Oral vitamin B12 can provide an effective alternative to intramuscular injections, so giving patients a choice and reducing costs in primary care. This study investigated the effectiveness, safety, and acceptability of oral vitamin B12 as replacement therapy in patients with vitamin B12 deficiency in a city general practice population. Forty patients previously maintained on vitamin B12 injections were given 1000 µg of oral cyanocobalamin daily for up to 18 months. All the patients maintained satisfactory serum B12 levels and showed normal haematology and neurology. Compliance and acceptability was excellent. The time for a change in practice has indeed arrived. V itamin B12 is given intramuscularly in the UK despite the fact that oral vitamin B12 in sufficiently large doses is equally effective. Historically, this passive absorption mechanism provided the first treatment for pernicious anaemia.1 2 In the absence of an intact ileum or intrinsic factor, 1.2% of an oral dose of vitamin B12 will pass across the small bowel.3 4 The dose absorption ratio is remarkably constant in an oral dose range from 1 to 100 000 µg of hydroxocobalamin and adequate levels of serum vitamin B12 have resulted using oral doses above 500 µg daily.5-9 Reflecting this, most vitamin B12 replacement therapy is now given orally in Sweden 10 11 and in the USA it is becoming a more popular mode of treatment. Nursing time spent on intramuscular injections is costly-an assessment of the costs of administering injections of vitamin B12 made in 1997 to the 89 patients in our combined inner city practice of 19 000 suggested that substantial savings could be made with an oral preparation.12 An oral preparation of vitamin B12 (Cytacon 50 µg) is available in the UK but the NHS licence restricts its use to vitamin B12 deficiency of dietary origin and for vegans. PATIENTS AND METHODSThis was a prospective case series of 50 of the 108 eligible patients with vitamin B12 deficiency within the combined practice populations of 19 000 patients. Ten patients had pernicious anaemia as confirmed by a positive Schilling test and/or raised intrinsic factor antibody (as confirmed by the autozyme test for anti-intrinsic factor antibody). Nine of the patients had gastrointestinal surgery related vitamin B12 deficiency and the remainder were intrinsic factor negative. Exclusions were because of refusal, cognitive impairment, or acute illness. Patients were recruited to the study at the rate of two or three per week but the study ended on a specific date such that patients took study medication for variable periods of time. There were 17 males and 33 females with an age range of 31 to 90. Ethical approval was obtained from the East Birmingham Local Research and Ethics Committee. At study entry patients completed a medical history and received a physical examination with emphasis on cognition and the nervous system. Repeat medical histories were taken every six months. Physical examination was repeated in all patients at the end of the study and if the serum vitamin B1...

The AMT4 may be useful in the initial assessment of cognition in elderly patients, with little loss of accuracy in detecting marked cognitive impairment when compared to the AMT.

No abstract

In patients admitted to the elderly medicine unit, the AMT gave predictive information about cognitive status as determined by the MMSE, and also a prediction of likely MMSE score.

The selection of patients, exclusions, assessments and analyses have been described previously. 8 Briefly, all patients aged 60 years and above admitted to the Department of Elderly Medicine during October and November 1997 were included in the study. Patients were assessed with the AMT followed by the MMSE, once the acute phase of the admission was over. The AMT4 score was derived from the AMT score. An AMT4 score of 0-3 indicated impaired cognition and a score of 4 normal cognition. 6 The AMT4 score was compared with the AMT and MMSE scores for each patient. Results During the study period 364 patients were admitted to the Department of Elderly Medicine, of whom 88 (24.2%) were excluded, leaving a study group of 276 patients. There was a strong relationship between the AMT4 and AMT when analysed dichotomously: χ 2 = 121.2, df = 1, p < 0.001. The predictive efficiency of the AMT4 for cognitive state by the AMT was 83.3% (230/276). The remaining performance parameters of the AMT4 against the AMT were as follows: positive predictive value 78.1% (107/137), negative predictive value 88.5% (123/139), sensitivity 87.0% (107/123) and speci