Use of Supplements in the Elderly

Supplements in the Care of the Aging

MARC EVANS M. ABAT, MD, FPCP, FPCGMInternal Medicine-Geriatric Medicine

Head, Center for Healthy Aging ,and Section Head, Geriatrics, The Medical CityClinical Associate Professor, Section of Adult Medicine, Department of Medicine

PGH

Outline

• Conceptual Framework for Supplementation• Summary of Evidence

– Multivitamins and Minerals– Antioxidants– Herbal Preparations– Nutraceuticals– Hormonals

Conceptual Framework

Contributors to risk of malnutrition

• The elderly are at higher risk of developing protein-calorie malnutrition and other vitamin and mineral deficiencies.

• The frequency of these events increases with advancing age due to problems such as poor dentition, loss of taste, difficulty swallowing, malabsorption, and drug-nutrient interaction


• Other physical limitations such as inability to obtain necessary food due to lack of transportation and dependence on others for shopping, lack of financial resources, and functional limitations can contribute to nutritional deficiencies


• Non-perishable foods frequently contain high amounts of sodium and nitrates, and processing can remove vitamins.

• Many drugs cause anorexia, gustatory changes, and anosmia as major side effects.

• Medications can also interfere with nutrient availability

Risk Factors for Poor Nutrition Status

Alcohol or substance abuse Limited mobility, transportation

Cognitive dysfunction Medical problems, chronic diseases

Decreased exercise Medications

Depression, poor mental health Poor dentition

Functional limitations Restricted diet, poor eating habits

Inadequate funds Social isolation

Limited education

Physiology-the “anorexia of aging”

Physiology

• Changes in body composition– Decreased bone mass– Decreased lean mass– Decreased water content– Increased total body fat (greater intra-abdominal fat

stores)

• Decline in organ function is highly variable among individuals and may affect assessment and intervention options

Drugs that can cause ANOREXIA

• digoxin• phenytoin• SSRI’s / lithium• Ca++ channel blockers• H2 receptor antagonists /

PPIs• Any chemotherapy• metronidazole

• narcotic analgesics• K+ supplements• furosemide• ipratropium bromide• theophylline• spironolactone• levodopa• fluoxetine

Drugs That Interfere With Gustation (taste) and Olfaction (smell)

Gustation • Allopurinol• Amitriptyline • Ampicillin• Baclofen • Dexamethasone • Diltiazem• Enalapril • Hydrochlorothiazide • Imipramine • Labetalol• Mexiletine• Ofloxacin• Nifedipine• Phenytoin• Promethazine • Propranolol• Sulfamethoxazole• Tetracyclines

Olfaction • Amitriptyline• Codeine• Dexamethasone• Enalapril• Flunisolide• Flurbiprofen• Hydromorphone• Levamisole• Morphine• Pentamidine • Propafenone

Drug-Nutrient Interaction Drug Reduced Nutrient Availability Alcohol Zinc, vitamins A, B1, B2, B6, folate, vitamin B12

Antacids Vitamin B12, folate, iron, total kcal

Antibiotics, broad-spectrum Vitamin K

Digoxin Zinc, total kcal (via anorexia)

Diuretics Zinc, magnesium, vitamin B6, potassium, copper

Laxatives Calcium, vitamins A, B2, B12, D, E, K

Lipid-binding resins Vitamins A, D, E, K

Metformin Vitamin B12, total kcal

Phenytoin/Salicylates Vitamin D, folate/Vitamin C, folate

SSRIs Total kcal (via anorexia)

Trimethoprim Folate

Some Evidence

Probiotics and Common Acute Respiratory Infections

British Journal of Nutrition (2014), 112, 41–54

Probiotics for Antibiotic-Associated Diarrhea and C. difficile

Multivitamins for Post-MI Patients in Trial to Assess Chelation Therapy (TACT)

• 1708 patients, age ≥50 years, ≥6 weeks post myocardial infarction, with creatinine level ≤ 176.8 μmol/L (2.0 mg/dL).

• 2x2 factorial design• Patients were randomly assigned to an oral 28-component

high-dose multivitamin and multimineral mixture or placebo.

• Intention to treat• The primary endpoint was time to total mortality,

recurrent myocardial infarction, stroke, coronary revascularization, or hospitalization for angina.

Ann Intern Med. 2013 December 17; 159(12): 797–805.



Vitamin C and Risk for Stroke

J Am Heart Assoc. 2013;2:e000329

J Am Heart Assoc. 2013;2:e000329

Vitamin B Complex and Stroke

PLoS ONE 8(11): e81577. doi:10.1371/journal.pone.0081577

Vitamin B12 in Cognitive Decline

• there does appear to be an association between elevated plasma homocysteine levels (a by-product of B vitamins) and the onset of dementia (very low quality evidence).

• treatment with B12 supplementation does not appreciably change cognitive function (moderate quality evidence, but with less than optimal duration of follow-up)

• treatment with vitamin B12 and folate in patients with mild cognitive impairment seems to slow the rate of brain atrophy (low to moderate quality of evidence)

• oral vitamin B12 is as effective as parenteral vitamin B12 in patients with confirmed B12 deficiency (moderate quality evidence).

Ontario Health Technology Assessment Series; Vol. 13: No. 23, pp. 1–45, November 2013

Multivitamins and mineral supplementation in cognitively-impaired elderly

• Increase in serum levels• No increase in intracellular levels• Changes in intracellular metabolic markers

noted• No change in Mini-Mental State examination

Nutrition Journal 2013, 12:148

Calcium and Community-Dwelling Chinese


Vitamin E Deficiency and Fracture Risk

Am J Clin Nutr 2014;99:107–14.

Am J Clin Nutr 2014;99:107–14.

Vitamin D Supplementation

BMJ 2014;348:g2035

BMJ 2014;348:g2035

Multivitamins and minerals vs. infection

• Meta-analysis• Poor or moderate

quality• Heterogenous

– Variable and surrogate outcomes

• Results do not support supplementing in older persons

BMJ 2005;331:142

Plant Sterols/Stanols for Cholesterol

J Acad Nutr Diet. 2014;114:244-249.

Supplements for Osteoarthritis

Int. J. Mol. Sci. 2013, 14, 23063-23085

Int. J. Mol. Sci. 2013, 14, 23063-23085

Int. J. Mol. Sci. 2013, 14, 23063-23085

Int. J. Mol. Sci. 2013, 14, 23063-23085

Int. J. Mol. Sci. 2013, 14, 23063-23085

Multi-component supplement for joint pain

• joint pain supplement containing glucosamine sulfate, methylsufonlylmethane (MSM), white willow bark extract (15% salicin), ginger root concentrate, boswella serrata extract (65% boswellic acid), turmeric root extract, cayenne, and hyaluronic acid.



Micronutrient Supplementation and Skin Aging

• 80 female volunteers with phototype II-IV skin

• Randomized to received placebo vs. 2 tablets of oral proprietary supplement x 4 months

• skin microrelief as the main outcome, and the secondary outcomes were results on standard macrophotography, skin tension, skin high-frequency ultrasound, and self-assessment.

Clinical Interventions in Aging 2013:8 1527–1537

• Results– For all pseudoroughness and microrelief indicators, there

was a significant increase from baseline to month 4 in the placebo group (P,0.05)

– a significant and dramatic difference between baseline and month 4 and between baseline and month 5.5 (P,0.05) in the active group, indicating decreasing anisotropy of the skin

– skin thickness was significantly decreased in the placebo group during winter but was stable in the treated group (P,0.01).

– The photography scaling and self-assessment questionnaire revealed no significant changes in either group.

Clinical Interventions in Aging 2013:8 1527–1537

Supplements used in a Mid-Western Cohort

BMC Complementary and Alternative Medicine 2013, 13:339

BMC Complementary and Alternative Medicine 2013, 13:339

Supplements used in a Mid-Western Cohort

Omega-3 supplementation to lower homocysteine in CKD patients

• 88 patients randomized in 2 groups, with 1 group receiving 3g/day of omega-3 supplementation

• Groups similar at baseline

Within group comparison

IJKD 2013;7:479-84

Glutamine in infections

• 120 patients, divided into 4 groups receiving IV glutamine, enteral glutamine , combined or enteral feeding only

• demonstrated that, a combined route of glutamine supplementation resulted in the most positive outcome in transferrin, creatinine/height index and nitrogen balance (at day 7 and 15) during the catabolic phase, in septic patients with malnutrition.

Asia Pac J Clin Nutr 2014;23(1):34-40

AntioxidantsStudy Design Intervention Results

Nutr J. 2011 Sep 21;10:94

86 subjects, randomized

Placebo vs supplement with Glycine max or Garcinia cambogia for 10 weeks

No effect on weight loss; lower total cholesterol and higher HDL with Glycine max

Nutr J. 2011 May 12;10:45.

10 subjects, open pilot, non-randomized

Açai (Euterpe oleracea Mart.) berry, 100g 2x a day for 1 month

Decreased total cholesterol and LDL, chole/HDL ratio

Lipids Health Dis. 2010 Oct 19;9:119.

51 CHD patients, double-blind randomized

Placebo vs. Time-released garlic powder tablets

16.21% drop-out rateSignificant decrease in total cholesterol and LDL compared with baseline and placebo

Kobe J Med Sci. 2008 May 23;54(1):E62-72

5 healthy volunteers

2 weeks of ground green tea

Increase oxidation time of plasma and LDL

Maturitas. 2011 Apr;68(4):299-310.

Meta-analysis Lycopene >25 mg/day, lower doses

Decrease total cholesterol and LDL, significant systolic BP lowering

http://www.ncbi.nlm.nih.gov/pubmed/21936892







• 67 randomised trials with 232,550 participants• no significant effect on mortality in a random-

effects meta-analysis (RR 1.02, 95% CI 0.99 to 1.06),

• significantly increased mortality in a fixed-effect model (RR 1.04, 95% CI 1.02 to 1.06)

• significantly increased mortality by vitamin A (RR 1.16, 95% CI 1.10 to 1.24), beta-carotene (RR 1.07, 95% CI 1.02 to 1.11), and vitamin E (RR 1.04, 95% CI 1.01 to 1.07)

Cochrane Database Syst Rev. 2008 Apr 16;(2):CD007176.

Resveratrol

• Mainly animal models– Decreased hypertension– Decreased myocardial infarction– Decresed cerebral infarction– Cardiac precondition via NO-dependent pathway


Herbal Preparations

J Fam Pract. 2003 Jun;52(6):468-78.

J Fam Pract. 2003 Jun;52(6):468-78.

J Fam Pract. 2003 Jun;52(6):468-78.

J Fam Pract. 2003 Jun;52(6):468-78.

J Fam Pract. 2003 Jun;52(6):468-78.

Dehydroepiandrosterone

J Clin Endocrinol Metab. 2008 February; 93(2): 534–538.

Placebo (n=14) DHEA (n=17) P value

Pre-training Post-training Pre-training Post-training

LDL (mg/ml) 123 (3) 119 (14) 128 (5) 127 (6) 0.339%Δ −10.2 (−25.9, 8.8; P =

0.436)%Δ −1.5 (−17.2, 17.2; P =

0.995)

HDL (mg/ml) 46 (3) 46 (3) 45 (3) 44 (3) 0.949%Δ −2.2 (−16.4, 14.4; P =

0.979)%Δ −1.7 (−14.8, 13.3; P =

0.987)

VO2Peak [ml/(kg FFM · min)]

34.3 (1.4) 38.7 (1.3) 35.7 (1.1) 1529 (47) 0.957%Δ 12.9 (4.5, 21.2; P <

0.001)%Δ 12.6 (5.3, 19.9; P <

0.001)

Peak power output (W)

119 (7) 138 (8) 115 (7) 40.2 (1.2) 0.370%Δ 16.0 (6.9, 25.0; P <

0.001)%Δ 20.6 (12.2, 29.1; P <

0.001)

Age Ageing. 2010 Jul;39(4):451-8

European Journal of Endocrinology (2004) 151: 1–14



Testosterone

Journal of Andrology, Vol. 30, No. 6, November/December 2009

Growth HormoneParameter No. of studies Result

Lipid profile 5 decreased total and low density lipoprotein (LDL) cholesterol levels by 4–8% and by 11–16%, respectively; increased high density lipoprotein (HDL) only by 17%

Body composition

6 rhGH did not affect BMI (2 out of 6);significant decrease in waist circumference (3 studies) and W/H ratios (4 studies)

QoL 5 significant improvements of scores in all studies.

Cognition 1 No improvement

Adverse reactions

6 Headaches, edema, arthralgia, impaired glucose metabolism, cerebrovascular disease, neoplasms

European Journal of Endocrinology (2011) 164 657–665

Comments

• Studies have varied strength/quality• Studies are heterogenous• Other studies not mentioned often involved

ANIMAL studies

Recommendations

• Supplement use (whether mentioned in this lecture or not) may boil down to PERSONAL CHOICE

• Some evidence support the use of certain supplements in judicious doses

• Weigh risks versus benefits

Health & Medicine

Use of Supplements in the Elderly