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1、Supplements in falls patientsDr Nick JohnDeepak Jadon (SHO)Older Peoples UnitOctober 2007OverviewlBackgroundlObjectivelStandardslMethodslResultslConclusionlRecommendationslDiscussionBackground-OsteoporosisProgressive skeletal disease characterised by llow bone mass lmicro-architectural deterioration
2、Resulting in l bone fragilityl susceptibility to fractureTargeting therapyIt is possible to target 3 groups though there is often much overlap1.at risk of osteoporosis2.at risk of falling3.at risk of fragility fracturesThe AuditObjectiveslTo ensure that all geriatric patients with a history of falls
3、 are on bone protective agents in the form of Calcium&Vitamin D to reduce the incidence of future osteoporotic fragility fracturesMethodologylRetrospective audit lPatients admitted to Victoria Ward l6 months(1st February-31st July 2007)lAdmitted under Acute Geriatric intake via lA&ElMAU lAnalysis of
4、 discharge summarieslCase notes if more elaboration neededResults-The sampleTotal admissions296No discharge summary27Patients analysed259Reason for admissionReason for admissionUse of supplementsIncident fall group (previous fall&no previous fall)Other group (non-incident fall gp,but with previous f
5、all)Non-incident(other)fall group compliance with guidelinesOverall compliance with guidelinesSuggested recommendationsl awareness amongst allied health professionalslImplementation of Falls Passport“All older people presenting with an injurious fall should be offered a multifactorial risk assessmen
6、t”-NICE guidance 2005-Currently used in EDAssesseslHx of fallslPreciptating factorslExacerbating factorslVulnerabilityTriages further referral&investigationFormally documents this assessmentlRe-audit in 1yearPharmacological agentsChoice of bone protecting agentNICE committee recommendationslElderly
7、population cant be assumed to have an adequate dietary intake of calcium&vit D lNormal serum concentrations of calcium&vitamin D are needed to ensure optimum effects of the treatments for osteoporosis lThus calcium+vitamin D prescribed unless lclinicians are confident that levels are normalEvidence
8、for Calcium&Vit D supplementationlReviewed in the 2001 RCP Osteoporosis GuidelineslGuidelines unclear if the benefits of Tx due to vitamin Dcalcium combination of bothlCalcium 1g/day bone loss in women with osteoporosis(level Ia)the risk of vertebral fracture(leveI Ib)effects on hip fracture are les
9、s certain(Level II)lVitamin D 800 iu/day hip&other#in the institutionalised frail elderly(level Ib)beneficial effects in the general community have not been demonstrated.lVitamin D&calcium in elderly female patients saves great resources&low marginal costsis recommended that these individuals be off
10、ered such treatment(grade A)Intervention Bone mineral Vertebral Hipdensity fracture fractureExercise A B BCalcium+vit D A B BDietary calcium B B BSmoking cessation B B BReduced alcohol C C BOestrogen A B BRaloxifene A A Etidronate A Alendronate A Preventive approachesmeta-analysis by RCP 2001Interve
11、ntion Bone mineral Vertebral Hipdensity fracture fractureCalcium+vit DA A BOestrogen A A BAlendronate A A AEtidronate A A BCalcitonin A A BFluoride A AAnabolic steroids A BCalcitriol A A CTreatment approaches meta-analysis by RCP 2001Older men with osteoporosislStudy results are conflictinglCalcium&
12、vitamin D supplementation may be usefullGrade CDietary SourcesDietary CalciumlIntake of calcium is essential throughout life childhood&adolescence when bone most actively formed lGroups where calcium intake may be Adolescents lSkeletal length&density changes considerablylDieting teenage girlsSports
13、people l calcium intake is well documented among women athletes sports where weight is important eg.jockeys,rowers,boxers,ballet dancers,gymnasts etcVegans lSoya milk(fortified with calcium&B12)good alternative to cows milkMalabsorption lIBD,coeliacs&lactose intolerants=reduction in nutrient intake/
14、calcium absorption Dietary Vit DlConsider supplementation of vitamin D lOlder peopleAgeing the permeability of skin to sunlight,the reliance on foodsSupplements are particularly recommended if lilllhousebound lresident in institutionlCare Home.WARNING:fish oil supplements are a rich source of vit D
15、avoid overdoselPureed dietslEthnic attireSunlight is the most important source of vitamin D.In UK,sunlight most effective between approximately the April OctPredictors of Vit D deficiencylA British study of 467 patients lIn 129 patients with hypovitaminosis D normal ALP 76%,normal calcium 90%normal
16、phosphate 95%lIn the 50 patients with the most severe hypovitaminosis D66%vegetarian/vegan72%clothing partially/completely occlusive of sunlight 60%went outdoors 5 times/week lConclusionlroutine measurement of ALP,calcium&phosphate is of no use in predicting hypovitaminosis Dlrisk factors for vitami
17、n D deficiency Good predictors of hypovitaminosis DASSESSMENT OF VITAMIN D DEFICIENCY:USEFULNESS OF RISK FACTORS,SYMPTOMS AND ROUTINE BIOCHEMICAL TESTS GR Smith1,PO Collinson2,PDW KielyFalls assessmentReducing the impact of fallslUsing external hip protectorslincorporated into specially designed underwear l1yr Danish study randomised 665 elderly NH residentslexternal hip protectors lcontrols (no hip protector)lResult50%reduction in hip#in hip protectors group.Problemslbulky luncomfortable(Lauritzen et al 1993)Thank you for listening!Any questions?
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