Why do physicians fail to recognize and treat malnutrition in older persons?

Assessment Tools of Biopsychosocial Frailty Dimensions in Community-Dwelling Older Adults: A Narrative Review

Frailty is a complex interplay between several factors, including physiological changes in ageing, multimorbidities, malnutrition, living environment, genetics, and lifestyle. Early screening for frailty risk factors in community-dwelling older people allows for preventive interventions on the clinical and social determinants of frailty, which allows adverse events to be avoided. By conducting a narrative review of the literature employing the International Narrative Systematic Assessment tool, the authors aimed to develop an updated framework for the main measurement tools to assess frailty risks in older adults, paying attention to use in the community and primary care settings. This search focused on the biopsychosocial domains of frailty that are covered in the SUNFRAIL tool. The study selected 178 reviews (polypharmacy: 20; nutrition: 13; physical activity: 74; medical visits: 0; falls: 39; cognitive decline: 12; loneliness: 15; social support: 5; economic constraints: 0) published between January 2010 and December 2021. Within the selected reviews, 123 assessment tools were identified (polypharmacy: 15; nutrition: 15; physical activity: 25; medical visits: 0; falls: 26; cognitive decline: 18; loneliness: 9; social support: 15; economic constraints: 0). The narrative review allowed us to evaluate assessment tools of frailty domains to be adopted for multidimensional health promotion and prevention interventions in community and primary care.

Screening Community-Living Older Adults for Protein Energy Malnutrition and Frailty: Update and Next Steps

Protein-energy malnutrition (PEM)/undernutrition and frailty are prevalent, overlapping conditions impacting on functional and health outcomes of older adults, but are frequently unidentified and untreated in community settings in the United States. Using the World Health Organization criteria for effective screening programs, we reviewed validity, reliability, and feasibility of data-driven screening tools for identifying PEM and frailty risk among community-dwelling older adults. The SCREEN II is recommended for PEM screening and the FRAIL scale is recommended as the most promising frailty screening tool, based on test characteristics, cost, and ease of use, but more research on both tools is needed, particularly on predictive validity of favorable outcomes after nutritional/physical activity interventions. The Malnutrition Screening Tool (MST) has been recommended by one expert group as a screening tool for all adults, regardless of age/care setting. However, it has not been tested in US community settings, likely yields large numbers of false positives (particularly in community settings), and its predictive validity of favorable outcomes after nutritional interventions is unknown. Community subgroups at highest priority for screening are those at increased risk due to prior illness, certain demographics and/or domiciliary characteristics, and those with BMI < 20 kg/m² or < 22 if > 70 years or recent unintentional weight loss > 10% (who are likely already malnourished). Community-based health professionals can better support healthy aging by increasing their awareness/use of PEM and frailty screening tools, prioritizing high-risk populations for systematic screening, following screening with more definitive diagnoses and appropriate interventions, and re-evaluating and revising screening protocols and measures as more data become available.

How Much Intake of Sodium Is Good for Frailty?: The Korean Frailty and Aging Cohort Study (KFACS)

OBJECTIVE

The aim of this study was to determine how sodium intake can affect frailty, but not anorexia, in community-dwelling older adults in Korea.

DESIGN

This was a cross-sectional study.

SETTING

The study used data from the Korean Frailty and Aging Cohort Survey (KFACS), a multi-center longitudinal study addressing 10 centers across urban, rural, and suburban communities in Korea, between 2016 and 2017.

PARTICIPANTS

A total of 954 older adults who underwent both 24-hour dietary recall assessment and physical function test during the first-year baseline investigation of the KFACS.

MEASUREMENTS

Frailty was determined according to the Fried frailty index (FFI).

RESULTS

Of the 954 participants, 461 (48.3%) were male and the mean age was 76.3 years old. The average daily sodium intake was 3857 mg. The frailty prevalence in first to third quartiles was 21.8%, 7.5%, and 5.4%, respectively, and increased in the fourth quartile of sodium intake to 8.9%. Using the second quartile of sodium intake (2504-3575 mg) as reference, the odds ratios of frailty were 1.64 (95% confidence interval: 0.84-3.22), 1.33 (0.57-3.06), and 4.00 (1.72-9.27) for the first (<2504 mg), third (3575-4873 mg), and fourth (≥4873 mg) quartiles, respectively, in a multivariate-adjusted analysis.

CONCLUSION

Low sodium intake (<2504 mg) is related to frailty in older people, but it seems to be a less important factor than other nutritional factors. The prevalence of frailty did not increase up to a daily sodium intake of 3575 mg, but it increased upon a daily sodium intake higher than 3575 mg.

Is continuing medical education sufficient? Assessing the clinical nutrition knowledge of medical doctors

OBJECTIVES

Provision of nutritional support (NS) can improve disease outcome and shorten hospital length of stay. NS, often prescribed by medical doctors, requires adequate clinical nutrition (CN) expertise. The aim of this study was to investigate self-perceived and actual CN knowledge among medical doctors in Greece.

METHODS

Internal medicine physicians and surgical specialties (residents and specialized) were asked to self-evaluate their CN expertise, via a seven-item questionnaire and to complete a 20-question multiple-choice test on CN topics, with the aim of evaluating their actual CN knowledge. Participants were discouraged from accessing literature/information during the completion of either questionnaire.

RESULTS

Of 182 invited medical doctors, 115 (50.4% surgical specialties) participated in the study (63.2% response rate). The majority of participants (65.2%) demonstrated inadequate CN knowledge, with 30.4% of those scoring low having a high self-perception of their CN expertise. Comparison of perceived and actual CN knowledge revealed that only 56.5% of the participants estimated their knowledge correctly. Those who had participated in CN continuous medical education courses demonstrated increased related expertise (P = 0.002).

CONCLUSIONS

Medical doctors in Greece demonstrate low knowledge of fundamental CN principles, jeopardizing the provision of high-quality and efficient NS. Most importantly, the majority of participants overestimated their CN knowledge and prescribe artificial nutrition or participate in related decision making. Physicians' CN knowledge should be enhanced accordingly, either by attending CN modules during their studies, by participating in basic and advanced courses or CN-specific continuous medical education, or both.

Algoplus® Scale in Older Patients with Dementia: A Reliable Real-World Pain Assessment Tool

Pain is still a neglected clinical issue in elderly people with dementia and/or communicative disorders, with an unacceptable higher rate of under diagnosis and under treatment. Cognitive deficit and emotional and psychological disturbances entangle pain symptoms, affecting patient self-report. So far, observational pain tools do not have fully adequate clinimetric properties and quality requirements for easy-to-use daily rating. Older patients with dementia represent a clinical challenge. The assessment of pain is important for improving clinical outcomes, such as functional status, frailty trajectories, comorbidity, and quality of life. The PAINAID scale appears to be the most accurate pain tool in people with dementia along with the Algoplus® scale, a recently developed tool to rapidly assess acute pain in hospitals settings. The present study aimed to assess the clinimetric properties of the Algoplus®, as compared to PAINAID, for detecting acute pain in a real-world cohort of hospitalized older patients with dementia.

Loss of appetite and strength in the geriatric population: diagnostic symptoms for dengue

In dengue endemic regions, a chief complaint of nocturnal fever often is a pathognomic phrase that triggers an investigation for dengue. This article looks at cases of patients who were tested for dengue based on their symptoms of weakness and loss of appetite, without fever as fever was absent in most cases. The article also examines the changes in weight that occur after diagnosis of dengue and compares it to weight loss (if any) that occurred prior to the diagnosis. Dealing with the anorexia and weight loss is challenging for physicians, patients and family members.

The automated malnutrition assessment

OBJECTIVE

We propose an automated nutritional assessment algorithm that provides a method for malnutrition risk prediction with high accuracy and reliability.

METHODS

The database used for this study was a file of 432 patients, where each patient was described by 4 laboratory parameters and 11 clinical parameters. A malnutrition risk assessment of low (1), moderate (2), or high (3) was assigned by a dietitian for each patient. An algorithm for data organization and classification using characteristic metrics for each patient was developed. For each patient, the algorithm characterized the patients' unique profile and built a characteristic metric to identify similar patients who were mapped into a classification. For each patient, the algorithm characterized the patients' classification.

RESULTS

The algorithm assigned a malnutrition risk level for different training sizes that were taken from the data. Our method resulted in average errors (distance between the automated score and the real score) of 0.386, 0.3507, 0.3454, 0.34, and 0.2907 for the 10%, 30%, 50%, 70%, and 90% training sizes, respectively. Our method outperformed the compared method even when our method used a smaller training set than the compared method. In addition, we showed that the laboratory parameters themselves were sufficient for the automated risk prediction and organized the patients into clusters that corresponded to low-, low-moderate-, moderate-, moderate-high-, and high-risk areas. The organization and visualization methods provided a tool for the exploration and navigation of the data points.

CONCLUSION

The problem of rapidly identifying risk and severity of malnutrition is crucial for minimizing medical and surgical complications. These are not easily performed or adequately expedited. We characterized for each patient a unique profile and mapped similar patients into a classification. We also found that the laboratory parameters were sufficient for the automated risk prediction.

Insufficient nutritional knowledge among health care workers?

BACKGROUND & AIMS

Though a great interest and willingness to nutrition therapy, there is an insufficient practice compared to the proposed ESPEN guidelines for nutrition therapy. The aim of this questionnaire was to study doctors and nurses' self-reported knowledge in nutritional practice, with focus on ESPEN's guidelines in nutritional screening, assessment and treatment.

METHODS

A questionnaire about different aspects of nutritional practice was answered by 4512 doctors and nurses in Denmark, Sweden and Norway.

RESULTS

The most common cause for insufficient nutritional practice was lack of nutritional knowledge. Twenty-five percent found it difficult to identify patient in need of nutritional therapy, 39% lacked techniques for identifying malnourished patients, and 53% found it difficult to calculate the patients' energy requirement and 66% lacked national guidelines for clinical nutrition. Twenty-eight percent answered that insufficient nutrition practice could lead to complications and prolonged hospital stay. Those that answered that their nutritional knowledge was good had also a better nutritional practice.

CONCLUSION

The self-reported nutritional knowledge was inadequate among Scandinavian doctors and nurses. Increased nutritional knowledge seems to improve the nutritional practice. A combination of an integrated nutrition curriculum during the education, together with post-graduated education for both physicians and nurses should be established.

Alimentação institucionalizada e suas representações sociais entre moradores de instituições de longa permanência para idosos em São Paulo, Brasil

Foram analisadas representações sociais sobre alimentação entre moradores de instituições de longa permanência para idosos, para identificar condicionantes do comportamento alimentar que podem interferir no estado nutricional destes indivíduos. Realizada pesquisa qualitativa e exploratória em cinco asilos de São Paulo, Brasil. Participaram quarenta idosos de ambos os gêneros, sem distúrbios cognitivos, residentes nas instituições há seis meses ou mais. Foram selecionados vinte sujeitos desnutridos ou em risco de desnutrição e vinte sem risco de desnutrição. Foram utilizadas entrevistas com roteiro semi-estruturado e os dados analisados pela técnica do Discurso do Sujeito Coletivo. Os resultados apontaram que, na percepção dos idosos, a rotina alimentar institucionalizada, os cardápios rotineiros e a oferta insuficiente de hortaliças e frutas interferem negativamente no processo de alimentação. Os idosos reconhecem que a alimentação equilibrada melhora a saúde e a qualidade de vida. Revelam que a inapetência de alguns está relacionada a comidas que não agradam ao paladar, problemas de saúde e à assistência inadequada durante as refeições. Este estudo contribuiu para identificar fatores psicológicos e sociais que podem concorrer para a maior freqüência de desnutrição entre idosos institucionalizados.

Cognitive function, body weight and body composition in geriatric patients

Weight loss is a frequent concomitant observation in dementia syndromes and is known to worsen the prognosis of elderly patients. This is a retrospective cross-sectional study of 1575 consecutive geriatric patients to obtain data about body weight and body composition in relation to gender and cognitive function. Fat mass (FM) and fat-free mass (FFM) were determined by bioelectric impedance analysis. Subjects with severe cognitive dysfunction (MMSE<11) had a significant lower body weight (6.5%), BMI (5.7%), FM (15.7%) and fat mass index (14.3%) than subjects without cognitive dysfunction (MMSE>26). FFM was not significantly decreased (2.1%). Subgroup analysis showed that mean body weight is closely related to the degree of cognitive dysfunction. Gender-related analysis showed no significant difference in body weight, BMI, FM and fat-mass index (FMI) between male subjects with severe cognitive dysfunction and male subjects with normal cognitive function. Only FFM was significantly decreased (7.0%) in males with severe cognitive dysfunction. Findings of this study indicate that patients with cognitive dysfunction lose substantial amounts of body weight, related to the degree of cognitive dysfunction. In this connection, female subjects seem to lose more weight than male subjects. At the same time female subjects predominantly lose FM, whereas male subjects seem to lose mainly FFM. Therefore patients with cognitive dysfunction should be regularly screened for weight loss and malnutrition to enable early nutritional intervention to prevent relevant weight loss. Future studies on weight loss in dementia should consider gender-related differences in body composition and weight loss.

Nutritional routines and attitudes among doctors and nurses in Scandinavia: A questionnaire based survey

BACKGROUND AND AIMS

Hospital malnutrition is prevalent, but nutritional practice in hospitals has a low priority. To improve the quality in nutritional routine, ESPEN has developed standards to improve the inadequate and insufficient nutritional treatments seen today. However, there is a discrepancy between the standards and clinical practice. This study was conducted to investigate nutritional practice in different hospital settings in relation to these standards (e.g.: screening of all patients, assessment of at-risk patients) among Scandinavian doctors and nurses.

METHODS

A questionnaire about nutritional attitudes and routine was mailed to doctors and nurses in Denmark, Sweden and Norway.

RESULTS

Altogether, 4512 (1753 doctors, 2759 nurses) answered the questionnaire. Both screening and assessment of at-risk patients differ between the countries. Nutritional screening was more common in Denmark (40%), compared to Sweden (21%) and Norway (16%). Measuring dietary intake in nutritional at-risk patients was more common in Denmark (46%), compared to Sweden (37%) and Norway (22%). However, all countries agreed that nutritional screening (92%, 88%, 88%) and measuring dietary intake (97%, 95%, 97%) were important, Denmark, Sweden and Norway, respectively.

CONCLUSION

There is a large discrepancy between nutritional attitudes and practice. The standards suggested from the ESPEN are not fulfilled.

Nutritional health promotion for older adults, where is the content?

PURPOSE

To describe nurse practitioners' (NPs') educational experiences related to older adult nutrition and eating abilities.

DATA SOURCES

Descriptive research with written survey data collected from 80 gerontological NPs recruited from a national nursing conference.

CONCLUSIONS

Older adults' nutritional health has been related to acute illness, pressure sore development, prolonged hospital stays, and other health problems. Current literature suggests that although nutrition screening and intervention promote older adults' health, practitioners may not consistently receive education on this content. Participants indicated that gerontological-nutrition content was important, that it was missing from their educational programs, and that it needed to be a part of the NP curriculum. Specific nutrition content concerns were organized by the categories (a) disease and functional issues, (b) psychosocial support and environmental impact, and (c) health care team and system considerations.

IMPLICATIONS FOR PRACTICE

NP programs need to self-evaluate for adequate and appropriate nutrition screening and intervention content. Frameworks such as those developed by the Nutrition Screening Initiative and others provide beginning guidance for further content development.

Undernutrition in medical outpatients

This article discusses the epidemiology, predisposing factors, and etiology of undernutrition in geriatric patients receiving ambulatory care. It presents the major aspects of the clinical evaluation of undernutrition in older adults. Interdisciplinary assessment of nutritional risk in the outpatient setting and the formulation of an outpatient nutritional intervention model are also discussed.

Effect of liquid dietary supplements on energy intake in the elderly

BACKGROUND

Undernutrition is a risk factor for increased mortality in older adults. Therapeutic intervention includes the administration of liquid dietary supplements.

OBJECTIVE

We investigated the effect of liquid dietary supplements on satiation, satiety, and energy intake in older adults.

DESIGN

This study had 2 phases in a within-subject, repeated-measures design. The energy intake of 15 elderly (aged >70 y) and 15 younger (aged 20-40 y) healthy subjects was measured after 4 liquid preloads: water, high fat, high carbohydrate, and high protein. The preloads were administered within 5 min of a test meal in phase 1 and >or=60 min before the test meal in phase 2. Palatability, fullness, and hunger were assessed by using visual analogue scales.

RESULTS

Mean energy consumption of the test meals was significantly lower in the older than in the younger subjects (P = 0.001), as was mean macronutrient consumption of fat and carbohydrate (P = 0.002 and 0.001, respectively). Mean energy intake and macronutrient consumption were higher in phase 2 than in phase 1 in both older and younger subjects (P < 0.05). Satiety lasted longer in older than in younger subjects after the high-protein and high-fat preloads (P = 0.001).

CONCLUSION

In the elderly, administration of dietary supplements between meals instead of with meals may be more effective in increasing energy consumption.

Malnutrition in subacute care

BACKGROUND

Dramatic weight loss and hypoalbuminemia often follow acute hospitalization.

OBJECTIVE

The objective was to examine the prevalence of undernutrition in a subacute-care facility.

DESIGN

We evaluated 837 patients consecutively admitted over 14 mo to a 100-bed subacute-care center. Nutritional status was assessed by anthropometric measurements, biochemical markers, and a Mini Nutritional Assessment (MNA) score. Primary outcome measures included length of stay and death. Secondary measures included readmission to an acute-care hospital and placement at discharge.

RESULTS

The subjects' mean (+/- SD) age was 76 +/- 13 y and 61% were women. Eighteen percent of the subjects had a body mass index (in kg/m(2)) <19. With the use of 35 g/L as a cutoff, 53% of the subjects had hypoalbuminemia. Only 8% of the subjects were classified as being well nourished according to the MNA. Almost one-third (29%) of the subjects were malnourished and almost two-thirds (63%) were at risk of malnutrition. Thus, >91% of subjects admitted to subacute care were either malnourished or at risk of malnutrition. The Geriatric Depression Score was higher in malnourished subjects than in nutritionally at-risk subjects (P = 0.05). Length of stay differed by 11 d between the malnourished group and the nutritionally at-risk group (P = 0.007). In the MNA-assessed group of largely malnourished subjects, 25% of subjects required readmission to an acute-care hospital compared with 11% of the well-nourished group (P = 0.06). Mortality was not found to be related to BMI.

CONCLUSION

Malnutrition reaches epidemic proportions in patients admitted to subacute-care facilities. Whether this reflects nutritional neglect in acute-care hospitals or is the result of profound illness is unclear. Nevertheless, strict attention to nutritional status is mandatory in subacute-care settings.

Involuntary weight loss in elderly individuals: assessment and treatment

CONTEXT

The loss of body weight and fat late in life is associated with premature death and increased risk of disability, even after excluding elderly subjects who have a preexisting disease. Although it is important to recognize that periods of substantially positive or negative energy balance and body weight fluctuation occur as a normal part of life, weight losses greater than 5% over 6 months should be investigated. We can divide the major causes of weight loss in the elderly into 4 categories: social, psychiatric, due to medical conditions, and age-related. The clinical evaluation should include a careful history and physical examination. If these fail to provide clues to the weight loss, simple diagnostic tests are indicated. A period of watchful waiting is preferable to blind pursuit of additional diagnostic testing that may yield few useful data, if the results of these initial tests are normal. The first step in managing patients with weight loss is to identify and treat any specific causative or contributing conditions and to provide nutritional support when indicated. Non-orexigenic drugs have found an established place in the management of protein-energy malnutrition. Early attention to nutrition and prevention of weight loss during periods of acute stress, particularly during hospitalization, may be extremely important, as efforts directed at re-feeding are often unsuccessful.

DESIGN

Narrative review.

Management of nutritional problems in subacute care

Poor nutritional status is one of the major factors associated with functional decline and mortality in older persons. Older persons are at increased risk for malnutrition because of the physiologic anorexia of aging. During a stay in a subacute care facility, attention to nutrition is a major component of the rehabilitative process. The pathophysiology of malnutrition, diagnostic techniques available to diagnose malnutrition, causes and management of protein energy malnutrition, specific nutritional problems caused by vitamin and trace element deficiency, and nutritional management of specific diseases (e.g., hip fracture and diabetes mellitus) are reviewed.

Assessment of protein energy malnutrition in older persons, Part II: Laboratory evaluation

A large proportion of chronic diseases affecting older persons can be either prevented or significantly improved by improving nutrition. This places an increased burden on health care professionals caring for older persons. Screening for malnutrition at an early stage allows the intervention to be most successful. History, physical examination, and anthropometric measurements are essential parts of any nutritional evaluation. However, these tools can be highly subjective and rely heavily on the knowledge and experience of the evaluator. Incorporating biochemical measurements in the routine nutritional assessment provides an often-needed objective dimension. Interpreting these measurements must take into consideration the normal biological changes seen with aging. In this article, we review many of the biochemical parameters used in nutritional assessment and their relation to morbidity and mortality, with a special focus on normal changes seen with aging.

Assessment of the aging man

Knowledge of the aging process and the care of older patients has been increasing at a rapid pace. It is important to recognize and separate disease from the physiologic aging process. It is important to do appropriate comprehensive assessments in aging men, so that problems may be identified early and interventions instituted at the right time to delay physical decline, maintain independent living, and ultimately improve the quality of life of this part of the population.

The identification and assessment of undernutrition in patients admitted to the age related health care unit of an acute Dublin general hospital

OBJECTIVES

To profile those over 65 yr admitted to an acute geriatric medical service. To identify and assess their undernutrition risk and quantify the nutritional intervention they received.

METHODS

Forty-nine consecutive admissions were recruited, 23 various parameters were assessed. A diagnosis of undernutrition was made according to a specifically designed flow chart.

RESULTS

Eighty-four per cent of recruits were at risk of undernutrition on admission and 80 per cent were moderately to severely at risk. There was deterioration from baseline nutritional status in 29 per cent of previously well nourished patients with hospitalization. In the undernourished group, an improvement and/or stasis from baseline was achieved in 75 per cent, with intervention.

CONCLUSIONS

The risk of undernutrition on admission to hospital and during treatment is an indicator of the need for nutrition services and nutritional screening for all acute medical services for older people.

A prospective study of the use of liquid oral dietary supplements in nursing homes

OBJECTIVE

To investigate the use of liquid oral dietary supplements among nursing home residents who were eating poorly and losing weight.

DESIGN

A prospective, descriptive, anthropological study.

SETTING

Two proprietary nursing homes with 105 and 138 beds.

PARTICIPANTS

Purposive sampling was used to select 40 residents from among the 100 residents who were not eating well. Dietary data were collected on this sub-sample of 40 residents.

MEASUREMENTS

Participant observation, in-depth interviews, event analysis, bedside dysphagia screenings, oral health examinations, body weight, body mass index (BMI), and chart review were used to collect data. Dietary data were collected over a 3-day period, and data were gathered on how supplements were ordered, served, and consumed.

RESULTS

Supplements had been ordered for 29 of the subsample of 40 residents. Only nine of 29 residents were served the correct number and type of supplements as ordered by their physicians, and only two residents consumed the full amount of supplement as ordered. The overall mean percentage of supplement consumed compared with that ordered was 55.1%. Although supplements were ordered primarily to prevent weight loss and to facilitate weight gain, nearly half (n = 14) of the residents continued to lose weight. Supplements were ordered without investigating the underlying factors contributing to weight loss, such as inadequate staffing and lack of supervision at mealtime, undiagnosed dysphagia, and poor oral health. Without evaluation of these factors, it is unknown which residents might benefit from oral supplements.

CONCLUSION

Findings indicate that supplements were used nonspecifically as an intervention for weight loss in nursing home residents without regard to dose, diagnosis and management of underlying problem(s), amount of supplement consumed, and outcome. Further research is needed to establish when supplements should be ordered, how to ensure that they will be taken, and whether they are effective.

Nutrition, ageing and ill health

There are physical, mental, social and environmental changes which take place with ageing; for example, decreased physical activity, increase in body fat, decrease in lean body mass and consequently decreased energy intake may be associated with physiological functions that affect metabolism, nutrient intake, physical activity and risk of disease. There are now many studies which have found that undernutrition is prevalent and often unrecognized in patients admitted to hospitals and institutions. There is also evidence which links protein-energy undernutrition or its markers with clinical outcomes in acute and non-acute hospital settings and that nutritional supplements can improve outcomes in some of these settings. However, most clinically-available nutrition screening instruments lack sensitivity and specificity, and abnormal nutritional indicators may simply reflect effects of age, functional disability, or severe underlying disease. Thus, causal relationship cannot be assumed without a sufficiently powerful intervention study which adequately adjusts for the effects of non-nutritional factors, such as the number and severity of co-morbid conditions on clinical outcome.

Use of the diagnosis "failure to thrive" in older veterans

OBJECTIVES

To describe how physicians apply the term "failure to thrive" (FTT) to older patients. Specifically, to describe the clinical presentation, underlying etiologies, diagnostic and therapeutic interventions, and discharge outcomes of veterans having the discharge diagnosis of FTT.

DESIGN

Retrospective chart review.

SETTING

The Department of Veterans Affairs Medical Center (VAMC), Portland, Oregon, a 400-bed referral and teaching hospital.

PARTICIPANTS

All veterans 65 years of age and older admitted to the Portland VAMC from October 1, 1990, through September 30, 1993, whose coded discharge diagnoses included FTT (n = 132).

MEASUREMENTS

Medical records were reviewed by a trained abstractor to obtain key data about clinical presentation, etiologies, interventions, and discharge outcomes.

RESULTS

Subjects were predominantly male (98%), with a mean age of 76 years +/- 9 years. Weight loss was a key feature: 67% of subjects had evidence of weight loss by study criteria. Anemia was present in 55%, low cholesterol in 50%, and low albumin in 44%. Lymphopenia was common, present in 66% of subjects. Most patients were admitted from home (83%); only 7% came from nursing homes. On admission, the majority (82%) were dependent in at least one ADL, and 36% were cognitively impaired. Cancer was the most common underlying diagnosis (30%), followed by infection (18%), dehydration (13%), and depression (12%). Only 46% of subjects were discharged home, while 34% went to nursing homes. Fourteen percent of subjects died during the hospitalization, an additional 11% died within 30 days after discharge, and 32% died within 1 year after discharge. The subgroup of subjects with cancer and/or infection had increased mortality rates at 30 days and 1 year after hospitalization.

CONCLUSION

We conclude that FTT may constitute a discrete syndrome with diagnostic, therapeutic and prognostic implications in older people, but in the absence of consensus about diagnostic criteria, there is a large degree of subjective variation in how physicians apply the term.

Nutritional risk in inner-city-dwelling older black Americans

OBJECTIVE

To define the degree of nutritional risk in older inner-city black Americans and to identify important underlying factors associated with high nutritional risk.

DESIGN

Cross-sectional descriptive study.

SETTING AND PARTICIPANTS

A population-based sample of 400 noninstitutionalized persons older than 69 years of age in north St. Louis (NSL), Missouri, and a community-based sample of 115 residents aged 50 years and older living in public housing in East St. Louis (ESL), Illinois. Both study areas have high levels of poverty.

MEASUREMENTS

Nutritional risk was measured using the Nutrition Screening Initiative Checklist. Demographic information, economic status, self-rated health, Geriatric Depression Scale score, and body mass index were assessed using established standardized instruments.

MAIN RESULTS

Forty-eight percent of NSL and 66% of ESL subjects scored high on the Checklist. Compared with a mostly white (96%) comparison group from New England, both samples demonstrated particularly high prevalence for limited intake of fruits, vegetables, and milk; tooth and mouth problems; lack of money for food; eating alone; polypharmacy; and inability to shop, cook or feed on their own. High levels of depressive symptoms, fair or poor self-rated health, perceived inadequacy of income, and low income levels were associated with high risk, but even those subjects with no or few such predisposing factors were still high on the Checklist score compared with the New England sample.

CONCLUSIONS

If confirmed, these results indicate that inner-city-dwelling older black Americans are at high nutritional risk. Attempts to reduce their nutritional risk should focus on improving nutritional content of their diet, oral health, polypharmacy, depressive symptoms, and poor general health; offering group meals; and providing assistance with shopping and cooking.

Controlled trial of a geriatric case-finding and liaison service in an emergency department

OBJECTIVE

To evaluate the effects of a program of case-finding and liaison service for older patients visiting the emergency department.

DESIGN

Nonrandomized controlled trial with systematically assembled intervention cohort and matched control group.

SETTING

An urban teaching hospital.

PARTICIPANTS

There were 385 intervention subjects aged 65 years and older and 385 control subjects matched by day of visit, gender, and age within 5 years.

INTERVENTIONS

Geriatric medical, dental and social problems were identified in intervention subjects by a geriatric nurse clinician using well validated assessment instruments during a 30-minute evaluation. Recommendations were made to the patient, family, and attending emergency department physician, and attempts were made to arrange appropriate follow-up services.

MEASUREMENTS

Frequency with which geriatric problems were identified in intervention subjects; physician, patient, and family compliance with recommendations; and mortality, institutionalization, health status, use of medical and social services, presence of an advanced directive, and quality of life at 3-month follow-up.

RESULTS

Sixty-seven percent of patients were dependent in at least one activity of daily living, 82% had at least one geriatric problem identified, and 77% reported at least one unmet dental or social support need. The cost of identifying geriatric and dental/social issues was $5 and $1, respectively, for each problem. Physicians compiled with 61.6% of suggestions, and patients and families complied with 36.6% of recommendations. Mortality and nursing home residence proportions at 3 months were not significantly different (9.3% vs 9.7% and 5.0% vs 2.5% in intervention and control groups, respectively). Intervention subjects reported more difficulty communicating (21% fair or poor ability vs 13%, P = 0.2) than did control subjects. There were strong trends for fewer subsequent visits to emergency departments (0.26 intervention vs 0.39 control, P = .06) and more advance directives in the intervention group (6.7% intervention vs 2.9% control, P = .07). There was no statistically or clinically significant difference in any other health outcome. The number of new dental or social services initiated per patient over the 3-month follow-up was nearly identical (1.7 in the intervention group vs 1.5 in the control). Results in subjects aged 75 years and older and those discharged home from the emergency department were essentially identical to those in the main group.

CONCLUSIONS

Numerous previously unrecognized geriatric medical and social problems can be detected in older persons visiting the emergency department. Despite this, an emergency department-based geriatric assessment and management program failed to produce improved outcomes. This suggests that either disease acuity is an overwhelming factor in subsequent outcome or, alternatively, more control over medical and social service delivery during and after the emergency department visit than was demonstrated in this program will be required before successful outcomes can be assured.

Idiopathic CD4+ T lymphopenia in older persons

OBJECTIVE

Survey of the association of idiopathic CD4+ T cell lymphocytopenia in older persons with protein energy undernutrition and unusual infections/colonizations.

METHOD

Retrospective chart analysis.

RESULTS

Five subjects aged 61 to 87 years, with unusual organisms and/or either marasmus or kwashiorkor, were noted to have absolute CD4+ and CD8+ T cell lymphocytopenia. All were HIV negative.

CONCLUSION

T cell lymphocytopenia may not be a uncommon finding in malnourished older persons, but additional studies to determine its prevalence need to be undertaken. Its role in disease and impact on therapeutic response needs to be further explored.

Causes of weight loss in a community nursing home

OBJECTIVE

To determine the causes of weight loss in nursing home residents.

DESIGN

Retrospective chart review of all weights over the previous 6 months and an in-depth examination of all residents who lost 5 or more pounds over that period.

SETTING

A for-profit community nursing home in an urban area.

SUBJECTS

All residents who had been in the nursing home for 3 or more months. Their mean age was 80.1 years, and 89% were female.

RESULTS

Weight loss of 5 pounds or more occurred in 19% of subjects. Only 15% of subjects had lost 5% of body weight, and 4% had lost more than 10% of their body weight. Depression accounted for 36% of the weight loss. Other causes of anorexia included medications, psychotropic drug reduction, swallowing disorders, paranoia, dementia with apraxia, gallstones, and obsessive-compulsive disorder. Increased energy utilization as a cause of weight loss was seen in two residents who wandered incessantly, one with tardive dyskinesia and one with chronic obstructive pulmonary disease. Dehydration was the cause of weight loss in two residents, and one resident had international weight loss for obesity. Cancer was the cause of weight loss in two residents. Four of 30 residents had more than one cause of weight loss. One of 25 tube-fed residents displayed weight loss.

CONCLUSIONS

A single cause of weight loss can be identified in most nursing home residents. Depression is the most common cause of weight loss. Psychotropic drug reduction may cause weight loss. The majority of causes of weight loss in a community nursing home are potentially treatable.

Nutrition and function: is there a relationship between body mass index and the functional capabilities of community-dwelling elderly?

OBJECTIVE

To determine if there is a relationship between body mass index and the ability to perform the usual activities of living in a sample of community-dwelling elderly.

DESIGN

Secondary data analysis of The National Health and Nutrition Examination Survey-I Epidemiologic Follow-up Study (1982-1984). Follow-up home interview of a population-based sample originally interviewed between 1971 and 1975 in the National Health and Nutrition Examination Survey-I (NHANES-I).

PARTICIPANTS

Survivors of the original NHANES-I cohort who were 65 years of age or older and who were living at home at the time of the second interview (n = 3061). Excluded were those who could not be found, refused participation, or were institutionalized (n = 220), and those without complete height and weight data (n = 194).

MAIN OUTCOME MEASURE

Functional status as measured by a 26-item battery.

RESULTS

Bivariate analysis revealed a greater risk for functional impairment for subjects with a low body mass index or a high body mass index. The greater the extreme of body mass index (either higher or lower), the greater the risk for functional impairment. Logistic regression analysis indicated that both high and low body mass index continued to be significantly related to functional status when 22 other potential confounders were included in the model.

CONCLUSION

The body mass index is related to the functional capabilities of community-dwelling elderly. The inclusion of this simple measurement in the comprehensive assessment of community-dwelling elderly is supported.

Nutrition and the older female: a review

Reviewed here are the major nutritional problems of older females, stressing where older female nutrition differs from that of older males. Older females have a higher body mass index and lower waist-to-hip ratio than do older males. Older females reduce their food intake compared to younger females much less than do older males compared to younger males. Total energy expenditure is minimally reduced in older females compared to young females. Resting metabolic rate is reduced by 13% in older females. The major nutritional problem faced by older females, protein energy malnutrition, and its reversible causes are addressed. Inability to recognize the need for fluids is a common problem leading to dehydration in older persons. Older persons are at major risk for ingesting less than two-thirds of the recommended dietary allowance for vitamins. Older women are more likely than men to take vitamin or mineral supplements. Osteopenia is a common problem leading to fractures in older women, and decreased calcium intake and vitamin D deficiency, as well as estrogen deficiency, play a role in the pathogenesis of osteopenia. Total cholesterol levels increase with age in older women, while high-density lipoprotein cholesterol levels decline. However, cholesterol levels that are optimum for survival are higher in older women than in older men. At < 65 years of age, diabetes mellitus (DM) is more common in females, and at > 65 years of age it is more common in males. Over one-half of older persons with DM are undiagnosed. Management of DM in older persons requires a judicious approach to balance the potential problems of hypo- and hyperglycemia.