Vitamin deficiency in the elderly
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Vitamin Deficiency in the Elderly. by Zoe Salgado Family Medicine Residency Program. Vitamins. Definition: Chemically unrelated organic compounds that are essential for normal metabolism Cannot be synthesized, therefore must be ingested

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Vitamin Deficiency in the Elderly

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Vitamin Deficiency in the Elderly

by Zoe Salgado

Family Medicine Residency Program


Vitamins

  • Definition:

    • Chemically unrelated organic compounds that are essential for normal metabolism

  • Cannot be synthesized, therefore must be ingested

  • Different from minerals (Ca, Fe) or food supplements (Herbs)


Vitamin A, D, E, K

Vitamin C and the B vitamins

B1-Thiamine

Riboflavin

B3-Niacin

Pantothenic acid

Biotin

B6-pyridoxine

B12

folate

Vitamins


Vitamin deficiency

  • Gross deficiencies are recognized by clinical syndromes

  • Are seen in poorer areas

  • Seen in Western societies in special populations

    • Elderly, vegans, new immigrants, the very poor, alcoholism, malabsorption (hx gastric bypass), parenteral nutrition


Daily values

  • Daily values=DV, prior known as RDA

  • established by the National Research Council and National Academy of Sciences

  • may not be sufficient for chronic disease

  • normal values in general are uncertain

  • many people have suboptimal levels


Question

  • Can optimizing vitamin intake prevent chronic disease?

    • some biochemical abnormalities can improve with intake, then reach a plateau causing no further improvement >>suggests a correctable metabolic disease Eg:

    • 1.homocysteine levels increase as folic acid decreases

    • 2. Methylmalonic acid levels increases with low B12

    • 3. PTH rises with low Vitamin D


Overview

  • Vitamin D---DV 400IU

  • Vitamin B12—DV 6 mcg

  • Folic Acid---400mcg


Vitamin A

  • First fat soluble vitamin to be discovered

  • Part of compounds called retinoids

  • Essential for vision, immune response, epithelial growth and repair

  • Can store 1 year of reserve

  • RBP=retinol binding protein-bonds to Vitamin A in blood


Requirements

  • Males > 10 yo need 1000mcg

  • Females > 10yo need 800 mcg

  • only 40-60% plant bioavailability vs 80-90% of animal protein

  • Zinc and/or Iron deficiency can interfere with metabolism

  • LABS

    • -RBP, CBC, serum retinol(costly)


Vitamin A deficiency

  • Complications

    • Dry skin, dry hair, broken nails-may be first sign

    • Night blindness

    • Xeropthalmia-no tears-predisposes to blindness

    • Hyperkeratosis-goose bump skin


Vitamin K(VK)

  • Found in green, leafy vegetables and oils

  • Plays a role in coagulation cascade

  • Body’s reserve lasts one week

  • 85% absorbed in terminal ileum


Vitamin K deficiency

  • Def due to

    • chronic illness, multiple abdominal surgeries, liver or biliary disease, alcoholism, drugs: Abics(cephalos) Coumadin, salicylates, sulfa

  • Clinical Manifestations

    • Bleeding, hematoma, ecchymosis


Vitamin K deficiency

  • Labs:

    • Pt/Ptt

    • Vit K level (0.2-1 ng/ml)

  • RX

    • Replace Vit K IM( 10 mg/d) , SQ, or PO (5-20 mg)

    • FFP( begin- 2 Units)


Vitamin D

  • Few foods contain Vit D (fatty fish and eggs)

  • Dermal synthesis or fortified foods (milk) are the main source

  • Two forms of Vitamin D-

    • Ergocalciferol -Vit D2

    • Cholecalciferol-Vit D3


Vitamin D Metabolsim

  • Vitamin D3 is synthesized in the skin during UV light exposure

  • Vit D3 from skin or diet is then hydroxylated in the liver, then kidneys to active form Vit D dihydrohycholecalciferol (calcitriol)


Vitamin D Deficiency

  • Causes

    • Decreased sun exposure

      In Boston and Edmonton Vit D cutaneous production ceases in winter (1)

      Low dietary intake/absorption

      • Half of elderly women take in less than 65 units/day

      • Achlorydia-common in elderly, decreases vitamin absorption

      • NOT common in IBD (including Chron's) per AGA guidelines

        1-Tangpricha, 2002


Prevalence

  • MSK pain (unrecognized !!!!!!)

  • Hospitalized pts

  • Women being treated for OP

  • CKD (usually 1,25DOH but also 25OHD

  • GI malabsorption

  • Gastric bypass

  • Cystic fibrosis

  • Extensive burns


Vitamin D deficiency

  • Independent predictors

    • Low Vitamin D intake

    • Winter

    • Housebound status

  • Who should be tested?

    • Institutionalized or home bound

    • Suspected malabsorption

    • Evaluation of osteoporosis


Vitamin D Deficiency and Bone health

  • Osteoporosis

    • Postmenopausal women with low 25 OHD levels have lower bone densities (3)

  • Falls

    • Meta analysis of 5 RCT with 1237 older patients, Vit D use reduced falls by 22% compared to Calcium or placebo (4)

    • One RCT of nursing home residents found 50% fall reduction over 5 months with Vit D 800 IU BUT not at lower doses(5)

      • 3-Villareal, 1991, 4-Bischoff-Ferrari, 2004, 5-Broe, 2007


Vitamin D deficiency and cancer

  • High levels of Vitamin D may decrease cancer risk

  • One 4year RCT compared Ca(1400-1500mg) alone, Ca + Vit D (1100IU/d) or placebo in 1179 women > 55yo (2)

    • Results: both Ca and Ca/Vit D appear to decrease the risk of incident cancer ( after 1 year RR 0.23, 95% CI)

    • Other RCT using different doses of Vit D have not found risk reduction

      • 2-Lappe,2007


Vitamin D serum levels

  • Test to order: serum 25 OH Vit D (calcidiol)

  • Normal cluster 30-32 ng/ml(75-80mmol/L)

  • “levels of 28-40 may lower the fracture risk”

  • No consensus on optimal 25OH concentration for skeletal health


Vitamin D serum levels

  • Different definitions of deficiency

  • Option #1

    • Vit D Insufficiency= 20-30ng/ml

    • Vit D Deficiency=< 20 ng/ml

  • Option #2

    • Vit D deficiency 9-28

    • Severe deficiency 8 or less


Optimal intake

  • 1997 national academy of sciences recommendation:

    • 400IU/d age 51-70

    • 600 IU/d age > 71

    • However more recent data shows avg adult needs 800-1000IU/d to maintain level of 30

    • Older persons confined indoors may have low levels even at this intake


Vitamin D levels in NHCU

  • Total patients in NHCU=85

  • # of patients tested 23

  • Moderate deficiency= 16

  • Severe deficiency (levels at 8 or less)=3

  • Normal=4

  • 82% of those tested had moderate deficiency, 13% had severe deficiency


25 OHD LEVELS OVER TIME IN NHCU

25 OHD LEVELS TESTED IN 23 PATIENTS March 2008


Vitamin D in NHCU

  • Of those tested:

    • Dx of falls=3…..(all had moderate deficiency)

    • Dx of fx= 5…..(4 had deficiency, one with severe deficiency)

    • Dx MSK pain=4.….(3 with moderate deficiency, 1 with severe)

    • Dx of OP=2…..(1 with deficiency, 1 normal)


NHCU Vitamin D Data

  • 1 1 patient with no MSK hx at all had Vit D level of 6

  • The highest Vit D level of 61, pt had hx of osteopenia

  • # of patients with continued current deficiency =14, of those only 7 were being treated


Current Recommendations

  • Do NOT screen (Grade 2C), but give supplementation below(Grade 2B)

  • Daily 800 IU at least and 1.2 g of elemental calcium

  • Lower intake-not as effective

  • Higher intake( safe upper limit 2000IU/day)-hypercalcemia

  • DO NOT recommend switching from daily 800IU to high dose intermittent (100,000 units q 4 months) unless pt is noncompliant


Vitamin D supplementation

  • For every 40 IU of D3 given, serum 25-OH D increased by 0.3-0.4 ng/ml

  • Rx for deficiency

    • PO: 50,000 units of D3 q week x 6-8 weeks, then 800-1000 IU daily

    • IM : D3 (300,000 IU) in 1 or 2 doses per year

  • Rx for Insufficiency

    • 800-1000 IU of D3 daily( will bring avg adult to serum level of 30 in 3 months)

  • Measure serum levels after 3 months of starting rx


Vitamin B12

  • Deficiency causes:

    • Neurologic disease

    • Megaloblastic anemia, pernicious anemia

    • May be important cause of hyperhomocysteinemia (CV disease, OP)

  • Subtle deficiency even without anemia may cause dementia and ?balance problems


TABLE 1 Clinical Manifestations of Vitamin B12 Deficiency

Hematologic

Megaloblastic anemia

Pancytopenia (leukopenia, thrombocytopenia)

Neurologic

Paresthesias

Peripheral neuropathy

Combined systems disease (demyelination of dorsal columns and corticospinal tract)

Psychiatric

Irritability, personality change

Mild memory impairment, dementia

Depression

Psychosis

Cardiovascular

Possible increased risk of myocardial infarction and stroke


Suboptimal B-12 deficiency

  • Caused by poor absorption and inadequate intake

  • Malabsorption-cobalamin unable to release from dietary proteins esp with low gastric acid secretions

  • Alcoholism


B12 level

  • Normal-> 300 pg/ml cobalamin deficiency unlikely

  • Borderline 200-300-deficiency possible

  • Low < 200 -deficiency


B 12 deficiency

  • Pts with low normal or even normal B12 levels may be deficient

  • Homocysteine (HC) and methylmalonic acid(MMA) levels will be high with deficiency


B12 deficiency

  • If deficiency measured by methylmalonic acid levels rising with low intake and falling with supplementation, there may be deficiency with even normal levels

  • One study showed 82% deficiency in 282 elderly patients


Monitoring B 12 deficiency

  • If folate> 4 ng/ml and cobalamin >300pg/ml, deficiencies unlikely, no further testing

  • If either of above levels are low, check methylmalonic acid and total homocysteine levels

    • If both normal>no deficiency

    • If both are high>clear B12 deficiency

    • If MMA is normal and HC is high, folate deficiency (sens 86%, spec99%)


B12 LEVELS IN NHCU

  • TOTAL PATIENTS=85

    • TOTAL TESTED=73

    • DEFICIENCY=0

    • BORDERLINE=7

    • NORMAL/HIGH=66

  • OF 73 TESTED PATIENTS, 66 HAD NEUROPSYCHIATRIC DIAGNOSIS

  • 9% PATIENTS TESTED HAD BORDERLINE DEFICIENCY


B 12 LEVELS OVER TIME NHCU


Recommendations for B12 supplementation

  • Older adults - 6mcg daily

  • Vitamin supplements have 100 mcg/dose

  • May be inadequate dose in:

    • Elderly

    • Atrophic gastritis

    • Vegans

    • Gastric bypass sx

    • Alcoholics

    • Poor dietary intake


Dosing of B12

  • Few studies to guide dosing

  • If pernicious Anemia dose of IM B12 is 100 -2000mcg/day (no toxicity at higher doses)

  • One RCT suggests dosing at higher than 50mcg/day may be needed to normalize B12 (no known toxicity at this level)

  • In high risk pts-recommendation to have periodic monitoring of either methylmalonic acid or B12 level


Folic acid

  • Found in green leafy vegetables, fruits, cereals, nuts, mats

  • Folic acid (the supplement form) has same effect but more bioavailable than folate

  • Deficiency leads to megaloblastic anemia


Folic Acid in Pregnancy

  • Decreases risk of neural tube defect

  • Appears dose dependent

    - In one study

    400 mcg decreased rate of NTD by 57%

    5000mcg decreased rate by 85%


Folic acid in Cardiovascular Disease

  • Elevated homocysteine associated with increased risk of CV disease

  • Folic acid, B6, B12 can decrease homocysteine

  • However RCTs of supplementations for secondary prevention do NOT support a beneficial effect of vitamins in CV disease


Folic acid and cancer

  • A functional polymorphism in MTHFR(major enzyme in folate metabolism) linked to colorectal cancer, >>Folate may protect DNA against damage during cell division

  • One RCT

    • -1 g of folic acid vs placebo in 1021 pts with colorectal adenoma found no difference in the risk of new adenoma at 3 years RR 1.04, 95%CI but found high risk of advanced lesions at 3 years

    • At 6 years f/o with colonscopy 607 pts results were repeated


Recommendations for folate supplementation

  • Do NOT take folic acid for reducing cancer risk

  • Evidence unclear and limited regarding association between hypertension and hearing loss


Toxicity

  • Water soluble vitamins

    • toxic at thousands x the DV

    • Vitamin C-increased risk of kidney stones-controversial

  • Fat soluble vitamins

    • Vit D- hypercalcemia at dose of 2000IU/d

    • Vitamin A –pregnancy-teratogenic

    • Vitamin E- above 400 IU may be associated with all cause mortality


Toxicity

  • Vitamin A -HA, dizziness, blurred vision, clumsiness, birth defects,

  • Vitamin D-Constipation, weakness, anorexia, weight loss, confusion

  • B3-Niacin-Flushing, redness of skin,

  • B6-pyridoxine-Numbness, paresthesia, ataxia

  • Vitamin C-kidney stones

  • Folate-can mask B12 deficiency


  • 1. Tangpricha, V et al, Am J Med 2002, June 1:112(8)659-62

  • 2.Lappe,LM, et al, Am J Clin Nut, Jun 85(6) 1586-91

  • 3. Villareal, Dt,et al, J Clin Endocrinol Metab, 991, Mar ;72 (3) : 628-34

  • 4.Bischoff-Ferrari, Ha, et al, JAMA, 2004, April 28;291(16):1999-2006

  • 5. Broe, KE, et al, J Am Geriatr Soc 2007 Feb;55(2)234-9


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