vitamin d and falls in the elderly???

a recent article, which got some general press, looked at the utility of exercise and/or vitamin D in fall prevention in older women (see vit d not prevent falls jama int med 2015 in dropbox, or JAMA Intern Med. 2015;175(5):703-711). The backdrop here is that falls are common in the elderly, and 20% lead to injury requiring medical attention. a systematic review and meta-analysis documented the benefit of vitamin D (see vit d and falls metanalysis 2011 in dropbox, or J Clin Endocrinol Metab, October 2011, 96(10):2997–3006), finding that in 26 studies with 46K people (majority elderly women), vitamin D was associated with 14% decreased risk of falls (47% in those vitamin D deficient, 10% in those not deficient, and both statistically significant), and this was especially true in patients who had calcium co-administered with the vitamin D. The US Preventive Services Task Force (USPSTF) in 2012 "recommends exercise or physical therapy and vitamin D supplementation to prevent falls in community-dwelling adults aged 65 years or older who are at increased risk for falls", a grade B recommendation. details of the new study:

--2-year double-blind, placebo controlled vitamin D and open exercise trial, with 409 home-dwelling women 70-80 years old in Finland who had at least 1 fall in previous year, did not use vitamin D supplements, and could exercise.

--median age 74, BMI 28, 25(OH) vit D level 27 ng/ml, PTH 5 pg/ml, MMSE 28, 45% with hypertension, 20% cardiovasc disease, 10% diabetes, 25-30% osteoarthritis, <5% depression

--4 groups: placebo without exercise, vitamin D 800 IU/d without exercise, placebo with exercise, and vitamin D 800 IU/d with exercise. exercise was group training 2x/week for first 12 months, then 1x/week, with alternating exercise classes (balance challenging, weight bearing, strengthening, agility, and functional exercises) and gym exercises (weight machines, free weights). also there was a home-training program for 5-15 minutes on all the other days.

--primary outcome: monthly reported falls.  secondary outcome: injurious falls, and the number of fallers and injured fallers

--results: in units of falls/100-person-years

    --placebo without exercise: 118.2, but secondary outcome of injurious fall rate: 13.2

    --vitamin D without exercise: 132.1, but secondary outcome of injurious fall rate: 12.9

    --placebo and exercise: 120.7, but secondary outcome of injurious fall rate: 6.5

    --placebo and vitamin D: 113.1, but secondary outcome of injurious fall rate: 5.0

    --hazard ratios for injured fallers were significantly lower among exercisers, both with (HR 0.38) and without vitamin D (HR 0.47)

    --vitamin D groups did maintain femoral neck bone mineral density and increased trabecular density slightly, vs small losses in the non-vitamin D groups

    --exercise improved muscle strength and balance, and vitamin D added nothing to that

    --adherence: 98.1% with pills and those on vitamin D had 25(OH) D levels increasing to 37.0 ng/ml at 24 months;72.8% for training sessions; 66.1% with home exercises

    --adverse effects: no severe effects/injuries from training program, though 22 in training program and 1 not in program saw MD for musculoskeletal concerns. 

their conclusions:

    --rate of injurious falls and injured fallers more than halved with strength and balance training

    --neither exercise nor vitamin D affected the rate of falls

    --exercise improved physical functioning

so, this study raises several issues. overall this was a group of quite healthy and quite fit women (both their baseline Short Physical Performance Battery and Mini Mential Status Exam were very close to the highest scores possible). but the devil is in the details. despite headlines like "neither vitamin D nor exercise affects overall fall rates in older women" in Journal Watch, and their comment that "these results weaken speculation that vitamin D supplementation alone can prevent falls", this trial was done in women who were not vitamin D deficient: the Endocrine Society in the US defines vitamin D deficiency as <20 ng/ml, and suggests maintenance vitamin D dosages of 1500-2000 IU/day in those who had been deficient-- see vit d Endocrine Guidelines 2011​ in dropbox, or doi: 10.1210/jc.2011-0385.  The meta-analysis above cited has diagrams showing the difference in fall prevention in people who are vs are not vitamin D deficient, though i will append at the bottom a more recent analysis done by the editorialists (see vit d not prevent falls edit jamaintmed 2015 in dropbox, or JAMA Intern Med. 2015;175(5):712-713).

bottom line: this study really does not add much overall. giving vitamin D to healthy, fit 74 year old women (even though they did fall in the year prior to the study), who already have sufficient vitamin D levels -- it is not so surprising that the added 800 IU didn't do much.  the exercise component does show value (as in other studies), though in this study it was not in falls overall but in injurious falls. so, i still would either check vitamin D levels/treat if low in elderly women, or just treat with vitamin D if the latitude and general assessment is that vitamin D deficiency is really common; i would also make sure that there is sufficient calcium in the diet or through supplements. and, of course, i would encourage balance and strengthening exercises. 

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