Older adults are at an increased risk for falls and fractures. The estimated medical cost of falls in 2010 was $28.2 billion. The lost quality of life, high rate of institutionalization, and cost to society caused by falls makes this an important topic to address. Low vitamin D can lead to balance problems, weakness, and low bone mineral density with higher fall and fracture rates. Vitamin D supplementation has been found to decrease falls sustained by elderly patients. The American Geriatrics Society has released a consensus statement, based on findings of a work group of researchers and clinicians with expertise in vitamin D and older adults, on the use of vitamin D for prevention of falls in elderly patients in either the community or institutions.
Recommendations to reduce falls and fractures in older people
The consensus statement recommends that patients 65 years and older in the community as well as in institutions should receive supplementation of at least 1,000 IU/day to help decrease the risk of falls and subsequent fractures. It was found in studies that less than 600 IU/day did not prevent falls. Calcium should be administered with the vitamin D at a dose of 1,000-1,200 mg/day. There are insufficient data to recommend vitamin D supplementation without calcium.
Optimizing vitamin D status
The goal vitamin D serum level is 30 ng/mL, and this is based on a review of trials with serum levels of > 24 ng/mL that showed lower fall rates and trials that showed higher relative risk for falls with vitamin D levels < 25 ng/mL. The vitamin D total intake found to achieve a level > 30 ng/mL (75 nmol/L) in 92% of older adults was 4,000 IU/day. This took into account dietary vitamin D, sun exposure, and supplementation. Taking 4,000 IU/day of vitamin D is well below 10,000 IU/day, the highest tolerable amount. There has not been shown to be any cases of vitamin D intoxication at levels less than 200 ng/mL or at supplement levels of less than 30,000 IU/day.
In patients without the comorbidities mentioned below, there was not found to be a role in checking vitamin D levels, before supplementation or for monitoring, if the recommended supplementation is given. For those who wish to monitor levels, you should check the vitamin 25(OH)D levels 4 months after vitamin D3 supplementation.
Patients who take medicines such as cholestyramine, phenytoin, and phenobarbital should have their levels monitored, as these drugs can decrease vitamin D levels. Also obese patients and patients with malabsorption syndromes may need more frequent monitoring.
Vitamin D supplementation individualized
To prescribe a personalized vitamin D3 supplementation regimen, first start with 3,000 IU and then add or subtract to determine the adequate supplementation. Subtract 150-225 IU/day for dietary intake and subtract vitamin D in multivitamins and calcium combination tablets. It is not recommended to encourage sun exposure to increase vitamin D levels, but you can subtract about 500-1,000 IU/day in the summer months for patients with regular unprotected sun exposure. About 500-800 IU/day should be added for obesity and about 300-600 IU/day should be added for darker skin pigmentation. A total of 4,000 IU/day supplementation should not be exceeded except in special populations.
Vitamin D 2 vs. D 3
Vitamin D3 has been shown to provide higher serum levels of 25(OH)D than vitamin D2. Vitamin D3 is available without prescription in 400, 800, 1,000, 2,000, 5,000, and 10,000 IU formulations. Vitamin D2 is available by prescription at a dose of 50,000 IU.
Vitamin D2 at a dose of 50,000 IU has not been FDA approved to increase serum 25(OH)D levels. Avoid giving vitamin D with cholestyramine, high-fiber cereals, and fiber-based stool softeners. It is best to be taken with meals with oil for better absorption. Daily, weekly, and monthly vitamin D3 supplementation has been shown to equally achieve target blood levels of vitamin D.
The bottom line
Preventing falls in our older adult population is important for many reasons including maintaining quality of life, limiting institutionalization, and helping to decrease medical cost. Maintaining adequate vitamin D serum levels has been shown to help reduce falls and fractures in older adults. A goal level of > 30 ng/mL has been shown to help with the prevention of falls and fractures. The work group came to a different conclusion from the Institute of Medicine Report, which recommended vitamin D serum levels > 20 ng/mL in older adults. In trials with serum levels of 24 ng/mL, there was a clear lower fall rate seen. In trials with levels < 25 ng/mL, there was a higher relative risk of falls. A total daily intake of vitamin D3 of 4,000 IU has been shown to reach a serum level of 30 ng/mL in 92% on patients 65 years and older. In order to reach this goal, older adults in the community and in institutions require about 1,000 IU of vitamin D3 supplementation daily. However, it is ideal to individualize the supplementation amount based on each person’s sun exposure, daily dietary intake, and other medications or comorbidities that they have.
American Geriatrics Society Consensus Statement on Vitamin D for Prevention of Falls and Their Consequences – American Geriatrics Society Workgroup on Vitamin D Supplementation for Older Adults. J. Am. Geriatr. Soc. 2014;62:147-52.
Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia. Dr. Bowry is a third year resident in the family medicine residency at Abington Memorial Hospital