Ageing Research Reviews 22 (2015) 9–19

Contents lists available at ScienceDirect

Ageing Research Reviews

journal homepage: www.elsevier.com/locate/arr

Review

Folates and aging: Role in mild cognitive impairment, dementia

and depression
João Ricardo Araújo a,∗ , Fátima Martel b , Nuno Borges c , João Manuel Araújo d ,
Elisa Keating a,e
a
Institut Pasteur, INSERM U1202, Unité de Pathogénie Microbienne Moléculaire, 75015 Paris, France
b
Department of Biochemistry, Faculty of Medicine, University of Porto, 4200-319 Porto, Portugal
c
Faculty of Nutrition and Food Sciences, University of Porto, 4200-465 Porto, Portugal
d
Health Service of Autonomous Region of Madeira (SESARAM), Madeira, Portugal
e
Center for Biotechnology and Fine Chemistry, School of Biotechnology, Portuguese Catholic University, 4200-702 Porto, Portugal

a r t i c l e i n f o a b s t r a c t

Article history: In almost all tissues, including the brain, folates are required for one-carbon transfer reactions, which are
Received 24 October 2014 essential for the synthesis of DNA and RNA nucleotides, the metabolism of amino acids and the occur-
Received in revised form 18 April 2015 rence of methylation reactions. The aim of this paper is to review the impact of folate status on the risk
Accepted 29 April 2015
of development of neuropsychiatric disorders in older individuals. The prevalence of folate deficiency
Available online 2 May 2015
is high among individuals aged ≥65 years mainly due to reduced dietary intake and intestinal malab-
sorption. Population-based studies have demonstrated that a low folate status is associated with mild
Keywords:
cognitive impairment, dementia (particularly Alzheimer’s disease) and depression in healthy and neu-
Aging
Folate
ropsychiatric diseased older individuals. The proposed mechanisms underlying that association include
Dementia hyperhomocysteinemia, lower methylation reactions and tetrahydrobiopterin levels, and excessive mis-
Depression incorporation of uracil into DNA. However, currently, there is no consistent evidence demonstrating that
Homocysteine folic acid supplementation improves cognitive function or slows cognitive decline in healthy or cogni-
B-vitamin supplements tively impaired older individuals. In conclusion, folate deficiency seems to be an important contributor
for the onset and progression of neuropsychiatric diseases in the geriatric population but additional stud-
ies are needed in order to increase the knowledge of this promising, but still largely unexplored, area of
research.
© 2015 Elsevier B.V. All rights reserved.

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
2. Causes of folate deficiency in the older population . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
3. Neuropsychiatric alterations associated with folate deficiency in the older population . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
3.1. Mild cognitive impairment (MCI) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
3.2. Dementia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
3.3. Depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
3.4. Mechanisms underlying neuropsychiatric alterations associated with folate deficiency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
3.4.1. Hyperhomocysteinemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
3.4.2. Lower occurrence of methylation reactions and tetrahydrobiopterin availability. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
3.4.3. Increased incorporation of uracil into DNA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
3.4.4. Shorter telomere length . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
4. Folate supplementation in the older population . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
5. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Conflicts of interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

∗ Corresponding author. Tel.: +33 1 45 68 83 84.

E-mail address: joao.diniz-de-araujo@pasteur.fr (J.R. Araújo).

http://dx.doi.org/10.1016/j.arr.2015.04.005
1568-1637/© 2015 Elsevier B.V. All rights reserved.
10 J.R. Araújo et al. / Ageing Research Reviews 22 (2015) 9–19
1. Introduction
“Folate” is the generic term used to designate the members of
the B9 family of essential vitamins (Mann and Truswell, 2002).
They occur in the oxidized and synthetic form (folic acid or pteroyl
monoglutamate), normally found in dietary supplements, and in
the reduced form (e.g., 5-methyltetrahydrofolate [5-MTHF]), the
most abundant form in foods and human body. Structurally, folates
consist of a pterin moiety linked to ␳-aminobenzoic acid which
is in turn linked to glutamic acid. Compared with the oxidized
form, reduced folates also have additional glutamate residues and
also one-carbon units (e.g., methyl, methylene, methenyl, formyl or
formimino) which are crucial for their metabolic functions (Mann
and Truswell, 2002). In fact, in most tissues, including the central
nervous system (CNS), folates are essential for one-carbon units
transfer reactions (Fig. 1) which are important for: (1) the syn-
thesis of purine and thymidine precursors of nucleic acids (e.g.,
deoxythymidine monophosphate [dTMP], which is formed from
deoxyuridine monophosphate [dUMP]) (Mann and Truswell, 2002;
Selhub et al., 2010); (2) the metabolism of some amino acids,
e.g., interconversion of serine to glycine and conversion of homo-
cysteine to methionine or cysteine (Mann and Truswell, 2002;
Reynolds, 2006); and (3) the synthesis of s-adenosylmethionine
(SAM). SAM is the major methyl group donor for the majority
of genomic and non-genomic methylation reactions (Reynolds,
2006). In the brain, these reactions are crucial for the synthesis
of neurotransmitters (serotonin, dopamine, norepinephrine and
acetylcholine), hormones (melatonin), membrane phospholipids
and myelin, and also for the epigenetic control of gene expres-
sion (Hughes et al., 2013; Reynolds, 2006). Besides folate, vitamin
B12 also plays an important role in the occurrence of methyla-
tion reactions since methionine synthase, the enzyme catalyzing
the transfer of a methyl group from 5-MTHF to homocysteine
thereby generating methionine (the precursor of SAM), requires
vitamin B12 as a cofactor (Reynolds, 2006) (Fig. 1). Accordingly,
a folate (and also vitamin B12 )-deficient state leads to a reduc-
tion in methionine synthase activity, and hence to a decrease in
the levels of SAM and an increase in the levels of homocysteine –
hyperhomocysteinemia – and s-adenosylhomocysteine (a potent
inhibitor of SAM-dependent methylation reactions) (Hughes et al.,
2013) (Fig. 1). Moreover, deficient levels of folate also impair
nucleotide synthesis, particularly thymidine, leading to an increase
in dUMP:dTMP ratio and consequently to misincorporation of uracil
into DNA (Reynolds, 2014). Consequently, rapidly dividing cells of
the bone marrow, such as leucocytes and platelets, are particularly
vulnerable to folate deficiency due to impaired DNA synthesis. In
a folate deficient state they cannot produce DNA quickly enough
to divide and their nuclei become enlarged, leading to the appear-
ance of megaloblastic anemia (Hughes et al., 2013; Selhub et al.,
2009). In the CNS, folate deficiency will also impair DNA synthesis,
transcription, methylation, and gene expression, thereby affecting
brain growth, differentiation, development and repair (Reynolds,
2006).
Aging is characterized by a progressive loss of physio-
logical integrity, leading to impaired function and increased
vulnerability to develop major human pathologies, including
neuropsychiatric and cardiovascular diseases (Lopez-Otin et al.,
2013; Navaratnarajah and Jackson, 2013). Neurocognitive changes,
particularly memory decline, are one of the most common physi-
ological changes associated with aging (Budson and Price, 2005).
Additionally, a greater risk of developing a deficient nutritional
status is also another important aging-associated change (Malara
et al., 2014). In fact, although a severe folate deficiency is rare in
humans, a milder and subclinical deficiency can be relatively com-
mon, particularly in older adults (Selhub et al., 2000). In a large
study based on three populations representative of UK adults with
65 years old or more, the prevalence of folate deficiency (blood
levels of folate <7 nM and homocysteine >20 ␮M) was found to
increase with age and to affect 5–20% of older adults (Clarke et al.,
2004). Interestingly, almost 40% of older adults with vitamin B12
deficiency (blood levels of vitamin B12 < 200 pM and homocysteine
>20 ␮M) also showed folate deficiency (Clarke et al., 2004). In a
similar way, concentrations of 5-MTHF in the cerebrospinal fluid
(CSF), which strongly correlates with 5-MTHF levels in the circula-
tion, were found to decrease with age, particularly in older adults
with more than 70 years-old (5-MTHF is the most abundant form
of folates found in blood and CSF) (Bottiglieri et al., 2000b). This
apparently elevated prevalence of folate deficiency in the geriatric
population may compromise cognitive functions and increase the
risk of developing neuropsychiatric diseases (Selhub et al., 2009,
2010). Taking this into consideration, we aimed to review and dis-
cuss the impact of folate status, particularly deficiency, on the risk
of developing neuropsychiatric disorders such as mild cognitive
impairment, depression and dementia in older people.
2. Causes of folate deficiency in the older population
Table 1 summarizes the causes of folate deficiency in older
individuals. Hand by hand with reduced dietary intake, intestinal
malabsorption is one of the main causes of folate deficiency in older
individuals (de Benoist, 2008), and is a consequence of atrophic gas-
tritis, a chronic inflammation of the stomach that affects 20–50%
of individuals aged >60 years which leads to atrophy of the gas-
tric mucosa and consequently to a reduced secretion of gastric
HCl (hypochlorhydria) (Allen, 2009; Selhub et al., 2000). Atrophic
gastritis-induced hypochlorhydria raises the pH in the proximal
small intestine (duodenum and proximal jejunum) from 6.6 to 7.1
(Selhub et al., 2000). Despite being modest, this pH elevation sig-
nificantly reduces folate intestinal absorption (Selhub et al., 2000)
since the main transporter responsible for folate transport across
the enterocytes – the proton-coupled folate transporter – is a high-
affinity carrier with an optimal activity at acidic pH (Zhao et al.,
2009). On the other hand, other diseases or conditions that affect
either the structure or function of the stomach or small intestine
and are prevalent in the older population – such as inflammatory
bowel disease, diverticulosis, coeliac disease and gastric or intesti-
nal resection – may also reduce folate intestinal absorption (Hughes
et al., 2013; Robins Wahlin et al., 2001).
As referred above, reduced dietary intake of folate is also an
important cause of folate deficiency in older people. This occurs as a
consequence of a decline in sensory function and appetite (Hughes
et al., 2013; Mann and Truswell, 2002; Reynolds, 2006), dyspha-
gia and mastication impairments (Agarwal et al., 2013), which are
normally associated with aging. On the other hand, the use of mul-
tiple therapeutic drugs is common in older adults and at least 50%
of individuals with more than 65 years-old take one or more med-
ications (Maher et al., 2014). For example, drugs used in cancer
treatment such as the antifolates methotrexate, aminopterin or
pemetrexed interfere with folate metabolism, e.g., by inhibiting
enzymes involved in one-carbon metabolism, thereby increasing
the risk of folate deficiency (Lambie and Johnson, 1985). In addition,
long-term use of high doses of suppressors of gastric acid secretion,
such as proton pump inhibitors and histamine H2 -receptor antago-
nists, may induce folate intestinal malabsorption in a similar way as
described for atrophic gastritis (Russell et al., 1988; Urquhart et al.,
2010). Also, old generation antiepileptic drugs, such as phenytoin
and barbiturates have been reported to decrease serum, red cell or
CSF folate levels, but the mechanisms involved in that effect are still
very poorly understood (Reynolds, 2006). Besides the ingestion of
therapeutic drugs, chronic alcohol consumption is also prevalent
in older individuals (Du et al., 2008; Ilomaki et al., 2013). In those,
 J.R. Araújo et al. / Ageing Research Reviews 22 (2015) 9–19 11

Fig. 1. Role of folate in the metabolism of one-carbon units. 5,10-MTHF: N5 ,N10 -methylenetetrahydrofolate; 5-MTHF: N5 -methyltetrahydrofolate; 10-FTHF: N10 -
formyltetrahydrofolate; BHMT: betaine–homocysteine methyltransferase; DHF: dihydrofolate; DMG: dimethylglycine; dTMP: deoxythymidine monophosphate; dUMP:
deoxyuridine monophosphate; MS: methionine synthase; MTHFR: methylenetetrahydrofolate reductase; SAH: S-adenosylhomocysteine; SAM: s-adenosylmethionine;
SHMT: serine hydroxymethyltransferase; THF: tetrahydrofolate; TS: thymidilate synthase and vit B12 : vitamin B12 .

serum folate concentrations have been shown to be decreased in
comparison with non drinkers (Cylwik et al., 2013) probably due to
the ability of ethanol to downregulate the activity (Halsted et al.,
1971) and expression (Hamid et al., 2007) of folate intestinal trans-
porters.
In summary, a decrease in folate intestinal absorption due to
atrophic gastritis, reduced dietary intake, consumption of thera-
peutic drugs (particularly those that cause hypochlorhydria) and
elevated alcohol ingestion increase the susceptibility of older
individuals to develop folate deficiency compared to younger indi-
viduals.
3. Neuropsychiatric alterations associated with folate
deficiency in the older population
Over the past 35 years the association between neuropsychiatric
dysfunction and B vitamin status has been extensively investigated
in the geriatric population (reviewed by (Reynolds, 2006, 2014;
Young, 2007)). The first quality evidence supporting an association
between folate (and also vitamin B12 ) deficiency and neuropsychi-
atric dysfunction derived from human clinical studies performed
in the 1980s (reviewed by (Reynolds, 2006, 2014)). Namely, in a
small epidemiological study of patients with megaloblastic ane-
mia due to severe folate deficiency, Shorvon et al. (1980) observed
that about a quarter had cognitive impairment and a half had an
affective disorder. In patients with megaloblastic anemia due to
severe vitamin B12 deficiency, the same authors observed that a
quarter had either cognitive impairment or an affective disorder
(Shorvon et al., 1980). Later on, the evidence that individuals with
mutations in genes that encode enzymes involved in one-carbon
metabolism, such as methylenetetrahydrofolate reductase (Fig. 1),
developed severe cognitive impairment also supported the asso-
ciation between folate deficiency and neuropsychiatric alterations
(Selhub et al., 2000).
In the following sections, we will present and discuss the most
relevant data linking folate deficiency and the risk of developing
mild cognitive impairment (MCI), dementia and depression in older
people.
3.1. Mild cognitive impairment (MCI)
MCI is defined as an impairment in cognitive function greater
than the expected for an individual’s age and education level
although it does not interfere notably with daily life activities
(Chertkow et al., 2008). In 1983, Goodwin et al. clearly demon-
strated for the first time that a folate deficient status was associated
with MCI in healthy older people (Goodwin et al., 1983). These
authors found that healthy individuals aged ≥60 years with low
blood concentrations or intake of folate (approximately 5–10% of
the study population) scored poorly on both memory and abstract
thinking tests. This association was still observed after stratifi-
cation for possible confounding variables such as age, education,
gender, and undiagnosed cognitive decline leading to malnutri-
tion (Goodwin et al., 1983), strengthening the consistency of this
association. After this study, many others have generally reiter-
ated these epidemiologic findings (reviewed by (Michelakos et al.,
2013; Reynolds, 2002; Robins Wahlin et al., 2001)). A meta-analysis
summarizing evidence from thirteen European and North Ameri-
can studies showed that low serum levels of folate were associated
with general and specific impairments in cognitive functions such
as attention, episodic and visuospatial memory or abstract reason-

Table 1
Causes of folate deficiency in older individuals.

• Intestinal malabsorption
-Atrophic gastritis
-Intestinal diseases (Crohn’s disease, celiac disease)
-Gastric and intestinal resection
• Reduced dietary intake (due to decreased sensory function and appetite, dysphagia)
• Therapeutic drugs (antifolates, inhibitors of gastric acid secretion, antiepileptics)
• Alcoholism
• Genetic polymorphisms in enzymes involved in one-carbon metabolism (e.g., methylenetetrahydrofolate reductase (MTHFR))
12 J.R. Araújo et al. / Ageing Research Reviews 22 (2015) 9–19
ing in individuals aged ≥60 years (OR: 1.66, 95% CI: 1.40–1.96)
(Michelakos et al., 2013). Since most of these studies used a cross-
sectional design, i.e., data was collected from a population at one
specific point in time, it is difficult to understand whether folate
deficient state is the cause or rather the consequence of cognitive
decline during aging (Michelakos et al., 2013).
Taken together, this data suggests that in older individuals, low
levels of folate may induce cognitive decline in terms of inability to
perform tasks that involve complex processing of information and
are unfamiliar, speeded and attention-demanding.
3.2. Dementia
Dementia is a severe impairment of cognitive function charac-
terized by an insidious and progressive loss of memory and higher
intellectual functions which ultimately leads to the inability of
the affected person to live independently and perform its daily
life activities (Clarke, 2006). This disease is a major public health
concern in aging populations, affecting approximately 6% of indi-
viduals over the age of 60 years in developed countries (Ferri et al.,
2005; OECD, 2012). In general terms, there are two major sub-
types of dementia: Alzheimer’s disease (AD), the most common
one, and vascular dementia (also known as post stroke demen-
tia) (Hughes et al., 2013). Systematic reviews of epidemiological
studies analyzing the association between folate deficiency and
the development of dementia in middle-aged and older individ-
uals are scarce and very difficult to conduct due to the marked
heterogeneity in studies design (e.g., low B-vitamin status defini-
tions and follow-up periods), methodologies used (e.g., cognitive
function tests and adjustment for confounding factors) and char-
acteristics of study populations (e.g., nutritional habits) (Dangour
et al., 2010; Hinterberger and Fischer, 2013; Morris, 2012; Young,
2007). So, herein we review and discuss the most important and
methodologically relevant original works about this topic. Ravaglia
et al. (2005) showed that, after a 4-year follow-up period, approx-
imately 25% of healthy older individuals with low serum folate
concentrations (≤11.8 nM) and hyperhomocysteinemia (plasma
homocysteine >15 ␮M) had a higher risk of developing demen-
tia after adjustment for several potential confounders (Ravaglia
et al., 2005). In the Vienna Transdanube Aging (VITA) study, that
prospectively followed 479 non-demented 75-years-old individ-
uals during 2.5 years, it was found that in those who developed
AD (which were approximately 23%), lower mean serum levels of
folate (<8.7 nM) was an independent risk factor for AD (OR = 0.92;
95% CI = 0.87–0.98) (Fischer et al., 2008). Moreover, in a 3-year lon-
gitudinal study of 370 healthy subjects aged ≥75 years, those with
low serum levels of folate (<10 nM) or vitamin B12 (<150 pM) had
a double risk of developing AD compared with those having nor-
mal levels (RR: 2.1 (95% CI: 1.2–3.5)). Curiously, this association
was even stronger in subjects with both low levels of folate and
good baseline cognition (relative risk of 3.1 (95% CI: 1.1–8.4)) being
independent of age, sex and educational level (Wang et al., 2001). In
contrast with these studies, other authors found that although ele-
vated levels of homocysteine (plasma concentrations ≥13 ␮M) was
a risk factor for the onset of dementia in older individuals – being
present in 12–17% of them – circulating levels of folate were not
associated with the development of either AD or vascular dementia
(Haan et al., 2007; Hooshmand et al., 2010). The authors suggested
that the adequate folate status of the study populations could have
precluded such association.
In a case–control study of 164 demented patients, Clarke et al.
(1998) observed that those clinically and histologically diagnosed
with AD had lower serum levels of folate (≤17 nM; approximately
70% of patients), vitamin B12 (≤199 pM) and higher serum lev-
els of homocysteine (>14 ␮M; approximately 50% of patients)
compared with age-matched control patients. These results were
obtained after adjustment for age, sex, social class, smoking, and
apolipoprotein E genotype, a known risk factor for AD (Clarke
et al., 1998). Similar results were also obtained in a case–control
study conducted by Refsum and Smith (2003) in 65 older patients
histopathologically diagnosed with AD (Refsum and Smith, 2003).
In addition, in patients clinically diagnosed with AD, folate and
homocysteine levels were not affected by disease duration (more
than 4 years vs. less than 2 years) suggesting that hypofolatemia
and hyperhomocysteinemia could already exist before the onset
of the disease, being eventually a cause rather than a consequence
of AD (Clarke et al., 1998). In another study, thirty nuns who died
at the mean age of 91 years – half of them having a postmortem
histological diagnose of AD – were prospectively studied by Snow-
don et al. (Snowdon et al., 2000). Of the eighteen nutritional factors
examined, only serum folate concentrations negatively correlated
with the severity of neocortex atrophy – a brain area involved in
complex functions such as conscious thought and language. This
occurred particularly in nuns with AD and in nuns without AD and
with minimal atherosclerosis and no infarcts (Snowdon et al., 2000)
suggesting that neocortex atrophy specifically occurred when low
folate concentrations were present. Although it is difficult to gen-
eralize these findings to the general population, many potential
confounders associated with epidemiological studies were min-
imized in this small study, since all participants lived in the
same environment, had the same reproductive and marital history,
socioeconomic status, nutritional habits and access to medical care
services (Snowdon et al., 2000). On the other hand, another study
showed that in older patients with dementia and extracerebral
vascular disease, plasma levels of homocysteine (mean of 14 ␮M),
but not serum levels of folate or vitamin B12 , was a predictor of
cognitive decline (Nilsson et al., 2012). In this case, the periph-
eral vascular disease, which is normally associated with high levels
of homocysteine, could explain homocysteine’s predictive role in
dementia.
In conclusion, the population-based studies reviewed above
suggest that low folate levels and hyperhomocysteinemia seem
to be associated with dementia, particularly AD, in healthy and
neuropsychiatric diseased older individuals. However, it is still
unknown if folate deficiency is a cause or a consequence of demen-
tia.
3.3. Depression
Depression has an overall estimated prevalence of 5–8% being
more common in individuals with more than 65 years of age
(15%), especially in those with dementia (Coppen and Bolander-
Gouaille, 2005; Pathy, 2012). Indeed, the prevalence of depression
has been reported to reach up to 50% in patients with AD (Pathy,
2012) which led to the proposal of designating this condition
as depression of Alzheimer’s type (Olin et al., 2002). Depression
is diagnosed when an individual exhibits, for a minimum of 2
weeks, at least one of the two core symptoms – depressed mood
and/or lack of interest in most activities – along with ≥4 (in the
case of major depression) or 1–3 (in the case of minor depres-
sion) of the following symptoms: feelings of worthlessness or
guilt; diminished ability to concentrate or make decisions; fatigue;
psychomotor agitation or retardation; insomnia or hypersomnia;
significant decrease or increase in weight or appetite; and recur-
rent thoughts of death or suicidal ideation (Pathy, 2012). Although
quality studies analyzing the association between folate status
and the risk of depression in the geriatric population are limited
(Beydoun et al., 2010; Bottiglieri et al., 2000a; Kim et al., 2008;
Tiemeier et al., 2002), they suggest that folate deficiency may be
associated with the development of depression. Namely, Bottiglieri
et al. described that red cell folate levels (which reflects long-
term folate stores) were decreased and plasma homocysteine levels
 J.R. Araújo et al. / Ageing Research Reviews 22 (2015) 9–19
increased in 30% of middle-aged and older depressed individuals
compared with a neurological control group (composed by indi-
viduals with various neurological disorders excluding depression
and cognitive decline) and a normal control group (composed by
healthy individuals) (Bottiglieri et al., 2000a). In addition, a sub-
group of depressed patients (28%) with low serum, red cell and CSF
folate levels and significantly elevated homocysteine concentra-
tions (plasma homocysteine >12 ␮M) showed lower CSF levels of
SAM and metabolites of serotonin, dopamine and noradrenaline
compared with patients from the neurological and/or normal
control groups (Bottiglieri et al., 2000a). These results suggest
that depressed individuals with folate deficiency and hyperho-
mocysteinemia might be more prone to have impairments in
brain methylation reactions and monoaminergic neurotransmit-
ters metabolism (Bottiglieri et al., 2000a). In another study (The
Rotterdam Study), 17% of Dutch depressed individuals with a mean
age of 73 years-old presented hyperhomocysteinemia (plasma
homocysteine >13.9 ␮M), 44% presented vitamin B12 deficiency
(serum levels <258 pM) and 19% presented folate deficiency (serum
levels <11.4 nM) in comparison with age-matched control patients
after multiple adjustments for different types of confounding fac-
tors (Tiemeier et al., 2002). Given that depression is commonly
associated with apathy, decreased appetite and dietary intake,
weight loss and anorexia, it might be intuitive to assume that folate
deficiency may be a consequence rather than a cause of depres-
sion. Nevertheless, some studies support that folate deficiency may
be involved in the etiology of depression (Beydoun et al., 2010;
Kim et al., 2008; Young, 2007). Kim et al. (2008) found that lower
serum levels of folate and vitamin B12 and higher plasma levels
of homocysteine in healthy individuals aged ≥65 years indepen-
dently predicted the risk of developing depression 2 years later,
after adjustment for a large number of potential confounding fac-
tors (OR: 1.94 (95% CI 0.58–6.47) for folate deficiency; OR: 1.78
(95% CI 0.90–3.51) for vitamin B12 deficiency and OR: 1.69 (95% CI
0.88–3.26) for hyperhomocysteinemia) (Kim et al., 2008). Addition-
ally, in North American older adults, an inverse dose-dependent
relationship was found between serum concentrations of folate and
depressive symptoms. However, vitamin B12 and homocysteine
serum levels were not associated with depression, which could be
explained by the lack of adjustment of results for some confounders
such as participant’s family history of depression and presence of
chronic illnesses (Beydoun et al., 2010).
Besides being correlated with the onset of depression, folate
deficiency has been associated with a poor response to standard
antidepressant therapy (Papakostas et al., 2005; Reynolds, 2002).
Papakostas et al., (2005) reported that middle-aged and older
depressed patients with low serum levels of folate (≤2.5 ng/ml)
treated during 8 weeks with fluoxetine, a selective serotonin reup-
take inhibitor, were more likely to experience a delay in the onset of
clinical improvement compared with depressed patients with nor-
mal folate levels (mean time to onset improvement was 5 and 3.5
weeks for patients with low and normal folate levels, respectively).
This finding was independent of depression severity at baseline
and of vitamin B12 or homocysteine levels at the time of clinical
improvement.
Taken together, the data reviewed in this section suggest that
folate deficiency may be an independent risk factor for the devel-
opment of depression in the geriatric population.
3.4. Mechanisms underlying neuropsychiatric alterations
associated with folate deficiency
Although the mechanisms underlying the neuropsychiatric
alterations associated with folate deficiency in the older popula-
tion are not completely understood, some hypotheses have been
advanced (Fenech, 2010). The most well described ones include: (a)
13
hyperhomocysteinemia (Loscalzo, 2002; Seshadri et al., 2002); (b)
lower occurrence of methylation reactions and tetrahydrobiopterin
availability (Coppen and Bolander-Gouaille, 2005; Fenech, 2010;
Reynolds, 2006); (c) increased incorporation of uracil into DNA
(Fenech, 2010; Young, 2007) and (d) shorter telomere length
(Fenech, 2010) (Fig. 2).
3.4.1. Hyperhomocysteinemia
Elevated blood levels of homocysteine are highly prevalent in
older individuals (Selhub et al., 2000) being a recognized risk fac-
tor for cardiovascular and cerebrovascular disease and thrombosis
(Clarke, 2006; Fenech, 2010; Selhub et al., 2000). Hyperhomo-
cysteinemia has been suggested to be the most important risk
factor for the development of dementia, particularly AD, in older
individuals with folate deficiency (“homocysteine hypothesis” of
dementia) (Loscalzo, 2002; Seshadri et al., 2002). Although still
on debate – as the available data relies mostly on animal and
cell culture studies, which do not truly represent what happens
in vivo in humans (Selhub et al., 2010) – hyperhomocysteinemia
may promote the development of dementia by several mechanisms
(Fig. 2) such as: (a) induction of cerebrovascular lesions and con-
sequently of microinfarcts, ischemia and oxidative stress in brain
areas critical for learning and memory such as the cerebral cor-
tex and hippocampus (particularly the CA1 pyramidal neurons),
leading to their atrophy (Clarke, 2006; Loscalzo, 2002; Seshadri
et al., 2008); (b) excitotoxicity of hippocampal neurons induced
by increasing concentrations of homocysteic acid, a metabolite of
homocysteine that overstimulates N-methyl-D-aspartate receptors
(which are involved in the transmission of electrical or chemical
signals between neurons) thereby inducing an excessive calcium
influx and reactive oxygen species generation (Lipton et al., 1997);
(c) enhanced sensitivity of hippocampal neurons to the neuro-
toxic effects (increased oxidative stress and disruption of cellular
ion homeostasis) and apoptosis induced by the accumulation
of amyloid-␤-peptide and hyperphosphorylated tau-protein, two
hallmarks of damaged neurons in AD (Fenech, 2010; Kruman et al.,
2002; Loscalzo, 2002; Pohanka, 2011; Reynolds, 2014).
Thus, it appears that the adverse effects of hyperhomocys-
teinemia on hippocampal neurons may constitute an important
explanation for the higher prevalence of dementia observed in the
geriatric population with folate deficiency.
3.4.2. Lower occurrence of methylation reactions and
tetrahydrobiopterin availability
A decrease in the occurrence of SAM-dependent methylation
reactions in neurons is another mechanism that might explain
the neuropsychiatric alterations associated with folate deficiency
(Fig. 2). This condition leads to: (a) hypomethylation of DNA (cova-
lent addition of methyl groups at cytosine bases of DNA) and
consequently to an alteration of DNA stability, transcription and
expression of genes involved in CNS development, differentiation
and repair and in the pathogenesis of AD (e.g., amyloid precursor
protein, tau and presenilin 1 genes) (Fenech, 2010; Hinterberger
and Fischer, 2013); (b) hypomethylation of myelin and membrane
phospholipids leading, respectively, to demyelination and lower
phospholipids synthesis in neurons which may have a negative
impact in the propagation of the nervous impulse (Reynolds, 2006);
(c) hypomethylation of metabolites involved in the biosynthesis
of monoaminergic neurotransmitters leading to an impairment in
their production, which has been recognized as an important con-
tributor to the etiology of depression and other mood disorders
(Coppen and Bailey, 2000; Coppen and Bolander-Gouaille, 2005;
Reynolds, 2002). In fact, and as already described in Section 3.3.,
older depressed patients with folate deficiency and hyperhomocys-
teinemia showed a reduction in brain methylation capacity (lower
levels of SAM in the CSF) and neurotransmitters concentrations
14 J.R. Araújo et al. / Ageing Research Reviews 22 (2015) 9–19
Fig. 2. Proposed mechanisms underlying the neuropsychiatric alterations (dementia and depression) associated with folate deficiency. A␤: amyloid-beta; tetrahydro-
biopterin: BH4 ; pTau: phosphorylated Tau.
(lower levels of serotonin, dopamine and noradrenaline metabo-
lites in the CSF) (Bottiglieri et al., 2000a). In agreement with these
findings, SAM has been proved to have effective antidepressant
properties in humans (Papakostas, 2009).
Besides decreasing SAM levels, folate deficiency also reduces
the availability of tetrahydrobiopterin, a cofactor whose synthe-
sis depends on folate availability. Tetrahydrobiopterin is required
for the hydroxylation of tyrosine, phenylalanine and trypto-
phan, which constitutes the rate-limiting step in the synthesis
of dopamine, noradrenaline and serotonin and also of melatonin
(Coppen and Bailey, 2000; Coppen and Bolander-Gouaille, 2005)
– a hormone produced in the pineal gland that controls circadian
rhythms (e.g., sleep) and possesses a strong antioxidant activity
(Pohanka, 2011). So, reduced levels of brain tetrahydrobiopterin
can also be involved the etiology of depression by decreasing the
levels of neurotransmitters and melatonin.
As a whole, these data suggest that lower brain methylation
reactions – and the consequent reduction in the synthesis of myelin,
phospholipids and monoaminergic neurotransmitters and alter-
ation in gene expression – and lower levels of tetrahydrobiopterin
may constitute a hypothesis for the higher prevalence of neuropsy-
chiatric disorders, particularly depression, in older patients with
folate deficiency.
3.4.3. Increased incorporation of uracil into DNA
Although the majority of CNS cells, i.e., neurons, do not divide
and are terminally differentiated their DNA needs to be constantly
repaired and maintained since DNA damages are more likely to
occur and accumulate in non-dividing than in rapidly dividing
cells (Fenech, 2010). Taking this into account, and also the role of
folate on purine and thymidine synthesis, the impact of folate defi-
ciency on neuron’s nuclear DNA is likely to be more related with
an impairment in DNA repair systems than with an impairment
in de novo DNA synthesis (Fenech, 2010). During folate deficiency,
the conversion of dUMP into dTMP is compromised and there is
an excessive misincorporation of uracil (instead of thymidine) into
nuclear DNA, which the repair systems try to remove (Fenech, 2010;
Young, 2007). However, due to the higher dUMP/dTTP ratio, uracil is
repeatedly misincorporated into DNA and the vicious cycle of uracil
removal, reincorporation and again removal increases the suscep-
tibility of appearance of abasic sites (without any base) and DNA
strand breaks, eventually leading to apoptosis of neurons, partic-
ularly hippocampal neurons (Young, 2007). Furthermore, besides
nuclear DNA, mitochondrial DNA of neurons is also affected by
folate deficiency (by inducing mitochondrial DNA deletions) (Chou
and Huang, 2009; Chou et al., 2007; Kronenberg et al., 2011) leading
to an elevation of oxidative stress levels (Chou et al., 2007).
As a whole, the data presented in this section suggest that
the higher occurrence of DNA strand breaks, as consequence
of impaired nucleotide synthesis, increases the susceptibility of
neuronal death, which may underlie the higher occurrence of
neuropsychiatric diseases in older patients with folate deficiency
(Fig. 2).
3.4.4. Shorter telomere length
It has been speculated that folate deficiency could induce cog-
nitive decline by affecting the dynamic and function of telomeres
in neurons (Fenech, 2010; Moores et al., 2011). Telomeres are
repeated DNA sequences ((TTAGGG)n) which cap the end of all
mammalian chromosomes and whose length is regarded as an indi-
cator of the biological age of a cell (Moores et al., 2011). Although
not scientifically proved, folate deficiency have been suggested to
be correlated with accelerated telomere shortening in neurons due
to an excessive removal of uracil bases present in telomeric DNA
and to hypomethylation of subtelomeric DNA (a more variable
region than the telomeric one in terms of base sequences) (Moores
et al., 2011). Consequently, both of these situations could act as
hypothetical triggers for the accelerated senescence and death of
hippocampal neurons (Fenech, 2010).
 J.R. Araújo et al. / Ageing Research Reviews 22 (2015) 9–19
4. Folate supplementation in the older population
A few randomized clinical trials (RCT) have investigated the
effect of folate and other B-vitamins supplementation on the pre-
vention and progression of neuropsychiatric alterations in older
individuals (Table 2). Among those, three high-quality RCT will
be discussed in detail since: (1) their sample sizes are large, (2)
their follow-up periods are long and similar, (3) detailed informa-
tion about subjects’ B-vitamin status is available, (4) the cognitive
functions evaluated are similar in the 3 studies, and (5) their conclu-
sions are robust (Durga et al., 2007; McMahon et al., 2006; Morris,
2012; Walker et al., 2012). In the first study, McMahon et al. (2006)
reported that in 276 New Zealand healthy individuals aged ≥65
years and with plasma homocysteine concentrations >13 ␮M, a 2-
year period of daily supplementation with 5-MTHF (1 mg), vitamin
B12 (0.5 mg) and vitamin B6 (10 mg) lowered plasma homocys-
teine levels but did not improve, and in some cases even worsened,
cognitive parameters (i.e., did not improve memory and slowed
information-processing speed) compared with a placebo group
(McMahon et al., 2006). Another study reported that in 818 Dutch
healthy adult individuals aged 50–70 years, and with plasma homo-
cysteine concentrations ≥13 ␮M, those supplemented with folic
acid alone (0.8 mg/day) for 3 years showed lower plasma homo-
cysteine levels and significant improvements in cognitive functions
(memory, information-processing speed and sensorimotor speed)
compared with those who received a placebo (Durga et al., 2007).
The discrepancy in results obtained in these two studies is intrigu-
ing, given that they had a similar design. However, this could be
explained by the different baseline folate levels of the two study
populations (Hughes et al., 2013). Indeed, in the RCT of Durga et al.
(2007) the mean folate concentration at the beginning of the study
was almost half of that of McMahon et al. (2006) (12 vs. 22.6 nM,
respectively); therefore the population of Durga’s trial benefited
more from folic acid supplementation. The fact that Durga’s trial
was conducted in the Netherlands, a country which does not per-
mit folic acid food fortification, whereas the trial of McMahon was
conducted in New Zealand, where folic acid food fortification is
allowed in a voluntary basis (Bradbury et al., 2014), could even-
tually explain, at least in part, the different baseline folate status
found in the two populations (Morris, 2012). Moreover, other rea-
sons may also account for the different findings obtained in both of
these trials, in particular the different cognitive function of study
populations (e.g., the cognitive function scores in the placebo group
remained intact during McMahon’s trial but declined in Durga’s
trial), participants age (Durga’s trial followed individuals as young
as 50 year-old whereas McMahon’s trial did not) and the differ-
ent formulations of B-vitamins supplements used (McMahon’s trial
used a multivitamin supplement whereas Durga’s trial used a folic
acid supplement only). A third and more recent RCT reported that
among 900 Australian healthy individuals aged 60–74 years, those
who received 0.4 mg of folic acid/day plus 0.1 mg of vitamin B12 /day
during 3 years showed a modest beneficial effect on cognitive
function, e.g., an improvement in memory but not in information-
processing speed, compared with those who received a placebo
(Walker et al., 2012). Although the comparison of this trial with
the above two may be hampered by the different way folate status
was assessed – red cell folate levels (this trial) and plasma folate
levels (which reflects recent intake) (other two trials) – the mod-
est effect of B-vitamins supplementation obtained in Walker’s trial
may be explained by the mean baseline red cell folate concentration
(573 nM) being well above the cut-off point for deficiency (225 nM)
(Mann and Truswell, 2002). So, this study population, which is from
a country where folic acid food fortification is mandatory, had a
good baseline folate status (Walker et al., 2012).
Besides these three important studies, other randomized clini-
cal trials also investigated the effect of B vitamins supplementation
15
on the cognitive function of healthy older individuals (please see
Table 2). In a recent trial, which included 2919 individuals aged
≥65 years, a two-year folic acid (0.4 mg), vitamin B12 (0.5 mg) and
vitamin D3 (0.15 mg) daily supplementation slightly slowed global
cognitive decline but did not specifically affect memory, attention,
information processing speed and executive function, compared
with a placebo group (van der Zwaluw et al., 2014). The authors
suggested that vitamin D3 might have diluted the potential bene-
ficial effect of B vitamins on cognitive function. In another study,
Eussen et al. (2006) showed that 24 weeks of daily supplementa-
tion with folic acid and vitamin B12 (1 and 0.4 mg, respectively)
in individuals aged ≥70 years with mild vitamin B12 deficiency,
did not improve cognitive function in comparison with a placebo
group (Eussen et al., 2006). Moreover, in 209 individuals with a
mean age of 76 years, those supplemented with 0.8 mg folic acid,
0.5 mg vitamin B12 and 3 mg vitamin B6 during 4 months did not
show changes in neuropsychological performance tests (Lewerin
et al., 2005). These two studies had however, two limitations: a
small sample size and a short follow-up period.
The impact of folate supplementation in cognitive functions of
demented or depressed older individuals has also been investi-
gated (Table 2). Two recent RCT reported that in mild cognitively
impaired (de Jager et al., 2012) or demented (Kwok et al., 2011)
patients with elevated homocysteine levels, a daily supplementa-
tion with B vitamins (folic acid, vitamin B12 and/or vitamin B6 )
over a 2-year period slowed down the decline of specific cog-
nitive functions, e.g., memory and/or construction. It is notable
that in the report by de Jager et al., cognitive decline was pre-
vented only in subjects with a high baseline homocysteine level.
Moreover, in middle-aged and older depressed patients, especially
those with folate deficiency, folic acid or 5-MTHF supplemen-
tation has been shown to improve mood/depressive symptoms,
short-term memory and social recovery (Coppen et al., 1986;
Godfrey et al., 1990; Passeri et al., 1993; Reynolds, 2006). Inter-
estingly, the combined administration of folate supplements plus
antidepressants or cholinesterase inhibitors (the first line treat-
ment for AD) to patients with depression (Almeida et al., 2014;
Coppen and Bailey, 2000) or AD (Connelly et al., 2008), respec-
tively, improved their response to those drugs compared with
patients receiving the drug only. Namely, Almeida et al. showed
that in middle-aged and older depressed individuals the use of
folic acid, vitamin B6 and vitamin B12 in combination with the
antidepressant citalopram enhanced the remission of depressive
episodes and reduced the frequency of relapse after 52 weeks in
comparision with depressed individuals taking citalopram only.
These beneficial effects were apparent in patients with elevated
baseline levels of homocysteine (Almeida et al., 2014). Results
from all these RCT must however be interpreted with caution
since all of them (with the exception of two (Almeida et al.,
2014; de Jager et al., 2012; Kwok et al., 2011)) had two main
pitfalls: short follow-up periods (≤1 year) – neuropsychiatric alter-
ations in response to folate supplementation occurs slowly and
normally take several weeks or some months to develop – or
small sample sizes (n = 41–127) (Hinterberger and Fischer, 2013;
Reynolds, 2006, 2014). On the other hand, Okereke et al., (2015)
recently demonstrated that in 4331 middle and old-aged women,
those receiving a daily supplementation of folic acid (2.5 mg),
vitamin B12 (1 mg) and vitamin B6 (50 mg) for 7 years did not
show an alteration in the overall depression risk compared with
a placebo group (Okereke et al., 2015). Moreover, no differences
in depressive symptoms were found in older men and woman
receiving folic acid (0.4 mg/day) and vitamin B12 (0.1 mg/day) dur-
ing 2 years compared with a placebo group (Walker et al., 2010).
Thus, it is of utmost importance to design further RCT with longer
follow-up periods and larger sample sizes to study the efficacy of
folate supplementation alone or in combination with psychotropic
Table 2
Summary of randomized clinical trials investigating the effect of folate supplementation on human cognitive functions.
Authors
Durga et al. (2007)
Eussen et al. (2006)
Lewerin et al. (2005)
McMahon et al. (2006)
van der Zwaluw et al. (2014)
Walker et al. (2012)
de Jager et al. (2012)
Connelly et al. (2008)
Kwok et al. (2011)
Okereke et al. (2015)
Almeida et al. (2014)
Walker et al. (2010)
Coppen and Bailey (2000)
Coppen et al. (1986)
Passeri et al. (1993)
Godfrey et al. (1990)
a
Homocysteine.
b
Mild cognitive impairment.
c
vs. cholinesterase inhibitors alone.
d
vs. citalopram alone.
e
Homocysteine levels not reported.
16
N Age (years) Follow-up period Intervention (daily) Cognitive outcomes
878 (healthy with plasma Hcya > 13 ␮M) 50–70 3 years 0.8 mg folic acid - Improvement in memory, information-processing speed
and sensorimotor speed;
- No improvement in global cognitive function, complex
speed and word fluency
195 (healthy with plasma Hcy > 14 ␮M and ≥70 24 weeks 0.4 mg folic acid + 1 mg vitamin - No changes in attention, construction, sensorimotor
mild vitamin B12 deficiency) B12 speed, memory, and executive function
209 (healthy with mean plasma Hcy of 76 (mean) 4 months 0.8 mg folic acid + 0.5 mg - No changes in the majority of mouvement or cognitive
17.8 ␮M) vitamin B12 + 3 mg vitamin B6 performance tests
276 (healthy with plasma Hcy > 13 ␮M) ≥75 2 years 1 mg 5-MTHF + 0.5 mg vitamins - No improvement in global cognitive function, memory,
B12 + 10 mg vitamins B6 learning capacity, word fluency and reasoning ability;
- Slower information-processing speed
2919 (healthy with plasma Hcy 12–50 ␮M) ≥65 2 years 0.4 mg folic acid + 0.5 mg - Slower decline of global cognitive function;
vitamin B12 + 0.15 mg vitamin - No change in memory, attention, information processing
D3 speed and executive function
J.R. Araújo et al. / Ageing Research Reviews 22 (2015) 9–19
900 (healthy with mean plasma Hcy of 9.6 ␮M) 60–74 2 years 0.4 mg folic acid + 0.1 mg - Improvement in overall cognitive scores and memory;
vitamin B12 - No changes in orientation, attention, processing speed
and informant report
223 (with MCIb and mean plasma Hcy of ≥70 2 years 0.8 mg folic acid + 0.5 mg - Slowerglobal cognitive decline and memory decline;
11.3 ␮M) vitamin B12 + 20 mg vitamin B6 - Improvement in clinical dementia rating scores;
- No changes in executive function
41 (with Alzheimer’s disease and mean plasma 76 (mean) 6 months 1 mg folic acid + variable doses - Improvement in daily life activities and social behaviorc ;
Hcy of 18.4 ␮M) of cholinesterase inhibitors - No changes in global cognitive declinec
140 (with dementia and mean plasma Hcy of ≥60 2 years 5 mg folic acid + 1 mg vitamin - Improvement in construction cognitive function;
14.1 ␮M) B12 - No change in global cognitive decline, attention,
conceptualization and memory
4331 (healthy with mean plasma Hcy of 64 (mean) 7 years 2.5 mg folic acid + 1 mg vitamin - No change in the risk of overall depression and
12.1 ␮M) B12 + 50 mg vitamin B6 depressive symptoms
153 (with depression and mean blood Hcy of ≥50 52 weeks 2 mg folic acid + 0.5 mg vitamin - Remission of major depressive episoded
11.2 ␮M) B12 + 25 mg vitamin - Decrease in the relapse of depressive symptomsd
B6 + 20–40 mg citalopram
909 (psychologically distressed with mean 60–74 2 years 0.4 mg folic acid + 0.1 mg - No change in depressive symptoms
serum Hcy of 9.6 ␮M) vitamin B12
127 (with depression and mean plasma Hcy of 44 (mean) 10 weeks 0.5 mg folic acid + 20 mg - Folic acid improved the antidepressant action of
9.5 ␮M) flouxetine fluoxetine
75 (with depression and receiving lithium 25–88 52 weeks 0.2 mg folic acid - Lower affective morbidity in participants with plasma
therapye ) folate concentration >13 ng/ml
96 (with depression and mild dementiae ) >65 8 weeks 50 mg 5-MTHF - Improvement in depressive symptoms and short-term
memory;
- No change in long-term memory
123 (with depression or schizophrenia and 20–70 6 months 15 mg methylfolate - Improvement in clinical and social recovery
folate defiencyd )
 J.R. Araújo et al. / Ageing Research Reviews 22 (2015) 9–19
drugs in the cognitive function of older depressed and demented
individuals.
A last point to discuss is the concern about the consumption of
folic acid fortified foods or supplements in older individuals with
low vitamin B12 status. It has been demonstrated that older individ-
uals with high serum levels of folate (as a consequence of fortified
foods or supplements intake) and low serum levels of vitamin B12
have a greater risk of developing anemia and cognitive decline com-
pared with those having low vitamin B12 and normal folate serum
levels or normal vitamin B12 and high folate serum levels (Morris
et al., 2007; Selhub et al., 2009). This could be explained by the fact
that folate overexposure may partially correct the anemia, by pro-
moting DNA synthesis, but not the neuropsychiatric deficits caused
by vitamin B12 deficiency, since the activity of methionine synthase
(a vitamin B12 -dependent enzyme) is low. So, the intake of folate
fortified foods or supplements may eventually mask vitamin B12
deficiency and allow the onset and progression of cognitive decline
(Reynolds, 2006). Moreover, two large studies, the Framingham
Heart Study (Morris et al., 2012) and the National Health and Nutri-
tion Examination Survey (NHANES) (Morris et al., 2010), suggested
that cognitive decline observed in older individuals with both high
folate and low vitamin B12 status might be mediated by elevated
levels of circulating unmetabolized folic acid. In the Framingham
Heart Study, rapid cognitive decline was associated with low levels
of plasma vitamin B12 (<258 pM) and high levels of plasma folate
(>20 nM) or use of supplements containing folic acid (Morris et al.,
2012). In the US National Health and Nutrition Examination Survey,
individuals with a low vitamin B12 status (serum vitamin B12 con-
centration <148 pM) and detectable circulating unmetabolized folic
acid levels had poorer cognitive function in comparison with those
having a low vitamin B12 status but no detectable unmetabolized
folic acid levels. This association was not observed for circulating
5-MTHF levels (Morris et al., 2010).
A last study that is important to mention was recently conducted
by Moore et al., (2014) which showed that older individuals with
high levels of red cell folate and either low or normal serum levels
of vitamin B12 , had both an increased risk of cognitive decline (OR:
3.45 (95% CI 1.60–7.43) for high folate and low vitamin B12 levels
and OR: 1.74 (95% CI 1.03–2.95) for high folate and normal vitamin
B12 levels) (Moore et al., 2014). This suggests that a high folate
status may be detrimental to cognitive function even when vitamin
B12 levels are in a low or normal range (Moore et al., 2014). Due to
the reduced number of participants with low vitamin B12 and high
folate status present in the study, and the impossibility to adjust the
results for some confounders (Moore et al., 2014), additional studies
are needed to better clarify the neuropsychiatric risks arising from
high folic acid intake in older individuals.
Altogether, these findings are consistent with the idea that a
high folate status may be detrimental to cognitive function in older
individuals, particularly when circulating vitamin B12 levels are
low. This is the reason why folic acid food fortification is not manda-
tory, and even prohibited, in some countries and why vitamin B12
has been suggested to be added to folic acid fortified foods (Clarke,
2006; Hughes et al., 2013).
In summary, and in accordance with two recently conducted
meta-analysis (Ford and Almeida, 2012; Malouf and Grimley Evans,
2008), the data showed in this section suggests that there is
not enough evidence to conclude that folic acid supplementation,
administered in isolation or in combination with other B vitamins,
improves cognitive function or slows cognitive decline in healthy or
cognitively impaired older individuals. Nevertheless, it is possible
that the benefits of folic acid supplementation may be restricted to
a subgroup of older individuals with high baseline homocysteine,
and/or low folate status folate status, as found in some of the trials
reviewed above.
17
5. Conclusions
The prevalence of folate deficiency is high among older indi-
viduals (it can be 20% or more) mainly due to reduced dietary
intake and intestinal malabsorption. This condition has been asso-
ciated with cognitive decline, dementia and depression in healthy
and neuropsychiatric diseased older individuals in a bidirectional
way, i.e., low folate status could be either the cause or the conse-
quence of neuropsychiatric alterations. The proposed mechanisms
underlying this association include hyperhomocysteinemia, lower
occurrence of methylation reactions and tetrahydrobiopterin lev-
els in neurons, and an excessive misincorporation of uracil into
neuron’s DNA. Since there is no consistent evidence that folic acid
supplementation, alone or in combination with other B vitamins,
prevents neuropsychiatric diseases in healthy older individuals or
slows cognitive decline in demented or depressed older patients,
additional studies are needed. In particular, RCT with follow-up
periods of at least 2–3 years, large sample sizes, detailed infor-
mation of subject’s folate status and uniform definition of folate
deficiency cut-off points. Also, the molecular mechanisms by which
hyperhomocysteinemia and shorter telomere length underlie the
adverse neurocognitive effects of folate deficiency is a priority area
for future research.
In conclusion, folate deficiency seems to be an important con-
tributor for the onset and progression of neuropsychiatric diseases
in the geriatric population but additional studies are needed in
order to increase the knowledge of this promising, but still largely
unexplored, area of research.
Conflicts of interest
The authors declare that they have no conflict of interest.
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