Identifying the elderly at risk for malnutrition. The Mini Nutritional Assessment

[Lung cancer in the elderly: performance status and/or geriatric indices?]

INTRODUCTION

Demographic aging poses a problem of management in patients over 65 years old with lung cancer (LC). Performance status (PS) is an index of global activity that, in part, determines treatment. Geriatric indices allow a multifactorial assessment of the elderly subject. The aim of our study is to evaluate whether PS correlates with the geriatric indices in elderly patients with lung cancer.

METHODS

In a single centre prospective study the geriatric indices (ADL, IADL, PINI, MMS) and the Charlson score (CS) were measured before treatment.

RESULTS

Forty one patients aged 75.7 +/- 6.6 years were included in the study. PS 3-4 was found in 15% of patients and 44% had stage IV disease. Half of them were ADL dependent and 95% were IADL dependent. A MMS<24 was found in 29% and 17% had a PINI > 20. The CS was 2.7 +/- 2.1. There was a correlation between PS and the geriatric indices but no correlation between PS and CS.

CONCLUSION

PS is significantly correlated with the geriatric indices but is independent of CS. PS appears to be a good parameter for the assessment of global activity in the elderly subject with LC.

Nutritional status determinants and cognition in the elderly

It is possible to identify risks or protective factors against dementia. Increased levels of homocysteine (HCY) and vitamin B deficiency, obesity and central adiposity in midlife are independent risk factors for the development of dementia. High dietary intake of antioxidants and omega-3 fatty acids lower the risk of Alzheimer disease (AD). The supplementation with single nutrients, like vitamin B, omega-3-polyunsaturated fatty acids (PUFA) or antioxidants is generally not effective in lowering the risk of dementia or in slowing the progression of the disease. It is probably necessary that these nutrients are part of a healthy diet (with at least five portions of fruit and vegetables per day and one portion of fish per week) during the lite where other factors interact with them as it happens in the Mediterranean diet. Nutritional strategies for modifying the clinical course of cognitive failure should consider the use of nutritional screening tools in the multidimensional geriatric evaluation. Moreover, the diet, oral supplementation, caregiver education could be important factors to prevent or treat weight loss and its consequences in AD while the use of artificial nutrition in demented patients may have questionable benefits.

Characteristics and trends in required home care by GPs in Austria: diseases and functional status of patients

Background

Almost all societies carry responsibility towards patients who require continuous medical care at home. In many health systems the general practitioner cooperates with community based services of home care and coordinates all medical and non medical activities. In Austria the general practitioner together and in cooperation with relatives of the patient and professional organisations usually takes on this task by visiting his patients.

This study was carried out to identify diseases that need home care and to describe the functional profile of home care patients in eastern Austria.

Methods

Cross sectional observational study with 17 GP practices participating during 2 study periods in 1997 and in 2004 in eastern Austria. Each GP identified patients requiring home care and assessed their underlying diseases and functional status by filling in a questionnaire personally after an encounter. Patients in nursing homes were excluded. Statistical tests used were t-tests, contingency tables, nonparametric Wilcoxon signed rank sum test and Fisher-combination test.

Results

Patients with degenerative diseases of the central nervous system (65%) caused by Alzheimer's disease and cerebrovascular occlusive disease and patients with degenerative diseases of the skeletal system (53%) were the largest groups among the 198 (1997) and 261 (2004) home care cases of the 11 (1997) and 13 (2004) practices. Malignant diseases in a terminal state constituted only 5% of the cases. More than two thirds of all cases were female with an average age of 80 years. Slightly more than 70% of the patients were at least partially mobile.

Conclusion

Home care and home visits for patients with degenerative diseases of the central nervous and skeletal system are important elements of GP's work. Further research should therefore focus on effective methods of training and rehabilitation to better the mental and physical status of patients living in their private homes.

Multifactorial intervention to prevent recurrent cardiovascular events in patients 75 years or older: the Drugs and Evidence-Based Medicine in the Elderly (DEBATE) study: a randomized, controlled trial

OBJECTIVE

We aimed to examine whether better use of preventive methods and treatments of cardiovascular disease would reduce recurrent events in home-dwelling patients 75 years or older.

METHODS

This was a randomized, controlled trial (a practical clinical trial, the DEBATE), conducted in 2000 to 2003 in Helsinki, Finland. We recruited 400 vascular patients with mean age of 80 years from the community, and they were randomly assigned to the intervention group (n = 199) where both nonpharmacological and pharmacological cardiovascular treatments were optimized by a geriatrician according to current guidelines. The control group (n = 201) received the usual care. Main outcome measures were major cardiovascular disease events and total mortality and changes in risk factors and medications.

RESULTS

The groups were balanced at baseline. Mean duration of follow-up was 3.4 years. At 3 years, drug treatments had become more evidence-based in the intervention group. Consequently, total and low-density lipoprotein cholesterol levels (P < .0001) and systolic (P = .005) and diastolic (P = .009) blood pressure were significantly improved in the intervention group. However, neither primary end points (52 and 53 events in the intervention and control groups, respectively) nor total mortality (36 and 35 deaths) were significantly different between the two groups. No special adverse effects were encountered.

CONCLUSION

It was possible and safe to institute evidence-based cardiovascular treatments and improve risk factors in patients 75 years or older in a pragmatic setting. During 3.4 years, however, this was not converted to clinical benefits.

Nutritional disorders in the elderly

Undernutrition is common in older people and has serious adverse effects. Weight loss and low body weight are key markers. Correctable causes, such as depression, are common and should be sought. Structured efforts to encourage food intake, together with nutritional supplements, often are of benefit. It is hoped that a better understanding of the underlying mechanisms will lead to targeted treatments. Overweight and obesity also are common in older people, and are associated with morbidity and impaired function. It is probably appropriate to recommend weight loss to obese older people who have associated comorbidities, particularly reduced mobility, but seldom, if ever, for increased weight alone.

Gender differences in factors associated with nutritional status of older medical patients

OBJECTIVES

To evaluate gender differences in nutritional risk of older people admitted to an acute-care general medical department, and identify gender-specific risk factors.

DESIGN

Cross-sectional study.

SETTING

Internal Medicine Department in an acute care, university-affiliated hospital in southern Israel.

SUBJECTS

204 cognitively intact patients aged 65 and over, admitted during a 12-month period to a general medical department.

MEASURES OF OUTCOME

Evaluation included demographic and clinical data consisting of the sum of medical conditions and of prescribed medications, evaluation of nutritional status, cognitive status, depression assessment and functional ability. Statistical analyses were conducted to evaluate the gender specific risk factors for under-nutrition.

RESULTS

32.5% of the men and 48.1% of the women admitted to an internal medicine department were at risk for under-nutrition. Those at nutritional risk had a higher rate of depression, lower cognitive and physical ability, poorer reported health status and more diagnosed diseases. Nutritional risk for men was associated with higher depression score, longer hospitalization, and poor appetite. For women, nutritional risk was associated with lower functional status and more diagnosed diseases. In a multivariate analysis, being a female increased the risk of under-nutrition by 3.3 fold.

CONCLUSION

Risk of under-nutrition is prevalent among older in-patients and is gender-related. Female inpatients are at markedly increased risk for under-nutrition. The mechanism of the gender discrepancy in factors related to nutritional deterioration is complex and poorly understood.

Adjuvant chemotherapy in the elderly: whom to treat, what regimen?

As the elderly population continues to grow, adjuvant chemotherapy treatment in the elderly is becoming an increasingly important issue for the practicing oncologist. Decisions regarding adjuvant treatment involve a careful assessment of the risk for recurrent disease and side effects from treatment, balancing these risks against the beneficial effects of treatment. In this review, we discuss methods for assessing the elderly patient in terms of life expectancy, comorbid disease, and functional capacity. This assessment can then be used to help identify appropriate candidates for adjuvant chemotherapy. Tools for estimating the risk for relapse and mortality and the reduction in these risks with various forms of treatment are useful for clarifying treatment options. Elderly patients have been underrepresented in clinical trials, and patients are often given less intense and possibly inferior standard treatment as a function of age. Ongoing clinical trials targeting the elderly patient may help answer questions about the relative risks and benefits of adjuvant treatment in this age group. Recent data show that most fit elderly patients derive a benefit from standard adjuvant chemotherapy regimens that is equal to that of younger patients.

Reliability of Mini Nutritional Assessment in Hemodialysis Compared With Subjective Global Assessment

Protein-energy malnutrition (PEM) is common in hemodialysis patients. Subjective Global Assesment (SGA) and Mini Nutritional Assessment (MNA) are two tools for monitoring PEM. Our aim was to determine reliability of MNA in detecting malnutrition in hemodialysis patients in comparison with SGA. The study population consisted of 137 patients with pure PEM with no signs of chronic inflammation. Nutritional statuses of patients were assessed concomitantly by SGA and MNA. Ninety-two patients were in SGA-A, 40 patients were in SGA-B, and 5 patients were in SGA-C. Forty-seven patients were in MNA-1, 77 patients were in MNA-2, and 13 patients were in MNA-3. Albumin (P = .0001), prealbumin (P = .0001), body mass index (P = .01), creatinine (P = .0001), and nPNA (P = .04) were statistically different between SGA groups. Creatinine (P = .001), blood urea nitrogen (P = .017), albumin (P = .001), prealbumin (P = .005), body mass index (P = .0001), and nPNA (P = .005) were statistically different between MNA groups. Fifty-two patients who had no evidence of malnutrition according to SGA were defined as having moderate malnutrition according to MNA. Seven patients who were in a state of moderate malnutrition determined by SGA were in good nutritional status according to MNA. SGA identified 8 patients as moderately malnourished; the same patients were defined as having severe malnutrition in MNA. Our results suggest that MNA might underestimate the nutritional status of hemodialysis patients who are not in an inflammatory state and may not be a reliable method for detecting moderate malnutrition when compared with SGA.

The anorexia of aging in humans

Energy intake is reduced in older individuals, with several lines of evidence suggesting that both physiological impairment of food intake regulation and non-physiological mechanisms are important. Non-physiological causes of the anorexia of aging include social (e.g. poverty, isolation), psychological (e.g. depression, dementia), medical (e.g. edentulism, dysphagia), and pharmacological factors. Physiological factors include changes in taste and smell, diminished sensory-specific satiety, delayed gastric emptying, altered digestion-related hormone secretion and hormonal responsiveness, as well as food intake-related regulatory impairments for which specific mechanisms remain largely unknown. Studies in healthy elderly individuals have shown that men who consume diets over several weeks providing either too few or too many calories relative to dietary energy needs subsequently do not compensate for the resulting energy deficit or surplus when provided an ad libitum diet. Healthy elders have also been shown to be less hungry at meal initiation and to become more rapidly satiated during a standard meal compared to younger adults. Studies in animal models are required to investigate potential mechanisms underlying these observations, while human studies should focus on examining the potential consequences of this phenomenon and practical therapeutic strategies for the maintenance of appropriate energy intake with increasing age. In light of this need, we have recently demonstrated that low reported hunger assessed using a simple questionnaire predicts unintentional weight loss in a sample of healthy older women, and thus may provide a clinically useful tool for identifying older individuals at risk for undesirable weight change and therefore at high priority for intervention.

Are malnourished patients complex patients? Health status and care complexity of malnourished patients detected by the Short Nutritional Assessment Questionnaire (SNAQ)

BACKGROUND

This article describes the characteristics of patients identified as malnourished using the Short Nutritional Assessment Questionnaire (SNAQ) in terms of health status (quality of life, functional capacity, and body composition) and care complexity. We expected that by using the quick and easy SNAQ method of screening on malnutrition, inferences could be made about general health status and care complexity. This information can be used for optimal multi-disciplinary treatment of the malnourished patient.

METHODS

The research population consisted of a group of 588 patients admitted to internal medicine and surgery wards of the VU university medical center. Patients with a SNAQ score of at least 3 points were considered malnourished. The SNAQ score was compared to the health status, which was determined by serum albumin, hand grip strength, quality of life, body composition, and estimated care complexity.

RESULTS

At admission, 172 patients (29%) had a SNAQ score of at least 3 points. These patients had a significantly poorer quality of life, poorer physical functioning, a lower fat free mass index, and higher care complexity.

CONCLUSION

These findings confirm our assumption that a considerable proportion of malnourished patients should be considered as complex patients and that malnutrition is an important aspect and indicator of overall health status of the patients. The SNAQ is a simple malnutrition screening tool, applicable in the current complex hospital situation, to identify these complex, malnourished patients.

Prise en charge et prévention de la dénutrition dans les établissements hospitaliers et institutions d′hébergement

INTRODUCTION

The elderly, especially the institutionalized elderly, are at risk of undernutrition, which institutions do not appear to identify or treat adequately.

OBJECTIVE

To identify activities undertaken to manage and prevent undernutrition in the elderly in institutions in Haute-Normandy (France).

METHODS

In February 2003, all institutions in Haute-Normandy likely to house the elderly received questionnaires for this cross-sectional study: public hospitals (PH) responded, private hospitals (PRH), and retirement homes, classified into two groups according to the medical services provided (RH, retirement homes, NH, nursing homes).

RESULTS

Slightly more than half the institutions responded: 34/36 PH, 20/28 PRH, and 62/161 RH and NH. Half Only 22% reported specific protocols for undernutrition; this figure ranged from 30.3% for PH to 13.6% for RH (p=0.22). Patients' food intake was tracked at 67% of the institutions - from 81.8% of the PH to 45.5% of the retirement homes (p=0.10). Meal choices were offered at 54% of the institutions: 85.0% of PRH hospitals offered a choice, but only 45.4% of the PH and of the RH (p=0.01). Overall, 51% asked about eating habits and preferences at admission. Nurses' aides provided help during meals in 46.9% of institutions, and 49% considered they had sufficient staff to help patients during meals: 95.5% in RH, but only 20.7% in PH (p<0.001).

DISCUSSION

Institutions for the elderly are well aware of the problems of undernutrition, but not enough of them appear to have a specific protocol to deal with it. Earlier screening for undernourishment would be useful. The study also shows the important role of nurses' aides in this area.

CONCLUSION

Institutions in Haute-Normandy agree about the need to screen for and treat undernutrition, but their interventions are not effective. Better organization and special training of health workers could improve this screening and treatment.

Nutrition and wound healing: the necessity of assessment

Wound healing is an intricate affair and good nutritional status is essential to promote effective growth and repair of body tissue. Nutrients play vital roles in the constitution of a well-balanced diet and any depletion in a person's nutritional intake, especially proteins, can lead to malnutrition and protein-energy malnutrition, conditions which are known to have considerable impact on health and well-being and on the wound healing process. A holistic nutritional assessment is paramount to the early detection of nutritional deficiency and the use of recognized nutritional assessment tools can significantly increase practitioners' awareness in its undertaking. While nurses are renowned to have a central role in the management of the patient who, nutritionally are at risk, it is equally important to remember that overall management is essentially a multidisciplinary task.

Evaluating predictive factors for determining enteral nutrition in patients receiving radical radiotherapy for head and neck cancer: A retrospective review

BACKGROUND AND PURPOSE

To identify objective pre-treatment clinical parameters that could be used to predict for patients at high risk of requiring enteral tube feeding prior to head and neck radiotherapy.

PATIENTS AND METHODS

A retrospective study was conducted on 160 consecutive patients attending for radiotherapy assessment. Regression analysis was used to determine various pre-treatment nutritional and tumour specific parameters associated with the use of enteral nutrition either before (prophylactic) or during (reactive) radiotherapy (RT). The significant parameters identified were then selected into categorical variables and compared between those who needed reactive enteral nutrition and the remainder of the group who did not. These results were used to generate predictive factors that could be used to identify those at high risk of malnutrition during RT for whom early or prophylactic enteral nutrition should be considered.

RESULTS

Fifty patients required enteral feeding of which 60% required this prior to radiotherapy. Multivariate analysis identified the following factors to be significant--body mass index, performance status (PS), advanced stage, pre-treatment weight loss, low serum albumin and protein, age, and smoking. The most significant categorical predictive parameters for reactive enteral feeding were stage 3-4 disease, PS 2-3, and smoking >20/day. The combination of these factors predicted a 75% chance of needing enteral nutrition.

CONCLUSION

Nutritional assessment is important prior to radiotherapy and is multifactorial. Using a combination of relatively simple and objective parameters, (performance status, smoking and disease stage) it is possible to identify those at high risk of needing enteral nutrition prior to starting RT.

[Nutritional assessment of the fragile elderly in primary care]

OBJECTIVE

To determine in primary care the nutritional status of elderly people at risk of malnutrition and to evaluate their evolution after an intervention.

DESIGN

Descriptive, with follow-up.

SETTING

Urban health centre.

SUBJECTS

Patients over 65, with criteria as fragile elderly or incapacitated and registered on a doctor's list (N=131). Nutritional risk factors were identified in the consultation or at home in 46 of those included in the study (March-September 2003).

MEASUREMENTS

Age, sex. Factors in risk of malnutrition: loss of weight, acute or chronic illness associated with malnutrition, social factors. Anthropometric indices: Body Mass Index (BMI), tricipital fold (TF) and percentage, brachial perimeter (BP), calf perimeter (CP), arm muscular circumference (AMC), and percentage. Analytic indices: lymphocytes, transferrin, albumin. Malnutrition: when at least 2 of the above parameters were disturbed. Type: calories, protein, mixed. Degree: light, moderate, or severe.

INTERVENTION

special diets and/or nutritional supplements. Parameters were re-assessed at 6 months (t test, paired samples).

RESULTS

Average age of 83, with 63% women. Nutritional risk factors: loss of weight 41%, acute illness 39%, chronic illness 10.5%, cognitive deterioration 4%, social risk 2%. 80.4% suffered malnutrition (32.5% calories, 46% mixed, 21.5% protein; 27% light, 56.7% moderate, 16.3% severe). Mean values on anthropometric parameters: BMI 21, TF 11.3 mm (TF% 72%), BP 22 cm, AMC 19.4 (%AMC 90%), CP 28 cm (%CP 87%). Mean analytic values were: transferrin 243, albumin 3.7, lymphocytes 1600. Nutritional supplements were indicated in 11 cases. 32 cases were re-evaluated later and no significant improvement was found for any parameter (=.05).

CONCLUSIONS

Malnutrition is common in the elderly with risk factors (loss of weight and acute illness), with calorie or mixed malnutrition the most common kinds. There was no improvement in anthropometric parameters at 6 months follow-up.

Mini nutritional assessment and screening scores are associated with nutritional indicators in elderly people with pressure ulcers

OBJECTIVE

To determine the association between the Mini Nutritional Assessment (MNA) or MNA Screening Form and standard indicators of nutritional status in male elders with pressure ulcers.

DESIGN

Cross-sectional study. MNA and MNA Screening Form scores were related to nutritional indicators using the Pearson correlation.

SUBJECTS/SETTING

Residents (79+/-1 years, N=23 men) of Veterans Affairs medical center nursing home care units with stage I to IV pressure ulcers were enrolled.

MAIN OUTCOME MEASURES

Correlation coefficients were obtained from correlations between the MNA or MNA Screening Form scores and biochemical and anthropometric indices of nutritional status or measures of body composition normalized for height by dividing by height in meters(2).

RESULTS

Hemoglobin (106+/-4 g/L; r=0.43, P=.0409, mean, standard error of the mean, Pearson's r, P value), hematocrit (0.32+/-0.01; r=0.44, P=.0358), body mass index (23.1+/-1.0; r=0.66, P=.0006), calf circumference (30.4+/-1.1 cm; r=0.46, P=.0286), fat-free mass index (18.3+/-0; r=0.60, P=.0063), body cell mass index (8.3+/-0.5; r=0.64, P=.0033), and fat mass index (3.7+/-0.4; r=0.50, P=.0275) positively correlated with MNA score. Serum albumin (31+/-1 g/L) and prealbumin (180+/-17 mg/L) did not correlate with MNA, but prealbumin inversely correlated with erythrocyte sedimentation rate (r=-0.52, P=.0134), a marker of inflammation. The inverse correlation between albumin and erythrocyte sedimentation rate approached statistical significance (r=-0.42, P=.0542). The MNA Screening Form showed similar correlations or lack of correlations observed with the MNA with the exception of hemoglobin and hematocrit.

CONCLUSIONS

The MNA and MNA Screening Form provide advantages over using visceral proteins in screening and assessing nutritional status of elderly people with pressure ulcers.

Nutrition and geriatric psychiatry: a neglected field

PURPOSE OF REVIEW

Nutritional issues have received little attention in geriatric psychiatry research. This review focuses on literature published in 2003 and 2004 on nutritional factors in mental illness in the elderly and proposes directions for future research.

RECENT FINDINGS

There has been more research on the role of micronutrients in psychiatric disorders of older adults but studies examining nutritional state in this population are lacking. The former research suggests associations between low folic acid/vitamin B12 status and depression in older adults whereas evidence for other micronutrients is still tentative. In the latter work, there is only one study that examines malnutrition in psychogeriatric patients despite the availability of well-validated screening tools for assessing nutritional state in the elderly and the known impact of undernutrition in ageing and the development of frailty. The role of obesity in ageing is also relevant especially as more people with schizophrenia live longer, although the current evidence in the non-mentally ill elderly suggests that being overweight may have protective effects in the elderly.

SUMMARY

Malnutrition is likely to have considerable impact on the mental and physical state of the elderly.

Elderly psychiatric patients at risk of folic acid deficiency: A case controlled study

In the elderly, folic acid deficiency may result in psychiatric symptoms or the increases in severity of other organic and non-organic mental diseases. We aimed to characterize elderly, community-dwelling, newly admitted patients to a large urban psychiatric hospital who are suffering from untreated folic acid deficiency in comparison with elderly inpatients who do not suffer from this deficiency. During a 2-year period, all subjects aged 65 years or older admitted to the large psychiatric center were tested for levels of serum folic acid levels. Subjects suffering from folic acid deficiency were compared (unpaired t-test) with matched patients with normal serum levels. Of the 293 newly admitted elderly patients 45 (15.7%) suffered from folic acid deficiency. Mean age for the folic acid deficient group was 77.3+/-8.1 years, 38% were diagnosed as suffering from dementia, 22% were depressed and 51% were living alone. In the comparison group mean age was 77.3+/-6.3 years, 33% were diagnosed as suffering from dementia, 24% were suffering from depression and 57% were living alone. We conclude that we could not find any "characteristic" of elderly subjects at risk of folic acid deficiency.

Relations between undernutrition and nosocomial infections in elderly patients

BACKGROUND

Hospital-acquired infections and malnutrition are of major concern in public health in elderly patients. However, the interactions between these two entities are not well established.

OBJECTIVES

To determine the incidence of nosocomial infections (NI) and its association with malnutrition.

SUBJECTS

185 hospitalised older adults aged 81.6+/-0.6 years old were nutritionally assessed on admission by measurement of anthropometric variables, serum nutritional proteins and evaluation of dietary intake. During hospitalisation, patients' progress was closely monitored, particularly for the detection of nosocomial infections.

RESULTS

The incidence rate of NI was 59% and the global infection rate was 7.6/1,000 bed days. The most common infection site was the urinary tract (n=63). The nutritional status of the population was studied by comparing three groups defined according to the absence (group I, n=116), presence of one infection (group II, n=38) or presence of more than one infection (group III, n=31). All but one anthropometric parameters varied among the three groups. Total energy intake also varied among the three groups. The group I had higher daily nutrient intake than the other two groups (respectively P=0.004 and P<0.0001). Albumin, transthyretin, and C-reactive protein levels differed significantly among the three groups (respectively P<0.0001, P<0.0001 and P=0.0003). Age, energy intake, length of hospital stay and the presence of a urinary catheter were independent risk factors of nosocomial infection.

CONCLUSION

Our findings show that patients with multiple NI were older, showed an altered nutritional status, a prolonged recovery, more frequently had urinary catheters and more discharge placement.

Gesunde Senioren zeigen auch bei normalem Ernährungszustand im Mini-Nutritional-Assessment (MNA) Risikobereiche und eingeschränkte Funktionen

Older adults are potentially vulnerable for malnutrition, risk which can be assessed by the Mini-Nutritional Assessment (MNA). To answer the question, whether the MNA can also assess healthy, normal nourished seniors and to check for correlations on functional disabilities and risk factors for functional status decline, 58 independent living, healthy elderly persons with an MNA above 24 points were studied. Different clinical and laboratory exams were performed and a comprehensive geriatric assessment was carried out. There was a non age-dependent correlation for the number of risks in the Lachs' screening, for the number of drugs taken, for the hemoglobin concentration, the level of the g- GT and for mobility assessment tested by the "Timed Up and Go Test" and the "POMA". The MNA can also distinguish in the "normal" range from 24 to 30 points between persons at risk for functional status decline or persons with slightly impaired functions.

Dynamics of nutritional health in a community sample of american elders: a multidimensional approach using roy adaptation model

Nutritional health of community-dwelling elders has been shown to be one of the prime indices of health, influencing the elders' ability to live independently. However, little research has been directed toward understanding the dynamics of nutritional health in community-dwelling elders using a multidimensional theory approach. The purpose of this study was to evaluate the dynamics of nutritional health within the context of Roy Adaptation Model. Factors associated with nutritional health of community-dwelling elders were cross-examined. Depressive symptoms, functional status, oral health, and income emerged as independent predictors of nutritional health adjusting for confounders. This finding lends support to the notion that multidimensional biopsychosocial factors contribute to the dynamics of nutritional health.

Malnutrition and associated factors among aged residents in all nursing homes in Helsinki

OBJECTIVE

To acquire information about nutritional problems and factors associated with them in all nursing homes in Helsinki, Finland.

DESIGN

Descriptive, cross-sectional study. The residents were assessed by the Mini Nutritional Assessment test (MNA) and information was gathered about residents' backgrounds, functional status, diseases and about daily routines in institutions providing nutritional care.

SETTING

All nursing homes in Helsinki community, the capital of Finland.

SUBJECTS

Of 2424 eligible subjects, 2114 (87%) aged residents, mean age 82 y, were examined.

RESULTS

One-third (29%) of the studied residents suffered from malnutrition (MNA < 17), and 60% were at risk (MNA 17-23.5). Malnutrition was associated with the female gender, a longer stay in the nursing home, functional impairment, dementia, stroke, constipation and difficulties in swallowing. In addition, eating less than half of the offered food portion, not eating snacks and resident's weight control at long intervals were associated with malnutrition. In logistic regression analysis mainly patient-related factors predicted malnutrition: impaired functioning (OR 3.71, 95% CI 2.76-4.99), swallowing difficulties (OR 3.03, 95% CI 2.10-4.37), dementia (OR 2.06, 95% CI 1.45-2.93), constipation (OR 1.84, 95% CI 1.38-2.47), but also eating less than half of the offered food portion (OR 3.03, 95% CI 2.21-4.15).

CONCLUSIONS

Although internal factors explain most about the poor nutritional status of aged residents in nursing homes, the factors related to nutritional care need further investigation to clarify their role in maintaining the nutritional status of aged residents.

Nutrition and Aging

Nutritional concerns are common among older adults seen in the primary care office. The food pyramid for people over the age of 70 years is a useful starting point for discussions about what reasonably healthy older adults should be eating and drinking. If there is a decline in the ability to perform IADLs or if there is a decrease in appetite or the discovery of unintended weight loss, careful assessment followed by targeted interventions may improve health outcomes and the quality of life. Restrictive diets are often not well tolerated, especially by frail older adults. Dietary recommendations blending the elements of the pyramid and the essential components of accepted medical nutritional therapy that are most consistent with the patient's lifelong eating patterns are most likely to succeed.

No correlation between mini-nutritional assessment (short form) scale and clinical outcomes in 73 elderly patients admitted for hip fracture

BACKGROUND AND AIMS

Malnutrition in general and protein deficiency in particular, both upon admission and during the recovery period, may adversely influence the clinical outcome after hip fracture. This study investigates the relationship between nutritional status measured by the Mini-Nutritional Assessment short form (MNA-SF) and biological markers in elderly hip-fractured patients.

METHODS

A prospective study in a university hospital. The MNA-SF nutritional scale and laboratory values (serum albumin, cholesterol, total lymphocyte count) were assessed within three days after hip fracture surgery.

RESULTS

Seventy-three patients were included: 61 (84%) were women and 12 men. Mean age was 81.5+/-7.1 years. Inhospital mortality was 10%. The mean MNA-SF score was 11+/-0.5 (range 3-14); according to these values, 39 patients (53%) were at risk of malnutrition. MNA-SF scores were not significantly correlated to patients' laboratory values. Fourteen episodes of nosocomial infection were diagnosed in 11 patients, and 6 patients developed pressure ulcers during hospitalization.

CONCLUSIONS

MNA-SF test scale values reflect a clinical process in post-operative hip-fractured patients which is different from serum albumin, cholesterol or lymphocyte count.

Hospitalization and emergency department visits among seniors receiving homecare: a pilot study

Background

Despite the recent growth in home health services, data on clinical outcomes and acute health care utilization among older adults receiving homecare services are sparse. Obtaining such data is particularly relevant in Ontario where an increasing number of frail seniors receiving homecare are awaiting placement in long-term care facilities. In order to determine the feasibility of a large-scale study, we conducted a pilot study to assess utilization of acute health care services among seniors receiving homecare to determine associated clinical outcomes.

Methods

This prospective cohort study followed forty-seven seniors admitted to homecare by two homecare agencies in Hamilton, Ontario over a 12-month period. Demographic information and medical history were collected at baseline, and patients were followed until either termination of homecare services, death, or end of study. The primary outcome was hospitalization. Secondary outcomes included emergency department visits that did not result in hospitalization and death. Rates of hospitalization and emergency department visits without admission were calculated, and univariate analyses were performed to test for potential risk factors. Survival curves for accumulative rates of hospitalization and emergency department visits were created.

Results

312 seniors were eligible for the study, of which 123 (39%) agreed to participate initially. After communicating with the research nurse, of the 123 who agreed to participate initially, 47 (38%) were enrolled in the study. Eleven seniors were hospitalized during 3,660 days of follow-up for a rate of 3.0 incident hospitalizations per 1,000 homecare-days. Eleven seniors had emergency department visits that did not result in hospitalization, for a rate of 3.3 incident emergency department visits per 1,000 homecare-days. There were no factors significantly associated with hospitalization or emergency department visits when adjustment was made for multiple comparisons.

Conclusion

The incidence of hospitalization and visits to the emergency department among seniors receiving homecare services is high. Getting satisfactory levels of enrolment will be a major challenge for larger prospective studies.

alpha-Tocopherol and selenium facilitate recovery from lipopolysaccharide-induced sickness in aged mice

The elderly suffer a decline in immune function that increases their vulnerability to infections. Because antioxidants improve some age-related deficits in immune and cognitive function, our goal was to determine whether dietary alpha-tocopherol (alpha-T) and selenium inhibit LPS-induced sickness behavior in aged mice. Male BALB/c mice were fed modified AIN93-M diets that were low, adequate, or high in both alpha-T (10, 75, or 500 mg/kg) and selenium (0.05, 0.15, or 2 mg/kg) from 18 to 21 mo of age. Sickness was quantified by measuring time in social exploration of a novel juvenile conspecific. The lipopolysaccharide treatment reduced social exploration by 74% at 2 h, regardless of diet. By 4 h, aged mice fed the low diet were 88% less social, whereas mice fed the adequate and high diets displayed only approximately 40% reductions due to LPS treatment. Mice fed the low diet had greater LPS-induced weight loss than mice fed the high diet. Plasma alpha-T concentration and glutathione peroxidase (GPX) activity increased with each increment in alpha-T and selenium 24 h post-LPS treatment. Brain alpha-T concentration and GPX activity were lower in mice fed the low diet than in those fed the adequate or high diet. Regardless of diet, interleukin (IL)-6, IL-1beta, and tumor necrosis factor (TNF)alpha mRNA levels were elevated by LPS approximately 3-fold in cortex, cerebellum, striatum, and hippocampus. Thus, antioxidants inhibit sickness behavior independently of IL-6, IL-1beta, and TNFalpha mRNA levels 2 h post-LPS in the brain regions analyzed. Taken together, these findings suggest that adequate intake of dietary alpha-T and selenium may help promote recovery from gram-negative bacterial infection in the aged.

Continuous glucose monitoring system signals the occurrence of marked postprandial hyperglycemia in the elderly

BACKGROUND

The aim of this study was to ascertain whether dysglycemic episodes occur in institutionalized elderly persons and, if that is the case, to determine whether such episodes are related to meal patterns. Another objective was to investigate the feasibility of subcutaneous (s.c.) glucose measurements in the elderly using a Medtronic MiniMed (Sylmar, CA) continuous glucose monitoring system (CGMS).

METHODS

Nine nursing home residents (74-95 years old) without known diabetes or other metabolic disorders were included. The s.c. glucose level was measured for 3 days with the Medtronic MiniMed CGMS. Capillary blood glucose was measured four times daily with a Glucometer Elite device (Bayer, Leverkusen, Germany). Body mass index and basal metabolic rate were calculated, and food intake was recorded.

RESULTS

The s.c. glucose level fluctuated noticeably over time; 22.5% of the values recorded during the 3-day period were > or = 8 mmol/L, and values < 3.5 mmol/L were rarely seen. A marked (> 5 mmol/L) and short-term (2-4 h) increase in s.c. glucose was seen after a meal. The mean capillary blood glucose concentration was 7.5 +/- 1.8 mmol/L. Capillary blood glucose > or = 8 mmol/L was recorded on 32.5% of the measurement occasions, and no values were < 3.5 mmol/L. The s.c. glucose values agreed with corresponding capillary blood glucose levels (mean r = 0.75; range 0.43-0.86). Five participants consumed less energy than recommended according to their age, weight, and physical activity level.

CONCLUSIONS

Postprandial hyperglycemia frequently occurs in elderly people living in nursing homes. The CGMS is convenient to use to detect hyperglycemia in this age group.

Body Weight Changes in Elderly Psychogeriatric Nursing Home Residents

OBJECTIVE

This study was undertaken to identify predictors of body weight change in nursing home patients with possible to severe dementia.

METHODS

For 24 weeks, 108 elderly residents of a nursing home were followed. Body weight was measured every 2 weeks. Other anthropometric characteristics, dietary intake, food behavior restrictions, psychological characteristics, medical status, and use of medicines were measured at baseline. Dietary intake was measured with a combined 3-day food record and by observations during the hot meals. Food behavior restrictions were measured following the classification of Berkhout. Dependency was measured by a questionnaire (Care Index Geriatrics), which measures restrictions in cognitive, physical, and social functioning. A generalized linear mixed effects model was used to investigate weight changes over time. The model was adjusted for age and sex.

RESULTS

During the follow-up period, 26% of the participants lost and 22% gained at least 2 kg of body weight. Dependency (beta = -0.11, 95% confidence interval [CI] = -0.21, -0.01) and decreased appetite (beta = -2.17, 95% CI = -4.32, -0.01) were significantly associated with body weight loss, whereas body mass index (beta = 2.25, 95% CI = 1.98, 2.51) and intake of fat (beta = 0.07, 95% CI = 0.01, 0.15) were predictors of weight gain.

CONCLUSION

Dependency, body mass index, intake of fat, and decreased appetite are significant predictors of body weight changes.

Fast and simple screening for nutritional status in hospitalized, elderly people

BACKGROUND

Undernutrition has been frequently reported among hospitalized elderly patients. The aim of this study was to evaluate the mini nutrition assessment (MNA) and a screening sheet for malnutrition (SSM) by full nutritional assessment (FNA) in elderly people, and to construct a shorter screening method by combining important questions from MNA and SSM. Having a screening tool as fast and simple as possible could increase its use in clinical routines.

METHODS

FNA, MNA and SSM were carried out on 60 hospitalized patients (>65 years). Sensitivity and specificity for MNA and SSM were calculated in comparison with FNA. In order to construct a short and simple screening tool, questions from the two screening tools, which differed significantly between mal- and well-nourished patients, were used in a multivariate, stepwise linear regression. The regression model was simplified to be suitable in clinical routines.

RESULTS

Malnourishment was diagnosed by FNA in 58.3% of the elderly patients, with no gender difference. Body mass index, unintended weight loss, recent surgery and loss of appetite were predictors of malnutrition in the regression model (R(2) = 60.1%). The sensitivity and specificity of the simplified regression model were 89 and 88%, respectively, which was more precise than MNA (77 and 36%) and SSM (89 and 60%).

CONCLUSION

According to FNA, malnutrition is frequent in elderly hospitalized patients. Four questions are sufficient to conduct precise nutritional screening for malnutrition in elderly hospitalized patients. This new screening tool should be verified in other samples.

Management of Diabetes Mellitus Medications in the Nursing Home

Nursing home staff are well aware of the increasing number of residents who experience diabetes mellitus. These residents consume an inordinate amount of resources and often have major disabilities and co-morbidities. Although nonpharmacological therapies, such as consistent carbohydrate intake and increased activity levels, are always indicated in diabetes management, pharmacological therapies are often necessary to prevent the acute complications of diabetes and delay some of the long-term complications. Residents with type 2 diabetes may be managed with oral antidiabetic agents and insulin, whereas residents with type 1 diabetes will always require insulin. Oral antidiabetic agents include insulin secretagogues, which stimulate endogenous insulin secretion and are most effective in leaner persons with type 2 diabetes. Metformin is another oral antidiabetic agent; this decreases inappropriate hepatic glucose release and is most effective in obese residents with high fasting blood glucose levels. The thiazolidinediones, also called glitazones, are insulin sensitisers that enable peripheral tissues to utilise insulin more effectively. The alpha-glucosidase inhibitors delay intestinal absorption of ingested carbohydrates. In addition to oral antidiabetic agents, insulin is frequently used in diabetes management. Insulin is always indicated in type 1 diabetes and is often necessary for residents with type 2 diabetes to optimise glycaemic control. Insulin can be rapid, fast, intermediate or long acting. In addition, basal insulin is now available. These insulins can be combined with each other and, in type 2 diabetes, with oral antidiabetic agents. In order to use pharmacological therapies appropriately, the glycaemic patterns of nursing home residents should be identified, using capillary blood glucose monitoring. Once these patterns have been identified, nonpharmacological therapies can be used, usually in conjunction with the many oral antidiabetic agents and various insulins available, to optimise glycaemic control in each resident.

Needs and Preference Assessment for an In-Home Nutrition Education Program Using Social Marketing Theory

Nutrition education programs for elder caregivers (CG) and their elder care recipients (CR) are important in preventing malnutrition. Using Social Marketing Theory, this study assessed the needs and preferences for nutrition education in elder CGs and their CRs in Guilford County, NC. Thirty-two pairs of community-residing elder CGs/CRs and three focus groups (FGs) participated. Health and diet questionnaires were administered to all CGs/CRs during in-home interviews. CGs/CRs and FGs evaluated nutrition education materials. Questionnaires were analyzed using SPSS v9. Ethnograph v5.0 was used to code the interviews regarding the education materials. The CGs were middle age (58.9 years), overweight (BMI = 28.8) Caucasian women. The CRs were old (79.4 years), overweight (BMI = 26.0) Caucasian women. Identified malnutrition risk factors of CGs and CRs included inadequate fluid and dietary intake, polypharmacy, and chronic disease. Identified nutrition needs and education preferences of CGs/CRs were similar. Perceived nutrition education preferences of the FGs did not reflect the interests of the CGs/CRs. This information is being used to revise the education materials and develop an in-home nutrition education program for CGs and CRs in Guilford County, NC.

Nutritional support and stroke

Following stroke poor nutritional status is common, under recognized and associated with worse outcomes. This article explores existing assessment and management strategies aimed at recognizing and reducing the impact of malnutrition in stroke patients.

Nutritional risk and body composition in free-living elderly participating in congregate meal-site programs

Early detection of nutritional risk in free-living elderly is critical in healthcare, yet comprehensive measurements are time consuming and can be frustrating to both health professionals and elderly. In addition, body composition measurements provide information regarding fat and fat-free mass that have been linked to morbidity and mortality in elderly. In this study, nutritional risk was assessed in 69 elderly, aged 50-90 years, attending congregate meal-site programs, using Mini Nutritional Assessment, and body composition was assessed by bioelectric impedance. Analysis revealed that 31.9% of the elderly were at risk for malnutrition and 2.9% were malnourished. Males had significantly greater body weight, height and fat-free mass, and females had significantly greater body fat as percentage of body weight, but there was no gender difference in nutritional risk. Of elderly, 36.2% had body mass index > 85th percentile and 8.7% < 15th percentile using national population reference standards. Age-related decline in fat-free mass was an early indicator of changes in body composition.

Improvement of weight and fat-free mass with oral nutritional supplementation in patients with Alzheimer's disease at risk of malnutrition: a prospective randomized study

OBJECTIVES

To study the effects of oral nutritional supplements (OS) on body weight, body composition, nutritional status, and cognition in elderly patients with Alzheimer's disease (AD).

DESIGN

Prospective, randomized, controlled study.

SETTING

Geriatric wards and day care centers in the Toulouse area, France.

PARTICIPANTS

Ninety-one subjects with AD aged 65 and older at risk of undernutrition as evaluated using the Mini Nutritional Assessment.

INTERVENTION

After randomization, 46 patients (intervention group) received 3-month OS. The other 45 patients (control group) received usual care.

MEASUREMENTS

Weight, body composition (evaluated using dual-energy x-ray absorptiometry), cognitive function, activities of daily living, eating behavior, and dietary intakes were evaluated at the beginning of the study and at 3 months and 6 months. Supplement compliance was recorded each day.

RESULTS

Between baseline and 3 months, energy and protein intakes significantly improved in the intervention group, resulting in a significant increase in weight and fat-free mass, but no significant changes were found for dependence, cognitive function, or biological markers. The nutritional benefit was maintained in the intervention group after discontinuation of OS at 3 months.

CONCLUSION

Three-month daily OS significantly improves body weight. It is practicable and effective, and the patients accepted it well. The improvement that was observed even in the control group showed that caregiver education is an important factor in maintaining the nutritional status of patients with AD. Moreover, regular courses of OS may help to maintain the increase in fat-free mass and improve the nutritional status of these patients.

Nutritional supplementation for diabetic foot ulcers: the first RCT

OBJECTIVE

To determine if oral nutritional supplementation improved wound healing in malnourished patients with diabetic foot ulcers when compared with a placebo.

METHOD

This prospective randomised controlled double-blind trial involved patients aged over 60 with diabetes mellitus and a Wagner grade I-II foot ulcer of over four weeks' duration. Patients received either 400 ml (400 kcal) oral nutritional supplementation (n = 26) or 400 ml placebo (n = 27) daily for six months. Patients were followed monthly for six months and after one and two years.

RESULTS

A third of the patients were classified as having protein-energy malnutrition at inclusion, with no difference between the two groups. Critical leg ischaemia was more common in the intervention group than in the placebo group (p = 0.008). Nine patients in the intervention group (35%) and four in the placebo group (15%) dropped out of the study (not significant). Of those who completed the study, the wound had healed at six months in eight out of 23 patients (41%) (placebo) and in seven out of 17 (35%) (intervention) (not significant). Twenty-four per cent of patients with protein-energy malnutrition at inclusion had healed at six months compared with 50% of those without it (not significant).

CONCLUSION

This is the first study to evaluate the possible benefits of nutritional supplementation on diabetic foot ulcers. A third of patients were malnourished. We encountered several methodological problems and were unable to demonstrate an improved wound healing rate in these patients.

Minimum Data Set for Nutritional Intervention Studies in Elderly People

Malnutrition, considered for the purpose of the present data set as undernutrition, is a major risk factor of mortality in elderly people. Such protein-energy malnutrition should be detected as soon as possible. Once established, this malnutrition state must be corrected by appropriate diet, supplementation, artificial nutrition, or therapeutic treatment. If carried out well, these interventions should reduce the risk of mortality and, for some diseases such as degenerative diseases, may postpone morbidity and dependence. The efficiency of nutritional interventions has already been evaluated by different means including the measurement of anthropometric and laboratory parameters. However, in the absence of a consensus on the use of these parameters, comparison between studies and even effectiveness of the proposed treatment are frequently unconvincing. The relevance of the most common markers used in epidemiologic studies on malnutrition and nutritional interventions in elderly persons was studied for establishing a minimum data set. The aim of this task force was to provide investigators and operators in the field of clinical nutrition with clear and expert validated clinical outcomes allowing them to design and set up conclusive trials.

[Preventing dependency in elderly persons: randomized study in the community]

The number of elderly people aged > 85 years will double by the year 2020. Helping the elderly to live independently at home is a major challenge for society. Physical exercise and protein energy intake might both be effective in preventing dependency. This paper describes the organisation of an ongoing study aimed at evaluating the preventive effect of such measures, involving 102 elderly persons randomised into two groups, one receiving preventive measures but not the other. The study organisation was based on representatives and selected workers from associations involved in home assistance for elderly. Their role consisted in recruiting persons for participation in the trial, encouraging them to perform exercises and take dietary supplements, and notifying the research team of all health-related events. This organisation has reached its objectives, even though the supervision of the domestic workers needs to be improved. This network, comprising stable workers (14 years of work experience on average in this study) offers the potential for future research in the community to evaluate preventive measures.