Combined nutritional status and activities of daily living disability is associated with one-year mortality after hip fracture surgery for geriatric patients: a retrospective cohort study

OBJECTIVE

We aimed to explore the association combined nutritional status and activities of daily living disability with all-cause mortality of older adults with hip fracture in the first year after hospitalization.

METHODS

This is a single-center retrospective cohort study in older adults with hip fracture patients. Clinical data and laboratory results were collected from electronic medical record system of our hospital (2014-2021). The endpoint of this study was all-cause mortality in the first year after hospitalization.

RESULTS

A total of 303 older adults were enrolled and all-cause mortality was 21.8%. The study population was categorized by CONUT score. Patients in CONUT score 5-12 had a higher age, ASA status, CRP and creatinine level, more patients with history of fracture, pneumonia and delirium, meanwhile, lower BMI and ADL score, lower hemoglobin, lymphocyte, total protein, albumin, triglyceride, total cholesterol and one year survival than those in CONUT score 0-4 (all P < 0.05). Multivariable Cox analysis showed that BMI, ADL score and CONUT score were independent risk factors for all-cause mortality of hip fracture in older adults (HR (95% CI):2.808(1.638, 4.814), P < 0.001; 2.862(1.637, 5.003), P < 0.001; 2.322(1.236, 4.359), P = 0.009, respectively). More importantly, the combined index of CONUT and ADL score had the best predictive performance based on ROC curve (AUC 0.785, 95% CI: 0.734-0.830, P < 0.0001). Kaplan-Meier survival curves for all-cause mortality showed that patients with CONUT score increase and ADL score impairment had a higher mortality rate at 1 year compared to CONUT score decrease and ADL score well (Log Rank χ2 = 45.717, P < 0.0001).

CONCLUSIONS

Combined CONUT and ADL score is associated with one-year mortality after hip fracture surgery for geriatric patients.

Predictors of 2-Year Post-Discharge Mortality in Hospitalized Older Patients

BACKGROUND

Understanding prognostic factors for adverse health outcomes is clinically relevant for improving treatment decision-making processes, potentially leading to enhanced patient prognosis. This secondary analysis of a prospective observational study aimed to identify independent factors associated with 2-year post-discharge mortality in acutely hospitalized older patients.

METHODS

All-cause mortality and date of death of 115 patients (83.3 ± 6.3 years, females: n = 75, 65.2%) admitted to acute geriatric wards were determined two years after hospital discharge through telephone interviews. Potential prognostic factors measured at hospital admission included demographic and clinical characteristics, nutritional, cognitive, and psychological status, Fried frailty phenotype, functioning in activities of daily living, locomotor capacity, and 24 h in-hospital mobility and objectively measured physical activity (PA) behaviors.

RESULTS

The 2-year mortality rate was 36.7% (n = 41). Univariate and multivariate Cox proportional hazards regression models revealed that mean daily PA level (hazards ratio (HR) = 0.59, 95% confidence interval (CI) 0.90-1.00; p = 0.042), frailty (HR = 3.39, 95% CI 1.20-9.51; p = 0.020), and underweight, in contrast to overweight (HR = 3.10, 95% CI 1.07-9.01; p = 0.038), at hospital admission were independently predictive of post-discharge mortality.

CONCLUSION

PA, frailty, and underweight at hospital admission should be considered when evaluating long-term survival prognosis, establishing risk profiles, and developing personalized care pathways in acute hospital care of older adults.

Relationship between nutritional status and clinical outcomes among older individuals using long-term care services: A systematic review and meta-analysis

BACKGROUND & AIMS

Nutritional status is a significant issue in an aging society; however, the impact of the nutritional status of older individuals using long-term care services on the caregiving burden remains unclear. This systematic review and meta-analysis aimed to investigate the impact of nutritional issues on adverse outcomes in older individuals using long-term care services.

METHODS

We used data from the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, Web of Science, CINAHL, and Ichu-shi Web databases. Original articles published in English or Japanese between January 2000 and July 2022 were included. The inclusion criteria were interventional and observational studies on individuals using long-term care services with aged ≥65 years and a focus on body weight or weight loss. Data on adverse outcomes related to caregiving burden, including the number of people requiring care, mortality, complications, activities of daily living (ADL), and quality of life, were collected.

RESULTS

The literature search yielded 7873 studies, of which 35 were ultimately included. Seven observational studies investigated mortality outcomes, and seven examined ADL outcomes. The meta-analysis revealed significantly higher mortality rates in individuals classified as underweight (BMI <18.5 kg/m2) than in those with BMI ≥18.5 kg/m2 (risk ratio [RR] 1.49; 95 % confidence interval [CI] 1.31 to 1.73, 0.22; I2 93 %). Further, on categorising the participants based on a BMI cutoff of 25 kg/m2, those with a BMI of <25 kg/m2 had a significantly increased mortality rate (RR 1.21; 95 % CI 1.04-1.40; I2 = 98 %). BMI and weight loss did not affect ADL.

CONCLUSIONS

Our findings indicate that underweight and weight loss are significantly associated with increased mortality in older individuals using long-term care services. Therefore, appropriate weight management is recommended for this population. However, further research is necessary owing to the high heterogeneity observed in this study.

The Obesity Paradox and Mortality in Older Adults: A Systematic Review

“Obesity paradox” describes the counterintuitive finding that aged overweight and obese people with a particular disease may have better outcomes than their normal weight or underweight counterparts. This systematic review was performed to summarize the publications related to the obesity paradox in older adults, to gain an in-depth understanding of this phenomenon. PubMed©, Embase©, and Scopus© were used to perform literature search for all publications up to 20 March 2022. Studies were included if they reported data from older adults on the relation between BMI and mortality. The following article types were excluded from the study: reviews, editorials, correspondence, and case reports and case series. Publication year, study setting, medical condition, study design, sample size, age, and outcome(s) were extracted. This review has been registered with PROSPERO (no. CRD42021289015). Overall, 2226 studies were identified, of which 58 were included in this systematic review. In all, 20 of the 58 studies included in this review did not find any evidence of an obesity paradox. Of these 20 studies, 16 involved patients with no specific medical condition, 1 involved patients with chronic diseases, and 2 involved patients with type 2 diabetes mellitus. Seven out of the nine studies that looked at short-term mortality found evidence of the obesity paradox. Of the 28 studies that examined longer-term mortality, 15 found evidence of the obesity paradox. In the studies that were conducted in people with a particular medical condition (n = 24), the obesity paradox appeared in 18 cases. Our work supports the existence of an obesity paradox, especially when comorbidities or acute medical problems are present. These findings should help guide strategies for nutritional counselling in older populations.

Prediction of Mortality in Older Hospitalized Patients after Discharge as Determined by Comprehensive Geriatric Assessment

Several dimensional impairments regarding Comprehensive Geriatric Assessment (CGA) have been shown to be associated with the prognosis of older patients. The purpose of this study is to investigate mortality prediction factors based upon clinical characteristics and test in CGA, and then subsequently develop a prediction model to classify both short- and long-term mortality risk in hospitalized older patients after discharge. A total of 1565 older patients with a median age of 81 years (74.0−86.0) were consecutively enrolled. The CGA, which included assessment of clinical, cognitive, functional, nutritional, and social parameters during hospitalization, as well as clinical information on each patient was recorded. Within the one-year follow up period, 110 patients (7.0%) had died. Using simple Cox regression analysis, it was shown that a patient’s Length of Stay (LOS), previous hospitalization history, admission Barthel Index (BI) score, Instrumental Activity of Daily Living (IADL) score, Mini Nutritional Assessment (MNA) score, and Charlson’s Comorbidity Index (CCI) score were all associated with one-year mortality after discharge. When these parameters were dichotomized, we discovered that those who were aged ≥90 years, had a LOS ≥ 12 days, an MNA score < 17, a CCI ≥ 2, and a previous admission history were all independently associated with one-year mortality using multiple cox regression analyses. By applying individual scores to these risk factors, the area under the receiver operating characteristics curve (AUC) was 0.691 with a cut-off value score ≧ 3 for one year mortality, 0.801 for within 30-day mortality, and 0.748 for within 90-day mortality. It is suggested that older hospitalized patients with varying risks of mortality may be stratified by a prediction model, with tailored planning being subsequently implemented.

Nutritional status related to poor health outcomes in older people: Which is better, obese or lean?

Good nutritional status is crucial for maintaining growth and health in all stages of life. However, the relationship between nutritional status and health and the effect on various health-related outcomes differ, depending on the life stage. Many adverse outcomes in older adults, directly linked to different nutritional status, are not present in middle-aged adults, and their ideal nutritional status may differ. This article will review the optimal nutritional status, mainly evaluated by anthropometric measurements such as body mass index, for older adults from various perspectives. Overall, in older adults low body mass index is at higher risk of health problems such as mortality and difficulties in physical functioning compared with middle-aged adults, reducing the risk of health problems for overweight and (abdominal) obesity. Overweight may be more beneficial than lower level of normal weight in older-old and vulnerable older people. While, with or without obesity, skeletal muscle loss or weakness as well as unintentional weight loss induces health problems in older adults. The impact of metabolic syndrome on the prognosis of older adults is clearly reduced compared with middle-aged adults, requiring a shift in medical attention in older adults from metabolic syndrome to frailty. There are still many unclear points regarding the optimal nutritional status of older people, and further research is needed to support healthy longevity. Geriatr Gerontol Int 2021; 21: 5-13.

The Phenomenon of "Obesity Paradox" in Neck of Femur Fractures

Objective

To determine the association of body mass index (BMI) with 30 days and 1-year mortality outcomes of orthopedic elderly patients after hip fracture surgery.

Methods

This is prospective study conducted at Department of Orthopaedics, at a tertiary care public sector hospital in Karachi between Jan-2016 to Jan-2018. In this short follow-up study, we included the data of 490 patients, who were operated for neck of femur fractures in a public sector tertiary care hospital between Jan-2016 to Jan-2018. Patients were divided into different categories on the basis of BMI; BMI <20 Kg.m^-2 underweight, 20-24.99 Kg.m^-2 normal weight, BMI 25-29.99 Kg.m^-2 overweight, ≥30 obese. Mortality at 30 days and 1-year mortality were primary study end-points.

Results

Rate of re-admission within 30 days, major adverse cardiovascular events (MACE) within 30 days and 30 days mortality was high in underweight and lowest in obese patients. Thirty-day mortality rate was 2.7% in underweight, 1.3% in normal weight, 0.64% in over-weight and 0.0% in obese patients but this was not significant statistically (p-value 0.29). One-year mortality rate was significantly high in under-weight patients, 34.2%, 25.9% in normal weight, 21.4% in overweight and only 14.5% in obese patients (p-value 0.009). Age ≥ 65 years (odds ratio 0.40 (0.26-0.63), and ASA III-IV (odds ratio; 0.27 (0.16-0.45) are also significant risk factors of 1-year mortality.

Conclusion

BMI classification can serve as an important indicator of adverse early outcomes after hip fracture surgery. Over-weight and obese patients have better survival outcomes and have lower 1-year mortality rate.

"Obesity Paradox" Holds True for Patients with Hip Fracture: A Registry-Based Cohort Study

BACKGROUND

Hip fractures are associated with high mortality and reduced quality of life. Studies have reported a high body mass index (BMI) as being positively associated with survival when linked to old age and some chronic diseases. This phenomenon is called the "obesity paradox." The association between BMI and survival after hip fracture has not been thoroughly studied in large samples, nor has to what extent the association is altered by comorbidities, sex, and age. The objective of this study was to investigate the association of BMI with survival after hip fracture and with the probability of returning to living at home after hip fracture.

METHODS

This cohort study was based on data from a prospectively maintained national registry of patients with hip fracture. A total of 17,756 patients ≥65 years of age who were treated for hip fracture during the period of 2013 to 2016, and followed until the end of 2017, were included. BMI was clinically assessed at hospital admission, comorbidity was measured with the American Society of Anesthesiologists (ASA) score, and the date of death was retrieved from a national database. Self-reported data on living arrangements were assessed on admission and 4 months after fracture. Multivariable regression models were used to estimate the associations.

RESULTS

Despite ASA scores being similar among all BMI groups, obese patients had the highest 1-year survival and patients with a BMI of <22 kg/m had the lowest. Adjustment for potential confounders strengthened the associations. For the chance of returning to living at home, no advantage was seen for obese patients, but patients with a BMI of <22 kg/m had clearly worse odds compared with patients who were of normal weight, overweight, or obese.

CONCLUSIONS

The obesity paradox appears to be true for hip fracture patients aged 65 and older. Attention should be given to patients with malnutrition and underweight status rather than to those with overweight status or obesity when developing the orthogeriatric care.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Fighting against a protean enemy: immunosenescence, vaccines, and healthy aging

The progressive increase of the aged population worldwide mandates new strategies to ensure sustained health and well-being with age. The development of better and/or new vaccines against pathogens that affect older adults is one pivotal intervention in approaching this goal. However, the functional decline of various physiological systems, including the immune system, requires novel approaches to counteract immunosenescence. Although important progress has been made in understanding the mechanisms underlying the age-related decline of the immune response to infections and vaccinations, knowledge gaps remain, both in the areas of basic and translational research. In particular, it will be important to better understand how environmental factors, such as diet, physical activity, co-morbidities, and pharmacological treatments, delay or contribute to the decline of the capability of the aging immune system to appropriately respond to infectious diseases and vaccination. Recent findings suggest that successful approaches specifically targeted to the older population can be developed, such as the high-dose and adjuvanted vaccines against seasonal influenza, the adjuvanted subunit vaccine against herpes zoster, as well as experimental interventions with immune-potentiators or immunostimulants. Learning from these first successes may pave the way to developing novel and improved vaccines for the older adults and immunocompromised. With an integrated, holistic vaccination strategy, society will offer the opportunity for an improved quality of life to the segment of the population that is going to increase most significantly in numbers and proportion over future decades.

Health determinants and survival in nursing home residents in Europe: Results from the SHELTER study

OBJECTIVE

The care processes directed towards institutionalized older people needs to be tailored on goals and priorities that are relevant for this specific population. The aim of the present study was (a) to describe the distribution of selected health determinants in a sample of institutionalized older adults, and (b) to investigate the impact on survival of such measures.

DESIGN

Multicentre longitudinal cohort-study.

SETTING

57 nursing homes (NH) in 7EU countries (Czech Republic, England, Finland, France, Germany, Italy, The Netherlands) and 1 non-EU country (Israel).

PARTICIPANTS

3036 NH residents participating in the Services and Health for Elderly in Long TERm care (SHELTER) study.

MEASUREMENTS

We described the distribution of 8 health determinants (smoking habit, alcohol use, body mass index [BMI], physical activity, social participation, family visits, vaccination, and preventive visits) and their impact on 1-year mortality.

RESULTS

During the one-year follow up, 611 (20%) participants died. Overweight (HR 0.79; 95% C.I. 0.64-0.97) and obesity (HR 0.64; 95% C.I. 0.48-0.87) resulted associated with lower mortality then normal weight. Similarly, physical activity (HR 0.67; 95% C.I. 0.54-0.83), social activities (HR 0.63; 95% C.I. 0.51-0.78), influenza vaccination (HR 0.66; 95% C.I. 0.55-0.80) and pneumococcal vaccination (HR 0.76 95% C.I. 0.63-0.93) were associated with lower mortality. Conversely, underweight (HR 1.28; 95% C.I. 1.03-1.60) and frequent family visits (HR 1.75; 95% C.I. 1.27-2.42) were associated with higher mortality.

CONCLUSIONS

Health determinants in older NH residents depart from those usually accounted for in younger and fitter populations. Ad hoc studies are warranted in order to describe other relevant aspects of health in frail older adults, with special attention on those institutionalized, with the ultimate goal of improving the quality of care and life.

Impact of Age-related Comorbidities on Five-year Overall Mortality among Elderly HIV-Infected Patients in the Late HAART Era--Role of Chronic Renal Disease

OBJECTIVES

To identify main prognostic factors for 5-year mortality among age-related comorbidities (ARCs) in older people living with HIV (PLHIV).

DESIGN

A prospective, multicentre cohort study with a 5-year follow-up period in the late HAART era (from January 2008 to December 2012).

SETTING

The Dat'AIDS cohort involving 12 French hospitals.

PARTICIPANTS

All actively followed HIV-1 infected patients aged 60 or older.

MEASUREMENTS

The study endpoint was all-cause five-year mortality. The following ARCs were considered: chronic renal disease, cardiovascular diseases, cancer, chronic pulmonary disease, cirrhosis, diabetes and nutritional status. Hepatitis C (HCV), hepatitis B (HBV) co-infection and sociodemographic characteristics were also evaluated. Cox's Proportional Hazards model was used for multivariate analysis.

RESULTS

Among 1415 PLHIV aged 60 or more patients included, mean age was 66±5.5 years; 154 died (mortality rate 2.47/100 patient-years). The most prevalent ARCs were chronic renal disease (20.1%), diabetes (14.2%) and cardiovascular diseases (12.2%). By multivariate analysis, chronic renal disease (adjusted hazard ratio (aHR)=2.25; 95% confidence interval (CI) [1.58-2.21]; p<10-4), cardiovascular diseases (aHR=2.40; 95%CI[1.64-3.52]; p<10-4), non-HIV related cancer (aHR=1.91; 95%CI[1.20-3.05]; p=0.007), cirrhosis (aHR=2.99; 95%CI[1.68-5.33]; p<10-3), HCV co-infection (aHR=2.00; 95%CI[1.18-3.38]; p=0.009), low body mass index (aHR=2.42; 95%CI[1.46-4.01]; p<10-3) and CD4 cell count < 200 cells/µl (aHR=2.23; 95%CI[1.36-3.65]; p=0.002) were independently associated with 5 year mortality.

CONCLUSION

Due to a high prevalence, chronic renal disease and cardiovascular disease are main prognostic factors for 5-year mortality among aged PLHIV.

Body composition and all-cause mortality in subjects older than 65 y

BACKGROUND

A low or high body mass index (BMI) has been associated with increased mortality risk in older subjects without taking fat mass index (FMI) and fat-free mass index (FFMI) into account. This information is essential because FMI is modulated through different healthcare strategies than is FFMI.

OBJECTIVE

We aimed to determine the relation between body composition and mortality in older subjects.

DESIGN

We included all adults ≥65 y old who were living in Switzerland and had a body-composition measurement by bioelectrical impedance analysis at the Geneva University Hospitals between 1990 and 2011. FMI and FFMI were divided into sex-specific quartiles. Quartile 1 (i.e., the reference category) corresponded to the lowest FMI or FFMI quartile. Mortality data were retrieved from the hospital database, the Geneva death register, and the Swiss National Cohort until December 2012. Comorbidities were assessed by using the Cumulative Illness Rating Scale.

RESULTS

Of 3181 subjects included, 766 women and 1007 men died at a mean age of 82.8 and 78.5 y, respectively. Sex-specific Cox regression models, which were used to adjust for age, BMI, smoking, ambulatory or hospitalized state, and calendar time, showed that body composition did not predict mortality in women irrespective of whether comorbidities were taken into account. In men, risk of mortality was lower with FFMI in quartiles 3 and 4 [HR: 0.78 (95% CI: 0.62, 0.98) and 0.64 (95% CI: 0.49, 0.85), respectively] but was not affected by FMI. When comorbidities were adjusted for, FFMI in quartile 4 (>19.5 kg/m(2)) still predicted a lower risk of mortality (HR: 0.72; 95% CI: 0.54, 0.96).

CONCLUSIONS

Low FFMI is a stronger predictor of mortality than is BMI in older men but not older women. FMI had no impact on mortality. These results suggest potential benefits of preventive interventions with the aim of maintaining muscle mass in older men. This trial was registered at clinicaltrials.gov as NCT01472679.

Prognostic indices of poor nutritional status and their impact on prolonged hospital stay in a Greek university hospital

Background. To ascertain the potential contributors to nutritional risk manifestation and to disclose the factors exerting a negative impact on hospital length of stay (LOS), by means of poor nutritional status, in a nonselected hospitalized population. Materials and Methods. NutritionDay project questionnaires were applied to 295 adult patients. Study parameters included anthropometric data, demographics, medical history, dietary-related factors, and self-perception of health status. Body Mass Index (BMI) and Malnutrition Universal Screening Tool (MUST) were calculated for each participant. MUST score was applied for malnutrition assessment, while hospital LOS constituted the outcome of interest. Results. Of the total cohort, 42.3% were at nutritional risk and 21.4% malnourished. Age, gender, BMI, MUST score, autonomy, health quality, appetite, quantity of food intake, weight loss, arm or calf perimeter (P < 0.001, for all), and dietary type (P < 0.01) affected nutritional status. Poor nutrition status (P = 0.000), deteriorated appetite (P = 0.000) or food intake (P = 0.025), limited autonomy (P = 0.013), artificial nutrition (P = 0.012), weight loss (P = 0.010), and arm circumference <21 cm (P = 0.007) were the most powerful predictors of hospital LOS >7 days. Conclusion. Nutritional status and nutrition-related parameters such as weight loss, quantity of food intake, appetite, arm circumference, dietary type, and extent of dependence confer considerable prognostic value regarding hospital LOS in acute care setting.

Is obesity a marker of robustness in vulnerable hospitalized aged populations? Prospective, multicenter cohort study of 1 306 acutely ill patients

BACKGROUND

The "obesity paradox" is poorly understood in vulnerable older hospitalized populations.

OBJECTIVES

To prospectively analyze the impact of body mass index (BMI) and comorbidities on early (6-week), one- and two-year mortality.

DESIGN

Prospective multicenter study with a two-year follow-up of old patients participating in the SAFES cohort study.

SETTINGS

Nine university hospitals in France.

PARTICIPANTS

Patients aged 75 or older hospitalized in medical divisions through the emergency department.

MEASUREMENT

Inpatients' characteristics were obtained through a comprehensive geriatric assessment of inpatients, conducted in the first week of hospitalization. All-cause mortalities at 6-week, one- and two-year were determined using bivariable and multivariable Cox proportional hazard model.

RESULTS

The SAFES cohort included 1,306 patients, aged 85±6 years, with a majority of women (65%). One- and two-year mortality were inversely associated with BMI ≥30 kg/m2 while early mortality was not, and positively associated with age, burden of comorbidities, walking disorders, level of dependency and presence of a dementia syndrome. Survival rates between patients in low (< 18.0 kg/m2) and intermediate (18-24.9 and 25-29.9 kg/m2) BMI categories were not significant.

CONCLUSION

While our findings seem to confirm the reality of the "obesity paradox" in vulnerable older hospitalized population, the exact understanding of underlying mechanisms and even the truthfulness of this paradoxical relationship are still fraught with considerable methodological, epidemiological and metabolic challenges.

[Gender aspects of malnutrition and associated sequelae. Prevention and therapy]

Malnutrition is related to a range of secondary complications. The prevalence of many of these sequelae is higher in elderly women than in men, thus resulting in a higher level of impairment and reduced quality of life. Multiple factors lead to the development of malnutrition and socioeconomic causes, such as poverty among the elderly and isolation, are more common in elderly women. The age-associated loss of muscle mass is more pronounced in women than in men and the risk of developing sarcopenia and frailty is increased. The prevalence of sarcopenic obesity is higher in women than in men. Malnutrition increases the risk of osteoporosis and about 80 % of all osteoporosis patients are women. Furthermore, low serum levels of vitamin D correlate more closely to a poorer cognitive outcome in elderly women than they do in men. The prevention, early diagnosis and therapy of malnutrition is of great clinical importance, particularly to preserve physical functional capacity and thus quality of life in elderly women.