Annals of Long-Term Care: Clinical Care and Aging. 2013;21(8):36-37.
Vitamin D and calcium are essential nutrients that work together to maintain bone health and other major functions of the body. Deficiencies in either of these two nutrients can have severe effects on health in older adults, including increased risk of osteopenia, osteomalacia, and osteoporosis, and increased risk of fracture. Hypocalcemia is also associated with poor appetite, arrhythmias, and, in rare cases, death. Fearing these effects, millions of Americans are taking vitamin D and calcium supplements despite the fact that most individuals are already receiving an adequate amount of these nutrients through their diet. Consequently, excessive intake of these nutrients has its own set of adverse effects.
Recently, some controversy has been generated over vitamin D and calcium supplementation in older men and women. This is because in February 2013, the US Preventive Services Task Force (USPSTF) issued a statement concluding that the current evidence is insufficient to assess the balance of the benefits and harms of daily supplementation with more than 400 IU of vitamin D3 and more than 1000 mg of calcium for the primary prevention of fractures in younger men and women (premenopausal) and in noninstitutionalized postmenopausal women.1 Based on this finding, the USPSTF recommended against daily use of these supplements for the primary prevention of fractures in noninstitutionalized postmenopausal women. In addition, the statement warned that even if used at lower doses, vitamin D and calcium supplements might increase the risk of kidney stones in older women.
Following this statement, there has been confusion among healthcare providers regarding the proper use of these supplements, but particularly among those caring for older institutionalized adults, as the USPSTF’s recommendation was not extended to this population. To shed light on this issue, Annals of Long-Term Care (ALTC) spoke with Eric G. Tangalos, MD, CMD, professor of medicine, Mayo Clinic College of Medicine, Rochester, MN, about how providers in long-term care settings can appropriately advise their patients to ensure they receive adequate levels of these essential nutrients, while mitigating any potential risk of harm.
ALTC: What are the risk factors of vitamin D deficiency and calcium deficiency in the long-term care population, and what can healthcare providers do to reduce the risk of deficiency?
Tangalos: The answer is still relatively unknown. Despite the observations that laboratory testing may show deficiency, clinical findings and outcomes are relatively hard to demonstrate. For the most part, our long-term care residents receive balanced diets that are frequently better than what they were exposed to in their home environment.
It is common for most of our long-term care residents to be on vitamin D3 50,000 IU once a month for falls prevention. The data supporting this recommendation is quite weak, but adding the D3 addresses the “floor” and there is no worry about vitamin D excess. What to do about calcium is not as clear-cut.
Do you advise the use of either vitamin D or calcium supplementation in long-term care patients? If so, which patients are considered to benefit from supplementation?
For the last couple of years I have uncoupled calcium and vitamin D supplementation. We teach our staff to consider each supplement separately. Vitamin D is 50,000 IU once a month for just about everybody. Calcium is constipating, and calcium carbonate (the most common preparation available) requires an acid medium in the stomach for absorption. Calcium has also drawn the most attention from the Institute of Medicine for having the potential to create complications for patients who may not need it.2
Calcium supplementation is generally not recommended if the patient is constipated and on regular therapy for this problem; is noncompliant and medication administration is a battle; is on a PPI [proton pump inhibitor] and needs it; is on an H2 blocker and needs it; has achlorhydria; and/or has kidney stones.
When I do use calcium in osteoporotic patients, I prefer calcium citrate. This formulation does not require an acid medium for absorption. And again, it is uncoupled from vitamin D. Patients never like taking calcium tablets, and I do want to be sure they are taking their vitamin D.
It seems that natural dietary sources of vitamin D and calcium are preferred over supplementation. Would you agree?
The Institute of Medicine report prefers dietary calcium to all supplements. It would appear the risks of cardiovascular events and renal stones are less.2
It has been estimated that osteoporosis affects as many as 80% of nursing home residents. Likewise, vitamin D deficiency in this setting is also high, estimated at 60%. However, the USPTSF recommendation does not apply to people who have already received a diagnosis of osteoporosis or vitamin D deficiency. So what does that mean for healthcare providers in long-term care settings?
We supplement patients with these diagnoses and we treat all patients with D3. So the only decision-making is about calcium. I strongly consider the patient and his/her symptoms of chronic constipation (which, in my experience, is even more prevalent than osteoporosis in long-term care). When calcium is used, it is calcium citrate and it is always uncoupled from the vitamin D3 to ensure compliance with the vitamin D3 regimen.
Given the high prevalence of vitamin D deficiency and osteoporosis in long-term care, should new patients be screened for either condition upon admission? Please explain why or why not.
The cost of a total vitamin D(vitamins D2 and D3) assay is quite expensive and has no value if your policy is to begin all patients on D3 for falls prevention. We don’t check vitamin D levels in the nursing home. We also do not screen for osteoporosis in the nursing home because of its high prevalence. For the most part, we assume the patient has osteoporosis. Hip fracture, vertebral compression fracture, immobility, or a previous history of bisphosphonate therapy or steroid use can usually be found. We decide on calcium supplementation as I described earlier. I generally stop more calcium prescriptions than I ever start.
- US Preventive Services Task Force. Vitamin D and calcium supplementation to prevent fractures. www.uspreventiveservicestaskforce.org/uspstf12/vitamind/vitdfact.pdf. Published February 2013. Accessed July 22, 2013.
- Dietary Reference Intakes for Calcium and Vitamin D. Report brief. Washington, DC: Institute of Medicine, 2011. Accessed July 22, 2013.
Dr. Tangalos is an editorial advisory board member of Annals of Long-Term Care: Clinical Care and Aging.