Vitamin B12 deficiency in the institutionalized elderly: A regional study

A 12-Week Ballroom Dance Training Improves Physical Fitness Performance More Than Walking Training in Older Women, Regardless of Vitamin B12 or D Adequacy

AIM

This study aimed to compare the effects of Ballroom Dancing (BD) versus Walking Training (WT) on the physical fitness performance in physically independent older women with adequate or inadequate levels of vitamins B12 and D.

METHODS

Forty-three sedentary women aged 68.5 ± 6.5 years, were allocated to the BD (n = 23) or WT (n = 20) groups. They took part in a 12-week intervention, performed 3 times a week, for about 50 minutes with moderate effort intensity. Data were collected through Short Physical Performance Battery (SPPB), 6 minutes Walk Test (6MWT), Hand Grip Test (HGT), Isokinetic tests for lower limbs and blood tests to detect serum levels of vitamins B12 and D.

RESULTS

The BD group performed better after the intervention in relation to the WT in the Sit and Stand Test (SST) (BD pre = 3.1 score vs post = 3.8 score; WT pre = 2.8 score vs post = 3.4 score; P = .02) and in the Peak Torque 180° extension (PKTOQ 180° extension) (BD pre = 56.7 Nm vs post = 61.2 Nm, WT pre = 56.7 Nm vs post = 56.1; P < .01).

CONCLUSION

A time effect was observed in all other variables, with the exception of HGT. Both interventions improved physical fitness performance, regardless of the adequacy of vitamins B12 and D, but the older women from BD obtained significant improvements in more variables than the WT.

Vitamin B12 supplementation improves cognitive function in middle aged and elderly patients with cognitive impairment

Introduction

Objectives: to determine the effects of vitamin B12 supplementation on neuropsychological function and disease progression in middle aged and elderly patients with cognitive impairment. Methods: this was a prospective case-control study. From May 2020 to May 2021, 307 participants clinically diagnosed with cognitive impairment in the Department of Neurology of the First Affiliated Hospital of Chongqing Medical University were enrolled. A total of 115 patients were included in this study. Meanwhile, 115 participants with cognitive impairment were randomly assigned in equal proportions to two groups: vitamin B12 treatment group (n = 58, vitamin B12 500 mg/d intramuscularly for seven days, followed by cobamamide 0.25 mg/d and methylcobalamin 0.50 mg/d) and the control group (n = 57). Demographic characteristics and blood biochemical variables were obtained from all participants. Cognitive performance was measured using the Mini-Mental State Examination (MMSE) and Montreal Cognitive Assessment (MoCA). Cognitive performance was measured at baseline and after six months. Results: the vitamin B12 supplementation treatment patients who presented with cognitive impairment showed significant improvement, especially in attention, calculation (p < 0.01) and visual-constructional ability (p < 0.05), in their neuropsychological function compared to their matched group. Conclusion: vitamin B12 supplementation may improve frontal function in patients with cognitive decline. Vitamin B12 levels should be investigated in all patients with cognitive impairment.

[Profiling of patients in a specialized geriatric outpatient clinic]

BACKGROUND

In Germany geriatric outpatient care is predominantly done by family doctors and general practitioners (GP). There are regionally different concepts for additional specialized geriatric outpatient care but they have not yet been validated and established. Still, it remains unclear whether a geriatric patient has to be diagnosed rather in a specialized outpatient or inpatient setting. The aim of the present study is the profiling of geriatric outpatients to find key distinctions from geriatric patients that have to be admitted to hospital.

METHODS

Retrospective data analysis of patients sent to a specialized geriatric outpatient clinic by their GP, compared with data of geriatric inpatients sent to hospital by their GP during the same time period. Study parameters comprised elements of the comprehensive geriatric assessment as well as results of routinely applied laboratory tests.

RESULTS

Patients sent to the specialized geriatric outpatient clinic showed better results of functional assessments. Regression analysis: improvement of Barthel Index, GFR and total protein increased the chance of outpatient treatment.

CONCLUSION

Early identification of geriatric patients who can be treated in a specialized outpatient setting would ease the burden for GPs by interdisciplinary cooperation and prevent cost-intensive readmissions to hospital.

Nutritional Assessment of the Symptomatic Patient on a Plant-Based Diet: Seven Key Questions

Plant-based diets, both vegan and vegetarian, which emphasize grains, vegetables, fruits, legumes, nuts, and seeds are increasingly popular for health as well as financial, ethical, and religious reasons. The medical literature clearly demonstrates that whole food plant-based diets can be both nutritionally sufficient and medically beneficial. However, any person on an intentionally restrictive, but poorly-designed diet may predispose themselves to clinically-relevant nutritional deficiencies. For persons on a poorly-designed plant-based diet, deficiencies are possible in both macronutrients (protein, essential fatty acids) and micronutrients (vitamin B12, iron, calcium, zinc, and vitamin D). Practitioner evaluation of symptomatic patients on a plant-based diet requires special consideration of seven key nutrient concerns for plant-based diets. This article translates these concerns into seven practical questions that all practitioners can introduce into their patient assessments and clinical reasoning. Ideally, persons on plant-based diets should be able to answer these seven questions. Each serves as a heuristic prompt for both clinician and patient attentiveness to a complete diet. As such, these seven questions support increased patient nutrition knowledge and practitioner capacity to counsel, refer, and appropriately focus clinical resources.

Ferric Carboxymaltose Versus Ferrous Glycine Sulfate For Treatment of Iron Deficiency Anemia and Their Effect On Vitamin B12 And Folic Acid: A Retrospective Study

Aim Anemia is a major public health problem, affecting about one-third of the world's population, and is most commonly caused by iron deficiency. Iron deficiency anemia requires oral or intravenous iron replacement therapy. The purpose of this study was to assess the change in several hematological parameters, vitamin B12, and folic acid from baseline to the first month of follow-up following therapy with oral ferrous glycine sulfate or intravenous ferric carboxymaltose. Methods: All patients who received oral ferrous glycine sulfate or intravenous ferric carboxymaltose for the treatment of iron deficiency anemia between January 1, 2016, and December 31, 2018, were included in the trial. Along with age and gender information, values of hemoglobin, ferritin, transferrin saturation, mean corpuscular volume, vitamin B12, and folic acid were derived from patients’ records at the beginning of treatment and first month follow-up. Results: Laboratory values obtained after treatment showed statistically significant improvement in both groups (intra group, p&lt;0.001). When the percentage of change between groups was compared: Percentage-based increases in hemoglobin, mean corpuscular volume, transferrin saturation and ferritin values were significantly higher in the ferric carboxymaltose group (p&lt;0.001). The percentage decrease in vitamin B12 and folic acid values was higher in the ferric carboxymaltose group (p=0.005 and p=0.01, respectively) when compared with oral ferrous glycine sulfate group. Conclusions: According to the findings of our study, iron deficiency anemia can be treated very successfully using ferric carboxymaltose; however, it should be remembered that concurrent supplementation of elements such vitamin B12 and folic acid is necessary for the appropriate progression of erythropoiesis.

Nutritional Aspects of Healthy Aging

Proper nutrition and healthy eating are key determinants of healthy aging. In older age, energy requirements decrease, yet micronutrient requirements stay the same or increase, which make older adults susceptible to nutrient deficiencies. Therefore, it is important to encourage older adults to consume nutrient-dense foods. Many older adults do not maintain proper hydration, so adequate water intake should also be encouraged. Most older adults have multiple chronic diseases that may influence their dietary intake and nutritional needs. However, currently, our understanding of how individual chronic diseases and their associated treatments influence dietary requirements is limited.

Analysis of the Impact of Selected Vitamins Deficiencies on the Risk of Disability in Older People

Vitamin deficiencies have a serious impact on healthy aging in older people. Many age-related disorders have a direct or indirect impact on nutrition, both in terms of nutrient assimilation and food access, which may result in vitamin deficiencies and may lead to or worsen disabilities. Frailty is characterized by reduced functional abilities, with a key role of malnutrition in its pathogenesis. Aging is associated with various changes in body composition that lead to sarcopenia. Frailty, aging, and sarcopenia all favor malnutrition, and poor nutritional status is a major cause of geriatric morbidity and mortality. In the present narrative review, we focused on vitamins with a significant risk of deficiency in high-income countries: D, C, and B (B6/B9/B12). We also focused on vitamin E as the main lipophilic antioxidant, synergistic to vitamin C. We first discuss the role and needs of these vitamins, the prevalence of deficiencies, and their causes and consequences. We then look at how these vitamins are involved in the biological pathways associated with sarcopenia and frailty. Lastly, we discuss the critical early diagnosis and management of these deficiencies and summarize potential ways of screening malnutrition. A focused nutritional approach might improve the diagnosis of nutritional deficiencies and the initiation of appropriate clinical interventions for reducing the risk of frailty. Further comprehensive research programs on nutritional interventions are needed, with a view to lowering deficiencies in older people and thus decreasing the risk of frailty and sarcopenia.

Cobalamin Deficiency in the Elderly

Older people are at risk for cobalamin (vitamin B₁₂) deficiency because of a number of common disorders (e.g., autoimmune gastritis) and drugs (e.g., antacids) that may alter its absorption and utilization. The prevalence of cobalamin deficiency increases with age, resulting, particularly elevated, in frail and institutionalized subjects. At variance with common sense, the diagnosis is far from simple. It requires a high degree of suspicion, due to heterogeneity and non-specificity of the signs and symptoms, ranging from macrocytosis (with or without anemia) to neuropsychiatric manifestations, that characterize several other aging-related disorders, like hematological malignancies, diabetes, hypothyroidism or vasculopathy. Furthermore, the detection of low levels of serum vitamin B₁₂ appears poorly sensitive and specific. Other biomarkers, like serum homocysteine or methylmalonic acid, have improved the diagnostic possibilities but are expensive, not widely available, and may be influenced by some confounders (e.g., folate deficiency, or chronic renal failure). Early recognition and treatment are crucial since a proportion of patients develop severe complications, such as bone marrow failure and irreversible neurological impairment. High-dose oral treatment has proven to be as effective as the parenteral route, even in subjects with malabsorption, ensuring the complete resolution in the majority of cases. In this review, we trace the essential role of cobalamin in humans, the possible causes and impact of deficiency, the diagnostic challenges and the therapeutic options, between old and emerging concepts, with a particular focus on the elderly.

Deficiência de vitamina B12 e fatores associados em idosos institucionalizados

Resumo Objetivo Avaliar a frequência de deficiência de vitamina B12 e fatores associados em idosos institucionalizados. Método Analisamos 65 idosos, com idade média de 80±9 anos (61-113), de uma instituição geriátrica filantrópica de longa permanência. A dosagem sérica de vitamina B12 foi analisada e classificada em: normal (≥299 pg/mL), limítrofe (200-298 pg/mL) e deficiência (<200 pg/mL). Foi analisada a associação com tempo de permanência na instituição, declínio cognitivo e funcional, uso regular de biguanidas e inibidores de bomba de prótons, considerados fatores de risco para hipovitaminose B12, utilizando os testes de análise bivariada (paramétrica e não paramétrica) e regressão de Poisson. Resultados A deficiência de vitamina B12 estava presente em 21,5% e valores limítrofes em 32,3% da amostra. Dentre os idosos, 52,9% apresentavam demência de causas diversas, 49,2% hipertensão arterial, 29,2% com anemia (21,5% normocítica, 4,6% microcítica e 3,1% macrocítica), 18,5% diabéticos; 27,7% faziam uso de polifarmácia, com 12,3% em uso de metformina e 16,9% com inibidores de bomba de prótons. No modelo multivariado não houve associação entre a deficiência de vitamina B12 com as variáveis estudadas. Conclusão Observamos uma frequência importante de valores limítrofes e baixos de vitamina B12 nos pacientes dessa instuição geriátrica de cuidados permanentes, porém sem associação com os fatores de risco para sua deficiência estudado, o que torna importante a inclusão da dosagem sérica dessa vitamina na rotina de exames laboratoriais desse grupo.

The Many Faces of Cobalamin (Vitamin B12) Deficiency

Although cobalamin (vitamin B12) deficiency was described over a century ago, it is still difficult to establish the correct diagnosis and prescribe the right treatment. Symptoms related to vitamin B12 deficiency may be diverse and vary from neurologic to psychiatric. A number of individuals with vitamin B12 deficiency may present with the classic megaloblastic anemia. In clinical practice, many cases of vitamin B12 deficiency are overlooked or sometimes even misdiagnosed. In this review, we describe the heterogeneous disease spectrum of patients with vitamin B12 deficiency in whom the diagnosis was either based on low serum B12 levels, elevated biomarkers like methylmalonic acid and/or homocysteine, or the improvement of clinical symptoms after the institution of parenteral vitamin B12 therapy. We discuss the possible clinical signs and symptoms of patients with B12 deficiency and the various pitfalls of diagnosis and treatment.

Association of metformin use with vitamin B12 deficiency in the institutionalized elderly

Elderly people living in long term care institutions are particularly at risk of vitamin B₁₂ deficiency. The prevalence of vitamin B₁₂ deficiency was 34.9% among the 1996 institutionalized elderly residents in our previous study. The present retrospective study evaluated the association of metformin use with vitamin B₁₂ deficiency in the same group of patients. Of 1996 patients, 507 (25.4%) had diabetes, of which 188 received metformin treatment. The prevalence of vitamin B₁₂ deficiency in diabetic patients taking metformin was 53.2% compared with 31% (P < 0.001) of diabetic patients not taking metformin and 33.3% (P < 0.001) of those without diabetes. Among the vitamin B₁₂ deficient patients, diabetic patients taking metformin had lower serum vitamin B₁₂ concentration (97 pmol/L) than the diabetic patients not taking metformin (113 pmol/L, P < 0.001) and those without diabetes (111 pmol/L, P < 0.001). Subanalysis of 174 metformin users found that dose and duration of metformin use were significantly associated with vitamin B₁₂ deficiency. Adjusted odds ratio for those taking metformin ≥1500 mg /day was 2.72 (95% CI 1.11-6.7, P = 0.029) compared with those using metformin <1000mg/day. Adjusted odds ratio for those taking metformin>4 years was 3.00 (95% CI 1.35-6.68, P = 0.007) compared with those taking metformin <2 years. Prevalence of vitamin B₁₂ deficiency among those taking metformin ≥1500 mg/day for >2 years was 75.9% and was more than 2 times that of patients taking metformin <1500 mg/day for ≤2 years (35.3%). In conclusion, metformin use is associated with increased risk and severity of vitamin B₁₂ deficiency in the institutionalized elderly residents. Patients taking metformin ≥1500 mg/day for >2 years are particularly at risk. Testing for vitamin B₁₂ status before and regularly after the start of metformin may be considered.

Nutritional Needs of the Older Adult

Older adults are particularly vulnerable to compromised nutritional status. With advancing age, the consumption of a high-quality, nutritionally dense diet is increasingly essential to optimize health and well-being. Proportionally, macronutrient needs for older adults are similar to younger adults, however overall calorie requirements tend to decline with age. Unique factors influencing food intake should be considered and individualized guidance should be designed to help overcome medical, physical, and social barriers to a healthy diet. The goal for nutrition intervention should ultimately be to promote health and quality of life across the continuum of the aging process.

Vitamin B12

The biosynthesis of B₁₂, involving up to 30 different enzyme-mediated steps, only occurs in bacteria. Thus, most eukaryotes require an external source of B₁₂, and yet the vitamin appears to have only two functions in eukaryotes: as a cofactor for the enzymes methionine synthase and methylmalonylCoA mutase. These two functions are crucial for normal health in humans, and in particular, the formation of methionine is essential for providing methyl groups for over 100 methylation processes. Interference with the methionine synthase reaction not only depletes the body of methyl groups but also leads to the accumulation of homocysteine, a risk factor for many diseases. The syndrome pernicious anemia, characterized by lack of intrinsic factor, leads to a severe, sometimes fatal form of B₁₂ deficiency. However, there is no sharp cutoff for B₁₂ deficiency; rather, there is a continuous inverse relationship between serum B₁₂ and a variety of undesirable outcomes, including neural tube defects, stroke, and dementia. The brain is particularly vulnerable; in children, inadequate B₁₂ stunts brain and intellectual development. Suboptimal B₁₂ status (serum B₁₂<300pmol/L) is very common, occurring in 30%-60% of the population, in particular in pregnant women and in less-developed countries. Thus, many tens of millions of people in the world may suffer harm from having a poor B₁₂ status. Public health steps are urgently needed to correct this inadequacy.

Effect of age, sex and body weight on the serum concentrations of cobalamin and folate in cats consuming a consistent diet

Objectives Multiple feline diseases involving the gastrointestinal tract, pancreas, liver and biliary tract are known to cause abnormal serum cobalamin and folate concentrations. Measuring the serum concentration of these vitamins can therefore be a helpful diagnostic tool. However, factors other than disease, in particular age, have also been suggested to have an effect on the serum concentration of cobalamin and folate. In previous studies, the dietary intake was not standardised, or even known, despite diet being the prinicpal source of both vitamins. Therefore, we evaluated the effect of age, sex and body weight on the serum concentration of folate and cobalamin in cats fed the same diet. Methods The serum cobalamin and folate concentrations were measured in 65 apparently healthy cats in a nutrition colony that had been fed an identical diet. A linear model was used to test the relationship between the serum concentration of cobalamin and folate with the variables age, sex and body weight. Results There was a large variation in the serum concentration of both folate and cobalamin, despite identical intake. Serum cobalamin was inversely associated with age ( P = 0.002), and males had higher concentrations than females ( P = 0.039). Serum folate was positively associated with age ( P = 0.01). Conclusions and relevance Independent of diet, serum cobalamin concentration decreases with age. Changes in gastrointestinal function, microflora or metabolism may be responsible. Older cats may be more susceptible to cobalamin deficiency secondary to inappetence or gastrointestinal disease.

High Serum Folate Is Associated with Brain Atrophy in Older Diabetic People with Vitamin B12 Deficiency

Previous studies have reported the adverse cognitive effects of high folate status in older individuals with vitamin B12 (VB12) deficiency. Thus, the aim of this study was to investigate how high serum folate and VB12 deficiency could collaboratively aggravate neuronal degeneration. In total, 146 older non-demented diabetic individuals with an average age of 75 ± 3.9 were recruited. VB12 deficiency and high folate status were based on high serum methylmalonic acid (MMA) concentrations (> 0.3 μmol/L) and the serum folate concentration being in the top tertile (> 31.4 nmol/L) respectively. Among these subjects, there were 20 with elevated MMA and high folate. The structural magnetic resonance imaging data of these subjects were analyzed by performing flexible factorial analysis with the "folate level" and "MMA level" added as main effects, and the interaction effect of folate and VB12 on brain volume was evaluated. The results showed significant gray matter atrophy of the right middle occipital gyrus and the opercular part of the inferior frontal gyrus in subjects with a simultaneous high folate status and VB12 deficiency. Together with previous observational studies on cognitive function, this study lends support to the notion that high serum folate concentrations in older people with VB12 deficiency may be associated with increased neurodegeneration.

Red blood cell distribution width predicts homocysteine levels in adult population without vitamin B12 and folate deficiencies

OBJECTIVES

Our aim in this study was to explore the relationship between red blood cell distribution width (RDW) and homocysteine levels in an adult population.

METHODS

The study included 344 subjects who underwent health check-up in our hospital. The demographic characteristics and laboratory parameters of participants were grouped in accordance with tertiles of RDW.

RESULTS

An increase of homocysteine levels was found from the first to third tertiles of RDW in all participants. There was a positive correlation between RDW and homocysteine (r=0.227, P<0.001) in all participants. After adjustment for gender, age, neutrophil count (NC), lymphocyte count (LC), hemoglobin (Hb), mean corpuscular volume (MCV), platelet count (PLC), creatinine (Cr), vitamin B₁₂ and folate. RDW was found to be strongly associated with homocysteine independently of age, NC, MCV and Hb values in multivariable logistic regression analysis (OR=1.501; 95% CI, 1.290-1.746; P<0.001).

CONCLUSIONS

The findings of the present study suggest that RDW may predict homocysteine levels among the study population, the results may support that elevated RDW should be considered to be a marker of cardiovascular events. However, the results need to be affirmed in future studies with larger samples.

Moderate 'multivitamin' supplementation improved folate and vitamin B12 status in the elderly

The dependent elderly are widely considered to be at higher risk of nutritional problems. Suboptimal micronutrient intake might put the elderly, especially those living in nursing homes, at high risk of morbidity. So far, no public authority, except for the Israel Ministry of Health, has issued particular recommendations for micronutrient supplementation for the elderly. We hypothesized that moderate 'multivitamin' supplementation could improve the vitamin status of the dependent elderly. The study took place in two nursing homes and included 144 dependent elderly (males/females, 35/109). Demographic and clinical data as well as routine blood tests were retrieved from the patient electronic medical records. After a two-year daily 'multivitamin' supplementation, containing 120μg of folic acid, there was a small and non-significant increase of 12% in serum folate; the same 'multivitamin' preparatory, containing 2.4μg of vitamin B12, significantly increased serum vitamin B12 by 8%. Three models of evaluation clearly showed the effect of a two- year vitamin supplementation: 1. The number of subjects with the lowest baseline concentration range, decreased, with moderate concentration, increased, with no difference at the higher concentrations; 2. Above each vitamin concentration, the number of subjects was higher than at baseline; 3. The two vitamins at the two lower concentration tertiles increased, and at the highest tertile, folate was not affected, whereas vitamin B12 decreased. Therefore, very moderate 'multivitamin' supplementation, as practiced in our study, has a high probability of improving vulnerable old population health status without causing any adverse effects to others.