Expert Insight Into: Vitamin D Deficiency is Associated with Worse Cognitive Performance and Lower Bone Density in Older African Americans

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Clinical Insights

Contrary to the general perception that older African Americans are at lower risk of the clinical consequences of vitamin D deficiency, recent data has shown that vitamin D deficiency is associated with decreased cognitive performance and lower hip bone density in older African Americans as well as their European American counterparts
Given that African Americans are at increased risk of vitamin D deficiency, these findings have particular relevance to physicians treating this population
Further prospective studies are needed to determine whether normalization of vitamin D levels can prevent/remedy the clinical effects of low vitamin D levels

PLEASE NOTE: The peer-reviewed journal article reviewed in this educational activity has been selected by faculty on the scientific merits of the new data and/or information being reported, which form the building blocks for a better understanding of the disease and its management. The evidence-based clinical findings provided in these articles are important in helping clinicians improve patient care and outcomes. Each article review is one part of a larger overall curriculum mosaic that provides a full and balanced perspective on this disease and its management. We suggest that you read all of the article reviews in this series.

Numerous studies have demonstrated that African Americans of all ages have a greater incidence of vitamin D deficiency than do individuals of other races/ethnicities, primarily due to lower levels of vitamin D synthesis in their skin in response to ultraviolet light exposure. However, since the most commonly observed clinical manifestation of vitamin D deficiency in older individuals – osteopenia/osteoporosis – is assumed to be less frequent in African Americans, vitamin D deficiency in older African Americans has attracted little attention. Recently, the perception that vitamin D deficiency in these individuals may not be of significant clinical importance has been challenged by results from studies linking vitamin D deficiency to cognitive performance, depressive symptoms, and physical disability. As a consequence, a study was undertaken to explore the implications of vitamin D status on nonskeletal as well as skeletal factors in older African Americans.

This was a small cross-sectional study of 30 African Americans and 30 European Americans, with each African American matched with a European American on the basis of a clinical dementia rating (CDR). All participants were older than 55 years, of normal or mildly impaired cognition, and were able to ambulate independently and complete all tasks assessed. Individuals with a history of stroke, or who had Parkinson’s disease, renal failure, or moderate to severe cognitive impairment were excluded, as were those using osteoporosis medications, prescription vitamin D supplements, or >800 IU/daily nonprescription vitamin D supplements. The CDR was based on items from the Mini-Mental State Examination (MMSE) and the Short Blessed Test (SBT), which measure memory, orientation, attention, and visual-spatial function, and which are particularly useful in detecting mild dementia and sub-threshold cognitive impairment. These tests were supplemented with interviews from a reliable person in the participant’s life, usually a spouse or adult child, concerning the participant’s past medical, social, and family history. The participant and the informant were also asked about possible cognitive changes compared to previous levels of functioning. Using the CDR, each participant was then rated in terms of six factors – memory; orientation; judgment and problem solving; community affairs; home management and hobbies; and personal care.

The presence or absence of an active mood disorder was determined using the depressive features inventory, a nine-item survey that has been used to diagnose depression. Participants also underwent a general physical and neurological examination and a modified physical performance test that included everyday tasks such as writing a sentence, dressing, picking up a coin from the floor, turning in a circle, and sitting in and rising from a chair.

Serum 25-hydroxyvitamin D levels were measured at the time of clinical assessment and the physical performance test. Those with serum 25-hydroxyvitamin D >20 ng/mL were considered to have normal vitamin D levels and those with levels <20 ng/mL were considered vitamin D deficient. Serum 25-hydroxyvitamin D was assessed only once. Bone mineral density (BMD) of the lumbar spine and proximal femur was determined by dual-energy x-ray absorptiometry, and T- and Z-scores were determined.

Thirty-one of the 60 participants (52%) – 8 European Americans and 23 African Americans – were vitamin D deficient. Other than the significantly higher vitamin D levels in European Americans (mean: 25.20 ng/mL) compared to African Americans (mean: 17.98 ng/mL)
(P <.0001), no significant differences were noted between racial groups. As a whole, participants with vitamin D deficiency had significantly lower SBT and physical performance test scores (P = .016 and P = .039, respectively), as well as significantly lower BMD of the hip (P = .005), differences which remained significant after adjustments for age, race, education, and weight. Interestingly, participants with vitamin D deficiency were also an average of 5 years younger than those with normal vitamin D levels (P = .021).

When examined as a sub-group, African Americans with vitamin D deficiency did poorer on both tests of cognitive function, the MMSE and the SBT, and had lower BMD of the hip than did African Americans with normal vitamin D levels (Table). As was observed in the total group of 60 participants, African Americans with lower vitamin D levels were also significantly younger (71.18 years) than African Americans with normal vitamin D levels (80.67 years) (P = .004). No significant differences as a function of vitamin D status were noted in terms of BMD of the spine, MMSE, or the presence of mood disorder in African Americans or in the total study population.

Table: Impact of Vitamin D Status on Cognitive Function and Bone Mineral Density in Older African Americans

	Cognitive Function		Bone Mineral Density
	MMSE^a	SBT^b	Hip BMD	Hip T-score
Vitamin D deficient (mean: 15.37 ng/mL)	24.65	11.78	.83	-1.22
Normal Vitamin D (mean: 26.53 ng/mL)	29.14	2.29	1.01	-0.414
P value	.008	.004	.0001	.014

^aIn the MMSE, 30 is the maximum score, with higher scores indicating better performance.
^bIn the SBT, 0 is the best score and 28 is the worst.
Abbreviations: MMSE, Mini-Mental State Examination; SBT, Short Blessed Test; BMD, bone mineral density

The recognition of an association between cognitive function and vitamin D status in older individuals has particular relevance for physicians who treat older African Americans, since these patients are not only more likely to be vitamin D deficient than their European American counterparts but also because historically it has been thought that they are at lower risk for osteoporosis/osteopenia, the most obvious consequence of vitamin D deficiency in the elderly. In light of the assumption that older African Americans are not at as great a risk of osteoporosis, it is of interest that African Americans and European Americans with vitamin D deficiency had similar low hip BMD. Although the small sample size and cross-sectional design of this study limits the conclusions that can be extrapolated to elderly African Americans in general, it strongly suggests the need for larger prospective studies to determine whether normalization of vitamin D status can prevent cognitive decline and physical impairment, particularly in this and other populations at high risk of vitamin D deficiency.

Reference:

Wilkins CH, Birge SJ, Sheline YI, Morris JC. Vitamin D deficiency is associated with worse cognitive performance and lower bone density in older African Americans. J Natl Med Assoc. 2009;101:349-354.

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Expert Insight Into:
Vitamin D Deficiency is Associated with Worse Cognitive Performance and Lower Bone Density in Older African Americans

Medical Writer: Karen Gravelle, PhD
Expert Faculty: E. Michael Lewiecki, MD, FACP, FACE

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Privacy Policy

Expert Insight Into: Vitamin D Deficiency is Associated with Worse Cognitive Performance and Lower Bone Density in Older African Americans

Medical Writer: Karen Gravelle, PhD Expert Faculty: E. Michael Lewiecki, MD, FACP, FACE

Available for CME/CE:

Physicians

Nurses

Pharmacists

Estimated time for completion of this activity:

Target Audience

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Learning Objective (s)

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CE Information: Nurses

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Pharmacists

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CE Information: Nurses

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Expert Insight Into:
Vitamin D Deficiency is Associated with Worse Cognitive Performance and Lower Bone Density in Older African Americans

Medical Writer: Karen Gravelle, PhD
Expert Faculty: E. Michael Lewiecki, MD, FACP, FACE