Kevin McCarroll

Vitamin D and orthostatic hypotension

INTRODUCTION we aimed to investigate on the potential relationship between vitamin D and orthostatic hypotension (OH) in a case-control model in older adults. METHODS all participants were community-dwelling adults who were not taking vitamin D supplements. Cases were subjects aged 64 or older who were diagnosed with OH at a Falls and Blackout Unit. Controls were age- (within 5 years) and gender-matched subjects who had no history of blackouts, falls or orthostatic dizziness in the preceding year. OH was defined according to standard criteria and was diagnosed with an active stand test. Serum vitamin D [25(OH)D] was measured by radioimmunoassay. RESULTS seventy-six subjects were included in the analysis (38 controls and 38 cases). Twenty-four in each group were female and mean age was between 78 and 79 years. Subjects with OH had lower serum 25(OH)D compared to controls (mean difference = 20.6 nmol/l, P = 0.0002). Lower vitamin D status was associated with an increased risk of OH after adjustment for season, body mass index, presence of stroke, diabetes and angina (P = 0.035) but not with impaired orthostatic haemodynamics. DISCUSSION findings suggest that vitamin D may play a role in the aetiology of OH. Further studies will be required to explore on this relationship.

Determinants of 25-hydroxyvitamin D in older Irish adults

BACKGROUND vitamin D deficiency is prevalent in older adults living in Northern Europe and is influenced by several factors which may vary significantly with age. OBJECTIVE we aimed to investigate the determinants of 25-hydroxyvitamin D [25(OH)D] in older Irish adults and in particular to examine the effect of supplement use and surrogate markers of sun exposure. METHODS subjects were non-institutionalised community dwelling Irish adults aged over 60 years who were participants of a large cross-sectional study comprising three disease defined cohorts. Serum 25(OH)D was measured by liquid chromatography mass spectroscopy. Associations between 25(OH)D and potential confounders were explored in forward regression models in each cohort. RESULTS the three cohorts comprised 1895, 1233 and 1316 participants (respective mean ages 70.1, 71.0 and 80.4 years). Statistical models explained between a fifth to a third of the variation in 25(OH)D. Supplement use and global solar radiation were positive predictors of 25(OH)D in all cohorts whereas the only universal negative predictor was body mass index. Supplement use was associated with a mean increase in 25(OH)D of between 21.4 and 35.4 nmol/l. The other main predictors varied by cohort but included sun holiday travel, enjoyment of sunshine when outside, use of vitamin D fortified milk, smoking, oily fish and egg consumption and physical frailty. CONCLUSION supplement use was the most important determinant of vitamin D status. Vitamin D fortified milk and spending time in the sun, even in the oldest old may also be useful strategies to improve 25(OH)D.

Hypovitaminosis D and orthostatic hypotension: a systematic review and meta-analysis.

Objectives: Orthostatic hypotension is a common condition among older adults and is associated with a range of deleterious outcomes. Recently, interest has developed in hypovitaminosis D (defined as low 25 hydroxiyvitamin D levels) as a potential risk factor for orthostatic hypotension. We conducted a systematic review and meta-analysis examining the association of orthostatic hypotension between study participants with and without hypovitaminosis D, including the adjustment of potential confounders (age, sex, BMI, renal function, comorbidities, seasonality, use of antihypertensive medications, and supplementation with cholecalciferol). Methods: A systematic literature search of major electronic databases from inception until 09/2015 was made for articles providing data on orthostatic hypotension and hypovitaminosis D. A random effects meta-analysis of cross-sectional studies investigating orthostatic hypotension prevalence comparing participants with vs. those without hypovitaminosis D was undertaken, calculating the odds ratios (ORs) and 95% confidence intervals (CIs). Results: Of 317 initial hits, five cross-sectional studies were meta-analysed including 3646 participants (1270 with hypovitaminosis D and 2376 without). The participants with hypovitaminosis D had a higher prevalence of orthostatic hypotension (OR = 1.88; 95% CI: 1.25–2.84; I2 = 68%) that was not affected by adjusting for a median of five potential confounders (OR = 2.03; 95% CI: 1.13–3.68; I2 = 73%). People with orthostatic hypotension had significantly reduced serum vitamin D concentrations (standardized mean difference = −0.42; 95% CI: −0.72 to −0.12). One longitudinal study confirmed the association between hypovitaminosis D and orthostatic hypotension. Conclusion: Our meta-analysis highlights that hypovitaminosis D is associated with orthostatic hypotension, independent of potential confounders. Further longitudinal studies and clinical trials are required to confirm these findings.

Ambient UVB Dose and Sun Enjoyment Are Important Predictors of Vitamin D Status in an Older Population

Background: UVB-induced skin synthesis is considered the key source of vitamin D, yet exposure to UVB is poorly accounted for in epidemiological studies.Objectives: The aim of this study was to examine the association of serum 25-hydroxyvitamin D [25(OH)D] concentration with accurately measured ambient UVB dose, sun enjoyment, supplements, and other factors.Methods: An all-Irish cohort of community-dwelling participants aged >60 y [median age: 73; 67% female; median 25(OH)D: 54.5 nmol/L] was used. Participants from this large, cross-sectional study completed a questionnaire to provide information on demographic factors and lifestyle (including supplement use and sun enjoyment). The Tropospheric Emission Monitoring Internet Service database was used to extract the daily ambient UVB dose at wavelengths that could induce vitamin D synthesis (D-UVB) over Ireland (latitude: 51°N-55°N). Blood sampling occurred throughout the year. Ambient exposure at the place of residence was calculated for each participant individually. Associations between determinants and serum 25(OH)D concentration were examined in a multivariate model. Random forest analysis was used to establish prediction models of vitamin D deficiency, and area under the curve (AUC) is shown.Results: In total, 5138 individuals were included. Median D-UVB was 63 mJ/cm2, which varied between seasons and latitudes, despite the small latitude differential. Vitamin D supplementation (β = 27.7; P < 10 × 10-10), D-UVB (β = 1.58 per 1000 mJ/cm2; P < 10 × 10-10), and sun enjoyment (β = 6.6; P < 0.001) were strongly positively associated with serum 25(OH)D. Those who avoided sunshine were largely at risk of deficiency (<40 nmol/L), whereas those who enjoyed sunshine tended to be vitamin D sufficient (≥50 nmol/L). D-UVB and sun enjoyment improved prediction of deficiency in non-supplement-taking individuals; the overall AUC improved by 3.5%.Conclusion: D-UVB and sun enjoyment are important predictors of vitamin D status, even in this elderly population at northern latitudes. Accurate estimation of ambient UVB can help to further clarify the role of other determinants of vitamin D status and inform sunshine recommendation guidelines.

Effect of Area‐Level Socioeconomic Deprivation on Risk of Cognitive Dysfunction in Older Adults

To investigate the relationship between area‐level deprivation and risk of cognitive dysfunction.

Dairy intakes in older Irish adults and effects on vitamin micronutrient status: Data from the TUDA study

BackgroundConsumption of dairy products has been associated with positive health outcomes including a lower risk of hypertension, improved bone health and a reduction in the risk of type 2 diabetes. The suggested dairy intake for health in older adults is three servings per day but recent analysis of the NHANES data for older adults reported 98% were not meeting these recommendations. No studies have investigated the consequences of such declines in the dairy intakes of Irish older adults and the subsequent effects on vitamin micronutrient status.ObjectivesTo study the daily dairy intakes of older Irish adults and to examine how the frequency of dairy food consumption affects vitamin micronutrient status.MethodsParticipants (n 4,317) were from the Trinity Ulster Department of Agriculture (TUDA) Study, a large study of older Irish adults (aged >60 yrs) designed to investigate gene-nutrient interactions in the development of chronic diseases of aging. The daily intake portion for milk, cheese and yoghurt was calculated from food frequency questionnaire (FFQ) responses. Blood samples were analysed for vitamin biomarkers as follows: vitamin B12 (total serum cobalamin and holotranscobalamin (holoTC)), folate (red cell folate (RCF) and serum folate), vitamin B2 (erythrocyte glutathione reductase activation coefficient (EGRac)), vitamin B6 (serum pyridoxal phosphate) and vitamin D (serum 25(OH)D).ResultsThe mean total reported dairy intake was 1.16 (SD 0.79) portions per day with males consuming significantly fewer total dairy portions compared to females (1.07 vs 1.21 respectively) (P<0.05). There was no significant difference in total daily dairy serving intakes by age decade (60-69, 70-79, >80 yrs). Overall, only 3.5% of the total population (n 151) achieved the recommended daily dairy intake of three or more servings per day. A significantly higher proportion of females (4%) compared to males (2.4%) met these dairy requirements (P=0.011). Blood concentrations of vitamin B12 biomarkers, RCF, vitamin B2 and vitamin B6 were significantly worse in those with the lowest tertile of dairy intake (0-0.71 servings) compared to those in the highest tertile (1.50-4.50 servings) (P<0.05).ConclusionThis study found that more than 96% of the older adults sampled did not meet current daily dairy intake recommendations. The study is the largest to-date examining dairy intakes in older Irish adults, and provides evidence that daily dairy intakes (in particular yogurt) contribute significantly to the B-vitamin and vitamin D biomarker status of older adults. These results suggest that older adults who are already vulnerable to micronutrient inadequacies, are forgoing the nutritional advantages of vitamin-rich dairy products.

229Review on Teriparatide (Forsteo) Treatment on Older Patient Attending Bone Health Clinic in St. James’s Hospital

Background: Teriparatide (Forsteo) is an anabolic agent used in treatment of osteoporotic patients with high risk of vertebral fracture. It has been shown to reduce the risk of moderate to severe vertebral fractures by up to 80–90%. Vertebral fractures due to osteoporosis are common in older women. Methods: We aimed to identify the characteristics of older adults receiving teriparatide therapy at our bone health service. We also aimed to evaluate the effect of treatment with teriparatide on bone mineral density (BMD) as well as persistence with therapy. Data were obtained from our bone health service for all adults aged 70 or older who were treated with teriparatide for at least 18 months. Data included age, gender, baseline BMD and T scores as well as changes same with treatment. We dichotomised patients by age (70–79) and (≥80 + ) to evaluate for differences in the ‘older’ old. Results: Data for 250 patients were initially available but 20% did not persist with therapy leaving 198 in our analysis, 98 aged between 70–79 and 100 aged 80 or older. Overall 95% of those were female and approximately 60% had vertebral fractures in both groups. Mean T scores were between −3.5 to −3.6 (spine) and −2.7 at hip.There was significant increase in BMD of spine of 15.3% for aged ≥ 80 + and 13.3% in those aged 70–79 with P value < 0.05. While BMD at hip increased by 1.9 to 2.4%. Conclusions: Teriparatide was as effective at increasing BMD of spine in both age groups (70–79) as well as (≥80+). Our findings support using teriparatide in older adults including the ‘oldest old’ who have high risk of vertebral fractures and where benefit may be greatest.

198Red and Green Bed Day Patient Flow System in an Acute Geriatric Medicine Unit

Background: Patient flow through acute hospital facilities is a challenge to healthcare organisations particularly in relation to older frailer individuals with multiple comorbidities and complex care needs. The Red and Green Bed Day patient flow system developed by Dr I. Sturguss in the NHS has been demonstrated to reduce acute hospital inpatient length of stay. Methods: We used the Red and Green Bed Day patient flow system, over 12 consecutive weekdays within 2 geriatric medical teams. A red-bed day was identified as a bed day where no activity had occurred to progress a patient to discharge and where patients were in receipt of care that did not require an acute hospital bed. Results: Over the 12 days of the study, there were 510 inpatient bed days assessed with the red and green bed day protocol. On average there were 45 (range 41 to 53) patients per day under the 2 teams with a median age of 82 years (range 71 to 98). The study identified 275 (54%) red days and 235 (46%) green days. Commonest reasons for redbed days included (n, %): awaiting long-term care (110, 40), awaiting home care package (91, 33.1), awaiting offsite transitional care (18, 6.5) awaiting care planning meeting (11, 4), awaiting diagnostics (10, 3.6), awaiting interventional procedure (14, 5.1), awaiting transfer to a hospice facility (8, 2.9) and awaiting specialist consultation (5, 1.8). Red-bed days due to community and hospital factors were 227 (82.5%) and 48 (17.5%) respectively. Conclusions: We established that the Red and Green Bed Day patient flow system can be used in an acute geriatric medicine unit. It served as a valuable tool in objectively identifying and quantifying factors contributing to unnecessary prolongation of acute hospital stay.

155Adherence and Persistence to Teriparatide Treatment

Background: Osteoporosis increases the risk of fracture and associated morbidity and mortality. Efficacy of anti-osteoporotic treatment is based on drug potency and adherence and persistence. Teriparatide (TPTD) is the first anabolic agent developed for the treatment of osteoporosis and can significantly reduce the incidence of vertebral fractures. We evaluated adherence and persistence to TPTD treatment in patients with severe osteoporosis in a specialised Bone Health Service. Methods: A cross-sectional and retrospective longitudinal study was performed of all patients in our clinic with severe osteoporosis treated with TPTD from 2004 to 2016. Results: 597 patients commenced TPTD from 2004 to 2016: 90% female, mean age 70 years (range 30–99); 225 (38%) had vertebral fractures; 136 (23%) had Colles fractures; and 75 (13%) had a hip fracture. 106 patients (18%) are currently on treatment. 491 (82%) are no longer on treatment with 367 (75%) having completed 18 months or more of treatment. 122 patients (25%) stopped treatment before 18 months. Of these, the mean length of time on treatment was 195 days. Reasons for prematurely stopping included self-discontinued 19 (16%), side effects 62 (51%), death from any cause 8 (7%), incidental cancer diagnosis 4 (3%), lost to follow up 8 (7%) and other 21 (17%). Most side effects experienced were mild and included rash 4 (6%), palpitations 4 (6%), headaches 6 (10%), fatigue 7 (11%), nausea 11 (18%), dizziness 12 (19%) and generalised/ joint pain 29 (47%). However a small number reported night sweats 1 (2%), UTI/kidney stones 3 (5%) and weight loss 1 (2%). Conclusion: In our study adherence and persistence with TPTD was higher than that reported with oral antiresorptive treatments. The major factor that reduced adherence and persistence was tolerability. These findings are important, as high adherence and persistence with therapy is necessary to ensure an optimal therapeutic outcome.

238Hyperparathyroidism: How Much do Calcium and Vitamin D Matter?

Background: Hyperparathyroidism is associated with increased bone turnover and fractures. We aimed to determine its prevalence in patients attending our osteoporosis clinic, and investigate relationships between their serum calcium, vitamin D, bone turnover markers, bone mineral density (BMD), DXA T-scores and fracture history. Methods: We identified records from 2003–2017, collecting data on parameters above, and parathyroid imaging. Normal calcium level defined as 2.35–2.50 nmol/litre; normal vitamin D =/> 50 nmol/litre; normal PTH < 2.65 pg/ml. Results: 7624 patients; 364 (4.77%) had elevated PTH; 27 with incomplete data excluded. Of remaining 337, 294 female, 43 male; median age 76, mean T-score spine −2.6, mean T-score hip −2.4; overall osteoporosis prevalence 68.8%; 19% had prior hip fracture, 49% vertebral, and 21% Colles. 16 with eGFR < 30 ml/min excluded. Of the remaining 321, 53 (16.5%) hypercalcaemic, 69 (21.5% normocalcaemic and 199 (62%) hypocalcaemic. 182 had low vitamin D, implying secondary hyperparathyroidism; 139 normal vitamin D, implying primary hyperparathyroidism. Of 139 with likely primary hyperparathyroidism, we compared those with normal calcium level to those with high calcium: No significant differences in BMD spine/hip, prevalence of osteoporosis or fragility fracture. P1NP – a bone formation marker – was significantly higher in normocalcaemic group (mean difference 17.483 ng/ml, p = 0.049). 57 patients had parathyroid ultrasound or isotope scans. 22 positive for adenoma; 35 negative. Scans significantly more likely to be positive in patients with high calcium compared with normal calcium (likelihood ratio 5.671, p = 0.0173, ChiSquare test). 13 positive scans were in patients with low vitamin D. Conclusions: Patients with hyperparathyroidism were relatively older, osteoporotic and had high prevalence of fractures, low serum calcium and vitamin D. Low vitamin D was a poor negative predictor of adenoma. Although normocalcaemic patients were less likely to have a radiologically-proven adenoma, they appeared to carry a similar risk of osteoporosis and fracture as those with high calcium/adenoma.