Relation between deficiency of vitamin D and cognitive impairment in elderly in Jeddah city

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1 Middle East Journal of Applied Sciences Volume : 08 Issue :02 April-June 2018 Pages: Relation between deficiency of vitamin D and cognitive impairment in elderly in Jeddah city Haneen H. Mouminah Food and Nutrition Department, Faculty of Home Economics, King Abdulaziz University, Kingdom Saudi Arabia. Received: 24 Jan / Accepted: 28 Mar. 2017/ Publication date: 05 April 2018 ABSTRACT The objective of the research is to study the relationship between vitamin D deficiency and cognitive impairment among elderly in the Jeddah city of Saudi Arabia. The data were collected through the work of questionnaire questionnaires distributed to a sample of 30 elderly males and females from the city of Jeddah aged 50 to 79 years of age. The sample was composed of 20 women, representing 66.7% and 10 males representing 33.3%. The ratio of vitamin D has been determined through blood analysis and the measurement of cognitive function of the sample members through testing using General Practitioner Assessment Cognition (GPCOG).and screening test and Memory Impairment Screen (MIS). The results showed that 16.7% of the sample had vitamin D deficiency, while the majority of the sample, which accounted for 73.3%, suffered from vitamin D insufficiency and only 10% of the sample did not have vitamin D deficiency. The results did not show the toxicity of any individuals of the sample vitamin D. Conclusion: It has been concluded that the cognitive impairment of old age in Jeddah city is related to vitamin D deficiency. Key words: Vitamin D deficiency, cognitive impairment in elderly, vitamin D sufficiency. Introduction Approximately 14% of the world has insufficient vitamin D levels (Dickens et al., 2011) dihydroxyvitamin D regulates more than 200 genes, and is responsible for musculoskeletal health and the protection of the nervous system. Inadequate levels of vitamin D lead to a higher risk of mortality, fractures and chronic disease in the elderly (Schottker et al., 2013). Vitamin D deficiency also increases the probability of stroke, diabetes, and hypertension, which leads to dementia (Sun et al., 2012). And may also be directly associated with the onset of neurodegenerative diseases. Vitamin D s neuro protective effect stems from its roles in calcium homeostasis, neurogenesis, immunomodulation, antioxidant defense, and amyloid beta clearance (Llewellyn et al., 2010). Vitamin D s relationship to cognitive impairment (CI) in the elderly may have significant implications for geriatric care and long-term care facilities planning. Vitamin D, known as the 'sunshine vitamin', is one of the most important vitamins for good health and wellbeing. A number of studies have emphasized its role in the prevention of osteoporosis, cardiovascular heart disease, arterial hypertension, cerebrovascular disease, chronic kidney disease, type 1 diabetes, autoimmune diseases, and some cancers (Kienreich et al., 2013). However, vitamin D deficiency has become a global epidemic which remains unrecognized and neglected as an issue that is responsible for increasing the healthcare burden worldwide (Palacios and Gonzalez, 2014). This is clearly a problem in Saudi Arabia, where summer temperatures can reach 50 C, and UV levels are high, thus preventing people from venturing out in the sunlight, which is how the human body produces vitamin D (Nagib, 2012). Vitamin D deficiency does not just lead to physical health problems; it can also be an underlying cause of depression and anxiety (Mansour and Alhadidi, 2012 and Huang et al., 2014). Vitamin D is a multipurpose, fat soluble, seco-steroid hormone. The two most important forms of vitamin D are cholecalciferol (vitamin D3) and ergocalciferol (vitamin D2). D3 is produced in the skin by sunlight, while the latter is contained in some fruits and vegetables and fortified foods. These forms of vitamin D are inactive until they are metabolized by the liver and kidney (Oudshoorn et al., 2008). Once Corresponding Author: Haneen H. Mouminah, Food and Nutrition Department, Faculty of Home Economics, King Abdulaziz University, Kingdom Saudi Arabia. hmouminah@kau.edu.sa 287

2 biologically active, vitamin D binds to intracellular VDRs, such as those expressed on neurons (Hayes, 2010). Vitamin D and Cognitive Impairment There is an abundance of research showcasing the role of vitamin D deficiency in cognitive impairment risk. Here are only a handful of the studies connecting vitamin D status to cognition: - According to a 2017, systematic review and meta-analysis of 26 observational and 3 intervention studies including over 19,000 participants, low vitamin D status was associated with cognitive decline (odds ratios (OR): 1.26) and poorer cognitive performance (OR: 1.24) among participants without dementia. However, this study did not find a significant benefit of vitamin D supplementation on cognition (Goodwill and Szoeke, 2017). - A study published in 2017, evaluated the role of vitamin D status in cognition among 369 individuals. The researchers found that those who were vitamin D deficient experienced a faster rate of cognitive decline. Additionally vitamin D deficiency was associated with a nearly 3-fold increased risk of developing Alzheimer s disease with a hazard ratio of 2.85 (Feart, 2017). - A 2016 study, found that vitamin D deficiency increased elderly Chinese individual s risk of developing dementia by over twofold. In addition, dementia risk increased as vitamin D levels decreased (Matchar, et al, 2016). - Research published in 2015; found that severe vitamin D deficiency was independently associated with future risk of mild cognitive impairment and dementia among elderly individuals. This was especially significant in those whose baseline cognitive function had decreased only modestly, researchers also discovered that vitamin D status is linked to poorer neurological skills School but not dementia or Alzheimer s disease (Karakis, 2015). - A study published in the Canadian Journal of Neurological Sciences found that both vitamin D insufficiency and seasonal decline of vitamin D levels are correlated with lower scores related to cognitive performance (Pettersen, 2014). - A meta-analysis and review reported that lower vitamin D levels are associated with decreased cognitive function and an increased risk of Alzheimer s disease (Balion et al., 2012). - A 2015 study suggested cognitive ability of individuals with low 25(OH) D declined three times faster than that of healthy subjects with 25(OH)D above 20 ng/ml (Miller et al., 2015). Vitamin D Deficiency; also called hypovitaminosis D, is prevalent among older adults due to both low dietary intake and inadequate sun exposure (Landel et al., 2016). Almost 50-80% of elderly people have low vitamin D levels. Nevertheless, due to lack of screening, the proportion of the geriatric population that has unrecognized vitamin D deficiency may be much larger. Those at highest risk for low vitamin D status include individuals with low sunlight exposure, females, those with poor nutrition, people who have dark pigmented skin, and the elderly (Johnson et al., 2003). Hypovitaminosis D is prevalent among older people, and so is the case in some adults, one of the leading causes of their higher fatigue levels (Mokta, 2016). Higher prevalence of hypovitaminosis D linked fatigue among elderly is their relatively lesser exposure to the sunshine. Besides fatigue, hypovitaminosis D is also a primary cause of body aches and pains among the elderly people also. A study by Farouk, (2016) explored the association of hypovitaminosis D amongst patients who are admitted for hip fracture. These patients often have less energy to do everyday tasks and due to an imbalance in their posture are prone to falls that lead to fractures and other injuries. According to previous researchers, most patients suffering from hypovitaminosis D are suffering from other longterm illnesses, such as cancer, diabetes, obesity and even depression. The majority of patients with musculoskeletal pain, headache and fatigue suffer some sought of hypovitaminosis and among this hypovitaminosis D is relatively higher (Walsh, 2014). It is important to mention here that fatigue equally affects both elderly men and women. There are some key factors which make elderly people more susceptible to fatigue as a result of hypovitaminosis. 25 dihydroxy vitamin D is an active form of Vitamin D for hormones. Hypovitaminosis D is defined as the level of 25 (OH) D < 30 nmol/l (< 12 ng/ml25 hydroxy vitamin D 25(OH) D) for the main reservoir and vitamin in our bodies. 288

3 An elderly person above 70 years synthesizes less than 30% Vitamin D as compared to the young who are exposed to the sun. The major health benefits of vitamin D are summarized as below: Vitamin D plays a crucial role in muscular function. Hypovitaminosis D is more prevalent in postmenopausal women and increases with age. Replacement of Vitamin D takes place within the body to improve muscle function, which reduces the risk of different factors associated with hypovitaminosis D. Vitamin D plays a crucial role in calcium for phosphorus homeostasis. The symptoms of hypovitaminosis D are similar to that for muscle fatigue and low bone mineral density. Vitamin D plays a central role in phosphorus and calcium homeostatic processes. The natural form of Vitamin D is ergocalciferol found in several food items, and this supports the synthesis taking place beneath the skin, which is triggered by exposure to ultraviolet light. Such a form of Vitamin D has to change with 25-hydroxyvitamin D (25(OH)) D, which facilitates hydroxylation in the kidney. The active function of hormones in the body enables perfect interaction with the Vitamin D receptor (D), which is based on dependent proteins. The biological effects may play some part in calcium and phosphorous homeostatic processes. The aim of this research was to study the relationship between vitamin D deficiency and cognitive impairment among elderly in Jeddah city of Saudi Arabia. Materials and Methods:- Blood test of vitamin D to all participates to detect the relation between vitamin D and cognitive impairment. Cognitive Assessments Forms General Practitioner Assessment of Cognition (GPCOG):- The General Practitioner Assessment of Cognition (GPCOG) is an instrument to screen for dementia specifically in a primary care setting. It takes less than 4 minutes to decide the patient assessment and 2 minutes to interview the caregiver, the General Practitioner Assessment of Cognition (GPCOG), performs at least as well as the standard screening tool, the Mini-Mental State Examination (MMSE). Informant interview, which is a completing test use as other tool is certain about the diagnosis in General Practitioner Assessment of Cognition (GPCOG) test. Analytic descriptive method, attempts to picture or document current conditions or attitudes that is to describe what exists at the moment. Participants:- This research included 30 of old adult In Jeddah city their ages ranging between 50 to 75 years old who has chosen randomly from south, north and east of Jeddah city. Period of research data will be collected during 1 st and 2 nd semester of Statistical analysis: The results analyses were submitted to the analysis of variance followed by Tukey test, using the SAS System Version 6 Program (SAS Institute, 1996). Probabilities of (P <0.05) were considered significant 289

4 Results and Discussion The participant s gender:- In this study 30 participants have been tested are shown in Fig (1), 20 of them were female and they represent 66.70% of this study. While, the other 10 were male and they represent 33.3% of total study participants. Male, 33.30% Female, 66.60% Fig. 1: The participant s gender. The participants Ages:- Three different age categories in this study as it shown in the Fig 2. The first categories for participants from age 50 to 59, they represent 80.0% of the participants. 17.0% represented second category with age range from age 60 to 69, while 3.0%of the participants represented the last category 70 to , 3.30% 60-69, 16.70% 50-59, 80% Fig. 2: Contribution of the participant ages 290

5 The General Practitioner Assessment of Cognition (GPCOG):- The general practitioner of cognition (GPCOG) results that indicated whether the study subject suffers from cognitive impairment or not. These results will determine whether they need more assessment to emphasize their diagnosis. Table (1) and Fig (3). Table 1: Participants diagnosis based on degree. Degree Diagnosis Based on Degree Frequency Percentage 9 Cognitive impairment and further testing not necessary % 5 to 8 More information required % 0 to 4 Cognitive impairment is indicated. Conduct standard investigations % Total % 60.00% 50.00% Percentage % 40.00% 30.00% 20.00% 10.00% 0.00% Cognitive impairment and further testing not necessary Degree 9 Morebinformation required Degree 5 to 8 Cognitive impairment is indicated.conduct standard investigation Degree 0 to 4 Fig. 3: Participants diagnosis based on degree Informant interview:- People who got scores from 5 to 8 in the general practitioner of cognition (GPCOG) screening test, had to do another test called Informant interview questionnaire to be certain about their health status whether they diagnosed with cognitive impairment or not. The questionnaire consist of six questions asked to patients escorts about how the patients mental health status is compared to when she/he was well, 5 10 years ago. The Fig (4) showed that, the displays the finding of Informant interview, about 43%of this study subject who got this test showed no cognitive impairment, whereas 13.3% indicated cognitive impairment. Vitamin D blood Test results:- Vitamin D blood Test results likewise showing the variance of the results by comparison of four vitamin D classification are shown in Table (2) and Fig (5). Most the participants were have vitamin D insufficiency by rate 73.30%, while 16.70% of the study subjects have vitamin D deficiency and 10% have vitamin sufficiency. Otherwise no one the participants has had vitamin d toxicity. 291

6 50.00% Percentage % 40.00% 30.00% 20.00% 10.00% 0.00% No cognitive impirment indicate Degree 4 to 6 No cognitive impirment indicate Degree 0 to 3 Fig. 4: Informant interview. Table 2: Vitamin D blood test Vitamin D Frequency Percentage Deficiency % Insufficiency % Sufficiency % Toxicity 0 0.0% Total % 80.00% 70.00% Percentage % 60.00% 50.00% 40.00% 30.00% 20.00% 10.00% 0.00% Vitamin D Deficiency Vitamin D Insufficiency Vitamin D Sufficienct Vitamin D Toxicity Fig. 5: Vitamin D blood Test. Relation between vitamin D and cognitive impairment:- Relation between vitamin D and cognitive impairment are presented in Table (3) and Fig (6). Total people who already diagnosed with cognitive impairment without need another test additionally to participants who diagnosed with cognitive impairment were 53.0% The association between vitamin D and cognitive impairment in the study subjects in 36.70% of the participants who diagnosed with cognitive impairment according to the two screening test have vitamin d insufficiency, where 16.70% have been diagnosed with vitamin D deficiency. In simulation, this study results demonstrate significant relationship between vitamin D and cognitive impairment. Moreover, it showed that the most of the study subject are suffering low levels of vitamin D. 292

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