Prevalence of anemia and malnutrition and their association in elderly nursing home residents

Applying generative AI with retrieval augmented generation to summarize and extract key clinical information from electronic health records

BACKGROUND

Malnutrition is a prevalent issue in aged care facilities (RACFs), leading to adverse health outcomes. The ability to efficiently extract key clinical information from a large volume of data in electronic health records (EHR) can improve understanding about the extent of the problem and developing effective interventions. This research aimed to test the efficacy of zero-shot prompt engineering applied to generative artificial intelligence (AI) models on their own and in combination with retrieval augmented generation (RAG), for the automating tasks of summarizing both structured and unstructured data in EHR and extracting important malnutrition information.

METHODOLOGY

We utilized Llama 2 13B model with zero-shot prompting. The dataset comprises unstructured and structured EHRs related to malnutrition management in 40 Australian RACFs. We employed zero-shot learning to the model alone first, then combined it with RAG to accomplish two tasks: generate structured summaries about the nutritional status of a client and extract key information about malnutrition risk factors. We utilized 25 notes in the first task and 1,399 in the second task. We evaluated the model's output of each task manually against a gold standard dataset.

RESULT

The evaluation outcomes indicated that zero-shot learning applied to generative AI model is highly effective in summarizing and extracting information about nutritional status of RACFs' clients. The generated summaries provided concise and accurate representation of the original data with an overall accuracy of 93.25%. The addition of RAG improved the summarization process, leading to a 6% increase and achieving an accuracy of 99.25%. The model also proved its capability in extracting risk factors with an accuracy of 90%. However, adding RAG did not further improve accuracy in this task. Overall, the model has shown a robust performance when information was explicitly stated in the notes; however, it could encounter hallucination limitations, particularly when details were not explicitly provided.

CONCLUSION

This study demonstrates the high performance and limitations of applying zero-shot learning to generative AI models to automatic generation of structured summarization of EHRs data and extracting key clinical information. The inclusion of the RAG approach improved the model performance and mitigated the hallucination problem.

Anemia and Its Connections to Inflammation in Older Adults: A Review

Anemia is a common hematological disorder that affects 12% of the community-dwelling population, 40% of hospitalized patients, and 47% of nursing home residents. Our understanding of the impact of inflammation on iron metabolism and erythropoiesis is still lacking. In older adults, anemia can be divided into nutritional deficiency anemia, bleeding anemia, and unexplained anemia. The last type of anemia might be caused by reduced erythropoietin (EPO) activity, progressive EPO resistance of bone marrow erythroid progenitors, and the chronic subclinical pro-inflammatory state. Overall, one-third of older patients with anemia demonstrate a nutritional deficiency, one-third have a chronic subclinical pro-inflammatory state and chronic kidney disease, and one-third suffer from anemia of unknown etiology. Understanding anemia's pathophysiology in people aged 65 and over is crucial because it contributes to frailty, falls, cognitive decline, decreased functional ability, and higher mortality risk. Inflammation produces adverse effects on the cells of the hematological system. These effects include iron deficiency (hypoferremia), reduced EPO production, and the elevated phagocytosis of erythrocytes by hepatic and splenic macrophages. Additionally, inflammation causes enhanced eryptosis due to oxidative stress in the circulation. Identifying mechanisms behind age-related inflammation is essential for a better understanding and preventing anemia in older adults.

Acute blood loss anemia in hospitalized patients is associated with adverse outcomes: An analysis of the Nationwide Inpatient Sample

BACKGROUND

Acute blood loss anemia is the most common form of anemia and often results from traumatic injuries or gastrointestinal bleeding. There are limited studies analyzing outcomes associated with acute blood loss anemia in hospitalized patients.

METHODS

The Nationwide Inpatient Sample (NIS) was analyzed from 2010 to 2014 (n = 133,809). The impact of acute blood loss anemia on in-hospital mortality, length of stay (LOS), healthcare cost, and disposition was determined using regression modeling adjusted for age, gender, race, and comorbidities.

RESULTS

Hospitalized patients with acute blood loss anemia had significantly higher healthcare cost (adj OR 1.04; 95% CI: 1.04-1.05), greater lengths of stay (adj OR 1.18; 95% CI: 1.17-1.18), and were less likely to be discharged home compared to the general medical population (adj OR 0.27; 95% CI: 0.26-0.28). Acute blood loss anemia was associated with increased risk for mortality in unadjusted models (unadj 1.16; 95% CI: 1.12-1.20) but not in adjusted models (adj OR 0.91; 95% CI: 0.88-0.94). When analyzing comorbidities, a "muscle loss phenotype" had the strongest association with mortality in patients with acute blood loss anemia (adj OR 4.48; 95% CI: 4.35-4.61). The top five primary diagnostic codes associated with acute blood loss anemia were long bone fractures, GI bleeds, cardiac repair, sepsis, and OB/Gyn related causes. Sepsis had the highest association with mortality (18%, adj OR 2.59; 95% CI: 2.34-2.86) in those with acute blood loss anemia.

CONCLUSIONS

Acute blood loss anemia is associated with adverse outcomes in hospitalized patients.

The Urgent Need for Nutritional Medical Care in Geriatric Patients-Malnutrition in Nursing Homes

Patients aged 65 and over who are accommodated in hospitals and nursing homes are at high risk of malnutrition and often show signs of it. The future relevance of this problem becomes clear, especially in view of the demographic development of the coming years and decades. In this study, the correlation between malnutrition, hypoalbuminemia, anemia, elevated CRP, and low transferrin levels, as well as mortality in seniors between 65 and 100 years, should be revealed. Therefore, the prevalence of disease-specific malnutrition (DRM), according to the criteria of the guidelines of the German Society of Nutritional Medicine (DGEM), and the prevalence of hypoalbuminemia were presented based on the data of 120 residents who were inpatients in a large Viennese nursing home between 01/2017 and 08/2020. Moreover, 86 of the inpatient residents were women and 34 were men, with a mean age of 84 years (SD: 8.7). In this examination, more than one-third of nursing home residents were malnourished. More than half of the residents were found to have low serum albumin or low transferrin saturation. However, no correlation between elevated CRP, low transferrin, or low serum albumin values and malnutrition could be established. Residents with low serum albumin or low transferrin levels, however, had a higher mortality rate. This study supports the urgent relevance of closer and individually personalized medical nutritional interventions, especially concerning hypoalbuminemic seniors aged 65 years and older.

[The proper use of carboxymaltose iron and its economic impact in the geriatric wards of a French university hospital]

The proper use and economic impact of carboxymaltose iron were evaluated for patients hospitalized in the geriatric wards of a French university hospital from November 2019 to April 2020. Martial supplementation was recommended for 75.7% of the 173 patients who received carboxymaltose iron: 43.4% had a real indication for carboxymaltose iron, while 14.4% could have received sucrose iron and 17.9% could have received per os iron. Compliance with the recommendations would have generated savings of 10,345.80 euros (32.1%).

Mortality, Cardiovascular, and Medication Outcomes in Patients With Myocardial Infarction and Underweight in a Meta-Analysis of 6.3 Million Patients

Although most of the current evidence on myocardial infarction focuses on obesity, there is growing evidence that patients who are underweight have unfavorable prognosis. This study aimed to explore the prevalence, clinical characteristics, and prognosis of this population at risk. Embase and Medline were searched for studies reporting outcomes in populations who were underweight with myocardial infarction. Underweight and normal weight were defined according to the World Health Organization criteria. A single-arm meta-analysis of proportions was used to estimate the prevalence of underweight in patients with myocardial infarction, whereas a meta-analysis of proportions was used to estimate the odds ratio of all-cause mortality, medications prescribed, and cardiovascular outcomes. Twenty-one studies involving 6,368,225 patients were included, of whom 47,866 were underweight. The prevalence of underweight in patients with myocardial infarction was 2.96% (95% confidence interval 1.96% to 4.47%). Despite having fewer classical cardiovascular risk factors, patients who were underweight had 66% greater hazard for mortality (hazard ratio 1.66, 95% confidence interval 1.44 to 1.92, p <0.0001). The mortality of patients who were underweight increased from 14.1% at 30 days to 52.6% at 5 years. Nevertheless, they were less likely to receive guideline-directed medical therapy. Relative to subjects with normal weight, Asian populations who were underweight had greater mortality risks than those of their Caucasian counterparts (p = 0.0062). In conclusion, in patients with myocardial infarction, those who were underweight tend to have poorer prognostic outcomes. A lower body mass index is an independent predictor of mortality, which calls for global efforts in addressing this modifiable risk factor in clinical practice guidelines.

Pancytopenia Secondary to Vitamin B12 Deficiency in Older Subjects

BACKGROUND

Vitamin B12 (cobalamin CBL) is a water-soluble vitamin required to form hematopoietic cells (red blood cells, white blood cells, and platelets). It is involved in the process of synthesizing DNA and myelin sheath. Deficiencies of vitamin B12 and/or folate can cause megaloblastic anemia (macrocytic anemia with other features due to impaired cell division). Pancytopenia is a less frequent exordium of severe vitamin B12 deficiency. Vitamin B12 deficiency can also cause neuropsychiatric findings. In addition to correcting the deficiency, an essential aspect of management is determining the underlying cause because the need for additional testing, the duration of therapy, and the route of administration may differ depending on the underlying cause.

METHODS

Here, we present a series of four patients hospitalized for megaloblastic anemia (MA) in pancytopenia. All patients diagnosed with MA were studied for a clinic-hematological and etiological profile.

RESULTS

All the patients presented with pancytopenia and megaloblastic anemia. Vitamin B12 deficiency was documented in 100% of cases. There was no correlation between the severity of anemia and deficiency of the vitamin. Overt clinical neuropathy was present in none of the cases of MA, while subclinical neuropathy was seen in one case. The etiology of vitamin B12 deficiency was pernicious anemia in two cases and low food intake in the remaining cases.

CONCLUSION

This case study emphasizes the role of vitamin B12 deficiency as a leading cause of pancytopenia among adults.

Malnutrition and its contributing factors for older people living in residential aged care facilities: Insights from natural language processing of aged care records

BACKGROUND

Malnutrition is a serious health risk facing older people living in residential aged care facilities. Aged care staff record observations and concerns about older people in electronic health records (EHR), including free-text progress notes. These insights are yet to be unleashed.

OBJECTIVE

This study explored the risk factors for malnutrition in structured and unstructured electronic health data.

METHODS

Data of weight loss and malnutrition were extracted from the de-identified EHR records of a large aged care organization in Australia. A literature review was conducted to identify causative factors for malnutrition. Natural language processing (NLP) techniques were applied to progress notes to extract these causative factors. The NLP performance was evaluated by the parameters of sensitivity, specificity and F1-Score.

RESULTS

The NLP methods were highly accurate in extracting the key data, values for 46 causative variables, from the free-text client progress notes. Thirty three percent (1,469 out of 4,405) of the clients were malnourished. The structured, tabulated data only recorded 48% of these malnourished clients, far less than that (82%) identified from the progress notes, suggesting the importance of using NLP technology to uncover the information from nursing notes to fully understand the health status of the vulnerable older people in residential aged care.

CONCLUSION

This study identified 33% of older people suffered from malnutrition, lower than those reported in the similar setting in previous studies. Our study demonstrates that NLP technology is important for uncovering the key information about health risks for older people in residential aged care. Future research can apply NLP to predict other health risks for older people in this setting.

Nutritional Status and Sarcopenia in Nursing Home Residents: A Cross-Sectional Study

OBJECTIVE

This study aimed to assess the nutritional status and sarcopenia in older people living in nursing homes.

METHODS

This cross-sectional study enrolled 386 older adults in nursing homes in Hunan Province, China. Assessments included the Mini Nutritional Assessment Short Form for nutrition risk, Dietary Diversity Score for dietary diversity and Mini Mental State Examination for cognitive status. Sociodemographic (e.g., age, sex and educational level), health-related characteristics (e.g., food intake, self-care status and medication), body composition (e.g., body mass index [BMI], protein, body fat mass [BFM], percent body fat [PBF], skeletal muscle index [SMI] and total body water [TBW]) and anthropometric parameters data (e.g., calf circumference [CC], upper arm circumference [UAC], handgrip and gait speed) were also collected. Malnutrition and their associated risk were analyzed by multivariable Poisson regression analysis.

RESULTS

In total, 32.4% of participants (n = 125) were at risk of malnutrition and 49.7% (n = 192) suffered from sarcopenia. Nutritional status was positively associated with age (risk ratio [RR] = 1.03), sarcopenia (RR = 1.88), tooth loss affecting food intake (RR = 1.45), low self-care status (RR = 1.82) and moderate/inadequate dietary diversity (RR = 2.04) and negatively associated with one child (RR = 0.27), BMI (RR = 0.82), protein (RR = 0.76), BFM (RR = 0.91), PBF (RR = 0.94), SMI (RR = 0.65), TBW (RR = 0.94), CC (RR = 0.89) and UAC (RR = 0.86).

CONCLUSIONS

Age, number of children, sarcopenia, food intake, self-care status, dietary diversity and body composition were associated with malnutrition among nursing home residents. For vulnerable groups, researchers should focus on raising the body composition indicators, such as BMI, protein, BFM, SMI and TBW and measuring CC and UAC for initial screening.

Generation of bioluminescent enzyme immunoassay for ferritin by single-chain variable fragment and its NanoLuc luciferase fusion

Ferritin, widely present in liver and spleen tissue, is considered as a serological biomarker for liver diseases and cancers. The detection of ferritin may be an important tool in health diagnosis. In this study, 14 non-immunized chicken spleens were utilized to construct a single-chain fragment (scFv) phage library. After 4 rounds of panning, 7 unique clones were obtained. The optimal clone was further screened and combined with NanoLuc luciferase (Nluc) as a dual functional immunoprobe to bioluminescent enzyme immunoassay (BLEIA), which was twice as sensitive as its parental scFv-based double-sandwich enzyme-linked immunoassay (ds-ELISA). The cross-reactivity analysis revealed that the proposed methods were highly selective and suitable for clinical detection. To further verify the performance of the immunoassays, serum samples were tested by the proposed methods and a commercial ELISA kit, and there was a good correlation between the results. These results suggested that scFv fused with Nluc might be a powerful dual functional tool for rapid, practically reliable, and highly sensitive ferritin detection.

Association between anemia and depression: The 2014, 2016, and 2018 Korea National Health and Nutrition Examination Survey

BACKGROUND

Several studies have reported an association between anemia and depression. However, whether anemia is independently associated with depression remains controversial. The current study aimed to investigate the association between anemia and depression according to sex in a large national sample population.

METHODS

Data from the 2014, 2016, and 2018 Korean National Health and Nutrition Examination Survey were analyzed, and 15,472 participants were included in this study. Anemia was defined as a hemoglobin level <13 g/dL in men and <12 g/dL in women. We defined a Patient Health Questionnaire-9 score ≥10 as depression and ≥5 as mild depressive symptoms.

RESULTS

The prevalence of depression was significantly higher in women with anemia than in women without anemia (8.9 % vs. 7.0 %, P = 0.036). In women, anemia was significantly associated with depression after adjusting all covariates in multilevel logistic regression analysis (odds ratio, 1.37; 95 % confidence interval, 1.08-1.75; P = 0.011). However, no significant association was observed in men.

LIMITATIONS

There is a limit to explaining the causal direction, and several factors may not have been considered as confounders. Also, patients with severe diseases were excluded from data acquisition. A structured diagnostic interview, other than the self-report method, was not conducted.

CONCLUSIONS

The findings of this study suggest that anemia is associated with depression in women but not in men. A decrease in tissue oxygenation, deterioration of physical performance due to anemia, and altered monoamine synthesis due to malnutrition may have an effect on depression.

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.

The prevalence of anemia and its associations with other geriatric syndromes in subjects over 65 years old: data of Russian epidemiological study EVKALIPT

Background. A low hemoglobin level in older adults impairs cognitive ability and functional status and associates with risk of falls and fractures, sarcopenia, malnutrition, depression, frailty, and decreased autonomy. Epidemiological data on the anemia prevalence in the geriatric population in our country is not available. Aim. To assess the prevalence of anemia and analyze its associations with geriatric syndromes (GS) in subjects aged 65 years. Materials and methods. 4308 subjects (30% of men) aged 65107 years, living in 11 regions of the Russian Federation, were examined and divided into age groups (6574 years, 7584 years and 85 years). All the participants underwent a comprehensive geriatric assessment and determined hemoglobin level. Results. The anemia prevalence in older adults was 23.9%. It has been shown that with an increase in age per 1 year, the risk of anemia detection increases by 4%. The incidence of anemia was higher in males than females (28.1% versus 22.1%; p0.001). In most cases, anemia was mild. The results of a comprehensive geriatric assessment show that patients with anemia had lower hand grip force, Barthel Index, the sum of points on Lawton instrumental activities of daily living scale, Mini Nutritional Assessment scale, the Mini-Cog test and higher the sum of points on the Geriatric Depression Scale (GDS-15) and the Age Is No Barrier scale. Patients with anemia were more likely to use hearing aids, absorbent underwear, and assistive devices during movement. Patients with anemia had a higher incidence of all GS, except for orthostatic hypotension and chronic pain syndrome. The presence of GS is associated with an increased risk of anemia by 1.33.4 times. Conclusion. EVKALIPT study obtained domestic data on the prevalence of anemia in older patients and examined its associations with other GS.

Additive Effect of Sarcopenia and Anemia on the 10-Year Risk of Cardiovascular Disease in Patients with Type 2 Diabetes

OBJECTIVE

To investigate the association between sarcopenia and anemia and the 10-year cardiovascular disease risk in diabetic patients.

METHODS

A cross-sectional study was conducted involving 4673 hospitalized patients (2271 men and 2402 women) with type 2 diabetes mellitus, with an average age of 60.66 ± 11.93 years, of whom 542 were followed up for a median follow-up period of 24 months. All participants underwent body composition measurements, and they were grouped by sex and presence of sarcopenia using the Framingham risk model to assess their 10-year cardiovascular risk. According to the changes in the cardiovascular risk during follow-up, the patients were divided into four groups: low-low, low-high, high-low, and high-high.

RESULTS

The prevalence of anemia was higher in the sarcopenia group than in the nonsarcopenia group (11.5% vs. 24.1% for men, P < 0.001; 13.9% vs. 19.7% for women, P < 0.05), and the difference remained significant after adjusting for confounders. Patients with sarcopenia and without anemia had a 46.2% increased risk of high 10-year cardiovascular disease (CVD) (odds ratio (OR) = 1.462, 95% confidence interval (CI) 1.085-1.972, P = 0.013), and the risk was twofold higher in patients with sarcopenia and anemia than in those without (OR = 3.283, 95% CI 2.038-5.289, P < 0.001). In follow-up studies, sarcopenia was associated with an increased risk of CVD at 10 years, and a reduction in appendicular skeletal muscle mass index independently predicted the increased risk of CVD.

CONCLUSION

Sarcopenia is associated with an increased risk of anemia, and the presence of both has an additive effect on the 10-year CVD risk in patients with type 2 diabetes. Loss of muscle mass can independently predict an increased CVD risk in diabetic patients.

What are optimum target levels of hemoglobin in older adults?

AIM

The aim of this study is to identify optimum target levels of hemoglobin (Hgb) in older males and females according to cognitive performance, mood state, nutrition intake, balance-walking functions, muscle strength and performance in daily life activities.

METHOD

A total of 1942 geriatric patients who had undergone comprehensive geriatric assessment were evaluated. The patient's demographic characteristics, comorbid diseases, number of drugs, cognitive performance, mood and nutritional states, basic and instrumental daily living activity indexes were obtained from hospital files. Hgb levels were analyzed on the same day. Receiver Operating Characteristic analysis was used to detect the optimum level of Hgb according to the best performance of geriatric assessment parameters.

RESULTS

1095 participants took part of who 71.9% were female and the mean age was 76.92 ± 7.38 years (65-103 years). There was a significant negative correlation between age, number of drugs used, Geriatric Depression Scale-15, Timed Up and Go test and Hgb in both sexes while a significant positive correlation was found between Barthel and Lawton activities of daily living, Tinetti test, Mini Nutritional Assessment, Mini-Mental State Examination and Hgb (p < 0.05). The optimum Hgb levels were ≥ 13.0 for females and ≥ 13.9 in males.

CONCLUSION

Findings from the present study in relation to Hgb and key geriatric evaluation parameters suggests that the optimum level of Hgb for older females and males is higher than the level of Hgb in current definitions. Data from this study suggest that the optimum value of the Hgb level is 13.0 for females and 13.9 for males.

Chronic toxicity studies of gandhaka rasayana - A herbo-mineral preparation used in Ayurvedic practice

BACKGROUND

Gandhaka rasayana (GR) is an important component of many Ayurvedic formulations besides being used as a standalone therapy. However, literature review revealed a chronic toxicity studies with longer duration.

OBJECTIVES

To delineate the safety profile of GR for 180 days administration in rats.

MATERIALS AND METHODS

Wistar albino rats of both sexes weighing 150 ± 10 g body weight in groups of 20 (10 male and 10 female) for each of the three GR dose levels i.e., 0.54 g, 1.08 g, and 5.4 g/kg were employed. Carboxyl methyl cellulose was administered to the control group in equal volume. Toxicity was assessed based on the changes observed, compared to control, in body weight gain, food and water consumption, organ weight and histopathology, clinical biochemistry, and hematological parameters as per AYUSH guidelines.

RESULTS

GR repeated dose administration caused significant changes in body weight gain, organ ponderal changes, few hematologic and biochemical parameters. Male rats administered with GR at 1.08 g/kg dose showed a significant decrease in the MCV and MCH compared to control, whereas female rat's administred with 1.08 g/kg and 0.54 g/kg dose showed a significant increase in the MCV and MCH. GR administered at 0.54 g/kg showed a significant increase in the serum glucose level in male rats, whereas female rats showed a significant elevation in the cholesterol level. GR at 0.54 g/kg and 5.4 g/kg showed a significant elevation in the serum SGPT level in male rats. These changes were not observed in female rats. Histological examination revealed mild pathological changes in organs like kidney, liver, spleen and jejunum.

CONCLUSION

The data generated shows that GR is safe and does not have any toxicity potential at the doses used in therapeutics. Some of the changes observed were at higher dose levels which is not likely to be used clinically.

Age- and sex-matched comparison of diet quality in patients with heart failure to similarly aged healthy older adults

The aims of this study were to (1) compare diet quality between patients with heart failure (HF) and age- and sex-matched community-dwelling healthy older adults and (2) determine whether having HF was associated with a lower Healthy Eating Index-2015 (HEI-2015) score and risk of micronutrient deficiency. The HEI-2015 and macro- and micronutrient intakes of patients with HF were compared with healthy older adults (N 102; 55-92 years old; 53 % female). A paired t-test or Wilcoxon singed-rank test, McNemar's test, and conditional logistic regression were used to assess the association between diet quality and HF status. Median values for HEI-2015 and the number of micronutrient deficiency were used to dichotomise into groups in the conditional logistic regression. There was no significant between-group difference in the HEI-2015 total score (P 0⋅059), whereas the whole grain component was lower in patients with HF than in healthy older adults (3⋅1 ± 3⋅5 v. 4⋅5 ± 3⋅1, P 0⋅037; respectively). Total caloric intake was lower in patients with HF than in healthy older adults (1683 ± 595 v. 2104 ± 670 kcal; P < 0⋅001). Patients with HF had a higher average number of micronutrient deficiencies than healthy older adults (4[2, 6] v. 1[0, 4], respectively, P < 0⋅001). Patients with HF had four times higher odds of being in a high micronutrient deficiency group than healthy older adults, controlling for socio-demographics and body mass index (adjusted odds ratio [95 % confidence interval]: 4⋅04[1⋅06, 15⋅41]). Our findings demonstrate that diet quality measured by nutritional intake identifies patients with HF with lower caloric intake and higher micronutrient deficiencies compared with age- and sex-matched healthy older adults.

Anaemia in the Hospitalized Elderly in Tanzania: Prevalence, Severity, and Micronutrient Deficiency Status

INTRODUCTION

Anaemia is a common problem in sub-Saharan Africa. While most literature has focused on children, women of childbearing age, and pregnant women, data for the elderly population are relatively scarce. Anaemia exhorts negative consequences to functional ability of elderly patients, both physically and cognitively. The purpose of this study was to determine the prevalence of anaemia, severity, and micronutrient deficiency status in the elderly hospitalized patients in Tanzania.

METHODS

A total of 156 hospitalized adults aged 60 years and above were enrolled in this study. A structured questionnaire was used to capture sociodemographic and clinical characteristics. Blood samples were collected, and a complete blood count, serum cobalamin, serum ferritin, and serum folate levels were measured to assess anaemia and micronutrient deficiency status in all participants who had anaemia.

RESULTS

The prevalence of anaemia was 79.5% (124/156) with severe anaemia in 33.9% (42/124) of participants, moderate anaemia in 42.7% (53/124) of participants, and 23.4% (29/124) of all participants had mild anaemia. Micronutrient deficiency was found in 14.5% (18/124) of all participants with anaemia. Combined deficiency (either iron and vitamin B12 deficiency or iron and folate deficiency) was the most common micronutrient deficiency anaemia with a frequency of 33.3% (6/18), followed by isolated iron and folate deficiencies at equal frequency of 27.8% (5/18) and vitamin B12 deficiency at 11.1% (2/18).

CONCLUSION

The prevalence of anaemia in the hospitalized elderly population is high warranting public health attention and mostly present in moderate and severe forms. Micro-nutrient deficiency anaemia is common in this age group and is mostly due to combined micronutrient deficiency.

Early intravenous iron administration in the Emergency Department reduces red blood cell unit transfusion, hospitalisation, re-transfusion, length of stay and costs

BACKGROUND

Moderate to severe iron deficiency anaemia is a common finding in patients admitted to the Emergency Department (ED). According to Patient Blood Management principles, intravenous iron should be the therapy of choice instead of blood transfusion for selected cases affected by chronic iron deficiency anaemia. However, this option is only rarely taken into account by physicians in the ED. As a result, in many circumstances, treatment of iron deficiency anaemia in the ED can differ from that of the Anaemia Clinic. With the aim of reducing inappropriate transfusions, and to implement intravenous iron usage, we shared a specific protocol with the ED.

MATERIAL AND METHODS

We reviewed the medical records of all subjects admitted to the ED (n=267, Post-protocol group) with hemoglobin ≤9.0 g/dL and mean corpuscular volume <80 fL in a 13-month period, except if the massive transfusion protocol was activated, and results were compared with an equivalent Pre-protocol historical cohort (n=226).

RESULTS

In comparison with the Pre-protocol series, the number of patients transfused did not change, but the appropriateness in terms of transfusion and red blood cell volume transfused improved sharply (87.0 vs 13.3%; p<0.001) with a significant increase in intravenous iron administration (50.2 vs 4.4% of cases; p<0.001). As a positive consequence, both the time spent in the ED by patients who were then directly discharged and costs per subject treated dropped by 37.9% and 59.0%, respectively. Treatment with infusion only in comparison with transfusion only led to a statistically significant Relative Risk reduction in transfusion on the ward and post-discharge transfusion of 55.6% and 44.4%, respectively.

DISCUSSION

The implementation of Patient Blood Management principles and early intravenous iron therapy in the Emergency Department have proved to be effective tools to optimise resources both in terms of units transfused and costs.

Maternal Protein Malnutrition: Current and Future Perspectives of Spirulina Supplementation in Neuroprotection

Malnutrition has been widely recognized as a grave burden restricting the progress of underdeveloped and developing countries. Maternal, neonatal and postnatal nutritional immunity provides an effective approach to decrease the risk of malnutrition associated stress in adulthood. Particularly, maternal nutritional status is a critical contributor for determining the long-term health aspects of an offspring. Maternal malnutrition leads to increased risk of life, poor immune system, delayed motor development and cognitive dysfunction in the children. An effective immunomodulatory intervention using nutraceutical could be used to enhance immunity against infections. The immune system in early life possesses enormous dynamic capacity to manage both genetic and environment driven processes and can adapt to rapidly changing environmental exposures. These immunomodulatory stimuli or potent nutraceutical strategy can make use of early life plasticity to target pathways of immune ontogeny, which in turn could increase the immunity against infectious diseases arising from malnutrition. This review provides appreciable human and animal data showing enduring effects of protein deprivation on CNS development, oxidative stress and inflammation and associated behavioral and cognitive impairments. Relevant studies on nutritional supplementation and rehabilitation using Spirulina as a potent protein source and neuroprotectant against protein malnutrition (PMN) induced deleterious changes have also been discussed. However, there are many futuristic issues that need to be resolved for proper modulation of these therapeutic interventions to prevent malnutrition.

Iron status in the elderly: A review of recent evidence

A comprehensive literature review of iron status in the elderly was undertaken in order to update a previous review (Fairweather-Tait et al, 2014); 138 summarised papers describe research on the magnitude of the problem, aetiology and age-related physiological changes that may affect iron status, novel strategies for assessing iron status with concurrent health conditions, hepcidin, lifestyle factors, iron supplements, iron status and health outcomes (bone mineral density, frailty, inflammatory bowel disease, kidney failure, cancer, cardiovascular, and neurodegenerative diseases). Each section of this review concludes with key points from the relevant papers. The overall findings were that disturbed iron metabolism plays a major role in a large number of conditions associated with old age. Correction of iron deficiency/overload may improve disease prognosis, but diagnosis of iron deficiency requires appropriate cut-offs for biomarkers of iron status in elderly men and women to be agreed. Iron deficiency (with or without anemia), anemia of inflammation, and anemia of chronic disease are all widespread in the elderly and, once identified, should be investigated further as they are often indicative of underlying disease. Management options should be reviewed and updated, and novel therapies, which show potential for treating anemia of inflammation or chronic disease, should be considered.

Anemia in the Elderly

Anemia affects a substantial fraction of the elderly population, representing a public health problem that is predicted to further increase in coming years because of the demographic drive. Being typically mild, it is falsely perceived as a minor problem, particularly in the elderly with multimorbidity, so that it often remains unrecognized and untreated. Indeed, mounting evidence indicates that anemia in the elderly (AE) is independently associated with disability and other major negative outcomes, including mortality. AE is generally multifactorial, but initial studies suggested that etiology remains unexplained in near one-third of cases. This proportion is consistently declining due to recent advances highlighting the role of several conditions including clonal hematopoiesis, "inflammaging," correctable androgen deficiency in men, and under-recognized iron deficiency. Starting from a real-world case vignette illustrating a paradigmatic example of anemia in an elderly patient with multimorbidity, we review the main clinical and pathophysiological aspect of AE, giving some practical insights into how to manage similar cases.

Magnitude of Anemia in Geriatric Population Visiting Outpatient Department at the University of Gondar Referral Hospital, Northwest Ethiopia: Implication for Community-Based Screening

Objective

This study is aimed at assessing the magnitude and its associated factors of anemia in geriatric population visiting outpatient department at the University of Gondar referral hospital, northwest Ethiopia.

Method

A cross-sectional study was conducted among elder patients in Gondar town, North Gondar District, in May 2013. A total of 200 randomly selected geriatric population participated in the study. Summary statistics were computed and presented in tables and figure. Both bivariate and multivariable binary logistic regression were fitted to identify associated factors. A P value < 0.05 was considered as statistically significant.

Result

The median age of the study participants was 65 years (Interquartile range (IQR): 8 years). The prevalence of anemia in the geriatric patients was 54.5% (n = 109), of which 61.5% (n = 67) were males. Mild type anemia was predominant, 55.96% (n = 61). Geriatric patients with an elevated erythrocyte sedimentation rate (AOR = 9.04, 95% CI: 4.2–19.7) and who are vegetarians (AOR = 2.2, 95% CI: 1.03–4.71) were at high risk of developing anemia.

Conclusion

The magnitude of anemia was high in geriatrics. Mild anemia was the predominant type. Vegetarians and geriatrics with elevated erythrocyte sedimentation rate were more likely to develop anemia. Hence, early diagnosis and management of anemia have paramount importance to prevent adverse outcomes in geriatrics.

The Role of Nutritional Status in Elderly Patients with Heart Failure

Evidence indicates that malnutrition very frequently co-occurs with chronic heart failure (HF) and leads to a range of negative consequences. Studies show associations between malnutrition and wound healing disorders, an increased rate of postoperative complications, and mortality. In addition, considering the increasing age of patients with HF, a specific approach to their treatment is required. Guidelines proposed by the European Society of Cardiology (ESC) for treating acute and chronic HF refer to the need to monitor and prevent malnutrition in HF patients. However, the guidelines feature no strict nutritional recommendations for HF patients, who are at high nutritional risk as a group, nor do they offer any such recommendations for the poor nutritional status subgroup, for which high morbidity and mortality rates have been observed. In the context of multidisciplinary healthcare, recommended by the ESC and proven by research to offer multifaceted benefits, nutritional status should be systematically assessed in HF patients. Malnutrition has become a challenge within healthcare systems and day-to-day clinical practice, especially in developed countries, where it affects the course of disease and patients' prognosis.

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.

Prevalence and factors associated with geriatric malnutrition in an outpatient clinic of a teaching hospital in Jeddah, Saudi Arabia

BACKGROUND

Malnutrition is highly prevalent among the elderly and is associated with poor clinical prognosis, decreased functional status, and increased morbidity and mortality.

OBJECTIVE

To estimate the prevalence of geriatric malnutrition among outpatients of a geriatric clinic and to determine factors associated with malnutrition.

DESIGN

Cross-sectional study.

SETTING

Geriatric outpatient clinic of the King Abdul Aziz University Hospital, Jeddah.

PATIENTS AND METHODS

All patients older than 60 years of age who attended the clinic during January 2016 were eligible for inclusion. Nutritional status was assessed using anthropometric data and by hemoglobin and albumin levels and lymphocyte count. The MNA was used to define malnutrition.

MAIN OUTCOME MEASURES

Anthropometric measures, biochemical tests, and the scores on the short version of the Mini Nutritional Assessment (MNA).

RESULTS

According to the MNA results, 8 (5.3%) of 152 elderly patients suffered overt malnutrition and 50 (32.9%) were at risk of malnutrition (71 males and 41 females; aged 72.4 [8.6] years). The prevalence of malnutrition was significantly higher among females (44.6%; 95% CI, 1.01-4.08; P=.044) than in males (28.3%). Malnourished patients were older than patients with normal nutritional status (mean 72.4 [8.6] years), and more common in patients who lived alone (62.5%). The malnourished patients had significantly smaller calf circumferences (63.4; 95% CI, 1.51-3.20; P=.001), and lower albumin and hemoglobin levels (P=.001). A significantly higher percentage of the malnourished patients compared with normal patients had experienced weight loss (37.9%; P < .001) and decreased food intake (56.9%; P < .001) during the previous three months. Binary logistic regression revealed that being female and living alone were significant predictors for being categorized as malnourished or at risk of malnutrition.

CONCLUSION

The prevalence of malnutrition is high among geriatric outpatients. Routine screening for malnutrition among geriatric patients would allow early diagnosis and prompt intervention.

LIMITATIONS

The heterogeneity of the study group (different diseases at different stages) could influence the generalizability of our findings. The relatively small number of patients (P=.002) is a potential limitation.