Frailty but not low muscle quality nor sarcopenia is independently associated with mortality among previously hospitalized older adults: A prospective study

New insights on the use of mini nutritional assessment: Impact of alternative calf circumference cutoffs

BACKGROUND & AIMS

The Mini Nutritional Assessment - Short Form (MNASF) is an easy, quick, and validated tool for screening and diagnosing malnutrition among older individuals. Despite its clinical relevance, using body mass index (BMI) and a universal calf circumference (CC) cutoff might pose limitations. Therefore, our study aimed to investigate the potential of using sex-specific and BMI-adjusted CC cutoff values within the MNA-SF to classify nutritional status and assess its prognostic significance.

METHODS

Older patients hospitalized with varied diagnoses were included. BMI and CC measurements were conducted by registered dietitians. MNA-SF, which considers either BMI or CC, was utilized to classify nutritional status. Patients scoring 0-7 points were classified as malnourished. Four different approaches for MNA-SF were considered: Traditional: i) using BMI, ii) the alternative/surrogate using a non-sex specific CC < 31 cm; Newly adapted approaches: iii) using sex-specific CC cutoff values ≤ 34 cm for men and ≤33 cm for women, without BMI adjustment factors; iv) using sex-specific BMI-adjusted CC cutoff values ≤ 34 cm for men and ≤33 cm for women. BMI adjustment factors were: -3 cm of CC for BMI 25-29.9 kg/m2, -7 cm for BMI 30-39.9 kg/m2, and -12cm for BMI ≥40 kg/m2. The prevalence of nutritional categories across different MNA-SF approaches was estimated. Cox regression analysis and Receiver Operating Characteristic (ROC) curve analysis were performed to evaluate and compare their predictive significance for overall survival.

RESULTS

This study included 242 patients (58.8 % men, median age of 68 years, interquartile range: 64 to 74). Cancer was the most frequent reason for hospitalization (36.6 %). Scores in MNA-SF were significantly lower when using sex-specific unadjusted & BMI-adjusted CC. The frequency of malnutrition ranged from 21.9 % (MNA-SF using BMI) to 41.7 % (MNA-SFadj.CC≤34/33). The incidence of mortality was significantly higher among malnourished patients classified using the sex-specific unadjusted (58.2 %) and BMI-adjusted CC approaches (63.3 %), compared to 38.2 % and 40 % when using BMI and the non-sex-specific CC < 31 cm, respectively. All approaches had similar survival prediction (area under the ROC curves 65-67 %), and were independently associated with mortality. Using BMI-adjusted CC with sex-specific cutoff values (≤33/34) within the MNA-SF significantly improved survival prediction sensitivity (63.6 % versus 38.2 % with BMI and 40 % with CC < 31). Malnourished patients classified by MNA-SF using sex-specific and BMI-adjusted CC cutoff values ≤ 33/34 exhibited the highest risk of mortality based on hazard ratios, compared to those classified by MNA-SF using BMI or CC < 31.

CONCLUSION

Our study demonstrates that using sex-specific, unadjusted, and BMI-adjusted CC cutoffs values within MNA-SF classified a greater number of patients at risk of or already experiencing malnutrition, as well as a higher incidence of mortality among malnourished individuals. These methods showed greater sensitivity and achieved a more balanced trade-off between sensitivity and specificity compared to traditional approaches (using BMI or CC < 31). Pending future validation, these approaches have potential to offer a more reliable alternative for assessing nutritional status and improving prognostication in this population.

Predictors of Coronavirus disease 2019 in older patients: Exploring body composition and muscle strength

BACKGROUND & AIMS

Evidence underscores the impact of the inflammatory response caused by Coronavirus Disease 2019 (COVID-19) on nutritional status. However, there remains a notable gap in research investigating preexisting alterations in body composition and muscle function as potential risk factors for COVID-19 development. Thus, this study aimed to examine the relationship between abnormalities in body composition and muscle function and the incidence of COVID-19 among older patients.

METHODS

This was a secondary analysis of a cohort study involving older patients. Body composition assessment was estimated using bioelectrical impedance analysis (BIA), and included measurements of fat mass (%), total body water (TBW, %), and appendicular lean soft tissues (ALST/ALSTI: ALST normalized to height2). Muscle function was evaluated through the handgrip strength (HGS) test. Data on COVID-19 status were collected through telephone interviews with patients or their immediate relatives, after 12-24 months after hospital discharge.

RESULTS

This analysis included 120 subjects (59.1 % males, median age: 69 years old). Higher values of fat mass (%) independently predicted COVID-19 infection (HR adjusted 1.11, 95 % CI 1.04 to 1.18, P = 0.003). We also observed a trend indicating that higher TBW% was associated with a potential lower hazard for COVID-19 infection (HR adjusted 0.94, 95 % CI 0.89 to 1.01, P = 0.08). ALST, ALSTI, and HGS were not associated with a higher hazard for COVID-19 infection (all P-values >.05).

CONCLUSION

This study demonstrates the relevance of addressing excess body fat in older patients to potentially mitigate the risk of COVID-19 infection.

Prognostic significance of novel muscle quality index utilization in hospitalized adults with cancer: A secondary analysis

BACKGROUND

This study aimed to investigate and propose novel approaches to calculate muscle quality index (MQI) using muscle mass derived from single-frequency bioelectrical impedance analysis (SF-BIA) and calf circumference in both unadjusted and body mass index (BMI)-adjusted forms. In addition, we examined their prognostic significance in patients with cancer.

METHODS

A secondary analysis was conducted on a prospective cohort study of patients with cancer. Handgrip strength was measured. SF-BIA was conducted to estimate appendicular lean soft tissue (ALST, in kilograms). MQI was calculated using three approaches: (1) the ratio of handgrip strength to ALST (MQISF-BIA), (2) the ratio of handgrip strength to calf circumference (MQIcalf circumference), and (3) the ratio of handgrip strength to BMI-adjusted calf circumference (MQIadj. calf circumference). Maximally selected log-rank was calculated to estimate their cutoff values to predict survival.

RESULTS

Two hundred eighty-four patients were included (51.1% men; median age, 61 years). Solid tumors were the most frequent (89.8%). All approaches to MQI (MQISF-BIA, MQIcalf circumference, and MQIadj. calf circumference) were independent predictors of 6-month mortality. The found cutoffs were (1) MQISF-BIA (<1.52 for men, <0.63 for women), (2) MQIcalf circumference (<0.74 for men, <0.24 for women), and (3) MQIadj. calf circumference (<0.75 for men, <0.25 for women).

CONCLUSION

This study introduces MQISF-BIA, MQIcalf circumference, and MQIadj. calf circumference as future potential surrogate methods for computing MQI in clinical practice when other robust procedures are unavailable, pending further validation.

Phase angle as a marker of muscle quality: A systematic review and meta-analysis

BACKGROUND & AIMS

Phase angle (PhA) is a biomarker derived from raw bioelectrical impedance analysis (BIA) values: resistance (R) and reactance (Xc). PhA reflects cellular membrane integrity and, as a result, has been considered a marker of fluid distribution, making it a potential prognostic indicator. A growing body of research demonstrates independent associations between PhA and muscle strength, mass, and composition. In this context, PhA has the extra potential to serve as a marker of muscle quality. However, the evidence supporting its use for this purpose is not well established. This study aimed to investigate the relationship between PhA and markers of muscle quality.

METHODS

This systematic review and meta-analysis (Internal Prospective Register of Systematic Reviews - PROSPERO on a registration code: CRD42024507853) focused on observational studies assessing the relationship between PhA and markers of both concepts of muscle quality: the muscle quality index (MQI: strength by a unit of mass) and the muscle composition (i.e., skeletal muscle radiodensity [SMD], muscle echogenicity, muscle fat fraction, inter- and intramuscular adiposity). Risk of bias was assessed using the Newcastle-Ottawa Scale (NOS) and Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2), while the certainty of evidence was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. Meta-analyses with a random-effects model were conducted.

RESULTS

Seventeen studies were included in this systematic review, encompassing 2710 participants. Meta-analyses demonstrated that PhA had a moderate positive correlation coefficient with SMD (4 studies, 924 participants; r = 0.54, 95 % confidence interval (CI) 0.38 to 0.69, heterogeneity (I2) = 92 %) and good accuracy (85 %) for classifying low SMD (2 studies, 390 participants; Area Under the Curve - AUCpooled 0.85, 95 % CI 0.78 to 0.92, I2 = 0 %). PhA was inversely-moderately correlated with muscle echogenicity (8 studies, 1401 participants; r = - 0.42, 95 % CI - 0.57 to - 0.24, I2 = 82 %) and positively-weakly correlated with MQI (2 studies, 191 participants; r = 0.36, 95 % CI 0.21 to 0.49, I2 = 17 %). All studies had a higher risk of bias. The certainty of evidence ranged from low to very low.

CONCLUSION

Despite technical challenges, this study demonstrates the potential of PhA as a surrogate marker for muscle quality, particularly expressing muscle composition (SMD). Future studies should utilize BIA with standardized protocols to potentially establish specific cutoff values for PhA, thereby enhancing its diagnostic accuracy and clinical applicability. These studies could additionally explore the mechanisms underlying the associations between PhA and muscle quality aspects. In cases where technical factors are not easily controlled, the use of standardized PhA (SPhA), which converts PhA into Z-scores, could be beneficial. Although this warrants investigation, this approach (SPhA) has the potential to account for variables such as age, sex, device differences, and health status.

Association between prognostic nutritional index and mortality risk in patients with community-acquired pneumonia: a retrospective study

BACKGROUND

The prognostic nutritional index (PNI), reflecting the body's immune-nutritional status, has been established as a correlate of prognosis across various diseases. However, its significance in community-acquired pneumonia (CAP) remains unclear. This study investigated the relationship between PNI and clinical outcomes in CAP patients.

METHODS

In this retrospective cohort study, we aimed to evaluate the prognostic value of the PNI in adults with CAP admitted to the ICU. Participants were selected from the Medical Information Mart for Intensive Care IV (MIMIC-IV) database and categorized into quartiles (Q1-Q4) according to their PNI values. We employed Kaplan-Meier survival analysis, multivariate Cox regression, and restricted cubic spline (RCS) models to explore the association between PNI and the clinical outcomes of these CAP patients.

RESULTS

In this study, we included 1,608 patients with CAP. The observed 30-day and 90-day mortality rates stood at 30.85% and 39.99%, respectively. Patients with higher PNI levels exhibited a reduced risk of both 30-day and 90-day mortality. Following adjustment for confounders, PNI showed a significant negative association with 30-day mortality [HR, 0.93 (0.91-0.94), P < 0.001] and 90-day mortality [HR, 0.94 (0.92-0.95), P < 0.001]. RCS analysis revealed a consistent trend of declining all-cause mortality risk corresponding to increasing PNI values. PNI demonstrated predictive value for 30-day and 90-day mortality in CAP patients, with AUCs of 0.71 and 0.68, respectively. Combining PNI with CURB-65 enhanced the predictive value of CURB-65.

CONCLUSION

Our investigation identified a significant negative association between the PNI and the risk of mortality in patients with CAP. Additionally, the PNI demonstrated superior predictive value for mortality risk in CAP patients when compared to the CURB-65 scoring system.

Body mass index-adjusted calf circumference is associated with mortality in hospitalized older patients with excess weight

OBJECTIVES

Given the innovative nature of the method, our study aimed to assess the prognostic significance of body mass index (BMI)-adjusted calf circumference (CC) in older patients who are hospitalized.

METHODS

This was a unique analysis as part of other cohorts comprising general hospitalized patients aged 60 years or older of both sexes. Only patients with excess weight (BMI ≥ 25 kg/m2) were included. CC was adjusted by reducing 3, 7, or 12 cm for BMI (in kg/m2) within 25-29.9, 30-39.9, and ≥40 kg/m2, respectively. CC was considered low if ≤ 34 cm for males and ≤ 33 cm for females. Clinical outcomes included prolonged length of hospital stay (LOS) and mortality.

RESULTS

A total of 222 patients were included. After BMI adjustments, 72.1% of the patients were reclassified from a normal CC category to a low CC category. The frequency of low CC increased from 33.8% to 81.9% following BMI adjustments. Among those reclassified to the low CC, 11 died, compared to only 2 patients in the group that maintained a normal CC classification. BMI-adjusted CC was inversely associated with mortality (HR adjusted 0.84, 95% CI 0.73 to 0.95), but not with prolonged LOS.

CONCLUSIONS

Our novel study highlights the prognostic value of BMI-adjusted CC. As an anthropometric marker of muscle mass, it proved to be a predictor of mortality in older patients with high BMI. This adjustment is further important because it may help to better detect low muscle mass in these patients where such conditions might be masked.

Prognostic value of the geriatric nutritional risk index and other hematological markers on long-term survival in the geriatric population

OBJECTIVES

The prognostic value of hematological markers has not been extensively explored in the geriatric population, particularly in the presence of the frailty phenotype among hospitalized individuals. Therefore, our study aimed to assess the influence of the frailty phenotype in hospitalized geriatric individuals on hematological markers and their impact on short- and long-term outcomes.

METHODS

This is a secondary analysis of a prospective cohort study. This study involved hospitalized individuals who were followed during their hospitalization and for nearly 2 years after discharge. At baseline, Fried's frailty phenotype was assessed, as well as hematological markers, including neutrophil-lymphocyte ratio, monocyte-lymphocyte ratio, neutrophil-monocyte ratio, platelet-lymphocyte ratio, systemic inflammation index, prognostic nutritional index, geriatric nutritional risk index (GNRI), and C-reactive protein-albumin ratio. The phase angle derived from bioelectrical impedance analysis was likewise considered a prognostic biomarker. Our main outcomes were hospital length of stay and mortality during follow-up.

RESULTS

Frailty occurred in 43.2% of the population. Individuals with the frailty phenotype exhibited worse hematological markers and lower phase angle values. Low GNRI and elevated C-reactive protein-albumin ratio values were independently associated with mortality (hazard ratio = 6.88, 95% confidence interval 2.0-23.6; hazard ratio = 2.2, 95% confidence interval 1.1-4.4). Only higher values of the systemic inflammation index were independently associated with prolonged hospital stays.

CONCLUSION

Hematological markers may serve as a feasible tool for prognostic assessment. Individuals with the frailty phenotype and low GNRI represented a worst-case scenario. Geriatr Gerontol Int 2024; 24: 312-318.