Vitamin D Toxicity Presenting as Altered Mental Status in Elderly Patients
Cureus . 2022 Dec 18;14(12):e32654. doi: 10.7759/cureus.32654. eCollection 2022 Dec.
Umar H Khan 1, Suhail Mantoo 1, Amrit Dhar 1, Afshan Shabir 1, Asma Shah 1, Nazia Mehfooz 1, Sonaullah Shah 1
Background and objective Around 25-30% of elderly patients present to emergency departments (ED) with altered mental status (AMS), with hypercalcemia being one of the metabolic causes. Elderly patients, due to their multiple vulnerability factors and relative homeostenosis, are susceptible to alterations in mental state at even milder grades of hypercalcemia. There is a trend of overzealous prescription of higher doses of vitamin D in elderly patients for various ailments, which often exceeds the requirements of the patients. In this study, we aimed to establish vitamin D toxicity (VDT) as an underlying cause of AMS in elderly patients presenting to the hospital.
Methods This was a descriptive case study conducted at a tertiary care university hospital in North India, from January 2015 to March 2020 for a total duration of five years. Elderly patients (aged ≥60 years) who were admitted with VDT as a cause for underlying hypercalcemia were included. The evaluation included patient history regarding the dosage of vitamin D received, route of administration, and biochemical parameters, such as serum calcium, intact parathyroid hormone (iPTH), 25-hydroxy vitamin D [25(OH)D], and albumin. All other potential causes for hypercalcemia and AMS were ruled out concurrently.
Results A total of 19 patients were enrolled in the study, with a mean age of 72.3 years (range: 62-86 years). All patients had received injectable vitamin D formulation. The mean serum calcium among the patients was 12.52 ± 1.12 mg/dL (range: 11.2-15.7 mg/dL), whereas the mean 25(OH)D was 196.34 ± 70.44 ng/mL (range: 107-356 ng/mL). The mean cumulative vitamin D supplement intake was 2.594 ± 0.841 million IU (range: 1.2 million-4.2 million IU). While six patients had mild hypercalcemia, 12 had moderate, and one person had severe hypercalcemia, with altered sensorium (85%) being the most common complaint for presenting to ED, followed by generalized weakness (15%).
Conclusion VDT can manifest with AMS as an initial presenting complaint. The geriatric population, due to various underlying vulnerability factors, is more susceptible than their younger counterparts. We strongly recommend that in elderly patients, higher doses of vitamin D should be prescribed only after checking their serum levels, and frequent monitoring of vitamin D should be performed
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Note: No indication of injection size, # of injections per year, % who had a problem (0.1%, 1%, 10%?)
Note: Successful High-dose vitamin D therapies typically avoid hypercalcemia by just reducing Calcium intake
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VitaminDWiki - Injection contains
- Vitamin D injections last longer (3 month vs 2 month) than loading doses
- Getting Vitamin D into your body shows the many ways of getting Vitamin D
- Injections are currently made by medical professionals into muscle
- Home injection of Vitamin D appears to be possible in the future
- Injections are useful for people who might forget to take their periodic supplement (children, elderly, etc) and those who cannot swallow or have poor digestion
- While Vitamin D2 is historically the common form, Vitamin D3 is far better
- Should check (if there is time) for possible allergic reaction to Vitamin D or lack of Magnesium for both for loading dose and injection
- Note 600,000 IU Vitamin D loading dose via capsules is 1/20th the cost($2.40) of an injection, and does not require a prescription
- 100,000 IU single dose of vitamin D - 2010 has the following
- Vitamin D injection lasts longer and has bigger response than weekly oral – Jan 2017 has the following
- Non-oral Vitamin D should be a better form for MS, food allergy, PTSD, etc. – many studies might include injection
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