Nutritional and cognitive status in elderly subjects living in service flats, and the effect of nutrition education on personnel

BACKGROUND

There is limited knowledge about the nutritional and cognitive status in elderly and chronically ill subjects living in sheltered housing.

OBJECTIVE

To perform a 6-month follow-up study in order to investigate (1) nutritional status and its relationship to cognitive function in elderly people living in service flats, and (2) the effect of a 9-hour educational program given to personnel working in the service flats.

METHODS

Of 93 eligible subjects, 28 agreed to participate (age 81 +/- 7 years, 75% women). Body mass index (BMI), triceps skin fold (TSF), arm muscle circumference (AMC), appetite, Subjective Global Assessment (SGA), serum albumin, serum insulin-like growth factor-1 (IGF-1) and Mini Mental Test (MMT) were assessed on two occasions with a 6-month interval. The staff of the service flats answered a questionnaire before and 6 months after an educational program.

RESULTS

At the start, BMI, TSF and AMC were within the normal ranges, e.g. BMI 26.6 +/- 3.1 for men and 25.6 +/- 3.2 for women. Three subjects were suspected to be malnourished and 2 were malnourished according to SGA. Among 20 randomly selected subjects who chose not to participate in the investigation, age, sex, BMI, weight loss and appetite were not significantly different from those values in participants. However, none of the latter had a BMI <20 compared to 10% in non-participants. The MMT results suggested cognitive dysfunction in 41% of the subjects. On the first test occasion, MMT correlated with BMI (r = 0.43, p < 0.03), weight loss (r = 0.4, p < 0.05) and age (r = -0.38, p < 0.05). The ability of the personnel to suggest suitable nutrition for fictitious patient cases appeared to have improved after the educational program. At the 6-month follow-up, the BMI in men rose to 27.0 +/- 3.4 (p < 0. 05), while other anthropometric measurements remained unchanged. Serum IGF-1 lay within the normal range, as did serum albumin which, however, rose from 39.1 +/- 2.9 to 41.2 +/- 3.5 g/l (p < 0.01).

CONCLUSION

Fifteen to twenty percent of the individuals studied in the service flats displayed definite or possible signs of malnutrition. Cognitive function correlated with BMI, weight loss and age. The educational program appeared to increase the nutritional knowledge in personnel working in the service flats. At the 6-month follow-up, the nutritional status of the residents had not deteriorated.

Impaired granulocyte formylpeptide-induced superoxide generation in chronically ill, malnourished, elderly patients

OBJECTIVE

Protein-energy malnutrition (PEM), often occurring in patients with chronic disease, is associated with a decreased capacity to combat infections. In this study we assessed polymorphonuclear neutrophil (PMN) superoxide anion (*O2-) formation in elderly PEM patients with various chronic diseases.

DESIGN AND SUBJECTS

Nineteen patients (75+/-1 years), with body mass index 17.1+/-0.4, and 19 age-matched healthy controls were included. Fourteen patients and 14 controls were re-examined in a 3 month follow-up.

SETTING

A service of internal medicine at a university-affiliated hospital.

INTERVENTIONS

Eight patients were prescribed a dietary liquid supplementation during the observation period.

MAIN OUTCOME MEASURES

Superoxide production in PMN induced by fMLP (a receptor ligand) and phorbol myristate acetate (PMA), which acts directly on protein kinase C.

RESULTS

fMLP-induced superoxide generation in the malnourished patients was 55+/-5% of that of the controls. However, the patients retained their capacity, 108+/-6% of control PMN generation, to respond to PMA. In those who received formula supplementation, fMLP-generated *O2- production levels were 48+/-8 and 73+/-13% (P = 0.12) of those of controls at the start and after 3 months, respectively. Corresponding figures in those who were not prescribed supplementation were 57+/-8 and 64+/-4% (P = 0.55).

CONCLUSION

Possibly contributing to reduced host defence, receptor ligand-induced PMN generation of *O2 is significantly lower in chronically ill, elderly patients with PEM than in age-matched healthy controls.

Nutrition and acute leukemia in adults: relation between nutritional status and infectious complications during remission induction

BACKGROUND

The purpose of this study was to determine whether nutritional state was related to infectious complications in adult patients with acute leukemia.

METHODS

During first-remission induction therapy (mean, 71 days), the duration of neutropenia, various infections, and fevers were related to changes in body weight and serum albumin concentrations as well as total parenteral nutrition (TPN) in 52 patients receiving standardized anti-infectious treatment.

RESULTS

Severe neutropenia prevailed for 27% and fever for 28% of the induction period. A mean weight loss of 5.1 kg, corresponding to a reduction of body mass index from 23.5 to 21.7, was correlated with the number of days that patients had fever (P = 0.026). Despite a normal serum albumin value at the time of admission, patients had severe hypoalbuminemia (<25 g/L) during 16% of the induction period. The drop in serum albumin was independently related to the weight loss (r = 0.37, P = 0.03). Moreover, the incidence and duration of hypoalbuminemia were significantly correlated with duration of fever (P < 0.0001), diarrhea (P = 0.03), and TPN administration (P = 0.00002).

CONCLUSIONS

Weight loss and severe hypoalbuminemia were common during remission induction for these adult patients with acute leukemia and were closely related to the patients' infections.

Low circulating leptin levels in protein-energy malnourished chronically ill elderly patients

OBJECTIVE

To evaluate serum leptin, a fat cell-derived protein, levels in relation to the malnutrition often observed in chronic disease.

DESIGN

A comparison of circulating leptin concentrations in malnourished chronically ill elderly and in age-matched controls.

SETTING

A university-affiliated teaching hospital in Stockholm, Sweden.

SUBJECTS

Nineteen protein-energy malnourished elderly patients (74 +/- 1 years) with various chronic nonmalignant diseases and 18 healthy controls (72 +/- 1 years).

MAIN OUTCOME MEASURES

Serum leptin levels measured by radioimmunoassay technique, nutritional status as expressed by body mass index (kg m[-2]), triceps skin fold, arm muscle circumference and serum albumin, and serum orosomucoid concentrations indicating inflammatory status.

RESULTS

Patients and controls displayed body mass indexes of 17.4 +/- 0.7 and 25.0 +/- 1.1 (P < 0.001), respectively. Triceps skin fold (TSF) measurements revealed a pronounced fat depletion in the patients, being 8.5 +/- 0.9 and 22.3 +/- 1.5 mm (P < 0.001) in female and 6.1 +/- 0.7 and 10.8 +/- 0.8 mm (P < 0.001) in male patients and controls, respectively. Patient serum leptin concentrations were less than half of the corresponding concentrations in the controls, 4.3 +/- 1.1 and 9.3 +/- 1.3 ng mL(-1)(P < 0.01), respectively. The highest leptin concentrations were registered in female controls, 12.1 +/- 1.6 ng mL(-1). The serum leptin levels in the controls correlated with TSF (r = 0.74: P < 0.001). No such correlation was found in the patients.

CONCLUSIONS

Serum leptin levels were low and did not seem to be directly associated with fat and muscle depletion in elderly patients with chronic illness, whereas they appeared to be positively correlated to body fat in healthy elderly.

Enhanced generation of interleukins 1 beta and 6 may contribute to the cachexia of chronic disease

The cachexia of disease may be promoted by proinflammatory cytokines, eg, interleukin (IL) 1 beta, tumor necrosis factor alpha (TNF-alpha), and IL-6. These, as well as some antiinflammatory cytokines, eg, IL-1 receptor antagonist (IL-1ra), IL-10, and transforming growth factor beta 1 (TGF-beta 1), were analyzed in serum (IL-6, IL-1ra, IL-10, TGF-beta 1) and stimulated blood monocytes (IL-1 beta, TNF alpha, IL-6) obtained from elderly patients with protein-energy malnutrition (PEM). Twenty-one uninfected malnourished patients aged 75 +/- 1 y (mean +/- SD), with a body mass index (BMI; in kg/m2) of 17.2 +/- 0.5 and various noncancer disorders, and 22 healthy matched control subjects aged 72 +/- 1 y, with a BMI of 25.4 +/- 0.7 (significantly different from patients, P < 0.001), were included. Fifteen patients and their corresponding control subjects were reexamined 3 mo later. Isolated monocytes were stimulated with lipopolysaccharide (LPS) and concentrations of IL-1 beta, TNF-alpha, and IL-6 were determined. Serum concentrations of IL-6, IL-1ra, IL-10, TGF-beta 1, and acute-phase reactants were analyzed. Serum concentrations of orosomucoid and IL-6 were higher in the malnourished subjects than in the control subjects (1.14 +/- 0.1 compared with 0.8 +/- 0.3 g/L, P < 0.001; and 5 ng/L compared with undetectable concentrations, P < 0.01, respectively). Higher generation of IL-1 beta (2.7-fold; P < 0.05) and IL-6 (3.7-fold; P < 0.05) was found in monocytes from patients with PEM relative to the control subjects when monocytes were stimulated with 0.1 microgram LPS/L. Monocyte TNF generation and serum concentrations of IL-10, IL-1ra, and TGF-beta 1 did not differ. Similar results were obtained at follow-up. IL-1ra was negatively correlated with delayed cutaneous hypersensitivity (r = -0.34, P < 0.05). We conclude that enhanced generation of proinflammatory cytokines such as IL-6 and IL-1 beta in malnourished patients may contribute to the PEM often encountered in chronic nonmalignant disorders.

Outcome of protein-energy malnutrition in elderly medical patients

PURPOSE

To assess the impact of protein-energy malnutrition (PEM) on mortality and the long-term variations in the nutritional status of subjects admitted as emergency cases in a 9-month prospective follow-up study.

PATIENTS AND METHODS

The study comprised 205 patients without cancer aged 75 years (+/- 1). Malnourished subjects were identified as having at least three nutritional variables (which included weight index, triceps skinfold thickness, arm muscle circumference, serum albumin, and delayed cutaneous hypersensitivity reaction) below the reference range.

RESULTS

The mortality was 44% in the 41 malnourished patients and 18% in the 164 nonmalnourished subjects (P < 0.001). Among malnourished patients with congestive heart failure the mortality was 80%. Multivariate analysis revealed congestive heart failure, multiple organ disease, and PEM to be predictors of death. When the interaction between these disorders and PEM was considered, the prognostic relevance of PEM remained among the patients with cardiac congestion. Of the surviving subjects, 125 were reexamined after 9 months. At admission, more than half of the patients had displayed elevated levels of serum acid glycoprotein as evidence of an ongoing inflammation and subnormal recordings for serum albumin and delayed cutaneous hypersensitivity. At the reexamination, these variables had normalized in the well-nourished patients and in the 9 patients who had recovered from PEM, but remained unchanged in the 10 patients with persistent PEM. The latter patients were severely malnourished, commonly infected, and often hospitalized.

CONCLUSIONS

Protein-energy malnutrition in noncancer medical patients is associated with an excess mortality in those with congestive heart failure. Improvement of PEM is accompanied by a decline in inflammatory activity.

Therapy-resistant hypertension associated with central obesity, insulin resistance, and large muscle fibre area

Obesity and an enhanced insulin response to oral glucose tolerance test are associated with therapy resistance in hypertension. In order to explore this association further we studied the insulin sensitivity of subjects with essential hypertension resistant to triple drug therapy (RH), with the euglycemic insulin clamp technique. Well controlled hypertensives, matched for age, gender and body mass index (BMI) served as controls. Male subjects (7 RH and 7 controls) were further investigated by biopsies of Musculus Vastus lateralis since structural conditions in skeletal muscles might have a role in the above association. Irrespective of pre-study drug therapy, therapy-resistant hypertensives had a lower insulin sensitivity index than controls (p < 0.05). In spite of the BMI-match waist/hip ratio (WHR) in the RH males tended to be higher (p < 0.07). Insulin clearance tended to be lower in RH subjects (p = 0.09). BMI correlated with a reduced muscular capillary density (r = -0.77, p < 0.01). The average cross-sectional muscle fibre area was larger in RH subjects (p < 0.05). The mean muscle fibre area correlated with basal serum insulin (r = 0.63; p < 0.05). Rarefaction of the muscular capillary bed appears to be related to obesity. Larger muscle fibres might be an effect of the growth factor properties of insulin and could possibly correspond to hypertrophy of smooth muscle in the resistance vessels. This factor might contribute to the association of hyperinsulinemia and hypertension and attenuate the response to antihypertensive therapy.

Nutritional status and performance capacity in internal medical patients

The nutritional status (3 anthropometric records, serum albumin and delayed cutaneous hypersensitivity (DCH)), recent weight loss, dynamometric capacity and mood were assessed in 205 recently admitted non-cancer internal medical patients. 20% of the subjects were classified as malnourished (3 of the 5 nutritional variables below the reference range). The occurrence of malnutrition was higher (1/3) in multiple organ dysfunction or chronic respiratory disease. In order to reduce the risk of overestimating malnutrition, the data for serum albumin and DCH were omitted when they appeared to be influenced by non-nutritional factors. Disease duration >2 years, old age and multiple organ dysfunction were independently related to malnutrition. Serum albumin correlated more strongly with the acute phase reactant, serum acid glycoprotein (r = 0.33, P < 0.001) than with the anthropometric variables (r < 0.24). Recalled recent weight loss >5% was found in 34% of the malnourished subjects. Malnourished, in comparison to well nourished patients, exhibited reduced (p < 0.05) recordings for hand grip strength, peak expiratory flow and time of ambulation. Depressive tendencies were seen in malnourished women (p < 0.05).

Nutritional status in recently hospitalized and free-living elderly subjects

Weight index (WI), triceps skinfold (TSF), serum albumin and delayed cutaneous hypersensitivity reaction (DCH) were measured in 96 hospitalized elderly patients and in 100 age- and sex-matched free-living controls. Using the 10th percentile of data obtained in the controls, WI was subnormal in 35% of the patients. Corresponding findings with regard to TSF, serum albumin and DCH were 32, 50 and 31%, respectively. The findings in the controls were mainly within the range observed in national reference groups. Patients were considered malnourished if they showed at least two variables (of which one was required to be anthropometric) below the cut-off limits used. When these limits were set at the 10th percentile of the recordings in the controls, the occurrence of undernutrition in the patients was 39%. By using the 5th percentile the corresponding figure was 16%. Malnourishment was most pronounced in patients with multiple organ disease and malignancy. It is concluded that low nutritional indices are a common occurrence in elderly subjects admitted to hospital and that undernutrition is related to the nature of the disease rather than age.

Skeletal muscle depressed calcium and phosphofructokinase in chronic heart failure are upregulated by captopril--a double-blind, placebo-controlled study

The effects of the angiotensin converting enzyme inhibitor captopril, after treatment for 5-6 weeks with 25 mg t.i.d., were studied in 12 patients with stable moderate heart failure. Five patients received placebo treatment, and the two groups were comparable at baseline. Angiotensin II levels decreased in response to captopril therapy. Skeletal muscle potassium, magnesium and chloride levels did not differ from reference values. Calcium was subnormal (P less than 0.0001), but increased to the reference range during captopril treatment. Phosphofructokinase, a rate-limiting glycolytic enzyme, was in the lower reference range and increased (P less than 0.04) in response to captopril therapy. In conclusion, stable moderate heart failure is associated with low levels of skeletal muscle calcium and phosphofructokinase activity, these metabolic changes tending to return to normal levels with captopril treatment.