Vitamin D Deficiency and Long-Term Cognitive Impairment Among Older Adult Emergency Department Patients

Christopher S. Evans, MD, MPH; Wesley Self, MD, MPH; Adit A. Ginde, MD, MPH; Rameela Chandrasekhar, PhD; E. Wesley Ely, MD, MPH; Jin H. Han, MD, MSc

Disclosures

Western J Emerg Med. 2019;20(6):926-930. 

In This Article

Abstract and Introduction

Abstract

Introduction: Approximately 16% of acutely ill older adults develop new, long-term cognitive impairment (LTCI), many of whom initially seek care in the emergency department (ED). Currently, no effective interventions exist to prevent LTCI after an acute illness. Identifying early and modifiable risk factors for LTCI is the first step toward effective therapy. We hypothesized that Vitamin D deficiency at ED presentation was associated with LTCI in older adults.

Methods: This was an observational analysis of a prospective cohort study that enrolled ED patients ≥ 65 years old who were admitted to the hospital for an acute illness. All patients were enrolled within four hours of ED presentation. Serum Vitamin D was measured at enrollment and Vitamin D deficiency was defined as serum concentrations <20 mg/dL. We measured pre-illness and six-month cognition using the short form Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE), which ranges from 1 to 5 (severe cognitive impairment). Multiple linear regression was performed to determine whether Vitamin D deficiency was associated with poorer six-month cognition adjusted for pre-illness IQCODE and other confounders. We incorporated a two-factor interaction into the regression model to determine whether the relationship between Vitamin D deficiency and six-month cognition was modified by pre-illness cognition.

Results: We included a total of 134 older ED patients; the median (interquartile range [IQR]) age was 74 (69, 81) years old, 61 (46%) were female, and 14 (10%) were nonwhite race. The median (IQR) vitamin D level at enrollment was 25 (18, 33) milligrams per deciliter and 41 (31%) of enrolled patients met criteria for vitamin D deficiency. Seventy-seven patients survived and had a six-month IQCODE. In patients with intact pre-illness cognition (IQCODE of 3.13), Vitamin D deficiency was significantly associated with worsening six-month cognition (β-coefficient: 0.43, 95% CI, 0.07 to 0.78, p = 0.02) after adjusting for pre-illness IQCODE and other confounders. Among patients with pre-illness dementia (IQCODE of 4.31), no association with Vitamin D deficiency was observed (β-coefficient: −0.1;, 95% CI, [−0.50–0.27], p = 0.56).

Conclusion: Vitamin D deficiency was associated with poorer six-month cognition in acutely ill older adult ED patients who were cognitively intact at baseline. Future studies should determine whether early Vitamin D repletion in the ED improves cognitive outcomes in acutely ill older patients.

Introduction

Long-term cognitive impairment (LTCI), defined as new or worsening deficit in cognition that persists following acute illness, is a well described phenomenon occurring in an estimated 16% of older adults who are acutely ill.[1] This often leads to increased disability, loss of independence, and decreased quality of life. Currently no effective therapies, especially those that can be administered early in the acute illness course, exist to prevent or treat LTCI following acute illness.

While the mechanism of LTCI has not been fully elucidated, it is hypothesized that systemic proinflammatory cytokines, in response to an acute medical illness such as sepsis,[2] lead to increased central nervous system (CNS) inflammation, microglial activation, and neuronal injury and death.[2] Vitamin D is a pleotropic hormone that modulates systemic and CNS inflammatory responses.[3] Therefore, patients with Vitamin D deficiency may be particularly vulnerable to LTCI following an acute illness. Several observational studies have suggested that Vitamin D deficiency is associated with poorer long-term cognition among community-dwelling adults.[4] However, the relationship between Vitamin D deficiency in the setting of acute illness and subsequent development of LTCI remains unknown in acutely ill patients, especially in the emergency department (ED) setting. Therefore, we sought to determine whether serum Vitamin D at ED presentation was associated with poorer six-month cognition in acutely ill older adults.

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