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A Case of Subclinical Vitamin D Deficiency
POSTER ABSTRACTS
A Case of Subclinical Vitamin D Deficiency Khine Win Phyu, MD, University of Nevada, Reno Author(s): Khine W. Phyu, MD; Htun Oo, MD; Diane Chau, MD Introduction/Objective: Vitamin D is a vitamin, which functions as a hormone, required by the body to maintain a healthy immune system, to regulate cell growth and differentiation. It plays a major role in balancing calcium and phosphorus in regulating bone health and muscle strength. According to the dietary supplement fact sheet of The National Institutes of Health (2007), the prevalence of vitamin D deficiency is particularly high in older adults, due to an age-associated decline in cutaneous vitamin D production and dietary vitamin intake. Even though vitamin D deficiency is not uncommon in the elderly, its diagnosis commonly occurs after the development of clinically recognized osteoporosis. Design/Methodology: Two cases of elderly veterans with risk factors for falls such as impaired gait testing and cognitive impairment were found to have low vitamin D levels from lab tests ordered upon admission to a nursing care unit. Similar characteristics existed among the two geriatric cases. Socially, both patients were home bound and spent most of their time indoors. Thus, despite living in a sunny city, both had lack of adequate sun exposure and this resulted in a decreased production of vitamin D. Further evaluation of vitamin D deficiency revealed different etiologies for vitamin D deficiency. Results: In the first case, vitamin D deficiency secondary to chronic kidney disease should increase his parathyroid hormone level. But his PTH did not respond appropriately. This can be due to dysfunctional hypoparathyroidism seen among elderly. Calcitriol was chosen because of his low 1, 25 hydroxyvitamin D and his impaired renal function. With impaired renal function, patients often have normal or elevated OH vitamin D levels and an inability to hydroxylate 25 OH vitamin D to its active 1, 25 form. This patient’s 1, 25 Vitamin D level came within normal range after two months of supplementation. Careful monitoring of calcium and phosphate level is required for patients with renal insufficiency so as not to exceed a calcium phosphate product of 70 mg2/dL2 to avoid calcinosis, the deposition of calcium and phosphate in the body’s soft tissue. In the second case, vitamin D deficiency most likely was due to poor oral intake and gut malabsorption. He responded well with high doses of ergocalciferol for eight weeks. During high dose ergocalciferol therapy, 25 Vitamin D level should be monitored monthly to avoid vitamin D toxicity which can present as nausea, vomiting, weakness, headache, altered mental status, dry mouth, tinnitus, vertigo and ataxia. Conclusion/Discussion: The recommended standard vitamin D serum level is between 30 and 60 ng/mL. Sub clinical vitamin D deficiency may be more common than previously reported and clinicians should have increased vitamin D awareness. Pitfalls commonly seen in clinical care of elderly are Vitamin D deficiency, missed diagnosis, or inadequate supplementation. Development guidelines for screening and management of vitamin D deficiency are needed. Disclosures: Diane Chau, MD and Khine W. Phyu, MD have no disclosures to be made that are pertinent to this abstract. As of submission, Htun Oo, MD has not provided disclosures.
A Population-Based Study of Elder Mistreatment in Albemarle County, Virginia Anna M. Hicks, MD, University of Virginia Author(s): Anna M. Hicks; MD, Claire E. Curry, JD; Jonathan M. Evans, MD, MPH Introduction/Objective: Identify and describe all reported allegations of elder abuse, neglect and/or financial exploitation in Albemarle County over a 3-year period including long-term care (LTC) facilities. Design/Methodology: Prospective cohort study conducted over a 36 month period from July 1, 2004 through June 30, 2007. Subjects included individuals age 18 and older residing in Albemarle County, Virginia reported to and POSTER ABSTRACTS
investigated by Adult Protective Services as alleged victims of mistreatment during the study period. Results: 1174 reports of alleged mistreatment involving 862 subjects were reviewed. Median age was 73 years (range 18-105). Of those, 65% of subjects were over 65 and 33% were age 80 and older. 65% of subjects were female. 77% of subjects were white. The majority of subjects (53%) lived at home either alone or with family while 38% lived in LTC settings. Neglect was alleged in 65%, abuse in 27% and exploitation in 18% of cases. More than one kind of mistreatment was alleged in 10% of cases. Sources of mistreatment were recognized as self-neglect (32%), spouse/relative (24%), paid care giver (26%), power of attorney (7%) or other (10%). Mandatory reporting accounted for 66% of all reports. Alleged mistreatment was substantiated in 56% of cases with self-neglect as the most common form of mistreatment including LTC facilities. Conclusion/Discussion: Elder mistreatment is relatively common. Self-neglect is the most substantiated form of mistreatment, even in LTC. Physical abuse is among the least common findings in cases of substantiated mistreatment. Disclosures: Jonathan M. Evans, MD, MPH received an honorarium from Merck & Co., Inc. All other authors have stated there are no disclosures to be made that are pertinent to this abstract. A Quality Improvement Initiative Aimed at Improving the Assessment and Treatment of Type 2 Diabetes in Skilled-Nursing Facility Residents Tommy Eldridge Philpot, PharmD, Profiles & Interventions, Inc Author(s): Tommy E. Philpot, PharmD Introduction/Objective: To query a long-term consultant pharmacist electronic database to determine the following: 1) acuity level for all type 2 diabetes patients reviewed in the study; 2) compliance with diabetes goals as set forth by the American Diabetes Association across all levels of patient acuity; 3) prevalence of sliding scale insulin usage; 4) analyze data related to the treatment regimens used in the management of type 2 diabetes; 5) determine infection rates at various levels of glycemic control across all levels of patient acuity; and 6) determine the prevalence of hypoglycemia and specific drug therapies involved in the event. Design/Methodology: Senior Health Consulting Alliance is an independent consultant pharmacist organization that provides consultant pharmacist services to 4100 skilled-nursing facility patients in Georgia, Tennessee, and Ohio. The consultant pharmacists use an electronic database/medical record routinely within their practice. The electronic database includes ICD coding, medications, laboratory testing, and MDS 2.0 data points, as well as, specific recommendations and progress notes. Specific de-identified data queries will be analyzed to meet the stated objectives. A total of 500 patients will be randomly selected from within the database using ICD coding pertaining to Type-2 DM. Each patient will be assigned an acuity level using the Charlson-Ghali Comorbidity Index based on ICD coding. Each grouping will then be analyzed to provide general statistics for each of the stated objectives. Descriptive statistics will be used to identify trends in diabetes care within our patient population in an attempt to identify areas of potential improvement in the care of LTC facility patients. Results: The study is currently in progress. Completion date is set for 12-31-08. Conclusion/Discussion: The study is currently in progress. Preliminary data suggests higher rates of infection and stasis ulcers within patients with HbA1c values exceeding 8.5%, but the statistical significance is yet to be determined. As expected, patients scoring higher on the Charlson-Ghali Index are treated less aggressively. Additional drug usage data suggests a low incidence of lipid screening and treatment, possibly related to acuity level and age. A higher than expected percentage of patients are treated to ADA goals in terms of HbA1c values. The usage of long-acting insulin products (basal insulin) is lower than expected. Blood pressure management is better than expected, however, the use of ACE inhibitors in Type 2 DM patients (in the absence of cough/allergy) is lower than expected. As stated under the results section of this document, the study is currently on-going and all data will be analyzed and a formal manuscript prepared by January 1, 2009. B3
A Case of Subclinical Vitamin D Deficiency Khine Win Phyu, MD, University of Nevada, Reno Author(s): Khine W. Phyu, MD; Htun Oo, MD; Diane Chau, MD Introduction/Objective: Vitamin D is a vitamin, which functions as a hormone, required by the body to maintain a healthy immune system, to regulate cell growth and differentiation. It plays a major role in balancing calcium and phosphorus in regulating bone health and muscle strength. According to the dietary supplement fact sheet of The National Institutes of Health (2007), the prevalence of vitamin D deficiency is particularly high in older adults, due to an age-associated decline in cutaneous vitamin D production and dietary vitamin intake. Even though vitamin D deficiency is not uncommon in the elderly, its diagnosis commonly occurs after the development of clinically recognized osteoporosis. Design/Methodology: Two cases of elderly veterans with risk factors for falls such as impaired gait testing and cognitive impairment were found to have low vitamin D levels from lab tests ordered upon admission to a nursing care unit. Similar characteristics existed among the two geriatric cases. Socially, both patients were home bound and spent most of their time indoors. Thus, despite living in a sunny city, both had lack of adequate sun exposure and this resulted in a decreased production of vitamin D. Further evaluation of vitamin D deficiency revealed different etiologies for vitamin D deficiency. Results: In the first case, vitamin D deficiency secondary to chronic kidney disease should increase his parathyroid hormone level. But his PTH did not respond appropriately. This can be due to dysfunctional hypoparathyroidism seen among elderly. Calcitriol was chosen because of his low 1, 25 hydroxyvitamin D and his impaired renal function. With impaired renal function, patients often have normal or elevated OH vitamin D levels and an inability to hydroxylate 25 OH vitamin D to its active 1, 25 form. This patient’s 1, 25 Vitamin D level came within normal range after two months of supplementation. Careful monitoring of calcium and phosphate level is required for patients with renal insufficiency so as not to exceed a calcium phosphate product of 70 mg2/dL2 to avoid calcinosis, the deposition of calcium and phosphate in the body’s soft tissue. In the second case, vitamin D deficiency most likely was due to poor oral intake and gut malabsorption. He responded well with high doses of ergocalciferol for eight weeks. During high dose ergocalciferol therapy, 25 Vitamin D level should be monitored monthly to avoid vitamin D toxicity which can present as nausea, vomiting, weakness, headache, altered mental status, dry mouth, tinnitus, vertigo and ataxia. Conclusion/Discussion: The recommended standard vitamin D serum level is between 30 and 60 ng/mL. Sub clinical vitamin D deficiency may be more common than previously reported and clinicians should have increased vitamin D awareness. Pitfalls commonly seen in clinical care of elderly are Vitamin D deficiency, missed diagnosis, or inadequate supplementation. Development guidelines for screening and management of vitamin D deficiency are needed. Disclosures: Diane Chau, MD and Khine W. Phyu, MD have no disclosures to be made that are pertinent to this abstract. As of submission, Htun Oo, MD has not provided disclosures.
A Population-Based Study of Elder Mistreatment in Albemarle County, Virginia Anna M. Hicks, MD, University of Virginia Author(s): Anna M. Hicks; MD, Claire E. Curry, JD; Jonathan M. Evans, MD, MPH Introduction/Objective: Identify and describe all reported allegations of elder abuse, neglect and/or financial exploitation in Albemarle County over a 3-year period including long-term care (LTC) facilities. Design/Methodology: Prospective cohort study conducted over a 36 month period from July 1, 2004 through June 30, 2007. Subjects included individuals age 18 and older residing in Albemarle County, Virginia reported to and POSTER ABSTRACTS
investigated by Adult Protective Services as alleged victims of mistreatment during the study period. Results: 1174 reports of alleged mistreatment involving 862 subjects were reviewed. Median age was 73 years (range 18-105). Of those, 65% of subjects were over 65 and 33% were age 80 and older. 65% of subjects were female. 77% of subjects were white. The majority of subjects (53%) lived at home either alone or with family while 38% lived in LTC settings. Neglect was alleged in 65%, abuse in 27% and exploitation in 18% of cases. More than one kind of mistreatment was alleged in 10% of cases. Sources of mistreatment were recognized as self-neglect (32%), spouse/relative (24%), paid care giver (26%), power of attorney (7%) or other (10%). Mandatory reporting accounted for 66% of all reports. Alleged mistreatment was substantiated in 56% of cases with self-neglect as the most common form of mistreatment including LTC facilities. Conclusion/Discussion: Elder mistreatment is relatively common. Self-neglect is the most substantiated form of mistreatment, even in LTC. Physical abuse is among the least common findings in cases of substantiated mistreatment. Disclosures: Jonathan M. Evans, MD, MPH received an honorarium from Merck & Co., Inc. All other authors have stated there are no disclosures to be made that are pertinent to this abstract. A Quality Improvement Initiative Aimed at Improving the Assessment and Treatment of Type 2 Diabetes in Skilled-Nursing Facility Residents Tommy Eldridge Philpot, PharmD, Profiles & Interventions, Inc Author(s): Tommy E. Philpot, PharmD Introduction/Objective: To query a long-term consultant pharmacist electronic database to determine the following: 1) acuity level for all type 2 diabetes patients reviewed in the study; 2) compliance with diabetes goals as set forth by the American Diabetes Association across all levels of patient acuity; 3) prevalence of sliding scale insulin usage; 4) analyze data related to the treatment regimens used in the management of type 2 diabetes; 5) determine infection rates at various levels of glycemic control across all levels of patient acuity; and 6) determine the prevalence of hypoglycemia and specific drug therapies involved in the event. Design/Methodology: Senior Health Consulting Alliance is an independent consultant pharmacist organization that provides consultant pharmacist services to 4100 skilled-nursing facility patients in Georgia, Tennessee, and Ohio. The consultant pharmacists use an electronic database/medical record routinely within their practice. The electronic database includes ICD coding, medications, laboratory testing, and MDS 2.0 data points, as well as, specific recommendations and progress notes. Specific de-identified data queries will be analyzed to meet the stated objectives. A total of 500 patients will be randomly selected from within the database using ICD coding pertaining to Type-2 DM. Each patient will be assigned an acuity level using the Charlson-Ghali Comorbidity Index based on ICD coding. Each grouping will then be analyzed to provide general statistics for each of the stated objectives. Descriptive statistics will be used to identify trends in diabetes care within our patient population in an attempt to identify areas of potential improvement in the care of LTC facility patients. Results: The study is currently in progress. Completion date is set for 12-31-08. Conclusion/Discussion: The study is currently in progress. Preliminary data suggests higher rates of infection and stasis ulcers within patients with HbA1c values exceeding 8.5%, but the statistical significance is yet to be determined. As expected, patients scoring higher on the Charlson-Ghali Index are treated less aggressively. Additional drug usage data suggests a low incidence of lipid screening and treatment, possibly related to acuity level and age. A higher than expected percentage of patients are treated to ADA goals in terms of HbA1c values. The usage of long-acting insulin products (basal insulin) is lower than expected. Blood pressure management is better than expected, however, the use of ACE inhibitors in Type 2 DM patients (in the absence of cough/allergy) is lower than expected. As stated under the results section of this document, the study is currently on-going and all data will be analyzed and a formal manuscript prepared by January 1, 2009. B3