219

ARTICLE
Vitamin B12 status in older adults living in Ontario long-term
care homes: prevalence and incidence of deciency with
supplementation as a protective factor
Kaylen J. Psterer, Mike T. Sharratt, George G. Heckman, and Heather H. Keller
Appl. Physiol. Nutr. Metab. Downloaded from www.nrcresearchpress.com by 111.95.132.244 on 11/29/16

Abstract: Vitamin B12 (B12) deciency, although treatable, impacts up to 43% of community-living older adults; long-term care
(LTC) residents may be at greater risk. Recommendations for screening require further evidence on prevalence and incidence in
LTC. Small, ungeneralizable samples provide a limited perspective on these issues. The purposes of this study were to report
prevalence of B12 deciency at admission to LTC, incidence 1 year post-admission, and identify subgroups with differential risk.
This multi-site (8), retrospective prevalence study used random proportionate sampling of resident charts (n = 412). Data at
admission extracted included demographics, B12 status, B12 supplementation, medications, diagnoses, functional indepen-
dence, cognitive performance, and nutrition. Prevalence at admission of B12 deciency (<156 pmol/L) was 13.8%; 47.6% had
normal B12 (>300 pmol/L). One year post-admission incidence was 4%. Better B12 status was signicantly associated with
supplementation use prior to LTC admission. Other characteristics were not associated with status. This work provides a better
estimate of B12 deciency prevalence than previously available for LTC, upon which to base protocols and policy. Prospective
studies are needed to establish treatment efcacy and effect on health related outcomes.

Key words: vitamin B12 deciency prevalence, older adults, long-term care, micronutrient malnutrition, incidence.
For personal use only.

Rsum : La dcience en vitamine B12 (B12) bien que traitable, touche jusqua 43 % des personnes ges vivant dans une
communaut; les patients aux soins de longue dure (SLD) seraient plus a risque. Il faut plus de donnes probantes sur la
prvalence et lincidence dans les SLD pour proposer des recommandations en matire de dpistage. Des tudes menes auprs
dchantillons restreints ne permettant pas de gnralisation prsentent une perspective limite a ce sujet. Cette tude a pour
objectif de rapporter la prvalence de dcience en vitamine B12 au moment de ladmission aux SLD, lincidence un an plus tard
et didentier des sous-groupes prsentant un risque diffrent. Cette tude rtrospective sur la prvalence ralise a plusieurs
sites (8) utilise un chantillonnage alatoire proportionnel des dossiers de rsidents (n = 412). Les donnes utilises a ladmission
sont : dmographiques, statut en vitamine B12, supplmentation en vitamine B12, mdication, diagnostic, autonomie fonction-
nelle, performance cognitive et nutrition. La prvalence de dcience en B12 (<156 pmol/L) a ladmission est de 13,8 %; 47,6 %
prsentent un taux normal de B12 (>300 pmol/L). Un an aprs ladmission, lincidence est de 4 %. Un meilleur statut en B12 est
signicativement associ a la consommation de supplments avant ladmission aux SLD. Les autres variables ne sont pas
associes au statut en B12. Cette tude procure une meilleure estimation de la prvalence de la dcience en B12 comparative-
ment a ce qui tait antrieurement disponible pour les SLD; cette tude permet dtablir des protocoles et une politique. Il faut
effectuer des tudes prospectives an de dterminer lefcacit du traitement et de son effet sur le bilan de sant. [Traduit par
la Rdaction]

Mots-cls : dcience en vitamine B12, personnes ges, soins de longue dure, micronutriment, malnutrition, incidence.

Introduction living older adult prevalence estimates of B12 deciency range

Up to 70% of older adults (65 years) living in long-term care
(LTC) homes are at risk for undernutrition (Wouters-Wesseling
et al. 2002; Isenring et al. 2012), which can lead to mortality and
morbidity (Pirlich and Lochs 2001). Micronutrient malnutrition
exists and is poorly studied in LTC older adults (Lam et al. 2015a,
2015b). Vitamin B12 (B12) is a nutrient of special concern in this
population because of age-related decreased absorptive ability
(Russell 2000; Morley and Thomas 2007) and polypharmacy
(Bronskill et al. 2012); absorption of this nutrient is commonly
affected by drug interactions (Raats et al. 2008). B12 deciency
leads to hematologic and neurologic abnormalities and is treat-
able (Baker et al. 1980; Baik and Russell 1999; Andrs et al. 2004).
Screening for B12 status at admission to LTC may be a worth-
while process. While little work has been done in LTC, community-
from 3%43% (Lindenbaum et al. 1994; Andrs et al. 2004; Pfeiffer
et al. 2005). Physically and cognitively dependent older adults
(Matteini et al. 2008) may be at increased risk. However, decision
for widespread screening relies on multiple factors, including im-
pact of diagnosis on clinical outcomes, required follow-up time,
screening and treatment effectiveness for improved health out-
comes, and cost of screening (Sackett et al. 1991). This knowledge
for B12 is currently lacking. Only 4 studies of the LTC population
in the past decade have reported B12 deciency prevalence from
8%34% (Paulionis et al. 2005; Lin et al. 2009; Gharaibeh et al. 2010;
Mirkazemi et al. 2012), none of which considered prevalence of
deciency at admission or incidence after admission to LTC. Fur-
thermore, generalizability of these studies is limited because of a
small sample size (Lin et al. 2009) or unclear group allocation and

Received 20 October 2015. Accepted 30 November 2015.

K.J. Psterer, M.T. Sharratt, G.G. Heckman, and H.H. Keller. University of Waterloo, 200 University Avenue West, Waterloo, ON N2L 3G1, Canada;
Schlegel-University of Waterloo Research Institute for Aging, 250 Laurelwood Drive, Waterloo, ON N2J 0E2, Canada.
Corresponding author: Heather H. Keller (email: hkeller@uwaterloo.ca).

Appl. Physiol. Nutr. Metab. 41: 219222 (2016) dx.doi.org/10.1139/apnm-2015-0565 Published at www.nrcresearchpress.com/apnm on 19 January 2016.
 220
extensive exclusion criteria resulting in a potentially biased sam-
ple (Gharaibeh et al. 2010). Work aimed at addressing prevalence
of B12 deciency and change of B12 status in LTC is needed to
inform future recommendations.
This concept of at admission to LTC is particularly noteworthy in
this population as persons receiving transitional care are generally
more vulnerable because of the stress and anxiety of relocation
(Wilson 1997); the potential for breakdown in communication on
medication and other treatments that are not incorporated into
the residents care plan post-admission (Coleman 2003); and
change in primary physician care for the resident. As a result, B12
treatment started in the community (especially intramuscular
Appl. Physiol. Nutr. Metab. Downloaded from www.nrcresearchpress.com by 111.95.132.244 on 11/29/16
modality, which is normally provided on a monthly basis, typi-
cally in a doctors ofce), may be overlooked and lost as a compo-
nent of the residents care plan. While understanding prevalence
at admission to LTC is a rst step for determining if standardized
screening and treatment protocols are required, understanding
incidence provides insight into how B12 status changes with age,
other factors, and over time while living in residence.
The purpose of this study was to determine the prevalence of
B12 deciency at admission to LTC. Secondary research aims were
to explore how admission B12 status and B12 levels are associated
with covariates of interest (e.g., supplementation use prior to ad-
mission), change in B12 status at 1 year post-admission, and
whether this change in status is associated with selected covari-
ates.
Materials and methods
This was a multi-site retrospective prevalence study conducted
For personal use only.
in 8 Ontario LTC homes, within 1 organization (Schlegel Villages),
which had a policy for admission and annual B12 testing for all
residents. Based on a listing of all current residents over the age of
65 years (N = 1061), a minimum sample size of 319 was required
to detect a 5% prevalence of B12 deciency at admission with
95% condence (Naing et al. 2006). Random proportionate sam-
pling was used to identify the preliminary sample. To be included,
the randomly chosen resident had to have available admission B12
blood work on their physical chart. Randomly selected residents
with unavailable admission blood work were replaced with the
next randomly selected, eligible (>65 years) resident. Nine hun-
dred and forty-six resident charts were reviewed to attain the nal
412 residents with accessible admission blood work. Missing
blood work was a result of culling of the physical chart or re-ling
of this form by site staff.
A data extraction form was created, reviewed by the research
team, and tested for feasibility in 30 charts. The rst author con-
ducted all chart reviews. The following data were extracted: de-
mographics (e.g., sex, age, length of stay); admission serum B12
levels; number of medications; number of diagnoses, and speci-
cally noting the presence of cardiovascular disease, dementia,
Alzheimers-type dementia, hypothyroidism, gastrointestinal condi-
tions, and mood conditions. The following additional variables
were included from the Minimum Data Set: cognitive perfor-
mance scale score, activities of daily living score, weight and
height to calculate body mass index (BMI), nutritional problems,
and weight change. Three biologically implausible BMI values
were removed in accordance with prior work (Keller and Hirdes
2000), assuming invalid data entry. Where available, rst annual
lab results were reviewed for B12 level at 1 year post-admission.
Because of differences in the cut-points used to dene B12 de-
ciency at different homes, this study dened B12 status as de-
ciency, subclinical, and normal status based on the authors
previous work: <156 pmol/L, 156300 pmol/L, and >300 pmol/L,1
1K.J. Psterer, M.T. Sharratt, G.G. Heckman, and H.H. Keller. Variability in Ontario long-term care practices for screening and treatment of vitamin B12
deciency. Unpublished results.
Appl. Physiol. Nutr. Metab. Vol. 41, 2016
respectively. Excepting admission serum B12 level, missing values
were permissible; thus, proportions of missing data varied across
covariates.
Data were analyzed using IBM SPSS Statistics for Windows
(version 23.0; IBM Corp., Armonk, N.Y., USA) and cleaned using
frequencies, descriptive analyses, and graphing. ANOVA were con-
ducted for B12 values and categorical variables. Where appropriate,
the Tukey B test was used to establish between group differences
(Norman and Streiner 2008). 2 tests were used to determine associ-
ations between categorical variables. Paired t tests were conducted
for all admission and rst annual bloodwork comparisons. The sig-
nicance level used was p 0.01 to account for multiple tests. A
2-proportion z test was used to establish whether the proportionate
samples were signicantly different than the planned sample pro-
portions using a signicance level of p < 0.05 (Berman 2015). This
study was reviewed and approved by the University of Waterloos
Ofce of Research Ethics.
Results
The proportion of charts included from each village did not
differ signicantly from the proportion of residents (p > 0.05).
However, the number of alternatives needed to reach sufcient
inclusion from each village ranged between 4 to 99 charts with a
mean and median of 67 and 72, respectively.
Of the 412 reviewed charts, 286 (69%) of residents were female.
The mean age at admission was 83 7 years (range: 65101 years).
The mean, standard deviation, and mode for length of stay from
admission to date of data collection were 22 20 months and
9 months respectively. The most recent admission and longest
length of stay between admission and data collection was
1 month and 11.2 years, respectively. The mean number of admit-
ting diagnoses and medications was 6.05 (SD 2.73, range: 118) and
10 (SD 4.5, range: 028), respectively. After the removal of 3 incon-
ceivable values, the average BMI in this sample was 28.18 (SD 6.58,
range: 13.2260.59). When BMI was grouped categorically, 6.7% of
residents had a low BMI (<20), 58.1% had a normal BMI (2030), and
35.2% had a high BMI (>30).
At admission to LTC, overall prevalence of B12 deciency
(<156 pmol/L) was 13.8% (57/412), subclinical deciency (156
300 pmol/L) was 38.3% (158/412), and 47.6% (197/412) of residents
had a normal B12 status (>300 pmol/L). The mean serum B12 level
at admission was 358.3 229.3 pmol/L. While prevalence of B12
deciency across sites ranged from 4.1% to 27.1%, these differences
were not signicant (p > 0.01); for prevalence estimates using
common lab-dened cut-points, see Table 1.
B12 supplementation use at admission to LTC was signicantly
associated with higher admission serum B12 (p < 0.001; 2 = 60.784
(df = 2)) (Table 1). A signicantly (p < 0.001) smaller proportion of
residents receiving B12 at admission had decient B12 status (2.3%
vs 18.4%) and a larger proportion had normal B12 status compared
with those not receiving B12 (84.1% vs 36.0%). The type of B12
supplementation method at admission approached signicance
with B12 status (p = 0.012; F = 11.620). Compared with those receiv-
ing intramuscular (IM) B12, those receiving oral B12 had a higher
proportion of normal B12 status (90% oral vs 57% IM), and lower
proportions of subclinical B12 status (8.5% oral vs 35.7% IM) and
decient B12 status (1.4% oral vs 7.1% IM). No other covariates were
associated with B12 status at admission.
Based on the subsample of charts with rst annual B12 recorded
(40%, 163/412), prevalence of B12 deciency at 1 year post-admission
was 7.0% (10/142); incidence of new B12 deciency cases in this
timeframe was 4.2% (6/142). Within this subsample, B12 status was
signicantly improved at rst annual bloodwork compared with
Published by NRC Research Press
 Psterer et al. 221

Table 1. Association between vitamin B12 (B12) status (decient, subclinical, normal) and covariates.
(a) Categorical covariates
Total sample, %
(n/sample size for Decienta, Subclinicala, Normala,
Characteristic characteristic) Category % (n) % (n) % (n)
B12 deciency across Villages 13.8 (57/412) Village1 25.8 (8) 25.8 (8) 48.4 (15)
Village2 4.1 (3) 44.6 (33) 51.4 (38)
Village3 12.9 (8) 38.7 (24) 48.4 (30)
Village4 7.5 (3) 42.5 (17) 50.0 (20)
Village5 27.1 (13) 31.3 (15) 41.7 (20)
Village6 7.4 (5) 36.8 (25) 55.9 (38)
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Village7 21.1 (12) 40.4 (23) 38.6 (22)

Village8 15.6 (5) 40.6 (13) 43.8 (14)
Sex (female) 69.4 (286/412) Female 12.2 (35) 38.8 (111) 49.0 (140)
Male 17.5 (22) 37.3 (47) 45.2 (57)
Marital status (married) 38.5 (129/335) Yes 14.7 (19) 40.3 (52) 45.0 (58)
No 16.0 (33) 35.9 (74) 48.1 (99)
Taking B12 supplements at admission** 26.0 (88/338) Yes 2.3 (2) 13.6 (12) 84.1 (74)
No 18.4 (46) 45.6 (114) 36.0 (90)
Form of B12 supplements at admission** 26.0 (88/338) Oralb 1.4 (1) 8.5 (6) 90.1 (64)
IMb 7.1 (1) 35.7 (5) 57.1 (8)
Oral+IM 0.0 (0) 33.3 (1) 66.7 (2)
None 18.4 (46) 45.6 (114) 36.0 (90)
Hypothyroidism 20.2 (74/366) Yes 12.2 (9) 31.1 (23) 56.8 (42)
No 14.0 (41) 40.4 (118) 45.5 (133)
CVD 38.0 (139/366) Yes 12.2 (17) 43.9 (61) 43.9 (61)
No 14.5 (33) 35.2 (80) 50.2 (114)
GI conditions 28.1 (103/366) Yes 13.6 (14) 38.8 (40) 47.6 (49)
No 13.7 (36) 38.4 (101) 47.9 (126)
Mood and mood-related disorders 57.7 (211/366) Yes 10.9 (23) 39.3 (83) 49.8 (105)
For personal use only.

No 17.4 (27) 37.4 (58) 45.2 (70)

Dementia 49.5 (181/366) Yes 14.9 (27) 35.4 (64) 49.7 (90)
No 12.4 (23) 41.6 (77) 45.9 (85)
Alzheimers type dementia 19.1 (70/366) Yes 11.4 (8) 40.0 (28) 48.6 (34)
No 14.2 (42) 38.2 (113) 47.6 (141)
Dementia or Alzheimers type dementia 66.1 (242/366) Yes 14.0 (34) 36.8 (89) 49.2 (119)
No 12.9 (16) 41.9 (52) 45.2 (56)
Categorical CPS [0,1,2 vs 3,4,5,6] 47.7 (156/327) Yes 16.0 (25) 39.1 (61) 44.9 (70)
No 10.5 (18) 35.1 (60) 54.4 (93)
MDS K3a: weight loss 5.8 (20/347) Yes 20.0 (4) 40.0 (8) 40.0 (8)
No 13.5 (40) 38.0 (113) 48.5 (144)
Unknown 13.3 (4) 36.7 (11) 50.0 (15)
MDS K3b: weight gain 6.6 (23/347) Yes 4.3 (1) 47.8 (11) 47.8 (11)
No 14.6 (43) 37.4 (110) 48.0 (141)
Unknown 13.3 (4) 36.7 (11) 50.0 (15)
MDS K4a: complains about taste of foods 4.6 (16/347) Yes 18.8 (3) 37.5 (6) 43.8 (7)
No 13.6 (45) 38.1 (126) 48.3 (160)
MDS K4b: regular or repetitive complaints 0.9 (3/347) Yes 33.3 (1) 66.7 (2) 0.0 (0)
of hunger No 13.7 (47) 37.8 (130) 48.5 (167)
MDS K4c: leave 25% or more of food 27.7 (96/347) Yes 14.6 (14) 39.6 (38) 45.8 (44)
uneaten at most meals No 13.5 (34) 37.5 (94) 49.0 (123)
MDS K4d: none of the above 68.9 (239/347) Yes 13.0 (31) 37.2 (89) 49.8 (119)
No 15.7 (17) 39.8 (43) 44.4 (48)
B12 status by lab cut-points (decient; <148; >220 11.4 (47) 20.6 (85) 68.0 (280)
normal) (412) <110; >150 2.7 (11) 9.7 (40) 87.6 (361)
<107; >133 1.7 (7) 5.3 (22) 93.0 (383)

(b) Continuous covariates

ADL (n) Mean SD Decient (n) Subclinical (n) Normal (n)
ADL-short (327) 6.64.2 6.63.3 (43) 6.34.1 (121) 6.94.8 (163)
ADL-long (327) 12.77.6 12.66.4 (43) 12.27.7 (121) 13.17.9 (163)
Note: ADL, activities of daily living; CPS, cognitive performance scale; CVD, cardiovascular disease; GI, gastrointestinal; IM, intramuscular; MDS, minimum data
set.**, Signicantly different (p < 0.01).
aB12 status levels (%, (n)) are classied as decient, 13.8% (57); subclinical, 38.3% (158); and normal, 47.8% (197).
bSignicance is nearly maintained, p < 0.012, upon comparison between these 2 treatment methods.

admission (p < 0.001; F = 25.6). Specically, the majority of resi- Discussion

dents initially with B12 deciency with year 1 data (n = 16) had The variation in prevalence (14% overall, range: 4.1%27%) across
improved B12 status after 1 year (75%); 25% improved to subclinical the 8 sites demonstrates the importance of assessing multiple
deciency, while 50% improved to normal. sites to determine an improved representative estimate of preva-

Published by NRC Research Press

 222
lence. This range of estimates is within that of both community
estimates (3%43%) (Lindenbaum et al. 1994; Andrs et al. 2004;
Pfeiffer et al. 2005) and the few studies conducted in LTC (8%34%)
(Paulionis et al. 2005; Lin et al. 2009; Gharaibeh et al. 2010;
Mirkazemi et al. 2012). It is important to note that point preva-
lence estimates of B12 deciency at admission (14%) and at 1 year
post-admission (7%) likely underestimate the true proportion of
residents impacted by metabolic changes associated with inade-
quate B12 status. A 2003 review summarized evidence to suggest
that a functional decit may be present at B12 levels under
332 pmol/L (400 ng/mL) and that approximately 15% of older adults
with apparent normal B12 levels have evidence of metabolic ab-
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normality (Grober et al. 2013).
A 4% incidence of B12 deciency indicates that B12 status is a
relevant form of malnutrition in this population. Yet, the present
study provides evidence that B12 status is amenable to treatment,
which is consistent with extant literature on intervention studies
(Baker et al. 1980; Wouters-Wesseling et al. 2002; Grieger et al.
2009; Rozgony et al. 2010; Favrat et al. 2011). Whether this remains
true for older adults after admission to LTC remains unknown and
further evidence for burden of illness and establishing causality of
improved B12 status on clinical outcomes is warranted. Lack of cova-
riates associated with prevalence suggests that targeted screening at
admission is not appropriate.
Inclusion of 8 sites resulted in a large sample with potentially
greater diversity than previously reported LTC research. Random
sampling was used with excellent representation of eligible resi-
dents (37%). This study reports on prevalence of B12 deciency at
admission to LTC (14%), at 1 year post-admission (7.0%) as well as
For personal use only.
incidence (4%) providing a point for comparison for future studies
designed to specically address incidence and associated covari-
ates. A limitation was the high proportion of missing data on the
rst annual follow-up. This subsample was likely biased. Yet, this
is the rst study to report on how B12 status changes over the rst
year of residence in LTC and as such adds new knowledge to the
eld. Future work to inform policy, intervention, and screening
protocols should use prospective methods focusing on delity to
treatment protocols, burden of illness, as well as to determine
incident B12 deciency in LTC and characteristics of residents that
result in these outcomes.
Conict of Interest
The authors declare that there are no conicts of interest.
Acknowledgements
The authors would like to acknowledge Dr. J. David Spence in
the early conceptualization of this work. This study was funded in
part by the Schlegel-University of Waterloo Research Institute for
Aging.
References
Andrs, E., Loukili, N.H., Noel, E., Kaltenbach, G., Abdelgheni, M.B., Perrin, A.E.,
et al. 2004. Vitamin B12 (cobalamin) deciency in elderly patients. Can. Med.
Assoc. J. 171(3): 251259. doi:10.1503/cmaj.1031155. PMID:15289425.
Baik, H.W., and Russell, R.M. 1999. Vitamin B12 deciency in the elderly. Annu.
Rev. Nutr. 19: 357377. doi:10.1146/annurev.nutr.19.1.357. PMID:10448529.
Baker, H., Frank, O., and Jaslow, S.P. 1980. Oral versus intramuscular vitamin
supplementation for hypovitaminosis in the elderly. J. Am. Geriat. Soc. 28(1):
4245. doi:10.1111/j.1532-5415.1980.tb00123.x. PMID:7350214.
Berman, H. 2015. Hypothesis test: Difference between proportions. Star Trek
Teach Yourself Statistics Retrieved 19/09/2015, 2015. from http://stattrek.com/
hypothesis-test/difference-in-proportions.aspx.
Bronskill, S.E., Gill, S.S., Paterson, J.M., Bell, C.M., Anderson, G.M., and
Rochon, P.A. 2012. Exploring variation in rates of polypharmacy across long
term care homes. J. Am. Med. Dir. Assoc. 13(3): 309.e315-321. doi:10.1016/j.
jamda.2011.07.001. PMID:21839687.
Appl. Physiol. Nutr. Metab. Vol. 41, 2016
Coleman, E.A. 2003. Falling through the cracks: challenges and opportunities
for improving transitional care for persons with continuous complex care
needs. J. Am. Geriatr. Soc. 51(4): 549555. doi:10.1046/j.1532-5415.2003.51185.x.
PMID:12657078.
Favrat, B., Vaucher, P., Herzig, L., Burnand, B., Ali, G., Boulat, O., et al. 2011. Oral
vitamin B12 for patients suspected of subtle cobalamin deciency: a multi-
centre pragmatic randomised controlled trial. BMC Fam. Pract. 12: 2. doi:10.
1186/1471-2296-12-2. PMID:21232119.
Gharaibeh, M.Y., Gahtan, R.A., Khabour, O.F., and Alomari, M.A. 2010. Hyperho-
mocysteinemia, low folate, and vitamin B12 deciency in elderly living at
home and care residences: a comparative study. Lab. Med. 41(7): 410414.
doi:10.1309/LM1P78OFXACYYHPQ.
Grieger, J.A., Nowson, C.A., Jarman, H.F., Malon, R., and Ackland, L.M. 2009.
Multivitamin supplementation improves nutritional status and bone quality
in aged care residents. Eur. J. Clin. Nutr. 63(4): 558565. doi:10.1038/sj.ejcn.
1602963. PMID:18043700.
Grober, U., Kisters, K., and Schmidt, J. 2013. Neuroenhancement with vitamin
B12-underestimated neurological signicance. Nutrients, 5(12): 50315045.
doi:10.3390/nu5125031. PMID:24352086.
Isenring, E.A., Banks, M., Ferguson, M., and Bauer, J.D. 2012. Beyond malnutri-
tion screening: appropriate methods to guide nutrition care for aged care
residents. J. Acad. Nutr. Diet. 112(3): 376381. doi:10.1016/j.jada.2011.09.038.
PMID:22717197.
Keller, H.H., and Hirdes, J.P. 2000. Using the minimum data set to determine the
prevalence of nutrition problems in an Ontario population of chronic care
patients. Can. J. Diet. Pract. Res. 61(4): 165171. PMID:11551365.
Lam, I.T., Keller, H.H., Duizer, L., and Stark, K. 2015a. Micronutrients on the
menu: enhancing the quality of food in long-term care for regular, nonthera-
peutic menus. Can. J. Diet. Practice Res. 76(2): 8692. doi:10.3148/cjdpr-2014-
036. PMID:26067418.
Lam, I.T.L., Keller, H.H., Duizer, L.M., Stark, K.D., and Duncan, A.M. 2015b. Noth-
ing ventured, nothing gained: acceptability testing of micronutrient forti-
cation in long-term care. J. Nursing Home Res. 1: 1827.
Lin, Y.T., Lin, M.H., Lai, H.Y., Chen, L.K., Hwang, S.J., and Lan, C.F. 2009. Regular
vitamin B12 supplementation among older Chinese men in a veterans care
home in Taiwan. Arch. Gerontol. Geriatr. 49(1): 186189. doi:10.1016/j.archger.
2008.07.007. PMID:18775574.
Lindenbaum, J., Rosenberg, I.H., Wilson, P.W., Stabler, S.P., and Allen, R.H. 1994.
Prevalence of cobalamin deciency in the Framingham elderly population.
Am. J. Clin. Nutr. 60(1): 211. PMID:8017332.
Matteini, A.M., Walston, J.D., Fallin, M.D., Bandeen-Roche, K., Kao, W.H.,
Semba, R.D., et al. 2008. Markers of B-vitamin deciency and frailty in older
women. J. Nutr. Health Aging, 12(5): 303308. PMID:18443711.
Mirkazemi, C., Peterson, G.M., Tenni, P.C., and Jackson, S.L. 2012. Vitamin B12
deciency in Australian residential aged care facilities. J. Nutr. Health Aging,
16(3): 277280. PMID:22456786.
Morley, J.E., and Thomas, D.R. 2007. Geriatric nutrition. CRC Press.
Naing, L., Than, W., and Rusli, B. 2006. Practical issues in calculating the sample
size for prevalence studies. Arch. Orofacial Sci. 1: 914.
Norman, G.R. and Streiner, D.L. 2008. Biostatistics: The Bare Essentials. Third Ed.
McGraw-Hill Europe.
Paulionis, L., Kane, S.L., and Meckling, K.A. 2005. Vitamin status and cognitive
function in a long-term care population. BMC Geriatr. 5: 16. doi:10.1186/1471-
2318-5-16. PMID:16351716.
Pfeiffer, C.M., Caudill, S.P., Gunter, E.W., Osterloh, J., and Sampson, E.J. 2005.
Biochemical indicators of B vitamin status in the US population after folic
acid fortication: results from the National Health and Nutrition Examina-
tion Survey 1999-2000. Am. J. Clin. Nutr. 82(2): 442450. PMID:16087991.
Pirlich, M., and Lochs, H. 2001. Nutrition in the elderly. Best practice & research.
Clinical Gastroenterology, 15(6): 869884. doi:10.1053/bega.2001.0246. PMID:
11866482.
Raats, M., De Groot, L., and van Asselt, D. 2008. Food for the ageing population.
Elsevier.
Rozgony, N.R., Fang, C., Kuczmarski, M.F., and Bob, H. 2010. Vitamin B12 de-
ciency is linked with long-term use of proton pump inhibitors in institution-
alized older adults: could a cyanocobalamin nasal spray be benecial? J. Nutr.
Elder. 29(1): 8799. doi:10.1080/01639360903574734. PMID:20391044.
Russell, R.M. 2000. The aging process as a modier of metabolism. AJCN
72(2 Suppl): 529s532s.
Sackett, D.L., Hynes, R.B., Guyatt, G.H., and Tugwell, P. 1991. Clinical epidemiol-
ogy a basic science for clinical medicine. Boston, Little, Brown and Company.
Wilson, S.A. 1997. The transition to nursing home life: a comparison of planned
and unplanned admissions. J. Adv. Nurs. 26(5): 864871. doi:10.1046/j.1365-
2648.1997.00636.x. PMID:9372389.
Wouters-Wesseling, W., Wouters, A.E., Kleijer, C.N., Bindels, J.G., de Groot, C.P.,
and van Staveren, W.A. 2002. Study of the effect of a liquid nutrition supple-
ment on the nutritional status of psycho-geriatric nursing home patients.
Eur. J. Clin. Nutr. 56(3): 245251. doi:10.1038/sj.ejcn.1601319. PMID:11960300.
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