Is calcium supplementation beneficial for elderly, frail patients with advanced dementia in long-term care for osteoporosis (OP) management, or should it be discontinued to reduce pill burden?

From the Guidelines

For elderly, frail individuals with advanced dementia in long-term care, reducing pill burden by discontinuing calcium supplementation is generally appropriate. The benefit of calcium supplements for osteoporosis prevention in this population is minimal compared to the burden of administration and potential side effects like constipation and medication interactions 1. Focus instead on ensuring adequate dietary calcium through fortified foods and dairy products when possible, which provides around 700-800mg daily for most long-term care diets. Vitamin D supplementation (800-1000 IU daily) remains important even when discontinuing calcium, as it helps with calcium absorption and has additional benefits for muscle function and fall prevention.

Key Considerations

• The decision to discontinue calcium supplementation should be individualized based on fracture risk, life expectancy, and goals of care 1.
• In advanced dementia, comfort and quality of life typically take precedence over preventive measures with marginal benefits, and reducing unnecessary medications aligns with appropriate palliative approaches to care.
• Optimizing dietary intake of calcium is important, especially in patients with increased urinary calcium excretion due to glucocorticoid use 1.
• More research is needed to examine the benefits and harms of supplemental calcium and vitamin D in patients with osteoporosis, particularly in the context of glucocorticoid-induced osteoporosis 1.

Clinical Implications

• Reducing pill burden can improve patient adherence and reduce the risk of medication interactions and side effects.
• Ensuring adequate dietary calcium and vitamin D intake can help maintain bone health and reduce the risk of falls and fractures.
• Individualized care plans should prioritize patient comfort, quality of life, and goals of care, particularly in patients with advanced dementia.

From the Research

Calcium Supplementation in Elderly, Frail Patients with Advanced Dementia

• The use of calcium supplementation in elderly, frail patients with advanced dementia for osteoporosis (OP) management is a topic of interest, with studies suggesting that these patients may be undertreated for osteoporosis 2.
• A population-based study found that people with dementia received less preventive treatment for osteoporosis compared to people without dementia, despite having a higher incidence of osteoporotic fractures 2.
• Another study highlights the importance of treating patients with dementia for osteoporosis, as they are at a higher risk of falls and fractures 3.

Benefits of Calcium Supplementation

• Calcium supplementation, often in combination with vitamin D, has been shown to reduce nonvertebral fractures in elderly patients 4.
• The use of calcium co-medication with bisphosphonate therapy is recommended to improve correct intake and drug adherence 5.
• A study found that a fixed-combination pack of risedronic acid and calcium carbonate improved patient understanding of dosing instructions and preference for the combination packaging 5.

Considerations for Supplementation

• The optimal dosage and regimen for calcium supplementation in elderly, frail patients with advanced dementia are not clearly established 4.
• Recent guidelines suggest measuring 25(OH)D concentration prior to supplementation and providing vitamin D supplementation with optimization of calcium intake to obtain a concentration between 30 and 60 ng/mL 6.
• Daily supplementation is recommended when possible, but intermittent dosing with the smallest available dose and shortest interval between doses may be used as a stopgap until reimbursement or adequate daily pharmaceutical forms are available 6.