often much overlap
at risk of osteoporosis
at risk of falling
at risk of fragility fractures
The Audit
Standards
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RCP working party report 2001 suggests
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consideration of Calcium + Vit D supplementation in patients
with
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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 treatment
Update on pharmacological interventions and an algorithm for management
Royal College of Physicians
Scottish guidelines
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Treating frail housebound patients with
Calcium & Vit D can
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↓ hip # by 35%
↓ non-vertebral # by 26%
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Calcium 1 – 1.2 g + 800 iu Vit D
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Not necessary to measure [Vit D] before Tx
(per day)
Scottish Intercollegiate Guidelines Network. Management of Osteoporosis.
A National Clinical Guideline. No. 71.
Objectives
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To ensure that all geriatric patients
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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
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Retrospective audit
Patients admitted to Victoria Ward
6 months (1st February - 31st July 2007)
Admitted under Acute Geriatric intake via
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A&E
MAU
Analysis of discharge summaries
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Case notes if more elaboration needed
Methodology – Key parameters
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Age & Gender
Reason for admission
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Agent
Dose
If not prescribed, reason
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(CP, SOB, confusion, CVA etc.)
History of previous falls
(Prevalent fall)
Calcium / Vit D prescribed on discharge
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Incident fall
Other
Intolerant
Palliative
Hypercalcaemia
Declined
No contraindication
(severe dyspepsia)
Concurrent use of bisphosphonate
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Agent
Dose
Results - The sample
Total admissions
296
No discharge summary 27
Patients analysed
259
Fem ale
Male
Reason for admission
62 (24%)
Incident fall
Other
197 (76%)
Reason for admission
No previous falls
200
Previous falls
150
180
100
50
0
41
21 (24%)
17 (9%)
Incident Fall
Other
Use of supplements
No supplement
Supplement
50
40
11 (27%)
30
20
3 (14%)
30
10
18
5 (29%)
12
0
IF +
prev falls
IF +
no
prev fall
other +
prev fall
Incident fall group
(previous fall & no previous fall)
1
2
Palliative
Severe Dyspepsia
Declined
No contraindication
No notes
No fall
4
1
5
1
Compliance with guidelines in incident falls group
5 (8% )
2 (3% )
55 (89% )
On supplement if appropriate
Non-compliant with guidelines
No Notes
Other group
(non-incident fall gp, but with previous fall)
1
1
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1
No CIx
Hypercalcaemia
Too gritty
No notes
No fall
Non-incident (‘other’) fall group
compliance with guidelines
1 (5% ) 1 (5%)
On supplement if appropriate
Non-compliant with guideline
No notes
17 (90%)
Overall compliance with guidelines
6 (7%)
Compliant
Non-compliant
76 (93%)
Conclusion
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93% compliance with guidelines is excellent !
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But always room for improvement
We are excellent at targeting incident fallers
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As it jogs our memory
Need to keep this issue at forefront of mind in
those presenting with other complaints
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Asking ‘Have you ever had a fall before?’ takes a few secs
Suggested recommendations
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↑ 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 -
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Currently used in ED
– Assesses
 Hx of falls
 Preciptating factors
 Exacerbating factors
 Vulnerability
– Triages further referral & investigation
– Formally documents this assessment
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Re-audit in 1year
Pharmacological agents
Choice of supplement
15%
85%
Calcichew D3 Forte
Adcal D3 forte
Choice of bone protecting agent
12%
6%
2%
82%
Aledronate
Risedronate
Strontium ranealate
None
NICE committee recommendations
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Elderly population can’t be assumed to have an
adequate dietary intake of calcium & vit D
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Normal serum concentrations of calcium &
vitamin D are needed to ensure optimum
effects of the treatments for osteoporosis
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Thus calcium + vitamin D prescribed unless
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clinicians are confident that levels are normal
Evidence for Calcium & Vit D supplementation
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Reviewed in the 2001 RCP Osteoporosis Guidelines
Guidelines unclear if the benefits of Tx due to
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Calcium 1g/day
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↓ 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
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vitamin D
calcium
combination of both
↓ 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
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saves great resources & low marginal costs
is recommended that these individuals be offered such treatment (grade A)
Preventive approaches
[meta-analysis by RCP 2001]
Intervention
Bone mineral
density
Vertebral
fracture
Hip
fracture
Exercise
Calcium + vit D
Dietary calcium
Smoking cessation
Reduced alcohol
Oestrogen
Raloxifene
Etidronate
Alendronate
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A
B
B
C
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B
B
B
B
C
B
A
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B
B
B
B
B
B
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Treatment approaches
[meta-analysis by RCP 2001]
Intervention
Bone mineral
density
Vertebral
fracture
Hip
fracture
Calcium + vit D
Oestrogen
Alendronate
Etidronate
Calcitonin
Fluoride
Anabolic steroids
Calcitriol
A
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A
A
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A
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A
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A
B
B
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B
B
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B
C
Older men with osteoporosis
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Study results are conflicting
Calcium & vitamin D supplementation may
be useful
Grade C
Dietary Sources
Dietary Calcium
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Intake of calcium is essential
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throughout life
childhood & adolescence when bone most actively formed
Groups where calcium intake may be ↓
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Adolescents
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Skeletal length & density changes considerably
Dieting teenage girls
Sports people
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↓ calcium intake is well documented among
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Vegans
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women athletes
sports where weight is important eg. jockeys, rowers, boxers, ballet dancers, gymnasts etc
Soya milk (fortified with calcium & B12) good alternative to cows milk
Malabsorption
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IBD, coeliacs & lactose intolerants = reduction in nutrient intake / calcium absorption
Dietary Vit D
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Consider supplementation of vitamin D
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Older people
Ageing ↓ the permeability of skin to sunlight, ↑the reliance on foods
– Supplements are particularly recommended if
 ill
 housebound
 resident in institution
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Care Home.
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WARNING: fish oil supplements are a rich source of vit D
– avoid overdose
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Pureed diets
Ethnic attire
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Sunlight is the most important source of vitamin D.
– In UK, sunlight most effective between approximately the April – Oct
Predictors of Vit D deficiency
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A British study of 467 patients
In 129 patients with hypovitaminosis D
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In the 50 patients with the most severe hypovitaminosis D
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normal ALP
76%,
normal calcium
90%
normal phosphate 95%
66% vegetarian / vegan
72% clothing partially / completely occlusive of sunlight
60% went outdoors < 5 times / week
Conclusion
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routine measurement of ALP, calcium & phosphate
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is of no use in predicting hypovitaminosis D
risk factors for vitamin D deficiency
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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
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Using external hip protectors
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1yr Danish study randomised 665 elderly NH residents
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incorporated into specially designed underwear
external hip protectors
controls
(no hip protector)
Result
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50% reduction in hip # in hip protectors group.
Problems
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bulky
uncomfortable
(Lauritzen et al 1993)
Thank you for listening !
Any questions?