Estimated height from knee-height in Caucasian elderly: implications on nutritional status by mini nutritional assessment

Predictive energy equations for spinal muscular atrophy type I children

BACKGROUND

Knowledge on resting energy expenditure (REE) in spinal muscular atrophy type I (SMAI) is still limited. The lack of a population-specific REE equation has led to poor nutritional support and impairment of nutritional status.

OBJECTIVE

To identify the best predictors of measured REE (mREE) among simple bedside parameters, to include these predictors in population-specific equations, and to compare such models with the common predictive equations.

METHODS

Demographic, clinical, anthropometric, and treatment variables were examined as potential predictors of mREE by indirect calorimetry (IC) in 122 SMAI children consecutively enrolled in an ongoing longitudinal observational study. Parameters predicting REE were identified, and prespecified linear regression models adjusted for nusinersen treatment (discrete: 0 = no; 1 = yes) were used to develop predictive equations, separately in spontaneously breathing and mechanically ventilated patients.

RESULTS

In naïve patients, the median (25th, 75th percentile) mREE was 480 (412, 575) compared with 394 (281, 554) kcal/d in spontaneously breathing and mechanically ventilated patients, respectively (P = 0.009).In nusinersen-treated patients, the median (25th, 75th percentile) mREE was 609 (592, 702) compared with 639 (479, 723) kcal/d in spontaneously breathing and mechanically ventilated patients, respectively (P = 0.949).Both in spontaneously breathing and mechanically ventilated patients, the best prediction of REE was obtained from 3 models, all using as predictors: 1 body size related measurement and nusinersen treatment status. Nusinersen treatment was correlated with higher REE both in spontaneously breathing and mechanically ventilated patients. The population-specific equations showed a lower interindividual variability of the bias than the other equation tested, however, they showed a high root mean squared error.

CONCLUSIONS

We demonstrated that ventilatory status, nusinersen treatment, demographic, and anthropometric characteristics determine energy requirements in SMAI. Our SMAI-specific equations include variables available in clinical practice and were generally more accurate than previously published equations. At the individual level, however, IC is strongly recommended for assessing energy requirements. Further research is needed to externally validate these predictive equations.

Clinical nutrition and physical rehabilitation in a long-term care setting: preliminary observations in sarcopenic older patients

BACKGROUND

Sarcopenia could have a negative prognostic impact in long-term care residents, which are characterized by multiple comorbidities and a high level of dependence. However, there is limited evidence on its prevalence and management in this healthcare setting.

METHODS

All residents living in a long-term care institution were screened for the presence of sarcopenia. Sarcopenic patients in whom functional status could be assessed were included, based on the Tinetti scale (TS) score, in two parallel single-arm trials and received a specific nutritional supplement for muscle mass recovery in combination (TS ≥ 10) or not (TS < 10) with a supervised physical exercise rehabilitation program for 12 months. The nutritional supplement was administered twice daily for the first 6 months; none for 3 months and again twice daily for the last 3 months.

RESULTS

We screened 95 residents and 81 had low skeletal muscle mass (SMM) according to bioimpedance. Thirty-nine residents were included in the intervention phase due to sarcopenia. At 6 months, patients receiving nutritional support alone (n = 17) showed a significant improvement in body weight (P = 0.009) and composition with an increase in SMM (from 15.3 ± 4.1 to 17.0 ± 5.1 kg, P = 0.013) and SMM index (SMI; from 6.24 ± 1.07 to 6.91 ± 1.54 kg/m², P = 0.013), but not in handgrip strength (HS). Patients assigned to the multidisciplinary program (n = 22) showed an improvement in both muscle mass [SMM (from 16.6 ± 6.0 to 17.3 ± 5.7 Kg, P = 0.050) and SMI (from 6.63 ± 1.65 to 6.91 ± 1.52 kg/m², P = 0.038)] and functional status [HS (from 13.5 ± 5.0 to 15.6 ± 6.7; P = 0.028), gait speed (from 0.44 ± 0.18 to 0.51 ± 0.20, P = 0.047) and Short Physical Performance Battery (from 4.6 ± 3.1 to 5.5 ± 3.2, P = 0.047)] at 6 months. The effect was no longer present after discontinuation of the intervention and was restored after its re-introduction at 12 months.

CONCLUSIONS

Nutritional and multidisciplinary interventions tailored on patient's functional status could be considered as strategies for the management of sarcopenia, a high prevalent condition in old adults living in long-term care institutions.

Prevalence of malnutrition and sarcopenia in a post-acute care geriatric unit: Applying the new ESPEN definition and EWGSOP criteria

BACKGROUNDS & AIMS

The European Society of Clinical Nutrition and Metabolism (ESPEN) consensus definition of malnutrition has been applied in hospitalized older diabetics and middle-aged patients, geriatric outpatients, and healthy elderly and young individuals. In a post-acute care setting, our aim was to assess malnutrition (ESPEN definition) and determine its relationship with sarcopenia in older in-patients deconditioned due to an acute process.

METHODS

Eighty-eight in-patients aged ≥70 years with body mass index (BMI) <30 kg/m² were included (84.1 years old; 62% women) and screened for malnutrition risk using biochemical markers and Mini-Nutritional Assessment-Short Form (MNA-SF). The ESPEN definition was applied: 1) BMI <18.5 kg/m² or 2) unintentional weight loss plus a) low BMI or b) low fat-free mass index (FFMI). European Working Group on Sarcopenia in Older People (EWGSOP) criteria were also applied.

RESULTS

Unintentional weight loss occurred in 27 (30.7%) of 88 in-patients considered "at risk" by MNA-SF. Malnutrition prevalence was 4.5%, 7.9%, and 17% using ESPEN definitions 1, 2a, and 2b, respectively; 19.3% were malnourished. Prevalence of sarcopenia was 37.5%, of which 90.9% fulfilled ESPEN malnutrition criteria, a significant association (p = 0.02). No differences in biochemical markers were observed between patients with or without malnutrition or sarcopenia.

CONCLUSIONS

ESPEN criteria constitute an appropriate tool to establish a malnutrition diagnosis in post-acute care. Sarcopenia, as defined by EWGSOP, was present in 37.5% of patients, of which 90.9% fulfilled ESPEN criteria; therefore, malnutrition was significantly related to sarcopenia. Additional work is needed to determine further implications of the ESPEN consensus definition.

Validation of bioelectrical impedance analysis for estimating limb lean mass in free-living Caucasian elderly people

BACKGROUND & AIMS

Aging is characterized by a loss of limb lean mass (LLM) that can lead to physical disability and death. Regional bioelectrical impedance analysis (BIA) may be a reliable method for estimating LLM, but no prediction equations are available for elderly Caucasian subjects. The aim of this study was to develop and validate a BIA-based equation for predicting LLM in healthy elderly Caucasians, taking dual X-ray absorptiometry (DXA) as the reference method.

METHODS

Using a cross-sectional design, 244 free-living healthy Caucasian subjects (117 men, 179 women) over 60 years of age were enrolled. LLM was measured with DXA (LLM_DXA), and the resistance (Rz) and reactance (Xc) of each limb were measured with a regional bioelectrical impedance analyzer. A resistive index (RI) was calculated from stature in meters divided by Rz of each arm. A BIA-based multiple regression equation for predicting the lean mass (LM) of dominant and non-dominant limbs was developed using a double cross-validation technique.

RESULTS

Using the sample as a whole, cross-validation resulted in an equation specific for each limb, as follows, where sex equals 1 for males, and 0 for females: LM (kg) = -0.081 + (0.061*RI) + (0.010*body weight) + (0.299*sex) for the dominant arm; LM (kg) = -0.026 + (0.014*RI) + (0.009*body weight) + (0.352*sex) for the non-dominant arm; LM (kg) = -0.462 + (0.027*RI) + (0.047*body weight) + (0.639*sex) + (0.026*Xc) for the dominant leg; and for the non-dominant leg, LM (kg) = -0.522 + (0.029*RI) + (0.045*body weight) + (0.569*sex) + (0.025*Xc). The DXA-measured and BIA-predicted LLM for each limb did not differ significantly.

CONCLUSION

Our newly-developed BIA equations seem to provide a valid estimation of LLM in older Caucasian adults.

Nutritional Care Needs in Elderly Residents of Long-Term Care Institutions: Potential Implications for Policies

OBJECTIVES

To collect information on actual nutritional intervention requirements in long-term care institutions and on the role of institutional factors in nutritional care.

DESIGN

A cross-sectional analysis of baseline data (collected between September 2011 and September 2013) within the context of a multicenter prospective cohort study.

SETTING

Nineteen long-term care institutions.

PARTICIPANTS

Thirteen hundred and ninety-four resident elderly (age ≥60 years).

MEASUREMENTS

The prevalence of nutritional derangements (MNA-Short Form) and the need to introduce nutritional interventions on the residents.

RESULTS

Prevalence of malnutrition and risk of malnutrition were 35.2% [95%CI, 32.8-37.8] and 52.6% [95%CI, 50.0-55.2], respectively. Malnutrition was more frequent upon admission and in larger institutions (≥50 beds). Overall, 50% of the residents requiring an individualized nutritional care plan (any type) were not receiving it. Oral diet, the use of fluid thickeners and oral nutritional supplements had to be introduced in 306 (22.5%), 201 (15%) and 175 (13%) residents, respectively. The need to implement the oral diet was mainly due to inadequacy of texture according to chewing and swallowing capabilities. In gender and age-adjusted multivariable logistic regression models, nutritional interventions were associated with worse nutritional status (P<0.001 for all). Moreover, while the duration of stay was unrelated to the need for nutritional interventions, we observed that residents living in larger long-term care institutions (≥50 beds) were more likely to require improvement in nutrition care.

CONCLUSIONS

In long-term care elderly residents nutritional derangements are very common, underdiagnosed and undertreated. Nutritional screening should be part of routine care. However, also the systematic involvement of a nutritional care specialist appears to be an urgent need, particularly in larger institutions where the standards of care are likely to be lower.

Altura do joelho como medida alternativa confiável na avaliação nutricional de idosos

Objetivo:Avaliar o uso da altura do joelho como medida alternativa confiável na avaliação nutricional de idosos atendidos em um ambulatório de geriatria.Métodos:Estudo transversal com idosos atendidos em ambulatório de geriatria de um hospital universitário, entre novembro de 2009 e novembro de 2010. Variáveis investigadas: gênero, idade, peso, estatura, altura do joelho, estatura estimada através das equações de Chumlea, índice de massa corporal para as medidas de estatura aferida e estimada e classificado segundo Lipschitz, e dados sociodemográficos. Na análise descritiva dos dados foram usadas medidas de tendência central, dispersão e proporção; a homogeneidade entre as medidas foi verificada através do coeficiente de correlação intraclasse e do gráfico de Bland e Altman e a concordância entre a avaliação nutricional baseada no índice de massa corporal calculado a partir da estatura aferida e a avaliação nutricional baseada no índice de massa corporal calculado a partir da estatura estimada foi avaliada através do coeficiente Kappa ponderado com pesos quadráticos.Resultados:Foram avaliados 186 idosos com média de idade de 74,3±7,1 anos. A média do índice de massa corporal aferido e estimado foi 28,96±5,86 kg/m2e 27,95±5,47 kg/m2, respectivamente, e a prevalência de sobrepeso foi de 59,7% para o índice de massa corporal aferido e 53,2% para o estimado. Foi observada uma boa concordância (Kappa=0,79; p<0,001) entre as duas avaliações.Conclusão:Os resultados mostraram ser possível utilizar a altura do joelho na estimativa da estatura para cálculo do índice de massa corporal em idosos atendidos em ambulatório, alternativa útil para aqueles que apresentam limitações na aferição das medidas, sendo esta uma medida alternativa importante na avaliação nutricional de idosos.

High degree of BMI misclassification of malnutrition among Swedish elderly population: Age-adjusted height estimation using knee height and demispan

BACKGROUND/OBJECTIVES

The degree of misclassification of obesity and undernutrition among elders owing to inaccurate height measurements is investigated using height predicted by knee height (KH) and demispan equations.

SUBJECTS/METHODS

Cross-sectional investigation was done among a random heterogeneous sample from five municipalities in Southern Sweden from a general population study 'Good Aging in Skåne' (GÅS). The sample comprised two groups: group 1 (KH) including 2839 GÅS baseline participants aged 60-93 years with a valid KH measurement and group 2 (demispan) including 2871 GÅS follow-up examination participants (1573 baseline; 1298 new), aged 60-99 years, with a valid demispan measurement. Participation rate was 80%. Height, weight, KH and demispan were measured. KH and demispan equations were formulated using linear regression analysis among participants aged 60-64 years as reference. Body mass index (BMI) was calculated in kg/m(2).

RESULTS

Undernutrition prevalences in men and women were 3.9 and 8.6% by KH, compared with 2.4 and 5.4% by standard BMI, and more pronounced for all women aged 85+ years (21% vs 11.3%). The corresponding value in women aged 85+ years by demispan was 16.5% vs 10% by standard BMI. Obesity prevalences in men and women were 17.5 and 14.6% by KH, compared with 19.0 and 20.03% by standard BMI. Values among women aged 85+ years were 3.7% vs 10.4% by KH and 6.5% vs 12.7% by demispan compared with the standard.

CONCLUSIONS

There is an age-related misclassification of undernutrition and obesity attributed to inaccurate height estimation among the elderly. This could affect the management of patients at true risk. We therefore propose using KH- and demispan-based formulae to address this issue.

Food security: who is being excluded? A case of older people with dementia in long-term care homes

OBJECTIVES

PURPOSE

To explore the extent of food security among older people, particularly those with cognitive impairments residing in Canadian long-term care homes (LTCHs) through a focused review of literature.

METHOD

Databases including Medline, Nursing and Health Sciences (SAGE), Psych Info, Social Sciences Abstract, the Cumulative Index of Nursing and Allied Health Literature (CINAHL) and HealthSTAR were searched for peer-reviewed articles related to food experiences of older individuals in industrialized countries including Canada. Only articles that were published in English between 1997-2012 were included.

RESULTS

Sixty two studies met the inclusion criteria. Of those 17 focused on older adults in LTCHs. The review found that food security has rarely been examined among older persons living in LTCHs, and has never been examined within the context of cognitive impairment. While a few studies have focused on residents' satisfaction with foods that are provided to them in LTCHs, none have explored the extent of food security in this population. Furthermore, food satisfaction surveys in the LTCH are limited to the assessment of foods that are served to residents, and do not capture residents' food accessibility beyond the food dispensing routines of the organization. Thus, food quality, food preferences, and the traditional meanings and rituals associated with food consumption are not purposefully evaluated. In addition, LTCHs are not required to monitor residents' food satisfaction using a consistent, regular, and standardized approach and there is no regulation in the LTCH Act that requires LTCHs to assess their residents' food security.

CONCLUSIONS

The findings highlight the need for: 1) expansion of food security research to non-community-based settings including LTCHs; 2) re-conceptualization of food security and modification of measurement tools to assess the extent and determinants of food security among older adults in LTCHs; 3) mandatory monitoring of food security via standardized and regular surveys tailored to meet the unique preferences and needs of the older population, particularly those with dementia; and 4) education of healthcare professionals regarding food security and its assessment in LTCHs.

Nutritional risk, functional status and mortality in newly institutionalised elderly

Previous studies have reported a close relationship between nutritional and functional domains, but evidence in long-term care residents is still limited. We evaluated the relationship between nutritional risk and functional status and the association of these two domains with mortality in newly institutionalised elderly. In the present multi-centric prospective cohort study, involving 346 long-term care resident elderly, nutritional risk and functional status were determined upon admission by the Geriatric Nutritional Risk Index (GNRI) and the Barthel Index (BI), respectively. The prevalence of high (GNRI <92) and low (GNRI 92–98) nutritional risk were 36·1 and 30·6 %, respectively. At multivariable linear regression, functional status was independently associated with age (P=0·045), arm muscle area (P=0·048), the number of co-morbidities (P=0·027) and mainly with the GNRI (P<0·001). During a median follow-up of 4·7 years (25th–75th percentile 3·7–6·2), 230 (66·5 %) subjects died. In the risk analysis, based on the variables collected at baseline, both high (hazard ratio (HR) 1·86, 95% CI 1·32, 2·63; P<0·001) and low nutritional risk (HR 1·52, 95% CI 1·08, 2·14; P=0·016) were associated with all-cause mortality. Participants at high nutritional risk (GNRI <92) also showed an increased rate of cardiovascular mortality (HR 1·93, 95% CI 1·28, 2·91; P<0·001). No association with outcome was found for the BI. Upon admission, nutritional risk was an independent predictor of functional status and mortality in institutionalised elderly. Present data support the concept that the nutritional domain is more relevant than functional status to the outcome of newly institutionalised elderly.

Nutritional risk and gastrointestinal dysautonomia symptoms in Parkinson's disease outpatients hospitalised on a scheduled basis

Dysautonomia symptoms of nutritional interest may often occur in Parkinson's disease (PD), but the role played in affecting the risk of malnutrition still needs to be clarified. A total of 208 consecutive PD outpatients hospitalised on a scheduled basis were assessed for nutritional risk by the Malnutrition Universal Screening Tool. Presence of dysautonomia symptoms (dysphagia, sialorrhoea and constipation) was investigated using clinical rating scales. In our population, prevalence of nutritional risk was 17·2 (95 % CI 12·1, 24·0) % and relied mainly on unintentional weight loss. Sialorrhoea, dysphagia, dysphagia to liquids and constipation were observed in 10·6, 11·0, 14·4 and 59·6 % of the patients, respectively. Nutritional risk was independently associated with the number of dysautonomia symptoms (OR 1·39 (95 % CI 1·00, 1·96); P= 0·048) but not with single symptoms. An independent association was also found with the severity of motor symptoms (Hoehn-Yahr stage, OR 1·48 (95 % CI 1·00, 2·55); P= 0·049) and levodopa dose (OR 1·16 (95 % CI 1·04, 1·31) mg/kg per d; P= 0·009). Nutritional risk in PD outpatients appears to depend mainly on dysautonomic syndrome, disease severity and levodopa dosage. Implications for outcome deserve further investigation. The assessment of nutritional status and of gastrointestinal dysautonomia symptoms should be part of the routine work-up of a PD patient.

Mini nutritional assessment

PURPOSE OF REVIEW

To summarize recent evidences and advances on the implementation and the use of the Mini Nutritional Assessment (MNA).

RECENT FINDINGS

Despite being introduced and validated for clinical use about 20 years ago, the MNA has recently received new attention in order to more widely disseminate among healthcare professionals the practice of a systematic nutritional screening and assessment of the old patient. Particularly, the structure has been implemented to face the difficulties in having the patients contributing to the assessment and to reduce further the time required to complete the evaluation. Recent data also confirm that in older populations prevalence of malnutrition by this tool is associated with the level of dependence. The rationale of nutritional assessment is to identify patients candidate to nutritional support. However, the sensitivity of the MNA is still debated because it has been associated with a high-risk 'overdiagnosis' and the advantages of a positive screening need to be assessed both in terms of outcome and money saving.

SUMMARY

The MNA is a simple and highly sensitive tool for nutritional screening and assessment. The large mass of data collected and the diffusion among healthcare professionals clearly support its use. However, the cost-effectiveness of interventions based on its scoring deserves investigation.

Anthropometric, body composition and health determinants of active ageing: a gender approach

This study applied a gender perspective to establish some of the anthropometric, body composition, health and socio-cultural determinants of active ageing. The variable 'active ageing' (presence/absence) was created based on cognitive and disability/illness/physical functioning, subjective health, satisfaction with life and productive activity performed, and used in predictive models to establish its relationship with anthropometric variables, physical health indicators and educational level. The sample consisted of 456 home-living individuals (169 men and 287 women; age range 54-75 years) from Madrid and Toledo in Spain. The women had a higher prevalence of obesity than the men (37.6% vs 29.0%), significantly greater fat accumulation in the abdominal area and worst perceived health (p=0.003). The frequency of active agers is higher in men than in women (38.4% vs 21.9%; p<0.001). Men and women were found to have distinctive ageing patterns. Health factors condition the presence of active ageing in women, while education factors are also relevant in men.