[DoctorBeaver (OP)]

Has there ever been any indication that pneumonia can trigger dementia in elderly people? Or is dementia maybe a symptom?

I ask because my friend's nan was in hospital with pneumonia & came home on Friday. She'd been there for 2 weeks. Now she's doubly incontinent and very confused. Half the time she doesn't know where she is or why. She calls myself & my friend by wrong names, thinks she still lives in the bungalow she moved from last summer and all sorts of things like that. Yesterday at around 10am we found her asleep on the floor in the kids' bedroom. She didn't know how she got there.

She wasn't like that before she caught pneumonia. She was alert & did a lot of puzzles like wordsearch etc. The hospital she was in is useless & wouldn't give us any information. We're going to see the GP in a couple of days but I was wondering if anyone here had come across pneumonia triggering the kind of symptoms I've described here.

[iko]

Hi Dr.Beaver,
more than two decades ago we routinely used parenteral vitamins to support the elderly in critical illnesses, when an already restricted diet had been heavily altered.
Intramuscle Benexol B12 (Vitamin B1, B6 and B12) was commonly used.
I use it for my mum from time to time (she eats like a bird!) and she seems to be happy with that...placebo effect?

These days it is even difficult to find reported evidence of its efficacy.
The alternative is to quickly get dosages of vitamin B1 and B12.
Neurologic symptoms of both deficiencies are irreversible in some cases.
If vitamin B12 deficiency is suspected, combined folate administration is mandatory.
Of course the cause could be a totally different one, but...this remedy doesn't cost anything.
Vitamin B1 deficiency can come out in 2-3 weeks, vitamin B12 deficiency could have been present much before, leading to neurological dysfunction, dysphagia and aspiration pneumonia.
Even ascorbic acid eventually may help her post-infectious condition.

ikod

One example for many:

Delirium associated with vitamin B12 deficiency after pneumonia.

Buchman N, Mendelsson E, Lerner V, Kotler M.
Ministry of Health, Beer-Yakov Mental Health Center, Israel.

A case is presented of a 65-year-old man with chronic schizophrenia who, after four years of remission, developed psychotic symptoms after pneumonia. The patient was found to be deficient in vitamin B12. His psychosis remitted within 5 days of administration of vitamin B12 and folic acid. This case emphasizes the need to measure vitamin B12 in psychogeriatric patients, especially when they present with a severe infection and organic mental symptoms.

Clin Neuropharmacol. 1999 Nov-Dec;22(6):356-8.

[ROBERT]

The neurological dysfunction in dementia can also include dysphagia.
Dysphagia can cause aspiration pneumonia.

So dementia can be the cause of pneumonia, (not the converse}.

[iko]

Hi Robert,

but here neuropsychological symptoms came AFTER pneumonia.

ikod

[iko]

Addendum (from NKS Forum):



Vitamin B12 deficiency is pretty rare (but exists!) in developed countries: as a result of malnutrition (alcoholics, faddists, anorectics etc.) or impaired adsorption caused by gastric atrophy.
Please find something about vitamin B12 from the "form of vitamin" topic of this forum (cells/microbes/viruses), two posts from few weeks ago:


Vitamin B12 deficiency could cause pernicious anemia and/or severe neurolgic damage, psychotic behaviour and in rare cases irreversible blindness. I remember a report of few years ago about a young man left completely blind after a badly managed vegan diet.

Dementia caused by vitamin B12 deficiency

Behrens MI, Diaz V, Vasquez C, Donoso A.
Departamento de Neurologia y Neurocirugia, Hospital Clinico Universidad de Chile.

Cyanocobalamin (vitamin B12) deficiency can cause polyneuropathy, myelopathy, blindness, confusion, psychosis and dementia.
Nonetheless, its deficiency as the sole cause of dementia is infrequent. We report a 59 years old man with a 6 months history of progressive loss of memory, disorientation, apathy, paranoid delusions, gait difficulties with falls, and urinary incontinence. He had suffered a similar episode 3 years before, with a complete remission. On examination there was frontal type dementia with Korsakoff syndrome, a decrease in propioception and ataxic gait. Cerebrospinal fluid examination showed a protein of 0.42 g/L. Brain computed tomography showed sequelae of a frontal left trauma. Brain single photon computed tomography (SPECT) was normal.
Complete blood count showed a macrocytic anemia with a hematocrit 29% and a mean corpuscular volume of 117 micron3.
Plasma vitamin B12 levels were undetectable, erythrocyte folate levels were 3.9 ng/ml and plasma folate was normal. The myelogram showed megaloblastosis and the gastric biopsy showed atrophic gastritis. Treatment with parenteral B12 vitamin and folic acid reverted the symptoms, with normalization of the neuropsychological tests and reintegration to work.

Rev Med Chil. 2003 Aug;131(:915-9.


I forgot to explain how vitamin B12 deficiency could develop even on a regular diet.
Gastric atrophy leads to impaired production of a special protein (Intrinsic Factor) that binds B12 and allows its absorption in the intestine. Liver can stock large amounts of B12 enough for approx. 6 months.
So if the stomach stops making IF, after 6m on a regular diet vitamin B12 deficiency becomes evident (to somebody who can diagnose it on the spot!). Large amounts of B12 by mouth can allow the intestine to absorbe enough vitamin anyway. But in case of severe deficiency, parenteral administration for a few days, plus folic acid orally, is recommended.
bye

iko

[iko]

Another piece for Dr.Beaver's puzzle
from the cod liver oil maniac!


ikod

The syndrome of food-cobalamin malabsorption revisited in a department of internal medicine.
 A monocentric cohort study of 80 patients.

Andres E, Perrin AE, Demangeat C, Kurtz JE, Vinzio S, Grunenberger F, Goichot B, Schlienger JL.
Department of Internal Medicine and Nutrition, Hopitaux Universitaires de Strasbourg, Strasbourg, France

BACKGROUND: To date, only case reports or small studies have documented the syndrome of food-cobalamin malabsorption in specific populations of patients or situations. In this paper, we present the data from 80 unselected patients with cobalamin deficiency related to food-cobalamin malabsorption.
METHODS: We studied 80 patients with well-established food-cobalamin malabsorption who were extracted from an observational cohort study (1995-2000) of 127 consecutive patients with cobalamin deficiency and who were followed in a department of internal medicine.
RESULTS: The median age of patients was 66 years and the female to male ratio was 1.2. The mean hemoglobin level was 113+/-27 g/l (range 32-159 g/l) and the mean erythrocyte cell volume was 95.4+/-12.3 fl (range 55-140 fl). Mean serum vitamin B12 and homocysteine levels were 153+/-74 pg/ml (range 35-200 pg/ml) and 20.6+/-15.7 mumol/l (range 8-97 mumol/l), respectively. The main clinical findings noted were peripheral neuropathy (46.2%), stroke (12.5%), confusion or dementia (10%), asthenia (18.7%), leg edema (11.2%), and digestive disorders (7.5%). The commonest associated conditions were atrophic gastritis (39%) with evidence of Helicobacter pylori infection (12.2%) and alcohol abuse (13.7%). Three patients had Sjogren's syndrome and one had systemic sclerosis. Ten percent of all patients were on long-term metformin (10%) and 7.5% on acid-suppressive drugs. Correction of the serum vitamin B12 levels and hematological abnormalities was achieved equally well in all patients treated with either intramuscular or oral crystalline cyanocobalamin.

CONCLUSION: This study suggests that food-cobalamin malabsorption may be the leading cause of vitamin B12 deficiency in adults. As other studies have also reported, the condition is often associated with neuro-psychiatric findings and with several other conditions. Oral and parenteral cobalamin appear to be equally effective in correcting serum B12 levels and hematological abnormalities and, in many cases, they also relieve symptoms.

Eur J Intern Med. 2003 Jul;14(4):221-226.

[another_someone]

Maybe not relevant at all, but one thing that occurred to me was the reports of Parkinsonism in the aftermath of the 1918 flu epidemic.  Although it seems that most opinion does not believe that the flu virus itself could have caused Parkinsonism, but it seems there is some opinion that a cytokine storm could be triggered by certain illnesses, including (but not limited to) flu, and that this can cause an attack on the nervous system.

Maybe total rubbish - who am I to judge.

[DoctorBeaver (OP)]

Thanks for your replies.
I don't think it's down to any dietary deficiency. She was eating fine before she went into hospital & although she didn't eat much in hospital I would imagine the food there is nutritious.
The comment about flu & Parkinson's is interesting. I'll look into that a bit more.
Where the incontinence is concerned, when my friend spoke to the GP she said that antibiotics (she was on amoxycillin) can cause some kind of bug to become active & that it can cause diarrhoea (sp?). Any thoughts on that?

[iko]

I don't think it's down to any dietary deficiency. She was eating fine before she went into hospital & although she didn't eat much in hospital I would imagine the food there is nutritious.

It is not a nutrition problem, read carefully, you may have missed how gastric atrophy leads to vitamin B12 in a few months...sorry about that, but this is probably why B12 deficiency is so often underdiagnosed!

Addendum (from NKS Forum):



Vitamin B12 deficiency is pretty rare (but exists!) in developed countries: as a result of malnutrition (alcoholics, faddists, anorectics etc.) or impaired adsorption caused by gastric atrophy.
Please find something about vitamin B12 from the "form of vitamin" topic of this forum (cells/microbes/viruses), two posts from few weeks ago:


Vitamin B12 deficiency could cause pernicious anemia and/or severe neurolgic damage, psychotic behaviour and in rare cases irreversible blindness. I remember a report of few years ago about a young man left completely blind after a badly managed vegan diet.

Dementia caused by vitamin B12 deficiency

Behrens MI, Diaz V, Vasquez C, Donoso A.
Departamento de Neurologia y Neurocirugia, Hospital Clinico Universidad de Chile.

Cyanocobalamin (vitamin B12) deficiency can cause polyneuropathy, myelopathy, blindness, confusion, psychosis and dementia.
Nonetheless, its deficiency as the sole cause of dementia is infrequent. We report a 59 years old man with a 6 months history of progressive loss of memory, disorientation, apathy, paranoid delusions, gait difficulties with falls, and urinary incontinence. He had suffered a similar episode 3 years before, with a complete remission. On examination there was frontal type dementia with Korsakoff syndrome, a decrease in propioception and ataxic gait. Cerebrospinal fluid examination showed a protein of 0.42 g/L. Brain computed tomography showed sequelae of a frontal left trauma. Brain single photon computed tomography (SPECT) was normal.
Complete blood count showed a macrocytic anemia with a hematocrit 29% and a mean corpuscular volume of 117 micron3.
Plasma vitamin B12 levels were undetectable, erythrocyte folate levels were 3.9 ng/ml and plasma folate was normal. The myelogram showed megaloblastosis and the gastric biopsy showed atrophic gastritis. Treatment with parenteral B12 vitamin and folic acid reverted the symptoms, with normalization of the neuropsychological tests and reintegration to work.

Rev Med Chil. 2003 Aug;131(:915-9.


I forgot to explain how vitamin B12 deficiency could develop even on a regular diet.
Gastric atrophy leads to impaired production of a special protein (Intrinsic Factor) that binds B12 and allows its absorption in the intestine. Liver can stock large amounts of B12 enough for approx. 6 months.
So if the stomach stops making IF, after 6m on a regular diet vitamin B12 deficiency becomes evident (to somebody who can diagnose it on the spot!). Large amounts of B12 by mouth can allow the intestine to absorbe enough vitamin anyway. But in case of severe deficiency, parenteral administration for a few days, plus folic acid orally, is recommended.
bye

from the handbook: "B12 for dummies" by ikod

[ROBERT]

Thanks for your replies.
I don't think it's down to any dietary deficiency. She was eating fine before she went into hospital & although she didn't eat much in hospital I would imagine the food there is nutritious.
The comment about flu & Parkinson's is interesting. I'll look into that a bit more.
Where the incontinence is concerned, when my friend spoke to the GP she said that antibiotics (she was on amoxycillin) can cause some kind of bug to become active & that it can cause diarrhoea (sp?). Any thoughts on that?

The double incontinence is analogous of dysphagia: they are consistent with dysautonimia caused by the neurological damage of dementia.

Iko is correct in saying that vitamin B deficiency can cause dementia, e.g. Pellagra, but extreme malnutrition is required.

PELLAGRA - literally rough skin; clinical syndrome due to deficiency of niacin (nicotinic acid) characterized by diarrhea, dermatitis and dementia

http://www.southalabama.edu/alliedhealth/cls/Ravine/glossary_of_pathology_and_%20medical_terms.htm#P

[iko]

Thanks for your replies.
I don't think it's down to any dietary deficiency. She was eating fine before she went into hospital & although she didn't eat much in hospital I would imagine the food there is nutritious.
The comment about flu & Parkinson's is interesting. I'll look into that a bit more.
Where the incontinence is concerned, when my friend spoke to the GP she said that antibiotics (she was on amoxycillin) can cause some kind of bug to become active & that it can cause diarrhoea (sp?). Any thoughts on that?

The double incontinence is analogous of dysphagia: they are consistent with dysautonimia caused by the neurological damage of dementia.

Iko is correct in saying that vitamin B deficiency can cause dementia, e.g. Pellagra, but extreme malnutrition is required.

PELLAGRA - literally rough skin; clinical syndrome due to deficiency of niacin (nicotinic acid) characterized by diarrhea, dermatitis and dementia

http://www.southalabama.edu/alliedhealth/cls/Ravine/glossary_of_pathology_and_%20medical_terms.htm#P

No Robert,
either you did not read my previous post,
or my english has recently gone rotten...
I suspected vitamin B12 deficiency, based on
gastric atrophy and no Intrinsic Factor (IF).
Normal diet, it is NOT a nutritional problem.

Pellagra is another story, bound to malnutrition
and deficiency of niacin, or nicotinic acid,
called vitamin B3 or PP (Pellagra Preventing).
Nothing to do with vitamin B12: you see how docs
cite one cofactor meaning another one these days?

ikod

I forgot to explain how vitamin B12 deficiency could develop even on a regular diet.
Gastric atrophy leads to impaired production of a special protein (Intrinsic Factor) that binds B12 and allows its absorption in the intestine. Liver can stock large amounts of B12 enough for approx. 6 months.
So if the stomach stops making IF, after 6m on a regular diet vitamin B12 deficiency becomes evident (to somebody who can diagnose it on the spot!). Large amounts of B12 by mouth can allow the intestine to absorbe enough vitamin anyway. But in case of severe deficiency, parenteral administration for a few days, plus folic acid orally, is recommended.
bye

from the handbook: "B12 for dummies" by ikod

 
http://home.caregroup.org/clinical/altmed/interactions/Images/Nutrients/niacin.gif
http://home.caregroup.org/clinical/altmed/interactions/Images/Nutrients/vitB12.gif

Nothing to do with vitamin B12: you see how docs
cite one cofactor meaning another one these days?

I forgot to tell a story to explain the whole thing:
years ago, a colleague of mine had vitamin B12 deficiency with
no anemia and didn't get a proper diagnosis until he could barely walk.
He was treated then, but a sort of limp persisted.

[DoctorBeaver (OP)]

Well she's been off the antibiotics for a few days and the diarrhoea is clearing up. The dementia is getting better too. Hopefully she can continue and make a full recovery.

But thanks again for all you comments. Much appreciated.

[another_someone]

Well she's been off the antibiotics for a few days and the diarrhoea is clearing up. The dementia is getting better too. Hopefully she can continue and make a full recovery.

But thanks again for all you comments. Much appreciated.

That is good news.

[iko]

Importance of vitamin B12 is being revisited
after long years of criticism and hostility.
Not a 'tsunami' effect like with vitamin D,
only a correct re-evaluation of its qualities.
This is one of many recent positive reports:

Vitamin B12, folic acid, and the nervous system.

Reynolds E.
Institute of Epileptology, King's College, Denmark Hill Campus, Cutcombe Road, London, SE5 6PJ, UK. reynolds@buckles.u-net.com

There are many reasons for reviewing the neurology of vitamin-B12 and folic-acid deficiencies together, including the intimate relation between the metabolism of the two vitamins, their morphologically indistinguishable megaloblastic anaemias, and their overlapping neuropsychiatric syndromes and neuropathology, including their related inborn errors of metabolism. Folates and vitamin B12 have fundamental roles in CNS function at all ages, especially the methionine-synthase mediated conversion of homocysteine to methionine, which is essential for nucleotide synthesis and genomic and non-genomic methylation. Folic acid and vitamin B12 may have roles in the prevention of disorders of CNS development, mood disorders, and dementias, including Alzheimer's disease and vascular dementia in elderly people.

Lancet Neurol. 2006 Nov;5(11):949-60.

Preventing Age-Related Cognitive Decline
By Laurie Barclay, MD

...
Replacement of B vitamins in deficient individuals often improves short-term memory and language skills. Elderly subjects who are low in folic acid show impairment in both word recall and object recall, suggesting a vital role for folic acid in memory function in later life. Memory impairment in the elderly related to vitamin B12 deficiency can be reversed by vitamin B12 injections or supplements.
High doses of vitamin B6 and folate reduce blood levels of homocysteine, a toxic buildup product linked to heart disease and cognitive impairment. In dementia patients with even mild deficiencies of vitamin B12 or folate, replacement can improve cognition, especially in those with elevated blood homocysteine levels. In a study of 76 elderly males, vitamin B6 was better than placebo in improving long-term information storage and retrieval.

Life Extension Magazine - April 2005    http://www.lef.org/magazine/mag2005/apr2005_cover_cognitive_02.htm 

http://www.lef.org/magazine/mag2005/images/apr2005_cover_cognitive_04.jpg

 

[iko]

Nutrition and good mental health
is not only bound to vitamin B12
and folic acid...
Of course cod liver oil matters!
Thanks to vitamin D  []
Maybe.

Is vitamin D important for preserving cognition?
A positive correlation of serum 25-hydroxyvitamin D concentration with cognitive function.

Przybelski RJ, Binkley NC.
School of Medicine and Public Health, University of Wisconsin-Madison, 2870 University Avenue, Suite 100, Madison, WI 53705, USA. rjprzybe@facstaff.wisc.edu

This study investigates the association of vitamin D status with cognitive function and discusses potential mechanisms for such an effect. The relationship of vitamin B12 with cognition was also assessed. A retrospective review of older adults presenting to a university-affiliated clinic providing consultative assessments for memory problems was performed. Charts of all patients (n=80) presenting for initial visits were reviewed to identify those who had serum 25-hydroxyvitamin D (25(OH)D), vitamin B12, and mini-mental state examination score (MMSE) all obtained on their first visit (n=32). Correlation analyses between MMSE and 25(OH)D and vitamin B12 levels were performed. Serum 25(OH)D concentration and MMSE showed a (p=0.006) positive correlation; no (p=0.875) correlation was observed between serum B12 concentration and MMSE.
In conclusion, the positive, significant correlation between serum 25(OH)D concentration and MMSE in these patients suggests a potential role for vitamin D in cognitive function of older adults.

Arch Biochem Biophys. 2007 Apr 15;460(2):202-5.