Low Vitamin D Raises Mortality Risk in Nursing Home Patients

Janis C. Kelly

March 12, 2012

March 12, 2012 — The first prospective cohort study to examine vitamin D deficiency and mortality among elderly female nursing home patients found that nearly all have 25(OH)D levels below the limits of normal, and that those with the lowest vitamin D levels were most likely to die within the next 27 months. Stefan Pilz, MD, from the Department of Internal Medicine, Division of Endocrinology and Metabolism, Medical University of Graz, Austria, and the Department of Epidemiology and Biostatistics and EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, the Netherlands and colleagues reported their results in an article published online February 8 in the Journal of Clinical Endocrinology and Metabolism.

Dr. Pilz, told Medscape Medical News, "Considering that the vast majority of nursing home patients are vitamin D deficient, it is, in my opinion, justified to implement a routine vitamin D supplementation with, eg, 800 IU per day. Testing for 25(OH)D levels to evaluate whether this supplementation is sufficient may be considered when these patients are at least 3 months on vitamin D supplementation (target values at least 20 ng/mL/50 nmol/L)."

In this study, researchers examined a sample of 961 nursing home residents from 95 nursing homes in Austria, with an average age of 83.7 years. The researchers recorded 284 deaths (30% of the study cohort) after a mean follow-up time of 27 months (range, 2 - 34 months). Their findings showed that vitamin D levels were below recommended levels in 92.8% of the study participants, suggesting that although vitamin D deficiency among frail and elderly populations has been acknowledged for several decades, no effective strategies to treat the deficiencies have been developed and implemented.

Dr. Pilz said, "I was surprised that nearly all patients were vitamin D deficient because I really thought that there exist more efforts to avoid and treat vitamin D deficiency and its related morbidity and mortality. The question that it raised for me was how to implement efficient strategies to improve the current situation; ie, to prevent and vitamin D deficiency in these patients."

The researchers found that during the mean follow-up time of 27 (±8) months, the age-adjusted hazard ratio (HR) for death from any cause was 1.49 (95% confidence interval, 1.07 - 2.10) for patients in the first quartile of 25(OH)D (<14.0 nmol/L) compared with those in the fourth quartile (>25.5 nmol/L). So few patients had 25(OH)D levels in the normal range that it was not possible to make a statistical comparison.

Dr. Pilz said that in general populations, the lowest mortality risk is at 25(OH)D levels ranging from 30 to 35 ng/mL (75 - 87.5 nmol/L).

He also said that concerns about toxicity from vitamin D supplementation are largely unwarranted. "Going out in the sun can lead to an endogenous vitamin D synthesis in the skin of up to 20,000 IU per day, and studies with oral vitamin D doses of up to 10,000 per day did not show any side effects. Health authorities such as the Institute of Medicine are quite conservative with their recommendations, but they also claim that a daily vitamin D dose of up to 4000 IU per day is safe," he noted. "Vitamin D toxicity, of course, exists, but only when you supplement extremely high doses of vitamin D that can then lead to hypercalcemia," he added.

Vitamin D and Hypertension

Dr. Pilz is currently working on an ongoing randomized controlled trial (the Styrian Vitamin D Hypertension Study) on the effects of vitamin D supplementation on blood pressure in 200 hypertensive patients. "Many unanswered questions remain on vitamin D such as the identification of those groups of individuals with the most significant benefit of vitamin D supplementation, questions on how to optimize vitamin D status in general populations (eg, food fortification), optimal dose of vitamin D and optimal levels of 25(OH)D, and usefulness of 25(OH)D testing in different clinical settings," Dr. Pilz said.

Clifford Rosen, MD, reviewed the study for Medscape Medical News. Dr. Rosen is director of clinical and translational research, a senior scientist at Maine Medical Center's Research Institute, and professor of medicine at Tufts University School of Medicine in Boston, Massachusetts. He was also on the committee that developed the 2011 Institute of Medicine dietary reference intakes for calcium and vitamin D.

Dr. Rosen said, "I would agree that this is a real finding. We have known for some time that low 25(OH)D in elders is an indicator of poor health, and therefore [they] have greater mortality. This work has been shown before, but not in the nursing home population. All nursing home patients should have a single test level of 25(OH)D because those with low values are likely to be at risk of major problems including falls and fractures. Also, 800 IU per day for deficient individuals might not help some individuals with really low values."

The study was sponsored by Roche International. One coauthor was supported by funding from the Austrian National Bank. Dr. Pilz and Dr. Rosen have disclosed no relevant financial relationships.

J Clin Endocrinol Metabol. Published online February 8, 2012. Abstract

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