New NICE guidance on managing vitamin B12 deficiency in older people

Older patients (aged 65 and over) with cognitive difficulties, mental health problems, and/or unexplained fatigue should be offered a vitamin B12 test, according to draft NICE guidance.

The updated guidance comes after the Committee agreed to include age as a risk factor for vitamin B12 deficiency.

This is because the ageing process causes physiological changes in the gastrointestinal system that can affect dietary intake of vitamin B12, as well as causing malabsorption.

Older people are also at higher risk of developing health problems such as cognitive impairment and dementia, which can impact their diet and eating habits.

Other symptoms and signs of possible vitamin B12 deficiency include:

• abnormal findings on a blood count such as anaemia or macrocytosis
• glossitis
• eyesight problems
• neurological or mobility problems
• symptoms or signs of anaemia.

What causes vitamin B12 deficiency?

Vitamin B12 deficiency is caused by a lack of the vitamin in the diet, problems with absorption from the gastrointestinal tract, or recreational nitrous oxide use.

The condition can lead to a wide range of symptoms and complications, including mental health problems and neurological problems such as cognitive impairment.

According to NICE, vitamin B12 deficiency is more common in older people and is thought to affect around 5% of people aged between 65 and 74 years and more than 10% of people aged 75 and over.

How is vitamin B12 deficiency diagnosed and treated?

Vitamin B12 deficiency is usually diagnosed and treated in primary care settings. A blood test for deficiency is usually done when people present with symptoms like fatigue or when there are abnormal findings on other blood tests.

Testing is also done when investigating conditions such as anaemia, macrocytosis, and neuropsychiatric or neurodegenerative symptoms or signs.

Treatment for vitamin B12 deficiency depends on the cause but the aim is to replace vitamin B12 and improve the person’s symptoms.

The most common treatments are intramuscular injections, given by a healthcare professional, or oral vitamin B12 replacement.

When to prescribe tablets vs injections

The guidance states that physicians should consider intramuscular vitamin B12 injections instead of oral supplementation if the person is older or they have delirium or cognitive impairment.

Intramuscular vitamin B12 replacement may also be the best option for people in whom treatment needs to work quickly because they are at risk of rapid deterioration that could significantly affect their quality of life.

Injections could also be a better option if there are concerns about adherence to oral supplementation. For example, if a patient is in or has recently been in hospital, if they have complex comorbidity, or have frailty linked to undernutrition, dementia or decompensation.

This group is likely to be prescribed a few different medicines to take on a daily basis, and having injections at 2 to 3-month intervals would mean one less medicine to take a day.