Ricki Lewis, PhD
Updated recommendations from the US Preventive Services Task Force (USPSTF) continue to support exercise and multifactorial interventions to prevent falls in community-dwelling adults aged 65 years or older, but advise against vitamin D supplementation, according to two statements published online today in JAMA.
"The USPSTF recommendation, with increased emphasis on exercise, warrants adoption and should prove helpful, especially because exercise interventions reduce injurious falls," write Heike A. Bischoff-Ferrari, MD, DrPH, from the University of Zurich, Switzerland, and colleagues in an accompanying editorial. The editorialists add that increasing physical activity reduces risks for other chronic diseases of aging.
Falls are the leading cause of injury-related morbidity and mortality among adults aged 65 years or older in the United States, affecting 29 million people in 2014 alone (28.7% of community-dwelling older adults) with 37.5% requiring medical treatment or restricting activities for a day or longer, according to the recommendation statement. Falls caused approximately 33,000 deaths in 2015.
The new guidelines continue the B recommendation for exercise interventions, which means clinicians should offer or provide the intervention and that there is high certainty that the net benefit is moderate, or moderate certainty that the net benefit is moderate to substantial.
The task force provides a C recommendation for selective offering of multifactorial interventions, which suggests there is limited benefit for some patients.
In contrast, USPSTF now recommends against vitamin D supplementation to prevent falls, with a D recommendation. The D recommendation means the task force discourages use because of moderate or high certainty of no net benefit or that harms outweigh benefits, which is a shift from the previous 2012 recommendation, when supplementation had a B grade.
That downgrade may be in part because USPSTF did not consider individuals taking vitamin D for deficiency for the current recommendation, but did include them in 2012.
An accompanying evidence report reviewed 62 randomized clinical trials involving 35,058 individuals to assess the effects of 7 types of interventions, focusing on three: 26 trials of multifactorial strategies, 21 trials of exercise, and 7 trials of vitamin D supplementation. Multifactorial and exercise interventions were associated with benefits and minimal harms, but vitamin D supplementation had "mixed results," with one trial indicating an increase in falls, number of people falling, and injuries.
Alex H. Krist, MD, MPH, a family physician at Virginia Commonwealth University in Richmond, coauthor and vice chair of the USPSTF, is a big proponent of exercise interventions, but also embraces multifactorial approaches. "Multifactorial interventions start with assessing an individuals' risk of falling and what's contributing to why they might be falling. Then a tailored intervention might include physical therapy, exercise, nutrition therapy, medication management, changing the home environment, and social or community services," he explained in a journal podcast.
Vitamin D, Calcium, and Combined Supplementation
The task force now concludes there is insufficient evidence to assess the balance of benefits and harms for vitamin D and calcium supplementation, alone or combined, to prevent fractures in asymptomatic men and premenopausal women (grade I).
Similarly, the task force says there is insufficient evidence to assess the balance of benefits and harms for supplement use by postmenopausal women for doses exceeding 400 IU of vitamin D and 1000 mg of calcium (grade I), and recommends against daily supplementation with 400 IU or less of vitamin D and 1000 mg or less of calcium in this patient population (grade D).
The task force, however, did find sufficient evidence confirming an increased risk for kidney stones with combined vitamin D and calcium supplementation, and indicating no increased incidence of cardiovascular disease with vitamin D supplementation.
The evidence report for supplementation evaluated 11 randomized controlled trials of 51,419 adults older than 50 years and not institutionalized or known to have vitamin D deficiency, osteoporosis, or prior fractures.
David B. Reuben, MD, from the David Geffen School of Medicine, points out in an editorial published in JAMA Internal Medicine that the recommendations are for patient actions that are ongoing, not a one-time intervention. Parsing data, however, may reveal benefits, he suggests, referring to the Women's Health Initiative, in which hip fracture decreased 29% among women who took at least 80% of the supplement tablets. He suggests that "perhaps the Task Force's recommendation should be for calcium or vitamin D supplementation that includes an intervention to promote high levels of adherence."
Dr Bischoff-Ferrari and colleagues note in their editorial that "the complementary articles reinforce the importance of fall prevention in reducing the risk of fractures (and other injuries) among older adults."
Added Dr Krist in the podcast, "We felt these topics were very similar. We decided we'd bundle the topics to make it easier to understand the evidence."
Dr Bhasin reported funding from AbbVie, MIB LLC, AliveGen, Abbott, Transition Therapeutics, and Novartis and holding equity interest in FPT LLC. The other researchers have disclosed no relevant financial relationships.
JAMA Intern Med. Published online April 17, 2018.
Exercise, rather than supplements like vitamin D, is the best way to avoid falls, the leading cause of injury-related death among people over 65, new US guidelines say