Evidence for Multivitamin Prescription in Elderly Care
A daily multivitamin may be appropriate for older adults, especially those with reduced energy intake, but routine prescription for all elderly patients is not supported by evidence for preventing cardiovascular disease, cancer, or mortality. 1, 2
General Multivitamin Supplementation in Elderly
The evidence for routine multivitamin supplementation in healthy older adults is limited:
The U.S. Preventive Services Task Force concludes there is insufficient evidence to assess the balance of benefits and harms of multivitamins for preventing cardiovascular disease or cancer (I statement - meaning the evidence is inadequate to make a recommendation either for or against use). 1, 2
Multiple randomized controlled trials found no effect on all-cause mortality with multivitamin supplementation. 2
Studies showed no effect on cardiovascular disease incidence or events. 2
Two trials showed a modest decrease in cancer incidence in men only, but not in women, limiting generalizability. 2
When Multivitamins ARE Appropriate in Elderly
Despite the lack of evidence for disease prevention, specific elderly populations may benefit:
Older adults with reduced energy intake should be considered for daily multivitamin supplementation. 1
Elderly individuals are at significant risk of two or more micronutrient deficiencies, and there is a clear association between multiple micronutrient deficiencies and frailty. 1
Older adults are more likely to have deficiencies in thiamine, vitamin B12, folate, vitamin C, and vitamin D, as well as calcium, zinc, and magnesium. 1
Multivitamin/mineral supplements substantially increase vitamin and mineral intakes and blood concentrations, thus improving overall micronutrient status in older adults. 3
Specific Nutrient Recommendations for Elderly (NOT General Multivitamins)
Rather than routine multivitamins, targeted supplementation based on specific deficiencies is more appropriate:
Calcium and Vitamin D
All older adults should be advised to have a calcium intake of at least 1,200 mg/day from diet or supplements. 1, 2
Vitamin D supplementation is recommended at 15 μg (600 IU) daily for older adults. 2
There is strong and compelling support for the health benefits of vitamin D and calcium supplements when intake/status is not optimal. 4
Vitamin B12
Vitamin B12 supplementation is recommended at 4-6 μg/day for older adults due to high prevalence of deficiency. 2
Older adults are particularly vulnerable to vitamin B12 deficiency. 3
Vitamins to AVOID in Elderly
β-carotene and vitamin E should NOT be used for disease prevention in healthy adults (Grade D recommendation). 1, 2
β-carotene increases lung cancer risk in smokers and those with asbestos exposure. 2
Vitamin E provides no net benefit for cardiovascular disease or cancer prevention. 2
Special Considerations for Elderly with Dementia
Persons with dementia should NOT be offered micronutrient supplements unless there is an indication of deficiency (strong consensus, 100% agreement). 1
No controlled intervention study has demonstrated cognitive benefit from supplementing single nutrients (folic acid, vitamins B, B12, D, E, or selenium) or combinations in persons with dementia. 1
In the case of specific nutrient deficiencies, the respective nutrient should be supplemented using normal doses (not mega-doses). 1
Clinical Approach for Elderly Patients
Screen for specific deficiency risk factors including: 2
- Age >65 years
- Restrictive diets
- Malabsorption conditions
- Medications like proton pump inhibitors, metformin, or diuretics
Assess for malnutrition indicators: 1
- Involuntary weight loss of >10 pounds or 10% of body weight in less than 6 months should be evaluated
Prioritize dietary intake over supplements: 1
- Provide adequate amounts of all essential nutrients primarily through a balanced dietary pattern
- Supplements do not replace a healthy diet rich in fruits, vegetables, and whole grains 2
If prescribing multivitamins: 2, 5
- Recommend adherence to Dietary Reference Intakes
- Avoid doses greatly exceeding Recommended Dietary Allowance
- Consider fat-soluble vitamins (A, D, E, K) accumulate over time, and lifetime effects of high doses must be considered 5
Important Safety Caveats
High-dose vitamin A can reduce bone mineral density at moderate doses and is hepatotoxic and teratogenic at high doses. 5
Exceeding upper intake levels of vitamins A and D can have known harms above tolerable upper limits. 5
If a patient chooses to take multivitamins despite lack of evidence, there is little reason to discourage use, except for β-carotene in smokers. 2