What is B12 Deficiency?
Vitamin B12 (cobalamin) deficiency is common in the population over 80, affecting approximately 10% of this age group. It can be a cause of unsteady gait (ataxia), sometimes accompanied by anemia (macrocytic), and loss of position sense. When associated with spinal cord disease, it is sometimes termed “subacute combined degeneration”. The ataxia is called a “sensory ataxia”, because it appears to be related to loss of position sensation from the feet. Other diseases that can produce similar symptoms include:
- Subacute combined degeneration (B12 deficiency)
- Tabes Dorsalis (syphilis)
- Fredriech’ ataxia
- Peripheral neuropathy
- Thoracic cord lesions
The term subacute combined degeneration was coined by Russell, Batten and Collier in 1900 to describe pathological changes in the spinal cord. While changes in the posterior columns are emphasized in clinical accounts, pathologically the lateral and anterior columns are also often affected. The peripheral nerves are generally unaffected.
In addition to ataxia and anemia, patients with B12 deficiency may have fatigue, weight loss, numbness and weakness in the extremities or mental status changes including dementia and depression.
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Causes of B12 deficiency
The liver stores enough B12 to last several years, and conditions that lead to B12 deficiency must be ongoing for at least 2 years before symptoms appear. B12 is bound to animal protein when it is ingested, from which it is released by gastric acid. Afterwards, B12 binds to intrinsic factor, a protein secreted by the stomach that allows B12 to be absorbed in the ileum.
Bowel conditions contributing to B12 deficiency include pancreatic deficiency states, ileal disease (e.g. Crohn’s disease), and surgery such as gastrectomy, or removal of the small bowel. Pernicious anemia accounts for 15-70% of B12 deficiency. In this situation autoimmune antibodies are produced against intrinsic factor, preventing its production in the stomach.
Food-cobalamin malabsorption is the inability of stomach secretions to release B12 from the animal protein it is bound to upon ingestion. Recent research has shown that in older adults, food-cobalamin malabsorption is the most common cause of B12 deficiency.
Drugs that reduce stomach acidity and gastritis (inflammation of the stomach) can also lead to B12 deficiency by decreasing absorption. B12 is available only from animal sources and thus strict vegetarians or people with poor diets are at risk of deficiency.
Infants who are breastfed by vitamin B12 deficient mothers can develop B12 deficiency themselves. Lov levels of B12 in infants can produce severe complications including developmental abnormalities, growth retardation and anemia.