Association Between Vitamin B12 Levels and Mortality in Hospitalized Older Adults

OBJECTIVES: To investigate the effect of various medications on vitamin B12 status and the association between vitamin B12 levels and mortality. DESIGN: Retrospective cross‐sectional study. SETTING: Four internal medicine departments and the geriatrics department at Kaplan Medical Center (KMC), Rehovot and Harzfeld Geriatrics Hospital, Gedera, Israel. PARTICIPANTS: One thousand five hundred seventy patients aged 65 and older hospitalized at the KMC and Hartzfeld Hospital in 2007. MEASUREMENTS: Blood vitamin B12 levels and demographic, clinical, and laboratory data obtained from electronic medical records. RESULTS: Vitamin B12 deficiency (≤200 pmol/L) was found in 15% of older hospitalized patients. Fifty percent of the patients had high vitamin B12 levels (≥350 pmol/L), 68.2% of whom were aged 80 and older. Metformin use was clearly associated with lower vitamin B12 levels. In patients aged 65 and older, an inverse correlation was found between vitamin B12 levels and albumin, metformin, and angiotensin‐converting enzyme (ACE) inhibitor use. Age, number of medications, and mortality were linearly correlated with vitamin B12 levels. CONCLUSION: Higher vitamin B12 levels were associated with greater mortality, but it is unclear whether vitamin B12 is a marker or a surrogate marker or even a substance that directly causes death. Further investigation is needed to clarify.     

Systolic BP and Mortality in Older Adults with CKD

Background and objectives

Optimal BP targets for older adults with CKD are unclear. This study sought to determine whether a nonlinear relationship between BP and mortality—as described for the broader CKD population and for older adults in the general population—is present for older adults with CKD.

Design, setting, participants, & measurements

A cohort of 21,015 adults age 65–105 years with a moderate or severe reduction in eGFR (<60 ml/min per 1.73 m²) were identified within the Kaiser Permanente Northwest Health Maintenance Organization population. The relationship between baseline systolic BP (SBP; ≤120, 121–130, 131–140, 141–150, >150 mmHg; referent, 131–140 mmHg) and all-cause mortality across age groups (65–70, 71–80, and >80 years) was examined; patients were followed for up to 11 years after cohort entry.

Results

The median times at risk were 3.15 years, 3.53 years, and 2.76 years for adults age 65–70, 71–80, and >80 years, respectively. Mortality during follow-up was 19.6% for those age 65–70 years, 33.4% for those age 71–80 years, and 55.7% for those age >80 years. The relationship between SBP and mortality varied as a function of age. The risk of death was highest for patients with the lowest SBP in all age groups. Only among adults age 65–70 years was an SBP>140 mmHg associated with a higher risk of death compared with the referent category. Patterns of age modification of the relationship between SBP and mortality were consistent in all sensitivity analyses.

Conclusions

In a cohort of older adults, the relationship between SBP and mortality varied systematically with age. A relationship between higher SBP and mortality was present only for younger members of this cohort and not for those older than 70. These results raise the question of whether the relative benefits and harms of lowering BP to recommended targets for older adults with CKD may vary as a function of age.     

Relationship Between Quality of Care of Hospitalized Vulnerable Elders and Postdischarge Mortality

OBJECTIVES: To assess the relationship between quality of hospital care, as measured by Assessing Care of Vulnerable Elders (ACOVE) quality indicators (QI), and postdischarge mortality for hospitalized seniors. DESIGN: Observational cohort study. SETTING: Single academic medical center. PARTICIPANTS: Patients aged 65 and older who were identified as “vulnerable” using the Vulnerable Elder Survey (VES‐13). MEASUREMENTS: Adherence to 16 ACOVE measures through chart audit; postdischarge mortality obtained from Social Security Death Index. RESULTS: One thousand eight hundred fifty‐six inpatient vulnerable older adults were enrolled. Mean quality‐of‐care score was 59.5±19.2%, and 495 (26.7%) died within 1 year of discharge. In multivariate logistic regression, controlling for sociodemographic and disease severity variables (Charlson comorbidity score, VES‐13 score, number of QIs triggered, length of stay, baseline activity of daily living limitations, code status), higher quality of care appeared to be associated with lower risk of death at 1 year. For each 10% increase in quality score, patients were 7% less likely to die (odds ratio=0.93, 95% confidence interval (CI)=0.87–1.00; P=.045). In Cox proportional hazard models, hospitalized patients receiving quality of care better than the median quality score were less likely to die during the 1‐year period after discharge (hazard ratio (HR)=0.82, 95% CI=0.68–1.00; P=.05). Patients who received a nutritional status assessment were less likely to die during the year after discharge (HR=0.61, 95% CI=0.40–0.93; P=.02). CONCLUSION: Higher quality of care for hospitalized seniors, as measured using ACOVE measures, may be associated with a lower likelihood of death 1 year after discharge. Given these findings, future work testing interventions to improve adherence to these QIs is warranted.