Elderly men (1)
1,194 of 9,767 (12.22%) patients were 70 years of age or older on the day of the first visit. There were 750 women and 444 men, with no difference in age distribution.
(1) although no difference was found in age distribution between women and men, dizziness was more prevalent among women, which may be because of the higher survival rate of women;
(2) the prevalence of paroxysmal positional vertigo was high, with apparent involvement of the posterior semicircular canal in most cases (it is strongly suspected that paroxysmal positional vertigo is frequently misdiagnosed as vascular disease in advanced age); and
(3) multisensory deficits, drugs, or systemic diseases, common in the elderly, may cause dizziness. Syndromes affecting the vestibular function, however, may be more prevalent in advanced age than is generally estimated.
Katsarkas A: Dizziness in aging: a retrospective study of 1194 cases. Otolaryngol Head Neck Surg, 1994 Mar, 110:3, 296-301.
Elderly men (1)
To evaluate the causes of dizziness in elderly men (more than 50 years of age).
The median duration of dizziness at first office visit was 45 weeks.
More than one diagnosis contributed to dizziness in 49% of patients.
Dysfunctions of the peripheral vestibular system were found in 71% and were the principal causes in 56%.
Benign positional vertigo was present in 34%.
Disorders of the visual system were found in 26% but were the major cause in only 1%.
Diagnoses involving the proprioceptive system were present in 17% and were the principal cause in 7%.
Structural lesions of the brainstem or cerebellum or metabolic disorders that affected normal brainstem function were identified in 59% and were the major diagnoses in 22%.
A psychophysiologic diagnosis was made in 6% but was the major diagnosis in only 3%.
At the 6-months follow-up, 55% of patients improved, 34% were unchanged, 4% worsened, and 7% were lost to follow-up.
Contrary to reports in the literature, dizziness in the elderly is more persistent, has more causes, is less often due to a psychophysiologic cause, and seems to be more incapacitating than dizziness in younger patients.
Davis LE: Dizziness in elderly men. J Am Geriatr Soc, 1994 Nov, 42:11, 1184-8.
Differentiate dizzy from non-dizzy patients and to design an investigational algorithm.
Blood profile, electrocardiography, electronystagmography, and magnetic resonance imaging failed to distinguish dizzy from control subjects because of the frequency of asymptomatic abnormalities in controls.
Posturography and clinical assessment (physical examination, dizziness provocation, and psychological assessment) showed significant differences between the groups.
The most common diagnoses were central vascular disease (105) and cervical spondylosis (98), often accompanied by poor vision and anxiety.
Expensive investigations are rarely helpful in dizzy elderly people. The cause of the dizziness can be diagnosed in most cases on the basis of a thorough clinical examination without recourse to hospital referral.
Colledge NR et al., Evaluation of investigations to diagnose the cause of dizziness in elderly people: a community based controlled study. BMJ, 313:788-92, 1996 Sep 28.
Dizziness is a common and potentially disabling complaint among older patients. A major consequence is falls, which can lead to death or significant functional disability.
Dizziness can be separated into four broad categories: vertigo, disequilibrium, near-syncope, and nonspecific.
Given its multitude of possible etiologies, dizziness often poses a diagnostic dilemma for the physician. Symptoms can result from a disturbance in any number of balance control systems, including the visual pathways, vestibular apparatus, cardiovascular system, and CNS.
Depending upon the organ system involved, an audiologist, otolaryngologist, neurologist, cardiologist, and/or psychiatrist should then be consulted for further assessment and management.
Weinstein BE & Devons CA The dizzy patient: stepwise workup of a common complaint. Geriatrics, 1995 Jun, 50:6, 42-6, 49; quiz 50-1.
In dementia, depression, and Parkinson's disease many contributing factors must be considered, including nutrition but the effects of the cognitive, attitudinal, and motor changes can produce permanent and severe nutritional compromise. Yet many simple steps can be taken to prevent poor nutrition in these diseases.
Dementia, depression, and nutritional status. Cohen-D. Prim-Care. 1994 Mar; 21(1): 107-19.
Diagnosis & Treatment
Diagnosis & Treatment
Neurologic damage may become permanent when the disorder is mistaken for multiple sclerosis or diabetic neuropathy--hence the need for prompt parenteral B12 in patients with pernicious anemia. The need for B12 injections is questionable for patients with achlorhydria and for those with a marginal or low serum B12 level but no signs or symptoms of deficiency.
Vitamin B12 deficiency: underdiagnosed, overtreated? Schilling-RF; Williams-WJ. Hosp-Pract-Off-Ed. 1995 Jul 15; 30(7): 47-52; discussion 52, 54.
BPH is an age-related condition that can give rise to urinary symptoms.
A range of effective treatments is available, and although there are certain absolute indications for surgery, patients with moderate or severe symptoms require counseling to reach a decision on the treatment modality most appropriate for them.
Concomitant age-related disease and use of multiple medications add to the complexity of treating elderly men for BPH.
In every case of BPH, the risks of each treatment option should be weighted against the potential benefits and a joint decision reached by physician and patient.
Guthrie R: Benign prostatic hyperplasia in elderly men. What are the special issues in treatment? Postgrad Med, 1997 May, 101:5, 141-3, 148, 151-4 passim.
Medical therapy with alpha 1-adrenergic blockers or 5 alpha-reductase inhibitors offers an alternative to the traditional choices of watchful waiting and surgery.
Patients with obstructive symptoms and a small prostate appear to respond to treatment with an alpha 1-adrenergic blocker, while a 5 alpha-reductase inhibitor may be the preferred agent for a large gland.
Albertsen PC: Prostate disease in older men: 1. Benign hyperplasia. Hosp Pract (Off Ed), 1997 May 15, 32:5, 61-4, 67-8, 77 passim.
Using data from an incident case-control study, this study evaluated the combined effect of dietary intake of folate, methionine, vitamin B6, vitamin B12, and alcohol and various forms of the MTHFR gene on risk of colon cancer. Individuals homozygous for the variant form of the MTHFR gene (TT) had a slightly lower risk of colon cancer than did individuals who were wild type (CC). High levels of intake of folate, vitamin B6, and vitamin B12 were associated with a 30-40% reduction in risk of colon cancer among those with the TT relative to those with low levels of intake who were CC genotype.
Slattery ML, Potter JD, Samowitz W, Schaffer D, Leppert M: Methylenetetrahydrofolate reductase, diet, and risk of colon cancer, Cancer Epidemiol Biomarkers Prev 1999 Jun;8(6):513-8
Determine the prevalence and describe the clinical correlates of subnormal cobalamin levels in subjects infected with the human immunodeficiency virus (HIV
Subnormal serum B12 levels were found in 61 subjects (30.5%). B12 deficient subjects were more likely to be taking zidovudine. (P = .007).
Malabsorption of vitamin B12 as evidenced by abnormal Schilling tests was more likely among patients with more advanced HIV disease, or gastrointestinal symptoms but was not necessarily associated with low B12 levels.
Decreased cobalamin levels are found frequently in HIV disease, especially among those treated with zidovudine. Evidence of B12 malabsorption is found among those with more advanced disease and gastrointestinal symptoms.
Clinical correlates of subnormal vitamin B12 levels in patients infected with the human immunodeficiency virus. Paltiel-O; Falutz-J; Veilleux-M; Rosenblatt-DS; Gordon-K. Am-J-Hematol. 1995 Aug; 49(4): 318-22.
Distal sensory peripheral neuropathy (DSPN) has been reported in 5 to 75% of patients with human immunodeficiency virus (HIV) infection, particularly in advanced stages of the disease.
Also investigate the role of vitamin B12 deficiency on the frequency of DSPN in HIV patients.
DSPN was present in 5% of patients with early HIV infection and did not appear to be more frequent in patients with concurrent vitamin B12 deficiency.
Sensorimotor neuropathy and abnormal vitamin B12 metabolism in early HIV infection. Veilleux-M; Paltiel-O; Falutz-J. Can-J-Neurol-Sci. 1995 Feb; 22(1): 43-6.
Patients who are taking omeprazole may be at an increased risk for vitamin B12 deficiency, as omeprazole prevents the cleavage of B12 from dietary proteins. While supplementation may prevent this problem, some of the studies suggest that the simple addition of juices or other acidic drinks into the diet may dramatically increase B12 absorption. Elderly patients are especially at risk for B12 deficiency if they take omeprazole, have gastrointestinal disorders, and/or have a poor dietary intake of vitamin B12. The researchers note that additional research into this area is necessary before any definite conclusions can be made.
Bradford GS, Taylor CT: Omeprazole and vitamin B12 deficiency, Ann Pharmacother 1999 May;33(5):641-3
Trace concentrations of inhalation anaesthetics polluting the air of operating theatres could have deleterious effects on the personnel's health. Nitrous oxide (N2O) oxidises vitamin B12 and thus decreases DNA production by inactivation of methionine synthase. Therefore, the United States and most European health authorities recommend threshold values to protect against potential health risks. [These values range from 25 to 100 ppm, expressed as time-weighted averages (TWA).]
[Nitrous oxide exposure to personnel in a recovery room with modern climate control] Hoerauf-K; Koller-C; Frohlich-D; Taeger-K; Hobbhahn-J. Anaesthesist. 1995 Aug; 44(8): 590-4.
Vitamin B12 supplementation effectively decreases both MMA and plasma tHcy in ESRD patients with low B12 levels, according to this study. Hyperhomocysteinemia is frequently found in patients with end-stage renal disease (ESRD). The researchers investigated the effects of intravenous injection of cyanocobalamin in ESRD patients with low serum cobalamin concentrations. All patients had elevated levels of plasma tHcy, methylmalonic acid (MMA), and cystathionine before supplementation. After supplementation, plasma tHcy and MMA decreased 35% and 48%, respectively; however, cystathionine levels were unchanged. The extent of the plasma tHcy reduction tended to be influenced by the C677T polymorphism of methylenetetrahydrofolate reductase (MTHFR). Serum cobalamin increased significantly upon supplementation, whereas serum folate levels were substantially reduced by 47%. In contrast, red blood cell (RBC) folate was unchanged.
Dierkes J, Domrose U, Ambrosch A, Schneede J, Guttormsen AB, Neumann KH, Luley C: Supplementation with vitamin B12 decreases homocysteine and methylmalonic acid but also serum folate in patients with end-stage renal disease, Metabolism 1999 May;48(5):631-5
To estimate the levels of vitamin B12 in patients with severe sickle cell disease compared to normal controls.
(43.5%) had serum vitamin B12 levels below normal values.
Patients with low B12 achieved a significant symptomatic improvement when treated with vitamin B12, 1 mg intramuscularly weekly for 12 weeks when compared with patients with normal B12 levels.
Many patients with severe sickle cell disease may suffer from unrecognized vitamin B12 deficiency.
Diminished vitamin B12 levels in patients with severe sickle cell disease. al-Momen-AK. J-Intern-Med. 1995 Jun; 237(6): 551-5.
Supplementation in older people
Older people (51 years or more) may be susceptible to vitamin B12 malabsorbtion, and may benefit from supplementation with synthetic B12, according to the National Academy of Sciences' Institute of Medicine. Protein-bound B12, the form found in food, may be malabsorbed in older people due to reduced pepsin activity and gastric acid secretion. Early diagnosis of these conditions is necessary to prevent B12 deficiency. Health officials recommend that people at risk should receive most of the RDA, 2.4 micrograms/day, in the synthetic form.
Ho C, Kauwell GP, Bailey LB: Practitioners' guide to meeting the vitamin B-12 recommended dietary allowance for people aged 51 years and older, J Am Diet Assoc 1999 Jun;99(6):725-7
Celiac Disease & Vitamin B12
Patients with celiac disease commonly exhibit vitamin B12 deficiency that may be corrected with a gluten-free diet and occasionally B12 supplementation, according to this study conducted on 39 biopsy-proven celiac disease patients. Of these patients, 16 were vitamin B12 deficient and 16 were anemic. All patients then adhered to a strict gluten-free diet for four months, and five patients received vitamin B12 supplementation. After the four-month trial, all patients exhibited normal levels of vitamin B12.
Dahele A, Ghosh S: Vitamin B12 deficiency in untreated celiac disease, Am J Gastroenterol 2001 Mar;96(3):745-50
According to this case report, a 42-year-old woman with a mood disorder with mixed depressed/manic features was suffering from vitamin B12 and folate deficiency. These vitamins are often associated with depressive disorders. In this case, the woman developed the disorder over a five-year period, but treatment with vitamin B12 and folate helped her return to psychological stability. The authors report that one year after treatment the patient's condition was still stable. They suggest that vitamin B12 and folate may be helpful in certain patients that do not respond well to drug treatment or who display abnormal mood symptoms.
Fafouti M, et al: Mood disorder with mixed features due to vitamin B12 and folate deficiency, Gen Hosp Psychiatry 2002 Mar-Apr;24(2):106-9
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