1. All elderly patients should receive Calcium and Vitamin D Latana Munang

2. Function Calcium Structure Structure Bones & teeth Bones & teeth Cell signalling Cell signalling Vasoconstriction & vasodilation Vasoconstriction & vasodilation Nerve impulse Nerve impulse Muscle contraction Muscle contraction Co-factor enzyme Co-factor enzyme Coagulation cascade Coagulation cascade Vitamin D Calcium metabolism Calcium metabolism Cell differentiation Cell differentiation Immune system modulator Immune system modulator T Cells Macrophages Blood pressure regulation Blood pressure regulation

3. Calcium homeostasis Vitamin D 25 OH Vit D (inactive) 1,25 (OH) 2 Vit D 3 (active) Vitamin D 25-hydroxylase 25 OH Vitamin D 1- α- hydroxylase PTH Serum calcium ↑ Bone resorption ↑ Calcium & phosphate absorption

4. Adequate Intake (AI) for Vitamin D Life Stage Age Males mcg/day (IU/day) Females mcg/day (IU/day) Infants 0-6 months 5 mcg (200 IU) Infants 7-12 months 5 mcg (200 IU) Children 1-3 years 5 mcg (200 IU) Children 4-8 years 5 mcg (200 IU) Children 9-13 years 5 mcg (200 IU) Adolescents 14-18 years 5 mcg (200 IU) Adults 19-50 years 5 mcg (200 IU) Adults 51-70 years10 mcg (400 IU) Adults 71 years and older 15 mcg (600 IU) Pregnancy all ages - 5 mcg (200 IU) Breastfeeding all ages - 5 mcg (200 IU)

5. Adequate Intake (AI) for Calcium Life Stage Age Males (mg/day) Females (mg/day) Infants 0-6 months210 Infants 7-12 months 270 Children 1-3 years 500 Children 4-8 years 800 Children 9-13 years 1,300 Adolescents 14-18 years 1,300 Adults 19-50 years 1,000 Adults 51 years and older 1,200 Pregnancy 18 years and younger- 1,300 Pregnancy 19 years and older- 1,000 Breastfeeding 18 years and younger- 1,300 Breastfeeding 19 years and older- 1,000

6. Calcium content 8-ounce glass of milk 300 mg 8-ounce glass of milk 300 mg 2 ounces of Swiss cheese 530 mg 2 ounces of Swiss cheese 530 mg 6 ounces of yogurt300 mg 6 ounces of yogurt300 mg 2 ounces of sardines with bones 240 mg 2 ounces of sardines with bones 240 mg 6 ounces of cooked turnip greens 220 mg 6 ounces of cooked turnip greens 220 mg 3 ounces of almonds 210 mg 3 ounces of almonds 210 mg

7. Should all elderly people be given Calcium and Vitamin D supplements?

8. Non-supplement usersSupplement usersDiet only Combined intakes 2 mg NHANES III Calcium MaleFemale n24322570 Non- supplement users Diet only Mean (mg) 735 ± 11 582 ± 11 Median (mg) 690 ± 13 523 ± 13 Below standard (%) 7587 Supplement users Diet only Mean (mg) 789 ± 15 632 ± 11 Median (mg) 716 ± 28 590 ± 12 Below standard (%) 7087 Combined intake Mean (mg) 909 ± 23 864 ± 16 Median (mg) 819 ± 36 747 ± 16 Below standard (%) 6066 Ervine RB, Kennedy-Stephenson J. Mineral Intakes of Elderly Adult Supplement and Non-Supplement Users in the Third National Health and Nutrition Examination Survey. J Nutr 2002; 132 (11): 3422-7

9. Vitamin D insufficiency Systematic review of post-menopausal women with & without osteoporosis Systematic review of post-menopausal women with & without osteoporosis 30 studies Jan 1994 – Apr 2004 30 studies Jan 1994 – Apr 2004 Community living 1.6% Community living 1.6% Institutionalised 86% Institutionalised 86% Osteoporotic women 12.5% - 76% Osteoporotic women 12.5% - 76% History of fracture(s) 50% - 70% History of fracture(s) 50% - 70% Gaugris S, Heaney RP, Boonen S, Kurth H, Bentkover JD, Sen SS. Vitamin D inadequacy among post-menopausal women: a systematic review. QJM 2005; 98(9): 667-76

10. Cumulative hazard for fallsCumulative hazard for fractures Calcium & Vit D supplementation Flicker L, MacInnis RJ, Stein MS, et al. Should older people in residential care receive vitamin D to prevent falls? Results of a randomized trial. Journal of the American Geriatrics Society 2005; 53(11): 1881-8

11. RECORD Trial Grant AM, Anderson FH, Avenell A, et al. Oral vitamin D3 and calcium for secondary prevention of low-trauma fractures in elderly people (Randomised Evaluation of Calcium or Vitamin D, RECORD): a randomised, placebo-controlled trial. Lancet 2005; 365 (9471): 1621-1628

12. Cochrane Systematic Review 38 trials 38 trials Vit D vs. placebo/no treatment Vit D vs. placebo/no treatment No evidence for annual injection of vit D in preventing hip or other osteoporotic fractures No evidence for annual injection of vit D in preventing hip or other osteoporotic fractures No evidence for oral vit D either as a 4-monthly bolus dose of 100,000 IU or daily doses up to 830 IU No evidence for oral vit D either as a 4-monthly bolus dose of 100,000 IU or daily doses up to 830 IU Further studies indicated with doses of ≥800 IU daily in very high risk populations with low sunlight exposure, such as people in nursing homes Further studies indicated with doses of ≥800 IU daily in very high risk populations with low sunlight exposure, such as people in nursing homes Avenell A, Gillespie WJ, Gillespie LD, O'Connell DL. Vitamin D and vitamin D analogues for preventing fractures associated with involutional and post-menopausal osteoporosis. Cochrane Database of Systematic Reviews 2005, Issue 3

13. Vit D + calcium vs. placebo/no treatment Vit D + calcium vs. placebo/no treatment 700-800 IU vit D3 + 1000 mg calcium reduces the incidence of hip fractures and all non-vertebral fractures 700-800 IU vit D3 + 1000 mg calcium reduces the incidence of hip fractures and all non-vertebral fractures Statistically significant effect seen in pooled data from institutionalised participants, but not in those living in the community. Statistically significant effect seen in pooled data from institutionalised participants, but not in those living in the community. No evidence that people with a prior fracture history, irrespective of age, benefit in respect of hip fracture incidence from vitamin D and calcium No evidence that people with a prior fracture history, irrespective of age, benefit in respect of hip fracture incidence from vitamin D and calcium Alfacalcidol Alfacalcidol 3 small trials, same author, evidence inconclusive 3 small trials, same author, evidence inconclusive Calcitriol Calcitriol Benefit unclear, increased risk of hypercalcaemia Benefit unclear, increased risk of hypercalcaemia

14. SIGN Guidelines In frail, elderly women (aged 80+ years) with a diagnosis of osteoporosis, with or without previous osteoporotic fractures In frail, elderly women (aged 80+ years) with a diagnosis of osteoporosis, with or without previous osteoporotic fractures To reduce hip fracture risk, frail elderly women who are housebound should receive oral calcium (1000-1200 IU daily + 800 IU Vitamin D) To reduce hip fracture risk, frail elderly women who are housebound should receive oral calcium (1000-1200 IU daily + 800 IU Vitamin D)