Prof Y Barak, MD, MHA1 Elderly psychiatric patients at risk of folic acid deficiency: A case controlled study D. Mazeh, A. Cholostoy, C. Zemishlani, Y. Barak Abarbanel Mental Health Center, Psychogeriatric Department,Bat-Yam, Israel

Prof Y Barak, MD, MHA2 This work is to be published: Arch Gerontol Geriatr Jun 14; [Epub ahead of print]

Prof Y Barak, MD, MHA3 Introduction Folic acid deficiency is common in elderly subjects and may lead to psychiatric symptoms, but even more often it increases the severity of other organic and non-organic mental diseases (Hultberg et al., 2001).

Prof Y Barak, MD, MHA4 The Literature (1) Multiple studies looking at folate deficiency and the associated clinical sequelae were reported in the last decade. In the Canadian Study of Health and Aging (Ebly et al., 1998), in a population of 1171 individuals 65 years and older, a cross-sectional analysis compared the relationship between serum folate levels and clinical symptomatology. Those with low folate levels were more likely to be demented, institutionalized and depressed.

Prof Y Barak, MD, MHA5 The Literature (2) Serum Vitamin B12, folic acid and hematological data from 147 elderly people who visited the special clinic for the elderly at Bangkok were investigated (Prayurahong et al., 1993). The percentage of folic acid deficiency was found to be 20.6%. A random sample of 235 persons 70 years or older in a defined geographical area in Sweden were invited to participate in a survey. Half had signs of low tissue levels of cobalamin or folate (Bjorkegren and Svardsudd, 2001).

Prof Y Barak, MD, MHA6 The Literature (3) In the last decade several attempts (Volkert and Stehle, 1999) have been made to assess the nutritional status of the elderly in Germany concluding that geriatric patients showed markedly lower folic acid blood concentrations compared to healthy subjects of the same age.

Prof Y Barak, MD, MHA7 Psychogeriatrics There is a paucity of data regarding the prevalence of low B12 and folic acid in frail, hospitalized, elderly patients, and its implications (Shahar et al., 2001). Forty percent of hospitalized elderly patients in geriatric centers in Israel have low or borderline serum levels of Vitamin B12 or folic acid, which may contribute to cerebrovascular disease and cognitive decline.

Prof Y Barak, MD, MHA8 Psychogeriatrics Folate status worsened over time in recently institutionalized elderly people without any evidence of functional deterioration (Essama-Tjani et al., 2000). Recent reports emphasize the need to use blood folate in psychogeriatric patients (Nilsson et al., 2002).

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10 Aim We have decided to undertake an audit of serum folic acid levels in newly admitted elderly psychiatric patients, find those with folic acid deficiency, and compare them with matched patients who are hospitalized and do not suffer from folic acid deficiency. characterize The aim of this study was to characterize the mentally ill elderly at risk of folic acid deficiency.

Prof Y Barak, MD, MHA11 Subjects & Method (1) This study was completed at a large, university affiliated, tertiary psychiatric facility. Our center provides services to 850,000 residents in an urban catchment area. From January 1999 to December 2001, all newly admitted elderly patients (aged 65 years or older) were screened for folic acid deficiency

Prof Y Barak, MD, MHA12 Subjects & Method (2) Fasting venous blood samples were extracted within 24 h of hospitalization. Analysis of folic acid serum levels was carried out by competitive protein binding assays using an Elecys 2010 analyzer (Roche Diagnostics). The normal folic acid level range in our laboratory is 9.5–45.2 nmol/l. All elderly patients were included in the screening procedure except patients who reported the use of folic acid supplementation.

Prof Y Barak, MD, MHA13 Subjects & Method (3) During the screening period, there were 293 newly hospitalized elderly patients of whom 45 were found to be suffering from folic acid deficiency. For each newly admitted patient with folic acid deficiency, a hospitalized patient matched for gender and birth year was randomly chosen. Demographic and clinical data, diagnosis, co- morbid medical conditions and treatment were recorded for each subject.

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Prof Y Barak, MD, MHA15 Results (1) During the study period, 293 elderly patients were newly admitted to our center. Of these, 6 reported treatment with folic acid prior to hospitalization and were excluded. 15.7% Thus, the 45 patients diagnosed as suffering from folic acid deficiency, comprise 15.7% of all new elderly admissions.

Prof Y Barak, MD, MHA16 Results (2) Characteristics of the patients suffering from folic acid deficiency and controls are summarized in Table 1. In brief, there was a slight preponderance of female subjects, the majority were living alone (either widowed, single or divorced), and distribution of psychiatric morbidity was non-specific in this group.

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Prof Y Barak, MD, MHA18 Results (3) Physical co-morbidity The great majority of subjects, both patients and controls (35/45; 77.8%) had at least one co-morbid physical disorder (necessitating treatment) at the time of hospitalization. The most frequent problem was hypertension, followed by diabetes mellitus, ischemic heart disease, and hypothyroidism.

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Prof Y Barak, MD, MHA20 Discussion (1) Folic acid deficiency is common in the elderly population, resulting in anemia, dementia, many neurological sequelae, and an indirect role in atheromatous disease (Keane et al., 1998). Epidemiological data suggest an association between low folic acid, high homocysteine, and dementia. Deficits of folic acid, and B12, riboflavin, and pyridoxine with which it interacts synergistically in methylation process and homocysteine control, plays a major role in dementia (Horrobin, 2002).

Prof Y Barak, MD, MHA21 Discussion (2) In the present study, elderly patients admitted to a large urban psychiatric hospital were tested for folic acid deficiency. In line with other reports published recently, a high percentage of subjects in our sample were found to be suffering from folic acid deficiency. We could not find any ‘‘characteristic’’ elderly subject at risk.

Prof Y Barak, MD, MHA22 Discussion (3) The combination of cognitive decline and lack of social and intimate support probably resulted in nutritional deficits that are reflected in our findings. It seems that old age by itself is a risk factor for folic acid deficiency. One may speculate that malnutrition and dementia are two parallel processes that may contribute one to the aggravation of the other.

Prof Y Barak, MD, MHA23 Discussion (4) The demented elderly person who neglects his or her basic nutritional needs reaches a high degree of malnutrition that contributes to the progress of dementia. This assumption is supported by findings in studies describing the dietary habits of the elderly in the community (Ortega et al, 2002).

Prof Y Barak, MD, MHA24 Discussion (5) Unfortunately, an increase in natural food folate is relatively ineffective in increasing the folate status. Thus a correction of the diet of the elderly person by itself would not help to ameliorate the damage that has been already done. What should be done is the use of folate fortification of foodstuffs. This was recommended by several expert panels and governmental agencies (Ray et al., 2000).

Prof Y Barak, MD, MHA25 Conclusions (1) Advances in the understanding of the relation between inadequate vitamin status and loss of cognitive function in the elderly may depend on the outcomes of both prospective studies and longitudinal studies in which nutritional intervention is provided before cognitive decline occurs (Selhub et al., 2000).

Prof Y Barak, MD, MHA26 Conclusions (2) Our findings suggest that living conditions may interact with cognitive impairment to create a subgroup of elderly at high risk of folic acid deficiency. Awareness must be increased among family physicians and other therapeutic agents in the community so that this population is offered the proper preventive measures.

Prof Y Barak, MD, MHA27 Thank you for your attention !!!