In the United States today, milk and infant formula are fortified with vitamin D and frank rickets is now uncommon. Vitamin D Biology Vitamin D is the precursor of calcitriol 1,dihydroxyvitamin Da hormone that has a number of important functions. Vitamin D is synthesized in the skin after UV light exposure or consumed, and then is stored until needed. When the serum concentration of vitamin D is below vitamin d and pain and elderly, both intestinal calcium and phosphorus absorption decrease.
Calcitriol stimulates intestinal calcium absorption by interacting with the vitamin D receptor in the small intestine. The net effect is an enhancement of calcium entry through an epithelial calcium channel. Vitamin D is 25 hydroxylated in the liver in a largely unregulated step and activated to calcitriol by hydroxyvitamin Dalpha hydroxylase in the kidney tightly regulated.
In the physiological state of calcium deficiency PTH levels rise resulting in Renal 1 hydroxylation of hydroxyvitamin D and increased production of 1,25 hydroxyvitamin D. Interaction with the RANK receptor on pre-osteoclasts induces maturation to fully mature osteoclasts that are essential for osteoclastic bone resorption with subsequent release of calcium into the extracellular space 3. One can get vitamin D in two ways: The main dietary sources of vitamin D are vitamin D fortified milk, margarine and cereal, vitamin d and pain and elderly, although fish, liver and egg yolks are good but lesser sources.
Sun exposure specifically UVB light is our predominant source of vitamin D via photo-conversion of vitamin D precursors to pre-vitamin D3 in skin. Considerable seasonal variation in vitamin D stores and bone density exists in people living north of 35oN — North Carolina and south of 35oS — Buenos Aires. Populations living in these latitudes are more susceptible to vitamin D insufficiency.
Furthermore, an elderly person over the age of 70 produces 3. This, combined with less efficient vitamin D intestinal absorption, makes the elderly shut-in patient particularly susceptible to vitamin D deficiency.
Significant amounts of vitamin D supplements must be supplied to overcome these effects. The definition of normal levels of hydroxyvitamin D has changed in recent years as the effects of mild vitamin D deficiency have become known. Although hypocalciuria 24 hour urine may suggest vitamin D deficiency, patients with inadequate vitamin D stores often have normocalciuria. Bone density studies performed on patients at the end of winter were shown to be significantly diminished.
This corresponds to the peak hip fracture time as well as the nadir hydroxyvitamin D level 8. Vitamin D Deficiency Clinical Importance The clinical consequences of vitamin D deficiency include osteomalacia, increased susceptibility to fragility fractures, bone pain, and muscle weakness.
Vitamin D deficiency should be suspected in patients who receive little or no direct sunlight e. Phenytoin, phenobarbital, cadmium, and rifampin are known to interfere with vitamin D metabolism, vitamin d and pain and elderly.
Cholestyramine inhibits vitamin D absorption. Less commonly, there are several known inherited and acquired disorders of metabolism of hydroxyvitamin D to 1,dihydroxyvitamin D. All of these conditions result in a state of secondary hyperparathyroidism. Secondary hyperparathyroidism is known to increase osteoclast activity and increase bone resorption that results in decreased bone density and increased risk of fragility fracture 9. There is a considerable body of evidence now suggesting that vitamin D deficiency contributes to increased risk for falling.
Vitamin D deficiency has been associated with weaker quadriceps, slower reaction times, impaired postural stability, and slower functional performance in one controlled study of patients referred to a fall clinic Treatment and Prevention of Vitamin D Deficiency While there is no generally accepted treatment guideline for vitamin D deficiency, one commonly used strategy is vitamin D 50, units one to three times a week orally for eight weeks followed by units daily. This has been shown to normalize PTH and vitamin D levels.
Repeating these levels vitamin d and pain and elderly be a prudent way to ensure treatment success 4.
One additional caveat is the considerable variability in serum vitamin D levels between laboratories 11, Clearly, vitamin d and pain and elderly, standardization of hydroxyvitamin D measurements is essential.
The combination of vitamin D and calcium supplementation has been shown to significantly reduce the incidence of non-vertebral and hip fractures in two large prospective double blind placebo controlled studies of elderly men and women 8, In these studies and others, it has been difficult to separate out the effects of vitamin D from calcium supplementation. There was no separate calcium supplement. The treatment was well tolerated and inexpensive.
Summary In summary, vitamin D deficiency is extremely prevalent among the elderly and is associated with a higher risk of fracture. Simple treatments with calcium and vitamin D have now been clearly demonstrated to reduce fracture risk and are well tolerated.
Most researchers currently feel that greater amounts of vitamin D are necessary, vitamin d and pain and elderly, particularly during the winter in the northern latitudes. Additional studies will assist in clarifying the specific requirements for vitamin D supplementation. Thomas MK et al, Hypovitaminosis D in medical inpatients. N Eng J Med ; Tangpricha V et al, Vitamin D insufficiency among free-living healthy young adults. Am J Med ; Malabanan M et al, Redefining vitamin D insufficiency.
Dawson-Hughes B et al, Effect of calcium and Vitamin D supplementation on bone density in men and women 65 years of age or older. Dhesi JK et al, Neuromuscular and psychomotor function in elderly subjects who fall and the relationship with vitamin D status. J Bone Miner Vitamin d and pain and elderly ; Binkley N et al, Assay variation confounds hypovitaminosis D diagnosis: Chapuy MC et al, Anti stealing lesson plans D3 and calcium to prevent hip fractures in elderly women.
N Engl J Med ; Trivedi DP et al, Effect of four monthly oral vitamin D3 cholecalciferol supplementation on fractures and mortality in men and women living in the community: Lips P et al, vitamin d and pain and elderly, An international comparison of serum hydroxyvitamin D measurements.
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