Aleah M. Rodriguez, PharmD
January 11, 2017

Question

Several dietary supplements claim to prevent falls. Does the evidence support the use of them?

Response from Aleah M. Rodriguez, PharmD
Natural Medicines Research Fellow, Instructor of Pharmacy Practice, Creighton University, Omaha, Nebraska

Of adults aged 65 years or older, 9.6% have reported falling at least once in the past 3 months.^[1] Besides leading to significant costs owing to emergency room visits, falls can affect a person’s quality of life because of fractures and other complications. Dietary supplements, especially vitamin D, creatine, and vitamin B₁₂, are used for fall prevention. Evidence to support the use of these supplements varies.

Vitamin D

Vitamin D receptors are found on muscle tissue. Muscle atrophy has been observed in severe vitamin D deficiency, and supplementation with vitamin D has been shown to increase type II fast-twitch muscle fibers in vitamin D–deficient patients. This type of muscle fiber is the first to be recruited when a quick response, such as fall prevention, is needed.

Vitamin D supplementation has been shown to improve strength, function, and balance in older adults.^[2]These findings have led researchers to investigate whether vitamin D supplementation could reduce fall risk. Studies have varied on the type of vitamin D used (ergocalciferol [D₂] vs cholecalciferol [D₃]), dose and dosing frequency, route of administration, calcium coadministration, and study population (age, sex, community-dwelling versus institutionalized). The majority of studies have addressed the use of vitamin D in older (≥ 65 years) female patients. The results of these studies have been mixed.

Several meta-analyses have attempted to address the heterogeneity among these studies and analyze the combined data. The body of evidence suggests that vitamin D supplementation may reduce the risk for falls by 13%-14% with a number needed to treat of 15.^[3-7] Subgroup analyses suggest that patients with vitamin D deficiency (serum concentration < 12 ng/mL or < 30 nmol/L) or vitamin D insufficiency (serum concentration < 30 ng/mL or 75 nmol/L) can expect a 30%-47% reduction in fall risk.^[4,7]

The reduction in fall risk also appears to be greater with concomitant calcium supplementation; vitamin D plus calcium reduced the risk for falls by 17%-21% in vitamin D–replete (serum concentration > 30 ng/mL or 75 nmol/L) patients.^[3,5,7] Daily doses of vitamin D and calcium used in the trials ranged from 400-800 IU vitamin D₃ plus 500-1000 mg calcium.^[3] Vitamin D doses of at least 700-1000 IU orally once daily without calcium also reduced the risk for falls by 18%-19%, while doses less than 700 IU per day did not appear effective.^[6]

Vitamin D supplementation in community-dwelling patients reduced the risk for falls by 20%-21%.^[5,7]Supplementation in institutionalized patients does not appear effective, but there has been less research on this population.

Subgroup analyses found a statistically significant difference in fall risk reduction only with vitamin D₃and not with vitamin D₂, although there were fewer studies with vitamin D₂. On the basis of this limited evidence, vitamin D₃ should be recommended over vitamin D₂.^[5]

Some studies have used intermittent, high-dose vitamin D such as vitamin D₂ (300,000 IU orally or intramuscularly once, or oral vitamin D₃ 500,000 IU annually). A meta-analysis of these studies found that these intermittent high doses were not effective for fall prevention. Most patients in these studies had sufficient vitamin D levels, but until more is known, this dosing schedule should be avoided. There is some concern that excessive vitamin D levels may negatively affect muscle function and that intermittent dosing may not adequately maintain plasma concentrations over the long term.^[8]

On the basis of these findings and the relative safety of vitamin D, vitamin D₃ 700-1000 IU once daily (with or without calcium) is a reasonable intervention for older adults to reduce fall risk, especially in patients who are vitamin D deficient/insufficient.

Creatine

Aging leads to sarcopenia (loss of muscle mass and strength). Studies suggest that supplementation with creatine may help improve muscle mass, strength, and functional performance both in the general adult population and in older adults, with or without exercise.^[9-11,12] Theoretically, these potential benefits may help reduce fall risk, but currently there is no clinical evidence to support the use of creatine for fall prevention.

There are also safety concerns with creatine supplementation, especially in the elderly. The duration of studies using creatine for sarcopenia has been a month or less, and the long-term safety for use in older patients is unknown.^[12]

Creatine supplementation may also negatively affect renal function. Patients with existing renal disease may experience a worsening of renal function, which may be difficult to recognize because creatine supplements are metabolized to creatinine and cause an increase in serum creatinine unrelated to renal function. Patients with a history of renal disease or those taking nephrotoxic medications may also be at an increased risk for kidney dysfunction.^[13] Due to these concerns, older patients with reduced kidney function may require a creatine dose reduction, but the current evidence is inconsistent.^[12]

Short-term creatine supplementation might improve sarcopenia, but there is not enough data to recommend it for fall prevention.

Vitamin B₁₂

Studies addressing the impact of vitamin B₁₂ supplementation on fall risk have not been published, but moderate to severe vitamin B₁₂ deficiency can cause gait disturbances and ataxia, which increase fall risk.^[14,15]

Absorption of vitamin B₁₂ from food becomes less efficient with aging. The prevalence of vitamin B₁₂deficiency (serum concentration < 200 pg/mL) in the United States is about 6% in patients ≥ 60 years. Approximately 20% of patients in this age group are borderline deficient (200-300 pg/mL). In patients aged 40-59 years, approximately 4% are deficient and 14%-16% are borderline deficient.^[16] Patients with deficiency and borderline deficiency may present with symptoms of inadequate B₁₂.

Risk factors for vitamin B₁₂ deficiency include pernicious anemia, gastrectomy, pancreatic insufficiency, malnutrition, genetic causes, and medications such as metformin, long-term histamine-2 receptor antagonists, and/or proton pump inhibitor therapy. Because vitamin B₁₂ is naturally found only in animal products, people following a vegetarian or vegan diet are also at an increased risk for deficiency.^[15]

Commonly, mild vitamin B₁₂ deficiency presents as fatigue and anemia, while moderate deficiency presents as anemia with some mild neurologic symptoms; however, not all patients experience anemia. Severe vitamin B₁₂ deficiency can include bone marrow suppression, neurologic symptoms, and cardiomyopathy. Neurologic symptoms may include neuropathy, balance and gait issues, abnormal reflexes, and motor and/or cognitive disturbances.^[15]

Patients diagnosed with deficiency and borderline deficiency should receive vitamin B₁₂supplementation. High-dose (1000-2000 µg daily) oral treatment is as effective as intramuscular treatment in patients with neurologic symptoms and is more cost-effective.^[15,17] Parenteral treatment is generally preferred with severe neurologic symptoms or in those with malabsorption.^[15]

References

1. Boyd R, Stevens JA. Falls and fear of falling: burden, beliefs and behaviours. Age Ageing. 2009;38:423-428. Abstract
2. Bischoff-Ferrari HA. Relevance of vitamin D in muscle health. Rev Endocr Metab Disord. 2012;13:71-77. Abstract
3. Gillespie LD, Robertson MC, Gillespie WJ, et al. Interventions for preventing falls in older people living in the community. Cochrane Database Syst Rev. 2012;9:CD007146.
4. Kalyani RR, Stein B, Valiyil R, Manno R, Maynard JW, Crews DC. Vitamin D treatment for the prevention of falls in older adults: systematic review and meta-analysis. J Am Geriatr Soc. 2010;58:1299-1310. Abstract
5. Bischoff-ferrari HA, Dawson-hughes B, Staehelin HB, et al. Fall prevention with supplemental and active forms of vitamin D: a meta-analysis of randomised controlled trials. BMJ. 2009;339:b3692.
6. Murad MH, Elamin KB, Abu Elnour NO, et al. Clinical review: The effect of vitamin D on falls: a systematic review and meta-analysis. J Clin Endocrinol Metab. 2011;96:2997-3006. Abstract
7. Guo JL, Tsai YY, Liao JY, Tu HM, Huang CM. Interventions to reduce the number of falls among older adults with/without cognitive impairment: an exploratory meta-analysis. Int J Geriatr Psychiatry. 2014;29:661-669. Abstract
8. Zheng YT, Cui QQ, Hong YM, Yao WG. A meta-analysis of high dose, intermittent vitamin D supplementation among older adults. PLoS ONE. 2015;10:e0115850.
9. Dempsey RL, Mazzone MF, Meurer LN. Does oral creatine supplementation improve strength? A meta-analysis. J Fam Pract. 2002;51:945-951. Abstract
10. Devries MC, Phillips SM. Creatine supplementation during resistance training in older adults-a meta-analysis. Med Sci Sports Exerc. 2014;46:1194-1203. Abstract
11. Lanhers C, Pereira B, Naughton G, Trousselard M, Lesage FX, Dutheil F. Creatine Supplementation and Lower Limb Strength Performance: A Systematic Review and Meta-Analyses. Sports Med. 2015;45:1285-1294. Abstract
12. Moon A, Heywood L, Rutherford S, Cobbold C. Creatine supplementation: can it improve quality of life in the elderly without associated resistance training?. Curr Aging Sci. 2013;6:251-7. Abstract
13. Yoshizumi WM, Tsourounis C. Effects of creatine supplementation on renal function. J Herb Pharmacother. 2004;4:1-7.
14. Jansen L, Van der linden CM. Falling due to vitamin B12 deficiency [abstract] [Dutch]. Ned Tijdschr Geneeskd. 2013;157:A5132.
15. Hunt A, Harrington D, Robinson S. Vitamin B12 deficiency. BMJ. 2014;349:g5226.
16. Allen LH. How common is vitamin B-12 deficiency? Am J Clin Nutr. 2009;89:693S-669S. Abstract
17. Masucci L, Goeree R. Vitamin B12 intramuscular injections versus oral supplements: a budget impact analysis. Ont Health Technol Assess Ser. 2013;1324:1-24.

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