To D or Not to D? Vitamin D Doesn't Reduce Falls in Older Adults

Nancy A. Melville

December 09, 2020

Higher doses of vitamin D supplementation not only show no benefit in the prevention of falls in older adults at increased risk of falling compared with the lowest doses, but they appear to increase the risk, new research shows.

Based on the findings, supplemental vitamin D above the minimum dose of 200 IU/day likely has little benefit, lead author Lawrence J. Appel, MD, MPH, told Medscape Medical News.

"In the absence of any benefit of 1000 IU/day versus 2000 IU/day [of vitamin D supplementation] on falls, along with the potential for harm from doses above 1000 IU/day, it is hard to recommend a dose above 200 IU/day in older aged persons, unless there is a compelling reason," asserted Appel, director of the Welch Center for Prevention, Epidemiology, and Clinical Research at Johns Hopkins Bloomberg School of Public Health, in Baltimore, Maryland.

"More is not always better — and it may even be worse," when it comes to vitamin D's role in the prevention of falls, he said.

The research, published this week in Annals of Internal Medicine, adds important evidence in the ongoing struggle to prevent falls, says Bruce R. Troen, MD, in an accompanying editorial.

"Falls and their deleterious consequences remain a substantial risk for older adults and a huge challenge for health care teams," writes Troen, a physician-investigator with  the University at Buffalo and the Veterans Affairs Western New York Healthcare System.

However, commenting to Medscape Medical News, Troen cautions: "There are many epidemiological studies that are correlative, not causative, that do show a likelihood for benefit [with vitamin D supplementation]."

"Therefore, there's no reason for clinicians to discontinue vitamin D in individuals because of this study."

"If you're monitoring an older adult who is frail and has multiple comorbidities, you want to know what their vitamin D level is [and] provide them an appropriate supplement if needed," he emphasized.

Some guidelines already reflect the lack of evidence of any role of vitamin D supplementation in the prevention of falls, including those of the 2018 US Preventive Services Task Force, which, in a reversal of its 2012 recommendation, now does not recommend vitamin D supplementation for fall prevention in older persons without osteoporosis or vitamin D deficiency, Appel and colleagues note.

No Prevention of Falls Regardless of Baseline Vitamin D

As part of STURDY (Study to Understand Fall Reduction and Vitamin D in You), Appel and colleagues enrolled 688 community-dwelling participants who had an elevated risk of falling, defined as a serum 25-hydroxyvitamin D [25(OH)D] level of 25 to 72.5 nmol/L (10 to 29 ng/dL).

Participants were a mean age of 77.2 years and had a mean total 25(OH)D level of 55.3 nmol/L at enrollment.

They were randomized to one of four doses of vitamin D3, including 200 IU/day (the control group), or 1000, 2000, or 4000 IU/day.

The highest doses were found to be associated with worse — not better — outcomes including a shorter time to hospitalization or death compared with the 1000 IU/day group. The higher-dose groups were therefore switched to a dose of 1000 IU/day or lower, and all participants were followed for up to 2 years.

Overall, 63% experienced falls over the course of the study, which, though high, was consistent with the study's criteria of participants having an elevated fall risk.

Of the 667 participants who completed the trial, no benefit in prevention of falling was seen across any of the doses compared with the control group dose of 200 IU/day, regardless of participants' baseline vitamin D levels.

Safety analyses showed that even in the 1000 IU/day group, a higher risk of first serious fall and first fall with hospitalization was seen compared with the 200 IU/day group.

A limitation is that the study did not have a placebo group, however, "200 IU/day is a very small dose, probably homeopathic," Appel told Medscape Medical News. "It was likely close to a placebo," he said.

Caveats: Comorbidities, Subgroups

In his editorial, Troen notes other studies, including VITAL (Vitamin D and Omega-3 Trial) also found no reduction in falls with higher vitamin D doses; however, that study did not show any significant risks with the higher doses.

He adds that the current study lacks information on subsets of participants.

"We don't have enough information about the existing comorbidities and medications that these people are on to be able to pull back the layers. Maybe there is a subgroup that should not be getting 4000 IU, whereas another subgroup may not be harmed and you may decide that patient can benefit," he said.

Furthermore, the trial doesn't address groups such as nursing home residents.

"I have, for instance, 85-year-olds with vitamin D levels of maybe 20 nmol/L with multiple medical issues, but levels that low were not included in the study, so this is a tricky business, but the bottom line is first, do no harm," he said.

"We really need trials that factor in the multiple different aspects so we can come up, hopefully, with a holistic and interdisciplinary approach, which is usually the best way to optimize care for frail older adults," he concluded.

The study received funding from the National Institute of Aging.

Ann Intern Med. Published December 7, 2020. Abstract, Editorial

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