By Mike Wakeman
A new, as yet unpublished, study shows that the elderly are very likely to seriously lack vitamin D, raising their risk of broken bones. What’s more care homes rarely offer supplements. Making the situation even worse are the cocktails of prescription drugs that many of these patients swallow daily. Few doctors are aware that common drugs can make it harder to absorb vitamins and minerals.
Four years ago in 2010, a study of over- 65-year-olds found that just 16% of men and 13% of women had serum vitamin D levels above the recommended level of 75nmol/l. Now, being short of vitamin D is not a trivial matter. For years the vitamin has been known to be vital for healthy bones, but recent evidence suggests that it may also play a significant role in a variety of other processes (1).
These include keeping your cardiovascular system healthy and maintaining muscle mass; it’s also essential for an effective immune system and to keep the nervous system working properly. Not having a healthy level of vitamin D is very likely to make you more vulnerable to inflammatory diseases such as arthritis and raise the risk of diabetes, cancer, infectious diseases and muscle weakness. This body-wide role of vitamin D is not really surprising, since it’s known to be involved in the regulation and expression of over 900 genes.
Why not simply supplement?
So given that supplementing vitamin D costs pennies a day and given that a deficiency can cause so much long term damage, a sane response to discovering just how many people were deficient would be to launch a supplementation programme. Instead public health authorities here and in the USA have effectively ignored it.
In fact the results of a recent US study that checked the vitamin D levels of older patients being admitted to an intensive care unit in Atlanta, dramatically highlighted just how bad the situation was (2). It is unlikely to be any better in the UK. The researchers found that 53% of elderly patients had severe vitamin D deficiency, 37% had moderate deficiency, 7% had mild deficiency, whilst only 3% of the patients had normal vitamin D levels.
And it’s a certainty that vitamin D was not the only nutrient these patients were short of.
How the current care system makes things even worse
A number of factors conspire to ensure that older people will generally be considerably sicker than they need to be. As you get older and frailer you are more likely to get ill because your body systems – cardiovascular, immune, hormonal – start to slow-down and become less efficient. A public health system can make the situation better or worse. Currently we make it worse with all the human and financial costs that involves.
A good diet can help with the natural slow down but older people often don’t eat very well, especially if they live on their own and have various chronic problems. So they are more likely to be admitted to hospital – about half of the admissions every year are for people over 65. There the effects of a poor diet become obvious; a third show up as malnourished – that’s two and a half million people in the UK (3).
Weight loss is one result, which can be beneficial but once you are over 65, losing more than 5% of your body weight “increases mortality.” Mineral and vitamin deficiencies are an inevitable part of malnourishment making you more vulnerable to infections and likely to recover more slowly (4).
A third of hospital patients malnourished
At this point good hospital food could help to reverse some of the problems but hospital food is infamously poor and in fact slightly more people leave hospital malnourished than were admitted.
Rather than attending to patients decline in general health, the official approach is to prescribe drugs to deal with their symptoms. By your mid-seventies you could easily be on up to ten or more drugs a day as the guidelines for each condition are carefully followed. But they are very likely to be making your nutritional state even worse.
Each drug comes with its’ own side effects, which can be as drastic as vomiting and gastric upsets, but also affect sense of smell and ability to chew properly, all of which can make it harder to eat a nutritious diet. So the amount of nutrients you are getting from your food drops still further.
How drugs block vitamins
But that’s not the worst of it. There is a problem linked to this rising drug consumption that is rarely discussed. Many of the drugs older people are regularly prescribed affect the way your body handles the vitamins and minerals from your diet. Doctors pay little if any attention to this effect.
This whole area is very complex and depends upon specific drugs, the health status of the individual and the number of multiple medications a person is taking. It’s an area of research that has received scant attention until recently, but the little that has been done paints an alarming picture. It is certainly going to be one of the factors contributing to those pitifully low levels of vitamin D.
What makes ignoring this deficiency so disastrous is that a number of the conditions that older people are particularly vulnerable to, are made worse by low vitamin D, such as poor bone health and muscle strength which would otherwise protecting against falls and fractures; while poorer immunity leads to increased susceptibility to infections.
The devastation vitamin D deficiency can cause
This is hugely unpleasant for the patients but it has bottom line costs – largely invisible in the NHS but easy to calculate in American hospitals. The Atlanta study found that for a patients who was severely vitamin D deficient their average length of stay in the Surgical Intensive Care Unit was 13 days versus 7 days and 5 days respectively for the moderate and mild vitamin D-deficient groups, which was clinically significant (P<.002).
The financial cost was correspondingly high, averaging around $60,000 for the severe vitamin D–deficient group, $40,000 for the moderate group, and $20,000 for the mild vitamin D–deficient group, which also was clinically significant (P< .027). Lack of vitamin D also meant you were more likely to die. The rate for the most deficient was 12% versus 11% in the moderate group (P< .125), whilst none of those who had a healthy vitamin D died. So vitamin D insufficiency comes at a high personal and economic cost as well.
But is not just poor food, lack of sun exposure and a general slowing down that makes older people more likely to have a dangerous lack of vitamin D. The ability of various common drugs to reduce vitamin absorption is likely to have been having an effect for years.
The drugs that cut vitamin D levels
The main vitamin D-lowering culprits include certain anti-epileptic drugs, blood pressure medications (antihypertensives) and drugs used to treat diabetes. A recent Dutch study of elderly people showed that drugs for diabetes, high blood pressure and the proton pump inhibitors (PPIs) drugs (widely used lower stomach acid to protect against the gut damage caused by painkillers) were especially likely lower vitamin D and the more drugs you were taking the lower your stores dropped (6).
So much for the theory but I wanted to know what effect this dangerous combination of poorer diet and the vitamin mugging effect of drugs having on residents in care homes in the UK? Were any being offered a supplement to compensate for it?
First step was a pilot study, as yet unpublished, that audited 65 completely anonymised prescription records from a retirement home. All of the patients were receiving more than one medication; the average was six and one was getting 12. Forty two of the patients were officially “at risk” of vitamin D deficiency because they were over 65
Of these, 25 had no vitamin D supplementation at all, the other 17 were getting some but it was rarely enough to bring them up to a healthy level. Although opinion varies about the precise level required at this age, most forward thinking experts recommend around 1000 IU per day for the elderly, but only those taking a prescribed vitamin D supplement were getting towards this target.
Damaging drug cocktails
Moreover, 21 patients officially “at risk” of deficiency were being prescribed one or more of the drugs (highlighted above) which are known to make absorbing and use of vitamin D less efficient but only eight of them were getting a vitamin D supplement.
This is the first time a study like this has been done and it badly needs to be repeated on a much larger scale with more detail, but it does show a lack of understanding of basic care for elderly people. This is a typical retirement home where over half of the patients likely to be deficient simply because of their age were getting no supplementation at all. That is quite apart from taking any action to protect patients who were are further risk because of the drugs they were taking.
There is a serious need for healthcare professionals to receive proper training about the personal and financial cost of deficiency and how treating it properly could improve their patients’ lives and save money.
- Hirani V et al. Age and aging 2010: 39;62-68
- Matthews R et al. Am. J. Surg. 2012; 204; 37-43
- Ageuk.org Later life in the United kingdom report November 2014
- Newman A. et al. J Am Geriatr Soc 2001; 49; 1309-1318
- Vitamin D, Third Edition ED Feldman D Academic Press ISBN 978-0-12-381978-9
- Sohl E et al. Eur J Endocrinol 2012; 166; 477-485