Vitamin D and calcium supplementation in the elderly

The evidence about the effectiveness of calcium and vitamin D has been conflicting and there have been some negative studies concerning the effectiveness of calcium and vitamin D supplementation in patients at risk of fractures.

Calcium and vitamin D play major roles in regulating bone homoeostasis and muscle cell differentiation, metabolism, and function

• in observational studies, low dietary calcium intake and low serum vitamin D levels have been associated with loss of bone mineral density, reduced muscle function, falls, and fractures
  • dosing of calcium and vitamin D supplementation
    • calcium (typically up to 1g) combined with 400-800 IU of Vitamin D per day

A meta-analysis examined the association between calcium or Vitamin D supplementation and fracture incidence in community-dwelling older adults and found (1)

• no evidence of reduced fracture incidence associated with calcium and/or vitamin D supplementation

Massé et al undertook a systematic review and meta-analysis to assess the effect of calcium, vitamin D, or combined supplementation on fractures and falls in adults (2):

• found little to no benefit on risk of fracture with calcium, vitamin D, or combined supplementation; all appeared to have little to no effect on other fracture and fall outcomes

An accompanying editorial notes (3):

• “..As Massé and colleagues point out, evidence for specific populations (eg, vitamin D deficient, previous fractures, taking osteoporosis drugs, living in a care home) was limited for several outcomes and leaves some room for doubt on the lack of supplement effectiveness...For most older people, Massé and colleagues’ findings show that calcium, vitamin D, or combined supplementation does not prevent fractures or falls..”

Long-Term Effect of Randomization to Calcium and Vitamin D Supplementation on Health in Older Women

• in post-hoc analysis of 7-year RCT (n=36,282 postmenopausal) (4):
  • supplementation (400mg elemental calcium + 400 IU vitamin D vs placebo) seemed to reduce cancer mortality (HR 0.93, 95%CI 0.87-0.99) & increase CVD mortality (1.06, 1.01-1.12) after more than 20 years of follow-up
    • there was no effect on all-cause mortality

SIGN guidance states (5):

• calcium and vitamin D treatment either alone or in combination are not recommended for prevention of fractures among community-dwelling postmenopausal women and older men
• calcium and vitamin D treatment may be considered for frail older people, for example nursing care residents, who are at high risk of vitamin D deficiency to reduce the risk of non-vertebral fractures
• is not necessary to measure an individual’s serum vitamin D level unless there is a clinical concern of osteomalacia
• is important to ensure patients taking antiresorptive therapy have sufficient calcium and vitamin D intake, through assessment of diet and supplementation with calcium/vitamin D or vitamin D alone accordingly

Notes:

• although the BNF states that pharmacological doses of vitamin D require monitoring, supplementation with 1-1.2g of elemental calcium and 800 iu of vitamin D, as suggested by many regimes for osteoporosis does not usually require routine monitoring of serum calcium levels
  • however patients receiving pharmacological doses of vitamin D should have the plasma-calcium concentration whenever nausea or vomiting are present
  • also caution should be taken on the use of calcium and vitamin D supplementation with thiazide diuretics (which may themselves cause hypercalcaemia)

Reference:

• 1) Zhao JG et al. Association Between Calcium or Vitamin D Supplementation and Fracture Incidence in Community-Dwelling Older Adults: A Systematic Review and Meta-analysis.AMA. 2017 Dec 26;318(24):2466-2482
• 2) Massé O et al. Calcium, vitamin D, or combined supplementation to prevent fractures and falls: systematic review and meta-analysis. BMJ 2026; 393 :e088050.
• 3) Pillay J et al. Calcium, vitamin D, or combined supplementation to prevent fractures and falls. BMJ 2026; 393 :s913.
• 4) Thomson CA et al. Long-Term Effect of Randomization to Calcium and Vitamin D Supplementation on Health in Older Women: Postintervention Follow-up of a Randomized Clinical Trial. Annals of Internal Medicine (March 12th 2024).
• 5) SIGN (January 2021). Management of osteoporosis and the prevention of fragility fractures.
• 6) BNF 9.6.4