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D-vitamiinin vaikutus yhdessä kalsiumin kanssa vanhusten tasapainoon ja kaatumisiin

Näytönastekatsaukset
Christel Lamberg-Allardt
11.4.2014

Näytön aste: B

D-vitamiini yhdessä kalsiumin kanssa ilmeisesti vähentää vanhusten kaatumisia.

Vuosien 2007–2012 välillä on julkaistu 7 systemaattista kirjallisuuskatsausta (systematic literature review, SLR) «Cranney A, Horsley T, O'Donnell S ym. Effectivenes...»1, «Chung M, Balk EM, Brendel M ym. Vitamin D and calc...»2, «Kalyani RR, Stein B, Valiyil R ym. Vitamin D treat...»3, «Cameron ID, Gillespie LD, Robertson MC ym. Interve...»4, «Gillespie LD, Robertson MC, Gillespie WJ ym. Inter...»5, «Michael YL, Whitlock EP, Lin JS ym. Primary care-r...»6, «Murad MH, Elamin KB, Abu Elnour NO ym. Clinical re...»7 aiheesta D-vitamiini ja kaatumisriski. Näitä on arvioitu systemaattisessa katsauksessa «Lamberg-Allardt C, Brustad M, Meyer HE ym. Vitamin...»8. Alla oleva teksti perustuu siihen.

Cranney et al. (2007) «Cranney A, Horsley T, O'Donnell S ym. Effectivenes...»1 evaluated the association of 25(OH)D concentrations with falls in postmenopausal women and elderly men. One RCT, three prospective cohorts and one case-control study were included in their analyses. The subjects included in the studies were elderly men and women. The RCT and the cohorts studies were of good quality and the case-control of fair quality. The authors concluded that “There is fair evidence of an association between lower serum 25(OH)D concentrations and an increased risk of falls in institutionalized elderly. PTH may be an important confounder. One study suggested a specific serum 25-(OH)D concentration of 39 nmol/l below which fall risk is increased.”

Cranney et al. (2007) «Cranney A, Horsley T, O'Donnell S ym. Effectivenes...»1 asked “What is the evidence regarding the effect of supplemental vitamin D on falls in postmenopausal women and elderly men?”. A total of 14 trials in 16 publications were included. Meta-analyses were conducted using data from the 12 RCTs. Vitamin D was given by injection in two studies and orally in all but one. Oral vitamin D was given as vitamin D3 in all but one study. Oral vitamin D was given without calcium in three trials. Oral vitamin D did not reduce the risk of falls in comparison to placebo or calcium. Oral vitamin D with calcium showed a reduction in falls as compared to placebo or calcium. Injectable vitamin D2 did not reduce the risk of falls in comparison to placebo. The authors summarized that the combined results from 12 trials (N = 14,101) demonstrated a small reduction in falls with vitamin D2/D3 (oral or injectable) +/- calcium. In the two factorial design trials, one demonstrated a significant fall reduction in postmenopausal women taking vitamin D3 plus calcium (whereas the other trial did not show a reduction in falls in elderly individuals taking vitamin D2. Moreover, the authors summarized that” the results from trials examining the effect of supplemental vitamin D on falls is consistent, with 12 of the 14 trials demonstrating a non-significant reduction in falls. However, when combining RCTs (by intervention method) there is inconsistent evidence regarding the effect of supplemental vitamin D on falls. The combination of 12 trials of either oral or injectable vitamin D2/D3 (+/-)calcium did demonstrate a small reduction in fall risk. Combination of eight RCTs of oral vitamin D2/D3 supplementation with calcium showed a reduction in fall risk, whereas four RCTs of oral vitamin D3 alone did not. Subgroup analyses showed a significant reduction in falls upon combining trials of postmenopausal women only. Sensitivity analyses showed a significant reduction in falls when combining (1) RCTs that explicitly defined falls and the method of fall ascertainment and (2) those in which the allocation concealment was unclear. However combining trials by degree of compliance and loss to follow up did not. Cranney et al. (2007) «Cranney A, Horsley T, O'Donnell S ym. Effectivenes...»1 concluded that “there is inconsistent evidence that supplemental vitamin D reduces falls in postmenopausal women and older men”.

Chung et al. (2010) «Chung M, Balk EM, Brendel M ym. Vitamin D and calc...»2 included and updated the report by Cranney et al. «Cranney A, Horsley T, O'Donnell S ym. Effectivenes...»1, and most of the results are presented and specified in the Cranney report. This report included two additional RCTs related to vitamin D and falls. Chung et al. «Chung M, Balk EM, Brendel M ym. Vitamin D and calc...»2 concluded that these reports did not change the conclusion made by Cranney et al. «Cranney A, Horsley T, O'Donnell S ym. Effectivenes...»1.

Kalayani et al (2010) «Kalyani RR, Stein B, Valiyil R ym. Vitamin D treat...»3 included 10 RCT´s performed in older adults for a systematic review on vitamin D treatment for the prevention of falls. Vitamin D3 was used in 6 studies, vitamin D2 in three studies and alfacalcidiolin one study. The methodological quality of the studies was in general good. In pooled analysis, vitamin D therapy (5–25 µg/d) resulted in 14% fewer falls than calcium or placebo. According to this SLR the following subgroups had significantly fewer falls: community-dwelling (aged < 80), adjunctive calcium supplementation, no history of fractures or falls, duration longer than 6 months, vitamin D3, and dose of 20 µg or greater. Meta-regression demonstrated no linear association between vitamin D dose or duration and treatment effect. Post hoc analysis including seven additional studies (17 total) without explicit fall definitions yielded smaller benefit and more heterogeneity but found significant intergroup differences favouring adjunctive calcium over none The authors concluded that ”vitamin D treatment effectively reduces the risk of falls in older adults”.

Cameron et al (2010) «Cameron ID, Gillespie LD, Robertson MC ym. Interve...»4, «»1 studied interventions for preventing falls in older people in nursing care facilities and hospitals and included 41 trials (25,422 participants). Five trials tested the effect of vitamin D supplementation on falls. The quality of the studies were generally good. Pooled data from the four studies with 4512 participants that provided falls rate data shows a statistically significant reduction in rate of falls Pooled data from all five studies with 5095 participants did not show a reduction in the risk of falling. The authors stated that caution may be required with interpretation of these pooled data because of statistical and clinical heterogeneity. Two studies investigated vitamin D3 and calcium and one vitamin D2 in combination with calcium. Two studies compared vitamin D plus calcium to calcium and showed a significant reduction on rate of falls but no reduction in risk of falling. Generally the baseline serum 25(OH)D concentrations were low in four of these studies The authors did not distinguish between trials including or not including calcium.. The authors concluded that “vitamin D supplementation is effective in reducing the rate of falls in nursing care facilities”.

Gillespie et al. (2010) «Gillespie LD, Robertson MC, Gillespie WJ ym. Inter...»5, «»2 included 13 RCTs focusing on the prevention of falls in older people living in the community. Thirteen studies (23,112 enrolled participants) evaluated the efficacy of vitamin D supplementation, either alone or with calcium co-supplementation for fall prevention. Two studies contained multiple intervention arms. The overall analysis of vitamin D versus control did not show a statistically significant difference in rate of falls or risk of falling. A subgroup analysis showed no significant difference in either rate of falling or risk of falls in trials recruiting participants with higher falls risk or trials not so doing, and no significant difference in effect size between the subgroups in either analysis The rate of falls was significantly reduced in trials recruiting participants with lower 25(OH)D concentrations but not in participants not so selected. There was a significant difference between these two subgroups with a greater reduction in rate of falls in the subgroup of trials only recruiting participants with lower 25(OH)D concentrations. The authors did not distinguish between trials including or not including calcium. The authors’ conclusion was ”Overall, vitamin D does not appear to be an effective intervention for preventing falls in older people living in the community, but there is provisional evidence that it may reduce falls risk in people with low vitamin D levels (25(OHD))”.

Michael et al. (2010) «Michael YL, Whitlock EP, Lin JS ym. Primary care-r...»6 published a SLR on primary care-relevant interventions on prevention of falling in older adults. It included 9 trial of vitamin D supplementation. Five of these included only women and the proportion of women in the others was 51–80 %. Five trials were conducted in populations defined as high risk because of recent falls or vitamin D deficiency. The remaining 4 studies used populations that were unselected except for age 65 years or older. All studies were rated as fair quality. The daily oral doses of vitamin D in the intervention ranged from 2,5 to 25 µg/d (median, 20 µg). One study provided a single intramuscular injection of 15 000 µg of vitamin D. Two studies evaluated vitamin D2 and the remaining studies evaluated vitamin D3. Six trials included calcium supplements with vitamin D. The control groups ranged from no intervention to placebo or calcium supplements only. Vitamin D with or without calcium was associated with a 17% (CI, 11% to 23%) reduced risk for falling during 6 to 36 months of follow-up. Trials of vitamin D with calcium compared with no treatment or placebo did not support any added benefit of calcium.

The authors concluded that “There is strong evidence that several types of primary care applicable falls interventions (i.e., comprehensive multifactorial assessment and management, exercise/physical therapy interventions, and vitamin D supplementation) reduce falls among those selected to be at higher risk for falling”.

Murad et al. (2011) «Murad MH, Elamin KB, Abu Elnour NO ym. Clinical re...»7 found 26 trials of moderate quality that enrolled 45,782 participants, the majority of which were elderly and female to evaluate the existing evidence on vitamin D use and the risk of falls. Eight studies used vitamin D2 and 18 vitamin D3, with or without calcium. In 24 studies vitamin D was given orally, in the remaining 2 intramuscularly. The results indicated that vitamin D use was associated with statistically significant reduction in the risk of falls. This effect was more prominent in patients who were vitamin D deficient a baseline and in studies in which calcium was coadministered with vitamin D. The quality of evidence was low to moderate because of heterogeneity and publication bias, 19 studies were rated high and 7 low. The authors concluded that “vitamin D combined with calcium reduces the risk of falls. The reduction in studies without calcium coadministration did not reach statistical significance. The majority of the evidence is derived from trials enrolling elderly women”.

Overall conclusion «Lamberg-Allardt C, Brustad M, Meyer HE ym. Vitamin...»8

Based on the SLRs it could be concluded that there was overall fair evidence that vitamin D with calcium is effective in preventing falls in the elderly especially in those with low baseline 25(OH)D concentrations, both community dwelling and in nursing care facilities (Lamberg-Allardt C et al 2013) «Lamberg-Allardt C, Brustad M, Meyer HE ym. Vitamin...»8. Only one SLR concluded that vitamin D alone was effective (Kanyali et al 2010) «Kalyani RR, Stein B, Valiyil R ym. Vitamin D treat...»3. Some but not all SLRs concluded that a dose greater than 20 µg was effective, in conjunction with calcium supplementation.

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Kirjallisuutta

  1. Cranney A, Horsley T, O'Donnell S ym. Effectiveness and safety of vitamin D in relation to bone health. Evid Rep Technol Assess (Full Rep) 2007:1-235 «PMID: 18088161»PubMed
  2. Chung M, Balk EM, Brendel M ym. Vitamin D and calcium: a systematic review of health outcomes. Evid Rep Technol Assess (Full Rep) 2009:1-420 «PMID: 20629479»PubMed
  3. Kalyani RR, Stein B, Valiyil R ym. Vitamin D treatment for the prevention of falls in older adults: systematic review and meta-analysis. J Am Geriatr Soc 2010;58:1299-310
  4. Cameron ID, Gillespie LD, Robertson MC ym. Interventions for preventing falls in older people in care facilities and hospitals. Cochrane Database Syst Rev 2012;12:CD005465 «PMID: 23235623»PubMed
  5. Gillespie LD, Robertson MC, Gillespie WJ ym. Interventions for preventing falls in older people living in the community. Cochrane Database Syst Rev 2012;9:CD007146 «PMID: 22972103»PubMed
  6. Michael YL, Whitlock EP, Lin JS ym. Primary care-relevant interventions to prevent falling in older adults: a systematic evidence review for the U.S. Preventive Services Task Force. Ann Intern Med 2010;153:815-25 «PMID: 21173416»PubMed
  7. Murad MH, Elamin KB, Abu Elnour NO ym. Clinical review: The effect of vitamin D on falls: a systematic review and meta-analysis. J Clin Endocrinol Metab 2011;96:2997-3006 «PMID: 21795448»PubMed
  8. Lamberg-Allardt C, Brustad M, Meyer HE ym. Vitamin D - a systematic literature review for the 5th edition of the Nordic Nutrition Recommendations. Food Nutr Res 2013;57:10.3402/fnr.v57i0.22671 «PMID: 24106457»PubMed