Malnutrition in Very Old Hospitalized Patients: A New Etiologic Factor of Anemia?

Nutrition-associated markers and outcomes among patients receiving enteral nutrition after ischemic stroke: a retrospective cohort study

BACKGROUND

Early nutrition after acute ischemic stroke is crucial. We explored early enteral nutrition for stroke patients and evaluated changes in blood indicators as a predictor of stroke prognosis.

METHODS

All hospitalized stroke patients receiving enteral nutrition were included in the study. We retrospectively collected the protein, energy, fat, and carbohydrate values for 7 days after admission. Serum albumin, total protein, and hemoglobin values were reviewed at admission and at one week. The main outcome indicators were the Modified Rankin Score, Barthel Index, and Quality of Life at 3 months.

RESULTS

A total of 354 patients (mean age, 70.7 years; 59.0% male) were included. The change in serum albumin at day 7 relative to at admission was positively correlated with the Quality of Life score (p = 0.001), the Barthel Index (p = 0.004), and the modified Rankin Score (p = 0.029). The change in total protein at day 7 relative to at admission was positively correlated with the Quality of Life score (p = 0.002), the Barthel Index (p = 0.001), and the modified Rankin score (p = 0.011). The change in hemoglobin values at day 7 relative to at admission was positively correlated with the Barthel Index (p = 0.037 but not with the Quality of Life score (p = 0.237) or the modified Rankin score (p = 0.730).

CONCLUSIONS

Improved nutrition-related blood indicators one week after admission were independently associated with good stroke outcomes. Nutritional support for acute ischemic stroke patients during the early hospitalization stage appears to be advisable.

TRIAL REGISTRATION

This review was a retrospective cohort study. The study was retrospectively registered in the Chinese Clinical Trial Registry (No: ChiCTR2300077228). Registration date: 1/11/2023.

Measures for Identifying Malnutrition in Geriatric Rehabilitation: A Scoping Review

Malnutrition is a common condition in geriatric rehabilitation settings; however, the accuracy and predictive validity of the measures to identify malnutrition have not been established. The current scoping review followed the Joanna Briggs Institute's evidence synthesis manual and the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Extension for Scoping Reviews checklist. Literature published through September 2023 was searched using MEDLINE and CINAHL. The inclusion criteria selected studies reporting malnutrition measures, which include static body weight and weight loss. Identified tools were classified as nutritional screening tools, nutritional assessment tools, or diagnostic criteria. The domains of each tool/criterion and their accuracy and predictive validity were extracted. Fifty-six articles fulfilled the inclusion criteria, and six nutritional screening tools, three nutritional assessment tools, and three diagnostic criteria for malnutrition were identified. These measures consisted of various phenotypes, e.g., weight loss, causes such as inflammation/disease, and risk factors of malnutrition, e.g., functional impairment. The predictive validity of nutritional screening tools (n = 6) and malnutrition diagnostic criteria (n = 5) were inconsistently reported, whereas those for nutritional assessment tools were scarce (n = 1). These findings highlight the need to distinguish the functional impairment of nutritional origin from that of non-nutritional origin in nutritional assessment procedures, and the need to study the accuracy and the predictive validity of these measures in geriatric rehabilitation patients.

Nutritional Status of People with a Coexisting Chronic Wound and Extended Assessment Using Bioelectrical Impedance

The diagnosis of malnutrition should be one of the pillars of comprehensive patient care, especially in the case of patients with large wounds, prolonged healing, or comorbidities. The condition for a reliable and accurate nutritional diagnosis is to link it with the parameters of nutritional status assessment at the basic level (anthropometric measurements and clinical assessment) and in depth (biochemical tests and bioelectrical impedance). A prospective study included a sample of 60 patients with coexisting chronic wounds (venous ulcers, diabetic foot syndrome, pressure injury) treated at the Wound Treatment Clinic of Fr. B. Markiewicz Podkarpackie Oncology Center (Poland). The method of estimation and diagnostic survey was used; the research tool was a scientific research protocol consisting of four parts. Self-care capacity was assessed based on the Barthel scale, nutritional status using blood biochemical parameters, and electrical bioimpedance. Wounds were classified according to the extent, depth of tissue structures, and potential infection. Subjects with pressure ulcers had statistically significantly lower fat-free mass component indices compared to those with diabetic foot syndrome and venous ulceration. The subjects with pressure ulcers had significantly lower values of body composition components compared to those with diabetic foot syndrome and venous ulcers. In the group of patients with pressure ulcers, the lowest values of albumin (3.20 g/dL), hemoglobin (10.81 g/dL), and nutritional risk index (NRI) (88.13 pts.) scores were confirmed. Subjects with pressure ulcers with limited self-care presented a non-physiological nutritional status, indicating a risk of malnutrition. Local actions related to wound treatment should be preceded by a general examination, considering the state of augmented nutrition with the use of electrical bioimpedance.

Night fasting as an alternative to improve nutritional support and glycaemic control in hospitalised patients with exclusive enteral nutrition

BACKGROUND

Enteral nutrition (EN) assists in the nutritional status of hospitalised patients unable to feed orally. The aim of this study was to determine which method-continuous EN or discontinuous EN, a diet in which the infusion is discontinued for 4h during the night,-is more effective in meeting nutrient recommendations and improving glycaemic control and biochemical parameters related to protein anabolism.

METHODS

Patients were divided into two groups: discontinuous (EN administered in mL/h, 18h/day, 4-h night fasting) and continuous (EN administered in mL/h, 22h/day). All patients with EN receive the diet over a 22-h daily period, in which the diet is suspended for two hours/day for daily hospital routines such as bathing, and physiotherapy, and followed for seven days. Evaluated data: prescribed and administered volume, calories, protein, and fibre; capillary blood glucose; erythrogram; serum albumin.

RESULTS

52 patients were followed-up, with 23 (44.2%) in the discontinuous group and 29 (55.8%) in the continuous group. Compared with the continuous group, the discontinuous group received volumes closer to those prescribed, equal or higher calories, and more protein. The capillary glucose values were within the reference range in the discontinuous group, while the continuous group presented elevated values. Both groups presented hypoalbuminaemia, haemoglobin, and haematocrit below the reference values; however, in the discontinuous group, the serum albumin values improved during hospitalisation relative to the continuous.

CONCLUSIONS

The method involving discontinuation of EN for 4h was more effective in meeting nutrient recommendations compared with the continuous method. Additionally, in the discontinuous group, we observed a better control of glycaemia when compared to that of the continuous group.

Anemia of geriatric patients

Anemia is a common finding in the elderly. Approximately 10 percent of the elderly suffers from anemia. Anemia per se is an independent factor of mortality in older patients regardless its cause. Frailty is also frequent in geriatric patients. That means that there is a decreased reserve capacity to react to different stress factors including anemia. The frequent presence of heart failure and also impaired cerebrovascular circulation makes more difficult to tolerate anemia in older age.

Anemia is a symptom, finding and treating the underlying cause is also important.

Treatment always depends on clinical findings: the more severe the symptoms, the more important to treat them. Severity of anemia depends not only the underlying cause, degree of anemia, co-morbidities and frailty of the patients, but also the speed of its development. Sudden blood loss due to an accident is less well tolerated than the same degree of anemia due to B12 deficiency.

Main causes of anemia in the elderly include nutritional deficiencies, chronic diseases, tumors, and certain hematological malignancies such as chronic lymphocytic leukemia, multiple myeloma, myelodysplastic syndrome.

Correlation between nutritional status and oral health quality of life, self-efficacy of older inpatients and the influencing factors

OBJECTIVE

This study explores the relationship between nutritional status and oral health quality of life, the self-efficacy of older inpatients and the correlative factors.

METHODS

In this study, the convenience sampling method was used to select 307 older inpatients in the southern section of the Renji Hospital affiliated to Shanghai Jiao Tong University School of Medicine from October to December 2020 as the main research participants. A mini nutritional assessment questionnaire was used to assess nutritional status, and the Chinese version of a geriatric oral health assessment index questionnaire was used to determine the oral health quality of life. Self-efficacy was assessed by a general self-efficacy scale questionnaire. Descriptive statistics were used to analyse data using the SPSS 22.0 software. Pearson correlation and multiple linear regression analysis were applied to explore the correlation between variables and factors concerned with nutritional status, respectively.

RESULTS

The results of this study showed that the self-efficacy and oral health quality of life of older inpatients were at a moderate level. Among the patients, 263 had one or more tooth defects, and only 128 had oral restorations or wore dentures. The risk of malnutrition in hospitalised older patients was 37.1%, and the incidence of malnutrition was 13.4%. The risk factors of nutritional status of older patients were age, oral-related quality of life, prealbumin index, self-efficacy, chronic disease, monthly income and tooth defect (P < 0.05).

CONCLUSION

The incidence of malnutrition and malnutrition risk in hospitalised older patients is relatively high. The main associated factors include age, tooth defect, oral health quality of life, self-efficacy, chronic disease status and monthly income. Therefore, older inpatients, especially those with prosthodontic problems, should carry out nutritional assessments, intervention and graded management as soon as possible to improve their self-efficacy, improve their nutrition and health status and reduce the incidence of a poor prognosis.

Optimal Protein Intake in Pre-Dialysis Chronic Kidney Disease Patients with Sarcopenia: An Overview

Multi-factors, such as anorexia, activation of renin-angiotensin system, inflammation, and metabolic acidosis, contribute to malnutrition in chronic kidney disease (CKD) patients. Most of these factors, contributing to the progression of malnutrition, worsen as CKD progresses. Protein restriction, used as a treatment for CKD, can reduce the risk of CKD progression, but may worsen the sarcopenia, a syndrome characterized by a progressive and systemic loss of muscle mass and strength. The concomitant rate of sarcopenia is higher in CKD patients than in the general population. Sarcopenia is also associated with mortality risk in CKD patients. Thus, it is important to determine whether protein restriction should be continued or loosened in CKD patients with sarcopenia. We may prioritize protein restriction in CKD patients with a high risk of end-stage kidney disease (ESKD), classified to stage G4 to G5, but may loosen protein restriction in ESKD-low risk CKD stage G3 patients with proteinuria <0.5 g/day, and rate of eGFR decline <3.0 mL/min/1.73 m²/year. However, the effect of increasing protein intake alone without exercise therapy may be limited in CKD patients with sarcopenia. The combination of exercise therapy and increased protein intake is effective in improving muscle mass and strength in CKD patients with sarcopenia. In the case of loosening protein restriction, it is safe to avoid protein intake of more than 1.5 g/kgBW/day. In CKD patients with high risk in ESKD, 0.8 g/kgBW/day may be a critical point of protein intake.

Betwixt and between: a surgical post-acute treatment unit (SPA) for the optimal care of elderly patients with isolated hip fractures

BACKGROUND

A performance improved project identified elderly trauma patients to have a disproportionate incidence of complications.

AIMS

The purpose of this study was to assess the efficacy of a small specialty care unit to decrease complications in patients who no longer warrant care in an intensive care unit (ICU).

METHODS

A surgical post-acute treatment unit (SPA) was developed with focused attention to cognition, nutrition, respiration, and mobilization needs of patients who no longer had physiologic need for an intensive care unit environment, but were still in need of increased attention at the bedside.

RESULTS

While ICU and hospital lengths of stay were unchanged, patients placed in the SPA experienced less complications and required less unplanned ICU re-admissions.

DISCUSSION

Geriatric patients, especially the elderly, are not simply old adults. They have unique needs as a consequence of the aging process, which can be encompassed by four pillars of intercession: cognition, nutrition, respiration, and mobilization.

CONCLUSIONS

By adapting a physical environment supported by bedside attention to address the interwoven needs of geriatric and elderly patients who no longer care in an ICU, complications and unplanned return admissions to the ICU can be decreased.

LEVEL OF EVIDENCE

III.

Nutritional assessment of older adults with diabetes mellitus

AIMS

We aimed to screen the nutritional status of older adults with diabetes mellitus, seeking to outline the needs of this population group considering their socioeconomic status.

METHODS

Cross-sectional study of 246 diabetic people aged 65-94 years in Northeastern Brazil. Semi-structured questionnaires were used to collect sociodemographic, general health and lifestyle data. The Mini Nutritional Assessment was used to screen nutritional status.

RESULTS

Participants' mean age was 73 ± 6.4 years, and there was a predominance of women (56.5%). The mean duration of diabetes was 14.1 years (±9.6 years). Patients aged 80 years or older presented a 3.7-fold higher risk of malnutrition (p < 0.001), and those who were uneducated exhibited a 5.8-fold higher risk of malnutrition (p = 0.040). Patients with BMI of 18.6-24.9 km/m² presented a 2.2-fold higher risk of malnutrition than overweight or obese patients (p < 0.001). Nutritional status was significantly associated with coronary artery disease (p = 0.010) and stroke (p < 0.001). Malnourished patients exhibited a 2.2-fold higher occurrence of infection in the past 6 months (p = 0.017) and 2-fold higher occurrence of foot injuries (p = 0.028) than their well-nourished peers.

CONCLUSION

Malnutrition in older diabetic patients exacerbates underlying diseases and contributes to unfavorable prognosis, particularly in the oldest old and in individuals with low levels of education.

The role of the Patient-Generated Subjective Global Assessment (PG-SGA) and biochemical markers in predicting anemia patients with cancer

PURPOSE

The causes of anemia and the common side effects of cancer are multifactorial. Malnutrition is one of the alleged components of the aforementioned complications. This study planned to investigate the relationship among biochemical markers, Patient-Generated Subjective Global Assessment (PG-SGA), and anemia in cancer patients.

METHODS

This analysis consisted of 234 patients who were enlisted in the Department of Oncology of the First Hospital of Shanxi Medical University between December 2016 and October 2017. The groups were divided into anemic and non-anemic patients. The gathered data primarily discussed the patients' basic information, specifically the age, gender, smoking, alcohol consumption, and nutritional status based on levels of serum biochemical markers and PG-SGA scores.

RESULTS

Among the participants, 31.2% of the cancer patients were diagnosed with anemia whereas, according to the scores of PG.SGA, 65.0% of patients experienced malnourishment. The anemia was significantly associated with biochemical markers, expecting a transferrin in univariable analyses. Binary logistic regression analysis between anemic cancer patients and non-anemic cancer patients suggested that high PG-SGA score (odds ratio 1.082; 95% CI 1.027-1.141) implied the risk factor for anemia, and high PG-SGA scores could potentially increase the risk of anemia. The multiple regression analysis showed that hemoglobin concentration (OR 0.575; 95% CI 0.450-0.736) and PG-SGA score (OR 1.231; 95% CI 1.013-1.496) were linked to anemia. However, total protein, albumin, prealbumin, serum iron, transferrin, and transferrin saturation lacked a strong relationship with anemia.

CONCLUSION

Anemia prevailed in cancer patients, as nutritionally assessed by PG-SGA, while hemoglobin established a linkage with anemia as they could provide extra predictive information about anemia in patients diagnosed with cancer.

Intakes, Adequacy, and Biomarker Status of Iron, Folate, and Vitamin B12 in Māori and Non-Māori Octogenarians: Life and Living in Advanced Age: A Cohort Study in New Zealand (LiLACS NZ)

Advanced-age adults may be at risk of iron, folate, and vitamin B₁₂ deficiency due to low food intake and poor absorption. This study aimed to investigate the intake and adequacy of iron, folate, and vitamin B₁₂ and their relationship with respective biomarker status. Face-to-face interviews with 216 Māori and 362 non-Māori included a detailed dietary assessment using 2 × 24-h multiple pass recalls. Serum ferritin, serum iron, total iron binding capacity, transferrin saturation, red blood cell folate, serum folate, serum vitamin B₁₂ and hemoglobin were available at baseline. Regression techniques were used to estimate the association between dietary intake and biomarkers. The Estimated Average Requirement (EAR) was met by most participants (>88%) for dietary iron and vitamin B₁₂ (>74%) but less than half (>42%) for folate. Increased dietary folate intake was associated with increased red blood cell (RBC) folate for Māori (p = 0.001), non-Māori (p = 0.014) and serum folate for Māori (p < 0.001). Folate intake >215 µg/day was associated with reduced risk of deficiency in RBC folate for Māori (p = 0.001). Strategies are needed to optimize the intake and bioavailability of foods rich in folate. There were no significant associations between dietary iron and vitamin B₁₂ intake and their respective biomarkers, serum iron and serum vitamin B₁₂.

Malnutrition in Hospitalised Older Adults: A Multicentre Observational Study of Prevalence, Associations and Outcomes

BACKGROUND

Malnutrition is common in older adults and is associated with high costs and adverse outcomes. The prevalence, predictors and outcomes of malnutrition on admission to hospital are not clear for this population.

DESIGN

Prospective Cohort Study.

SETTING

Six hospital sites (five public, one private).

PARTICIPANTS

In total, 606 older adults aged 70+ were included. All elective and acute admissions to any speciality were eligible. Day-case admissions and those moribund on admission were excluded.

MEASUREMENTS

Socio-demographic and clinical data, including nutritional status (Mini-Nutritional Assessment - short form), was collected within 36 hours of admission. Outcome data was collected prospectively on length of stay, in-hospital mortality and new institutionalisation.

RESULTS

The mean age was 79.7; 51% were female; 29% were elective admissions; 67% were admitted to a medical specialty. Nutrition scores were available for 602/606; 37% had a 'normal' status, 45% were 'at-risk', and 18% were 'malnourished'. Malnutrition was more common in females, acute admissions, older patients and those who were widowed/ separated. Dementia, functional dependency, comorbidity and frailty independently predicted a) malnutrition and b) being at-risk of malnutrition, compared to normal status (p < .001). Malnutrition was associated with outcomes including an increased length of stay (p < .001), new institutionalisation (p =<0.001) and in-hospital mortality (p < .001).

CONCLUSIONS

These findings support the prioritisation of nutritional screening in clinical practice and public health policy, for all patients ≥70 on admission to hospital, and in particular for people with dementia, increased functional dependency and/or multi-morbidity, and those who are frail.