What are the current recommendations for calcium supplementation in elderly women with regard to osteoporosis prevention?

From the Guidelines

The current recommendation for calcium supplementation in elderly women is 1,200 mg of elemental calcium daily, combined with 800-1,000 IU of vitamin D, as stated in the 2017 American College of Physicians guideline update 1. This total calcium intake includes both dietary sources and supplements. For supplementation, calcium citrate or calcium carbonate are commonly used forms, with calcium citrate being better absorbed, especially for women with reduced stomach acid or those taking acid-reducing medications. Calcium supplements should be taken in divided doses of no more than 500-600 mg at once to maximize absorption, preferably with meals. Calcium carbonate specifically should be taken with food, while calcium citrate can be taken with or without food. These recommendations aim to maintain bone health and reduce fracture risk in elderly women who are at increased risk of osteoporosis due to age-related bone loss and declining estrogen levels after menopause. Adequate calcium and vitamin D are essential for bone mineralization, with vitamin D facilitating calcium absorption in the intestines. Women should also engage in weight-bearing exercise and maintain adequate protein intake to support bone health. Before starting supplements, elderly women should consult healthcare providers to assess their current calcium intake, medication interactions, and kidney function, as excessive calcium can increase the risk of kidney stones in susceptible individuals, as noted in the US Preventive Services Task Force recommendation statement 1. Key considerations for calcium supplementation include:

• The American College of Physicians recommends offering pharmacologic treatment with alendronate, risedronate, zoledronic acid, or denosumab to reduce the risk for hip and vertebral fractures in women with known osteoporosis 1.
• The US Preventive Services Task Force recommends vitamin D supplementation to prevent falls in community-dwelling adults aged 65 years or older who are at increased risk for falls because of a history of recent falls or vitamin D deficiency 1.
• Research is needed to determine whether daily supplementation with greater than 400 IU of vitamin D3 and greater than 1000 mg of calcium reduces fracture incidence in postmenopausal women or older men 1.

From the Research

Current Recommendations for Calcium Supplementation in Elderly Women

• The combination of calcium and vitamin D is effective in reducing the incidence of non-vertebral and hip fractures in elderly women, with recommended dosages of at least 1200 mg and 800 IU per day, respectively 2.
• Calcium citrate is preferred over other calcium salts due to its greater solubility and absorption, and can be taken between meals to minimize side effects and optimize patient compliance 2.
• The importance of calcium co-medication in bisphosphonate therapy for osteoporosis is emphasized, with recommendations for calcium supplements or calcium/vitamin D combinations to be taken in amounts ranging from 500 to 1000 mg/day above individual dietary intake 3.
• A fixed-combination pack of bisphosphonate and calcium can improve patient understanding of dosing instructions and increase adherence to therapy 3.

Dietary Recommendations for Calcium and Vitamin D

• A diet high in fruits and vegetables, adequate in protein, and with adequate calcium and vitamin D intakes through low-fat dairy or calcium-fortified foods is recommended for optimizing bone health 4.
• Supplemental calcium can be used to meet individual needs, with 500 mg or less consumed at each meal to optimize absorption 4.
• Vitamin D intakes of at least 600 IU per day (up to 1000 IU/day) are recommended for individuals older than 70 years, in addition to a calcium requirement of 1200 mg per day 4.

Practical Approach to Calcium and Vitamin D Supplementation

• Daily supplementation with 800 IU of vitamin D is advocated in most guidelines and appears to be safe, without the need for prior determination of vitamin D levels 5.
• Calcium supplementation should be tailored to the patient's need, usually 500 mg per day, to achieve a total intake of 1,200 mg or 1,000 mg per day 5.
• Calcium citrate is preferred over calcium carbonate due to its better absorption, independent of intake with meals 5.

Calcium and Vitamin D Needs in Elderly Women

• Postmenopausal women should consume 1000-1500 mg of calcium and 400 to 800 IU of vitamin D per day to minimize bone loss 6.
• High-dose calcium supplementation can modestly reduce cortical loss from long bones, while vitamin D enhances the effectiveness of supplemental calcium 6.