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Vitamin Deficiency in the Elderly

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1 Vitamin Deficiency in the Elderly
by Zoe Salgado Family Medicine Residency Program

2 Vitamins Definition: Cannot be synthesized, therefore must be ingested
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)

3 Vitamins Vitamin A, D, E, K Vitamin C and the B vitamins B1-Thiamine
Riboflavin B3-Niacin Pantothenic acid Biotin B6-pyridoxine B12 folate

4 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

5 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

6 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

7 Overview Vitamin D---DV 400IU Vitamin B12—DV 6 mcg Folic Acid---400mcg

8 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

9 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)

10 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

11 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

12 Vitamin K deficiency Def due to Clinical Manifestations
chronic illness, multiple abdominal surgeries, liver or biliary disease, alcoholism, drugs: Abics(cephalos) Coumadin, salicylates, sulfa Clinical Manifestations Bleeding, hematoma, ecchymosis

13 Vitamin K deficiency Labs: RX Pt/Ptt Vit K level (0.2-1 ng/ml)
Replace Vit K IM( 10 mg/d) , SQ, or PO (5-20 mg) FFP( begin- 2 Units)

14 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

15 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)

16 Vitamin D Deficiency Causes Decreased sun exposure 1-Tangpricha, 2002
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

17 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

18 Vitamin D deficiency Independent predictors Who should be tested?
Low Vitamin D intake Winter Housebound status Who should be tested? Institutionalized or home bound Suspected malabsorption Evaluation of osteoporosis

19 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

20 Vitamin D deficiency and cancer
High levels of Vitamin D may decrease cancer risk One 4year RCT compared Ca( mg) 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

21 Vitamin D serum levels Test to order: serum 25 OH Vit D (calcidiol)
Normal cluster ng/ml(75-80mmol/L) “levels of may lower the fracture risk” No consensus on optimal 25OH concentration for skeletal health

22 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

23 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 IU/d to maintain level of 30 Older persons confined indoors may have low levels even at this intake

24 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


26 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)

27 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

28 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

29 Vitamin D supplementation
For every 40 IU of D3 given, serum OH D increased by ng/ml Rx for deficiency PO: 50,000 units of D3 q week x 6-8 weeks, then IU daily IM : D3 (300,000 IU) in 1 or 2 doses per year Rx for Insufficiency 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

30 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

31 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

32 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

33 B12 level Normal-> 300 pg/ml cobalamin deficiency unlikely
Borderline deficiency possible Low < 200 -deficiency

34 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

35 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

36 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%)



39 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

40 Dosing of B12 Few studies to guide dosing
If pernicious Anemia dose of IM B12 is mcg/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

41 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

42 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%

43 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

44 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

45 Recommendations for folate supplementation
Do NOT take folic acid for reducing cancer risk Evidence unclear and limited regarding association between hypertension and hearing loss

46 Toxicity Water soluble vitamins Fat 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

47 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

48 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) 3. Villareal, Dt,et al, J Clin Endocrinol Metab, 991, Mar ;72 (3) : 4.Bischoff-Ferrari, Ha, et al, JAMA, 2004, April 28;291(16): 5. Broe, KE, et al, J Am Geriatr Soc 2007 Feb;55(2)234-9

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