A growing number of studies have documented the importance of vitamin D for elderly patients, and many experts are supporting regular supplementation for long term care facility residents. The benefits are numerous and the cost minimal. Yet, inadequate vitamin D intake—and even deficiency—is too common in this population.
With a few simple steps, facilities can take huge leaps ahead in ensuring that their residents get enough vitamin D and enjoy its benefits, such as decreased falls and fewer fractures.
Why Vitamin D?
That vitamin D has benefits is not news, but only recently have studies documented how high a dose is necessary to have a positive impact on the elderly. “Basically, people have not realized the importance of high doses of vitamin D,” says John Morley, MD, physician and Dammert professor of gerontology, director of the Division of Geriatric Medicine, and acting director of the Division of Endocrinology at Saint Louis University School of Medicine. “They thought that as long as patients got some vitamin D supplement, they were getting enough.”
Vitamin D is essential for bone growth and bone remodeling. It also is necessary for promoting calcium absorption and maintaining adequate serum calcium and phosphate concentrations to enable normal bone mineralization and prevent hypocalcemic tetany.
Without sufficient vitamin D, bones can become thin and brittle. Adequate calcium intake, coupled with vitamin D sufficiency, help protect older adults from osteoporosis. However, in recent years, studies have shown that vitamin D can have a positive impact on a wide variety of diseases and ailments that affect the elderly, including diabetes, infections, and cancer.
The best indicator of vitamin D status is serum concentration of 25(OH)D, which reflects vitamin D both produced naturally and obtained from food and supplements. However, it is important to note that serum 25(OH)D levels do not indicate the amount of vitamin D stored in body tissues. Circulating 1,25(OH)2D is not a good indicator of vitamin D status because it has a short half-life of 15 hours, and serum concentrations are not closely regulated by parathyroid hormone, calcium, and phosphate. Levels of 1,25(OH)2D generally do not decrease until vitamin D deficiency is severe.
Many sites in the body recognize or synthesize vitamin D, including skeletal muscle, the brain, the heart, the prostate, dermal capillaries, keratinocytes, macrophages, vascular smooth muscle, leukocytes, the pancreas, and the colon.
The Food and Nutrition Board (FNB) at the Institute of Medicine defines 15 nanograms per milliliter (ng/mL) or higher as an adequate or normal vitamin D level. In his book, “The Vitamin D Solution,” Michael Holick, MD, PhD, notes that currently “many experts agree that both children and adults need a minimum of 1,000 International Units [IU] of vitamin D a day (and preferably 2,000 IU a day) to maintain a blood level of 25-vitamin D that we consider to be healthful.”
He adds, “It’s a bit of a shame that even though all this fascinating and alarming research has emerged since 1997 to change our perspective on vitamin D, the government continues to advocate subadequate daily allowances.” For example, FNB defines adequate daily intake of vitamin D for people aged 51 to 70 as 400 IU and 600 IU for those aged 71 and older.
The Columbia, Md.-based American Medical Directors Association’s “Clinical Practice Guideline: Osteoporosis and Fracture Prevention” is one long term care-specific document that supports a higher dosage. The guideline defines 800-1,000 IU/d or 50,000 IU monthly of vitamin D3 as acceptable supplementation of vitamin D for long term care facility residents.
F. Michael Gloth III, MD, FACP, associate professor of medicine at Johns Hopkins University School of Medicine and corporate medical director at Mid-Atlantic Healthcare in Baltimore, actually supports even greater daily amounts of vitamin D, including input from sunlight. “We have learned that the amount of vitamin D needed to normalize the vast majority of individuals actually is much higher—approximately 4,000 IU daily,” he says.
Low vitamin D levels are associated with many problems, including falls, fractures, and reduced physical functioning. One study has linked low vitamin D with cognitive impairment.
Getting Past The Myths
While it is true that many are touting vitamin D as a miracle product because of its potential to have a positive impact on many diseases and conditions, until recently some studies led people to believe that vitamin D supplementation really didn’t produce significant benefits.
As Gloth explains, “Studies were coming out that used low dosages of vitamin D and showed little impact. Also, many involved patients who were younger and spent more time outdoors. Old standards often were used in studies, and we now know that the doses used were way too low to enable people to respond adequately.
“Studies using higher doses in populations demonstrated to be deficient have shown benefits in many arenas, including falls and fractures, certain infections, seasonal affective disorder, strength, functioning, balance, and even multiple sclerosis,” he adds.
In adults, Holick says that vitamin D reduces the risk of Type 2 diabetes and may improve outcomes with some types of cancer. “We know that prostate cancer is associated with vitamin D deficiency, and one study has shown that vitamin D intake is associated with a reduced risk of breast cancer. It also can help reduce upper respiratory infections significantly,” he says. “If you are vitamin D deficient, you are at higher risk of having and dying from a heart attack. And we are just beginning to appreciate vitamin D’s impact on the autoimmune system.”
There also are many myths and misconceptions about vitamin D that continue to perpetuate, and these may keep practitioners and others from fully appreciating its benefit for their patients. For example, Holick notes, “There is a myth that elderly people can’t absorb vitamin D as well as younger people. While it’s true that they can’t make as much vitamin D as their more youthful counterparts, older people can still benefit from vitamin D exposure.”
Sunshine, Milk Aren’t Enough
Holick notes that while osteoporosis has gotten much attention, people seem to forget about vitamin D deficiency. “Physicians are taught that if you have a well-balanced diet, you won’t be vitamin D deficient, but nothing could be further from the truth. And this condition can have some serious consequen-ces for elders.” It causes people to lose phosphorus in the urine, he says, and it doesn’t permit collagen to be mineralized. People with vitamin D deficiency may have severe bone pain. However, once they receive adequate vitamin D and their levels rise to normal, Holick says, “They have dramatic improvements in terms of pain and feelings of well-being.”
While it is true that sunlight is the best, most natural source of vitamin D, it often is not feasible for nursing facility residents to spend time outdoors. And there are some misconceptions about sunlight that can prevent older people from getting enough rays to get the vitamin D they need. For example, Gloth says, “Many facilities have solariums or sun rooms, and residents sit in these for hours getting the light of day. However, the glass blocks out positive rays, so this exposure does nothing to impact vitamin D status.”
Staff may be concerned about skin exposure and send residents outdoors only with sunscreen coverage. While this may benefit their skin, it doesn’t help their vitamin D absorption. And the truth is that short exposures can make a positive difference in terms of vitamin intake without subsequent skin damage. As Holick says, “If arms and legs are exposed a couple of times a week, that helps.” Morley notes, “You just need about 20 minutes to get adequate vitamin D, and there are little data showing that 20-30 minutes creates much skin damage.”
While foods such as milk are a good source of vitamin D, most experts agree that it is not realistic to rely on dietary intake to get enough vitamin D. As Todd Goldberg, MD, CMD, a West Virginia-based physician, says, “You would have to drink four to eight glasses of milk or more daily to get a minimum daily requirement that still likely would be too low.” He adds, “I certainly encourage people to drink milk, but they shouldn’t count on it as their only source of vitamin D.”
Supplements, Supplements
Since it isn’t practical for elderly long term care facility residents to get adequate vitamin D from sunlight and diet, supplements usually are necessary. Gloth recommends 50,000 IU capsules, two capsules once monthly. “This comes out to between 3,000 and 4,000 international units per day,” he says.
There are two options to get vitamin D in such a large dosage. Vitamin D2 (ergocalciferol) comes from irradiation of yeast and the plant/plant sterol ergosterol. This is a prescription-only product and has a half-life of eight to 10 days. Vitamin D3, an over-the-counter product, comes from oily fish and cod liver oil and has a half-life of 25 to 30 days.
“Most people think of large doses of vitamin D as a prescription product, and it’s easy to see why people have been confused,” says Gloth. In fact, until recently, high-dose vitamin D was only available in a prescription form as vitamin D2. Even now, there are only a few companies manufacturing the over-the-counter high-dose vitamin D3, and many pharmacies don’t carry it.
Gloth says that he recommends vitamin D3 for several reasons. “We think that vitamin D3 is the preferred source of vitamin D if patients are going to take it on a monthly basis. We find that if you take vitamin D2, levels of hydroxyvitamin D rise but taper off rather quickly within a week or so. With vitamin D3, those levels stay up there for a month.”
Some facilities implement standing orders for vitamin D. “All facilities where I work have this standard in place,” says Gloth. “I think this largely is dependent on the medical director or if the facility is in an area where there are experts on aging and bone disease. I don’t see any negatives to making vitamin D a standard. Some people express concerns that people may get toxic, but 4,000-5,000 IU won’t cause toxicity in any of our older patients.”
The benefits of vitamin D supplementation outweigh any burdens, experts concur. “For one thing, it is dirt cheap. You can go online and get 100 capsules of vitamin D3 for $30. It literally costs pennies a year to treat someone,” says Gloth. He notes that some people may want to take vitamin D2 because it is a prescription product that is covered by their drug plan. However, he notes, the cost may be higher than the cost for vitamin D3.
Holick adds, “The cost for D3 is about 25 cents a pill, compared to $7 for the prescription vitamin D2. They are equally efficacious, but the over-the-counter product is more cost-effective. In fact, it is the most cost-effective way of improving health in the elderly.”
For residents who can’t or won’t tolerate a pill or capsule, Holick notes, “You can empty the capsule into juice or milk, and it works fine. Or you can get a liquid form.” Additionally, while oral dosing is recommended, it is possible to administer vitamin D2 or D3 intramuscularly or intravenously—although some data suggest that the IM route may not be as effective.
Vitamin D can be administered daily, weekly, or even monthly, which simplifies medication administration and doesn’t increase the burden on nursing staff. However, Goldberg notes, “it does make a difference when in the day you take it. It is fat-soluble, so it makes sense that it has better absorption with a big meal instead of on an empty stomach.”
To Measure Or Not To Measure
The 25-hydroxyvitamin D test is the most accurate way to measure vitamin D levels in the body. Blood is drawn and tested, and a range of 30 to 74 ng/mL is considered normal, according to researchers F.L. Weng et. al, whose study of risk factors for low serum 25-hydroxyvitamin D concentrations was published in the American Journal of Clinical Nutrition.
While the test is useful, it isn’t always necessary. As Holick explains, “I don’t recommend screening for my nursing facility residents. I believe that all residents should get 50,000 units of vitamin D once a week for eight weeks. This is easier than daily supplementation, and we know it works.” As stated earlier, fears about vitamin D toxicity (defined as having levels of 25-hydroxyvitamin D above 150 ng/mL with high blood calcium) in the elderly are generally unfounded, although only vitamin D supplementation—and not diet and/or sun exposure—can cause toxicity.
As Goldberg explains, “I have had a handful of patients who tested for high levels of D after going on supplementation, but they didn’t experience any noticeable harm.” In the rare instance of toxicity, however, there are serious implications such as nausea, vomiting, loss of appetite, constipation, and weight loss. In more serious cases, toxicity could cause seizures, spasms, or heart problems. However, Holick stresses, “Vitamin D toxicity is extremely rare and happens only in unusual circumstances.”
There are some residents whose vitamin D levels should be monitored once they go on supplementation. These include people with diseases related to malabsorption such as Crohn’s disease and those taking certain anti-epilepsy drugs. Patients who are obese may need higher dosages. Additionally, patients with tuberculosis and sarcoidosis should have their vitamin D levels monitored, as should bypass patients and individuals who are obese. In general, however, “there is no need to broadly screen elderly patients,” says Gloth.
Vitamin D: The Facility’s Friend
The word about the value of vitamin D is spreading rapidly, and more facilities are making high-dose vitamin D a key part of routine care. As Morley says, “Over the last two to three years, many more facilities have begun to make this a standard of care. There will always be early ‘uptakers’ of ideas, and eventually others start to recognize the value and follow suit.”
Most clinicians agree that the benefits of vitamin D—reduced falls and fractures among them—are well worth the low cost. And the flexibility of dosing reduces any additional medication administration time or effort. Clearly, vitamin D’s benefits outweigh any burdens. Morley says, “Once you exclude people with high blood calcium, there is no down side to vitamin D supplementation for our residents.”
Office of Dietary Supplements. Dietary Supplement Fact Sheet: Vitamin D. Available at http://ods.od.nih.gov/factsheets/vitamind.asp.
Joanne Kaldy is a freelance writer and communications consultant based in Harrisburg, Pa.