Current issues of ACP Journal Club are published in Annals of Internal Medicine


Therapeutics

Review: Prophylactic use of vitamin D reduces falls in older persons

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ACP J Club. 2004 Nov-Dec;141:66. doi:10.7326/ACPJC-2004-141-3-066


Clinical Impact Ratings

GIM/FP/GP: 6 stars

Geriatrics: 6 stars


Source Citation

Bischoff-Ferrari HA, Dawson-Hughes B, Willett WC, et al. Effect of vitamin D on falls: a meta-analysis. JAMA. 2004;291:1999-2006. [PubMed ID: 15113819]


Abstract

Question

In older persons, is prophylactic use of vitamin D effective for preventing falls?

Methods

Data sources: 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 to 2002). Bibliographies of relevant studies were reviewed, and experts in the field were contacted for unpublished studies.

Study selection and assessment: Randomized controlled trials (RCTs) that compared prophylactic use of any type of vitamin D with a control condition in community-dwelling or institutionalized 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.

Outcomes: Low-trauma falls defined as unintentionally coming to rest on the ground, floor, or other lower level.

Main results

5 RCTs (n = 1237) (mean age 70 y, 81% women) met the selection criteria. Comparisons included cholecalciferol, 800 IU/d plus calcium, 1200 mg/d with calcium, 1200 mg/d (2 RCTs); cholecalciferol, 400 IU/d plus calcium, 800 to 1000 mg/d from dairy products with placebo (1 RCT); calcitriol, 0.5 µg/d with placebo (1 RCT); and 1α-calcidiol, 1 µg/d 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).

Conclusion

In older persons, prophylactic use of vitamin D is effective for reducing falls.

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.

For correspondence: Dr. H.A. Bischoff-Ferrari, Brigham and Women's Hospital, Boston, MA, USA. E-mail hbischof@hsph.harvard.edu.


Table. Vitamin D prophylaxis vs a control condition (e.g., calcium or placebo) in older persons at 3 months to 3 years*

Outcome Number of trials (n) Weighted event rates RRR (95% CI) NNT (CI)
Vitamin D Control
Participants who had ≥ 1 fall 5 (1237) 30% 37% 19% (6 to 31) 15 (9 to 52)

*Abbreviations defined in Glossary; weighted event rates, RRR, NNT, and CI calculated from data in article using a random-effects model.


Commentary

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 and colleagues 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 muscle strength, noting evidence for cell growth after stimulation of the “highly specific nuclear vitamin D receptor” in human muscle. Indeed, the rapid onset of benefit (in 2 to 3 mo in 2 of the selected 5 RCTs) parallels results seen in studies emphasizing 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. Hypercalcemia was not reported, and of the 4 trials that measured postintervention levels 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 elderly (2) 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, health care providers should consider routine vitamin D supplementation for older persons as recommended by Bischoff-Ferrari and colleagues in this review.

Bruce E. Johnson, MD
Brody School of Medicine at East Carolina University
Greenville, North Carolina, USA


References

1. Campbell AJ, Robertson MC, Gardner MM, et al. Randomised controlled trial of a general practice programme of home based exercise to prevent falls in elderly women. BMJ. 1997;315:1065-9. [PubMed ID: 9366737]

2. Gillespie LD, Gillespie WJ, Robertson MC, et al. Interventions for preventing falls in elderly people. Cochrane Database Syst Rev. 2003;(4):CD000340. [PubMed ID: 14583918]