Ageing and muscle: the effects of malnutrition, re-nutrition, and physical exercise

Association of oral health with nutritional status of the older adults: a cross-sectional study

OBJECTIVES

The potential association between oral health and nutritional status of the very old, has been poorly investigated. Thus, we carried out the cross-sectional study to evaluate the association of oral health with the nutritional status of the older adults.

METHODS

210 participants aged over 75 years were included in the study. Nutritional status was assessed by the Short-form Mini-Nutritional Assessment (MNA-SF) and body composition measurement. Data were available for self-reported oral health (10-item Eating Assessment Tool (EAT-10) and Chewing Function Questionnaire (CFQ)) and specific experimental tests including salivary flow, tongue and lip pressure, occlusal force, water swallow test and taste test for the detection of oral functions. Spearman rank correlation was used to analyze the correlation between body composition and oral health. Logistic regression and restricted cubic spline models were applied to examine the association of oral health with malnutrition.

RESULTS

The study reveals that poor oral health is related to the malnutrition. The tongue pressure and molar occlusal force were significantly associated with malnutrition in an L-shaped dose-response relationship after adjustment for potential confounding factors. The higher the tongue pressure and molar occlusal force, the lower the risk of malnutrition. Besides, the CFQ score, salty, sour, and bitter taste, are risk factors for malnutrition.

CONCLUSIONS

The presence of malnutrition is significantly associated with poor oral health in older adults. Our study supposes that the design of food suitable for oral conditions of the older adults may be another feasible solution to the nutritional problems among them.

Actual situation of nutritional management and factors related to activities of daily living ability at discharge in convalescent rehabilitation ward

Saito T, Kamachi M. Actual situation of nutritional management and factors related to activities of daily living ability at discharge in convalescent rehabilitation ward. Jpn J Compr Rehabil Sci 2024; 15: 71-78.

Objective

In this study, we aimed to investigate changes in the Geriatric Nutritional Risk Index (GNRI), a nutrition-related prognostic indicator, in our convalescent rehabilitation ward and determine how this index relates to activities of daily living (ADL) ability at discharge.

Methods

We retrospectively analyzed data of 107 patients admitted to our convalescent rehabilitation ward between April and September 2023. We used the GNRI as the nutritional risk index and Functional Independence Measure (FIM) as the ADL index.

Results

The patients' mean age was 80.0 ± 10.3 years; 38 were males and 69 females. The patients' mean body weight at admission was 51.2 ± 10.2 kg, which significantly decreased to 50.2 ± 9.4 kg at discharge (p = 0.0006). Their mean body mass index (BMI) also significantly decreased from 21.4 ± 3.4 at admission to 20.0 ± 8.2 at discharge (p = 0.002). The mean GNRI significantly decreased from 93.1 ± 8.6 at admission to 91.7 ± 8.4 at discharge (p = 0.023). The mean body weight decreased until the fourth month after admission; however, no decreasing trend after the fifth month was observed. The mean monthly energy intake gradually increased after admission and reached the calculated energy requirement of 1,415 ± 22 kcal at the fifth month. Multivariate analysis demonstrated that at discharge, the GNRI score was positively associated with the FIM score (β = 0.21, p = 0.0008).

Conclusion

Body weight and GNRI scores decreased after admission but stopped decreasing after the fifth month due to a gradual increase in energy intake. At discharge, the FIM score was positively associated with the GNRI score. We expected that active nutritional therapy from the beginning of hospitalization would increase the GNRI by the time of discharge and eventually improve ADL ability at discharge.

Nutritional Status and Post-Cardiac Surgery Outcomes: An Updated Review with Emphasis on Cognitive Function

Background/Objectives: Nutritional status significantly influences cardiac surgery outcomes, with malnutrition contributing to poorer results and increased complications. This study addresses the critical gap in understanding by exploring the relationship between pre-operative nutritional status and post-operative cognitive dysfunction (POCD) in adult cardiac patients. Methods: A comprehensive search across key databases investigates the prevalence of malnutrition in pre-operative cardiac surgery patients, its effects, and its association with POCD. Factors exacerbating malnutrition, such as chronic illnesses and reduced functionality, are considered. The study also examines the incidence of POCD, its primary association with CABG procedures, and the impact of malnutrition on complications like inflammation, pulmonary and cardiac failure, and renal injury. Discussions: Findings reveal that 46.4% of pre-operative cardiac surgery patients experience malnutrition, linked to chronic illnesses and reduced functionality. Malnutrition significantly contributes to inflammation and complications, including POCD, with an incidence ranging from 15 to 50%. CABG procedures are particularly associated with POCD, and malnutrition prolongs intensive care stays while increasing vulnerability to surgical stress. Conclusions: The review underscores the crucial role of nutrition in recovery and advocates for a universally recognized nutrition assessment tool tailored to diverse cardiac surgery patients. Emphasizing pre-operative enhanced nutrition as a potential strategy to mitigate inflammation and improve cognitive function, the review highlights the need for integrating nutrition screening into clinical practice to optimize outcomes for high-risk cardiac surgery patients. However, to date, most data came from observational studies; hence, there is a need for future interventional studies to test the hypothesis that pre-operative enhanced nutrition can mitigate inflammation and improve cognitive function in this patient population.

The Association of Malnutrition and Health-Related Factors among 474,467 Older Community-Dwellers: A Population-Based Data Mining Study in Guangzhou, China

BACKGROUND

This study aimed to examine the prevalence and associated factors of malnutrition in older community-dwellers and explore the interaction between associated factors.

METHODS

A total of 474,467 older community-dwellers aged 65 or above were selected in Guangzhou, China. We used a two-step methodology to detect the associated factors of malnutrition and constructed logistic regression models to explore the influencing factors and interactive effects on three patterns of malnutrition.

RESULTS

The prevalence of malnutrition was 22.28%. Older adults with both hypertension and diabetes (RERI = 0.13), both meat or fish diet and hypertension (RERI = 0.79), and both meat or fish diet and diabetes (RERI = 0.81) had positive additive interaction effects on the risk of obesity, whereas those on a vegetarian diet with hypertension (RERI = -0.25) or diabetes (RERI = -0.19) had negative additive interaction effects. Moreover, the interactions of physical activity with a meat or fish diet (RERI = -0.84) or dyslipidemia (RERI = -0.09) could lower the risk of obesity.

CONCLUSIONS

Malnutrition was influenced by different health factors, and there were interactions between these influencing factors. Pertinent dietary instruction should be given according to different nutritional status indexes and the prevalence of metabolic diseases to avoid the occurrences of malnutrition among older adults.

Beneficial Effects of Oral Nutrition Supplements on the Nutritional Status and Physical Performance of Older Nursing Home Residents at Risk of Malnutrition

The purpose of this study was to compare the effects of nutritional supplement drinks (NSDs) and nutritional education (NE) on the nutritional status and physical performance of older nursing home residents who were at risk of malnutrition. This study was a clustered, randomized, parallel, multi-center clinical trial, with 107 participants more than 65 years old and at risk of malnutrition recruited from several nursing homes in this study. Participants were divided into two groups: an NE group (n = 50) and an NSD group (n = 57). The NE group was given NE by a dietitian, while the NSD group was provided with two packs of NSD except receiving NE (Mei Balance, Meiji Holdings, Tokyo, Japan) per day as a snack between meals and before bed. Anthropometric data, blood pressure, nutritional status, blood biochemical biomarkers, and physical performance were measured before and after 12-week interventions. After 12 weeks of NE combined with NSD intervention, body weight, body-mass index, the mini nutritional assessment-short form (MNA-SF) score, walking speed, and SF-36 questionnaire score were improved in older nursing home residents at risk of malnutrition.

Cardiovascular Outcomes in Acute Coronary Syndrome and Malnutrition: A Meta-Analysis of Nutritional Assessment Tools

Background

There is emerging evidence that malnutrition is associated with poor prognosis among patients with acute coronary syndrome (ACS).

Objectives

This study seeks to elucidate the prognostic impact of malnutrition in patients with ACS and provide a quantitative review of most commonly used nutritional assessment tools.

Methods

Medline and Embase were searched for studies reporting outcomes in patients with malnutrition and ACS. Nutritional screening tools of interest included the Prognostic Nutrition Index, Geriatric Nutritional Risk Index, and Controlling Nutritional Status. A comparative meta-analysis was used to estimate the risk of all-cause mortality and cardiovascular events based on the presence of malnutrition and stratified according to ACS type, ACS intervention, ethnicity, and income.

Results

Thirty studies comprising 37,303 patients with ACS were included, of whom 33.5% had malnutrition. In the population with malnutrition, the pooled mortality rate was 20.59% (95% CI: 14.95%-27.67%). Malnutrition was significantly associated with all-cause mortality risk after adjusting for confounders including age and left ventricular ejection fraction (adjusted HR: 2.66, 95% CI: 1.78-3.96, P = 0.004). There was excess mortality in the group with malnutrition regardless of ACS type (P = 0.132), ethnicity (P = 0.245), and income status (P = 0.058). Subgroup analysis demonstrated no statistically significant difference in mortality risk between individuals with and without malnutrition (P = 0.499) when using Controlling Nutritional Status (OR: 7.80, 95% CI: 2.17-28.07, P = 0.011), Geriatric Nutritional Risk Index (OR: 4.30, 95% CI: 2.78-6.66, P < 0.001), and Prognostic Nutrition Index (OR: 4.67, 95% CI: 2.38-9.17, P = 0.023).

Conclusions

Malnutrition was significantly associated with all-cause mortality risk following ACS, regardless of ACS type, ethnicity, and income status, underscoring the importance of screening and interventional strategies for patients with malnutrition.

Development and validation of a novel nomogram of 1-year mortality in the elderly with hip fracture: a study of the MIMIC-III database

OBJECTIVE

Hip fracture is a prevalent condition with a significant death rate among the elderly. We sought to develop a nomogram-based survival prediction model for older patients with hip fracture.

DESIGN

A retrospective case-control study.

SETTING

The data from Medical Information Mart for Intensive Care III (MIMIC-III V.1.4).

PARTICIPANTS

The clinical features of elderly patients with hip fracture, including basic information, comorbidities, severity score, laboratory tests and therapy, were filtered out based on the MIMIC-III V.1.4.

METHODS AND MAIN OUTCOME MEASURES

All patients included in the study were from critical care and randomly divided into training and validation sets (7:3). On the basis of retrieved data, the least absolute shrinkage and selection operator (LASSO) regression and multiple logistic regression analysis were used to identify independent predictive variables of 1-year mortality, and then constructed a risk prediction nomogram. The predictive values of the nomogram model were evaluated by the concordance indexes (C-indexes), receiver operating characteristic curve, decision curve analysis (DCA) and calibration curve.

RESULTS

A total of 341 elderly patients with hip fracture were included in this study; 121 cases died within 1 year. After LASSO regression and multiple logistic regression analysis, a novel nomogram contained the predictive variables of age, weight, the proportion of lymphocyte count, liver disease, malignant tumour and congestive heart failure. The constructed model proved satisfactory discrimination with C-indexes of 0.738 (95% CI 0.674 to 0.802) in the training set and 0.713 (95% CI 0.608 to 0.819) in the validation set. The calibration curve shows a good degree of fitting between the predicted and observed probabilities and the DCA confirms the model's clinical practicability.

CONCLUSIONS

The novel prediction model provides personalised predictions for 1-year mortality in elderly patients with hip fractures. Compared with other hip fracture models, our nomogram is particularly suitable for predicting long-term mortality in critical patients.

Role of phase angle in older adults with focus on the geriatric syndromes sarcopenia and frailty

Age-related changes in body composition reflect an increased risk for disease as well as disability. Bioimpedance analysis is a safe and inexpensive bed side method to measure body composition, but the calculation of body compartments with BIA is hampered in older adults. Phase angle, a raw parameter derived from bioimpedance analysis, is free from calculation-inherent errors. It declines with age and disease and is highly predictive of a variety of clinical outcomes as well as mortality. This review summarizes the current evidence linking the phase angle to geriatric syndromes such as malnutrition, sarcopenia and frailty and also investigates whether the phase angle reacts to interventions. Since the majority of studies show an association between the phase angle and these geriatric syndromes, a low phase angle is not suitable to exclusively indicate a specific condition. It does not inform on the underlying cause and as such, a low phase angle mainly indicates increased risk. Phase angle decline over time is reflected by deterioration of e.g. frailty status. It reacts to physical training and detraining, but studies investigating whether these induced changes are also associated with improved outcome are missing.

The concept of aggressive nutrition therapy and clinical indication: A position paper

Aggressive nutrition therapy is a nutritional management method that sets energy intake requirements by adding the amount of energy accumulated to energy consumption. It is used to treat patients with undernutrition and sarcopenia. However, evidence for aggressive nutrition therapy is insufficient, and validation through high-quality clinical research is essential. Therefore, this paper aimed to clarify the concept of aggressive nutrition therapy, present indications and contraindications; and describe the effects, limitations, and the need to individualize aggressive nutrition therapy for different pathological conditions. Aggressive nutrition therapy should be accompanied by the etiology of undernutrition, sarcopenia, and nutritional metabolism in various states. In addition to calculating nutritional requirements, the nutritional management methods of oral intake, tube feeding, and parenteral nutrition should be appropriately selected. A nutrition plan with the amount of energy accumulated should also be a vital issue. This position paper was authored by the Registered Dietitian Subcommittee of the Japanese Association of Rehabilitation Nutrition and was approved by the Japanese Association of Rehabilitation Nutrition.

Patient body mass index modifies the association between waiting time for hip fracture surgery and in-hospital mortality: A multicenter retrospective cohort study

BACKGROUND

Patient body mass index (BMI) plays an important role in stress exposure, especially in elderly patients with hip fracture. However, how BMI modifies the relationship between the waiting time for surgery and mortality remains unclear.

METHODS

We investigated the association between waiting time and mortality using a nationwide multicenter database of patients undergoing hip fracture surgery. The primary outcome was in-hospital mortality and secondary outcomes were complications. We performed prespecified subgroup analysis with stratification by BMI.

RESULTS

Overall, 305,846 patients (mean age, 83.5; standard deviation [SD], 8.2); women, 79.5% (n = 243,214) were included in our study. A cubic spline curve revealed two inflection points in the association between waiting time and mortality, and we statistically divided patients into three groups accordingly: the reference group (80,110 patients [26.2%] who waited 1 day for surgery), the delayed group (184,778 patients [60.4%] who waited 2-6 days for surgery), and the extremely delayed group (40,958 patients [13.4%] who waited more than 6 days for surgery). Multivariable logistic regression models showed that the odds of mortality in the delayed group was 14% higher than that in the reference group (adjusted odds ratio [aOR], 1.14; p = 0.002), whereas the odds of mortality in the extremely delayed group was 52% higher than that of the reference group (aOR, 1.52; p < 0.001). Patients with lower BMI were more negatively affected by delayed surgery compared to patients with normal BMI (p for interaction = 0.002). Respiratory disorders were most frequent and the spline curve was accordant with in-hospital mortality.

CONCLUSION

Patients underwent surgery within 1 day, particularly with lower BMI, had a lower mortality than normal BMI. To optimize limited health care resource, patient's BMI should be considered for hip fracture management, and further investigation in prospective study should be needed to address causal relationship.

LEVEL OF EVIDENCE

Therapeutic Level III.

Assessing the income-related inequality in obesity among the elderly in China: A decomposition analysis

Background

Obesity among the elderly imposes a significant health and economic burden. The purpose of this study was to measure the obesity prevalence and income-related inequality among older adults in China and to explore the determinants of the inequity.

Methods

Data were obtained from 4,541 older adults (60 years and older) participating in the China Family Panel Study, 2018. Obesity was defined as body mass index (BMI) ≥28 kg/m². Normalized concentration index and concentration curve were calculated to measure the income-related inequality. Decomposition analysis was used to measure the contribution of each factor to the overall unfairness.

Results

The prevalence of obesity among the respondents was 7.99%. The 95% confidence interval for the overall prevalence was 7.20-8.78%. The normalized concentration index of obesity in the elderly was 0.075 (95% confidence interval: 0.047-0.103), indicating that obesity was more concentrated among the rich (p < 0.05). Socioeconomic factors contributed the most to the overall inequality (68.73%). Health behavior factors explained 16.38% of the observed income-related inequality in obesity among the elderly in China.

Conclusions

In 2018, obesity was more concentrated among the elderly with higher incomes in China. The pro-poor income-related inequality was mainly due to the higher socioeconomic status of higher-income older adults. Health behaviors and psychosocial factors could also exacerbate the inequality. To prevent the heavy burden of obesity on the health and finances of older adults, more attention should be paid to those who are financially better off, especially those who smoke and are physically inactive, while extroverted older adults also need to be focused on. For developing countries, concern needs to be given to the obesity of the wealthy elderly as a result of economic development.

Nutrition and Exercise Treatment of Sarcopenia in Hip Fracture Patients: Systematic Review

Background

This study aimed to investigate nutritional or rehabilitation intervention protocols for hip fracture patients with sarcopenia and to analyze the effect of these protocols through a systematic review of studies that reported clinical results.

Methods

Studies were selected based on the following criteria: (1) study design: randomized controlled trials or non-randomized comparative studies; (2) study population: patients with hip fracture; (3) intervention: nutritional or rehabilitation; and (4) reporting the clinical outcomes and definition of sarcopenia.

Results

Of the 247 references initially identified from the selected databases, 5 randomized controlled studies and 2 comparative studies were selected for further investigation. The total number of patients was 497. We found 2 specific rehabilitation interventions, one medication intervention using erythropoietin, and 4 nutritional interventions using amino-acid or protein. Among the studies included in this systematic review, 2 studies did not find a clear statistical difference in assessment tools compared to controls after intervention. On the other hand, the rest of the studies positively interpreted the results for intervention. The most frequently used assessment tool for intervention was handgrip strength.

Conclusions

Although mainstream methods of intervention for sarcopenia include nutritional, exercise, and drug interventions, the validity of these interventions in elderly hip fractures has not been clearly proven. In addition, as most studies only reported short-term results, there is no consensus on the optimal long-term treatment.

Inverse relation of body weight with short-term and long-term mortality following hip fracture surgery: a meta-analysis

Background

The obesity paradox, which suggests that high body weight is positively associated with survival in some diseases, has not been proven in patients with hip fracture. In this study, meta-analysis of previous studies on the impacts of body weight on postoperative mortality following hip fracture surgery in older adults was conducted.

Methods

PubMed, Embase, and Cochrane library were searched for studies investigating the correlation between mortality after hip fracture surgery and body weight. The search main items included: (“Body mass index” OR “BMI” or “body weight”) and (“hip fracture” or “hip fractures”). Studies contained data on short-term (≤ 30-day) and long-term (≥ 1 year) mortality after hip fracture and its association with distinct body weight or BMI groups were reported as full-text articles were included in this meta-analysis.

Results

Eleven separate studies were included. The definitions of underweight and obesity differed among the included studies, but the majority of the enrolled studies used the average body weight definition of a BMI of 18.5 to 24.9 kg/m²; underweight referred to a BMI of < 18.5 kg/m²; and obesity pertained to a BMI of > 30 kg/m². Based on the generalized definitions of body-weight groups from the enrolled studies, the group with obesity had lower long-term (odds ratio [OR]: 0.63, 95% CI: 0.50–0.79, P < 0.00001) and short-term (OR: 0.63, 95% CI: 0.58–0.68, P ≤ 0.00001) mortality rates after hip fracture surgery when compared with patients with average-weight group. However, compared with the average-weight group, the underweight group had higher long-term (OR: 1.51, 95% CI: 1.15-1.98, P=0.003) and short-term (OR: 1.49, 95% CI: 1.29-1.72, P<0.00001) mortality rates after hip fracture surgery.

Conclusions

Current evidence demonstrates an inverse relation of body weight with long-term and short-term mortality after hip fracture surgery in older adults.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13018-022-03131-3.

The Association between Malnutrition and Physical Performance in Older Adults: A Systematic Review and Meta-Analysis of Observational Studies

In recent years the focus of healthcare and nutritional science in older adults has shifted from mortality towards physical performance and quality of life. The aim of this review was to summarize observational studies on physical performance in malnourished (MN) or at risk of malnutrition (RMN) older adults compared with well-nourished (WN) older adults. Eligible studies had to report on nutritional status and objectively measured physical performance in older adults (≥60 y). MN or RMN groups had to be compared with a WN group, measured with a validated nutrition screener. Ovid Medline and Web of Science were searched until 13 November, 2020. Study quality was scored using a modified Newcastle-Ottawa Scale (NOS). Results were analyzed by meta-analysis when possible, or narratively reviewed otherwise. Forty-five studies (16,911 participants in total) were included from studies in outpatient clinics (n = 6), nursing homes (n = 3), community-dwelling older adults (n = 20), hospitalized patients (n = 15), or a combination (n = 1). Studies used 11 different screeners of malnutrition, and 8 types of physical performance measures. Meta-analysis showed that compared with MN, WN groups had better hand grip strength (mean difference [MD] = 4.92 kg; 95% CI: 3.43, 6.41; P < 0.001; n = 23), faster gait speed (MD = 0.16 m/s; 95% CI: 0.05, 0.27; P = 0.0033; n = 7), performed faster on timed-up-and-go (MD = -5.94 s; 95% CI: -8.98, -2.89; P < 0.001; n = 8), and scored 1.2 more short physical performance battery points (95% CI: 1.32, 2.73; P < 0.001; n = 6). Results were less pronounced when compared with RMN. Narratively, all studies showed an association for knee extension strength, 6-min walking test, and multicomponent tests, except for the chair stand test. Study limitations include no studies scoring "good" on NOS, lack of confounder adjustment, and high heterogeneity. Overall, evidence from cross-sectional studies indicate an association between malnutrition and worse physical performance in older adults. This study is registered in PROSPERO as CRD42020192893.

Goal setting for nutrition and body weight in rehabilitation nutrition: position paper by the Japanese Association of Rehabilitation Nutrition (secondary publication)

The most important nutrition goals in rehabilitation nutrition are improving function and quality of life, and they are useful to set body weight goals to further improve these aspects. In this paper, we clarified our position, as the Japanese Association of Rehabilitation Nutrition, on body weight goal setting. Body weight goals should be SMART (Specific, Measurable, Achievable, Realistic/Relevant, and Timed). The standard amount of energy accumulation/deficit needed to gain/lose 1 kg body weight is 7500 kcal. In other words, if the nutrition goal is set at 1 kg body weight gain per month, daily energy accumulation can be calculated as approximately 250 kcal. It is necessary to reconcile the rehabilitation goal setting, the content, quantity, and quality of physical activity and exercise therapy, and the patient's general condition and intentions to set nutrition goals. Body weight goal setting is more variable than rehabilitation goal setting, and it is important to confirm the degree of achievement through rehabilitation nutrition monitoring.

Stored Energy Increases Body Weight and Skeletal Muscle Mass in Older, Underweight Patients after Stroke

We conducted a retrospective observational study in 170 older, underweight patients after stroke to elucidate whether stored energy was associated with gains in body weight (BW) and skeletal muscle mass (SMM). Energy intake was recorded on admission. The energy requirement was estimated as actual BW (kg) × 30 (kcal/day), and the stored energy was defined as the energy intake minus the energy requirement. Body composition was measured by bioelectrical impedance analysis. The study participants gained an average of 1.0 ± 2.6 kg of BW over a mean hospital stay of 100 ± 42 days with a mean stored energy of 96.2 ± 91.4 kcal per day. They also gained an average of 0.2 ± 1.6 kg of SMM and 0.5 ± 2.3 kg of fat mass (FM). This means about 9600 kcal were needed to gain 1 kg of BW. In addition, a 1 kg increase in body weight resulted in a 23.7% increase in SMM and a 45.8% increase in FM. Multivariate regression analyses showed that the stored energy was significantly associated with gains in BW and SMM. Aggressive nutrition therapy is important for improving nutritional status and function in patients with malnutrition and sarcopenia.

Malnutrition in Older Adults-Recent Advances and Remaining Challenges

Malnutrition in older adults has been recognised as a challenging health concern associated with not only increased mortality and morbidity, but also with physical decline, which has wide ranging acute implications for activities of daily living and quality of life in general. Malnutrition is common and may also contribute to the development of the geriatric syndromes in older adults. Malnutrition in the old is reflected by either involuntary weight loss or low body mass index, but hidden deficiencies such as micronutrient deficiencies are more difficult to assess and therefore frequently overlooked in the community-dwelling old. In developed countries, the most cited cause of malnutrition is disease, as both acute and chronic disorders have the potential to result in or aggravate malnutrition. Therefore, as higher age is one risk factor for developing disease, older adults have the highest risk of being at nutritional risk or becoming malnourished. However, the aetiology of malnutrition is complex and multifactorial, and the development of malnutrition in the old is most likely also facilitated by ageing processes. This comprehensive narrative review summarizes current evidence on the prevalence and determinants of malnutrition in old adults spanning from age-related changes to disease-associated risk factors, and outlines remaining challenges in the understanding, identification as well as treatment of malnutrition, which in some cases may include targeted supplementation of macro- and/or micronutrients, when diet alone is not sufficient to meet age-specific requirements.

Rehabilitation Nutrition and Exercise Therapy for Sarcopenia

Sarcopenia is an age-related loss of skeletal muscle associated with adverse outcomes such as falls, fractures, disability, and increased mortality in older people and hospitalized patients. About half of older male nursing home residents have sarcopenia. The diagnostic criteria by the European Working Group on Sarcopenia in Older People (EWGSOP) and the Asian Working Group for Sarcopenia (AWGS) have led to increased interest in sarcopenia. Exercise and nutritional management are crucial for the prevention and treatment of sarcopenia. Nutritional therapy for sarcopenia that includes 20 g of whey protein and 800 IU of vitamin D twice a day improves lower limb strength. Exercise therapy for sarcopenia, such as resistance training and 6 months of home exercises, improves muscle strength and physical function. Combination therapy that includes both nutritional and exercise therapy improves gait speed and knee extension strength more than either exercise alone or nutrition therapy alone. Excessive bedrest and mismanagement of nutrition in medical facilities can lead to iatrogenic sarcopenia. Iatrogenic sarcopenia is sarcopenia caused by the activities of health care workers in health care facilities. Appropriate nutritional management and exercise programs through rehabilitation nutrition are important for prevention and treatment of iatrogenic sarcopenia. Nutritional and exercise therapy should be started very early after admission and adjusted to the level of inflammation and disease status. Repeated assessment, diagnosis, goal setting, interventions, and monitoring using the rehabilitation nutrition care process is important to maximize treatment effectiveness and improve patients' functional recovery and quality of life.

Aggressive nutrition therapy in malnutrition and sarcopenia

Aggressive nutrition therapy is essential to improve nutrition and function in patients with malnutrition and sarcopenia. Malnutrition and sarcopenia negatively affect functional recovery and activities of daily living. Nutrition improvement is associated with better functional recovery. Target energy intake in aggressive nutrition therapy is defined as total energy expenditure (TEE) plus the amount of energy accumulated. The amount of energy accumulation per 1 kg of body weight is generally 7500 kcal. If the goal is to gain 1 kg of weight over 30 d, TEE + 250 kcal is the target daily energy intake. Aggressive nutrition therapy is implemented using a rehabilitation nutrition care process, which consists of five steps: assessment and diagnostic reasoning, diagnosis, goal setting, intervention, and monitoring. Aggressive nutrition therapy sets clear goals using the Specific, Measurable, Achievable, Relevant, and Time-bound principles. The application and effect of aggressive nutrition therapy differs depending on the etiology and condition of malnutrition. Precachexia, short bowel syndrome, and older people with mild to moderate dementia are indications for aggressive nutrition therapy. Nevertheless, aggressive nutrition therapy is usually contraindicated in cases of refractory cachexia, acute disease or injury with severe inflammation, and bedridden patients with severe dementia and reduced activity. Aggressive nutrition therapy should be combined with aggressive exercise and rehabilitation. Enhanced nutritional therapy combined with rehabilitation in patients with cerebrovascular disease, hip fracture, or acute disease is recommended in the 2018 clinical practice guidelines for rehabilitation nutrition. Further evidence for aggressive nutrition therapy is however required.

A review of nutrition screening tools used to assess the malnutrition-sarcopenia syndrome (MSS) in the older adult

BACKGROUND

Malnutrition and sarcopenia are common in older adults. A new clinical syndrome has been suggested - the Malnutrition Sarcopenia Syndrome (MSS) - that may provide improved management, by highlighting two older adult conditions that can interact in a cumulative way to affect functional independence and health outcomes. This paper evaluates the published literature reporting data on both nutrition and sarcopenia evaluation simultaneously in the population studied, and creates a diagnostic algorithm.

METHODS

An inclusive, systematic literature search was done for articles including a simultaneous standardised evaluation of sarcopenia and nutritional status, from 1990-date. Sarcopenic status needed to be evaluated using accepted guidelines published by international guideline committees which include a functional muscle evaluation and a quantitative evaluation using bioimpedence assay or dual energy X-ray absorptiometry. Nutritional status needed to evaluated with a standardised, validated nutritional screening tool that was not disease specific.

RESULTS

11 studies met these criteria. They differed in their methodology for screening both sarcopenia and nutritional issues. They differed as to the population studied (community versus institutionalised versus hospitalised).

CONCLUSIONS

No one methodology was consistent for evaluation of sarcopenia or malnutrition. The concept of the Malnutrition Sarcopenia Syndrome intuitively makes sense to clinicians. This opinion paper suggests a possible clinical approach. The management and interventions for both conditions are likely to have considerable overlap. There needs to be some consensus on how to evaluate it, in order to be able to accurately interpret the impact of interventions that may be undertaken for one or both conditions simultaneously.

Rehabilitation Nutrition for Iatrogenic Sarcopenia and Sarcopenic Dysphagia

Sarcopenia is a very important issue in rehabilitation medicine and nutritional care. The prevalence of sarcopenia in older people is approximately 50% in the rehabilitation setting, and also approximately 15% of inpatients without sarcopenia upon admission developed sarcopenia during hospitalization. There is a concern that secondary sarcopenia may occur iatrogenically during hospitalization. Iatrogenic sarcopenia is defined as sarcopenia caused by the activities of medical staff including doctors, nurses, or other health care professionals in healthcare facilities. Iatrogenic sarcopenia is categorized into activity-related, nutrition-related and disease-related-iatrogenic sarcopenia. Especially in acute phase hospitals, concentrating on the treatment of diseases with less attention to nutrition and activity is more likely to cause iatrogenic sarcopenia. Sarcopenic dysphagia is also an important aspect in rehabilitation medicine and nutritional care. Sarcopenic dysphagia is characterized by swallowing difficulty because of a loss of mass and function in whole-body skeletal and swallowing muscles. Sarcopenic dysphagia can be diagnosed using a 5-step algorithm for the condition. Iatrogenic sarcopenia and sarcopenic dysphagia are affected by nutrition, activity and diseases in a complex manner. Therefore, treatment of iatrogenic sarcopenia and sarcopenic dysphagia requires comprehensive interventions through nutrition management and rehabilitation. Rehabilitation nutrition is effective for preventing and treating iatrogenic sarcopenia and sarcopenic dysphagia. Rehabilitation nutrition can be practiced more effectively and comprehensively by using the rehabilitation nutrition care process, which is a systematic problem-solving method. Further research is required to verify the efficacy of rehabilitation nutrition for preventing or improving iatrogenic sarcopenia and/or sarcopenic dysphagia.

Nutritional management of older adults with gastrointestinal cancers: An International Society of Geriatric Oncology (SIOG) review paper

Malnutrition is one of the most common physical manifestations of gastrointestinal (GI) cancers and is often under-diagnosed and under-treated. Like cancers, malnutrition occurs more commonly in older adults, with potential negative consequences to quality of life, functional status, tolerance to treatment, and prognosis. Nutritional assessment and management require a proactive and systematic, multi-disciplinary approach. Early assessment, detection, and prompt intervention of cancer-associated malnutrition and cachexia are equally essential to achieve better quality nutritional care for older oncology patients. This article aims to provide an overview of the evidence associated with poor nutrition and outcomes in older adults with GI cancers, and recommends a management approach from a geriatric oncologist's perspective.

Nutritional problems in older adults with Alzheimer’s disease: Risk of malnutrition and sarcopenia

ABSTRACT Objective Understand the nutritional problems and detect the presence of sarcopenia in older adults with Alzheimer’s disease. Methods Descriptive cross-sectional study carried out among elderly patients with Alzheimer’s disease receiving care at the Unidade de Saúde de Atenção ao Idoso (Elderly Care Unit) in a capital city in Southern Brazil between November 2010 and July 2011. The Clinical Dementia Rating scale was used for the evaluation of staging severity of dementia. Participants’ nutritional status was classified using The Mini Nutritional Assessment. The following tests were used to diagnose sarcopenia: bioelectrical impedance, hand grip strength, and the Timed Up and Go test. Anthropometric measurements and laboratory tests (hemoglobin, lymphocytes, serum albumin, and total cholesterol) were performed. Results Ninety-six older adults (mean age of 78 years) were evaluated. It was observed prevalence of mild Alzheimer’s disease in 54.2% of the participants; 55.2% were at risk of malnutrition; unintentional weight loss was observed in 64.6%, 55.3% had lower number of lymphocytes, and 43.7% had severe sarcopenia. Conclusion The prevalence of risk of malnutrition and sarcopenia is high among older adults with Alzheimer’s disease. Future studies should focus on the evaluation of nutritional interventions aimed at maintaining the nutritional status and muscle mass in these individuals.

Mitigating Nutrition and Health Deficiencies in Older Adults: A Role for Food Innovation?

The aim of this review is to describe the factors contributing to diminished food intake, resulting in nutritional deficiencies and associated health conditions in older adults and proposes food innovation strategies to mitigate these. Research has provided convincing evidence of a link between healthy eating patterns and healthy aging. There is a need to target new food product development (NPD) with functional health benefits specifically designed to address the particular food-related needs of older consumers. When developing foods for older adults, consideration should be given to the increased requirements for specific macro- and micronutrients, especially protein, calcium, vitamin D, and vitamin B. Changes in chemosensory acuity, chewing difficulties, and reduced or poor swallowing ability should also be considered. To compensate for the diminished appetite and reduced intake, foods should be energy dense, nutritionally adequate, and, most importantly, palatable, when targeting this cohort. This paper describes the potential of new food product development to facilitate dietary modification and address health deficiencies in older adults.

Increased 1-year survival and discharge to independent living in overweight hip fracture patients: A prospective study of 843 patients

BACKGROUND AND PURPOSE

Hip fracture patients usually have low body mass index (BMI), and suffer further postoperative catabolism. How BMI relates to outcome in relatively healthy hip fracture patients is not well investigated. We investigated the association between BMI, survival, and independent living 1 year postoperatively.

PATIENTS AND METHODS

This prospective multicenter study involved 843 patients with a hip fracture (mean age 82 (SD 7) years, 73% women), without severe cognitive impairment and living independently before admission. We investigated the relationship between BMI and both 1-year mortality and ability to return to independent living.

RESULTS

Patients with BMI > 26 had a lower mortality rate than those with BMI < 22 and those with BMI 22-26 (6%, 16%, and 18% respectively; p = 0.006). The odds ratio (OR) for 1-year survival in the group with BMI > 26 was 2.6 (95% CI: 1.2-5.5) after adjustment for age, sex, and physical status. Patients with BMI > 26 were also more likely to return to independent living after the hip fracture (OR = 2.6, 95% CI: 1.4-5.0). Patients with BMI < 22 had similar mortality and a similar likelihood of independent living to those with BMI 22-26.

INTERPRETATION

In this selected group of patients with hip fracture, the overweight and obese patients (BMI > 26) had a higher survival rate at 1 year, and returned to independent living to a higher degree than those of normal (healthy) weight. The obesity paradox and the recommendations for optimal BMI need further consideration in patients with hip fracture.

Effects of protein-rich nutritional supplementation and bisphosphonates on body composition, handgrip strength and health-related quality of life after hip fracture: a 12-month randomized controlled study

BACKGROUND

The catabolic state that follows hip fracture contributes to loss of muscle mass and strength, that is sarcopenia, which impacts functional ability and health-related quality of life. Measures to prevent such long-term postoperative consequences are of important concern. The aim of this study was to evaluate the combined effects of protein-rich nutritional supplementation and bisphosphonate on body composition, handgrip strength and health-related quality of life following hip fracture.

METHODS

The study included 79 men and women with hip fracture, mean age 79 years (SD 9), without severe cognitive impairment, who were ambulatory and living independently before fracture. Patients were randomized postoperatively to receive liquid supplementation that provided 40 g of protein and 600 kcal daily for six months after the fracture, in addition to bisphosphonates once weekly for 12 months (group N, n = 26), or bisphosphonates alone once weekly for 12 months (group B, n = 28). All patients, including the controls (group C, n = 25) received calcium 1 g and vitamin D3 800 IU daily. Body composition as measured by dual-energy X-ray absorptiometry (DXA), handgrip strength (HGS) and health-related quality of life (HRQoL) were registered at baseline, six and 12 months postoperatively.

RESULTS

There were no differences among the groups regarding change in fat-free mass index (FFMI), HGS, or HRQoL during the study year. Intra-group analyses showed improvement of HGS between baseline and six months in the N group (P = 0.04). HRQoL decreased during the first year in the C and B groups (P = 0.03 and P = 0.01, respectively) but not in the nutritional supplementation N group (P = 0.22).

CONCLUSIONS

Protein-rich nutritional supplementation was unable to preserve FFMI more effectively than vitamin D and calcium alone, or combined with bisphosphonate, in this relatively healthy group of hip fracture patients. However, trends toward positive effects on both HGS and HRQoL were observed following nutritional supplementation.

TRIAL REGISTRATION

Clinicaltrials.gov NCT01950169 (Date of registration 23 Sept 2013).

The impact of delivery profile of essential amino acids upon skeletal muscle protein synthesis in older men: clinical efficacy of pulse vs. bolus supply

Essential amino acids (EAA) are responsible for skeletal muscle anabolic effects after nutrient intake. The pattern of appearance of EAA in blood, e.g., after intake of "slow" or "fast" protein sources or in response to grazing vs. bolus feeding patterns, may impact anabolism. However, the influence of this on muscle anabolism is poorly understood, particularly in older individuals. We determined the effects of divergent feeding profiles of EAA on blood flow, anabolic signaling, and muscle protein synthesis (MPS) in older men. Sixteen men (∼70 yr) consumed EAA either as a single dose (bolus, 15 g; n = 8) or as small repeated fractions (pulse, 4 × 3.75 g every 45 min; n = 8) during (13)C6 phenylalanine infusion. Repeated blood samples and muscle biopsies permitted measurement of fasting and postprandial plasma EAA, insulin, anabolic signaling, and MPS. Muscle blood flow was assessed by contrast-enhanced ultrasound (Sonovue). Bolus achieved rapid insulinemia (12.7 μiU/ml 25-min postfeed), essential aminoacidemia (∼3,000 μM, 45-65 min postfeed), and mTORC1 activity; pulse achieved attenuated insulin responses, gradual low-amplitude aminoacidemia (∼1,800 μM 80-195 min after feeding), and undetectable mTORC1 signaling. Despite this, equivalent anabolic responses were observed: fasting FSRs of 0.051 and 0.047%/h (bolus and pulse, respectively) increased to 0.084 and 0.073%/h, respectively. Moreover, pulse led to sustainment of MPS beyond 180 min, when bolus MPS had returned to basal rates. We detected no benefit of rapid aminoacidemia in this older population despite enhanced anabolic signaling and greater overall EAA exposure. Rather, apparent delayed onset of the "muscle-full" effect permitted identical MPS following low-amplitude-sustained EAA exposure.

Comparison of posterolateral lumbar fusion and posterior lumbar interbody fusion for patients younger than 60 years with isthmic spondylolisthesis

STUDY DESIGN

Prospective randomized study.

OBJECTIVE

To determine whether single-level posterolateral lumbar fusion (PLF) or posterior lumbar interbody fusion (PLIF) was associated with better outcomes for patients 60 years or younger with isthmic spondylolisthesis.

SUMMARY OF BACKGROUND DATA

Although both PLF and PLIF are considered effective surgical treatments for isthmic spondylolisthesis, it is unknown which treatment leads to better outcomes. In addition, previous studies of the therapeutic efficacy of PLIF and PLF had several weaknesses, so they could not provide clear data on the therapeutic outcomes of each treatment.

METHODS

Of the 85 patients screened for this study, 4 did not meet the study criteria. Thus, 81 patients were enrolled and randomly assigned into group A (PLF, n = 39) or group B (PLIF, n = 42). The primary outcome measure was the fusion rate based on dynamic radiographs and computed tomographic scans at postoperative 1 and 2 years. The secondary outcome measures were (1) clinical outcomes as assessed with a visual analogue scale and the Oswestry Disability Index, (2) surgical outcomes, and (3) additional outcomes such as infection and metal failure.

RESULTS

No patients were lost to follow-up. The fusion rate was similar between groups: fusion occurred in 84.6% (33/39) in group A and 85.7% (36/42) in group B at 1 year after surgery (P = 0.86), and 89.7% (35/39) in group A and 90.4% (38/42) in group B at 2 years after surgery (P = 0.93). Postoperative pain levels and functional outcomes did not differ significantly between groups at any of the regular follow-up visits. The prevalence of complications also did not differ significantly between groups; the only serious complication (deep infection) occurred in 1 patient in the PLIF group.

CONCLUSION

Both PLF and PLIF are viable surgical options for patients with isthmic spondylolisthesis 60 years or younger.

Long-lasting improved amino acid bioavailability associated with protein pulse feeding in hospitalized elderly patients: a randomized controlled trial

OBJECTIVE

Aging is associated with a blunted anabolic response to dietary intake, possibly related to a decrease in systemically available amino acids (AAs), which in turn may stem from increased splanchnic AA metabolism. Splanchnic sequestration can be saturated by pulse feeding (80% of daily protein intake in a single meal), enabling increased protein synthesis. The aim of this study was to explore whether protein pulse feeding increased postprandial AA concentrations, and if so whether this increase persisted after 6 wk of dietary treatment.

METHODS

This prospective randomized study enrolled 66 elderly malnourished or at-risk patients in an inpatient rehabilitation unit. All were given a controlled diet for 6 wk. In a spread diet (SD) group (n = 36), dietary protein was spread over the four daily meals. In a pulse diet (PD) group (n = 30), 72% of dietary protein (averaging 1.31 g/kg body weight daily) was consumed in one meal at noon. The patients were evaluated on day 1 and at 6 wk for plasma postprandial (five times from 0 to +180 min) AA concentrations (expressed as area under the curve above baseline).

RESULTS

Protein pulse feeding was more efficient than protein spread feeding at increasing plasma postprandial AA concentrations, notably of essential AAs. This increased postprandial AA bioavailability was maintained after 6 wk.

CONCLUSIONS

This study demonstrates that increased postprandial AA bioavailability induced by protein pulse feeding persists after 6 wk (i.e., that there is no metabolic adaptation blunting AA bioavailability).

Screening for malnutrition in nursing home residents: comparison of different risk markers and their association to functional impairment

OBJECTIVES

To identify nursing home residents with malnutrition or at risk of malnutrition by using different markers, determine if the Mini Nutritional Assessment (MNA®) is able to identify all residents at risk according to single risk markers and explore the relation between risk markers and functional impairment.

DESIGN

Cross-sectional study.

SETTING

Six German nursing homes.

PARTICIPANTS

286 residents (86±7y, 89% female).

MEASUREMENTS

Screening for malnutrition or its risk included low BMI (≤22 kg/m²), recent weight loss (WL), low food intake (LI) as single risk markers and MNA (<24 points, p.) as composite marker. Prevalence of single nutritional risk markers in different MNA categories was compared by cross-tables. Mental (cognition, mood) and physical function (mobility) were assessed by interviewing nursing staff and association of impaired status to nutritional risk markers determined by Chi² test.

RESULTS

32.9% of residents had a low BMI, 11.9% WL and 21.3% LI. 60.2% were categorized malnourished (18.2%) or at risk of malnutrition (42.0%) by MNA. 64% presented at least one of these nutritional risk markers. Of those classified malnourished by MNA, 96.2% also showed low BMI, WL or LI. In contrast, eleven residents (9.6%) considered well-nourished by MNA presented single risk markers (9 low BMI, 2 WL). Cognitive impairment, depressive symptoms and immobility was present in 59.0%, 20.8% and 25.5%, respectively. Functional impairment, and in particular severe impairment, was to a higher proportion present in residents at nutritional risk independent of the chosen marker (MNA<24 p., low BMI, WL, LI).

CONCLUSION

The high prevalence of nutritional risk highlights the importance of regular screening of nursing home residents. The MNA identified nearly all residents with low BMI, WL and LI. The close association between nutritional risk and functional impairment requires increased awareness for nutritional problems especially in functionally impaired residents, to early initiate nutritional measures and thus, prevent further nutritional and functional deterioration.

Nutritional status and short-term outcome of hip arthroplasty

PURPOSE

To review nutritional status and outcome of 90 patients who underwent total hip arthroplasty (THA) or hemiarthroplasty.

METHODS

Records of 51 women and 39 men aged 26 to 96 (median, 71) years who underwent elective THA (n=48) for osteoarthritis, or trauma-related THA (n=10) or hemiarthroplasty (n=32) for subcapital femoral neck fractures using an uncemented femoral stem were retrospectively reviewed. Patient demographics and intra- and post-operative complications were recorded. Patient co-morbidities were assessed according to the Charlson grading system. Nutritional status was assessed using haematological markers of serum albumin (ALB) level and total lymphocyte count (TLC). Samples were taken on the day of the operation and within 24 hours of operation. Suboptimal nutrition was defined as a serum ALB level of <3.5 g/dl and a TLC of <1.50 cells/mm.

RESULTS

86% of trauma patients and 30% of elective patients were malnourished preoperatively (p<0.001). Preoperatively, more males than females had suboptimal ALB levels (28% vs. 8%, p=0.033) and TLC (82% vs. 31%, p<0.001). Age was inversely proportional to preoperative ALB and TLC values; patients older than 75 years had significantly lower values. Of those staying >7 days in hospital, 67% were aged >75 years as opposed to 31% were aged ≤ 75 years (p=0.001). Male gender, old age, and presentation with trauma were risk factors for suboptimal nutritional parameters (p<0.001 for all). Patients with suboptimal ALB and TLC values had a significantly longer stay in hospital (p=0.032 and p=0.021, respectively).

CONCLUSION

The rate of malnourishment was significantly higher in patients having trauma-related surgery than in those having elective surgery. Malnourished patients are at greater risk of prolonged hospital stay. Preoperative nutritional assessment may be useful in predicting patients at high surgical risk.

Impact of protein pulse feeding on lean mass in malnourished and at-risk hospitalized elderly patients: a randomized controlled trial

BACKGROUND & AIMS

Aging is associated with a blunted anabolic response to dietary intake, possibly related to a decrease in systemically available amino acids (AAs), which in turn may stem from increased splanchnic AA metabolism. This splanchnic sequestration can be saturated by pulse feeding (80% of daily protein intake in a single meal), enabling increased protein synthesis. This study aimed to evaluate the efficacy of a new nutritional strategy, termed protein pulse feeding.

METHODS

This prospective randomized study (ClinicalTrials.gov registration number NCT00135590) enrolled 66 elderly malnourished or at-risk patients in an inpatient rehabilitation unit. All were given a controlled diet for 6 weeks. In a spread diet (SD) group (n = 36), dietary protein was spread over the four daily meals. In a pulse diet (PD) group (n = 30), 72% of dietary protein (1.31 g/kg weight/d on average) was consumed in one meal at noon. The patients were evaluated at admission and at 6 weeks for body composition [lean mass (LM), appendicular skeletal muscle mass (ASMM), and body cell mass (BCM) indices, measured by X-ray absorptiometry combined with bioelectrical impedance analysis] (primary outcome), hand grip strength, and activities of daily living (ADL) score.

RESULTS

Protein pulse feeding was significantly more efficacious than protein spread feeding in improving LM index (mean changes from baseline for PD group: +0.38 kg/m(2); 95% confidence interval (CI), [0; 0.60]; for SD group: -0.21 kg/m(2); 95% CI, [-0.61; 0.20]; p = 0.005 between the two groups), ASMM index (+0.21 kg/m(2); 95% CI, [0; 0.34] and -0.11 kg/m(2); 95% CI, [-0.20; 0.09]; p = 0.022), BCM index (+0.44 kg/m(2); 95% CI, [0.08; 0.52] and -0.04 kg/m(2); 95% CI, [-0.09; 0.10]; p = 0.004). There was no significant effect for hand-grip strength or ADL score.

CONCLUSIONS

This study demonstrates for the first time that protein pulse feeding has a positive, clinically relevant effect on lean mass in malnourished and at-risk hospitalized elderly patients.

The frailty syndrome: a comprehensive review

The frailty syndrome is defined as unintentional weight and muscle loss, exhaustion, and declines in grip strength, gait speed, and activity. Evidence with respect to the clinical definition, epidemiology, mechanisms, interactions, assessment, prevention, and treatment of frailty in the older adult is reviewed.

Nutritional status and associations with falls, balance, mobility and functionality during hospital admission

OBJECTIVES

To explore associations between nutritional status, falls and selected falls risk factors amongst older hospitalized people. Lengths of stay amongst fallers and the malnourished were assessed.

DESIGN

An observational longitudinal cohort study.

SETTING

Geriatric Assessment and Rehabilitation Unit (GARU) of a tertiary teaching hospital.

PARTICIPANTS

Admissions to the GARU during a six-month period were included.

MEASUREMENTS

Associations between nutritional status and falls during hospitalization, reported preadmission history of falls, functional status, balance and mobility during GARU admission were analysed. Associations between nutritional status or experiencing a hospital fall and length of stay were also examined.

RESULTS

Malnutrition prevalence was 39% (75/194, 95% CI 32-46%) with odds of falling during admission being 1.49 (95%CI: 0.81, 2.75), p< 0.20). Patients assessed as malnourished were older (p<0.001) and more likely to have a poorer score on both the admission (p<0.05) and discharge (p<0.009) timed "Up and Go" test. Malnutrition was associated with reduced mobility (p<0.05). Those who fell during admission had statistically greater lengths of stay compared with non-fallers [median (range): 57.0 (7-127) vs 35.0 (5-227) days; p<0.002].

CONCLUSION

Evidence of reduced mobility was evident during GARU admission amongst older people assessed as malnourished. Considering the results, a larger study concerning nutritional status, functionality and falls in the hospitalized population is warranted. The influence of nutritional status upon a person's physical functioning should be considered more broadly in falls research.

Insulin resistance after cardiopulmonary bypass in the elderly patient

OBJECTIVES

Preoperative carbohydrate administration attenuates insulin resistance. We studied effects of preoperative oral carbohydrate loading in elderly patients undergoing coronary artery bypass grafting.

DESIGN

Eighteen patients were assigned either to get a carbohydrate drink or to be controls. Perioperatively, glucose was administered. A gastric emptying test was performed. Glucose and insulin concentrations were measured. Levels of glucose, insulin and stress hormones were studied pre-, per- and postoperatively.

RESULTS AND DISCUSSION

Preoperative carbohydrate loading did not affect stress hormones. Gastric residual after the carbohydrate drink was 11+/-3% (mean+/-SEM). Glucose concentration was lower before anaesthesia induction in the carbohydrate group, possibly due to increased insulin release. Insulin levels differed at baseline, induction and day six. All patients returned to baseline on day six.

CONCLUSIONS

The study group was insulin resistant on postoperative day one and two. The effects were explainable by the traumatic stress response. No adverse effect was noted from the carbohydrate drink. If glucose is administered intravenously during surgery, there is no obvious advantage of preoperative carbohydrate loading on insulin resistance or stress hormone response.

The effects of different nutritional measurements on delayed wound healing after hip fracture in the elderly

BACKGROUND

It has been well recognized that malnutrition causes wounds to heal inadequately and incompletely. Malnutrition is often observed in the elderly, and it appears to be more severe in patients with hip fracture than in the general aging population. Few prospective studies give a detailed account of the identification and classification of nutritional status in the elderly. The objective of this study was to evaluate the effects of different nutritional measurements on wound healing status after hip fracture in the elderly.

METHODS

From September 2002 to December 2007, 207 hip fracture patients older than 60 y treated surgically were reviewed for preoperative nutritional status. There were 81 males and 126 females with an average age of 75.93 y (62-91 y); 131 cases with femoral neck fractures, 76 cases with intertrochanteric fractures. Parameters indicative of nutritional status (serum albumin, serum transferrin, serum pre-albumin, and total lymphocyte count levels) at the time of admission were assessed, along with anthropometric measurements, Rainey MacDonald nutritional index, and MNA tool. Suture removal was performed on postoperative day 14.

RESULTS

Delayed wound healing complicated 46 (22.2%) of the 207 cases. The preoperative serum transferring total lymphocyte count levels, MNA total score, and Rainey MacDonald nutritional index were significantly lower for patients who subsequently had delayed wound healing. When all variables were subjected to multivariate analysis, only total lymphocyte count levels and MNA total score showed significant value in predicting which patients would have delayed wound healing. Through prophylactic antibiotics and adherence to strict aseptic precautions, on follow-up, wound healing was normal in all patients.

CONCLUSIONS

Patients at risk for delayed wound healing problems after hip fracture can be identified using relatively inexpensive laboratory test such as TLC and MNA tool. The clinician must be aware of the risk values of both measurements. We believe this information is particularly important before planning procedures of hip fractures in the elderly.

Effects of food fortification on nutritional and functional status in frail elderly nursing home residents at risk of malnutrition

OBJECTIVE

Malnutrition is a frequent problem in the elderly and is associated with an impaired functional status and higher morbidity and mortality. In this study we evaluated the effect of a 12-wk nutritional intervention with fortified food on nutritional and functional status in nursing home residents at risk of malnutrition.

METHODS

Nutritional status was assessed with the Mini Nutritional Assessment. Body composition was measured with bioelectrical impedance analysis. Functional status was assessed with handgrip strength, peak flow, the Barthel Index, and the Physical Functioning component of the Short Form 36 questionnaire. The residents were assigned to a group receiving the standard food of the nursing home or a group with a protein- and energy-enriched diet and snacks.

RESULTS

Sixty-five nursing home residents were included; 62 were at nutritional risk and 3 were severely malnourished according to the Mini Nutritional Assessment. Protein intake was significantly higher in the group on the enriched diet, whereas energy intake did not differ from the group on the standard diet. Both groups significantly improved most nutritional and body composition parameters during the intervention period. We did not observe convincing improvements in muscle function. Furthermore, the Barthel Index and the Physical Functioning component of the Short Form 36 questionnaire declined in all participants.

CONCLUSION

Standard food in this nursing home provided sufficient energy and macronutrients. Provision of snacks was not effective in increasing energy intake. Although nutritional status improved, functional status did not increase as a consequence. Functional frailty in this study population seems to be influenced more by age-related morbidity and immobilization than by nutritional intake.

Health-related implications and management of sarcopenia

The loss of muscle mass experienced in sarcopenia is a slow, progressive process. The condition is analogous to osteoporosis as a normal, albeit deleterious and equally costly, consequence of aging. There is an almost universal lack of awareness of sarcopenia, its consequences, and its prevention or management, however--which is not the case for osteoporosis. Sarcopenia has a multifactorial etiology, and interventions targeting the various mechanisms contributing to its pathogenesis have been investigated. Exercise is the only intervention that reliably increases muscle mass, strength, and power. The benefits of exercise, particularly ST, include a reduction in disease, better balance with fewer falls, and fewer fractures. Equally compelling, exercise is associated with increased independence and quality of life. Obtaining adequate nutrition via a healthy diet is a fundamental adjunct to physical activity in managing sarcopenia. Even though diet and exercise guidelines are an established part of public health recommendations, most people are not meeting target levels for physical activity or nutritional goals. Greater efforts are needed to achieve behavioral and lifestyle change on a national level. Until those changes occur, health care providers must champion the cause and make wellness strategies a priority in their practices.

Malnutrition and ageing

This article aims to provide an overview of the problems that exist in relation to malnutrition and the elderly population. The changes that occur in body composition during ageing are described and how this may affect disease risk. The possible metabolic processes behind weight loss are discussed and the numerous factors that affect nutritional status in the older age group are described. Prevention of malnutrition in this group is important and so the roles of nutrition screening and assessment are examined.