Miriam Casey

Vitamin D deficiency is associated with inflammation in older Irish adults.

CONTEXT Inadequate vitamin D status is common within elderly populations and may be implicated in the etiology of autoimmune disease and inflammation. Few studies have investigated the relationship between vitamin D status and age-related immune dysfunction in humans. OBJECTIVE The aim of this study was to investigate the association between vitamin D status and immune markers of inflammation in a large sample of older adults. DESIGN, SETTING, AND PARTICIPANTS An observational investigation of 957 Irish adults (>60 years of age) recruited in Northern Ireland (55°N latitude) as part of the Trinity Ulster Department of Agriculture aging cohort study. MAIN OUTCOME MEASURE We measured serum 25-hydroxyvitamin D (25(OH)D) by liquid chromatography tandem mass spectrometry and serum cytokines IL-6, TNF-α, IL-10, and C-reactive protein (CRP) by ELISA. RESULTS Concentrations of IL-6, CRP, and the ratios of IL-6 to IL-10 and CRP to IL-10 were significantly higher in individuals with deficient (<25 nmol/L) serum 25(OH)D compared with those with sufficient (>75 nmol/L) status after adjustment for age, sex, and body mass index (P < .05). Vitamin D status was a significant predictor of the IL-6 to IL-10 cytokine ratio, and those participants defined as deficient were significantly more likely to have an IL-6 to IL-10 ratio >2:1 compared with those defined as sufficient. CONCLUSIONS This study demonstrated significant associations between low vitamin D status and markers of inflammation (including the ratio of IL-6 to IL-10) within elderly adults. These findings suggest that an adequate vitamin D status may be required for optimal immune function, particularly within the older adult population.

Diagnostic Accuracy of Holotranscobalamin, Methylmalonic Acid, Serum Cobalamin, and Other Indicators of Tissue Vitamin B12 Status in the Elderly

BACKGROUND Vitamin B₁₂ deficiency is common among the elderly, and early detection is clinically important. However, clinical signs and symptoms have limited diagnostic accuracy and there is no accepted reference test method. METHODS In elderly subjects (n = 700; age range 63-97 years), we investigated the ability of serum cobalamin, holotranscobalamin (holoTC), total homocysteine (tHcy), methylmalonic acid (MMA), serum and erythrocyte folate, and other hematologic variables to discriminate cobalamin deficiency, defined as red blood cell cobalamin <33 pmol/L. RESULTS Serum holoTC was the best predictor, with area under the ROC curve (95% CI) 0.90 (0.86-0.93), and this was significantly better (P ≤ 0.0002) than the next best predictors; serum cobalamin, 0.80 (0.75-0.85), and MMA, 0.78 (0.72-0.83). For these 3 analytes, we constructed a 3-zone partition of positive and negative zones and a deliberate indeterminate zone between. The boundaries were values of each test that resulted in a posttest probability of deficiency of 60% and a posttest probability of no deficiency of 98%. The proportion of indeterminate observations for holoTC, cobalamin, and MMA was 14%, 45%, and 50%, respectively. Within the holoTC indeterminate zone (defined as 20-30 pmol/L), discriminant analysis selected only erythrocyte folate, which correctly allocated 65% (58/89) of the observations. Renal dysfunction compromised the diagnostic accuracy of MMA but not holoTC or serum cobalamin. CONCLUSIONS This study supports the use of holoTC as the first-line diagnostic procedure for vitamin B₁₂ status.

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.

Outcomes among older people in a post-acute inpatient rehabilitation unit

Purpose: Designated multidisciplinary rehabilitation units have been shown to provide several benefits for the frail older population. The aim of this research was to evaluate changes in strength, mobility, balance, endurance, frailty and quality of life (QoL) following a 6-week multidisciplinary inpatient rehabilitation programme. Method: This was a prospective, observational study performed in a post-acute multidisciplinary geriatric inpatient rehabilitation service. A consecutive sample of heterogenous frail older adults (n = 32) participated. Subjects were assessed on admission to the rehabilitation service (T1) and following 6 weeks of rehabilitation (T2). A range of outcome measures were used to assess function and QoL: Berg Balance Scale (BBS), Timed Up and Go (TUG), 6-Minute Walk Test (6MWT), Barthel Index (BI), EuroQol-Visual Analogue Scale (EQ-VAS), Clinical Frailty Scale (CFS), lower limb and grip dynamometry. Results: The majority were female (n = 25), the mean age was 82.9 years (SD 6.35). The median length of stay was 49 days. Patients improved significantly between T1 and T2 assessments in the BBS (p ≤ 0.0001); TUG (p ≤ 0.0001); 6MWT (p ≤ 0.0001); BI (p ≤ 0.0001); EQ-VAS (p = 0.002); CFS (p ≤ 0.0001); and in some aspects of grip and lower limb strength. Conclusion: This study has demonstrated that positive outcomes occurred in a range of measures in an older, frail inpatient rehabilitation population. Implications for Rehabilitation Elderly inpatients undergoing rehabilitation programmes improve across a range of measures looking at impairment, activity, participation and quality of life. However, gains were modest and patients did not attain their baseline level of performance after a 6-week programme of inpatient rehabilitation. Using outcome measures in clinical rehabilitation practice can facilitate comparison between units and can form the basis for future research in this population.

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.

Osteoporosis in patients with Parkinson's disease.

comparison group, according to an in-home assessment using the Kohlman Evaluation of Living Skills (KELS) test. Of those with intact cognitive function (defined by a MiniMental State Examination score 424), older people with self-neglect syndrome remained significantly more likely to have functional impairments. Pavlou and Lachs’ equivocal findings regarding selfneglect and functional decline may be related to the inconsistent methodology used in the studies in their review to assess functional status. In our experience, self-report is a less reliable method of assessment among self-neglecters, and valid measurements of functional assessment require self-report, observation, and performance, underscoring the strength of the KELS test in this setting. Nonetheless, we believe that the article by Pavlou and Lachs makes a significant and important contribution to the evidence base supporting self-neglect as a geriatric syndrome.

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.

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.