MSHO Calcium and Vitamin D PIP

2008 Care Coordinator Training

Q & A Card Summary

Calcium and Vitamin D-specific

What is the recommended dosage for Ca/Vit. D? Food is always the best source for calcium, but it is hard to get the required daily amount in older people as they tend to eat less. All persons over 65 should have an intake of at least 1200mg per day of calcium. Calcium supplements should be taken with food, with no more than 500 mg at one time. Also, remind members to have an adequate fluid intake when they take calcium and that they should also take fiber, which will help with constipation.The current recommended daily intake for vitamin D is 400 IU/day, but newer research is showing that 800 IU/day is needed and that is the recommendation being used in this PIP.

Why are some Ca+ supplements advertised as being “better absorbed?” Even my pharmacist suggested one being better than another. Though you may see this in advertising, in fact, most calcium supplements are absorbed well. Both calcium carbonate and calcium citrate are commonly used supplements and both are absorbed well. Typically, about 30 % of calcium intake from food or supplements is absorbed. Calcium is best absorbed from an acid environment so those who use acid blocking medications to control heartburn or gastric reflux will get better absorption from calcium citrate. This form can be purchased in tablets and liquid and is the form that is used in supplementing orange juice. Some people have trouble with the size of calcium carbonate tablets. These can be crushed or broken or Tums or other chewable forms may be a good choice.

Is there any problem with absorption if Ca+ tablets are crushed? There should be no problem with absorption if the tablets are crushed.

Thyroid

Do you have any information on how thyroid disease affects bone health?

Excess or low thyroid hormones can interfere with your body’s ability to absorb calcium, which can lead to osteoporosis.

Dementia

  • There are studies that show Ca/Vit. D can speed up the development of dementia. What can you tell us about this? Some recent research shows that excess Ca/Vit. D may be related to brain lesions linked to dementia, but this is very preliminary research. The causes of the development of dementias are not known and the mechanisms or metabolic abnormalities that might relate various nutrients to the development of dementias are also unknown. Much more research is needed.

Can we get references for Ca/Vit. D and dementia? For further information, Google Calcium and Vitamin D and Dementia or visit the following web sites*:

  • The Independent:
  • Medical News Today:
  • Our Alzheimer’s.com:

* Note: As with any information you find on the web, you need to consider the scientific credibility of the source of the information and any site reporting second hand on scientific research.

Osteoporosis

What is the prescribed medication for osteoporosis and how does this affect taking a supplement? There are several medications approved by the Federal Drug Administration (FDA). It is important for a member to speak with their physician about which medication may be right for them.In all cases, sufficient vitamin D and calcium will be needed along with the medication for best effect.

Will Ca/Vit. D supplements reverse osteoporosis, or just prevent further bone loss? Bone is living tissue. Throughout our lives, the body breaks down old bone and replaces it with new bone. But as people age, more bone is broken down than is replaced. Ca/Vit. D helps to slow bone loss.Several of the medications used to treat osteoporosis can increase bone mass when used with sufficient vitamin D and calcium.

Exercise

How many side hip raises should a person do 3-5 times a week? This would depend on the current activity level and strength and balance of the person. They may only be able to do one or two. They should increase the number gradually as their capability increases up to a goal of two to three sets of 10-15 repetitions of hip raises between three to five times a week. Similarly, the goal for sit to stand is to work up to 10-15 repetitions without using the hands to push off, but an individual should start where the are and work up gradually.

Do you get as much benefit (in terms of bone density) from an “EFX” or other standing, “constant contact” type of exercise machine vs. a “heal strike” from walking? Arthritis in the knees and/or hips prevents some of my members from walking. For maximum benefit in terms of fall prevention, it is recommended that each person’s exercise routine include both weight-bearing (i.e., walking, swimming, biking, dancing, stair climbing, etc.) and resistance/strength/flexibility and balance training. The effects on bone density are greatest with those activities like walking that have a heel strike. Activities that include maintaining a standing posture, including those with constant contact will be more effective than those that don’t involve standing posture, but not as effective as those involving a heel strike. It is still important to remember that any kind of activity is better than none in promoting health. Have member speak with their physician before beginning any exercise program, to decide which types of exercise are best.

Physician Education

What about physician education and push? Many of my members are not on any type of Calcium or Ca/Vit. D supplement unless we initiate. Also, rarely are physicians routinely checking Vit. D levels to begin with. They are key! The Collaborative sent a physician communication at the initiation of this project. The plans are looking into additional options such as mailings and tools for communicating with providers to help support the initiative. Thank you for your input.

I recommend the PIP committee focus on educating the physicians regarding this project. I have had doctors tell my brother they won’t bother writing a prescription for an OTC medication. The Collaborative sent a physician communication at the initiation of this project. The plans are looking into additional options such as mailings and tools for communicating with providers to help support the initiative. Thank you for your input.

Fall Prevention

Is the number of incidents of falls really rising, or, is it the increased number of elderly population? Both are true. The number of older adults is increasing and the number of falls among those older adults is increasing. It is possible to count with some certainty, the number of fall-related deaths, but the number of nonfatal falls is much greater than those we capture when counting those that result in a call to a health care provider or a visit to the emergency room.

What are the patterns of increase in falls? Where do you see the increase occurring? The detailed data related to falls that would answer this question well are not available. Data systems that routinely collect information on falls other than fatal falls do not exist. Some studies related to the conditions around falls related to traumatic brain injuries are currently underway and may give more insight into more specific patterns that will help us target prevention efforts. As a person ages, their risk of falling increases due to physical abilities such as vision, hearing, sensation and balance. Physical environment and fear of falling also play major roles in falls. The Minnesota Falls Prevention Initiative website has information for both consumers and professionals and consumer materials are now available as downloadable PDFs. Visit Another good site is the Fall Prevention Center of Excellence at Information from this web site is also available in many languages.

Dr. York mentioned funding available for local agencies for fall prevention. How does a county find out more information on funding towards a fall prevention project?

The Minnesota Falls Prevention Initiative operates a listserv that provides information about grants that may be available that can be used for falls prevention activities. Sign up for the listserv on the Falls Prevention Initiative website at

Other

Is there a way to keep track of clients taking OTC Ca/Vit. D when they do not currently have an Rx from their physician? Some of my clients take Ca/Vit. D supplements but forget or just don’t have an Rx. If you happen to come across a member that falls into this category, please notify your participating health plan for future reference.

  • I don’t see men taking Ca/Vit. D supplements. It will be harder to convince male members to take Ca/Vit. D. You can help! Explain to them that as they age, they are at greater risk for falls and that, while low, there are percentages (approx. 2%) of men who do get osteoporosis. Men have a lifetime risk of an osteoporosis-related fracture of almost 1 in 4. Men who fall are more likely to sustain serious injuries including dying from their fall. This may be related to the severity of their other chronic conditions. Calcium and vitamin D have been shown to not only help prevent and manage osteoporosis, but also to help prevent falls. In addition, vitamin D and possibly vitamin D and calcium may help manage other chronic conditions including heart disease and diabetes and prevent cancer.
  • What Ca/Vit. D supplement is easiest on the GI system? Calcium and vitamin D supplements do not usually cause GI upset. Calcium carbonate may sometimes cause constipation. In this case, be sure that the individual is not taking more calcium than is needed and is dividing the dose so they are not taking more than 500 mg at one time. Taking the supplements with meals and making sure they get enough fiber and fluid in their diet is also important. They could also try a different form – liquid or chewable or a different brand. If this does not solve the problem, using calcium citrate may work better.

Are members with end-stage renal disease excluded from the project? There are no exclusions in this project. The primary care provider will need to assess which supplements and which forms are most appropriate given the nature and status of a member’s disease.

Will Ca/Vit. D supplementation be of benefit in the very old (age 80 or 85), if they’ve never taken supplements before? Yes. Older adults can slow the loss of bone and decrease their risk of falls. Since people over the age of 65 are very likely to have inadequate calcium in their diet, a Ca/Vit. D supplement is recommended. There are benefits to all ages, even the very old.

Up to what age should a person (male/female) get a bone density test? Is there a cut-off age where they’re no longer needed? It is recommended that women age 65 and older be screened for osteoporosis using a bone density test like a DEXA scan. The frequency of follow-up scans needs to be determined by the physician. Follow-up scans may be used to monitor the effect of treatment on bone density and the frequency of those scans will vary.

Translations

I have members with a variety of ethnic backgrounds (Hmong, Somali, and Laotian) who cannot read English. Can we get audio tapes made to give to the member for family members to help them better understand? Currently, we do not have audio tapes. This is something the collaborative is working towards and will communicate when a decision has been made. We do, however, have translated flyers that are available to the care coordinators. They are available in Spanish, Somali and Russian, along with English.