Nutritional Status: Key to Preventing Functional Decline in Hospitalized Older Adults:

Predictive Effect of Malnutrition on Long-Term Clinical Outcomes among Older Men: A Prospectively Observational Cohort Study

OBJECTIVES

To determine whether nutritional status can predict 3-year cognitive and functional decline, as well as 4-year all-cause mortality in older adults.

DESIGN

Prospectively longitudinal cohort study.

SETTING AND PARTICIPANTS

The study recruited 354 men aged 65 years and older in the veteran's retirement community.

MEASURES

Baseline nutritional status was evaluated using the Mini-Nutritional Assessment-Short Form (MNA-SF). Cognitive function and Activities of Daily Living (ADL) function were determined by the Mini-Mental State Examination (MMSE) and the Barthel Index, respectively. Three-year cognitive and functional decline were respectively defined as a >3 point decrease in the MMSE scores and lower ADL scores than at baseline. Univariate and multivariable logistic regression analyses were conducted to identify nutritional status as a risk factor in poor outcome. The Kaplan-Meier method and Cox proportional regression models were used to estimate the effect of malnutrition risk on the mortality.

RESULTS

According to MNS-SF, the prevalence of risk of malnutrition was 53.1% (188/354). Multivariate logistic regression found risk of malnutrition significantly associated with 3-year cognitive decline (Adjusted odds ratio [OR] 2.07, 95% Confidence Interval [CI] 1.05-4.08, P =0.036) and functional decline (Adjusted OR 1.83, 95% CI 1.01-3.34, P =0.047) compared with normal nutritional status. The hazard ratio (HR) for all-cause mortality was 1.8 times higher in residents at risk of malnutrition (Adjusted HR 1.82, 95% CI 1.19-2.79, P =0.006).

CONCLUSIONS

Our results provide strong evidence that risk of malnutrition can predict not only cognitive and functional decline but also risk of all-cause mortality in older men living in a veteran retirement's community. Further longitudinal studies are needed to explore the causal relationship among nutrition, clinical outcomes, and the effect of an intervention for malnutrition.

Outcomes of hospitalized patients undergoing emergency general surgery remote from admission

BACKGROUND

Emergency general surgery during hospitalization has not been well characterized. We examined emergency operations remote from admission to identify predictors of postoperative 30-day mortality, postoperative duration of stay >30 days, and complications.

METHODS

Patients >18 years in The American College of Surgeons National Surgical Quality Improvement Program (2011-2014) who had 1 of 7 emergency operations between hospital day 3-18 were included. Patients with operations >95th percentile after admission (>18 days; n = 581) were excluded. Exploratory laparotomy only (with no secondary procedure) represented either nontherapeutic or decompressive laparotomy. Multivariable logistic regression was used to identify predictors of study outcomes.

RESULTS

Of 10,093 patients with emergency operations, most were elderly (median 66 years old [interquartile ratio: 53-77 years]), white, and female. Postoperative 30-day mortality was 12.6% (n = 1,275). Almost half the cohort (40.1%) had a complication. A small subset (6.8%) had postoperative duration of stay >30 days. Postoperative mortality after exploratory laparotomy only was particularly high (>40%). In multivariable analysis, an operation on hospital day 11-18 compared with day 3-6 was associated with death (odds ratio 1.6 [1.3-2.0]), postoperative duration of stay >30 days (odds ratio 2.0 [1.6-2.6]), and complications (odds ratio 1.5 [1.3-1.8]). Exploratory laparotomy only also was associated with death (odds ratio 5.4 [2.8-10.4]).

CONCLUSION

Emergency general surgery performed during a hospitalization is associated with high morbidity and mortality. A longer hospital course before an emergency operation is a predictor of poor outcomes, as is undergoing exploratory laparotomy only.

Can the Mini Nutritional Assessment (MNA) Be Used as a Nutrition Evaluation Tool for Subacute Inpatients over an Average Length of Stay?

OBJECTIVE

The prevalence of malnutrition in subacute inpatient settings has been reported to be 30-50%. While there are a number of nutrition evaluation tools which have been validated to diagnose malnutrition, the use of a validated nutrition evaluation tool to measure changes in nutritional status during an average length of stay for a subacute inpatient has not yet been tested. This study aims to determine the potential of the full MNA (full Mini Nutritional Assessment) and MNA (Mini Nutritional Assessment Short Form) scores to measure change in nutritional status over an average subacute inpatient stay (21 days).

DESIGN

A prospective observational study.

SETTING

The study was performed in three Rehabilitation and Geriatric Evaluation and Management (GEM) wards of the Kingston Centre, Monash Health, Melbourne, Australia.

PARTICIPANTS

All patients ≥65 years admitted to these wards with an expected length of stay of at least 14 days were considered for inclusion in this study.

MEASUREMENTS

Nutritional status was assessed on admission using the full MNA as part of usual dietetic care and patients were provided with nutrition intervention/diet therapy based on full MNA classification. Full MNA score (0-30), MNA score (0-14), anthropometry (weight and height) and nutritional biochemistry (serum albumin, transthyretin and C-reactive protein) were compared between admission and day 20.5 ± 2.4.

RESULTS

Mean age (± SD) of 83 ± 7 years, n=114. For those patients diagnosed at risk of malnutrition or malnourished (n=103), there were significant increases in full MNA score (1.8 ± 2.4, p<0.001), MNA score (0.9 ± 1.7, p<0.001), weight (0.6 ± 2.5 kg, p=0.017) and serum albumin (1.4 ± 4.4 g/L, p=0.003) over the study period. All four of the full MNA domain sub-scores, also increased significantly in those patients diagnosed at risk of malnutrition or malnourished (n=103): anthropometric assessment (p<0.001), dietary assessment (p<0.001), general status assessment (p=0.019) and self-perceived health and nutrition states (p=0.033).

CONCLUSION

Both the MNA and full MNA can be used to evaluate nutrition progress within the subacute inpatient setting over a three week time period, thereby providing clinicians with feedback on a patient's nutrition progress and assisting with ongoing care planning. Due to its ease of use and shorter time required to complete, the MNA may be the preferred nutrition evaluation tool in this setting.

Recently hospital-discharged older adults are vulnerable and may be underserved by the Older Americans Act Nutrition Program

The home-delivered meal (HDM) program of the Older Americans Act Nutrition Program (OAANP) has traditionally served frail homebound older adults; however, due to gaps in the continuum of care, enrollment in this program following hospital discharge remains a challenge. Trained interviewers at 6 HDM sites in 6 U.S. states assigned 566 hospital-discharged individuals, ages 60-96 years, into either early (48 hour) or delayed (2 weeks) enrollment groups and assessed their health and nutrition status. Regardless of elapsed time at enrollment, more than 80% reported at least one limitation in activities and instrumental activities of daily living. About 20% had impaired cognition and more than 40% had depressive symptoms. Also, 40% reported fair or poor appetite. Despite intense recruitment from hospitals, only 30% of participants were referred from hospitals. The recently hospital-discharged older adult population may include a higher prevalence of individuals with poor functional status and at nutritional risk than participants in the OAANP HDM program and yet may be underserved by this program.

Screening tools to identify hospitalised elderly patients at risk of functional decline: a systematic review

BACKGROUND

The elderly patient admitted to the emergency department (ED) of an acute care hospital is at risk of declining functionally, both during the stay at the hospital as an inpatient and postdischarge. Accurate and early identification of this population may lead to improved outcomes through targeted early interventions.

OBJECTIVES

To identify, critically appraise and characterise available screening tools to screen for elderly patients at risk of functional decline presenting to the ED of acute care hospitals.

SELECTION CRITERIA

Screening tools administered in the ED to identify elderly patients at risk of functional decline during hospital stay and/or postdischarge. All primary quantitative and qualitative study types were included. Population included age > 65 years presenting to the ED of an acute care hospital.

RESULTS

Six studies reporting on five screening tools were identified. Two instruments reported acceptable discriminative ability; however, one of these has not been prospectively validated. No studies that validated any of the instruments in a setting other than the development setting were identified. A single study reported good test-retest reliability data for one instrument, the Identification of Seniors at Risk.

CONCLUSION

This review was unable to identify a 'gold standard' tool to screen for risk of functional decline for the elderly patient admitted to the ED. Further research should be carried out to determine adjunctive processes to increase the accuracy of the identification of elderly patients at risk of functional decline. Further research should also be carried out to determine the appropriateness, or generalisability of these tools in different healthcare settings.

Undernutrition in older adults across the continuum of care: nutritional assessment, barriers, and interventions

Undernutrition can be a significant deterrent to healthy aging and can nega tively affect health outcomes in older adults. Researchers have identified the prevalence of undernutrition in older adults and the need for intervention yet the incidence remains high. The purpose of this article is twofold: to emphasize the need for nutritional assessment across the continuum of care a experienced by older adults, and to identify possible barriers to effective treatment. The assessment of nutritional status and the implementation of effective nutritional interventions are essential to the health of older adults.

Functional and self-efficacy changes of patients admitted to a Geriatric Rehabilitation Unit

BACKGROUND

Geriatric Rehabilitation Units (GRUs) have been established to restore functional abilities of older hospitalized patients. Although considerable health care resources have been allocated to these units, few outcome-based research studies have been reported on Canadian GRUs.

AIM

The aim of this paper is to report a study examining the effect of admission to a GRU on changes in patients' functional ability and self-efficacy in performing everyday activities at home.

METHODS

Following Institutional Review Board approval, data were collected from 40 patients age 65-101 years (mean 83.8, sd 6.57) admitted to a 21-bed interdisciplinary GRUs over a 7-month period. All were living independently prior to hospital admission. Data were collected on admission to the unit and on discharge using two instruments: the Functional Independence Measure and Falls Efficacy Scale.

RESULTS

Statistically significant improvements were found in functional ability and self-efficacy following admission to the GRUs.

CONCLUSIONS

Although functional level and feelings of self-efficacy on admission to the unit were at levels which may have prevented participants from returning home, the majority were discharged to the community. Results suggest that admission to a GRU helps prepare patients to return to community living.