Weight loss in older persons

Effect of oral nutrition supplements on anthropometric and functional parameters among community-dwelling older adults: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Oral nutrition supplement (ONS) prescription in older adults is affordable for preventing malnutrition through the use of multiple nutrients and energy products. However, there is a gap in knowledge regarding the benefits of ONS supplementation on anthropometric and functional parameters in malnourished older adults without complicated conditions, known as community-dwelling older people.

METHODS

Electronic databases, including PubMed/Medline, SCOPUS, Web of Science, and the Cochrane Central Register of Controlled Trials, were searched to answer this question through August 10, 2023. The study adhered to the PRISMA guidelines and was registered on PROSPERO. The Cochrane risk of bias tool assessed the quality of randomized controlled trials (RCTs). The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) tool was used to evaluate the certainty of evidence. In total, 12 RCTs (n = 1320) were initially included.

RESULTS

ONS had a positive effect on body weight (weighted mean difference (WMD): 1.33, 95% CI: 0.94, 1.72, P = 0.00) with moderate certainty, BMI (WMD: 0.36, 95% CI: 0.06, 0.68, P = 0.02), calf circumference (WMD: 0.27, 95% CI: 0.08, 0.46, P < 0.001) with low certainty and midarm circumference (WMD: 0.38, 95% CI: -0.14, 0.89, P = < 0.15, I2: 87.2 P < 0.00) with very low certainty. Significant improvements in grip strength (WMD: 1.012, 95% CI: 0.37, 1.65, P < 0.00) and a slightly positive change in gait speed (WMD: 0.04, 95% CI: 0.004.0.083, P = 0.03, I2:0.0, P:0.72) were also observed.

CONCLUSION

ONS in community-dwelling older persons without complicated conditions can also have beneficial effects in terms of anthropometric and functional parameters.

Wasting syndrome and associated factors in hospitalized older people

Wasting syndrome (WS) is characterized by clinically important unintentional weight loss >5 % in six to 12 months. This syndrome is responsible for a significant portion of hospitalizations throughout the world and is an important indicator of serious diseases, especially in individuals with 60 years of age or older. The aim of the present study was to investigate WS and associated factors in hospitalized older people. An observational cross-sectional study was developed at a university hospital in Brazil with male and female patients ≥60 years of age. WS was considered in the occurrence of unintentional weight loss of 10 % in 12 months, 7.5 % in six months or >5 % in three months. Data were collected on sociodemographic, clinical, lifestyle, nutritional and biochemical characteristics. This study received approval from the local institutional review board and all participants signed a statement of informed consent. The sample was composed of 178 older people with a mean age of 70.0 ± 8.0 years. The prevalence of WS was 45.5 %. WS was associated with the following clinical variables: conservative CKD (p = 0.007), dysphagia (p = 0.035), dementia (p = 0.017), anorexia (p < 0.001), fatigue (p = 0.001), functional dependence (measured using the Barthel Index) (p = 0.001) and medications that cause malabsorption (p = 0.020); the following nutritional variables: body mass index (p < 0.001), low calf circumference (p < 0.001), low muscle strength (p = 0.001), low muscle mass (p < 0.001) and undernourishment or risk of malnutrition (evaluated using the Mini Nutritional Assessment); and the following biochemical variables: high CRP (p = 0.027), hypoalbuminemia (p = 0.005) and anemia (p < 0.001). The prevalence of WS was high among the hospitalized older people in the present sample and was associated with clinical and biochemical aspects as well as all nutritional variables analyzed. In contrast, lifestyle and sociodemographic characteristics were not associated with wasting syndrome.

Unintentional Weight Loss in Adults 65 Years or Older: A Symptom of Physical and Psychiatric Etiologies

ABSTRACT

Unintentional weight loss is defined as a more than 5% decrease in body weight within 1 year. Various physical and psychiatric etiologies cause unintentional weight loss, including major depressive disorder (MDD). We present the case of a 69-year-old woman who lost 10 kg in 2 months. She had anhedonia, mobility limitations, and incontinence. Her Mini Nutritional Assessment score indicated malnutrition, whereas her Geriatric Depression Scale score indicated a diagnosis of MDD. Whole-body fluorodeoxyglucose (FDG)-positron emission tomography/computed tomography showed intensely increased FDG uptake in the muscles adjacent to the right and left mandibular rami and the temporal muscle, compatible with jaw clenching associated with the patient's MDD. Subsequent temporal muscle biopsy did not suggest the causes of malignant disorders, dermatomyositis, or polymyositis. Having ruled out all possible organic pathologies, the patient was thus diagnosed with MDD. Escitalopram was prescribed for her MDD, and oral nutritional supplement treatments were initiated for her malnutrition. Patients who present with unintentional weight loss should be assessed first for physical etiologies, and then psychiatric etiologies, particularly as weight loss may be a major symptom of MDD in older adults.

Effectiveness of Oral Nutritional Supplements on Older People with Anorexia: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Nutrition plays an important role in maintaining the overall health of older people. Inadequate intake may lead to impaired body function, higher morbidity, and mortality. Oral nutritional supplements (ONS) showed positive effect on the nutritional status of the elderly; however, systematic evidence is currently lacking on the effect of ONS on the elderly with anorexia.

AIMS

The current systematic review and meta-analysis included randomized controlled trial (RCT) articles to investigate the effectiveness of ONS on the main aspects of anorexia of aging (AA).

METHODS

By using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) method, researchers independently searched PubMed/MEDLINE, EMBASE, CINAHL, PsycINFO, the Cochrane Library, China National Knowledge Infrastructure (CNKI) and other gray literature resources for publications that met the inclusion criteria by October 2020. The Cochrane Risk of Bias Tools were used for quality assessment. The inverse-variance method was used for the fixed model (FM) while the DerSimonian-Laird method was used for the random model (RM). Respective 95% confidence intervals (95% CIs), mean difference (MD) or standardized mean difference (SMD) was used for indices in terms of effect size (ES).

RESULTS

2497 records were found through the systematic search, while 17 RCTs (n = 1204) were included, with a mean age of 81.9 years (range: 74-87 years). Supplementation occurred in the morning, mid-day, and evening, while the times varied from one to three times a day. The results of meta-analysis showed that, generally, ONS had a positive effect on the overall appetite, MD = 0.18, 95% CI (0.03, 0.33), p = 0.02, and consumption, MD = 1.43, 95% CI (0.01, 2.86), p = 0.05; but not significant in terms of other aspects of appetite: hunger, p = 0.73; fullness, p = 0.60; desire to eat, p = 0.80; preoccupation, p = 0.15. Additionally, it showed an increase in the overall energy intake, SMD = 0.46, 95% CI (0.29, 0.63), p < 0.001, in protein intake, SMD = 0.59, 95% CI (0.16, 1.02), p = 0.007, and in fat intake, MD = 3.47, 95% CI (1.98, 4.97), p < 0.001, while no positive effect was found on carbohydrates intake, p = 0.06. Significance differences were also found in the body weight, SMD = 0.53, 95% CI (0.41, 0.65), p < 0.001, and body mass index (BMI), MD = 0.53, 95% CI (0.12, 0.95), p = 0.01. Moreover, subgroup analyses were conducted according to the nutrient density with no positive results showed except for the low-density ONS on overall energy intake.

CONCLUSIONS

The results of the present study indicated that ONS had beneficial effects on overall appetite, energy intake, body weight and BMI.

Effects of oral nutrition supplements in persons with dementia: A systematic review

OBJECTIVE

Persons with dementia are at risk of malnutrition, evidenced by low dietary intake, which has consequences for nutritional status, activity of daily living and disease progression. The effects of oral nutrition supplements (ONS) on nutritional intake, nutritional status, and cognitive and physical outcomes in older persons with dementia were evaluated.

METHODS

PubMed, Medline, Embase, CINAHL and the Cochrane Central Register of Controlled Trials were searched in December 2017, and this was repeated in May 2019. The Preferred Reporting Items for Systematic Reviews and Analysis (PRISMA) checklist was used. Papers were considered if they presented experimental clinical trials using oral nutritional supplements to persons diagnosed with dementia, including Alzheimer's disease and mild cognitive impairment, and conducted in hospitals, nursing homes or homes.

RESULTS

We included ten articles reporting nine clinical trials. A total of 407 persons with dementia were included, of whom 228 used ONS for 7 to 180 days. Nutritional intake improved by 201 to 600 kcal/day. Energy intake from ordinary foods was not affected, thus ONS improved the persons daily intake of energy and protein. Body weight, muscle mass, and nutritional biomarkers in blood improved in the intervention groups compared with the control groups. No effects on cognition or physical outcomes were observed.

CONCLUSION

ONS increases the intake of energy and protein and improves nutritional status in persons with dementia; however, RCTs with longer intervention periods are needed to investigate the impact on cognitive and functional outcomes.

Impact of specialized oral nutritional supplement on clinical, nutritional, and functional outcomes: A randomized, placebo-controlled trial in community-dwelling older adults at risk of malnutrition

BACKGROUND & AIMS

The world's over-65 population is expanding rapidly, and the risk of malnutrition is prevalent in this population. Meeting nutritional needs is a recognized strategy to reduce and address multiple debilitating adverse health outcomes associated with malnutrition. The objective of this randomized, controlled trial was to determine the effects of oral nutritional supplement (ONS) containing beta-hydroxy-beta-methylbutyrate (HMB), along with dietary counseling, on health outcomes in community-dwelling older adults at risk of malnutrition.

METHODS

Strengthening Health In ELDerly through nutrition (SHIELD) studied adults aged ≥ 65 years in Singapore who were recruited between August 2017 and March 2019. Participants were community ambulant and classified as medium or high risk for malnutrition using Malnutrition Universal Screening Tool (MUST). Participants (n = 811) were randomly assigned to one of two study treatments for 180 days: (i) two servings/day of ONS containing HMB with dietary counseling (n = 405) or (ii) two servings/day of placebo supplement with dietary counseling (n = 406). The primary composite outcome was 'survival without hospital (re)admission and with at least 5% weight gain to day 180'. Dietary intakes, nutritional and functional outcomes were measured at baseline, 30, 90, and 180 days.

RESULTS

A higher proportion in intervention group met the 180-day primary composite outcome compared to placebo (33.4% vs. 8.7%, P < 0.001), largely driven by body weight component (36.2% vs. 9.4%, P < 0.001). Survival and hospital (re)admission rate were not significantly different between the groups. Weight, BMI, and mid upper arm circumference were significantly greater in the intervention group compared to placebo during the study (all P < 0.001), and at days 30, 90, and 180 (all P < 0.05). The odds of having better nutritional status during the study were also significantly higher in the intervention group compared to placebo, as measured using MUST risk (OR = 2.68, P < 0.001) and vitamin D status (OR = 4.23, P < 0.001). Intervention group had significantly higher energy, protein, fat, and carbohydrate intakes than the placebo group (all P ≤ 0.017). Leg strength at day 90 was significantly greater for the intervention group than for the placebo group (LSM ± SE: 12.85 ± 0.22 vs. 12.17 ± 0.22; P = 0.030). Handgrip strength for females was significantly higher at day 180 for the intervention group compared to placebo (LSM ± SE: 14.18 ± 0.17 vs. 13.70 ± 0.17; P = 0.048). Within the low appendicular skeletal muscle mass index (ASMI) subgroup, the intervention group had significantly greater calf circumference at days 90 and 180 compared to placebo (both P ≤ 0.0289).

CONCLUSIONS

For community-dwelling older adults at risk of malnutrition, daily consumption of specialized ONS containing HMB and vitamin D for six months, along with dietary counseling, significantly improved nutritional and functional outcomes compared to placebo supplement with dietary counseling.

CLINICAL TRIAL REGISTRATION

www.ClinicalTrials.govNCT03245047.

High Serum Aspartate Aminotransferase, Underweight, and Weight Loss in Older People: Results of the KITCHEN-4

Background: Reduced muscle mass is frequently observed in older people and can lead to being underweight and/or weight loss (WL), but prediction and screening systems utilizing hematological biochemical parameters are limited. High serum aspartatSe aminotransferase in conjunction with normal serum alanine aminotransferase (HASNAL) can reflect systemic muscle damage. HASNAL and the incidence of being underweight concomitant with WL (UWWL) were investigated in the present 6-year community-based cohort study. Methods: Clinical parameters, lifestyle, the incidence of being underweight, ≥ 5% WL, and UWWL were investigated in 238,536 Japanese people aged 40-68 years who had normal serum alanine aminotransferase. HASNAL was defined as serum aspartate aminotransferase ≥ 30 U/L and serum alanine aminotransferase < 30 U/L. The subjects were divided into a younger group (< 55 years) and an older group (≥ 55 years). Results: After 6 years, overall body weight had increased by 0.4% in the younger group and decreased by 0.4% in the older group. In logistic regression analysis, in the younger group ≥ 5% WL was significantly associated with baseline HASNAL compared to baseline low serum aspartate aminotransferase (< 20 U/L). In the older group, baseline HASNAL was significantly associated with being underweight, ≥ 5% WL, and UWWL, even after adjustment for potential confounders, and UWWL was inversely associated with regular exercise and daily alcohol consumption-both of which modified the aforementioned associations. Conclusions: Older subjects with HASNAL were at an increased risk of UWWL, possibly via skeletal muscle damage, which may be affected by common lifestyles.

Using MRI to measure in vivo free radical production and perfusion dynamics in a mouse model of elevated oxidative stress and neurogenic atrophy

Mitochondrial dysfunction, reactive oxygen species (ROS) and oxidative damage have been implicated to play a causative role in age-related skeletal muscle atrophy and weakness (i.e. sarcopenia). Mice lacking the superoxide scavenger CuZnSOD (Sod1-/-) exhibit high levels of oxygen-derived radicals and oxidative damage, associated with neuronal and muscular phenotypes consistent with sarcopenia. We used magnetic resonance imaging (MRI) technology combined with immunospin-trapping (IST) to measure in vivo free radical levels in skeletal muscle from wildtype, Sod1-/- and SynTgSod1-/- mice, a mouse model generated using targeted expression of the human Sod1 transgene specifically in neuronal tissues to determine the impact of motor neuron degeneration in muscle atrophy. By combining the spin trap DMPO (5,5-dimethyl-1-pyrroline N-oxide) and molecular MRI (mMRI), we monitored the level of free radicals in mouse hindlimb muscle. The level of membrane-bound macromolecular radicals in the quadriceps muscle was elevated by ~3-fold in Sod1-/- mice, but normalized to wildtype levels in SynTgSod1-/- rescue mice. Skeletal muscle mass was reduced by ~25-30% in Sod1-/- mice, but fully reversed in muscle from SynTgSod1-/- mice. Using perfusion MRI we also measured the dynamics of blood flow within mouse hindlimb. Relative muscle blood flow in Sod1-/- is decreased to ~50% of wildtype and remained low in the SynTgSod1-/- mice. Our findings are significant in that we have shown for the first time that in vivo free radical production in skeletal muscle is directly correlated to muscle atrophy in an experimental model of oxidative stress. Neuron-specific expression of CuZnSOD reverses the in vivo free radical production in skeletal muscle in the Sod1-/- mouse model and prevents muscle atrophy. These results further support the feasibility of using in vivo assessments of redox status in the progression of a pathological process such as sarcopenia. This approach can also be valuable for evaluating responses to pharmacologic interventions.

Unintentional Weight Loss in Older Adults: A Geriatric Interprofessional Simulation Case Series for Health Care Providers

Introduction

Interprofessional teams can provide better care and management of complex geriatric patients. Unintentional weight loss in older patients can lead to significant morbidity and mortality and functional decline. This simulation curriculum focuses on teaching learners from all health care professions how to use the Carolina Geriatrics Workforce Enhancement Program unintentional weight loss tool and flowchart (T&F) to identify, diagnose, and create a plan of care for weight loss in geriatric patients.

Methods

A presentation on use of the T&F and two standardized patient cases utilizing the T&F in an interprofessional team are included. Case 1 presents a 71-year-old male with dementia who has lost 20 pounds, with weight loss secondary to cognitive impairment, denture problems, oral candidiasis, and polypharmacy. Case 2 presents a 67-year-old female with a history of depression and breast cancer who has lost 15 pounds, likely related to alcohol dependence, social isolation, oral cancer, and food insecurity. Pre- and posttests measure knowledge gained through the course.

Results

Overall knowledge of unintentional weight loss improved in the 14 learners who participated in two pilot sessions. Test scores improved an average of 1.2 points from pre- to posttest. Participants felt that interprofessional teams increased the quality of care provided to patients and job satisfaction.

Discussion

This tool can be utilized by practitioners from multiple disciplines. By completing the curriculum, learners gain knowledge of how to identify geriatric patients with significant weight loss, determine next steps in diagnosis and workup, and work in an interprofessional group.

Nutrition and dementia care: developing an evidence-based model for nutritional care in nursing homes

Background

There is a growing volume of research to offer improvements in nutritional care for people with dementia living in nursing homes. Whilst a number of interventions have been identified to support food and drink intake, there has been no systematic research to understand the factors for improving nutritional care from the perspectives of all those delivering care in nursing homes. The aim of this study was to develop a research informed model for understanding the complex nutritional problems associated with eating and drinking for people with dementia.

Methods

We conducted nine focus groups and five semi-structured interviews with those involved or who have a level of responsibility for providing food and drink and nutritional care in nursing homes (nurses, care workers, catering assistants, dietitians, speech and language therapists) and family carers. The resulting conceptual model was developed by eliciting care-related processes, thus supporting credibility from the perspective of the end-users.

Results

The seven identified domain areas were person-centred nutritional care (the overarching theme); availability of food and drink; tools, resources and environment; relationship to others when eating and drinking; participation in activities; consistency of care and provision of information.

Conclusions

This collaboratively developed, person-centred model can support the design of new education and training tools and be readily translated into existing programmes. Further research is needed to evaluate whether these evidence-informed approaches have been implemented successfully and adopted into practice and policy contexts and can demonstrate effectiveness for people living with dementia.

The Effects of Weight and Waist Change on the Risk of Long-Term Mortality in Older Adults- The Bambuí (Brazil) Cohort Study of Aging

OBJECTIVE

We aimed to investigate the risk of long-term mortality associated with weight and waist circumference (WC) change among older adults, particularly the overweight and obese ones.

DESIGN

Cohort Study.

SETTING

The Bambuí (Brazil) Cohort Study of Aging.

PARTICIPANTS

Community-dwelling elderly (n=1138).

MEASUREMENTS

Weight and WC were reassessed three years after baseline. Mortality risk associated with a 5% weight/WC loss and gain was compared to that of weight/WC stability by Cox models adjusted for clinical, behavioral and social known risk factors for death (age, gender, BMI, smoking, diabetes, total cholesterol, hypertension, Chagas disease, major electrocardiographic changes, physical activity, B-type natriuretic peptide, C-reactive protein, creatinine, education and household income).

RESULTS

Female sex was predominant (718; 63.1%). Mean age was 68 (6.7) years. Weight stability (696; 61.1%) was more common than weight loss (251; 22.1%) or gain (191; 16.8%). WC remained stable in 422 (37.3%), decreased in 418 (37.0%) and increased in 291 (25.7%) participants. There were 334 (29.3%) deaths over a median follow-up time of 8.0 (6.4-8.0) years from weight/WC reassessment. Weight loss (HR 1.69; 95% CI 1.30-2.21) and gain (HR 1.37; 95% CI 1.01-1.85) were associated with increased mortality, except in those who were physically active in which weight gain was associated with decreased mortality. Results were similar for participants who were overweight/obese or with abdominal obesity at baseline (HR 1.41; 95%CI 1.02-1.97 and HR 2.01; 95%CI 1.29-3.12, for weight loss and gain, respectively). WC change was not significantly associated with mortality.

CONCLUSION

Although weight loss has been recommended for adults with excessive weight regardless of age, weight change might be detrimental in older adults. Rather than weight loss, clinical interventions should target healthy lifestyle behaviors that contribute to weight stability, particularly physical activity in overweight and obese older adults.

Weight Gain in Survivors Living in Temporary Housing in the Tsunami-Stricken Area during the Recovery Phase following the Great East Japan Earthquake and Tsunami

Introduction

Survivors who lost their homes in the Great East Japan Earthquake and Tsunami were forced to live in difficult conditions in temporary housing several months after the disaster. Body weights of survivors living in temporary housing for a long period might increase due to changes in their life style and psychosocial state during the medium-term and long-term recovery phases. The aim of this study was to determine whether there were differences between body weight changes of people living in temporary housing and those not living in temporary housing in a tsunami-stricken area during the medium-term and long-term recovery phases.

Materials and methods

Health check-ups were performed about 7 months after the disaster (in 2011) and about 18 months after the disaster (in 2012) for people living in a tsunami-stricken area (n = 6,601, mean age = 62.3 y). We compared the changes in body weight in people living in temporary housing (TH group, n = 2,002) and those not living in temporary housing (NTH group, n = 4,599) using a multiple linear regression model.

Results

While there was no significant difference between body weights in the TH and NTH groups in the 2011 survey, there was a significant difference between the mean changes in body weight in both sexes. We found that the changes in body weight were significantly greater in the TH group than in the NTH group in both sexes. The partial regression coefficients of mean change in body weight were +0.52 kg (P-value < 0.001) in males in the TH group and +0.56 kg (P-value < 0.001) in females in the TH group (reference: NTH group).

Conclusion

Analysis after adjustment for life style, psychosocial factors and cardiovascular risk factors found that people living in temporary housing in the tsunami- stricken area had a significant increase in body weight.

Evaluation of a Continuing Educational Intervention for Primary Health Care Professionals about Nutritional Care of Patients at Home

OBJECTIVE

Evaluate the effectiveness of a continuing educational intervention on primary health care professionals' familiarity with information important to nutritional care in a palliative phase, their collaboration with other caregivers, and their level of knowledge about important aspects of nutritional care.

DESIGN

Observational cohort study.

SETTING

10 primary health care centers in Stockholm County, Sweden.

PARTICIPANTS

140 district nurses/registered nurses and general practitioners/physicians working with home care.

INTERVENTION

87 professionals participated in the intervention group (IG) and 53 in the control group (CG). The intervention consisted of a web-based program offering factual knowledge; a practical exercise linking existing and new knowledge, abilities, and skills; and a case seminar facilitating reflection.

MEASUREMENTS

The intervention's effects were measured by a computer-based study-specific questionnaire before and after the intervention, which took approximately 1 month. The CG completed the questionnaire twice (1 month between response occasions). The intervention effects, odds ratios, were estimated by an ordinal logistic regression.

RESULTS

In the intra-group analyses, statistically significant changes occurred in the IG's responses to 28 of 32 items and the CG's responses to 4 of 32 items. In the inter-group analyses, statistically significant effects occurred in 20 of 32 statements: all 14 statements that assessed familiarity with important concepts and all 4 statements about collaboration with other caregivers but only 2 of the 14 statements concerning level of knowledge. The intervention effect varied between 2.5 and 12.0.

CONCLUSION

The intervention was effective in increasing familiarity with information important to nutritional care in a palliative phase and collaboration with other caregivers, both of which may create prerequisites for better nutritional care. However, the intervention needs to be revised to better increase the professionals' level of knowledge about important aspects of nutritional care.

Ageing Is Associated with Decreases in Appetite and Energy Intake--A Meta-Analysis in Healthy Adults

It is not well recognized that in the elderly weight loss is more common than weight gain. The aim of this analysis was to determine the effect of ageing on appetite (hunger/fullness) and energy intake, after overnight fasting and in a postprandial state, by meta-analyses of trials that included at least two age groups (>18 years). We hypothesized that appetite and energy intake would be less in healthy older compared with younger adults. Following a PubMed-database systematic search up to 30 June 2015, 59 studies were included in the random-effects-model meta-analyses. Energy intake was 16%-20% lower in older (n = 3574/~70 years/~71 kg/~25 kg/m²) than younger (n = 4111/~26 years/~69 kg/~23 kg/m²) adults (standardized mean difference: -0.77 (95% confidence interval -0.90 to -0.64)). Hunger was 25% (after overnight fasting; weighted mean difference (WMD): -17 (-22 to -13) mm) to 39% (in a postprandial state; WMD: -14 (-19 to -9) mm) lower, and fullness 37% (after overnight fasting; WMD: 6 mm (95% CI: 1 to 11 mm)) greater in older than younger adults. In conclusion, appetite and energy intake are less in healthy older than younger adults, suggesting that ageing per se affects food intake.

ESPEN guidelines on nutrition in dementia

BACKGROUND

Older people suffering from dementia are at increased risk of malnutrition due to various nutritional problems, and the question arises which interventions are effective in maintaining adequate nutritional intake and nutritional status in the course of the disease. It is of further interest whether supplementation of energy and/or specific nutrients is able to prevent further cognitive decline or even correct cognitive impairment, and in which situations artificial nutritional support is justified.

OBJECTIVE

It is the purpose of these guidelines to cover these issues with evidence-based recommendations.

METHODS

The guidelines were developed by an international multidisciplinary working group in accordance with officially accepted standards. The GRADE system was used for assigning strength of evidence. Recommendations were discussed, submitted to Delphi rounds and accepted in an online survey among ESPEN members.

RESULTS

26 recommendations for nutritional care of older persons with dementia are given. In every person with dementia, screening for malnutrition and close monitoring of body weight are recommended. In all stages of the disease, oral nutrition may be supported by provision of adequate, attractive food in a pleasant environment, by adequate nursing support and elimination of potential causes of malnutrition. Supplementation of single nutrients is not recommended unless there is a sign of deficiency. Oral nutritional supplements are recommended to improve nutritional status but not to correct cognitive impairment or prevent cognitive decline. Artificial nutrition is suggested in patients with mild or moderate dementia for a limited period of time to overcome a crisis situation with markedly insufficient oral intake, if low nutritional intake is predominantly caused by a potentially reversible condition, but not in patients with severe dementia or in the terminal phase of life.

CONCLUSION

Nutritional care and support should be an integral part of dementia management. In all stages of the disease, the decision for or against nutritional interventions should be made on an individual basis after carefully balancing expected benefit and potential burden, taking the (assumed) patient will and general prognosis into account.

Changes in the Relationships Between Body Mass Index and Health Outcomes Across Middle Age and Older Adulthood

OBJECTIVE

To examine patterns of the incidence of diabetes, hypertension, and mortality by single units of body mass index (BMI) and 5-year age groups using longitudinal data from middle-aged and older women.

PATIENTS AND METHODS

Middle-aged (born between 1946 and 1951; N = 13,715) and older (born between 1921 and 1926; N = 12,432) participants in the Australian Longitudinal Study on Women's Health completed surveys in 1996 and at approximately 3-year intervals thereafter until 2011. Proportions of women with diabetes, hypertension, and mortality over 3-year intervals were estimated for each unit of BMI and 5-year age group (45 to < 50, 50 to < 55, 55 to < 60, 70 to < 75, 75 to < 80, and 80 to < 85 years) using generalized additive modeling with adjustment for time-varying covariates.

RESULTS

Three-year incidence of diabetes (1.2%-3.6%), hypertension (5.2%-17.8%), and death (0.4%-9.5%) increased with age. For both diabetes and hypertension, the associations with BMI were curvilinear in middle-aged women and became almost linear in older women. With increasing age, the slope became steeper, and the increase started at lower BMI values. For hypertension, there was a marked increase in intercept from 75 years onward. In contrast, mortality risks were highest for low BMI (≤ 20) in all age groups. A clear U-shaped curve was observed only in the oldest age group.

CONCLUSION

The shapes of the relationships between BMI and incidence of diabetes, hypertension, and mortality change with age, suggesting that weight management interventions should be tailored for different age groups.

Association between change in body weight after midlife and risk of hip fracture-the Singapore Chinese Health Study

The relationship between change in body weight and risk of fractures is inconsistent in epidemiologic studies. In this cohort of middle-aged to elderly Chinese in Singapore, compared to stable weight, weight loss ≥10 % over an average of 6 years is associated with nearly 40 % increase in risk of hip fracture.

INTRODUCTION

Findings on the relationship between change in body weight and risk of hip fracture are inconsistent. In this study, we examined this association among middle-aged and elderly Chinese in Singapore.

METHODS

We used prospective data from the Singapore Chinese Health Study, a population-based cohort of 63,257 Chinese men and women aged 45-74 years at recruitment in 1993-1998. Body weight and height were self-reported at recruitment and reassessed during follow-up interview in 1999-2004. Percent in weight change was computed based on the weight difference over an average of 6 years, and categorized as loss ≥10 %, loss 5 to <10 %, loss or gain <5 % (stable weight), gain 5 to <10 %, and gain ≥10 %. Multivariable Cox proportional hazards regression model was applied with adjustment for risk factors for hip fracture and body mass index (BMI) reported at follow-up interview.

RESULTS

About 12 % experienced weight loss ≥10 %, and another 12 % had weight gain ≥10 %. After a mean follow-up of 9.0 years, we identified 775 incident hip fractures among 42,149 eligible participants. Compared to stable weight, weight loss ≥10 % was associated with 39 % increased risk (hazard ratio 1.39; 95 % confidence interval 1.14, 1.69). Such elevated risk with weight loss ≥10 % was observed in both genders and age groups at follow-up (≤65 and >65 years) and in those with baseline BMI ≥20 kg/m(2).There was no significant association with weight gain.

CONCLUSIONS

Our findings provide evidence that substantial weight loss is an important risk factor for osteoporotic hip fractures among the middle-aged to elderly Chinese.

Inflammation and Nutritional Science for Programs/Policies and Interpretation of Research Evidence (INSPIRE)

An increasing recognition has emerged of the complexities of the global health agenda—specifically, the collision of infections and noncommunicable diseases and the dual burden of over- and undernutrition. Of particular practical concern are both 1) the need for a better understanding of the bidirectional relations between nutritional status and the development and function of the immune and inflammatory response and 2) the specific impact of the inflammatory response on the selection, use, and interpretation of nutrient biomarkers. The goal of the Inflammation and Nutritional Science for Programs/Policies and Interpretation of Research Evidence (INSPIRE) is to provide guidance for those users represented by the global food and nutrition enterprise. These include researchers (bench and clinical), clinicians providing care/treatment, those developing and evaluating programs/interventions at scale, and those responsible for generating evidence-based policy. The INSPIRE process included convening 5 thematic working groups (WGs) charged with developing summary reports around the following issues: 1) basic overview of the interactions between nutrition, immune function, and the inflammatory response; 2) examination of the evidence regarding the impact of nutrition on immune function and inflammation; 3) evaluation of the impact of inflammation and clinical conditions (acute and chronic) on nutrition; 4) examination of existing and potential new approaches to account for the impact of inflammation on biomarker interpretation and use; and 5) the presentation of new approaches to the study of these relations. Each WG was tasked with synthesizing a summary of the evidence for each of these topics and delineating the remaining gaps in our knowledge. This review consists of a summary of the INSPIRE workshop and the WG deliberations.

The association between depression and widowhood and nutritional status in older adults

This study aimed to investigate the association of depression and widowhood on the nutritional status of older adults. A cross-sectional study of community-dwelling older adults in the rural United States was conducted. Dietary intake was measured via questionnaires. Depression status was classified by asking participants if they have ever been diagnosed with the condition, or by review of medical records. The final sample consisted of 1065 participants with 141 (13.2%) depressed, 384 (36.1%) widowed, and 67 (6.3%) both depressed and widowed. Mean caloric intake for total study population was low; widows and widowers had the lowest energy consumption among all groups. Greater intake of several nutrients was observed in depressed and/or widowed subjects. Nutritional services, such as congregate and home delivered meal programs, were not identified as significant contributors to the nutritional intake in older adults who were depressed, widowed, or both. Health care professionals may contribute to meal-based nutrition programs by offering their assistance in aspects of nutritional education and counseling for the promotion of healthy aging.

The malnutrition screening tool versus objective measures to detect malnutrition in hip fracture

BACKGROUND

The Malnutrition Screening Tool (MST) is the most commonly used screening tool in Australia. Poor screening tool sensitivity may lead to an under-diagnosis of malnutrition, with potential patient and economic ramifications. The present study aimed to determine whether the MST or anthropometric parameters adequately detect malnutrition in patients who were admitted to a hip fracture unit.

METHODS

Data were analysed for a prospective convenience sample (n = 100). MST screening was independently undertaken by nursing staff and a nutrition assistant. Mid upper arm circumference (MUAC) was measured by a trained nutrition assistant. Nutritional risk [MST score ≥ 2, body mass index (BMI) < 22 kg m(-2) , or MUAC < 25 cm] was compared with malnutrition diagnosed by accredited practicing dietitians using International Classification of Diseases version 10-Australian Modification (ICD10-AM) coding criteria.

RESULTS

Malnutrition prevalence was 37.5% using ICD10-AM criteria. Delirium, dementia or preadmission cognitive impairment was present in 65% of patients. The BMI as a nutrition risk screen was the most valid predictor of malnutrition (sensitivity 75%; specificity 93%; positive predictive value 73%; negative predictive value 84%). Nursing MST screening was the least valid (sensitivity 73%; specificity 55%; positive predictive value 50%; negative predictive value 77%). There was only fair agreement between nursing and nutrition assistant screening using the MST (κ = 0.28).

CONCLUSIONS

In this population with a high prevalence of delirium and dementia, further investigation is warranted into the performance of nutrition screening tools and anthropometric parameters such as BMI. All tools failed to predict a considerable number of patients with malnutrition. This may result in the under-diagnosis and treatment of malnutrition, leading to case-mix funding losses.

Barriers to nutritional intake in patients with acute hip fracture: time to treat malnutrition as a disease and food as a medicine?

Inadequate energy and protein intake leads to malnutrition; a clinical disease not without consequence post acute hip fracture. Data detailing malnutrition prevalence, incidence, and intake adequacy varies widely in this patient population. The limited success of reported interventional strategies may result from poorly defined diagnostic criteria, failure to address root causes of inadequate intake, or errors associated with selection bias. This pragmatic study used a sequential, explanatory mixed methods design to identify malnutrition aetiology, prevalence, incidence, intake adequacy, and barriers to intake in a representative sample of 44 acute hip fracture patients (73% female; mean age, 81.7 ± 10.8 years). On admission, malnutrition prevalence was 52.2%. Energy and protein requirements were only met twice in 58 weighed 24 h food records. Mean daily patient energy intake was 2957 kJ (50.9 ± 36.1 kJ·kg–1) and mean protein intake was 22.8 g (0.6 ± 0.46 g·kg–1). This contributed to a further in-patient malnutrition incidence of 11%. Barriers to intake included patient perceptions that malnutrition and (or) inadequate intake were not a problem, as well as patient and clinician perceptions that treatment for malnutrition was not a priority. Malnutrition needs to be treated as a disease not without consequence, and food should be considered as a medicine after acute hip fracture.

The efficacy and safety of newer anticonvulsants in patients with dementia

Anticonvulsants are a class of medications that have received considerable interest as possible treatments in patients with behavioural disturbances in dementia. The role of these medications for such a use remains controversial. The current paper reviews the published evidence surrounding the safety and efficacy (i.e. as a behavioural and cognitive treatment) of newer anticonvulsants in patients with dementia. A MEDLINE, International Pharmaceutical Abstracts, PsycINFO and clinicaltrials.gov search through to December 2011 was conducted for anticonvulsants that have received regulatory approval since 1996. Studies reporting behavioural or cognitive outcomes in patients with dementia were included. Nine trials involving only four medications met selection criteria and were included: levetiracetam (n = 4), oxcarbazepine (n = 1), topiramate (n = 2) and zonisamide (n = 2). Levetiracetam may have a role in the treatment of behavioural symptoms in dementia but study limitations substantially hinder the strength of such a recommendation. Oxcarbazepine and topiramate, based on limited data, do not appear to be effective treatments of behavioural symptoms in dementia. A lack of trials do not allow for conclusions to be made regarding zonisamide. From a cognitive standpoint, levetiracetam was the anticonvulsant most examined in patients with dementia, it appears to have less deleterious effects than some anticonvulsants. Limited data are available on the safety of these medications in elderly patients; however, studies completed thus far have demonstrated some adverse events that are more common or problematic with the use of these drugs in this patient population (i.e. somnolence, dizziness, hyponatraemia, weight loss).

Anorexia, undernutrition, weight loss, sarcopenia, and cachexia of aging

During the period between 2000 and 2030, the number of persons older than 65 years is projected to grow from 550 to 937 million worldwide. Globally, this growth represents an increase from 6.9 to 12 %. Studies have found that 74.6 % of women and 67.4 % of men aged 65 years or older suffer from many clinical and subclinical syndromes and problems, including anorexia, undernutrition, weight loss, sarcopenia, and cachexia, which are often overlooked or managed inadequately. These issues are very common in the elder. The key clinical question is whether these changes in the elder are distinct entities or an interdependent continuum. In this article, we reviewed these issues of related basic, clinical knowledge. The purpose of this review is to enhance the recognition of anorexia, undernutrition, weight loss, sarcopenia, and cachexia.