Iron, folate and vitamin B12 status of an elderly South African population

A clinical profile of inpatient admissions to the psychogeriatric unit at Stikland Hospital

Background

Globally, the number of older people is rising. As a consequence of greater longevity, an increased burden on both medical and mental health care is expected. As a first step towards developing strategies to provide quality mental health care for this growing population, practitioners need to have a thorough understanding of the composition and needs of these patients.

Aim

To profile the inpatient population of a psychogeriatric unit in terms of demographics, diagnostic makeup, average length of stay and selected outcomes.

Setting

This study was conducted at the psychogeriatric unit of Stikland Hospital, Western Cape, South Africa.

Methods

Demographic and clinical data were retrospectively collected from patient files, discharge summaries and an admission database over a 3-year period.

Results

A total of 903 patients were referred to Stikland Hospital during a 3-year period. Of the 498 patients who were admitted, 56 were readmissions. The mean age of patients was 67 years, and more than 57% of patients were female. The majority of patients (97.1%) were admitted as involuntary mental health users. The diagnosis of a cognitive disorder was made in 49.5% of admissions followed by psychotic disorders in 36.9% and mood disorders in 23.2%. The median length of stay was 53 days.

Conclusion

The findings of this study illustrate that mental health services for the elderly in the Western Cape are insufficient, as only patients with severe illness and comorbidity could be admitted. The study emphasises the need for the restructuring of resources and the implementation of strategies, which may decrease the frequency of admissions to inpatient geriatric units.

Serum micronutrient status and nutrient intake of elderly Yoruba people in a slum of Ibadan, Nigeria

OBJECTIVE

The present study was conceived in response to a perceived lack of data about the nutritional status of free-living elderly Yoruba people living in a poor urban area in south-western Nigeria. The major focus was to assess the micronutrient status of elderly Yoruba people living in a slum of Ibadan.

DESIGN

A cross-sectional descriptive study was designed to collect data on dietary intake and micronutrient status.

SETTING

By means of a structured questionnaire and the estimated food record method, nutrient intake was assessed. Blood was taken from 120 people to determine serum micronutrient levels.

SUBJECTS

A total of 240 elderly Yoruba people were selected from Ibadan, Oyo State, Nigeria using a random sampling technique.

RESULTS

The diet of the elderly Yoruba participants was mainly plant based and inadequate in B vitamins (especially B1, B6 and folic acid) and micronutrients such as Zn. The intake of vitamin A ranged from 269 to 487 μg/d, while vitamin B1 and B2 intakes ranged from 0·20 to 0·82 mg/d in both males and females. The intake of vitamin C varied from 24·8 to 42·8 mg/d. The majority of participants had insufficient serum levels of vitamins and minerals relative to reference values. Forty per cent were deficient in serum Ca, 71% were deficient in serum Zn and 51% were deficient in serum 25-hydroxyvitamin D.

CONCLUSIONS

The majority of the elderly Yoruba people were deficient in Zn, ferritin and vitamin B6. This is the result of a diet lacking in vitamins and minerals.

Systematic review with dose-response meta-analyses between vitamin B-12 intake and European Micronutrient Recommendations Aligned's prioritized biomarkers of vitamin B-12 including randomized controlled trials and observational studies in adults and elderly persons

BACKGROUND

Many randomized controlled trials (RCTs) and observational studies have provided information on the association between vitamin B-12 intake and biomarkers. The use of these data to estimate dose-response relations provides a useful means to summarize the body of evidence.

OBJECTIVE

We systematically reviewed studies that investigated vitamin B-12 intake and biomarkers of vitamin B-12 status and estimated dose-response relations with the use of a meta-analysis.

DESIGN

This systematic review included all RCTs, prospective cohort studies, nested case-control studies, and cross-sectional studies in healthy adult populations published through January 2010 that supplied or measured dietary vitamin B-12 intake and measured vitamin B-12 status as serum or plasma vitamin B-12, methylmalonic acid (MMA), or holotranscobalamin. We calculated an intake-status regression coefficient ( ) for each individual study and calculated the overall pooled and SE ( ) by using random-effects meta-analysis on a double-log scale.

RESULTS

The meta-analysis of observational studies showed a weaker slope of dose-response relations than the meta-analysis of RCTs. The pooled dose-response relation of all studies between vitamin B-12 intake and status indicated that a doubling of the vitamin B-12 intake increased vitamin B-12 concentrations by 11% (95% CI: 9.4%, 12.5%). This increase was larger for studies in elderly persons (13%) than in studies in adults (8%). The dose-response relation between vitamin B-12 intake and MMA concentrations indicated a decrease in MMA of 7% (95% CI: -10%, -4%) for every doubling of the vitamin B-12 intake. The assessment of risk of bias within individual studies and across studies indicated risk that was unlikely to seriously alter these results.

CONCLUSION

The obtained dose-response estimate between vitamin B-12 intake and status provides complementary evidence to underpin recommendations for a vitamin B-12 intake of populations.

The relationship between indices of iron status and selected anthropometric cardiovascular disease risk markers in an African population: the THUSA study

There is evidence that certain indices of iron status are associated with anthropometric measures, which are used independently as markers of cardiovascular disease (CVD) risk. This study examined whether this association exists in an African population. The study was a cross-sectional comparative study that examined a total of 1 854 African participants. Ferritin was positively associated with body mass index (BMI), waist circumference (WC), waist-to-hip ratio (WHR), percentage body fat and subscapular skinfold thickness. Serum ferritin concentration was higher in the high-WHR category than the normal-WHR category for both genders. Additionally, WC and WHR increased with increasing ferritin concentrations in both genders. Serum iron was lower in the obese than the normal-weight and pre-obese women only. In this population-based study, increased serum ferritin concentrations associated positively with increased WHR and WC, indicating that individuals or populations at risk of iron overload as defined by high serum ferritin concentrations may be at a greater risk of developing CVD.

Nutrition, health, and aging in sub-Saharan Africa

The proportion of the population that is > or = 60 years of age in sub-Saharan Africa (SSA) is increasing rapidly and is likely to constrain healthcare systems in the future. Nevertheless, the elderly are not a health policy priority for African countries. This paper reviews the nutritional and health status of older adults in SSA and their determinants. Literature was abstracted through the Medline, Google Scholar, and Dogpile databases using the following search terms: sub-Saharan Africa, older adults, nutrition, health. Findings showed that up to half (6-48%) of elderly Africans in SSA are underweight and almost a quarter (2.5-21%) are overweight, while 56% of older South Africans are obese. Low-quality diets contribute to poor nutritional status. Poverty, HIV/AIDS, and complex humanitarian emergencies are major determinants of undernutrition. Effective interventions need to consider socioeconomic, health, and demographic factors; social pensions may be the most cost-effective option for improving the health and nutritional status of the elderly in SSA.

Prevalence of anaemia in older persons: systematic review

Background

Ageing populations will impact on healthcare provision, especially since extra years are not necessarily spent in good health. It is important to identify and understand the significance of common medical problems in older people. Anaemia may be one such problem. We report on the prevalence of anaemia in cohorts of elderly people in the general population. The presence of anaemia is associated with a worse prognosis for both morbidity and mortality.

Methods

Electronic searching and reference lists of published reports were used to identify studies that reported on prevalence of anaemia in cohorts of at least 100 individuals predominantly aged 65 years and over living in developed countries, together with criteria used to define anaemia. Studies of anaemia prevalence in specific disease groups or published before 1980 were excluded. Prevalence data for the entire cohort, for men and women separately and for different age bands were extracted.

Results

Forty-five studies contributed data. Thirty-four studies (n = 85,409) used WHO criteria to define anaemia. The weighted mean prevalence was 17% (3–50%) overall, and 12% (3–25%) in studies based in the community (27, n = 69,975), 47% (31–50%) in nursing homes (3, n = 1481), and 40% (40–72%) in hospital admissions (4, n = 13,953). Anaemia prevalence increased with age, was slightly higher in men than women, and was higher in black people than white. Most individuals classified as anaemic using WHO criteria were only mildly anaemic.

Conclusion

Anaemia, as defined by WHO criteria, is common in older people living in the community and particularly common in nursing home residents and hospital admissions. Predicted demographic changes underline the need to understand more about anaemia in older people.

Cobalamin: a critical vitamin in the elderly

Vitamin B(12) deficiency is a common problem in elderly subjects. If a serum cobalamin level of about 150 pmol/L (200 pg/mL) is considered normal, 10-15% of the elderly are deficient. Today, however, a threshold of 220-258 pmol/L (300-350 pg/mL) is recognized as desirable in the elderly, or else sensitive markers like the blood concentration of homocysteine or methylmalonic acid (MMA) are used. Then the prevalence of cobalamin deficiency rises to up to 43%. In the elderly, this high prevalence of poor cobalamin status is predominantly caused by atrophic gastritis type B. Atrophic gastritis results in declining gastric acid and pepsinogen secretion, and hence decreasing intestinal absorption of the cobalamin protein complexes from food. About 20-50% of the elderly are affected. Furthermore, the reduced acid secretion leads to an alkalinization of the small intestine, which may result in bacterial overgrowth and thus to a further decrease of the bioavailability of the vitamin. In addition, some drugs such as proton pump inhibitors or H2 receptor antagonists inhibit the intestinal absorption of vitamin B(12). An already moderately reduced vitamin B(12) level is associated with vascular disease and neurocognitive disorders such as depression and impaired cognitive performance. Furthermore, a poor vitamin B(12) status is assumed to be involved in the development and progression of dementia (e.g., Alzheimer's dementia). This is especially observable if the folic acid status is reduced as well. Due to the insecure supply, the cobalamin status of elderly persons (>/=60 years) should be regularly controlled and a general supplementation with vitamin B(12) (>50 microg/day) should be considered.

Folate status and folate related anemia: a comparative cross-sectional study of long-term care and post-acute care psychogeriatric patients

Aging is associated with increased risk of anemia, poor nutrition, chronic illness, and impaired folate status. We aimed to investigate and compare folate status in long-term care psychogeriatric patients (LTCPP) and in post-acute care psychogeriatric patients (PACPP). This is a cross-sectional study conducted in a psychogeriatric medical center with long-term care and post-acute care wards. A total number of 553 LTCPP and 373 PACPP were studied. Low serum folic acid levels were found in 10% of LTCPP and in 13% of PACPP. Folic acid anemia (FAA) was found in 67% of LTCPP and 87% of PACPP (P = 0.046) with low serum folate levels. Mean levels of serum folate were similar but red blood cells folate (RBC-folate) was higher in PACPP (P = 0.025) and in males compared with women (P = 0.009). 56% of PACPP and 68% of LTCPP who had folic acid anemia presented with another type of anemia. Anemia of chronic disease was the most frequent coexisting anemia and was found in 65% of LTCPP and 52% of PACPP, followed by B12 deficiency anemia and iron deficiency anemia. We conclude that PACPP represent only a slightly different group, compared with LTCPP, with regard to the folate status. These high rates of folate and RBC-folate deficiencies, as well as of FAA and coexisting anemia, call for a routine evaluation of folate status in all psychogeriatric patients, whether LTCPP or PACPP.

Anemia at the end of life: prevalence, significance, and causes in patients receiving palliative care

While data exist on the prevalence and causes of anemia in defined groups of the elderly, information on palliative care patients is limited. Compared to actively treated oncology patients, for whom anemia treatment has demonstrated improved quality of life and symptom alleviation, studies of treatment outcomes in palliative care patients are limited. Knowledge of the extent and causes of anemia in palliative care patients is needed, as correction of anemia in these patients could potentially improve their physical, emotional, and cognitive functioning. In the present study, clinical data and blood test results of 105 patients meeting specific eligibility criteria were examined to estimate the prevalence of anemia and investigate its causes. Ninety-five (90.5%) patients had advanced cancer. Based on World Health Organization criteria, anemia was found in 77% of men (Hb <130 g/l) and 68.2% of women (Hb <120 g/l). The diagnosis was anemia of chronic disease in 76.7% of women and 46.8% of men. Patients with prostate cancer had a significantly lower mean Hb level (P=0.007) and more evidence of bone metastases (P=0.0007) than those with other cancers. Neutrophil hypersegmentation, suggesting occult folate deficiency, was present in 28.6% of patients, being more common in those with major weight loss (58.3%) than those with moderate (37%) or mild/no weight loss (26%) (P=0.019). The findings suggest that anemia is highly prevalent in the palliative care setting. Although anemia of chronic disease is most common, occult folate deficiency may be more prevalent than previously suspected. The findings suggest that a low serum folate level is an insensitive marker of occult folate deficiency. A randomized controlled trial of folic acid treatment is proposed.

Anemia and aging: an overview of clinical, diagnostic and biological issues

Anemia, usually mild, is one of the more common problems of the aged, especially in men. Although the anemia is often multifactorial, the specific entities can be grouped into three broad categories: (a) anemias due to causes more common in the elderly; (b) anemias without special predilection for the elderly; (c) anemias of unknown cause. The major biological questions concern the third category, which accounts for 14-17% of the anemias, and whether senescence itself contributes to anemia. Current opinion favors a diminished erythropoietic reserve with aging, but the data are inconsistent and the mechanism has not been established. It may be that cytokine modulation of erythropoiesis is abnormal. Some findings in unexplained anemia bear partial resemblance to the changes of anemia of chronic disease, suggesting the possibility that subtle unidentified inflammatory responses of unknown origin may be operative in many elderly people. Of the anemias of known cause that are especially common in the elderly, anemia of chronic disease is an important entity but is sometimes obscured or overlooked and its diagnosis rests on crude tests. Cobalamin deficiency is very common also, although most cases are mild and not accompanied by anemia. Because the basic diagnostic approach to anemia is neither complex nor very invasive and anemia may be a marker of poor prognosis, attribution of anemia to senescence is not advisable until other causes have been ruled out.

Trace element deficiency and toxicity

Trace elements are involved in enzymatic activities, immunological reactions, physiological mechanisms and carcinogenesis. Deficiency in some trace elements, such as iron and iodine, is still an important health problem, especially in developing countries. Some groups of individuals are more likely to develop trace element deficiency. The role of trace elements deficiency is suspected in various clinical situations and is now confirmed by well designed supplementation studies. Although toxicity of trace elements with clinical manifestations is rare, it has been observed that manganese toxicity may occur in patients receiving parenteral nutrition. Recent data about trace elements deficiency and toxicity are indicated in this review.

Relationship between alcohol and nutrient intakes and blood status indices of older people living in the UK: further analysis of data from the National Diet and Nutrition Survey of people aged 65 years and over, 1994/5

OBJECTIVE

To examine the relationships between alcohol consumption and a range of nutrient intakes and blood status indices in older people.

DESIGN

National Diet and Nutrition Survey: cross-sectional survey of nationally representative sample of people aged 65 years or over.

SETTING

Mainland Britain during 1994/5.

SUBJECTS

1198 people (623 males, 575 females) aged 65 years or over, of whom 925 were living in private households and 273 were living in institutions.

RESULTS

Intermediate alcohol consumption (particularly 0.1-14 units week(-1); 1 unit = 8 g) derived from a 4-day diet diary or a 12-month recall questionnaire, was associated with higher intakes of vitamins C, E, B1, iron, calcium, energy from food, carbohydrate and non-starch polysaccharides than heavy alcohol consumption (28 + units week(-1)) or abstinence, after adjustment for a number of factors (age, sex, domicile, social class, cigarette smoking, self-reported health, grip strength and total energy intake). Intermediate alcohol consumption was also associated with higher blood concentrations (independent of intake) of vitamin C, beta-cryptoxanthin, lutein and calcium, with the lowest concentrations being found in heavy alcohol users. The lowest concentrations of serum ferritin were found in light drinkers and the highest levels in heavier alcohol drinkers. Alcohol consumption ranging from 0.1 to >28 units week(-1) was directly correlated with intakes of B vitamins, total energy and fat, with blood concentrations (independent of intake) of lycopene, high density lipoprotein (HDL)-cholesterol, plasma pyridoxal phosphate and retinol, and with blood pressure and grip strength.

CONCLUSIONS

Compared with abstinence and heavy drinking, light to moderate alcohol consumption in older people is associated with higher intakes of certain nutrients, and higher blood concentrations (independent of intake) of some micronutrient status indices, including antioxidants. The explanation for the latter associations remains unclear and further investigation is recommended. Heavier alcohol consumption is associated with both beneficial and adverse effects with respect to nutrient intakes and health status.