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Kumar, Sreenivas, and Kasturi: A ssociation of calcium and Vitamin D levels in fragility fractures in the elderly: A study in a tertiary care centre


Introduction

One of the most common morbidities that is associated with the elderly is the fragility fractures. The main cause of fragility fractures is due to osteopororsis. 1 Osteoporosis is a very common skeletal disease the results in progressive destruction of the skeletal mass and the microarchitecture of the bone. 1 Osteoporosis is estimated to occur in 50% of the females and in 20% of the males worldwide. It is thus, one of the most commonly encountered conditions. 2 The most common complication due to the fragility fractures is death. There has been a marked increase of 3.17 times risk of death in the first year after a fragility hip fracture. In case of vertebral fracture, the risk of death is 2.71 times in the second year. 3

Osteoporosis is of two types- primary osteoporosis, which is due to the normal ageing of the individual, which usually results in the lowered levels of estrogen, and secondary osteoporosis which is due to other diseases such as low Vit D levels, diabetes type 2, cardiovascular disease and others. 4, 5, 6 The causes of osteoporosis can be a mix of genetic, metabolic and environmental factors such as alcohol consumption, smoking, low physical activity, low sun exposure. Medications such as anticonvulsants and glucocorticoids also have a great affect on osteoporosis. 7 The common areas where the fragility fractures occur are pelvis, forearm and ribs in the elderly especially the persons aged more than 65 years. In such patients, the morbidity is high, with severe health and social problems not to mention the increase in expenditure. 8 Hip fractures are usually associated with chronic pain, disability, reduced mobility of the person and therefore a longtime nursing care, with increased mortality rate. The mortality rate is more common in men than women. 9, 10, 11, 12, 13, 14

Therefore, the prevention and the treatment of these fragility fractures is very important to reduce the morbidity and mortality of the patients. Of the various lines of treatments available for osteoporosis, one of the primary managements are Calcium and Vitamin D. 15 Bone consists of a very high density of calcium and this is dependant on the intake of calcium during adolescence. As the age progresses, the density begin to slowly reduce. A high intake in the younger years will help in the slow age related loss of calcium in the body. 16, 17, 18, 19 Inadequate intake of calcium will increase the prevalence of osteoporosis as the age advances. 20 Vitamin D is one of the important agents which helps in the absorption of calcium in the body, and also reduces with age. 21 Apart from calcium homeostasis, Vitamin D also ie reported to have an effect on the muscular strength, receptors of which are expressed in the skeletal muscle tissue. Studies have shown that lower levels of Vit D are associated with a higher risk of falls and fractures. 22, 23

The normal dosage of the supplementation in elderly is 1200 IU of calcium and 800IU of Vit D per day. 24, 25, 26 Vit D insufficiency is classified into mild, moderate and severe. Mild insufficiency ranges from 25-50 nmol/l of serum 25OHD, moderate is 12.5-25 nmol/l and severe is <12.5nmol/l.

This study was done therefore to assess the levels of vitamin D among the elderly with fragility fractures.

Materials and Methods

This prospective hospital based study was done by the Department of Orthopedics at RVM institute of medical sciences and research center from November 2019 to April 2020. 76 patients over the age of 60 years, who had been admitted in our hospital due to fragility fractures were included into the study. All the persons who were included were mobile, either independently or with help such as stick, walking frame or wheel chair. Those bedridden persons who sustained fractures due to falling off were excluded from the study. All the subjects had no serious medical ailments and had a life expectance of another 10 years. Persons who received drugs which can alter the bone metabolism were excluded, such as corticosteroids, anticonvulsants, thyroxine or fluoride salts.

This study was done after the approval of the institutional ethical committee clearance and after attaining the informed consent from all the subjects. The demographic details such as age, height, weight, Body Mass Index was collected from al the patients. They were subjected to medical and clinical analysis. The nature and the extent of the fracture was confirmed by X-Ray of the concerned area. Blood was collected and regular investigations such as hemoglobin, complete blood picture, random blood sugar, cholesterol alkaline phosphatase, creatinine were done using standard methods.

The Vitamin D3 levels were classified as sufficient, insufficient and deficient based on Pearce et al classification1.Statistical analysis using graphs and tables and fisher’s test was done.

Results

76 patients with fragility fractures in different parts of the body were included into the study. Out of them, 21 (27.6%) were males and 55 (72.4%) were females (Figure 1).

Figure 1

Gender categorization of the patients

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All the patients included in the study were above 60 years of age, the mean was 75.9 ± 4.6, with the range being 60 – 92 years, the oldest being 92 years old. The BMI was measured for all the patients based on the height and weight. Out of the 21 males, 1 (4.8%) was underweight, with a BMI of <18.5, 5 (23.8%) had a normal BMI, 14 (66.7%) were overweight while 1 (4.8%) was obese. Among the women, 5 (9.1%) was underweight, 11 (20%) had normal BMI, 26 (47.3%) were overweight, 13 (23.7%) were obese. This data showed that there was a significant relation to a higher BMI and fragility fractures (Table 1).

Table 1

General details of the patients

Variables Males n= 21 Females n=55
Mean Age 75.9 ± 4.6 72.4 ± 7.1
Mean weight (kgs) 82.67 ± 9.1 74.66 ± 4.6
BMI
Underweight (<18.5) 1 (4.8%) 5 (9.1%)
Normal (18.5 – 24.9) 5 (23.8%) 11 (20%)
Overweight (25.0 – 29.9) 14 (66.7%) 26 (47.3%)
Obese ( >30) 1(4.8%) 13 (23.7%)

Majority of the patients with fractures (47.4%) were either walking with 2 sticks or with a walking frame at the time of their fall. 11 (14.5%) of the patients were independently walking, without any support, while 25 (32.9%) of them were walking with slight support, mostly with the help of a stick. In some cases, an attender or a family member aided the patient to walk. 4 (5.3%) of them were on a wheelchair (Table 2).

Table 2

Mobility of the patients

Mobility Number Percentage
Unaided walk 11 14.5%
Walk with help / 1 stick 25 32.9%
Walk with 2 sticks/ frame 36 47.4%
Wheelchair 4 5.3%

At the time of admission, 43 (56.6%) of the patients had insufficient Vitamin D levels in their blood stream, 18 (23.7%) had deficient levels (<25 nmol/lit). 11 (14.5%) had sufficient levels and 4 (5.3% were in the optimal range (>75 nmol/lit) (Table 3)

Table 3

Classification of Vit D levels in patients

Vit D Levels Number Percentage
Optimal (>75 nmol/lit) 4 5.3%
Sufficient (50-75 nmol/lit) 11 14.5%
Insufficient (25-50 nmol/lit) 43 56.6%
Deficient (<25 nmol/lit) 18 23.7%

Most of the patients were admitted due to fracture of the hip during the fall, which was seen in 33 (43.4%). 9 (11.8%) each had fracture of the wrist or hip and wrist, followed by 7 (9.2%) with vertebral fractures (Figure 2 ).

Figure 2

Location of fracture

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At the time of admission, majority of the patients 57 (75%), were not on any supplements, neither calcium of calcium with Vit D. 13 (17.1%) however were taking Calcium as well as Vit D3 supplements and 6 (7.9%) were taking only Calcium supplements (Figure 3).

Figure 3

Supplements taken by the patients

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Discussion

Low vitamin D levels are very often seen in elderly patients along with low calcium levels. This results in fragility fractures in these patients, with severe morbidity and mortality.27

In the present study, the number of females were 2 to 3 times more than the males. A study by Saini et al reported the male to female ration to be 1:3.5, 28 however in other studies such as that by Gallacher et al found no significant difference with sex of the patient to be associated with lower vitamin D levels. 29 The mean age in our study was 75.9 years in males and 72.4 years in females. A study by Gallacher et al reported 80.5 years to be the mean age among the patients with osteoporosis. 30

In our study, 47.4% of the patients were walking with 2 sticks or a frame prior to the fall and subsequent fracture and 32.9% were walking with help or a stick. In a similar study by Saini et al, 52% of the patients walked with the help of a stick and 11.8% of them walked with the help of 2 sticks or a frame. 28

BMI seems to play an important role in the Vit D levels. Around 70% of the patients were either overweight or obese. It has been reported that BMI is significantly associated with the Vitamin D deficiency and could be due to sequestration of Vit D in the compartments of the body fat, thereby reducing the bioavailable Vit D. 30

The daily necessary levels of Vitamin D is 400-800IU. Most of it is attained from sunlight. As the age increases, the outdoor activities of the persons reduces. As the person spends more and more time indoors, the level of Vit D also reduces.

In our study, 56.6% of the patients had Vit D insufficiency and 23.7% were deficient in Vit D. In a study by Saini et al, around 76% of the patients had Vit D deficiency and 16% had insufficient Vit D. These values were higher than that of our study. Another study by Gallacher et al observed 82% to have vitamin D levels less than 70nmol/l and 72% below 50nmol/l. 29 Another study reported about 75% of the patients with the serum 25OHD <50 nmol/l and 68% with 25OHD of <30nmol/l. 31 The Vitamin D levels show regional variation. It has reported to be 36% in Finland, 32, 33 around 50-80% in the US, 34, 35 40-70% in Britain, 36 as high as 90% in Japan. 37, 38

Most of the fragility fractures in our study (60.5%) involved the hip. Others involved vertebrae, wrist and humerus. Hip fractures were the most common type of fragility fractures. In a study by Saini et al, 51% of the patients had hip fractures. 28

Studies have shown that Vitamin D, when administered alone does not have any affect in the prevention of fractures, but when given with calcium as a supplement, there is definitely a positive response. 39, 40 Studies have shown that there was a significant difference between the persons who were on Vit D and Calcium supplementation to those without. 28

It has been reported that elderly patients who have been given high doses of vit D and calcium supplements are at lower risk of falls and fractures. 41 This is because the Vit D is associated with the increase in muscle mass and strength. So a reduction in the vit D levels, would result in lower muscle strength and bone mass. 42, 43 This muscle weakness is reversible, when Vit D is supplemented. 44

Conclusion

Most of the patients were either had insufficient or deficient Vitamin D level at the time of their fall. Therefore, after the onset of menopause and especially in the elderly, it is imperative to keep a watch on the vitamin D levels and supplement calcium and vitamin D in medications so that the risk of fall is reduced. This will further reduce the morbidity, quality of life and cost of hospitalization of the patients.

Source of Funding

None.

Conflict of Interest

None.

References

1 

V Fischer A Ignatius M Haffner-Luntzer M Amling Calcium and vitamin D in bone fracture healing and post-traumatic bone turnoverEur Cells Mater20183536585

2 

K. Lippuner H. Johansson J. A. Kanis R. Rizzoli Remaining lifetime and absolute 10-year probabilities of osteoporotic fracture in Swiss men and womenOsteoporos Int2009207113140

3 

George Ioannidis Alexandra Papaioannou Lehana Thabane Amiram Gafni Anthony Hodsman Brent Kvern The utilization of appropriate osteoporosis medications improves following a multifaceted educational intervention: the Canadian quality circle project (CQC)BMC Med Educ20099154

4 

J. A. Kanis F. Borgström J. Compston K. Dreinhöfer E. Nolte L. Jonsson SCOPE: a scorecard for osteoporosis in EuropeArch Osteoporos201381-2144

5 

S H Ralston A G UitterlindenGenetics of osteoporosisEndocr Rev201031562962

6 

T Miazgowski M Kleerekoper D Felsenberg J J Stepan P SzulcSecondary osteoporosis: endocrine and metabolic causes of bone mass deteriorationJ Osteoporos2012907214

7 

L Lenchik D J Sartoris Current concepts in osteoporosisAJR Am J Roentgenol1997168490511

8 

S P Tuck R M Francis Best practice: osteoporosisPostgraduate Med J20017852632

9 

G S Keene M J Parker G A Pryor Mortality and morbidity after hip fractures.BMJ1993307124850

10 

Nancy Fox Ray Julien K. Chan Mae Thamer L. Joseph Melton Medical Expenditures for the Treatment of Osteoporotic Fractures in the United States in 1995: Report from the National Osteoporosis FoundationJ Bone Miner Res 19971212435

11 

Bahman Y. Farahmand Karl Michaëlsson Anders Ahlbom Sverker Ljunghall John A. Baron Survival after hip fractureOsteoporos Int 20051612158390

12 

Jean-Philippe Empana Patricia Dargent-Molina G Breart Effect of Hip Fracture on Mortality in Elderly Women: The EPIDOS Prospective StudyJ Am Geriatr Soc 200452568590

13 

Kristine E. Ensrud Desmond E. Thompson Jane A. Cauley Michael C. Nevitt Deborah M. Kado Marc C. Hochberg Prevalent Vertebral Deformities Predict Mortality and Hospitalization in Older Women with Low Bone MassJ Am Geriatr Soc 20004832419

14 

Jacqueline R Center Tuan V Nguyen Diane Schneider Philip N Sambrook John A Eisman Mortality after all major types of osteoporotic fracture in men and women: an observational studyLancet199935387882

15 

J Y Reginster Treatment of postmenopausal osteoporosisBMJ200533085960

16 

J P Bonjour A L Carrie S Ferrari H Clavien D Slosman G Theintz Calcium-enriched foods and bone mass growth in prepubertal girls: a randomized, double-blind, placebo-controlled trial.J Clin Invest 1997996128794

17 

R P Heaney Nutritional Factors in OsteoporosisAnnu Rev Nutr 1993131287316

18 

Marjo KM Lehtonen-Veromaa Timo T Möttönen Ilpo O Nuotio Kerttu MA Irjala Aila E Leino Jorma SA Viikari Vitamin D and attainment of peak bone mass among peripubertal Finnish girls: a 3-y prospective studyAm J Clin Nutr 2002766144653

19 

M J Valimaki M Karkkainen C Lamberg-Allardt K Laitinen E Alhava J Heikkinen Exercise, smoking, and calcium intake during adolescence and early adulthood as determinants of peak bone massBMJ19943092305

20 

R. P. Heaney Calcium in the prevention and treatment of osteoporosisJ Intern Med 1992231216980

21 

R P Heaney J C Gallagher C C Johnston R Neer A M Parfitt G D Whedon Calcium nutrition and bone health in the elderlyAm J Clin Nutr 19823659861013

22 

Michael F. Holick Vitamin D DeficiencyN Engl J Med2007357326681

23 

P Yao L Sun L Lu Effects of genetic and nongenetic factors on total and bioavailable 25(OH)D responses to vitamin D supplementationJ Clin Endocrinol Metab2017102110010

24 

A C Ross J E Manson S A Abrams The 2011 report on dietary reference intakes for calcium and vitamin D from the Institute of Medicine: what clinicians need to knowJ Clin Endocrinol Metab2011961538

25 

Michael F. Holick Neil C. Binkley Heike A. Bischoff-Ferrari Catherine M. Gordon David A. Hanley Robert P. Heaney Evaluation, Treatment, and Prevention of Vitamin D Deficiency: an Endocrine Society Clinical Practice GuidelineJ Clin Endocrinol Metab2011967191130

26 

D C Grossman S J Curry D K Owens US Preventive Services Task Force. Vitamin D, calcium, or combined supplementation for the primary prevention of fractures in community-dwelling adults: US Preventive Services Task Force recommendation statementJAMA20183191515929

27 

Paul Lips Vitamin D Deficiency and Secondary Hyperparathyroidism in the Elderly: Consequences for Bone Loss and Fractures and Therapeutic ImplicationsEndocr Rev2001224477501

28 

Aaron K. Saini Edward J.C. Dawe Simon M. Thompson John W. Rosson Vitamin D and Calcium Supplementation in Elderly Patients Suffering Fragility Fractures; The Road not TakenOpen Orthop J201711112305

29 

S. J. Gallacher C. McQuillian M. Harkness F. Finlay A. P. Gallagher T. Dixon Prevalence of vitamin D inadequacy in Scottish adults with non-vertebral fragility fracturesCurr Med Res Opin2005219135561

30 

Roxane Ducloux Estelle Nobécourt Jean-Marc Chevallier Hervé Ducloux Negib Elian Jean-Jacques Altman Vitamin D Deficiency Before Bariatric Surgery: Should Supplement Intake Be Routinely Prescribed?Obes Surg201121555660

31 

O. Sahota Hypovitaminosis D and functional hypoparathyroidism'--the NoNoF (Nottingham Neck of Femur) studyAntiageing200130646772

32 

P. Lips W. H. L. Hackeng M. J. M. Jongen F. C. van Ginkel J. C. Netelenbos Seasonal Variation in Serum Concentrations of Parathyroid Hormone in Elderly People*J Clin Endocrinol Metab19835712046

33 

J von Knorring P Slätis TH Weber T Helenius Serum levels of 25-hydroxyvitamin D, 24,25-dihydroxyvitamin D and parathyroid hormone in patients with femoral neck fracture in southern FinlandClin Endocrinol198217218994

34 

Meryl S. LeBoff Occult Vitamin D Deficiency in Postmenopausal US Women With Acute Hip FractureJAMA199928116150511

35 

J Glowacki S Hurwitz T S Thornhill M Kelly M S LeBoff Osteoporosis and vitamin-D deficiency among postmenopausal women with osteoarthritis un-dergoing total hip arthroplastyJ Bone Joint Surg Am2003851223717

36 

M R Baker H McDonnell M Peacock B E Nordin Plasma 25-hydroxy vitamin D concentrations in patients with fractures of the femoral neck.Br Med J197916163589

37 

M. Sakuma N. Endo T. Oinuma T. Hayami E. Endo T. Yazawa K. Vitamin D and intact PTH status in patients with hip fractureOsteoporos Int20061711160814

38 

T Nakano N Tsugawa A Kuwabara M Kamao K Tanaka T Okano High prevalence of hypovitaminosis D and K in patients with hip fractureAsia Pac J Clin Nutr20112015661

39 

R M Francis F H Anderson S Patel O Sahota T P Van Staa Calcium and Vitamin D in the prevention of osteoporotic fracturesQJM: Int J Med200699635563

40 

D. P Trivedi Effect of four monthly oral vitamin D3 (cholecalciferol) supplementation on fractures and mortality in men and women living in the community: randomised double blind controlled trialBMJ20033267387469

41 

H A Bischoff-Ferrari B Dawson-Hughes H B Staehelin J E Orav A E Stuck R Theiler Fall prevention with supplemental and active forms of vitamin D: a meta-analysis of randomised controlled trialsBMJ2009339oct01 1b3692

42 

Heike A. Bischoff-Ferrari Walter C. Willett John B. Wong Andreas E. Stuck Hannes B. Staehelin E. John Orav Prevention of Nonvertebral Fractures With Oral Vitamin D and Dose DependencyArch Intern Med2009169655161

43 

H. A. Bischoff H. B. Stähelin A. Tyndall R. Theiler Relationship between muscle strength and vitamin D metabolites: are there therapeutic possibilities in the elderly?Zeitschrift für Rheumatologie20005913941

44 

H. Glerup K. Mikkelsen L. Poulsen E. Hass S. Overbeck J. Thomsen Commonly recommended daily intake of vitamin D is not sufficient if sunlight exposure is limitedJ Int Med200024722608



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