Prevalence of Vitamin D Deficiency In Secure Mental Health Setting: is routine screening required?

Transcription

1 Prevalence of Vitamin D Deficiency In Secure Mental Health Setting: is routine screening required? Dr Neel Halder, Consultant Psychiatrist and Senior Honorary Lecturer, Manchester University Dhana Govindaraj, Nurse Practitioner & Nurse Prescriber

2 1: Vitamin D Overview Vitamin D has several important roles: Helps to regulate the amount of calcium and phosphate in the body and improves the bone health. Source: Science photo library P.2

3 2: Vitamin D Overview Recent researches suggests, low vitamin D is related to increased risk of bowel cancer, heart disease, hypertension, diabetes and multiple sclerosis. These studies are still inconclusive and further studies required to establish causal relationship. Ref: Rosen CJ, Adams JS, Bikle DD et al. The non-skeletal effects of Vit D: an endocrine society scientific statement. Endocr Rev 2012; 33: Yin L, Grandi N, Raum E, Haug U, Arndt V, Brenner H. Meta-analysis: longitudinal studies of serum vitamin D and colorectal cancer risk. Aliment Pharmacol Ther. 2009; 30: Wang TJ, Pencina MJ, Booth SL, et al. Vitamin D deficiency and risk of cardiovascular disease. Circulation. 2008; 117: P.3

4 3: Vitamin D and Mental Health Vit D has been implicated in correlations with Schizophrenia, cognitive dysfunction and depression (Belvederi,2013) Links with Alzheimer s (Kapoor, 2014) Little research in this area P.4

5 4: Vitamin D Levels Measuring serum 25 hydroxyvitamin (25 OHD) is the best way of assessing patients vitamin D status. According to National Osteoporosis Society guidelines(2014) Vitamin D levels were classified as: < 30 nmol/l indicates deficiency nmol/l is insufficient/sub Optimal >= 50 nmol/l is sufficient level Are you D-ficient? P.5

6 5: Sources of Vitamin D Major source of vitamin D is exposure to sunlight (90%) Vit D overdose is impossible from UV radiation Little and often sun exposure is best (to prevent skin cancer) Recommended exposing hands, arms, and face between 10am & 3pm for approx 5-15 minutes, 2 to 3 times/week ( No sunscreen) P.6

7 6: Sources of Vitamin D Oily Fish (7mcg of Vit D in 100grams) Egg Yolk (1mcg/ egg) Fortified foods - vitamin D added, e.g. breakfast cereals and powdered milk P.7

8 7: Metabolism of Vitamin D P.8

9 8: At Risk People Infants and young children(< 5 years) Pregnant and breast feeding women People aged >=65 years People with darker skin (Ethnicity) Those who aren t exposed to much sun: - cover up their skin for cultural reasons - people who stay indoors for long periods of time (e.g. inpatients in mental health settings/secure environment). Source: NICE guidelines [PH56] Published date: November 2014 P.9

10 9: Vitamin D Overview DoH recommends a daily vitamin D supplement for the following people: Children aged 6 months to 5 years (Vit D drops 7-8.5mcg daily) Pregnant and breastfeeding women and those rarely exposed to the sun (10mcg daily) >= 65 Years (10mcg daily) P.10

11 10: Treating Deficiency / Insufficiency Treating Deficiency: A fixed loading regimen to provide a total of IU vitamin D, dose given either weekly/daily over 6 10 weeks Followed by maintenance therapy : 800 2,000 IU daily (occasionally up to 4,000 IU daily) or intermittently at higher doses Treating Insufficiency: Life style advise and over the counter (OTC) IU daily P.11

12 11: Our Study - Method Retrospective audit carried out to study the prevalence of Vit.D deficiency. The following data was audited: - demographic details - vitamin D levels of adults > 18 years - male and female wards were included. study covers both low secure and medium secure hospital population. Data collected over 1 month period from electronic blood reports and clinical notes Cross sectional audit P.12

13 12: Results Sample population 61 7 patients(12%) had normal Vit D levels; among them 4 patients on Vit D supplements. Total Vit D deficiency: 35 (57%) Total Vit D Insufficiency: 19(31%) Results of Vitamin D Levels 12% Deficiency 31% 57% Insufficiency Normal P.13

14 13: Results Gender comparison Total sample Male : 45; Female: 16 Normal: Male 6 (13.3%); Female : 1 (6.25%) Insufficiency: Male 14 (31.1%); Female 5 (31.25%) Deficiency: Male 25 (55.6 %); Female 10(62.5%) Prevalence of Vitamin D Deficiency In Secure Mental Health P.14

15 14: Prevalence of Vitamin D deficiency and Insufficiency comparing with age group Vitamin D levels Years Years 51-65Years 65+ N= % N=24 % N=7 % N=5 % 25 Normal Insufficiency Deficiency Key: % Percentage P.15

16 15: Literature findings Only 8% adults(19-64yrs) had low Vit D July - September, compared with 39% in January to March(National Diet and Survey,2012). Primary care spending for treating vit D deficiency increased from 28million in 2004 to 76million in 2011(Stephen Robinson,2012; Prescription cost analysis England,2011). P.16

17 16: Pros and Cons of screening Pros Early identification Prompt Rx Protect bone health Minimise risk of fracture Possible other mental health benefits Cons 20 screening cost per test Supplementation cost Increased workload P.17

18 17: Service Improvement Plan Patient s education on importance of Vit D and sources of Vit D Facilitating more outdoor activities Replace smoke breaks with fresh air garden access Screening of risk populations as part of admission and annual health reviews especially patients with SMI and LD Vit D posters on the wards to promote awareness Treat Vit D deficiency & Supplementation as per Primary Health Care Protocol. P.18

19 18: Conclusions Primary care protocol supports Vit D screening is not routinely required for risk population unless patients are symptomatic. However patients with SMI and LD are less likely to express their symptoms of aches/pains in their muscles and joints. Weighing risks and benefits, screening, lifestyle education and supplementation is recommended to protect patients health. P.19

20 19: Your views??????? Is routine screening required for risk populations? Is it feasible? Should we prescribe supplementation without screening? P.20

21 20: References Belvederi Murri M, Respino M, Masotti M, Innamorati M, Mondelli V, Pariante C, Amore M. Vitamin D and psychosis: Mini meta-analysis. Schizophr Res Jul 29. pii: S (13) ) DoH(2012) Vitamin D - advice on supplements for at risk groups: Chief Medical Officers report Jill Murie, Claudia-Martina Messow, Bridie Fitzpatrick (2012)Feasibility of screening for and treating vitamin D deficiency in forensic psychiatric inpatients. Journal of Forensic and Legal medicine. Nov ;19(8): Kapoor S. Influence of Vit D consumption and the levels on the development of psychiatric disorder (2014). Journal of Clinical Psychopharmacology. Vol 34 (4): The National Diet and Nutrition Survey results from Years 1 to 4 of the rolling Programme( ) NS_Statistical_press_notice_14May2014.pdf P.21

22 21: References NICE(2014) Vitamin D : Increasing supplements use in at-risk groups. Rosen CJ, Adams JS, Bikle DD et al. The non-skeletal effects of Vit D: an endocrine society scientific statement. Endocr Rev 2012; 33: Stephen Robinson (2012)Treating vitamin D deficiency /nutrition/article/ Terry J. Aspray; Claire Bowring; William Fraser; Neil Gittoes; M. Kassim Javaid; Helen Macdonald; Sanjeev Patel; Peter Selby; Nuttan Tanna; Roger M. Francis(2014) National Osteoporosis Society Vitamin D Guideline Summary. Vitamin D Position Statement(NICE,2010) Yin L, Grandi N, Raum E, Haug U, Arndt V, Brenner H. Meta-analysis: longitudinal studies of serum vitamin D and colorectal cancer risk. Aliment Pharmacol Ther. 2009; 30: Wang TJ, Pencina MJ, Booth SL, et al. Vitamin D deficiency and risk of cardiovascular disease. Circulation. 2008; 117: P.22