Effect of an enriched drink on cognitive function in frail elderly persons

Mineral supplementation in patients with frailty and sarcopenia-a systematic review

AIM

Addressing sarcopenia and frailty in aging populations is crucial for enhancing quality of life and reducing healthcare dependence. While the importance of energy, protein, and amino acid supplementation is known, the role of minerals needs further exploration. This systematic review evaluates the effectiveness of these minerals in managing sarcopenia and frailty.

METHODS

We analyzed data from the Cochrane Central Register of Controlled Trials, MEDLINE, and Ichu-shi Web from January 2000 to March 2023. Studies were selected if they were interventional or observational, focused on individuals with frailty or sarcopenia who were aged 65 or older, and involved mineral supplementation. The risk of bias in these studies was assessed using the Cochrane Risk of Bias 2 tool.

RESULTS

Of the 615 studies identified, seven met the inclusion criteria. These studies mainly focused on the effects of combined nutrient supplements, with few focusing on individual minerals. The findings were mixed, demonstrating some improvements in muscle strength, activity of daily living, and cognitive functions. Notably, minerals appeared to offer benefits as part of multi-nutrient interventions, especially for cognitive and immune health, but had limited impact on muscle mass or strength when used alone. The limited number and variable outcomes of studies precluded a feasible meta-analysis.

CONCLUSIONS

The effect of mineral supplementation on sarcopenia and frailty remains uncertain, suggesting a need for tailored nutritional strategies. Future studies should aim for well-designed clinical trials in order to gain a better understanding of the roles of minerals in improving muscle health and functional outcomes, leading to clearer recommendations for clinical practice. Geriatr Gerontol Int 2024; 24: 850-858.

Effects of Vitamin D Supplementation on Cognitive Outcomes: A Systematic Review and Meta-Analysis

Clinical studies examining the effects of vitamin D on cognition have reported inconsistent results. To date, no comprehensive study has examined this effect on the basis of sample characteristics or intervention model-related factors. This systematic review and meta-analysis of randomized controlled trials investigated the effects of vitamin D supplementation on global cognitive function and specific cognitive domains. This review was preregistered in the PROSPERO database (CRD42021249908) and comprised 24 trials enrolling 7557 participants (mean age: 65.21 years; 78.54% women). The meta-analysis revealed that vitamin D significantly influenced global cognition (Hedges' g = 0.128, p = .008) but not specific cognitive domains. A subgroup analysis indicated that the effect size of vitamin D was stronger for vulnerable populations (Hedges' g = 0.414) and those with baseline vitamin D deficiency (Hedges' g = 0.480). On the basis of subgroup analyses in studies without biological flaws (Hedges' g = 0.549), we suggest that an intervention model should correct baseline vitamin D deficiency. Our results indicate that vitamin D supplementation has a small but significant positive effect on cognition in adults.

Hydrolyzed Chicken Extract (ProBeptigen®) on Cognitive Function in Healthy Middle-Aged People: A Randomized Double-Blind Trial

Cognitive decline is an important issue of global public health. Cognitive aging might begin at middle adulthood, the period particularly vulnerable to stress in lifespan. Essence of chicken (EOC) has consistently demonstrated its beneficial effects on various cognitive domains as nutritional supplementation. This study primarily aimed to examine the cognitive enhancement effects of ProBeptigen^® (previously named CMI-168), hydrolyzed peptides extracted from EOC, in healthy middle-aged people under mild stress. Ninety healthy subjects were randomly assigned into the ProBeptigen^® or placebo group for eight weeks. Neurocognitive assessment, event-related potentials (ERPs), and blood tests were conducted before, during, and after the treatment. The ProBeptigen^® group outperformed placebo group on Logical Memory subtests of Wechsler Memory Scale-third edition (WMS-III) and Spatial Working Memory task in the Cambridge Neuropsychological Test Automated Battery (CANTAB). The anti-inflammatory effects of ProBeptigen^® in humans were also confirmed, with progressively declining high-sensitivity C-reactive protein (hs-CRP) levels. Regular dietary supplementation of ProBeptigen^® is suggested to improve verbal short- and long-term memory as well as spatial working memory, and reduce inflammation in middle-aged healthy individuals with stress. The effects of ProBeptigen^® on cognition warrant further investigation. (NCT03612752)

Vitamin and mineral supplementation for maintaining cognitive function in cognitively healthy people in mid and late life

BACKGROUND

Vitamins and minerals play multiple functions within the central nervous system which may help to maintain brain health and optimal cognitive functioning. Supplementation of the diet with various vitamins and minerals has been suggested as a means of maintaining cognitive function, or even of preventing dementia, in later life.

OBJECTIVES

To evaluate the effects of vitamin and mineral supplementation on cognitive function in cognitively healthy people aged 40 years or more.

SEARCH METHODS

We searched ALOIS, the Cochrane Dementia and Cognitive Improvement Group's (CDCIG) specialised register, as well as MEDLINE, Embase, PsycINFO, CINAHL, ClinicalTrials.gov and the WHO Portal/ICTRP from inception to 26th January 2018.

SELECTION CRITERIA

We included randomised controlled trials that evaluated the cognitive effects on people aged 40 years or more of any vitamin or mineral supplements taken by mouth for at least three months.

DATA COLLECTION AND ANALYSIS

Study selection, data extraction, and quality assessments were done in duplicate. Vitamins were considered broadly in the categories of B vitamins, antioxidant vitamins, and combinations of both. Minerals were considered separately, where possible. If interventions and outcomes were considered sufficiently similar, then data were pooled. In order to separate short-term cognitive effects from possible longer-term effects on the trajectory of cognitive decline, data were pooled for various treatment durations from 3 months to 12 months and up to 10 years or more.

MAIN RESULTS

In total, we included 28 studies with more than 83,000 participants. There were some general limitations of the evidence. Most participants were enrolled in studies which were not designed primarily to assess cognition. These studies often had no baseline cognitive assessment and used only brief cognitive assessments at follow-up. Very few studies assessed the incidence of dementia. Most study reports did not mention adverse events or made only very general statements about them. Only 10 studies had a mean follow-up > 5 years. Only two studies had participants whose mean age was < 60 years at baseline. The risk of bias in the included studies was generally low, other than a risk of attrition bias for longer-term outcomes. We considered the certainty of the evidence behind almost all results to be moderate or low.We included 14 studies with 27,882 participants which compared folic acid, vitamin B12, vitamin B6, or a combination of these to placebo. The majority of participants were aged over 60 years and had a history of cardio- or cerebrovascular disease. We found that giving B vitamin supplements to cognitively healthy adults, mainly in their 60s and 70s, probably has little or no effect on global cognitive function at any time point up to 5 years (SMD values from -0.03 to 0.06) and may also have no effect at 5-10 years (SMD -0.01). There were very sparse data on adverse effects or on incidence of cognitive impairment or dementia.We included 8 studies with 47,840 participants in which the active intervention was one or more of the antioxidant vitamins: ß-carotene, vitamin C or vitamin E. Results were mixed. For overall cognitive function, there was low-certainty evidence of benefit associated with ß-carotene after a mean of 18 years of treatment (MD 0.18 TICS points, 95% CI 0.01 to 0.35) and of vitamin C after 5 years to 10 years (MD 0.46 TICS points, 95% CI 0.14 to 0.78), but not at earlier time points. From two studies which reported on dementia incidence, there was low-certainty evidence of no effect of an antioxidant vitamin combination or of vitamin E, either alone or combined with selenium. One of the included studies had been designed to look for effects on the incidence of prostate cancer; it found a statistically significant increase in prostate cancer diagnoses among men taking vitamin E.One trial with 4143 participants compared vitamin D3 (400 IU/day) and calcium supplements to placebo. We found low- to moderate-certainty evidence of no effect of vitamin D3 and calcium supplements at any time-point up to 10 years on overall cognitive function (MD after a mean of 7.8 years -0.1 MMSE points, 95% CI -0.81 to 0.61) or the incidence of dementia (HR 0.94, 95% CI 0.72 to 1.24). A pilot study with 60 participants used a higher dose of vitamin D3 (4000 IU on alternate days) and found preliminary evidence that this dose probably has no effect on cognitive function over six months.We included data from one trial of zinc and copper supplementation with 1072 participants. There was moderate-certainty evidence of little or no effect on overall cognitive function (MD 0.6 MMSE points, 95% CI -0.19 to 1.39) or on the incidence of cognitive impairment after 5 years to 10 years. A second smaller trial provided no usable data, but reported no cognitive effects of six months of supplementation with zinc gluconate.From one study with 3711 participants, there was low-certainty evidence of no effect of approximately five years of selenium supplementation on the incidence of dementia (HR 0.83, 95% CI 0.61 to 1.13).Finally, we included three trials of complex supplements (combinations of B vitamins, antioxidant vitamins, and minerals) with 6306 participants. From the one trial which assessed overall cognitive function, there was low-certainty evidence of little or no effect on the TICS (MD after a mean of 8.5 years 0.12, 95% CI -0.14 to 0.38).

AUTHORS' CONCLUSIONS

We did not find evidence that any vitamin or mineral supplementation strategy for cognitively healthy adults in mid or late life has a meaningful effect on cognitive decline or dementia, although the evidence does not permit definitive conclusions. There were very few data on supplementation starting in midlife (< 60 years); studies designed to assess cognitive outcomes tended to be too short to assess maintenance of cognitive function; longer studies often had other primary outcomes and used cognitive measures which may have lacked sensitivity. The only positive signals of effect came from studies of long-term supplementation with antioxidant vitamins. These may be the most promising for further research.

Vitamin and mineral supplementation for preventing dementia or delaying cognitive decline in people with mild cognitive impairment

BACKGROUND

Vitamins and minerals have many functions in the nervous system which are important for brain health. It has been suggested that various different vitamin and mineral supplements might be useful in maintaining cognitive function and delaying the onset of dementia. In this review, we sought to examine the evidence for this in people who already had mild cognitive impairment (MCI).

OBJECTIVES

To evaluate the effects of vitamin and mineral supplementation on cognitive function and the incidence of dementia in people with mild cognitive impairment.

SEARCH METHODS

We searched ALOIS, the Cochrane Dementia and Cognitive Improvement Group's (CDCIG) specialised register, as well as MEDLINE, Embase, PsycINFO, CENTRAL, CINAHL, LILACs, Web of Science Core Collection, ClinicalTrials.gov, and the WHO Portal/ICTRP, from inception to 25 January 2018.

SELECTION CRITERIA

We included randomised or quasi-randomised, placebo-controlled trials which evaluated orally administered vitamin or mineral supplements in participants with a diagnosis of mild cognitive impairment and which assessed the incidence of dementia or cognitive outcomes, or both. We were interested in studies applicable to the general population of older people and therefore excluded studies in which participants had severe vitamin or mineral deficiencies.

DATA COLLECTION AND ANALYSIS

We sought data on our primary outcomes of dementia incidence and overall cognitive function and on secondary outcomes of episodic memory, executive function, speed of processing, quality of life, functional performance, clinical global impression, adverse events, and mortality. We conducted data collection and analysis according to standard Cochrane systematic review methods. We assessed the risk of bias of included studies using the Cochrane 'Risk of bias' assessment tool. We grouped vitamins and minerals according to their putative mechanism of action and, where we considered it to be clinically appropriate, we pooled data using random-effects methods. We used GRADE methods to assess the overall quality of evidence for each comparison and outcome.

MAIN RESULTS

We included five trials with 879 participants which investigated B vitamin supplements. In four trials, the intervention was a combination of vitamins B6, B12, and folic acid; in one, it was folic acid only. Doses varied. We considered there to be some risks of performance and attrition bias and of selective outcome reporting among these trials. Our primary efficacy outcomes were the incidence of dementia and scores on measures of overall cognitive function. None of the trials reported the incidence of dementia and the evidence on overall cognitive function was of very low-quality. There was probably little or no effect of B vitamins taken for six to 24 months on episodic memory, executive function, speed of processing, or quality of life. The evidence on our other secondary clinical outcomes, including harms, was very sparse or very low-quality. There was evidence from one study that there may be a slower rate of brain atrophy over two years in participants taking B vitamins. The same study reported subgroup analyses based on the level of serum homocysteine (tHcy) at baseline and found evidence that B vitamins may improve episodic memory in those with tHcy above the median at baseline.We included one trial (n = 516) of vitamin E supplementation. Vitamin E was given as 1000 IU of alpha-tocopherol twice daily. We considered this trial to be at risk of attrition and selective reporting bias. There was probably no effect of vitamin E on the probability of progression from MCI to Alzheimer's dementia over three years (HR 1.02; 95% CI 0.74 to 1.41; n = 516; 1 study, moderate-quality evidence). There was also no evidence of an effect at intermediate time points. The available data did not allow us to conduct analyses, but the authors reported no significant effect of three years of supplementation with vitamin E on overall cognitive function, episodic memory, speed of processing, clinical global impression, functional performance, adverse events, or mortality (five deaths in each group). We considered this to be low-quality evidence.We included one trial (n = 256) of combined vitamin E and vitamin C supplementation and one trial (n = 26) of supplementation with chromium picolinate. In both cases, there was a single eligible cognitive outcome, but we considered the evidence to be very low-quality and so could not be sure of any effects.

AUTHORS' CONCLUSIONS

The evidence on vitamin and mineral supplements as treatments for MCI is very limited. Three years of treatment with high-dose vitamin E probably does not reduce the risk of progression to dementia, but we have no data on this outcome for other supplements. Only B vitamins have been assessed in more than one RCT. There is no evidence for beneficial effects on cognition of supplementation with B vitamins for six to 24 months. Evidence from a single study of a reduced rate of brain atrophy in participants taking vitamin B and a beneficial effect of vitamin B on episodic memory in those with higher tHcy at baseline warrants attempted replication.

Food-based anthocyanin intake and cognitive outcomes in human intervention trials: a systematic review

BACKGROUND

Preclinical evidence suggests that the anthocyanins, which comprise a subclass of dietary flavonoids providing the purple and red pigmentation in plant-based foods, may have a beneficial impact on cognitive outcomes.

METHODS

A systematic review was conducted to identify the published literature on food-based anthocyanin consumption and cognitive outcomes in human intervention trials. The literature search followed PRISMA guidelines and included six databases, as well as additional hand searching.

RESULTS

Seven studies were included in this review, comprising acute trials (n = 4) and longer-term (n = 3) interventions that assessed multiple cognitive outcomes in children, adults and older adults with cognitive impairment. Six of seven studies reported improvements in either a single, or multiple, cognitive outcomes, including verbal learning and memory, after anthocyanin-rich food consumption. As a result of methodological limitations and the large clinical and methodological diversity of the studies, the pooling of data for quantitative analysis was not feasible.

CONCLUSIONS

The impact of food-based anthocyanin consumption on both acute and long-term cognition appears promising. However, adequately powered studies that include sensitive cognitive tasks are needed to confirm these findings and allow the translation of research into dietary messages.

NutriLive: An Integrated Nutritional Approach as a Sustainable Tool to Prevent Malnutrition in Older People and Promote Active and Healthy Ageing—The EIP-AHA Nutrition Action Group

The present document describes a nutritional approach that is nested in the European Innovation Partnership for Active and Healthy Aging (EIP-AHA) and aims to provide the first common European program translating an integrated approach to nutritional frailty in terms of a multidimensional and transnational methodology. The document has been developed by the A3 Nutrition Action Area of the EIP-AHA and aims at providing a stepwise approach to malnutrition in older citizens, identifying adequate interventions based on a unified assessment and ICT-supported solutions. “NutriLive” is an integrated nutritional approach, represented by a structured Screening-Assessment-Monitoring-Action-Pyramid-Model (SAM-AP). Its core concept is the stratification of the nutritional needs, considered by the working group as the key for targeted, effective, and sustainable interventions. “NutriLive” tries to close gaps in epidemiological data within an aging population, creating a unified language to deal with the topic of nutrition and malnutrition in Europe. By assembling all the validated screening, assessment, and monitoring tools on malnutrition in a first pyramid, which is interrelated to a second intervention pyramid, the A3 Nutrition WG identifies a common, integrated vision on the nutritional approach to frailty, which applies to the various health care settings.

Improved blood biomarkers but no cognitive effects from 16 weeks of multivitamin supplementation in healthy older adults

Supplementation with vitamins, minerals and phytonutrients may be beneficial for cognition, especially in older adults. The aim of this study was to assess the effects of multivitamin supplementation in older adults on cognitive function and associated blood biomarkers. In a randomised, double blind, placebo-controlled trial, healthy women (n = 68) and men (n = 48) aged 55–65 years were supplemented daily for 16 weeks with women’s and men’s formula multivitamin supplements. Assessments at baseline and post-supplementation included computerised cognitive tasks and blood biomarkers relevant to cognitive aging. No cognitive improvements were observed after supplementation with either formula; however, several significant improvements were observed in blood biomarkers including increased levels of vitamins B₆ and B₁₂ in women and men; reduced C-reactive protein in women; reduced homocysteine and marginally reduced oxidative stress in men; as well as improvements to the lipid profile in men. In healthy older people, multivitamin supplementation improved a number of blood biomarkers that are relevant to cognition, but these biomarker changes were not accompanied by improved cognitive function.

Single-micronutrient and broad-spectrum micronutrient approaches for treating mood disorders in youth and adults

Several different vitamins and minerals appear to be effective augmenting agents for mood-modifying drugs, but are not potent monotherapies in themselves for treating psychiatric disorders. In contrast, broad-spectrum micronutrient interventions appear in early trials to be as effective as psychiatric medications with fewer adverse effects for treating mood disorders, ADHD, aggressivity, and misconduct in youth and adults. Broad-spectrum treatments also may improve stress responses, cognition, and sense of well-being in healthy adults, but have been less well studied in youth. Current clinical data justify an extensive expansion of research on micronutrient mechanisms and treatments in psychiatry.

Micronutrients supplementation and nutritional status in cognitively impaired elderly persons: a two-month open label pilot study

BACKGROUND

Malnutrition is a widespread problem in elderly people and is associated with cognitive decline. However, interventional studies have produced ambiguous results. For this reason, we wanted to determine the effect of micronutrient supplementation on blood and tissue levels and on general nutritional status in persons with mild or moderate cognitive impairment.

METHODS

We performed a 2-month, open-label trial, administering a daily micronutrient supplement to 42 memory clinic patients with mild cognitive deficits. Blood levels of antioxidants, zinc, and B vitamins were determined before and after supplementation. In addition, we assessed metabolic markers for B vitamins and intracellular (buccal mucosa cell [BMC]) antioxidant levels. Nutritional status was assessed by using the Mini Nutritional Assessment (MNA).

RESULTS

Blood levels of B vitamins, folic acid, lutein, β-carotene, α-carotene, and α-tocopherol increased significantly. Decreases in homocysteine levels and the thiamine pyrophosphate effect and an increase in holotranscobalamin were observed. We found no increase in intracellular antioxidant levels of BMC. The MNA score in subjects at risk for malnutrition increased significantly, mainly owing to better perception of nutritional and overall health status.

CONCLUSIONS

Micronutrient supplementation improved serum micronutrient status, with improved metabolic markers for B vitamins but not for intracellular antioxidant status, and was associated with improved self-perception of general health status. Our data underline the necessity of determining micronutrient status and support the use of additional assessments for general health and quality of life in nutritional supplementation trials.

Copper and iron in Alzheimer's disease: a systematic review and its dietary implications

Fe and Cu could represent dietary risk factors for Alzheimer's disease (AD), which has become a global health concern. To establish the relationship between diets high in Cu and Fe and cognitive decline or AD, we have conducted a systematic review of the literature (up to January 2011). We identified two meta-analyses, two systematic reviews, eleven placebo-controlled trials, five observational studies, forty-five case-control studies, thirty autopsy and five uncontrolled studies, and one case report. There were eleven interventional trials that tried to either supplement or deplete Fe and Cu, but none of them provided clear evidence of a beneficial effect on cognitive performance in patients with AD. The prospective studies revealed an association between a diet simultaneously high in SFA and Cu and cognitive decline. Case-control and autopsy studies showed elevated Fe levels in the brains of AD patients, whereas the evidence was less consistent for Cu. In most of the studies, Cu concentrations were unchanged in the cerebrospinal fluid and the brain but increased in the serum. In conclusion, the existing data suggest that diets excessive in Fe or Cu, together with a high intake of SFA, should be avoided in the elderly who are not at risk of anaemia. Basic studies and, building on this, clinical investigations are needed to further elucidate in which dietary patterns and in which patient groups an Fe- and Cu-rich diet might foster the risk of developing AD.

Validation of reaction time as a measure of cognitive function and quality of life in healthy subjects and patients

OBJECTIVE

Malnutrition is a common problem in hospitalized patients and is related to decreased cognitive function and impaired quality of life (QoL). We investigated the validity of reaction time as a simple bedside tool for measuring cognitive function in healthy subjects and patients, and additionally the relationships with QoL and malnutrition in patients.

METHODS

Healthy subjects (N = 130) were assessed for simple and complex reaction time and cognitive function (Addenbrooke cognitive examination, ACE). Patients (N = 70) were assessed for simple and complex reaction time, cognitive function (ACE), and QoL (short-form health survey) (N = 40).

RESULTS

Reaction time was related to cognitive function in both healthy subjects and patients. Reaction time was inversely related to the physical component summary of QoL in patients (r = -0.42, P < 0.001). Five of eight QoL scales and the mental component summary of QoL were significantly lower in malnourished patients. Reaction time and ACE were impaired in patients compared to healthy subjects, but not further impaired in malnourished patients.

CONCLUSION

Simple reaction time test is related to cognitive function in healthy subjects and patients and to QoL in patients. Complex reaction time test is related to more components of cognitive function. Thus, simple and complex reaction time tests could serve as bedside measurements reflecting, respectively, QoL or cognitive function.

Comparisons of plasma/serum micronutrients between Okinawan and Oregonian elders: a pilot study

Certain micronutrients are protective against cognitive decline. We examined whether there is any uniform pattern of circulating micronutrients cross-culturally that are associated with successful cognitive aging. For the U.S. sample, we used the stored serum/plasma of 115 participants, collected in Oregon, USA. The Okinawa sample consisted of 49 participants selected using similar inclusion criteria as the Oregon sample, from the Keys to Optimal Cognitive Aging Project. All participants were aged 85 years and older without cognitive impairment. We found that the Okinawan elders used fewer vitamin supplements but had similar levels of vitamin B(12) and α-tocopherol, lower folate and γ-tocopherol, compared with Oregonian elders. That is, we did not find a uniform pattern of circulating micronutrients, suggesting that micronutrients other than those examined here or other lifestyle factors than nutrition could play an important role in achieving successful cognitive aging.

Interventions to reduce cognitive decline in aging

As the population ages, risks for cognitive decline threaten independence and quality of life for older adults and present challenges to the health care system. Nurses are in a unique position to advise older adults about cognitive health promotion and to develop interventions that optimize cognition in older adults. A literature review was conducted to provide nurses in mental health and geriatric care with an overview of research related to the promotion of successful cognitive aging for older adults. Research evaluating cognitively stimulating lifestyles and the effects on cognitive function in older adults of interventions targeting cognitive training, physical activity, social engagement, and nutrition were reviewed. Overall research findings support positive effects of cognitive and physical activity, social engagement, and therapeutic nutrition in optimizing cognitive aging. However, the strength of the evidence is limited by research designs. Applications for health promotion to optimize cognitive aging and future directions for research are discussed.

Cognitive tests used in chronic adult human randomised controlled trial micronutrient and phytochemical intervention studies

In recent years there has been a rapid growth of interest in exploring the relationship between nutritional therapies and the maintenance of cognitive function in adulthood. Emerging evidence reveals an increasingly complex picture with respect to the benefits of various food constituents on learning, memory and psychomotor function in adults. However, to date, there has been little consensus in human studies on the range of cognitive domains to be tested or the particular tests to be employed. To illustrate the potential difficulties that this poses, we conducted a systematic review of existing human adult randomised controlled trial (RCT) studies that have investigated the effects of 24 d to 36 months of supplementation with flavonoids and micronutrients on cognitive performance. There were thirty-nine studies employing a total of 121 different cognitive tasks that met the criteria for inclusion. Results showed that less than half of these studies reported positive effects of treatment, with some important cognitive domains either under-represented or not explored at all. Although there was some evidence of sensitivity to nutritional supplementation in a number of domains (for example, executive function, spatial working memory), interpretation is currently difficult given the prevailing ‘scattergun approach’ for selecting cognitive tests. Specifically, the practice means that it is often difficult to distinguish between a boundary condition for a particular nutrient and a lack of task sensitivity. We argue that for significant future progress to be made, researchers need to pay much closer attention to existing human RCT and animal data, as well as to more basic issues surrounding task sensitivity, statistical power and type I error.

The effect of a nutrient dense drink on mental and physical function in institutionalized elderly people

OBJECTIVES

To determine whether in the current study the supply of a nutrient dense drink has a positive effect on mental and physical function of institutionalized elderly people.

DESIGN

A 24-week, randomized, double-blind, placebo-controlled, parallel-group, intervention trial.

SETTING

Homes for the elderly and nursing homes in the Netherlands.

PARTICIPANTS

Institutionalized elderly people older than 60 years, with a BMI < or = 30 kg/m2, and a Mini-Mental State Examination score of at least 10 points.

INTERVENTION

In addition to their usual diet the participants (n=176) received either a nutrient dense drink or a placebo drink twice a day during 24 weeks.

MEASUREMENTS

The functionality measures included cognitive function, mood, physical performance and the ability to perform activities of daily living.

RESULTS

In the supplement group a favorable effect of the intervention drink on body weight (1.6 kg difference in change; P = .035), calf circumference (0.9 cm difference in change; P = .048), and blood values (e.g. Hcy decreased from 16.8 to 11.2 mumol/L in the supplement group) was found. In the total group no significant effect was found on functionality outcomes. However, a subgroup of participants with BMI at baseline below 24.4 kg/m2 performed better on the cognitive subscale of Alzheimer's Disease Assessment Scale (P = .09), and its language sub score (P = .01) after 24 weeks of intervention.

CONCLUSION

The results in the total group of this trial suggest that the nutritional supplement used in this study improves nutritional status. Furthermore, the results of this trial suggest that it is effective as treatment for decreasing function in a subgroup of institutionalized elderly people with low BMI.

Nutritional assessment of residents in long-term care facilities (LTCFs): recommendations of the task force on nutrition and ageing of the IAGG European region and the IANA

Unintentional weight loss and Undernutrition are major problems among older people living in Long-Term Care Facilities (LTCF). Undernutrition manifests in LTCF particularly as weight loss and low Body Mass Index (BMI) and is associated with increased morbidity and mortality as well as with functional decline. There are many factors associated with poor nutritional status and affecting protein-energy intake and/or energy expenditure. These include age of 85 years or older, low nutrient intake, loss of ability to eat independently, swallowing and chewing difficulties, becoming bed-ridden, pressure ulcers, history of hip fracture, dementia, depressive symptoms and suffering from two or more chronic illnesses. Nutritional evaluation is an essential part of the Comprehensive Geriatric Assessment (CGA). This evaluation ranges from methods such as BMI to several validated tools such as Mini-Nutritional Assessment (MNA). After diagnosis, the management of undernutrition in LTCF requires a multidisciplinary approach which may involve dietary and environmental improvements and managing multiple co-morbidities, while avoiding polypharmacy as far as possible. Finally, the need for supplementation or artificial (tube) feeding may be considered taking into account the CGA and individual needs. This document presents a succinct review and recommendations of evaluation and treatment of undernutrition.

Protein and energy supplementation in elderly people at risk from malnutrition

BACKGROUND

Evidence for the effectiveness of nutritional supplements containing protein and energy, often prescribed for older people, is limited. Malnutrition is more common in this age group and deterioration of nutritional status can occur during illness. It is important to establish whether supplementing the diet is an effective way of improving outcomes for older people at risk from malnutrition.

OBJECTIVES

This review examined trials for improvement in nutritional status and clinical outcomes when extra protein and energy were provided, usually as commercial 'sip-feeds'.

SEARCH STRATEGY

We searched The Cochrane Library, MEDLINE, EMBASE, Healthstar, CINAHL, BIOSIS, CAB abstracts. We also hand searched nutrition journals and reference lists and contacted 'sip-feed' manufacturers.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials of oral protein and energy supplementation in older people, with the exception of groups recovering from cancer treatment or in critical care.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trials prior to inclusion and independently extracted data and assessed trial quality. Authors of trials were contacted for further information as necessary.

MAIN RESULTS

Sixty-two trials with 10,187 randomised participants have been included in the review. Maximum duration of intervention was 18 months. Most included trials had poor study quality. The pooled weighted mean difference (WMD) for percentage weight change showed a benefit of supplementation of 2.2% (95% confidence interval (CI) 1.8 to 2.5) from 42 trials. There was no significant reduction in mortality in the supplemented compared with control groups (relative risk (RR) 0.92, CI 0.81 to 1.04) from 42 trials. Mortality results were statistically significant when limited to trials in which participants (N = 2461) were defined as undernourished (RR 0.79, 95% CI 0.64 to 0.97).The risk of complications was reduced in 24 trials (RR 0.86, 95% CI 0.75 to 0.99). Few trials were able to suggest any functional benefit from supplementation. The WMD for length of stay from 12 trials also showed no statistically significant effect (-0.8 days, 95% CI -2.8 to 1.3). Adverse effects included nausea or diarrhoea.

AUTHORS' CONCLUSIONS

Supplementation produces a small but consistent weight gain in older people. Mortality may be reduced in older people who are undernourished. There may also be a beneficial effect on complications which needs to be confirmed. However, this updated review found no evidence of improvement in functional benefit or reduction in length of hospital stay with supplements. Additional data from large-scale multi-centre trials are still required.

Nutritional problems in the elderly

Despite the high prevalence of malnutrition among elderly patients, nutritional problems are still not recognized as a priority forthem by health professionals. The need for nutritional assessment and intervention is particularly crucial in this age group, in whom the incidence of chronic illness is high and a myriad of socio-economic factors enhance the likelihood of malnutrition. Malnutrition could be considered as an element of frailty among the old, leading to increased risk of many geriatric syndromes such as falls, delirium, functional decline, depressed immunity, etcetera. However, detection of nutritional risk and nutritional intervention are effective in frail patients. Nutritional assessment should be part of routine clinical practice in elderly hospitalized patients. A comprehensive screening tool for assessment of nutritional status that is clinically relevant and cost effective to perform is therefore needed. If malnutrition is suggested by such screening tests, then a supplemental conventional nutritional assessment should be performed before treatment is planned.

Effect of multivitamin and multimineral supplementation on cognitive function in men and women aged 65 years and over: a randomised controlled trial

BACKGROUND

Observational studies have frequently reported an association between cognitive function and nutrition in later life but randomised trials of B vitamins and antioxidant supplements have mostly found no beneficial effect. We examined the effect of daily supplementation with 11 vitamins and 5 minerals on cognitive function in older adults to assess the possibility that this could help to prevent cognitive decline.

METHODS

The study was carried out as part of a randomised double blind placebo controlled trial of micronutrient supplementation based in six primary care health centres in North East Scotland. 910 men and women aged 65 years and over living in the community were recruited and randomised: 456 to active treatment and 454 to placebo. The active treatment consisted of a single tablet containing eleven vitamins and five minerals in amounts ranging from 50-210 % of the UK Reference Nutrient Intake or matching placebo tablet taken daily for 12 months. Digit span forward and verbal fluency tests, which assess immediate memory and executive functioning respectively, were conducted at the start and end of the intervention period. Risk of micronutrient deficiency at baseline was assessed by a simple risk questionnaire.

RESULTS

For digit span forward there was no evidence of an effect of supplements in all participants or in sub-groups defined by age or risk of deficiency. For verbal fluency there was no evidence of a beneficial effect in the whole study population but there was weak evidence for a beneficial effect of supplementation in the two pre-specified subgroups: in those aged 75 years and over (n 290; mean difference between supplemented and placebo groups 2.8 (95% CI -0.6, 6.2) units) and in those at increased risk of micronutrient deficiency assessed by the risk questionnaire (n 260; mean difference between supplemented and placebo groups 2.5 (95% CI -1.0, 6.1) units).

CONCLUSION

The results provide no evidence for a beneficial effect of daily multivitamin and multimineral supplements on these domains of cognitive function in community-living people over 65 years. However, the possibility of beneficial effects in older people and those at greater risk of nutritional deficiency deserves further attention.

Nutritional supplementation and dietary advice in geriatric patients at risk of malnutrition

BACKGROUND & AIM

Effects of combined nutritional treatment of patients at risk of protein-energy malnutrition (PEM) discharged from a geriatric service were evaluated.

METHODS

Patients (n=108, age 85+/-6 years) at risk of malnutrition according to the short form of the mini nutritional assessment were randomly allocated to dietary counseling, including liquid and multivitamin supplementation, i.e. intervention (I, n=51) and to controls (C, n=57). Body weight, biochemical indices (e.g. insulin-like growth factor I (IGF-I)), Katz activities of daily living (ADL) index, mini mental status examination (MMSE) and quality of life (QoL) by SF-36 were assessed at the start of the study and after 4 months. Statistical analyses were performed on "intention-to-treat" and on "treated-as-protocol" bases.

RESULTS

Fifty-four patients, 29 in the I-group (86+/-7 years, 66% females) and 25 in the C-group (85+/-7 years, 72% females) completed the study according to the protocol. Both modes of analysis revealed a significant positive effect of the combined nutritional intervention on weight maintenance. Treated-as-protocol analyses showed that Katz ADL index improved in the I-group (p<0.001; p<0.05 between the groups). Serum IGF-I levels increased in the I-group (p<0.001), but were unchanged in the C-group (p=0.07 between the groups). QoL was assessed to be low and had not changed after nutritional treatment.

CONCLUSIONS

Combined nutritional intervention prevented weight loss and improved ADL functions in discharged geriatric patients at risk of malnutrition.

The impact of nutrition on cognition in the elderly

The possibility that nutritional manipulation may protect against cognitive decline and dementia is an inviting prospect. However data supporting a beneficial effect of a particular dietary pattern is limited. Although studies have demonstrated a health benefit to dietary plans that are high in fiber, whole grains, natural sugar and fish while maintaining lower intake in meat dairy and poultry, the ability to identify the most salient factors of these diets have been unsuccessful. Several aspects of diet have been studied in detail and provided support for potential mechanisms for improving cognition. Clinical trials have explored these mechanisms through supplementation studies with minimal benefits being observed. Continuing work to hone the mechanisms and refine our knowledge of dietary benefits is described.

Nutritional status is altered in the self-neglecting elderly

Elder self-neglect is the most common form of elder mistreatment. Individuals who cannot provide basic needs for themselves may develop social, functional, and physical deficits. The systematic characterization of self-neglecting individuals is the goal of the Consortium for Research in Elder Self-Neglect of Texas project. This study reports on the nutritional status of self-neglecting elderly. Self-neglectors (SN) were recruited based on referrals along with matched control (CN) subjects. Data are for 40 SN subjects (age 76 +/- 7 y) and 40 CN subjects (76 +/- 7 y). Blood samples were collected and analyzed for indices of nutritional status. SN subjects had a greater serum concentration of total homocysteine than CN subjects (13.6 +/- 4.5 vs. 11.6 +/- 5.6 micromol/L, P < 0.05) and a lower concentration of red blood cell folate (1380 +/- 514 vs. 1792 +/- 793 nmol/L, P < 0.05). Plasma beta-carotene and alpha-tocopherol were lower in SN subjects (0.28 +/- 0.2 vs. 0.43 +/- 0.33 micromol/L; 23.2 +/- 9.3 vs. 27.8 +/- 9.3 micromol/L, P < 0.05). SN subjects had a lower serum concentration of 25-hydroxyvitamin D than CN subjects (33.7 +/- 16.4 vs. 44.1 +/- 19.6 nmol/L, P < 0.05). These differences in markers of nutritional status show that the self-neglecting elderly are at risk for altered nutritional status, particularly of folate, antioxidants, and vitamin D. Evaluation of these data in relation to other functional and cognitive assessments are critical for evaluating the relation between nutrition and self-neglect.

Micronutrients in health and disease

Micronutrients play a central part in metabolism and in the maintenance of tissue function. An adequate intake therefore is necessary, but provision of excess supplements to people who do not need them may be harmful. Single micronutrient deficiency states are comparatively easily recognised and treated. Subclinical deficiency, often of multiple micronutrients, is more difficult to recognise, and laboratory assessment is often complicated by the acute phase response. Clinical benefit is most likely in those people who are severely depleted and at risk of complications, and is unlikely if this is not the case. There is little evidence for supplements leading to a reduction in the incidence of infections in the elderly population, in coronary artery disease, or in malignant disease. The best evidence for benefit is in critical illness, and in children in developing countries consuming a deficient diet. More clinical trials are required with good clinical outcomes to optimise intake in prevention and treatment of disease.