Vitamin Deficiency in the Elderly by Zoe Salgado Family

1
Vitamin Deficiency in the Elderly

• by Zoe Salgado
• Family Medicine Residency Program

2
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)

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 valuesDV, 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 gtgtsuggests 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 B12DV 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
• RBPretinol binding protein-bonds to Vitamin A in
  blood

9
Requirements

• Males gt 10 yo need 1000mcg
• Females gt 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
• Bodys reserve lasts one week
• 85 absorbed in terminal ileum

12
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

13
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)

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
• 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
• 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(1400-1500mg) alone, Ca
  Vit D (1100IU/d) or placebo in 1179 women gt
  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 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

22
Vitamin D serum levels

• Different definitions of deficiency
• Option 1
• Vit D Insufficiency 20-30ng/ml
• Vit D Deficiencylt 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 gt 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

24
Vitamin D levels in NHCU

• Total patients in NHCU85
• of patients tested 23
• Moderate deficiency 16
• Severe deficiency (levels at 8 or less)3
• Normal4
• 82 of those tested had moderate deficiency, 13
  had severe deficiency

25
25 OHD LEVELS OVER TIME IN NHCU

• 25 OHD LEVELS TESTED IN 23 PATIENTS March 2008

26
Vitamin D in NHCU

• Of those tested
• Dx of falls3..(all had moderate deficiency)
• Dx of fx 5..(4 had deficiency, one with severe
  deficiency)
• Dx MSK pain4..(3 with moderate deficiency, 1
  with severe)
• Dx of OP2..(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 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

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
(No Transcript)
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-gt 300 pg/ml cobalamin deficiency unlikely
• Borderline 200-300-deficiency possible
• Low lt 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 folategt 4 ng/ml and cobalamin gt300pg/ml,
  deficiencies unlikely, no further testing
• If either of above levels are low, check
  methylmalonic acid and total homocysteine levels
• If both normalgtno deficiency
• If both are highgtclear B12 deficiency
• If MMA is normal and HC is high, folate
  deficiency (sens 86, spec99)

37
B12 LEVELS IN NHCU

• TOTAL PATIENTS85
• TOTAL TESTED73
• DEFICIENCY0
• BORDERLINE7
• NORMAL/HIGH66
• OF 73 TESTED PATIENTS, 66 HAD NEUROPSYCHIATRIC
  DIAGNOSIS
• 9 PATIENTS TESTED HAD BORDERLINE DEFICIENCY

38
B 12 LEVELS OVER TIME NHCU
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 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

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, gtgtFolate 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, 95CI 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
• 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
  1112(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
  28291(16)1999-2006
• 5. Broe, KE, et al, J Am Geriatr Soc 2007
  Feb55(2)234-9