As a result of hearing this PT’s comment I searched the literature again and looked at falls through a different lens, the one that views the null hypothesis of drugs not causing falls. In an article published in 2003 in Pharmacy & Therapeutics, the authors stated: “Beta- blockers do not contribute to falls”. Perhaps they needed to know about the systemic effects of beta blocker eye drops because Australian data have proven timolol eye drops to be the number one risk factor for falls in patients with glaucoma. (One must also understand that any drug that can cause bradycardia or hypotension can cause a fall.) The authors also stated that “Chronic therapy with blood pressure lowering medications rarely cause falls.” They referred to older studies and meta-analyses from the 1990′s, clearly older evidence that conflicts with more recent data.  I found other references that state medications are key contributors to falls, and that is also backed by years of professional experience where changes in antihypertensive medications eliminated dizziness and reduced the incidence of falls. Dr. James Cooper, PharmD, has shown that medications play a key role in causing falls, as reviewed in Medication Interventions for fall prevention in the older adult, Pharmacy Today, 2009 where he referred to his research in reducing the incidence of falls in nursing home residents by 70%. The literature is replete with references showing that alterations in medications reduces the incidence of falls in older adults, and I could fill a few pages with those validated studies.

I am fascinated by the conflicting “evidence” in the literature, and it is now beginning to amuse me. It also shows me that years of reviewing the literature, combined with clinical experience, helps paint a clearer picture that precludes any conclusions from a meta-analysis or retrospective database review that implies cause and effect after “adjusting for confounding factors”. If I followed the advice in some of the literature over the last couple of years I would: Adhere to a complex medication regimen that causes me to be cognitively impaired, dizzy and  to fall down the stairs breaking a hip, all because someone said non-adherence causes falls. I would have also stopped taking my calcium, because it is associated with higher risk of death, for which I then might be at greater risk of fracture. I would also have stopped taking a multivitamin with iron and become anemic, thereby further contributing to my risk of falling by causing weakness, and last but not least, I would be typing this post from my nursing home room.

If you don’t know where to look then you won’t know where to find the truth. It’s also wise to work as a team addressing all the identifiable risk factors for falls.

All older adults (>65y/o) should have their vitamin D blood level checked by their physician. If it’s low, <30, they should be treated in order to get that blood level up to about 40.  Supplements may be needed to maintain that blood level over time. Vitamin D is an essential nutrient and many of us do not make enough due to inadequate sun exposure, along with the fact that this mechanism doesn’t work well as we get older. (NOTE: The IOM INCREASED the recommended daily amount of vitamin D to 800 units for older adults, a very conservative number, and set the upper limit at 4000units a day.) We recommend that older adults consider achieving daily intakes between 1000 and 2000 units if there are no reasons why they should not. Keep in mind, more processed foods are now supplemented with vitamin D so you need to count how much you normally take in each day, and don’t forget most multiple vitamins contain about 400 units. In summary, if you are an older adult who has had a low level, continue with what your doctor told you. Most older adults are safe with taking a daily supplement. An excellent review of the benefits of vitamin D can be found at the Linus Pauling Institute at Oregon State University. Here’s the link: http://lpi.oregonstate.edu/infocenter/vitamins/vitaminD/index.html

Regarding calcium, the daily recommended intake for older adults is set in the report summary between 1200mg and 1500mg daily, which is what we normally recommend. There’s really no big deal into this report and you should appreciate the benefits to getting enough calcium and vitamin D each day as they are essential nutrients. The IOM report in brief is in PDF format in the link below.

http://www.iom.edu/~/media/Files/Report%20Files/2010/Dietary-Reference-Intakes-for-Calcium-and-Vitamin-D/Vitamin%20D%20and%20Calcium%202010%20Report%20Brief.pdf

Now for some guidance when it comes to health information in the news. Watch out! This is the worst source of information, the general news media. We have a link to the National Institute of Aging web site that provides you with a publication on how to interpret what’s in the news and other health research findings. Take a look at the link below. It will help you stay on track and not get so confused when you hear conflicting information.

http://www.nia.nih.gov/NR/rdonlyres/43F218DA-2188-40BC-90CE-7B740E8FA701/10421/Understanding_RiskWhat_Do_Those_Headlines_Really_M.pdf

It has long been understood that B-12 deficiency can cause anemia, neuropathy and, if severe, memory loss which can be irreversible if left untreated. Prevention is your best best to staying healthy as you age. Make sure you take the supplements recommended for older adults to help manage risk since prevention is more efficient than reacting to a deficiency and trying to correct it before it’s too late. Check out my blog on supplements. The link is below.

http://elderdrugs.com/2010/05/supplements-what-older-adults-should-take/

Here’s the skinny: Don’t bother to take stock in this article. We all know that dietary sources of calcium are most reliably absorbed and should be the mainstay of calcium intake. But if we are calcium-deficient, we need to consider a supplement to get our daily intake to 1200-1500mg of (elemental) calcium. You know, it’d be ironic if we learned that it’s not the calcium supplement that’s correlated with higher cardiovascular risk but that most calcium supplements are poorly absorbed. So perhaps it’s more a calcium deficiency? Hmmmmm, now that would be interesting! Especially since about 25% of older adults take “Prilosec-like” drugs (proton pump inhibitors) that reduce calcium absorption. Oh well, more information is needed before changing calcium intake recommendations. In the mean time, eat a balanced diet that targets foods with the important micro-nutrients you need to age well, such as calcium, vitamin D, and B-12 in amounts that are now recommended by the huge body of literature that says they’ll help you and not harm you.

Calcium

Over 50% of the American population is deficient in calcium, a vital nutrient needed to help maintain bone health and reduce our risk of a life-altering fracture. As we age our bones become less dense and this predisposes us to a fracture. Calcium intake, when high enough, has been shown to reduce our risk of a fracture but it must be maintained throughout the life-cycle.

If our bones become less dense to the point of developing osteoporosis, we may need a bone health drug like Fosamax, Actonel or Bonvia, in order to maintain or build back our bone density. Calcium is needed to help these drugs work properly. In fact, taking a bone health drug without sufficient calcium may even be dangerous in some people.

How much calcium do I take? The recommended amount of calcium, measured or expressed as the elemental amount of calcium, is between 1200 and 1500mg per day for an older adult. Setting a target of 1200mg is a good start. But can’t I get calcium from foods? The answer is yes but have you ever done a “calcium count” to see how much calcium you ingest each day? Each glass of milk has 300mg of calcium. Many orange juice and yogurt products are fortified with calcium. So it is possible to get enough calcium each day from your diet, which is preferred, but if you count your calcium intake each day for three days, you’ll be surprised that you may not be reaching the required amount. To find a list of foods with their calcium content, search our articles section under nutrition and look for calcium-rich foods.

So if I am not getting enough calcium in my diet, is a supplement a good idea? Yes, a supplement is just that, a supplement to add to your diet when your aren’t getting enough calcium from foods. Most supplements express the amount of calcium as elemental calcium so if you see a supplement that says Calcium 500mg, then you can take one of these to add to a diet that may contain 1000mg of calcium to reach 1500mg per day. CAUTION: A recent study published in the British Medical Journal, 2010; 341:c3691, reported a moderate increase in the risk of myocardial infarction in those who took calcium supplements WITHOUT vitamin D. Even though the risk is moderate, we caution on erring to the side of conservatism and take calcium with vitamin D and always look first to getting your calcium first from dietary sources. (Other studies show there was not a higher risk when calcium was obtained from dairy and other dietary sources.) Updated Feb. 17, 2012: More recent data show no link with the use of calcium supplements and increased mortality, and a review of the literature and analysis does not support the claim that calcium supplements are associated with harm.

But what about all the different forms of calcium? Now it can get confusing! Calcium comes in many forms or salt forms. The most common is calcium carbonate, which is readily available and cheap. However, calcium carbonate is poorly absorbed and can be even more poorly absorbed if you are taking drugs like Nexium, Prilosec, Aciphex and Protonix, drugs which cut the production of acid in your stomach. Because of this these drugs were shown to increase the risk of fractures. It is thought that this happens since acid is needed to absorb calcium carbonate and these drugs eliminate the much needed acid. One alternative is to take your calcium supplement with food, always. Food aids in the absorption of calcium. However, one sure-fire way of making sure you get all the calcium absorbed is to take another form of calcium, called calcium citrate. This form is absorbed even without acid in the stomach and can be taken without food.

Vitamin D – The ‘Sunshine Vitamin’

Isn’t vitamin D needed to absorb calcium? Yes, and many older adults are also deficient in vitamin D. Vitamin D is actually a potent hormone just misnamed as a vitamin. It’s also called “the sunshine vitamin” but that is misleading since most older adults don’t make vitamin D from sun exposure and many of us use sunscreen that blocks the conversion to active vitamin D in the skin. So what I’m getting at is, yes, you need to take additional vitamin D.

Vitamin D is shown to also reduce fall risk and reduce the risk of fractures. What is also interesting is that vitamin D may improve cognition or memory in those who are deficient. The amount of vitamin D recommended for older adults is 1000 to 2000 units each day. You can take it once daily whereas calcium must be taken no more than 600mg at a time which may require more than once daily dosing. If you are an older adult you should have your vitamin D level checked by your doctor since supplementation doesn’t always get your blood level up to where it should be. That’s when the doctor may prescribe a “whopping dose” of vitamin D for a short period of time to get your blood level up into the healthy range. Then you can take supplements to help keep it there. Otherwise, most people who are not deficient can take the above recommended amount.

Vitamin B-12

Vitamin B-12 is an important vitamin for older adults. In fact, vitamin B-12 deficiency can lead to serious anemia but also irreversible nerve damage or even memory loss. And this is another vitamin that is affected by low acid levels in the stomach and was also shown to be poorly absorbed in those taking the acid suppressing drugs mentioned above. As we get older we can also lose the ability to absorb vitamin B-12 efficiently so it is recommended to take higher doses to ensure you get enough absorbed. You can take up to 1000 micrograms each day and it would be safe. Vitamin B-12 tablets are available over the counter and are inexpensive. Updated Feb. 15, 2012: A recent literature search came up short in producing strong evidence that PPIs reduce vitamin B-12 levels in the body. However, that analysis had a limitation in that it did not address that a B-12 level alone is not necessarily a good indication of early B-12 deficiency, and that other more sensitive tests may detect signs of B-12 malabsorption from PPIs. That analysis also suggested a different mechanism of how PPIs reduce B-12 absorption, that being the drug effect on parietal cells (stomach cells that produce acid and other gastric enzymes) that leads to reduced secretion of intrinsic factor, the factor needed to absorb B-12. However, some data suggest intrinsic factor is not necessarily needed if B-12 supplementation is high enough, and that B-12 gets absorbed by a passive mechanism when its stomach concentration is high enough.

Multiple Vitamin

Another supplement that is recommended  is a multiple vitamin. We can’t possibly get all the vitamins we need from food and other “B-vitamins”, such as vitamin B-6, are needed to prevent anemia from developing that are more common in old age. Taking a multiple vitamin can’t hurt and can only help. However, if you eat 3-5 servings of vegetables each day, perhaps you can do without a multiple vitamin.

There you have it, your “pot pourri” of supplements and here’s the list to summarize.

1) Calcium 1200-1500mg each day

2) Vitamin D 1000- 2000 units each day

3) Vitamin B-12 up to 1000mcg each day

4) Multiple vitamin  One each day