Association Between Hypovitaminosis D in Elderly Women and Long- and Short-Term Mortality-Results from the Osteoporotic Prospective Risk Assessment Cohort

On-admission serum 25(OH)D level and mortality within one year in older patients

BACKGROUND

Mounting evidence suggests that vitamin D deficiency is associated with a higher risk of many chronic non-skeletal, age-associated diseases as well as mortality.

AIM

To determine, in older patients aged ≥ 80, the prevalence of vitamin D deficiency and its association with comorbidity, laboratory tests, length of stay and mortality within one year from blood withdrawal on admission to acute geriatrics ward.

METHODS

We retrospectively surveyed electronic hospital health records of 830 older patients. The recorded data included patient demographics (e.g., age, sex, stay duration, readmissions number, death within one year from blood withdrawal on admission), medical diagnoses, laboratory results, including 25-hydroxyvitamin D [25(OH)D], and medications. We compared the characteristics of the patients who survived to those who died within one year.

RESULTS

On admission, in 53.6% patients, vitamin D levels were lower than 50 nmol/L, and in 32%, the levels were ≤ 35 nmol/L. Persons who died were likely to be older, of male sex, were likely to be admitted for pneumonia or CHF, were likely to have lower level of albumin or hemoglobin, lower level of vitamin D or higher vitamin B12 and higher level of creatinine, were also likely to have had a lengthier hospitalization stay, a greater number of hospitalizations in the last year, a higher number of comorbidities, to have consumption of ≥5 drugs or likely to being treated with insulin, diuretics, antipsychotics, anticoagulants or benzodiazepines. Higher age, male sex, on-admission CHF, higher number of drugs, lower albumin, higher vitamin B12, vitamin D < 50 nmol/L, and consumption of antipsychotics and anticoagulants - were predictors of mortality.

CONCLUSION

Hypovitaminosis D is predictive of mortality in older patients within one year from hospitalization in the acute geriatric ward, but a causal relationship cannot be deduced. Nevertheless, older patients in acute care settings, because of their health vulnerability, should be considered for vitamin D testing. In the acutely ill patients, early intervention with vitamin D might improve outcomes. Accurate evaluation of mortality predictors in this age group patients may be more challenging and require variables that were not included in our study.

Longitudinal Changes in Kidney Function Estimated from Cystatin C and Its Association with Mortality in Elderly Women

BACKGROUND/AIMS

Prospective data on age-related changes in kidney function are required, especially since the current Kidney Disease Improving Global Outcomes (KDIGO) definition has been suggested to classify a large number of elderly people with CKD.

OBJECTIVE

This study, a complement to our previous Cr-based study in the same cohort, is aimed at evaluating cystatin C (cysC)-based changes in kidney function during aging in older women and analyzing the association between CKD and mortality through 10 years of follow-up.

METHODS

cysC was available in 981 women from the Osteoporosis Prospective Risk Assessment (OPRA) cohort, all aged 75 years on entry. Reinvestigations were made after 5 (n = 685) and 10 years (n = 365). Kidney function was estimated (estimated glomerular filtration rate [eGFR]) using Chronic Kidney Disease Epidemiology Collaboration cysC and Caucasian, Asian, Pediatric, and Adult cysC equations and the change in function calculated. Women were staged equivalent to CKD stage 1, 2, 3a, or 3b-5 according to the KDIGO classification. Mortality risk was estimated for 5-year or 10-year follow-up time using Cox proportional hazard analyses (reference category, CKD stages 1 and 2).

RESULTS

Mortality risk for women with the worst kidney function (CKD stages 3b-5) increased during both 5-year follow-up times compared to that for women in stages 1 and 2 (age 75-80 years: adjusted Hazard Ratio [HRadj] 3.9, 95% confidence interval [CI] 2.3-6.5; age 80-85 years: HRadj 1.7, 95% CI 1.0-2.7). In contrast, women in stage 3a had increased risk only in the first 5-year follow-up (HRadj 1.7, 95% CI 1.0-3.0, age 75-80 years). Change in kidney function amounted to a loss of 1.9 (±1.4) mL/min/1.73 m2 per year during the 10-year follow-up, and at age 85 years, 4 of every 5 women had an eGFR equivalent to CKD.

CONCLUSION

In the future, an age-adapted definition of CKD, lowering the threshold for CKD in the elderly, may be beneficial to avoid overdiagnosis of CKD.

Association Between Vitamin D, Frailty, and Progression of Frailty in Community-Dwelling Older Women

CONTEXT

Vitamin D (25OHD) is involved in many physiological functions that decline with age, contributing to frailty and increased risk for negative health outcomes. Whether 25OHD is a long-term risk marker for frailty over a longer time and whether it is consistent with advancing age is unclear.

OBJECTIVE

To investigate the association between 25OHD and frailty in older women followed for 10 years.

DESIGN AND SETTING

Prospective, population-based, cohort study in Malmö, Sweden.

PARTICIPANTS

Community-dwelling women, age 75 years (N = 1044) with reassessments at ages 80 (n = 715) and 85 (n = 382) years.

METHODS

Frailty was quantified using a 10-variable frailty index. Women were categorized as 25OHD insufficient (<50 nmol/L) or sufficient (≥50 nmol/L).

RESULTS

At ages 75 and 80 years, women with insufficient 25OHD were frailer than women with sufficient 25OHD (0.23 vs 0.18, P < 0.001; and 0.32 vs 0.25, P = 0.001, respectively). At age 80 years, 25OHD insufficiency was associated with subsequent frailty 5 years later (0.41 vs 0.32; P = 0.011). Accelerated progression of frailty was not associated with lower 25OHD levels, and 25OHD level >75 nmol/L was not additionally beneficial with regard to frailty. No association between 25OHD and frailty was observed at age 85 years. Within the frailty index, variables associated with 25OHD were related to muscle strength and function.

CONCLUSION

In this study, 25OHD insufficiency was associated with increased frailty in all but the oldest old. This study supports the value of maintaining sufficient 25OHD levels for healthy aging.

Surgical Considerations for Vitamin D Deficiency in Foot and Ankle Surgery

Vitamin D deficiency affects nearly one-sixth of the world's population and is common in patients undergoing foot and ankle surgery. Vitamin D is critical for calcium homeostasis and plays an important role in the maintenance of bone health. Patients undergoing foot and ankle procedures can be evaluated preoperatively with vitamin D level testing, and deficiencies can be addressed with either preoperative or postoperative supplementation. Current data suggest that patients with adequate vitamin D levels may have better outcomes, but the details are not yet clear. Vitamin D supplementation is well tolerated with rare side effects.

Vitamin D Status and Mortality: A Systematic Review of Observational Studies

Epidemiological evidence suggests that vitamin D deficiency is associated with increased mortality, but it is unclear whether this is explained by reverse causation, and if there are specific causes of death for which vitamin D might be important. We conducted a systematic review of observational studies investigating associations between circulating 25-hydroxyvitamin D (25(OH)D) concentration and all-cause or cause-specific mortality in generally healthy populations. Relevant studies were identified using PubMed and EMBASE searches. After screening 722 unique records and removing those that were ineligible, 84 articles were included in this review. The vast majority of studies reported inverse associations between 25(OH)D concentration and all-cause mortality. This association appeared to be non-linear, with progressively lower mortality with increasing 25(OH)D up to a point, beyond which there was no further decrease. There is moderate evidence that vitamin D status is inversely associated with cancer mortality and death due to respiratory diseases, while for cardiovascular mortality, there is weak evidence of an association in observational studies, which is not supported by the data from intervention or Mendelian randomization studies. The relationship between vitamin D status and other causes of death remains uncertain due to limited data. Larger long-term studies are required to clarify these associations.

Longitudinal Assessment of PTH in Community-Dwelling Older Women-Elevations Are Not Associated With Mortality

Context:

In older women, the magnitude of elevated parathyroid hormone (PTH) and its consequence is unclear.

Objective:

To describe normal PTH profiles over time and the association with mortality.

Design and Participants:

There were 1044 community-dwelling women in the Malmö Osteoporosis Prospective Risk Assessment cohort (OPRA) who attended baseline (age 75 years). Follow-ups were attended by 715 (age 80 years) and 382 (age 85 years).

Main Outcome Measures:

PTH, estimated glomerular filtration rate (eGFR), 25-hydroxyvitamin D (25OHD) and mortality.

Results:

At age 75 years, PTH levels for most (n = 877, 88%) were within the normal reference range (NRR) (i.e., <6.9 pmol/L). Longitudinally, between ages 75 and 80 years, PTH increased in 60% of all women (n = 390) but increases of up to 50% above baseline values (64%; n=250) still resulted in PTH levels within the NRR. These women had lower 25OHD levels (74 vs 83 nmol/L, P = 0.001). Only when increases were >50% was PTH elevated beyond the NRR (mean 7.1 ± 3.3). Here, a pronounced decline in eGFR (56 vs 61 mL/min/1.73 m², P = 0.002) was found, despite no further changes in 25OHD. Extending the observational period until age 85 years gave similar results. Baseline PTH levels above NRR were associated with mortality (hazard ratio, 1.4; 95% confidence interval (CI), 1.1-1.8; P = 0.007), although not after adjustment for covariates (P = 0.082).

Conclusions:

Most women remained within normal PTH ranges despite large increases of up to 50%. PTH elevated above normal is not independently associated with mortality; impaired kidney function and low 25OHD status may be more prognostic in the very old.