Frailty and nutrition: searching for evidence

Frailty Assessment in Hospitalized Older Adults Using the Electronic Health Record

INTRODUCTION

Frailty, a clinical syndrome of decreased physiologic reserve and dysregulation in multiple physiologic systems, is associated with increased risk for adverse outcomes.

PURPOSE

The aim of this retrospective, cross-sectional, correlational study was to characterize frailty in older adults admitted to a tertiary-care hospital using a biopsychosocial frailty assessment and to determine associations between frailty and time to in-hospital mortality and 30-day rehospitalization.

METHODS

The sample included 278 patients ≥55 years old admitted to medicine units. Frailty was determined using clinical data from the electronic health record (EHR) for symptoms, syndromes, and conditions and laboratory data for four serum biomarkers. A frailty risk score (FRS) was created from 16 risk factors, and relationships between the FRS and outcomes were examined.

RESULTS

The mean age of the sample was 70.2 years and mean FRS was 9.4 ( SD, 2.2). Increased FRS was significantly associated with increased risk of death (hazard ratio = 1.77-2.27 for 3 days ≤ length of stay (LOS) ≤7 days), but depended upon LOS ( p < .001). Frailty was marginally associated with rehospitalization for those who did not die in hospital (adjusted odds ratio = 1.18, p = .086, area under the curve [AUC] = 0.66, 95% confidence interval for AUC = [0.57, 0.76]).

DISCUSSION

Clinical data in the EHR can be used for frailty assessment. Informatics may facilitate data aggregation and decision support. Because frailty is potentially preventable and treatable, early detection is crucial to delivery of tailored interventions and optimal patient outcomes.

Impact of a Home-Based Physical and Nutritional Intervention Program Conducted by Lay-Volunteers on Handgrip Strength in Prefrail and Frail Older Adults: A Randomized Control Trial

A randomized controlled trial was performed to compare the effects of a home-based physical and nutritional intervention program carried out by lay-volunteers to home visits with social support alone. Buddies visited 80 prefrail or frail older persons at home twice a week for 12 weeks. The physical training and nutrition group (PTN, n = 39) performed two sets of six strength exercises, discussed nutritional topics and received social support. The social support group (SoSu, n = 41) received home visits with social support only. In the PTN group, handgrip strength increased significantly by 2.4 kg (95% CI: 1.0–3.8). In the SoSu group we did not see a significant improvement. However, no significant between-group difference was found. Physical performance increased in both groups, although with a higher increase of 1.0 point (95% CI: 0.1–2.0) in the PTN group. In none of the groups muscle mass changed. Further results showed that frail individuals benefit more from the intervention than prefrail individuals (OR: 2.78; 95% CI: 1.01–7.66). Handgrip strength in the intervention group increased by a clinically relevant value and this effect is comparable to that obtained by health-care professionals. Therefore, home visits with a physical training and nutritional program could offer a new perspective in the care of community-dwelling prefrail and frail older persons.

Micronutrient deficiencies in the elderly - could ready meals be part of the solution?

Micronutrient deficiencies contribute to many age-related disorders. One group at particular risk of micronutrient deficiencies is the elderly. Many elderly, such as the frail and those living in institutions, rely on ready meals of variable, often poor, nutritional quality for a significant part of their daily nutritional needs. New policies are needed to ensure that micronutrients (vitamins and minerals) and phytochemicals of known nutritional value are retained during the manufacture of ready meals. This together with increased awareness of the importance of micronutrients for health, and simple, clear labelling of the micronutrient content of ready meals would help in the choice of healthier products. Professionally prepared ready meals monitored by nutritionists and dietitians can help achieve these goals so that ready meals become part of the solution to poor nutrition in the elderly, rather than being viewed as part of the problem.

Low Nutrient Intake and Frailty Among Overweight and Obese Migrant Women From Ethnically Diverse Backgrounds Ages 60 Years and Older: A Mixed-Methods Study

OBJECTIVE

To examine associations between energy/nutrient intakes and frailty in older migrant women, and to explore perceptions of body weight, dietary intake, and physical function.

DESIGN

Cross-sectional, mixed-methods study.

SETTING

Birmingham, United Kingdom.

PARTICIPANTS

Seventy-six first-generation migrant women ≥ 60 years of age.

MAIN OUTCOME MEASURES

Energy/nutrient intakes (assessed by 24-hour dietary recall), frailty (using the frailty phenotype), and links between perceptions of body weight, dietary intake, and physical function (via semi-structured interviews).

ANALYSIS

Bivariate and logistic regression analyses examined associations between frailty and low energy/nutrient intakes. Interviews were analyzed using inductive thematic analysis.

RESULTS

Seventy-six women completed a 24-hour dietary recall; 46 participated in a semi-structured interview. Low energy intake was associated with frailty (odds ratio [OR], 11.71; 95% confidence interval [CI], 2.36-57.97). After adjusting for energy and other confounders, a low intake of > 3 nutrients was associated with frailty (OR, 6.58; 95% CI, 1.01-43.08). Qualitative data suggest that dietary intake was influenced by concerns about body weight and perceptions that unhealthy foods reduce mobility.

CONCLUSIONS AND IMPLICATIONS

Among older migrant women with high prevalence of overweight/obesity, an inadequate dietary intake may be a stronger predictor of frailty than weight loss. Dietary interventions should focus on healthy weight maintenance and optimization of nutritional adequacy and physical function.

Validation of the Photography Method for Nutritional Intake Assessment in Hospitalized Elderly Subjects

OBJECTIVE

The aim of the present study was to validate the photographic indirect method as an accurate and specific tool to assess nutritional intake in a cohort of elderly hospitalized patients.

DESIGN

this is a prospective observational study.

SETTING

hospital (geriatric acute ward and transitional care of IRCCSS AUO San Martino Hospital, Genoa, Italy).

PARTICIPANTS

255 consecutive elderly hospitalized patients.

MEASUREMENTS

assessment of malnutrition by: Mini nutritional assessment (MNA) and abbreviated Comprehensive geriatric assessment (CIRS; Barthel index, SPMSE). The direct method (Gold standard): food dish weight (before lunch) and residual (after lunch) food dish weight and estimation of the percentage of eaten food and of residual food for each dish. The percentages of food intake and residual food were calculated according to the following formula: intake %= initial weight of the dishes- residual food weight)/ initial weight dish x100. The unit of variable was the percentage. The indirect photographic method with extrapolation of the lunch food intake by photographic method confronting initial meal and residual meal (25% quartile food dish estimation).

RESULTS

The results showed a significant correlation between the direct method (weighing residual food) and the indirect photographic method(n=255; r=0.9735; p<0.001) as well as a significant positive correlation between the indirect photographic method and the food caloric estimation calculated by the direct method (n=255; r= 0.6489, p<0.001). Intraclass coefficient (ICC), showed a highly significant degree of agreement between the gold standard and the indirect photographic method (ICC: 0.69; p<0.0001). Additionally, the results showed a good inter rater agreement of the indirect photographic method (kappa-statistic measure of interrater agreement: (Z=13.04; p<0.001); agreement 70.29% e Kappa=0.5965) and a good specificity of the indirect method as it was independent on the single food item.

CONCLUSIONS

The study originally provided the validation of the indirect photographic method for the assessment of nutritional intake in a vast cohort of hospitalized elderly subjects. The present results moved a step forward in the appropriate assessment of nutrition intake in frail elderly, providing an easy to use tool that may be incorporate in routine clinical practice for early and targeted therapeutic interventions.

Anorexia of aging and its role for frailty

PURPOSE OF REVIEW

The purpose of this review is to examine the concept of anorexia of aging, including its complex pathophysiology and the multifaceted interventions required to prevent adverse health consequences from this geriatric syndrome.

RECENT FINDINGS

Anorexia of aging is extremely common, occurring in up to 30% of elderly individuals; however, this diagnosis is frequently missed or erroneously attributed to a normal part of the aging process. With aging, impairments in smell and taste can limit the desire to eat. Alterations in stress hormones and inflammatory mediators can lead to excess catabolism, cachexia, and reduced appetite. In addition, mood disorders, such as anxiety and depression, are powerful inhibitors of appetite. Anorexia of aging, with its negative consequences on weight and muscle mass, is a risk factor for the development of frailty and is important to screen for, as early intervention is key to reversing this debilitating condition.

SUMMARY

Anorexia of aging is a complex geriatric syndrome and a direct risk factor for frailty and thus should not be accepted as normal consequence of aging. Early diagnosis and formulating a plan for targeted interventions is critical to prevent disability and preserve function in elderly patients.

Nutritional Aspects of Dysphagia Management

This chapter describes the nutritional aspects of dysphagia management by starting with the definition of these two conditions (dysphagia and malnutrition) that share three main clinical characteristics: (a) their prevalence is very high, (b) they can lead to severe complications, and (c) they are frequently underrecognized and neglected conditions. From an anatomical standpoint, dysphagia can result from oropharyngeal and/or esophageal causes; from a pathophysiological perspective, dysphagia can be caused by organic or structural diseases (either benign or malignant) or diseases causing impaired physiology (mainly motility and/or perception disorders). This chapter gathers up-to-date information on the screening and diagnosis of oropharyngeal dysphagia, the consequences of dysphagia (aspiration pneumonia, malnutrition, and dehydration), and on the nutritional management of dysphagic patients. Concerning this last topic, this chapter reviews the rheological aspects of swallowing and dysphagia (including shear and elongational flows) and its influence on the characteristics of the enteral nutrition for dysphagia management (solid/semisolid foods and thickened liquids; ready-to-use oral nutritional supplements and thickening powders), with special focus on the real characteristics of the bolus after mixing with human saliva.

Frailty and cardiac rehabilitation: A call to action from the EAPC Cardiac Rehabilitation Section

Frailty is a geriatric syndrome characterised by a vulnerability status associated with declining function of multiple physiological systems and loss of physiological reserves. Two main models of frailty have been advanced: the phenotypic model (primary frailty) or deficits accumulation model (secondary frailty), and different instruments have been proposed and validated to measure frailty. However measured, frailty correlates to medical outcomes in the elderly, and has been shown to have prognostic value for patients in different clinical settings, such as in patients with coronary artery disease, after cardiac surgery or transvalvular aortic valve replacement, in patients with chronic heart failure or after left ventricular assist device implantation. The prevalence, clinical and prognostic relevance of frailty in a cardiac rehabilitation setting has not yet been well characterised, despite the increasing frequency of elderly patients in cardiac rehabilitation, where frailty is likely to influence the onset, type and intensity of the exercise training programme and the design of tailored rehabilitative interventions for these patients. Therefore, we need to start looking for frailty in elderly patients entering cardiac rehabilitation programmes and become more familiar with some of the tools to recognise and evaluate the severity of this condition. Furthermore, we need to better understand whether exercise-based cardiac rehabilitation may change the course and the prognosis of frailty in cardiovascular patients.

Association Between Tooth Loss, Receipt of Dental Care, and Functional Disability in an Elderly Japanese Population: The Tsurugaya Project

OBJECTIVES

To examine whether number of remaining teeth and regular dental care affect incident functional disability in elderly Japanese adults.

DESIGN

Prospective cohort study.

SETTING

Tsurugaya district, Sendai, Japan.

PARTICIPANTS

Community-dwelling individuals aged 70 and older (N = 834).

MEASUREMENTS

The outcome measurement was incident functional disability, defined as first certification of long-term care insurance in Japan, which is determined on the basis of a strictly established uniform nationwide standard. During a median follow-up of 7.9 years (interquartile range 4.8-7.9 years), information on long-term care insurance was obtained from the Sendai Municipal Authority. Oral health was assessed according to number of remaining teeth and presence or absence of regular dental care. Data were also collected on age, sex, body mass index, medical history, smoking, alcohol consumption, duration of education, depressive symptoms, cognitive impairment, physical functioning, and social support.

RESULTS

Participants with 10 to 19 teeth (adjusted hazard ratio (aHR) = 1.42, 95% confidence interval (CI) = 1.03-1.94), one to nine teeth (aHR = 1.46, 95% CI = 1.04-2.03), and no teeth (aHR = 1.49, 95% CI = 1.03-2.14) were more likely to develop functional disability than those with 20 or more teeth. There was no significant difference in risk of functional disability between participants with 20 or more teeth and those with zero to 19 teeth who were receiving regular dental care, whereas those with zero to 19 teeth without regular dental care had a significantly greater risk of functional disability than those with 20 or more teeth (HR = 1.46, 95% CI = 1.11-1.92).

CONCLUSION

Tooth loss was associated with greater risk of functional disability in community-dwelling elderly Japanese. Regular dental care might moderate the risk of functional disability in elderly individuals with missing teeth.

A Prospective Cohort Study to Examine the Association Between Dietary Patterns and Sarcopenia in Chinese Community-Dwelling Older People in Hong Kong

OBJECTIVES

Dietary pattern analysis has recently emerged as an alternative approach to investigate the association between diet and sarcopenia. This study examined the association of dietary patterns with sarcopenia in Chinese community-dwelling older people.

METHODS

Chinese men and women aged 65 years or older participating in a cohort study examining the risk factors for osteoporosis completed a validated food frequency questionnaire at baseline between 2001 and 2003. Adherence to a priori dietary patterns, namely the Diet Quality Index-International (DQI-I) and the Mediterranean Diet Score (MDS) was assessed. Factor analysis identified 3 a posterior dietary patterns: "vegetables-fruits," "snacks-drinks-milk products," and "meat-fish." Sarcopenia was defined using the Asian Working Group for Sarcopenia algorithm. Multiple logistic regression was used for cross-sectional analysis (n = 3957) to assess the associations between dietary patterns and prevalent sarcopenia, and for longitudinal analysis (n = 2948) on their associations with 4-year incident sarcopenia with adjustment for sociodemographic and lifestyle factors.

RESULTS

There were 290 (7.3%) (185 men, 105 women) sarcopenic cases at baseline and 264 (9.0%) (160 men, 104 women) incident sarcopenic cases at the 4-year follow-up. At baseline, men in the highest quartile of DQI-I had reduced odds of sarcopenia (Adjusted OR 0.50, 95% CI 0.31-0.81, Ptrend = .004) compared with men in the lowest quartile. Men in the highest quartile of "vegetables-fruits" pattern score (Adjusted OR 0.60, 95% CI 0.36-0.99, Ptrend = .034) showed lower likelihood of sarcopenia compared with men in the lowest quartile. Higher quartile of "snacks-drinks-milk products" pattern score was associated with lower odds of sarcopenia in men (Adjusted OR 0.41, 95% CI 0.24-0.70, Ptrend < .001). There was no association between dietary patterns and prevalent sarcopenia in women. None of the dietary patterns was associated with incident sarcopenia at 4-year in both sexes.

CONCLUSIONS

Higher DQI-I, higher "vegetables-fruits" dietary pattern score, and higher "snacks-drinks-milk products" dietary pattern score were associated with lower odds of prevalent sarcopenia in Chinese older men.

Dietary Patterns and Risk of Frailty in Chinese Community-Dwelling Older People in Hong Kong: A Prospective Cohort Study

Dietary pattern analysis is an emerging approach to investigate the association between diet and frailty. This study examined the association of dietary patterns with frailty in 2724 Chinese community-dwelling men and women aged > 65 years. Baseline dietary data were collected using a food frequency questionnaire between 2001 and 2003. Adherence to a priori dietary patterns, including the Diet Quality Index-International (DQI-I) and the Mediterranean Diet Score (MDS) was assessed. Factor analysis identified three a posteriori dietary patterns, namely "vegetables-fruits", "snacks-drinks-milk products", and "meat-fish". Incident frailty was defined using the FRAIL scale. Binary logistic regression was applied to examine the associations between dietary patterns and four-year incident frailty. There were 31 (1.1%) incident frailty cases at four years. Every 10-unit increase in DQI-I was associated with 41% reduced risk of frailty in the sex- and age-adjusted model (odds ratio (OR) (95% confidence interval (CI)): 0.59 (0.42-0.85), p = 0.004). The association attenuated in the multivariate adjusted model (0.69 (0.47-1.02), p = 0.056). No association between other dietary patterns and incident frailty was observed. Our study showed that a better diet quality as characterized by higher DQI-I was associated with lower odds of developing frailty. The contribution of MDS or a posteriori dietary patterns to the development of frailty in Chinese older people remains to be explored.