Orthostatic tolerance in older patients with vitamin B12 deficiency before and after vitamin B12 replacement

Orthostatic hypotension is very common in the elderly. It increases morbidity and is an independant predictor of all cause mortality. It is defined as a fall in systolic blood pressure greater than 20 mm Hg or a fall in diastolic blood pressure greater than 10 mm Hg within 3 minutes of standing. Symptoms include light headedness, weakness, blurred vision, fatigue and lethargy and falls. Most patients have orthostatic hypotension due to non neurogenic causes. Drugs like antihypertensives and tricyclic antidepressants are very common causes of orthostatic hypotension. Diagnosis is based on the history and a thorough clinical examination. Based on the history and physical examination, further testing of the heart, kidneys and autonomic nervous system may be required in selected patients. Non pharmacological methods like slow position change, increased fluid and sodium intake, compression stockings and elevation of head of the bed are the key to management of orthostatic hypotension. After these methods, pharmacological treatment with fludrocortisone and midodrine should be tried. Other drugs like desmopresin acetate, xamoterol, erythropoetin and ocreotide can be used as second line agents in selected patients.

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“…In patients with vitamin B 12 deficiency, vitamin B 12 replacement leads to increased orthostatic tolerance [40].…”

Section: How Do We Treat Oh?mentioning

confidence: 99%

A Clinical, Physiology and Pharmacology Evaluation of Orthostatic Hypotension in the Elderly

2005

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“…Während in einer retrospektiven Analyse ein hoher Prozentsatz von Patienten mit Perniziosa auf eine Cobalamintherapie ansprach, sprach in ein darauf folgenden prospektiven Studie nur ein Drittel an [71]. In einer anderen Studie [98] [104] oder auf das Vibrationsgefühl [105].…”

Section: Wirksamkeit Der Vitamin B 12 -Therapieunclassified

Vitamin B12 deficiency: New data on an old disease

Lechner

Födinger

Grisold

et al. 2005

Wien Klin Wochenschr

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Cobalamin deficiency is a common finding. In the elderly the prevalence is 10-20%, but only 5-10% of these are clinically symptomatic. Typical clinical symptoms include macrocytic anemia, neuropsychiatric symptoms and glossitis. In many cases this triad is lacking, however. The serum cobalamin assay is the best first line test, but the results must be carefully interpreted, since a normal level does not exclude deficiency. Markers of cobalamin activity, such as serum homocysteine or methylmalonic acid may be helpful in this situation. The main cause of cobalamin deficiency is atrophic gastritis. It is either caused by an autoimmune process which leads to achlorhydria and severe intrinsic factor deficiency ("classical pernicious anemia") or by atrophic gastritis from other causes, in particular helicobacter pylori infection. In the latter cases the lack of gastric acid does not allow separation of cobalamin from proteins, but intrinsic factor, although low, is sufficient for cobalamin protection (food cobalamin malabsorption). Helicobacter pylori eradication may cure some of these patients. While in food cobalamin malabsorption syndrome small doses of oral cobalamin are effective, parenteral therapy or high oral doses are required for treatment of pernicious anemia. While almost all patients respond hematologically, only half of the patients with neurological signs, and a small minority of psychiatric patients respond to treatment. Patients with pernicious anemia and atrophic gastritis have a greatly increased long-term risk for gastric carcinoids.

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“…Given the high incidence of both cobalamin deficiency [21] and falls [26] (beside sensor neuropathy and mental impairment) in the old population and given the reported improvement of cobalamin therapy on the autonomic (and somatic) nervous system function as shown in the study of Moore et al [17], this could be a pragmatic option, although a systematic population based study on the magnitude of the association of cobalamin deficiency and falls is lacking. In conclusion, modern technology including homocysteine and methyl malonic acid determinations in serum for the detection of cobalamin deficiency and non-invasive beat to beat blood pressure measurements and power spectral analysis of heart rate and blood pressure variability for the detection of autonomic failure are necessary to detect a common [20,21], curable [17], and often life terminating disease of the old. Given the number of non-invasive beat to beat blood pressure measurement devices in use one can calculate that at least 95 % of hospitals whose daily bread is also the evaluation of falls and syncope use equipment unsuited for that purpose.…”

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confidence: 97%

“…In this issue, Moore et al [17] report a study in a small group of eight patients with cobalamin deficiency and orthostatic hypotension, who were investigated before and after treatment with cobalamin over 6 months. The authors found that the orthostatic hypotension improved considerably after such a relatively short period of treatment.…”

mentioning

confidence: 97%

“…The study by Moore et al [17] demonstrates the exciting possibility of not only offering symptomatic therapy, but also therapy directed toward the cause of a commonly overlooked disease. This improvement of orthostatic hypotension was also observed in the first a Task Force™ Monitor, www.cnsystems.at case report of cobalamin deficiency associated with orthostatic hypotension [11].…”

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confidence: 98%

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