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Living FRIendly Summaries of the Body of Evidence using Epistemonikos (FRISBEE)
Medwave 2016;16(Suppl 1):e6368 doi: 10.5867/medwave.2015.6368
Is vitamin D supplementation effective for the prevention of falls in elderly people?
Franco Scheel, Marcela Carrasco
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Abstract

Falls in elderly people are common and come with important effects on morbidity and mortality, dependence and institutionalization. It has been proposed that supplementation of vitamin D could prevent the occurrence of this event. Searching in Epistemonikos database, which is maintained by screening 30 databases, we identified 18 systematic reviews including 31 randomized trials. We combined the evidence using meta-analysis and generated a summary of findings table following the GRADE approach. We concluded the use of vitamin D probably leads to little or no difference in the risk of falling in elderly people.


 
Problem

Falls syndrome is an important problem in geriatric population. The third part of patients above 65 years old experience a fall every year and the risk of falling increases with age [1],[2]. Approximately, one of ten people would have serious consequences, such as bone fracture, subdural hematoma, soft tissue injury or cranial trauma [3],[4],[5]. On the other hand, it is associated with a decrease in functionality and earlier entry to care facilities and hospitals [6].

Vitamin D has diverse physiological effects due to the existence of 1,25-hydroxi-vitamin D receptors around the majority of the human body tissues. The presence of these receptors in muscles would explain the relationship between vitamin D deficiency and myopathy, weakness and muscular pain [7]. It has been proposed that supplementation of vitamin D would lead to an improvement in muscular strength and prevention of falls [8],[9], even in patients with no vitamin D deficiency.

Methods

We used Epistemonikos database, which is maintained by screening more than 30 databases, to identify systematic reviews and their included primary studies. With this information we generated a structured summary using a pre-established format, which includes key messages, a summary of the body of evidence (presented as an evidence matrix in Epistemonikos), meta-analysis of the total of studies, a summary of findings table following the GRADE approach and a table of other considerations for decision-making.

Key messages

  • The use of vitamin D probably leads to little or no difference in the risk of falling in elderly people.
  • There could be a subgroup of patients that might benefit, such as those with low levels of vitamin D demonstrated or highly probable.
About the body of evidence for this question

What is the evidence.
See evidence matrix  in Epistemonikos later

We found 18 systematic reviews [10],[11],[12],[13],[14],[15],[16],[17],[18],[19],
[20],[21],[22],[23],[24],[25],[26],[27],
which in total included 31 randomized controlled studies reported in 66 references
[8],[26],[27],[28],[29],[30],[31],[32],[33],[34],[35],[36],[37],[38],[39],[40],[41],
[42],[43],[44],[45],[46],[47],[48],[49],[50],[51],[52],[53],[54],[55],[56],[57],[58],
[59],[60],[61],[62],[63],[64],[65],[66],[67],[68],[69],[70],[71],[72][73],[74],[75],
[76],[77],[78],[79],[80],[81],[82],[83],[84],[85],[86],[87],[88],[89],[90],[91].

What types of patients were included

The patients that were included corresponded to elderly people (65 years or above) in care facilities, hospitals or patients living in the community. Studies did not restrict their inclusion criteria according to levels of vitamin D prior to supplementation.

Most patients were women. 

What types of interventions were included

Interventions varied regarding calcium combination, doses, schemes and ways of administration of vitamin D. Twenty-four different ways of intervention were identified including vitamin D. Thirteen studies [9],[34],[39],[49],[51],[63],[64],[68],[69],[70],[75],[76][83],[84] included calcium in the intervention group.

Different vitamin D doses schemes were used. Doses under 800 Ul per day were used in six different studies [34],[38][49],[58],[60],[64].

In 22 studies [8],[9],[30],[38],[39],[45],[49],[51],[58],[60],[61],[63],
[64],[68],[69],[70],[75],[76],[84] vitamin D was given daily, in two [33],[91] weekly, in one [57],  every three months and in one [90] every four months.

In other two studies [82],[87] it was used annually and in three studies [18],[43],[61] in a single dose. The comparison was against placebo, control group, strategies for falling prevention and calcium administration in 600 mg, 1000 mg and 1200 mg doses.

What types of outcomes
were measured

This summary, as well as the majority of the identified reviews, analyses only the outcome of falls.

We found three systematic reviews [5], [6], [7], including 14 studies   reported in 21 references [8], [9], [10], [11], [12], [13], [14], [15], [16],   [17], [18], [19], [20], [21], [22], [23], [24], [25], [26], [27], [28]. Eight   studies correspond to randomized controlled trials (15 references [9], [10],   [11], [12], [13], [14], [16], [17], [19], [21], [22], [23], [24], [26], [27]).   This table and the summary in general are based on the latter. One study [15]   did not contribute data to any of the outcomes of interest.

Summary of findings

The information on the effects of vitamin D on the risk of falls is based on 31 randomized trials that include 45,616 patients. However, three of these studies did not present data in a way that could be combined [33],[51],[82].

  • The use of vitamin D probably leads to little or no difference in the risk of falling in elderly people. The certainty of the evidence is moderate.


Other considerations for decision-making

To whom this evidence does and does not apply

  • This evidence applies to patients 65 years old or more, living in the community, care facilities or hospitals.
  • This evidence does not apply to selected patients such as patients with low levels of vitamin D, issue that has not been covered along this summary. 
About the outcomes included in this summary
  • According to the authors of this summary, fallings are considered as one of the critical outcomes for decision-making in most elderly patients considering this intervention. The possible benefit of vitamin D administration on other outcomes has not been considered in this summary.
Balance between benefits and risks, and certainty of the evidence
  • The evidence shows that administration of vitamin D in elderly people probably has no benefit in falls prevention.
Resource considerations
  • While it is a safe and low cost intervention, having no benefits makes the cost/benefits balance not favourable.

Differences between this summary and other sources

  • The key messages from our summary are consistent with the main systematic reviews identified [12],[16],[17],[19],[20]. Their conclusions are the supplementation of vitamin D does not appear to reduce the risk of falling, but it may have benefits in some subgroups, such as those with low levels of vitamin D [16],[19], when vitamin D is combined with calcium [20] or in patients at care facilities or hospitals [16].
  • The main conclusion of this study is discordant with the guideline of The American Geriatric Society [92], which recommends vitamin D with calcium supplementation for preventing falls in patients living in the community, care facilities or hospital. 
Could this evidence change in the future?
  • The probability that future information changes the main conclusions of this summary is low, due to the certainty of the evidence.
  • New systematic reviews including all of the existing evidence could give more information about subgroups that might benefit.

How we conducted this summary

Using automated and collaborative means, we compiled all the relevant evidence for the question of interest and we present it as a matrix of evidence.

Follow the link to access the interactive version: Vitamin D for falls prevention

Notes

The upper portion of the matrix of evidence will display a warning of “new evidence” if new systematic reviews are published after the publication of this summary. Even though the project considers the periodical update of these summaries, users are invited to comment in Medwave or to contact the authors through email if they find new evidence and the summary should be updated earlier. After creating an account in Epistemonikos, users will be able to save the matrixes and to receive automated notifications any time new evidence potentially relevant for the question appears.

The details about the methods used to produce these summaries are described here http://dx.doi.org/10.5867/medwave.2014.06.5997.

Epistemonikos foundation is a non-for-profit organization aiming to bring information closer to health decision-makers with technology. Its main development is Epistemonikos database (www.epistemonikos.org).

These summaries follow a rigorous process of internal peer review.

Conflicts of interest
The authors do not have relevant interests to declare.

Licencia Creative Commons Esta obra de Medwave está bajo una licencia Creative Commons Atribución-NoComercial 3.0 Unported. Esta licencia permite el uso, distribución y reproducción del artículo en cualquier medio, siempre y cuando se otorgue el crédito correspondiente al autor del artículo y al medio en que se publica, en este caso, Medwave.

 

Las caídas en el adulto mayor son frecuentes y conllevan importante morbimortalidad, dependencia e institucionalización. Se ha planteado que la suplementación con vitamina D podría prevenir la ocurrencia de este evento. Utilizando la base de datos Epistemonikos, la cual es mantenida mediante búsquedas en 30 bases de datos, identificamos 18 revisiones sistemáticas que en conjunto incluyen 31 estudios aleatorizados. Realizamos un metanálisis y tablas de resumen de los resultados utilizando el método GRADE. Concluimos que el uso de vitamina D probablemente no disminuye el riesgo de caídas en adultos mayores.

Authors: Franco Scheel[1,3], Marcela Carrasco[2,3]

Affiliation:
[1] Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
[2] Departamento de Geriatría, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
[3] Proyecto Epistemonikos, Santiago, Chile

E-mail: fcscheel@uc.cl

Author address:
[1] Facultad de Medicina
Pontificia Universidad Católica de Chile
Lira 63
Santiago Centro
Chile

Citation: Scheel F, Carrasco M. Is vitamin D supplementation effective for the prevention of falls in elderly people?. Medwave 2016;16(Suppl 1):e6368 doi: 10.5867/medwave.2015.6368

Publication date: 26/1/2016

PubMed record

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  78. Sanders KM, Stuart AL, Merriman EN, Read ML, Kotowicz MA, Young D, et al Trials and tribulations of recruiting 2,000 older women onto a clinical trial investigating falls and fractures: Vital D study. BMC Med Res Methodol. 2009 Nov 25;9:78. | CrossRef | PubMed |
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  82. Sato Y, Kanoko T, Satoh K, Iwamoto J. Menatetrenone and vitamin D2 with calcium supplements prevent nonvertebral fracture in elderly women with Alzheimer's disease. Bone. 2005 Jan;36(1):61-8. | PubMed |
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Prince RL, Austin N, Devine A, Dick IM, Bruce D, Zhu K. Effects of ergocalciferol added to calcium on the risk of falls in elderly high-risk women. Arch Intern Med. 2008 Jan 14;168(1):103-8. | CrossRef | PubMed |

Ralston SH, Binkley N, Boonen S, Kiel DP, Reginster JY, Roux C, et al. Randomized trial of alendronate plus vitamin D3 versus standard care in osteoporotic postmenopausal women with vitamin D insufficiency. Calcif Tissue Int. 2011 Jun;88(6):485-94. | CrossRef | PubMed |

Salovaara K, Tuppurainen M, Kärkkäinen M, Rikkonen T, Sandini L, Sirola J, et al. Effect of vitamin D(3) and calcium on fracture risk in 65- to 71-year-old women: a population-based 3-year randomized, controlled trial--the OSTPRE-FPS. J Bone Miner Res. 2010 Jul;25(7):1487-95. | CrossRef | PubMed |

Sanders K, Stuart A, Williamson E, Simpson J, Kotowicz M, Nicholson G. The efficacy of high-dose oral vitamin D3 administered once a year: A randomised, double-blind, placebo-controlled trial (vital D study) for falls and fractures in older women. Journal of bone and mineral research. 2010 2010;25:S50. | Link |

Sanders KM, Stuart AL, Merriman EN, Read ML, Kotowicz MA, Young D, et al Trials and tribulations of recruiting 2,000 older women onto a clinical trial investigating falls and fractures: Vital D study. BMC Med Res Methodol. 2009 Nov 25;9:78. | CrossRef | PubMed |

Sanders KM, Stuart AL, Williamson EJ, Simpson JA, Kotowicz MA, Nicholson GC. Annual high-dose oral vitamin D for falls and fractures in elderly women: A randomised, double-blind, placebo-controlled trial (Vital D Study). Osteoporosis International. 2010 2010;21(Suppl 1):s30. | Link |

Sanders KM, Stuart AL, Williamson EJ, Simpson JA, Kotowicz MA, Young D, et al. Annual high-dose oral vitamin D and falls and fractures in older women: a randomized controlled trial. JAMA. 2010 May 12;303(18):1815-22. | CrossRef | PubMed |

Sato Y, Iwamoto J, Kanoko T, Satoh K. Low-dose vitamin D prevents muscular atrophy and reduces falls and hip fractures in women after stroke: a randomized controlled trial. Cerebrovasc Dis. 2005;20(3):187-92. | PubMed |

Sato Y, Kanoko T, Satoh K, Iwamoto J. Menatetrenone and vitamin D2 with calcium supplements prevent nonvertebral fracture in elderly women with Alzheimer's disease. Bone. 2005 Jan;36(1):61-8. | PubMed |

Smith H, Anderson F, Raphael H, Cooper C. The Wessex Research Network fracture prevention study - a large pragmatic trial of annual vitamin D injection in older people [abstract]. Osteoporosis international. 2000;11(Suppl 1):S64. | Link |

Smith H, Anderson F, Raphael H, Crozier S, Cooper C. Effect of annual intramuscular vitamin D supplementation on fracture risk: population-based, randomised, double-blind, placebo-controlled trial [abstract]. Osteopor Int. 2004;15(Suppl 1):S8. | Link |

Smith H, Anderson F, Raphael H, Maslin P, Crozier S, Cooper C. Effect of annual intramuscular vitamin D on fracture risk in elderly men and women--a population-based, randomized, double-blind, placebo-controlled trial. Rheumatology (Oxford). 2007 Dec;46(12):1852-7. | PubMed |

South Glasgow Division of Greater Glasgow Health B. Does vitamin D stop inpatients falling? A randomised controlled trial. isrctncom. [on line]. | CrossRef |

The Sir Jules Thorn Charitable T. A trial of vitamin D in preventing hip fracture. isrctncom [on line]. | CrossRef |

Trivedi DP, Doll R, Khaw KT. Effect of four monthly oral vitamin D3 (cholecalciferol) supplementation on fractures and mortality in men and women living in the community: randomised double blind controlled trial. BMJ. 2003 Mar 1;326(7387):469. | PubMed |

Witham MD, Crighton LJ, Gillespie ND, Struthers AD, McMurdo ME. The effects of vitamin D supplementation on physical function and quality of life in older patients with heart failure: a randomized controlled trial. Circ Heart Fail. 2010 Mar;3(2):195-201 | CrossRef | PubMed |

American Geriatrics Society Workgroup on Vitamin D Supplementation for Older Adults. Recommendations abstracted from the American Geriatrics Society Consensus Statement on vitamin D for Prevention of Falls and Their Consequences. J Am Geriatr Soc. 2014 Jan;62(1):147-52. | CrossRef | PubMed |

Sato Y, Iwamoto J, Kanoko T, Satoh K. Low-dose vitamin D prevents muscular atrophy and reduces falls and hip fractures in women after stroke: a randomized controlled trial. Cerebrovasc Dis. 2005;20(3):187-92. | PubMed |

July 2019, Vol 19, Issue 6
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