A 68-year-old woman is concerned about falling and fracturing bones after a friend's injury and asks if vitamin D supplements could help. A review of 4 randomized controlled trials found no evidence that vitamin D reduces fall-related fractures in older adults, and one study found it increased falls. The woman would not likely benefit from vitamin D for fracture prevention based on current evidence.

1. Does taking vitamin D supplements reduce
fall-related fractures among geriatric
patients?
Mohamad Beydoun
Kim Kirkpatrick
Jeffrey Oboite
Rafael Otero De Santiago

2. Patient case
MC is a 68 y/o caucasian female who lives at villages of Homeland apartments
alone. She comes to the pharmacy to pick up her medications and asked the
pharmacist a question regarding vitamin D supplements. A close friend of
hers recently had a fall-related fracture and has her worried. She has heard
that vitamin D can help lower your chances of falls and fractures and wants to
know if vitamin D would be beneficial for her in the future.
Home Medications:
● Escitalopram 10mg PO QD
● Metoprolol Succinate 25mg PO QD
● Simvastatin 10mg PO QD
● Albuterol 1-2 puffs every 4-6 hrs PRN
PMH:
● Depression
● Hypertension
● Hyperlipidemia
● Asthma

3. Vitamin D1
• Vitamin D is a fat-soluble vitamin
• Function
• Promotes calcium absorption in
the gut
• Maintains adequate serum
calcium and phosphate
concentrations
• Bone growth and bone
remodeling
• With calcium - helps protect older
adults from osteoporosis
• Vitamin D sources
• UV B radiation (sun)
• Fatty fish (salmon, tuna)
• Cod liver oil
• Beef liver
• Cheese
• Milk
Drug interactions
Steroids (prednisone)
Weight loss drug (Orlistat)
Cholesterol lowering drug (cholestyramine)
AEDs (phenytoin and phenobarbital)

4. Vitamin D1,2
• Supplement Form
• D2 - ergocalciferol
• D3 - cholecalciferol

5. Fall-related fractures3
• 1 out of 3 older people fall each year.
• 1 out of 5 falls causes serious injuries
such as broken bone or head injury.
• Each year over 700,000 people are
hospitalized because of fall related
injuries like head injury or hip fractures
• Falling once makes people afraid of
falling again so they would decrease
their daily activities making their bones
more fragile.
• Falling once double your chances of
falling again.
Centers for Disease Control and Prevention
http://www.cdc.gov/homeandrecreationalsafety/falls/adultfalls.html
(Accessed 2016 April 5)

6. Geriatric population4,5
• “Baby Boomers”
• Define as people ≥ 65 y/o
• Growing population
• At high risk for falls because of
comorbidities or medications
• Fall-related fractures can be
very complicate in this
population
• Increase mortality rate
Eldercare Workforce Alliance
http://www.eldercareworkforce.org/research/issue-briefs/research:america-
solution-jobs-crisis-better-care-for-older-adults/ (Accessed 2016 April 5)

7. Inclusion and Exclusion criteria
Inclusion
• Clinical trials
• Population ≥ 60 y/o
• Fractures as an outcome
• Vitamin D dietary supplementation
• Sample size ≥ 100
• No year restriction
Exclusion
• Secondary literature
• Population < 59 y/o
• Studies with bone mineral density as
the only outcome
• Studies with falls as the only
outcome
• Sample size < 99

8. Search Strategy - PubMed
Filters: english language, human subjects,
clinical trials, aged 65+ years
MeSH: “Vitamin D” + “Bone fractures” +
“Accidental falls”
218
articles
22
articles
Applied our inclusion and exclusion criteria 5
articles

9. Search Strategy - Trip Database
Applied our inclusion and exclusion criteria
P: Geriatric, I: Vitamin D, C: (blank),
O: Bone fracture
112
articles
2
articles

10. Search Strategy - Medline
English language
Vitamin D AND Geriatric AND Falls AND
Fractures (TX All Text)
36
articles
22
articles
Applied our inclusion and exclusion criteria/
Excluded duplicates
0
articles

11. POEM
P Geriatric population
I Vitamin D dietary supplementation
C No vitamin D dietary supplementation or Placebo
O Incidence of fall-related fractures

12. Article #1 Can Vitamin D
Supplementation Reduce
the Risk of Fracture in the
Elderly? A Randomized
Controlled Trial
Meyer et al. Can Vitamin D Supplementation
Reduce the Risk of Fracture in the Elderly? A
Randomized Controlled Trial. Journal of Bone and
mineral research. 2002. Vol 17, Num 4: 709-15.

13. Meyer et al.6
P Patients >75 y/o with a life expectancy of more than half a
year, able to take their medications and not permanently
bedridden
I 400 IU of vitamin D3 daily
C Placebo
O Effectiveness of vitamin D in the prevention of
fractures in the elderly people
T 2 years
S Doubled-blinded randomized controlled trial

14. Results6

15. Results6

16. Limitations of the study6
• 761 patients discontinued the treatment after and average
treatment period of 10 months.
• High percentage of females (75%)
• High percentage of patients had a history of hip fractures
(30%).
• The study was done in the city with the highest incidence
rates of hip fractures ever reported internationally.
• Both groups were receiving vitamin A and calcium.
• No vitamin D adverse effects were reported
• Possible reporting bias

17. Clinical Implications6
• Vitamin D group, compared with the controlled group, did not
show any significant benefit in the prevention of hip fractures
and/or nonvertebral fractures.
• There was no difference in mortality between the control group
and the vitamin D group

18. Article #2 Vitamin D
Supplementation and
Fracture in Elderly
Persons: A Randomized,
Placebo-Controlled
Clinical Trial
Lips et al. Vitamin D Supplementation and Fracture
in Elderly Persons: A Randomized, Placebo-
Controlled Trial. Ann Intern Med. 1996. 124: 400-
406.

19. Lips et al.7
P Patients ≥ 70 y/o
I 4000 IU of vitamin D3 daily
C Placebo
O Hip and peripheral bone fractures
T 4 years
S Doubled-blinded randomized controlled trial

20. Results7

21. Results7
• Kaplan-Meier display of
cumulative proportion of
participants with first hip
fracture

22. Limitations of the study7
• Additional medications taken during the study were not
reported
• Baseline chronic disease states were not reported
• Frailer elderly persons refrained from participation

23. • Subgroup analysis may reveal confounding variables
• Vitamin D3 4000 IU daily does not reduce incidence of bone
fracture in Dutch elderly population
Clinical Implications7

24. Article #3 Annual High-Dose Oral
Vitamin D and Falls and
Fractures in Older Women A
Randomized Controlled Trial
Sanders et al. Annual High-Dose Oral Vitamin D
and Falls and Fractures in Older Women
A Randomized Controlled Trial. JAMA. 2010;
303(18): 1815-22

25. Sanders et al.8
P Women >70 y/o with a high risk of hip fracture
I 500,000 IU of vitamin D3 orally once a year
C Placebo
O Falls and fractures
T 4 years
S Double-blinded, placebo-controlled randomized trial

26. Results8

27. Results8

28. Results8

29. Limitations of the study8
• Possible reporting bias
• Self-reported falls
• Only radiologically confirmed fractures were reported in
the study
• Baseline characteristics obtained through questionnaire
• Patient population
• Possible confounding

30. Clinical Implications8
• Vitamin D resulted in higher incidence of falls and provided no
benefit in reduction of fractures

31. Article #4 Vitamin D supplementation
and the prevention of
fractures and falls: results
of a randomised trial in
elderly people in
residential accommodation
Law et al. Vitamin D supplementation and the
prevention of fractures and falls: results of a
randomised trial in elderly people in
residential accommodation. Age and ageing.
2006; 35: 482-486

32. Law et al.9
P Patients > 60 y/o not currently taking vitamin D, calcium, or
other drugs that can increase bone density.
I 1100 IU of vitamin D2 daily
C No vitamin D (no placebo)
O Nonvertebral fractures, hip fractures and falls
T 10 months
S Randomized controlled trial of cluster design

33. Results9

34. Limitations of the study9
• Possible selection bias since data on ineligible patients was not provided.
• 10 months long
• No blinding
• No placebo
• Follow up was only 6 or 12 months

35. Clinical Implications9
• There was no reduction in the incidence of fractures or falls in the
vitamin D-treated group.
• Indeed, the incidence of fractures was directionally higher in the treated
group (3.6%) than in the control group (2.6%), but this was not statistically
significant.
• There was no evidence to support vitamin D supplementation and the
prevention of fall-related fractures.

36. Overview/Assessment
Articles Conclusions
Meyer et al.1 (2002) No benefit
Lips et al.2 (1996) No benefit
Sanders et al.3 (2010) Increased falls risk
Law et al.4 (2006) No benefit

37. Limitations of our systematic review
• Possible reporting bias
• No discontinuation of other medications or supplements
• 80% of the participants in our studies were females
• Dose of vitamin D were different

38. Recommendation
Should MC start vitamin D dietary supplementation for the prevention of fall-
related fractures?
MC would not benefit from taking vitamin D supplements for the prevention
of fall-related fractures

39. References
1. National Institutes of Health https://ods.od.nih.gov/factsheets/VitaminD-HealthProfessional/#en1(Accessed 2016 April 5)
2. GlobalRPh http://www.globalrph.com/2008/vitamin_d_synthesis.gif(Accessed 2016 April 5)
3. Centers for Disease Control and Prevention http://www.cdc.gov/homeandrecreationalsafety/falls/adultfalls.html(Accessed 2016
April 5)
4. World Health Organization http://www.who.int/healthinfo/survey/ageingdefnolder/en/(Accessed 2016 April 5)
5. Eldercare Workforce Alliance http://www.eldercareworkforce.org/research/issue-briefs/research:america-solution-jobs-crisis-
better-care-for-older-adults/(Accessed 2016 April 2016 5)
6. Meyer et al. Can Vitamin D Supplementation Reduce the Risk of Fracture in the Elderly? A Randomized Controlled Trial. JJ
Bone Miner Res. 2002. Vol 17, Num 4: 709-15.
7. Lips et al. Vitamin D Supplementation and Fracture in Elderly Persons: A Randomized, Placebo-Controlled Trial. Ann Intern
Med. 1996. 124: 400-406
8. Sanders et al. Annual High-Dose Oral Vitamin D and Falls and Fractures in Older Women A Randomized Controlled Trial.
JAMA. 2010; 303(18): 1815-22
9. Law et al. Vitamin D supplementation and the prevention of fractures and falls: results of a randomised trial in elderly people in
residential accommodation. Age Ageing. 2006; 35: 482-486

40. Questions