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

Relationship between nutrition status and dental occlusion in community-dwelling frail elderly people

AIM

This study aimed to determine the risk of malnutrition in some communities where the frail elderly receive public long-term care insurance. We also clarified the dental problems in those at risk of malnutrition.

METHODS

A total of 716 frail elderly who lived in eight cities in Japan (240 males and 476 females with a mean age of 83.2±8.6 years) were divided into three groups according to Mini Nutritional Assessment short form results: well nourished, at risk of malnutrition and malnourished. They were also divided into three groups in terms of remaining teeth occlusion and denture occlusion: group A, natural dentition with adequate function; group B, partially or fully edentulous, but maintaining functional occlusion with dentures in either or both jaws; and group C, functionally inadequate occlusion with no dentures. The relationship between nutrition status and dental occlusion was evaluated using logistic regression analysis with sex, age, activities of daily living and cognitive function as covariates.

RESULTS

The number of participants in each of the groups was as follows: 251 well nourished, 370 at risk of malnutrition and 95 malnourished. When they were divided into just two groups, (i) well nourished and (ii) at risk of malnutrition plus malnourished, in order to study malnutrition risk factors, there were significant relationships between their nutritious status and sex, Barthel index, and occlusion.

CONCLUSION

This large-scale cross-sectional survey showed that loss of natural teeth occlusion was a risk factor for malnutrition among community-dwelling frail elderly.

Risk of death associated with use of PPIs in three cohorts of institutionalized older people in Finland

OBJECTIVES

To (1) explore clinical and demographic characteristics of users and nonusers of PPIs in 3 cohorts of institutionalized older people in Finland, and (2) compare the risk of death associated with use of PPIs in each setting.

DESIGN

Cross-sectional assessment of 3 institutionalized cohorts with 1-year follow-up of all-cause mortality.

SETTING AND PARTICIPANTS

A total of 1389 residents of 69 assisted living facilities (first cohort), 1004 residents of long term care hospitals (second cohort), and 425 residents in acute geriatric wards or in nursing homes (third cohort).

MEASUREMENTS

Demographic, drug use, and diagnostic data were collected during structured assessments conducted by trained nurses or geriatricians. Cox proportional hazards models were used to compute unadjusted and adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) for the association between use of PPIs and mortality.

RESULTS

In the assisted living facility, the mortality was 20.2% (n = 74) and 20.4% (n = 208) among users and nonusers of PPIs, respectively (P = 0.94). PPIs were not associated with mortality in unadjusted or adjusted analyses. In the long term care hospitals, use of PPIs was associated with increased mortality (HR, 1.36; 95% CI 1.04-1.77) when adjusted for age, sex, comorbidity, use of SSRIs, and malnutrition. In the acute geriatric wards and nursing homes, use of PPIs was associated with increased mortality (HR, 1.90; 95% CI 1.23-2.94) when adjusted for age, sex, comorbidity, delirium, and use of aspirin and SSRIs.

CONCLUSION

PPIs were not associated with mortality among residents in assisted living facilities, but were associated with increased mortality in settings where residents experienced higher levels of disability and possible susceptibility to adverse drug events.

Efficacy of a home-based intervention programme on the physical activity level and functional ability of older people using domestic services: a randomised study

OBJECTIVE

Our main objective was to assess whether a home-based program supervised by home helpers (HH) during their normal working hours can prevent excessive sedentariness (mainly maximum walking time and distance) and preserve functional status in elderly people at risk for frailty or disability and using domestic services.

DESIGN

A four-month, open label, randomised trial with two groups called "prevention" and "control".

SETTING

In the homes of study participants.

PARTICIPANTS

The participants were all over 78 years old, lived independently at home, and received the visits of HHs at least once a week.

INTERVENTION

The intervention combined a self-administered exercise program, with 10 g amino-acid supplementation under the supervision of HHs.

MEASUREMENTS

Main outcome measures included physical activity (the PASE questionnaire), functional tests, nutritional and autonomy scores, and compliance (50% or more was considered satisfactory). Non-parametric methods were used for comparisons between the two groups. A linear regression model was fitted to assess the effect of the intervention on the relative variation of outcomes, adjusted for unbalanced baseline co-variables.

RESULTS

One hundred and two persons (prevention n=53, control n=49) with a median age of 85 years were included. Their median Activities of Daily Living and Instrumental Activities of Daily Living (IADL) scores were 6 and 7 respectively. Twenty-three (44%) were good compliers for both interventions. The maximum walking time remained stable while decreasing by 25% in the control group (p=0.0015); and fewer participants had a worsened IADL score in the prevention group (p=0.05). The baseline IADL Score was significantly associated with good compliance to the prevention program (p=0.0011). In good compliers, maximum walking distance and maximum walking time increased by 29.15% (0.0 to 66.7) and 33.3% (-20.0 to 50.0) respectively.

CONCLUSION

This study confirms the feasibility of a prevention program supervised by HHs, and some benefit from the intervention and identifies predictors for better compliance. It will help in the design of prevention trials for elderly people at risk for frailty.

Evidence-based dietary guidance and the role of dairy products for appropriate nutrition in the elderly

Food consumption surveys in the elderly come to the general conclusions that most elderly people outside institutions eat reasonably well. There is, however, tremendous variation in health status between older adults. The aging process is complex and influenced not only by factors intrinsic to the individual but also by extrinsic factors. The latter includes nutrition. In the various phases in the aging process, nutritional status and thus appropriate nutrition differ. Undernutrition is a great concern. In community-dwelling people older than 70 years, 5%-10% are undernourished, and for institutionalized elderly, this is up to 30%-65%. The cause is often inappropriate food consumption, and treatment is not always evidence based. National evidence-based dietary guidelines are mainly for healthy elderly people and vary between regions and even between institutes within the same region. To understand these differences, insight is required into the paradigm applied for nutritional science and the designs, selection of the older population, methodology, and endpoints of studies supplying the science behind the guidelines. A European project (Eurecca) compiles and harmonizes dietary guidelines. These activities underpin the need for sound evidence to improve the nutrition of older adults in different health phases. For frail elderly, there is also a plea to take into account results of studies on food satisfaction. First studies in this field show the effectiveness of an adapted social context for meals, appropriate nutritional care, and availability of tasty drinks and foods for selected groups of older adults. Because of the nutrient richness of dairy products and their good taste, these foods are helpful in the diet of healthy as well as frail elderly people. Key teaching points: Most elderly people eat reasonably well. There are, however, large differences in health status between elderly people and therefore also in nutrient requirements. Undernutrition is a main concern. In community-dwelling people older than 70 years, 5%-10% are undernourished, and for institutionalized elderly, this is up to 30%-65%. Evidence-based dietary guidelines are developed mainly for healthy elderly people and vary between regions. Harmonization will improve public health as well as clinical nutritional strategies. Given the nutrient density of dairy products, these products are included in balanced dietary advice for older adults.

Healthy eating perceptions of older adults living in Canadian rural and northern communities

Aging produces physiologic changes that can affect the nutritional health of the older adult. It is estimated that 80% of community-dwelling older adults have inadequate intakes of four or more nutrients. Socioeconomic factors, such as income and geographic location, can also play an important role in nutritional status; however, limited research is available that specifically explores this. The purpose of this qualitative study was to examine the healthy eating perceptions of older adults residing in rural and northern communities in one Canadian province. Five focus groups were conducted in three rural and two northern Manitoba communities. Thirty-nine older adults participated in audio-recorded focus groups. Five themes emerged from the discussions. All respondents stated that healthy eating was important, but knowledge deficits were observed regarding label reading, understanding and visualizing portion sizes, and vitamin D recommendations and sources. Food programs were not commonly attended by participants due to availably and resistance. Regularly delivered nutrition education programs would assist in providing current nutrition information to older adults and their families in rural settings.

Oral health-related quality of life and nutritional status of institutionalized elderly population aged 60 years and above in Mysore City, India

OBJECTIVE

To assess whether oral health-related quality of life (OHRQoL) is associated with nutritional status in the institutionalised elderly population of Mysore.

BACKGROUND

Malnutrition in the elderly has an evident impact on their general health and quality of life. Analysis of data of the Geriatric Oral Health Assessment Index (GOHAI) and their association with the Mini Nutritional Assessment (MNA) results improves our understanding of the complex relationship between oral health and malnutrition.

MATERIALS AND METHODS

The study was conducted among the institutionalised elderly population in Mysore city, Karnataka. Data on socio-demographic, oral health status were gathered. OHRQoL was evaluated using GOHAI, and malnutrition risk using MNA.

RESULTS

Out of 141 elderly, 41.1% were men and 58.9% were women with mean age of 72.2 ±7.5 years. Mean GOHAI score was 47.03 ± 9.2, with 69.5% had low perception of oral health. Mean MNA score was 9.91 ± 2.4, 15.6% were malnourished, 52.5% were at risk of malnutrition and 31.9% were adequately nourished. A strong association was found between the mean GOHAI and MNA scores.

CONCLUSION

 Oral health-related quality of life was associated with nutritional deficit, and it requires a greater integration between dentistry and nutrition in the health promotion of older adults.

Testing two self-care-related instruments among older home-dwelling people in Norway

BACKGROUND

Older persons' ability and agency for self-care is an important issue. Therefore, the development of reliable and valid instruments to measure self-care with regard to both clinical nursing practice and personal health is important for nursing research and practice. Aim and objective.  To test reliability and validity of the Norwegian versions of the two self-care-related instruments, the Self-care Ability Scale for the Elderly (SASE) and the Nutritional Form For the Elderly (NUFFE) among older home-dwelling individuals.

METHODS

A postal questionnaire that contained these instruments, background variables, health-related questions and two other self-care-related instruments was completed by a randomised sample of 158 older persons in southern Norway. Reliability was assessed as internal consistency and validity as concurrent and construct validity.

RESULTS

SASE reached a Cronbach's alpha coefficient of 0.85 and significant Spearman's rank correlations for 16 of 17 items. For NUFFE, a Cronbach's alpha coefficient of 0.64 was obtained and significant correlations for 13 of 15 items. Validity was supported for both instruments. An appropriate cut-off was found for SASE. For NUFFE, a low cut-off point was obtained.

CONCLUSIONS

SASE was shown to have sufficient psychometric properties and can be used in research and clinical practice among older persons. Implications for practice.  The psychometric properties of NUFFE can be assessed as sufficient, but further studies are needed regarding the cut-off point.

Mini-Nutritional-Assessment (MNA) without body mass index (BMI) predicts functional disability in elderly Taiwanese

Nutritional status and functional ability are mutually dependent especially in the elderly. This study examined the functional status-predictive ability of the MNA in a cross-sectional study. We analyzed the dataset of the "Survey of Health and Living Status of the Elderly in Taiwan" (SHLSET). Subjects were 2948≥65 year-old persons who were rated with the long-form (LF) and short-form (SF) MNA with or without BMI for the risk of malnutrition, and with the Activities of Daily Living (ADL) and the Instrument Activities of Daily Living (IADL) for functional status. The ADL and IADL scores were calculated according to rated nutritional status. Receiver Operating Characteristic (ROC) curves were generated for ADL and IADL status predicted by the MNA. Logistic regression was performed to evaluate the association of rated MNA scores with ADL or IADL status. Results showed that both SF and LF of MNA-T1 and T2 were able to predict ADL and IADL disabilities. Those who were rated malnourished or at risk of malnutrition had drastically higher risk of ADL or IADL dependency compared to those who were rated normal. The SF versions performed well in rating nutritional status and predicting ADL and IADL status. Overall, MNA-T2-SF performed at least equally well as MNA-T1-SF in rating functional decline. These results suggest the MNA is able to predict functional decline of the elderly. MNA-T2, especially the SF, a version without BMI should be particularly useful in clinical, long-term care and community settings.

Financial Strain Is Associated with Malnutrition Risk in Community-Dwelling Older Women

This study examined the relationship between financial strain, or difficulty acquiring necessities, and malnutrition risk in a community dwelling sample of frail and nonfrail women aged 70-79 in the Women's Health and Aging Study (n = 679). Malnutrition risk was measured with a modified version of the Mini-Nutritional Assessment Short Form (MNA-SF) and defined as a score <11, financial strain was measured by (1) sufficiency of money on a monthly basis and (2) adequacy of income for food, and income was measured by ordinal categories. Mean (SD) modified MNA-SF score was 12.2 (1.80), and 14.7% of women had malnutrition risk. Women who usually did not have enough money to make ends meet had more than four-fold increased odds of malnutrition risk (OR = 4.54; 95% CI: 2.26, 9.14) compared to their counterparts who had some money left over each month. This was only slightly attenuated after control for income and education, (OR = 4.08; 95% CI: 1.95, 8.52) remaining robust. These results show an association between financial strain and malnutrition risk, independent of income, in older women. Self-reported financial strain may be preferable to income as a screener for malnutrition risk in older adults in clinical and research settings.

Geriatric assessment tools

In addition to medical diseases, psychological, social, cognitive, and functional issues influence the health of older persons. Therefore, the traditional medical assessment alone is often not enough to evaluate the older population with multiple comorbidities. Out of this recognized need, the geriatric assessment has been developed, which emphasizes a broader approach to evaluating contributors to health in older persons. Geriatric assessment uses specific tools to help determine patient's status across several different dimensions, including assessment of medical, cognitive, affective, social, economic, environmental, spiritual, and functional status. This article reviews specific tools that practitioners can use in their screening for the following geriatric syndromes: hearing impairment, vision impairment, functional decline, falls, urinary incontinence, cognitive impairment, depression, and malnutrition. This article also reviews spiritual, economic, and social assessment. By identifying conditions that are common in the elderly, geriatric assessment can provide substantial insight into the comprehensive care of older persons, from those who are healthy and high-functioning to those with significant impairments and multiple comorbidities.

Diagnostic performance of the Minimal Eating Observation and Nutrition Form - Version II (MEONF-II) and Nutritional Risk Screening 2002 (NRS 2002) among hospital inpatients - a cross-sectional study

BACKGROUND

The usefulness of the nutritional screening tool Minimal Eating Observation and Nutrition Form - Version II (MEONF-II) relative to Nutritional Risk Screening 2002 (NRS 2002) remains untested. Here we attempted to fill this gap by testing the diagnostic performance and user-friendliness of the MEONF-II and the NRS 2002 in relation to the Mini Nutritional Assessment (MNA) among hospital inpatients.

METHODS

Eighty seven hospital inpatients were assessed for nutritional status with the 18-item MNA (considered as the gold standard), and screened with the NRS 2002 and the MEONF-II.

RESULTS

The MEONF-II sensitivity (0.61), specificity (0.79), and accuracy (0.68) were acceptable. The corresponding figures for NRS 2002 were 0.37, 0.82 and 0.55, respectively. MEONF-II and NRS 2002 took five minutes each to complete. Assessors considered MEONF-II instructions and items to be easy to understand and complete (96-99%), and the items to be relevant (87%). For NRS 2002, the corresponding figures were 75-93% and 79%, respectively.

CONCLUSIONS

The MEONF-II is an easy to use, relatively quick and sensitive screening tool to assess risk of undernutrition among hospital inpatients. With respect to user-friendliness and sensitivity the MEONF-II seems to perform better than the NRS 2002, although larger studies are needed for firm conclusions. The different scoring systems for undernutrition appear to identify overlapping but not identical patient groups. A potential limitation with the study is that the MNA was used as gold standard among patients younger than 65 years.

Association between oral health and body cell mass in hospitalised elderly

OBJECTIVE

To examine whether oral health in hospitalised elderly was associated with body cell mass (BCM) measured with Bioimpedance spectroscopy.

BACKGROUND

Body cell mass is the tissue producing the metabolic work necessary for all body functions. BCM is mainly muscle tissue. Low BCM is associated with diseases, ageing and poor nutritional status. Reduced oral health is also associated with these parameters; thus, BCM and oral health may be related.

METHODS

Body cell mass was measured using Bioimpedance spectroscopy in 138 acutely hospitalised elderly ≥70 years. The number of own teeth, posterior occluding tooth pairs and decayed teeth were registered. Oral hygiene was registered with Mucosal-Plaque Score, an index based on assessment of plaque accumulation and mucosal/gingival inflammation. Mini Nutritional Assessment-Short Form, body mass index and handgrip strength were used as nutritional indicators. Comorbidity was assessed with Cumulative Index Rating Scale.

RESULTS

Mean age was 83.2 ± 5.9 years, ranging from 70 to 101 years. Dentition status was significantly and positively associated with BCM. Reduced oral hygiene was significantly associated with low BCM. These findings remained significant after adjusting for confounders.

CONCLUSION

These results show that compromised oral health was significantly associated with reduced BCM in hospitalised elderly.

Evaluation of the efficacy of six nutritional screening tools to predict malnutrition in the elderly

BACKGROUND & AIMS

Malnutrition in the elderly is a multifactorial problem, more prevalent in hospitals and care homes. The absence of a gold standard in evaluating nutritional risk led us to evaluate the efficacy of six nutritional screening tools used in the elderly.

METHODS

Two hundred forty eight elderly patients (129 men, 119 female women, aged 75.2 ± 8.5 years) were examined. Nutritional screening was performed on admission using the following tools: Nutritional Risk Index (NRI), Geriatric Nutritional Risk Index (GNRI), Subjective Global Assessment (SGA), Mini Nutritional Assessment - Screening Form (MNA-SF), Malnutrition Universal Screening Tool (MUST) and Nutritional Risk Screening 2002 (NRS 2002). A combined index for malnutrition was also calculated.

RESULTS

Nutritional risk and/or malnutrition varied greatly, ranging from 47.2 to 97.6%, depending on the nutritional screening tool used. MUST was the most valid screening tool (validity coefficient = 0.766, CI 95%: 0.690-0.841), while SGA was in better agreement with the combined index (κ = 0.707, p = 0.000). NRS 2002 although was the highest in sensitivity (99.4%), it was the lowest in specificity (6.1%) and positive predictive value (68.2%).

CONCLUSIONS

MUST seem to be the most valid in the evaluation of the risk for malnutrition in the elderly upon admission to the hospital. NRS 2002 was found to overestimate nutritional risk in the elderly.

Evidence-based risk factors for adverse health outcomes in older patients after discharge home and assessment tools: a systematic review

The current health care system is discharging elderly patients "quicker" and "sicker" from acute care facilities. Consequently, hospital readmission is common; however, readmission may be only one aspect of adverse outcomes of importance to social work discharge planners. The early recognition of risk factors might ensure a successful transition from the hospital to the home. A systematic review was conducted to identify factors associated with adverse outcomes in older patients discharged from hospital to home. Using a content analysis, factors were characterized in five domains: demographic factors, patient characteristics, medical and biological factors, social factors, and discharge factors. The most frequently reported risks were depression, poor cognition, comorbidities, length of hospital stay, prior hospital admission, functional status, patient age, multiple medications, and lack of social support. A systematic search identified four discharge assessment tools for use with the general population of elderly patients. Practice and research implications are offered.

Usefulness of body mass index to characterize nutritional status in patients with heart failure

The obesity paradox in heart failure (HF) is criticized because of the limitations of body mass index (BMI) in correctly characterizing overweight and obese patients, necessitating a better evaluation of nutritional status. The aim of this study was to assess nutritional status, BMI, and significance in terms of HF survival. Anthropometry and biochemical nutritional markers were assessed in 55 HF patients. Undernourishment was defined as the presence of ≥2 of the following indexes below the normal range: triceps skinfold, subscapular skinfold, arm muscle circumference, albumin, and total lymphocyte count. Patients were also stratified by BMI and followed for a median of 26.7 months. Across BMI strata, no patient was underweight, 31% were normal weight, 42% were overweight, and 27% were obese. Undernourishment was present in 53% of normal-weight patients, 22% of overweight patients, and none of the obese patients (p = 0.001). Undernourished patients had significantly higher mortality (p = 0.009) compared to well-nourished patients. In multivariate analysis, only undernutrition (hazard ratio 3.149, 95% confidence interval 1.367 to 7.253), New York Heart Association functional class (hazard ratio 3.374, 95% confidence interval 1.486 to 7.659), and age (hazard ratio 1.115, 95% confidence interval 1.045 to 1.189) remained in the model. Among nutritional indicators, subscapular skinfold was the best predictor of mortality; patients with subscapular skinfold in the fifth percentile had higher mortality (p = 0.0001). In conclusion, BMI does not indicate true nutritional status in HF. Classifying patients as well nourished or undernourished may improve risk stratification.

[Geriatric assessment contribution to treatment decision-making in thoracic oncology]

BACKGROUND

Lung cancer is a frequently occurring disease among elderly people. The objective of this study was to search for a relationship between multimodal geriatric assessment and a decision-making in the treatment of patients with this condition.

METHODS

Forty-nine elderly patients (aged 70 years and over) diagnosed with a primary lung cancer underwent a geriatric assessment before decision for treatment was made in a multidisciplinary meeting. We described the impact of the geriatric assessment on the management decisions made.

RESULTS

Almost half of treatment (44.9%) decisions were modified by the geriatric assessment. For patients with so called "pre-frailty" according to Balducci's criteria, 60% of treatment decisions were modified by the results of geriatric assessment (use of only one chemotherapeutic drug, dose disease or best supportive care). For this group of patients, Folstein MMSE and IADL were predictive of change in decision-making, with the threshold estimated to be 26 points. Only the MMSE was significantly associated with the medical decision in multivariate analysis.

CONCLUSION

Geriatric assessment should be integrated into treatment decision-making for patients with primary lung cancer aged more than 70 years, particularly those where frailty is a concern. Folstein's MMSE was predictive in our study for changes in decision-making.

Complications and outcomes after spinal deformity surgery in the elderly: review of the existing literature and future directions

Object

The elderly population (age > 60 years) is the fastest-growing age group in the US. Spinal deformity is a major problem affecting the elderly and, therefore, the demand for surgery for spinal deformity is becoming increasingly prevalent in elderly patients. Much of the literature on surgery for adult deformity focuses on patients who are younger than 60 years, and therefore there is limited information about the complications and outcomes of surgery in the elderly population.

In this study, the authors undertook a review of the literature on spinal deformity surgery in patients older than 60 years. The authors discuss their analysis with a focus on outcomes, complications, discrepancies between individual studies, and strategies for complication avoidance.

Methods

A systematic review of the MEDLINE and PubMed databases was performed to identify articles published from 1950 to the present using the following key words: “adult scoliosis surgery” and “adult spine deformity surgery.” Exclusion criteria included patient age younger than 60 years. Data on major Oswestry Disability Index (ODI) scores, visual analog scale (VAS) scores, patient-reported outcomes, and complications were recorded.

Results

Twenty-two articles were obtained and are included in this review. The mean age was 74.2 years, and the mean follow-up period was 3 years. The mean preoperative ODI was 48.6, and the mean postoperative reduction in ODI was 24.1. The mean preoperative VAS score was 7.7 with a mean postoperative decrease of 5.2. There were 311 reported complications for 815 patients (38%) and 5 deaths for 659 patients (< 1%).

Conclusions

Elderly patient outcomes were inconsistent in the published studies. Overall, most elderly patients obtained favorable outcomes with low operative mortality following surgery for adult spinal deformity.

Mini-Nutritional Assessment predicts functional decline of elderly Taiwanese: result of a population-representative sample

Nutrition is a key element in geriatric health and is important for functional ability. The present study examined the functional status-predictive ability of the Mini-Nutritional Assessment (MNA). We analysed the dataset of the ‘Survey of Health and Living Status of the Elderly in Taiwan’, a population-based study conducted by the Bureau of Health Promotion of Taiwan. Study subjects ( ≥ 65 years old) who completed both the 1999 and 2003 surveys were rated with the long form and short form of the MNA at baseline and with the Activities of Daily Living (ADL) and the Instrument Activities of Daily Living (IADL) scales 4 years later (end-point). The ability of the MNA to predict ADL or IADL dependency was evaluated with logistic regression models. The results showed that the elderly who were rated malnourished or at risk of malnutrition at baseline generally had significantly higher ADL or IADL scores 4 years later. Lower baseline MNA scores also predicted a greater risk of ADL or IADL dependency. These associations exist even among the elderly who were free of ADL or IADL dependency at baseline. The results clearly indicate that the MNA is able to predict ADL and IADL dependency (in addition to rating current nutritional status) of the elderly. The MNA, especially the short form, should be a valuable tool for identifying elderly at risk of functional decline and/or malnutrition in clinical practice or community programmes.

Cut-off scores for the Minimal Eating Observation and Nutrition Form - Version II (MEONF-II) among hospital inpatients

Background and objective

The newly developed Minimal Eating Observation and Nutrition Form – Version II (MEONF-II) has shown promising sensitivity and specificity in relation to the Mini Nutritional Assessment (MNA). However, the suggested MEONF-II cut-off scores for deciding low/moderate and high risk for undernutrition (UN) (>2 and >4, respectively) have not been decided based on statistical criteria but on clinical reasoning. The objective of this study was to identify the optimal cut-off scores for the MEONF-II in relation to the well-established MNA based on statistical criteria.

Design

Cross-sectional study.

Methods

The study included 187 patients (mean age, 77.5 years) assessed for nutritional status with the MNA (full version), and screened with the MEONF-II. The MEONF-II includes assessments of involuntary weight loss, Body Mass Index (BMI) (or calf circumference), eating difficulties, and presence of clinical signs ofUN. MEONF-II data were analysed by Receiver Operating Characteristics (ROC) curves and the area under the curve (AUC); optimal cut-offs were identified by the Youden index (J=sensitivity+specificity–1).

Results

According to the MEONF-II, 41% were at moderate or high UN risk and according to the MNA, 50% were at risk or already undernourished. The suggested cut-off scores were supported by the Youden indices. The lower cut-off for MEONF-II, used to identify any level of risk for UN (>2; J=0.52) gave an overall accuracy of 76% and the AUC was 80%. The higher cut-off for identifying those with high risk for UN (>4; J=0.33) had an accuracy of 63% and the AUC was 70%.

Conclusions

The suggested MEONF-II cut-off scores were statistically supported. This improves the confidence of its clinical use.

Novel approaches to perioperative assessment and intervention may improve long-term outcomes after colorectal cancer resection in older adults

Colorectal cancer (CRC) is common among older adults and surgical resection with curative intent is the primary treatment of CRC. Despite the changing demographics of CRC patients and increasing prevalence of multiple comorbidities, surgery is increasingly performed in this complex aging population. Clinically important short-term outcomes have improved for this population, but little is known about long-term outcomes. We review the literature to evaluate trends in CRC surgery in the geriatric population and the outcomes of surgical treatment. We explore the specific gaps in understanding longitudinal patient-centered outcomes of CRC treatment. We then propose adaptations from the geriatrics literature to better predict both short and long-term outcomes after CRC surgery. Interventions, such as prehabilitation, coupled with comprehensive geriatric assessment may be important future strategies for identifying vulnerable older patients, ameliorating the modifiable causes of vulnerability, and improving patient-centered longitudinal outcomes. Further research is needed to determine relevant aspects of geriatric assessments, identify effective intervention strategies, and demonstrate their validity in improving outcomes for at-risk older adults.

A roadmap of aging in Russia: the prevalence of frailty in community-dwelling older adults in the St. Petersburg district--the "Crystal" study

OBJECTIVES

To categorize the health problems of older Russians and identify the number of frail older adults using different approaches.

DESIGN

Cross-sectional study.

SETTING

The Kolpino district of St. Petersburg.

PARTICIPANTS

A random sample of 611 community-dwelling adults aged 65 and older was selected from a population-based register and stratified into two age groups (65-74, ≥75).

MEASUREMENTS

Anthropometry, medical history, nutritional status, Physical Performance Battery, activities of daily living, grip strength, spirometry, renal function, 15-item Geriatric Depression Scale, Mini-Mental State Examination, and sense of coherence.

RESULTS

The female:male ratio was 2.5:1; 19% were malnourished or at risk for malnutrition, and 78.6% presented with one to three chronic pathologies, with no differences according to age or sex. Problems with hearing (60.7%), vision (89.5%), and incontinence (40.9%) were highly prevalent. Moreover, 25.9% of the younger group (65-74) and 42.5% of the older group (≥75) were found to be at risk for depression. Mild to severe cognitive impairment was found in 34.5% of the participants, and 14.4% of those aged 65 to 74 and 33.0% of those aged 75 and older reported dependence in daily living activities. The prevalence of frailty assessed using different models varied from 21.1% to 43.9%. The Fried model revealed the strongest associations with the frailty outcomes (dependence and performance). No significant differences between the sexes were found in either age group (P=.82), although the percentage of frail women increased with age (P=.001).

CONCLUSION

The findings emphasize the need for attention and resources to be shifted from disease-oriented to functional approaches in the older Russian population. The population studied is consistent with the Fried model, in which one in five older adults can be labeled as frail.

Long-form but not short-form Mini-Nutritional Assessment is appropriate for grading nutritional risk of patients on hemodialysis--a cross-sectional study

BACKGROUND

Routine screening/assessment of protein-energy status is essential for preventing uremic malnutrition in patients on hemodialysis (HD). A simple, low cost, reliable and non-invasive tool is greatly desired.

OBJECTIVE

This study aimed to evaluate the appropriateness of using the long-form (LF) and the short-form (SF) Mini Nutritional Assessment (MNA) for grading the risk of protein-energy malnutrition in patients on HD. DESIGN AND SAMPLING: A cross-sectional study with purposive sampling.

SETTING

A hospital-managed hemodialysis center.

PARTICIPANTS

152 adult ambulatory patients on hemodialysis.

METHODS

The nutritional status of each patient was graded with MNA-LF and MNA-SF, each in two versions--a normalized-original (content-equivalent) version (by adopting population-specific anthropometric cut-off points) and an alternative version that replaced calf circumference for BMI in the scale. The SGA, serum albumin and serum creatinine served as references. Cross-tabulation test was used to evaluate the consistency of the versions.

RESULTS

MNA-SF versions rated fewer HD subjects malnourished or at risk of malnutrition (32.2% and 24.3% for T1 and T2, respectively) compared to MNA-LF versions (40.8% and 36.2%) or the SGA (47.4%). MNA-SF versions (kappa=0.450 and 0.446) also did not perform as well as MNA-LF versions (kappa=0.734 and 0.666) in predicting the risk of malnutrition in HD patients using the SGA as the reference. MNA-SF also did not perform as well as the MNA-LF using serum albumin or serum creatinine as the reference.

CONCLUSIONS

The MNA-LF is appropriate for predicting protein-energy malnutrition in HD patients but MNA-SF may under-rate these patients. Effort should be made to improve the MNA-SF for HD patients since the short-form is more time-efficient and thus, greatly desired in clinical practice.

Concomitant use of SSRIs, NSAIDs/aspirin and gastroprotective drugs among residents of long-term care facilities: a medical record review

BACKGROUND AND OBJECTIVES

Concomitant use of selective serotonin reuptake inhibitors (SSRIs) and nonsteroidal anti-inflammatory drugs (NSAIDs) [including aspirin (acetylsalicylic acid)] may potentiate the likelihood of upper gastrointestinal haemorrhage (UGIH). The objectives of this study were to determine the prevalence and factors associated with concomitant SSRI/NSAID use among residents of long-term care facilities, and to investigate the use of gastroprotective drugs among concomitant SSRI/NSAID users.

METHODS

The study sample comprised 1087 out of 1444 residents of all 53 long-term care wards in Helsinki, Finland, in September 2003. Data were extracted from residents' medication charts and medical records by trained nurses. Medication, diagnostic and mortality data were available for 1004 residents.

RESULTS

Among the 1004 residents (mean ± SD age 81.3 ± 10.9 years), 28% used an SSRI, 38% used an NSAID and 24% used a gastroprotective drug. Thirteen percent of residents were concomitant users of SSRIs/NSAIDs. Concomitant use was associated with diabetes mellitus (p < 0.001), previous stroke (p < 0.001) and a higher degree of co-morbidity (p < 0.001). Gastroprotective drugs were used by 27% of concomitant users of SSRIs/NSAIDs compared with 37%, 20% and 22% of SSRI users, NSAID users and non-users of SSRIs/NSAIDs, respectively. One-year all-cause mortality was similar among all groups.

CONCLUSION

The long-term facility residents in this study sample were frequently exposed to drug-drug interactions that potentiate the risk of UGIH. Only about one-quarter of concomitant users of SSRIs/NSAIDs were prescribed a gastroprotective drug. Further initiatives are needed to optimize the use of SSRIs, NSAIDs and gastroprotective drugs.

Body composition assessment of undernourished older subjects by dual-energy x-ray absorptiometry and bioelectric impedance analysis

BACKGROUND

The prevention and treatment of diseases related to changes in body composition require accurate methods for the measurement of body composition. However, few studies have dealt specifically with the assessment of body composition of undernourished older subjects by different methodologies.

OBJECTIVES

To assess the body composition of undernourished older subjects by two different methods, dual energy x-ray absorptiometry (DXA) and bioelectric impedance (BIA), and to compare results with those of an eutrophic group.

DESIGN

The study model was cross-sectional; the study was performed at the University Hospital of the School of Medicine of Ribeirão Preto, University of São Paulo, Brazil.

PARTICIPANTS

Forty-one male volunteers aged 62 to 91 years. The groups were selected on the basis of anamnesis, physical examination and nutritional assessment according to the Mini Nutritional Assessment (MNA) score. Body composition was assessed by DXA and BIA.

RESULTS

Body weight, arm and calf circumference, body mass index (BMI), fat free mass (FFM) and fat mass (FM) were significantly lower in the undernourished group as compared to the eutrophic group. There were no significant differences between FFM and FM mean values determined by DXA and BIA in both groups, but the agreement between methods in the undernourished group was less strong.

CONCLUSION

Our results suggest caution when BIA is to be applied in studies including undernourished older subjects. This study does not support BIA as an accurate method for the individual assessment of body composition.

Depression among the very old with dementia

OBJECTIVES

The aim of this study was to investigate the prevalence of depression among very old individuals with dementia compared to those without dementia and to examine if there were any differences regarding associated factors between people with or without depression in these conditions.

METHODS

In a population-based study in Sweden, 363 participants aged 85 years and above, were evaluated for depression and dementia.

RESULTS

The prevalence of depression was significantly higher among the people with dementia than without dementia, 43% vs. 24% (p < 0.001). Approximately 2/3 of the depressed in both groups used antidepressants and of those, approximately 50% had responded. Depression in the group without dementia was, among other factors, associated with higher total number of medication, the use of significant more analgesics and benzodiazepines, loneliness, inability of going outside and recent loss of child. The loss of a child was the only factor that was independently associated with depression in those with dementia.

CONCLUSIONS

The present study confirms that in the very old, depression is more common among people with dementia than without dementia. A large proportion, both with and without dementia, are under-diagnosed and untreated, and in addition many subjects in both groups studied were non-responders to treatment. Many of the factors associated with depression among people without dementia in this study were not associated with depression among those with dementia, thus supporting the theory that the spectrum of associated factors for depression in dementia seems to be different from that for depression in people without dementia.

Prevalence of malnutrition in orally and tube-fed elderly nursing home residents in Germany and its relation to health complaints and dietary intake

Objective. To investigate the prevalence of malnutrition in orally and tube-fed nursing home (NH) residents in Germany and its relation to common health complaints and dietary intake. Methods. In 350 NH residents, subjects' characteristics, Mini Nutritional Assessment (MNA), and several health problems were inquired with the nursing staff using standardised interviews. In a subset of 122 residents, dietary intake was assessed by 3-day weighing records. Results. 7.7% of the participants were tube fed. 24.1% of orally nourished and 57.7% of tube-fed residents were malnourished (MNA < 17 p.). Malnutrition was significantly related to nausea/vomiting, constipation, pressure ulcers, dehydration, infections, antibiotic use, and hospitalisation. Mean daily energy intake was 1535 ± 413 kcal and mean protein intake was 54.2 ± 0.9 g/d irrespective of the nutritional state. Conclusion. In Germany, malnutrition is widespread among NH residents and is related to common health problems. The MNA rather reflects health condition than currently reduced dietary intake.

Nutritional approach for inhibiting bone resorption in institutionalized elderly women with vitamin D insufficiency and high prevalence of fracture

BACKGROUND

Nutritional approach to the deterioration of bone integrity and increased fracture risk appears to be particularly appropriate in elderly women living in nursing homes.

OBJECTIVE

To investigate the beneficial effect of the consumption of soft plain cheese on bone resorption markers in institutionalized elderly women.

DESIGN

Prospective, randomized crossover controlled study.

SETTING

Six French nursing homes or other institutions for elderly.

PARTICIPANTS

Institutionalized women ≥ 65 years old with low vitamin D status and calcium intake below 700 mg/day.

INTERVENTION

Consumption of soft plain cheese made of semi-skimmed milk which was fortified by both vitamin D3 (+1.25 µg/100g) and milk extracted Ca, thus achieving a total Ca content of 151 mg/100g as compared to about 118 mg/100g for standard fresh cheese. Two servings were taken every day during the 6 weeks that preceded or followed a period of 6 weeks without soft plain cheese consumption.

MEASUREMENTS

The primary end point was the change in serum carboxy terminal cross-linked telopeptide of type I collagen (CTX) selected as a marker of bone resorption.

RESULTS

29 women aged 73-94 yr were selected, 21 of them with mean age 87.2±6.1 years remained compliant. The intervention increased calcium and protein intakes by 51% (904±228 vs. 599±122 mg/d) and 33 % (74.2±17.1 vs. 55.6±12.7 g/d, mean±SD), respectively. The dietary intervention was associated with a statistically significant increase in serum levels of both 25OHD and IGF-I, while those of [corrected] CTX and TRAP5b were significantly reduced. Compliance was 93,4 %. The daily consumption of two servings of soft plain cheese was well accepted in terms of tastiness and appetite suited portion size.

CONCLUSION

This randomized crossover controlled trial demonstrates that in elderly women living in nursing homes, the consumption of soft plain cheese increasing the supply of vitamin D, calcium and proteins, could reduce bone resorption and thereby reduce the risk of incidental fragility fractures in the long term.

Hypodipsia discriminates progressive supranuclear palsy from other parkinsonian syndromes

BACKGROUND

The objective of this study was to evaluate whether the sensation of thirst differs between patients with progressive supranuclear palsy (PSP), multiple system atrophy with predominant parkinsonism (MSA-P), and Parkinson's disease (PD).

METHODS

We administered a standardized thirst questionnaire to age-, sex-, and stage-matched patients with probable PSP, PD, and MSA-P and healthy controls (HC), n = 15/group. In an independent cohort (n = 10/group), we provoked thirst by infusing hypertonic NaCl in age-, sex-, and stage-matched patients with PSP, PD, and MSA-P and recorded plasma osmolality and thirst (visual analog scale).

RESULTS

On questioning, 73% of PSP patients reported a reduced sensation of thirst (hypodipsia) compared with previous years (HC, 0%; PD, 7%; MSA-P, 7%; P < .0001). On NaCl infusion, PSP patients reported significantly lower thirst than did PD and MSA-P patients for all times from 20 to 95 minutes (P < .05). The thirst score at 25 minutes discriminated individual PSP patients well from PD and MSA-P patients.

CONCLUSIONS

Hypodipsia appears helpful in differentiating PSP from PD and MSA-P.

Suitability of the short-form Mini Nutritional Assessment in free-living elderly people in the northwest of Spain

OBJECTIVE

To evaluate the Mini Nutritional Assessment (MNA) test and the short-form MNA (MNA-SF) as screening tools for malnutrition risk and malnutrition in the free-living elderly of northwestern Spain.

DESIGN

transversal study.

SETTING

free-living elderly people of northwestern Spain.

SUBJECTS

728 participants (36.4% men and 63.6% women), the average of age for both genders was 80.7 ± 7.4.

RESULTS

according to MNA screening 12.5% subjects were classified as undernutrition (MNA < 17) and 57.5% were at risk for undernutrition (17 ≤ MNA ≤ 23.5). Significant correlations were found between MNA-SF and the full version (r=0.916; p < 0.000). The sensibility and specificity of the MNA-SF for the full MNA version were 81.4% and 92.7%, respectively. The regression analyses showed that weight loss had more influence on the MNA score, followed by the Body Mass Index (BMI), acute illness or psychological stress, mobility, self-perceived health status and neuropsychological problems.

CONCLUSIONS

These data showed a high prevalence of undernutrition risk among the free-living elderly people in northwestern Spain using the MNA test in two steps. The high sensitivity and specificity of MNA-SF might be sufficient for medical practice to identify patients at undernutrition risk or undernutrition. Generally, the full MNA confirmed the diagnosis for persons identified at risk by the MNA-SF, and planning was needed for nutritional interventions.

Self-reported socio-economic status, social, physical and leisure activities and risk for malnutrition in late life: a cross-sectional population-based study

OBJECTIVES

Our goal was to evaluate the proportion of community-dwelling elderly people at risk for malnutrition and the effect of different socioeconomic status (SES) indicators as well as social, physical and leisure activities in late life on the risk for malnutrition.

DESIGN

A cross-sectional population-based study.

SETTING

A sub-urban area in Northern Italy.

PARTICIPANTS

698 community-dwelling older persons.

MEASUREMENTS

The nutritional status of participants was assessed through the Mini Nutritional Assessment-Short Form (MNA-SF). SES was defined by means of early-life education, longest occupation, and late-life financial conditions. The following indicators were also evaluated: social contacts, and performing mental, physical and leisure activities during late-life. Chronic diseases, functional, cognitive and affective status were considered as potential confounders when examining the risk for malnutrition by logistic regression models.

RESULTS

8% of the participants (average age 75.6 years, 408 women) were at risk for malnutrition (MNA-SF ≤ 11). Low education, poor financial condition, and lack of physical and leisure activities showed a crude association with risk for malnutrition. Multi-adjusted logistic regression models showed that only low education (OR=2.9; 95% CI=1.2-6.8) and lack of physical activity (OR=4.4;95%CI=2.0-9.7) were independently associated with the risk for malnutrition.

CONCLUSIONS

Low education and lack of physical activity in late-life may affect the risk for malnutrition in the elderly. Further studies are needed to clarify the cause-effect relationship between lack of physical activity and malnutrition.

Analysis of the food consumption of 87 elderly nursing home residents, depending on food texture

OBJECTIVES

Texture-modified food (chopped, mashed, or mixed) is often used for patients, and particularly for dependent elderly people facing swallowing disorders or dental problems. Food must be energy and protein enriched, because dilution is needed for preparation, and several meals like bread can be removed. The aim of the study was to assess the food consumption of residents in four French nursing homes depending on diet texture. DESIGN/PARTICIPANTS/MEASUREMENTS: The food consumption of 87 elderly people followed by a nutrition network, randomly taken and living in nursing homes in which texture-modified food enrichment was practiced was evaluated according to the type of texture used.

RESULTS

13.8% of residents had chopped texture and 29.9% mixed texture. There was no relationship between used food textures and nutritional status residents. Calorie consumption was below the recommended intakes for elderly nursing home residents in France, whatever the type of texture. The mixed texture had more protein than the normal one and was better balanced regarding fat intake. Protein consumption was at the lower limit of the recommended intakes. Residents in overweight were those whose food consumption relative to their weight was the lowest.

CONCLUSION

It seems important to check the mode of preparation of texture-modified food in nursing homes and to assess the real energy and protein consumptions of residents receiving this food.

Nutritional screening tools for HIV-infected patients: implications for elderly patients

BACKGROUND

Nutrition is a crucial issue for elderly HIV-infected patients. Screening tools (''DETERMINE your nutrition health checklist'' [NSI], the Mini-Nutritional Assessment [MNA], the Malnutrition Universal Screening Tool [MUST] test, and the modified version of the Subjective Global Assessment [SGA]-HIV) might not detect problems in visceral fat accumulation, visceral protein loss, and lipodystrophy in elderly HIV-positive populations.

METHODS

Literature review of articles in English, French, and Spanish published in Medline and Cochrane databases through January 2010.

RESULTS

New studies question the use of body mass index (BMI) and weight loss as proxies for nutritional problems in HIV-positive patients. In the case of elderly HIV-infected patients, screening tools to deal with the aforementioned issues are currently being investigated.

CONCLUSION

The authors suggest that a unique nutritional screening test that contains measures including BMI, weight loss, waist-to-hip (W/H) ratio, and mid-arm circumference may be able to detect nutritional problems in elderly patients infected with HIV. Further trials combining these 4 anthropometric measures in elderly HIV-infected patients are needed.

Nutritional status in older adults with mild cognitive impairment living in elderly homes in Cairo, Egypt

OBJECTIVES

To delineate the difference in nutritional risk between older adults with normal cognitive function and mild cognitive impairment living in elderly homes.

DESIGN

Cross-sectional study.

SETTING

Three elderly homes in Cairo, Egypt.

PARTICIPANTS

One hundred twenty older adults; men and women aged 60 years and older.

MEASUREMENTS

Comprehensive geriatric assessment was done for every participant to evaluate medical, functional, cognitive and affective aspects. Nutritional status was assessed by using the mini-nutritional assessment (MNA). Nutritional deficit was considered to be present if the individuals were classified as malnourished or at nutritional risk by means of the MNA. The cognitive function was assessed by using the Mini-Mental State Examination (MMSE) and the Montreal Cognitive Assessment (MoCA).

RESULTS

MCI was identified in 46 (38.3%) of the participants. According to the MNA classification, 58 (48.3%) of the sample study was assessed as well nourished, 49 (40.8%) at risk of malnutrition and 13 (10.8%) as malnourished. Older adults with MCI had significantly higher frequency of being at risk of malnutrition or malnourished than those with normal cognition. Multiple logistic regression analysis revealed that the associations between MCI and nutritional deficit remained significant after adjustment for age, illiteracy, female gender and depression.

CONCLUSION

These results suggest that MCI may be associated with nutritional risk, which emphasizes the importance of early identification of nutritional status among individuals with MCI. It remains to be demonstrated whether improvement in nutritional status may improve the cognitive function or delay progression to dementia in these patients.