Serum albumin and prealbumin as predictors of clinical outcomes of hospitalized elderly nursing home residents

U-shaped association between serum albumin and pediatric intensive care unit mortality in critically ill children

Introduction

The detailed association between albumin levels and mortality has not been studied in critically ill children. The aim of this study was to reveal an association between albumin levels in detail and mortality in critically ill children.

Materials and methods

We retrospectively collected data from children admitted to four pediatric intensive care units (PICUs) in China between January 2015 and October 2020. Restricted cubic spline curves based on logistic regression models were generated to evaluate the detailed associations between serum albumin levels and PICU mortality. Threshold effect analysis was performed using two piecewise regression models.

Results

The study included 9,123 children. The overall mortality was 5.3%. The detailed association between serum albumin levels and the risk of mortality followed a U-shape. The risk of mortality decreased with increasing serum albumin levels (OR = 0.919; 95% CI: 0.886, 0.954) in children with serum albumin levels < 43.2 g/L and increased with increasing serum albumin levels (OR = 1.174; 95% CI: 1.044, 1.316) in children with serum albumin levels ≥ 43.2 g/L.

Conclusion

There was a U-shaped association between serum albumin levels and mortality in critically ill children in the PICU.

Relationship of Nutritional Status, Inflammation, and Serum Albumin Levels During Acute Illness: A Prospective Study

BACKGROUND

Low serum albumin levels resulting from inflammation-induced capillary leakage or disease-related anorexia during acute illness are associated with poor outcomes. We investigated the relationship of nutritional status and inflammation with low serum albumin levels and 30-day mortality in a large cohort.

METHODS

We prospectively enrolled adult patients in the medical emergency department of a Swiss tertiary care center and investigated associations of C-reactive protein (CRP) and Nutritional Risk Screening 2002 as markers of inflammation and poor nutritional status, respectively, with low serum albumin levels and mortality using multivariate regression analyses.

RESULTS

Among the 2465 patients, 1019 (41%) had low serum albumin levels (<34 g/L), 619 (25.1%) had increased nutritional risk (Nutritional Risk Screening 2002 ≥3), and 1086 (44.1%) had CRP values >20 mg/L. Multivariate analyses adjusted for age, gender, diagnosis, and comorbidities revealed elevated CRP values (adjusted odds ratio [OR] 10.51, 95% confidence interval, 7.51-14.72, P <.001) and increased malnutrition risk (adjusted OR 2.87, 95% confidence interval, 1.98-4.15, P <.001) to be associated with low serum albumin levels, even adjusting for both parameters. Low serum albumin levels, elevated CRP values, and increased nutritional risk independently predicted 30-day mortality, with areas under the curve of 0.77, 0.70, and 0.75, respectively. Combination of these 3 parameters showed an area under the curve of 0.82 to predict mortality.

CONCLUSIONS

Elevated parameters of inflammation and high nutritional risk were independently associated with hypoalbuminemia. All 3 parameters independently predicted mortality. Combining them during initial evaluation of patients in emergency departments facilitates mortality risk stratification.

Which laboratory malnutrition markers best predict 1-year mortality in hospitalized older adults?

PURPOSE

To study which laboratory malnutrition markers best predict 1-year mortality in the general population of hospitalized older adults as well as among patients at risk for malnutrition.

METHODS

A historical prospective study. All older adults (age ≥ 65 years) hospitalized in one geriatric department during 9 months were included. Malnutrition Universal Screening Tool (MUST) was used to determine malnutrition risk. Laboratory malnutrition markers included albumin serum levels, transferrin serum levels, total cholesterol serum levels, vitamin D serum levels, and lymphocyte count. A receiver operating characteristic (ROC) curve analysis was used to study which markers best predict 1-year mortality.

RESULTS

Overall, 437 patients (63.2% women; mean age 84.7 years) were included. Overall, 126 (28.8%) patients died in the year following admission. ROC curve analysis showed that low albumin serum levels best predict 1-year mortality (AUC 0.721, p < 0.001), followed by low transferrin serum levels (AUC 0.661, p < 0.001) and low lymphocyte count (AUC 0.575, p = 0.016). Among 178 (40.7%) patients at risk for malnutrition, 63 (35.4%) patients died in the year following admission. ROC curve analysis showed that albumin serum levels best predict 1-year mortality in patients at risk for malnutrition (AUC 0.720, p < 0.001), followed by transferrin serum levels (AUC 0.659, p = 0.001). Regression analysis showed that low albumin serum levels were also independently associated with 1-year mortality among the whole cohort and among patients at risk for malnutrition (OR 0.2, 95% CI 0.1-0.4, p < 0.001, for both).

CONCLUSIONS

Low albumin serum levels best predict 1-year mortality in hospitalized older adults, followed by low transferrin serum levels.

Pressure Ulcer and Nutrition

Pressure ulcers can diminish global life quality, contribute to rapid mortality in some patients and pose a significant cost to health-care organizations. Accordingly, their prevention and management are highly important. Nutritional deprivation and insufficient dietary intake are the key risk factors for the development of pressure ulcers and impaired wound healing. Unplanned weight loss is a major risk factor for malnutrition and pressure ulcer development. Suboptimal nutrition interferes with the function of the immune system, collagen synthesis, and tensile strength. No laboratory test can exactly define an individual's nutritional status. Although serum albumin, prealbumin, transferrin, and retinol-binding protein as well as anthropometric measures such as height, weight, and body mass index and the other laboratory values may be suitable to establish the overall prognosis, still they might not well represent the nutritional status. Although the ideal nutrient intake to encourage wound healing is unknown, increased needs for energy, protein, zinc, and Vitamins A, C, and E and also amino acids such as arginine and glutamine have been documented. Hydration plays a vital role in the preservation and repair of skin integrity. Dehydration disturbs cell metabolism and wound healing. Adequate fluid intake is necessary to support the blood flow to wounded tissues and to prevent additional breakdown of the skin. The main aim of the present article is to review the current evidence related to hydration and nutrition for bedsore prevention and management in adults.

Low Albumin Levels Are Associated with Mortality Risk in Hospitalized Patients

BACKGROUND

The aim of this study was to investigate the association of albumin levels on admission and change in levels during hospitalization with hospitalization outcomes.

METHODS

Historical prospective data of patients hospitalized between 2011 and 2013 were collected. Levels of albumin were classified as marked hypoalbuminemia (<2.5 mg/dL), mild hypoalbuminemia (2.5-3.5 mg/dL), normal albumin (3.5-4.5 mg/dL), and hyperalbuminemia (>4.5 mg/dL). Main outcomes were length of hospitalization, in-hospital mortality, and long-term mortality.

RESULTS

The cohort included 30,732 patients (mean age 67 ± 18 years, 51% male). Most patients had normal albumin levels on admission (n = 20,124, 65%), 29% of patients had hypoalbuminemia, mostly mild (n = 7,334, 24%), and 5% of patients had marked hypoalbuminemia (n = 1436). Hyperalbuminemia on admission was evident in 6% of the patients (n = 1838). Follow-up (median ± standard deviation) was 1675 ± 325 days. Compared with in-hospital mortality with normal albumin on admission (2%), mortality was higher with mild (12%) and marked hypoalbuminemia (34%) and lower with hyperalbuminemia (0.3%). Mortality rate at the end of follow-up was 29% with normal albumin levels, 67% and 83% with mild and marked hypoalbuminemia, respectively. Patients with hyperalbuminemia on admission and before discharge have the best short- and long-term survival. This pattern was similar when analyzed separately in different age groups. In patients with hypoalbuminemia on admission, normalization of albumin levels before discharge was associated with better short- and long-term survival, compared with patients with hypoalbuminemia before discharge.

CONCLUSIONS

Low albumin levels on admission are associated with increased short- and long-term mortality. Normalization of albumin levels before discharge was associated with lower mortality risk, compared with hypoalbuminemia before discharge.

Comparison Between Quality of Care Provided by Trained Feeding Assistants and Certified Nursing Assistants During Between-Meal Supplementation in Long-Term Care Settings

The purpose of this study was to compare the quality of feeding assistance provided by trained non-nursing staff with care provided by certified nursing assistants (CNAs). Research staff provided an 8-hr training course that met federal and state requirements to non-nursing staff in five community long-term care facilities. Trained staff were assigned to between-meal supplement and/or snack delivery for 24 weeks. Using standardized observations, research staff measured feeding assistance care processes between meals across all study weeks. Trained staff, nurse aides, and upper level staff were interviewed at 24 weeks to assess staff perceptions of program impact. Trained staff performed significantly better than CNAs for 12 of 13 care process measures. Residents also consumed significantly more calories per snack offer from trained staff ( M = 130 ± 126 [ SD] kcal) compared with CNAs ( M = 77 ± 94 [ SD] kcal). The majority of staff reported a positive impact of the training program.

Cost-Effectiveness of Nutrition Intervention in Long-Term Care

OBJECTIVES

To determine the cost-effectiveness of two nutrition interventions on food, beverage, and supplement intake and body weight.

DESIGN

Randomized, controlled trial.

SETTING

Five skilled nursing home facilities.

PARTICIPANTS

Long-stay residents with orders for nutrition supplementation (N = 154).

INTERVENTION

Participants were randomized into a usual care control group, an oral liquid nutrition supplement (ONS) intervention group, or a snack intervention group. Research staff provided ONS, according to orders or a variety of snack foods and beverages twice per day between meals, 5 days per week for 24 weeks and assistance to promote consumption.

MEASUREMENTS

Research staff independently weighed residents at baseline and monthly during the 24-week intervention. Resident food, beverage and supplement intake and the amount of staff time spent providing assistance were assessed for 2 days at baseline and 2 days per month during the intervention using standardized observation and weighed intake procedures.

RESULTS

The ONS intervention group took in an average of 265 calories more per day and the snack intervention group an average of 303 calories more per day than the control group. Staff time required to provide each intervention averaged 11 and 14 minutes per person per offer for ONS and snacks, respectively, and 3 minutes for usual care. Both interventions were cost-effective in increasing caloric intake, but neither intervention had a significant effect on body weight, despite positive trends.

CONCLUSION

Oral liquid nutrition supplements and snack offers were efficacious in promoting caloric intake when coupled with assistance to promote consumption and a variety of options, but neither intervention resulted in significant weight gain.

Pressure ulcers: Current understanding and newer modalities of treatment

This article reviews the mechanism, symptoms, causes, severity, diagnosis, prevention and present recommendations for surgical as well as non-surgical management of pressure ulcers. Particular focus has been placed on the current understandings and the newer modalities for the treatment of pressure ulcers. The paper also covers the role of nutrition and pressure-release devices such as cushions and mattresses as a part of the treatment algorithm for preventing and quick healing process of these wounds. Pressure ulcers develop primarily from pressure and shear; are progressive in nature and most frequently found in bedridden, chair bound or immobile people. They often develop in people who have been hospitalised for a long time generally for a different problem and increase the overall time as well as cost of hospitalisation that have detrimental effects on patient's quality of life. Loss of sensation compounds the problem manifold, and failure of reactive hyperaemia cycle of the pressure prone area remains the most important aetiopathology. Pressure ulcers are largely preventable in nature, and their management depends on their severity. The available literature about severity of pressure ulcers, their classification and medical care protocols have been described in this paper. The present treatment options include various approaches of cleaning the wound, debridement, optimised dressings, role of antibiotics and reconstructive surgery. The newer treatment options such as negative pressure wound therapy, hyperbaric oxygen therapy, cell therapy have been discussed, and the advantages and disadvantages of current and newer methods have also been described.

Relationship between near-infrared spectroscopy, and subcutaneous fat and muscle thickness measured by ultrasonography in Japanese community-dwelling elderly

AIM

Near-infrared spectroscopy (NIRS) allows estimation of the percentage of body fat (%BF) regardless of the patient's posture; thus, it is useful for assessment of elderly patients with severe decline of basic activity who cannot hold a standing position. However, the accuracy by which the near-infrared light emitted from NIRS reflects subcutaneous tissue is unknown. The aim of this study was to assess how correctly NIRS reflects the subcutaneous fat and muscle thickness derived from ultrasonography in community-dwelling elderly.

METHODS

A total of 93 community-dwelling older adults aged 65 years and older were enrolled in this study (mean 75.8 years, 6.7 SD). Participants were assessed according to optical density (OD) measurements by NIRS, subcutaneous fat and muscle thickness by ultrasonography, and muscle strength. Pearson's correlation coefficients were calculated for each sex. Stepwise multiple regression analysis was used to identify factors that contributed to OD for each sex.

RESULTS

OD measured at the forearm and thigh were significantly correlated with subcutaneous fat thickness. In stepwise multiple regression analyses, subcutaneous fat thickness was found to be a significant determinant of OD in men (forearm β = -0.37, P = 0.01; thigh β = -0.63, P < 0.001) and women (forearm β = -0.50, P < 0.001; thigh: β = -0.52, P < 0.001).

CONCLUSIONS

These results suggest that NIRS can appropriately estimate fat-free mass. By adding other variables to OD as the predictive variable, skeletal muscle mass might be estimated in the elderly population.

Identifying geriatric malnutrition in nursing practice: the Mini Nutritional Assessment (MNA®)-an evidence-based screening tool

Protein calorie malnutrition (PCM) is common and often undiagnosed in older adults. Left untreated, PCM carries both clinical and financial risks, including decreased quality of life, declining functionality, the inability to live independently, and increased health care costs. The prevalence of PCM in older adults calls for a systematic and standardized approach to nutrition screening that includes the use of a validated screening tool. Recommended by international organizations, the Mini Nutritional Assessment® (MNA) is highly specific and reliable and the most well-validated nutrition screening tool for adults 65 and older. Simple, noninvasive, inexpensive, and easy for nurses and other clinicians to use, the newest MNA-short form (MNA-SF) can quickly and easily identify older adults who are at risk for malnutrition or malnourished. Nurses are key players in successful malnutrition screening in hospitals, long-term care, home care, and community settings. It is strongly recommended that nurses incorporate the newest MNA-SF into all practice settings where older adults receive care.

The profile of inflammatory and metabolic response in children undergoing heart transplantation

Inflammatory and metabolic response is an important factor to determine clinical outcomes. However, it remains unknown in children undergoing heart transplantation (HTx). We examined the perioperative changes in the inflammatory and metabolic response markers C-reactive protein (CRP) and prealbumin (PA) in 38 heart-transplanted children. Data obtained prior to and within one month after HTx included CRP, PA, total and differential white blood cell counts, doses of inotropes and immunosuppressants, cultures of blood and body fluids, duration of cardiopulmonary bypass (CPB), aortic cross clamp and donor heart ischemia, and days in the intensive care unit (ICU) and hospital. CRP was 32±49 mg/L before HTx, increased to 130±55 mg/L on postoperative day 1-2, and decreased to 21±31 mg/L by one month after HTx. PA was 0.15±0.06 g/L before HTx, decreased to 0.12±0.03 g/L on postoperative day 1-2, and then gradually increased to 0.21±0.10 g/L by one month after HTx. Postoperative CRP positively correlated with epinephrine dosage and CPB duration. PA positively correlated with age. In conclusion, inflammatory and metabolic response is present before HTx and acutely intensified after HTx. It may be mainly influenced by CPB duration and cardiovascular function status.

Risk of malnutrition among Brazilian institutionalized elderly: a study with the Mini Nutritional Assessment (MNA) questionnaire

BACKGROUND

Brazilian population has passed for a process of demographic transition throughout latest years, characterized for the increase of the elderly population. Malnutrition is a serious problem to frail elderly.

OBJECTIVE

The objective of this study was o evaluate the risk of malnutrition among institutionalized elderly resident in municipal shelters in the city of Rio de Janeiro, Brazil, using the tool Mini Nutritional Assessment (MNA).

DESIGN

344 institutionalized elderly aged over 60 years old were tested in a cross-sectional study using MNA. This tool classifies the nutricional status of the elderly in three groups: malnutrition (score < 17), risk of malnutrition (score 17 - 23,5) and well-nourished (score > = 24). Anthropometric measurements such as calf circumference (CC), mid-arm circumference (MAC) and Body mass index (BMI) were also evaluated. The variables were evaluated using the chi-square or ANOVA test. To correlate it was used Pearson's Correlation Coefficient (r).

RESULTS

Mean age were 75.4 (+- 9.4) years old. Most of the elderly were female gender (59.6%). According to MNA 8.3% were with malnutrition, 55.6% at risk of malnutrition and 36.1% well-nourished. BMI classified 10.0% of the elderly as underweight. CC classified 10.0 % of them as inadequate in muscular mass. MNA was well correlated to BMI (r=0.412 p=0.000), age (r=-0.124 p=0.031), CC (r=0.399 p = 0.000) and MAC (r=0.391 p=0.000).

CONCLUSION

Risk of malnutrition was high among the institutionalized elderly from public shelters in Rio de Janeiro - Brazil. MNA is a useful diagnostic tool for the identification on the frail elderly at risk of malnutrition.

Nutrition: a critical component of wound healing

PURPOSE

To enhance the clinician's competence in using nutrition as an integral part of wound healing.

TARGET AUDIENCE

This continuing education activity is intended for physicians and nurses with an interest in skin and wound care.

OBJECTIVES

After participating in this educational activity, the participant should be better able to: 1. Analyze the effects of specific nutritional deficiencies and patient parameters on wound healing capabilities. 2. Accurately interpret laboratory values related to nutritional status. 3. Apply evidence-based nutrition guidelines for improved wound healing.

Cost-effectiveness of nutrition interventions in nursing home residents: a pilot intervention

OBJECTIVES

Unintentional weight loss is a prevalent and costly clinical problem among nursing home (NH) residents. One of the most common nutrition interventions for residents at risk for weight loss is oral liquid nutrition supplementation. The purpose of this study was to determine the cost effectiveness of supplements relative to offering residents' snack foods and fluids between meals to increase caloric intake.

DESIGN

Randomized, controlled trial.

SETTING

Three long-term care facilities.

PARTICIPANTS

Sixty-three long-stay residents who had an order for nutrition supplementation.

INTERVENTION

Participants were randomized into one of three groups: (1) usual NH care control; (2) supplement, or (3) between-meal snacks. For groups two and three, trained research staff provided supplements or snacks twice daily between meals, five days per week, for six weeks with assistance and encouragement to promote consumption.

MEASUREMENTS

Research staff observed residents during and between meals for two days at baseline, weekly, and post six weeks to estimate total daily caloric intake. For both intervention groups, research staff documented residents' caloric intake between meals from supplements or snack items, refusal rates and the amount of staff time required to provide each intervention.

RESULTS

Both interventions increased between meal caloric intake significantly relative to the control group and required more staff time than usual NH care. The snack intervention was slightly less expensive and more effective than the supplement intervention.

CONCLUSIONS

Offering residents a choice among a variety of foods and fluids twice per day may be a more effective nutrition intervention than oral liquid nutrition supplementation.

Serum albumin as an outcome predictor in hospital emergency medical admissions

BACKGROUND

To examine the relationship between admission serum albumin and 30-day mortality during an emergency medical admission.

METHODS

An analysis was performed of all emergency medical patients admitted to St. James's Hospital (SJH), Dublin between 1st January 2002 and 31st December 2008, using the hospital in-patient enquiry (HIPE) system, linked to the patient administration system, and laboratory datasets. Mortality was defined as an in-hospital death within 30 days. Logistic regression was used to calculate unadjusted and adjusted odds ratios (ORs) and 95% confidence intervals for defined albumin subsets.

FINDINGS

Univariate analysis using predefined criteria based on distribution, identified the groups of <10% and between 10 and 25% of the serum albumin frequency distribution as at increased mortality risk. Their mortality rates were 31.7% and 15.4% respectively; their unadjusted odds rates were 6.35 (5.68, 7.09) and 2.11 (1.90, 2.34). Patients in the lowest 25% of the distribution had a 30-day mortality of 19.9% and this significantly increased risk persisted, after adjustment for other outcome predictors including co-morbidity and illness severity (OR 2.95 (2.49, 3.48): p<0.0001).

INTERPRETATION

Serum albumin is predictive of 30-day mortality in emergency medical patients; mortality is non-linearly related to baseline albumin. The disproportionate increased death risk for patients in the lowest 25% of the frequency distribution (<36 g/L) is not due to co-morbidity factors or acute illness severity.

Serum albumin levels as an independent predictor of 4-year mortality in a community-dwelling 80-year-old population

BACKGROUND AND AIMS

Although serum albumin levels are associated with mortality in non-institutionalized elderly people under 80 years old, as well as in the institutionalized very elderly, little is known about the relationship in community-dwelling very elderly people. We, therefore, examined the association in a Japanese population of 80-year-old community residents.

METHODS

Serum albumin levels were measured in 672 (267 men, 405 women) out of 1282 80-year-old individuals. Over the following 4 years, the dates and causes of death were recorded from resident registration cards and official death certificates.

RESULTS

Of the above individuals, 107 subjects died (58 men, 49 women: 27 due to cancer, 27 cardiovascular disease, and 22 pneumonia). Survival rates were compared among 4 groups (highest >or=45 g/L, higher than 43-44 g/L, lower than 41-42 g/L, lowest <or=40 g/L). After adjustment for confounding factors, total death or cardiovascular death in the lowest albumin group was 3.1 times and 10.7 times more incident than in the highest albumin group, but there were no differences among groups as regards deaths due to cancer or pneumonia.

CONCLUSION

Serum albumin levels are an independent predictor of mortality due to all-cause or cardiovascular disease, but not of mortality due to cancer or pneumonia in very elderly Japanese community residents.

The Mini Nutritional Assessment--its history, today's practice, and future perspectives

In the early 1990s, the Mini Nutritional Assessment (MNA; Nestle Nutrition, Vevey, Switzerland) was developed for nutrition screening in the elderly. Since then, it became the most established and widespread screening tool for older persons and has been translated into many different languages. The MNA shows prognostic relevance with regard to functionality, morbidity, and mortality of the elderly in different settings. This article recalls the development of the MNA with its short form (MNA-SF) and reviews the literature, focusing on the most recent publications. Specific features of the application of the MNA in different settings (community, nursing home, hospital) are considered. Minor shortcomings of the tool, such as the resources and the cooperation necessary for completion of the MNA, are discussed. Future options for the adaptation of this valuable tool are briefly characterized.

Gastric bypass is not associated with protein malnutrition in morbidly obese patients

BACKGROUND

Patients undergoing bariatric surgery with a gastric bypass lose about 66% of excess weight. Although this procedure induces weight loss, it is unknown whether it leads to protein malnutrition, which is studied here.

METHODS

One hundred ten obese patients (body mass index, 47.9 +/- 8.6 kg/m(2)) undergoing gastric bypass had a measurement of plasma albumin and transthyretin (formerly prealbumin) and a calculation of nutritional risk index (NRI) before and throughout the 2 years following the surgery.

RESULTS

All but five patients lost more than 15% of initial weight; the mean loss of excess weight was 65.2 +/- 26.4% at 2 years. Plasma concentrations of albumin and transthyretin decreased after surgery, but while albumin returned to initial values after 12 months, transthyretin remained low. Only one patient had an albumin below 30 g/l; another one had a transthyretin lower than 110 mg/l. All NRI scores were lower than 83.5 (62 +/- 5, ranging 44-70), qualifying patients for severe malnutrition.

CONCLUSION

Malnutrition is difficult to diagnose in obese patients undergoing surgery. The large weight loss is most often not associated with protein malnutrition. Whether gastric bypass induces protein malnutrition remains to be established.

Relationship between serum albumin level and aging in community-dwelling self-supported elderly population

While lower serum albumin concentration is often found in the elderly, a relation between serum albumin and age has not been fully elucidated. We conducted population-based cross-sectional and 5-y longitudinal study to examine the relation. A total of 22,705 male and 40,149 female, aged 65 y and older, living in Gifu, participated in the health check service conducted by Gifu City Medical Association. They were self-supported in the activity of daily living and 3,438 of them were followed up every year from 1999 to 2003. Serum albumin levels decreased with age in both men and women. In the cross-sectional study, median value declined from 4.3 g/dL in males aged 65-69 y to 3.9 g/dL in 90< or = y, and 4.3 g/dL to 4.0 g/dL in females. Incidence of hypoalbuminemia (serum albumin < or =3.5 g/dL) increased in parallel with age from 1.2% (65-69 y) to 6.6% (85-89) in males, and 0.6% to 4.1% in females. In the longitudinal study, regression analysis showed a significant decline in serum albumin of 0.015 g/dL per year (r= -0.716) in males, and 0.012 g/ dL per year (r= -0.794) in females. Relative reduction of serum albumin in 5 y was larger in advanced age; 1.2% in females aged 65-69 y and 3.1% in 85-89 y (p<0.05), but not in males. In conclusion, a fall in serum albumin concentration in community-dwelling, self-supported elderly persons was associated significantly with aging.

Inflammation as the key interface of the medical and nutrition universes: a provocative examination of the future of clinical nutrition and medicine

There has been tremendous interest in inflammation by researchers, the medical community, and the lay public. Modulation of injury response is felt to represent a tenuous balance of pro- and anti-inflammatory cytokines. Adverse outcomes may result from severe, sustained, or repeated bouts of inflammation. A critical observation is that nutrition support alone is inadequate to prevent muscle loss during active inflammation. It is necessary to take inflammation into consideration in conducting appropriate nutrition assessment, intervention, and monitoring. A host of medical conditions are actually inflammatory states that have important implications for nutrition care. Multifaceted interventions that may include anti-inflammatory diets, glycemic control, physical activity, appetite stimulants, anabolic agents, anti-inflammatory agents, anticytokines, and probiotics, will be necessary to blunt undesirable aspects of inflammatory response to preserve body cell mass and vital organ functions. Nutrition practitioners can seize this opportunity to be a part of the future medical team that brings highly individualized patient care to the bedside.

Low serum concentrations of 25-hydroxyvitamin D in older persons and the risk of nursing home admission

BACKGROUND

The prevalence of vitamin D deficiency in nursing home patients is high.

OBJECTIVE

We aimed to ascertain whether lower serum 25-hydroxyvitamin D [25(OH)D] concentrations increase the risk of future nursing home admission and early death.

DESIGN

We included 1260 independent, community-dwelling persons aged > or =65 y who were participating in the Longitudinal Aging Study Amsterdam (1995-1996). Study outcomes were time to nursing home admission during 6 y of follow-up and time to death until 1 April 2003.

RESULTS

Vitamin D deficiency [25(OH)D < 25 nmol/L] and insufficiency [25(OH)D = 25-49.9 nmol/L] were present in 127 (10.1%) and 462 (36.7%) subjects, respectively. During follow-up, 138 subjects (11.0%) were admitted to nursing homes, and 380 subjects (30.2%) died. The risk of nursing home admission for participants with 25(OH)D deficiency was 53 cases per 1000 person-years higher than that for those with high 25(OH)D (> or =75 nmol/L) concentrations (58 compared with 5 cases). After adjustment for potential confounders, the hazard ratio (95% CI) of nursing home admission was 3.48 (1.39, 8.75) for vitamin D-deficient, 2.77 (1.17, 6.55) for vitamin D-insufficient, and 1.92 (0.79, 4.66) for vitamin D-borderline persons as compared with persons with high 25(OH)D (P for trend = 0.002). The results remained after additional adjustment for frailty indicators. Lower 25(OH)D was associated with higher mortality risk, but this association was not significant after adjustment for frailty indicators.

CONCLUSION

Lower serum 25(OH)D concentrations in older persons are associated with a greater risk of future nursing home admission and may be associated with mortality.

Poor nutritional habits are predictors of poor outcome in very old hospitalized patients

BACKGROUND

Malnutrition is prevalent in elderly populations. Recommended methods of nutritional screening are often too complicated and time-consuming for routine application in frail, very old, hospitalized patients.

OBJECTIVE

Our aims were to identify risk factors for development of malnutrition in very old hospitalized patients and to evaluate the total Mini Nutritional Assessment (MNA) score and MNA subscores as predictors of in-hospital and long-term mortality.

DESIGN

A prospective cohort study of patients aged > or =75 y was conducted in a geriatric hospital. Assessment included demographic, clinical, and laboratory data and cognitive, functional, and nutritional status. Follow-up was conducted for < or =2.7 y.

RESULTS

Of the 414 patients studied, only 73 (17.6%) were well-nourished. Low serum albumin and phosphorus concentrations, dementia, and cerebrovascular accident (CVA) were significant risk factors for malnutrition. Survival was significantly lower in malnourished patients and patients at risk of malnutrition than in well-nourished patients (P < 0.0001). Low MNA-3 subscores (dietary habits) were significantly correlated with laboratory indexes of malnutrition and were significantly lower in patients with infections, malignancy, pressure ulcers, dementia, recent orthopedic surgery, and CVA. Multivariate analysis showed that a low MNA-3 score was an independent predictor of mortality; scores <7.5 increased the risk of death 2.05-fold.

CONCLUSIONS

The prevalence of malnutrition was high in elderly hospitalized patients. Dietary habits were significant predictors of poor hospitalization outcome. A questionnaire on dietary habits can serve as a useful tool in assessing nutritional status and prognosis in elderly patients.

Hypoalbuminemia 3 months after hospital discharge: significance for long-term survival

OBJECTIVES

To determine change in albumin from hospital discharge to 3-month follow-up and the prognostic significance of persistent hypoalbuminemia in older veteran patients.

DESIGN

A prospective cohort study.

SETTING

A geriatric rehabilitation unit of a university-affiliated Department of Veterans Affairs hospital.

PARTICIPANTS

The study population consisted of 282 subjects (of 322 randomly selected discharges who were free of cancer and terminal conditions) that completed the 90-day postdischarge assessment; most were older (75.4+/-8.6), white (76%), and male (99%).

MEASUREMENTS

Each subject completed a comprehensive discharge assessment, had a repeat albumin an average of 94 days later, and was then tracked for 5 years. The strongest predictors of survival were identified using Cox proportional hazards regression analysis.

RESULTS

Between hospital discharge and the 3-month reassessment, albumins improved by more than 2 g/L in 122 subjects (43%), stayed the same in 112 subjects (40%), and deteriorated by more than 2 g/L in the rest. During follow-up, 190 subjects (67%) died. Of the 38 nutritional, functional, demographic, and illness severity variables evaluated, the 3-month postdischarge albumin was the strongest predictor of long-term mortality. Those with albumins less than 35 g/L had a 2.6 times greater mortality than those with albumins of 40 g/L or greater (relative risk=2.6, 95% confidence interval=1.8-3.8). After controlling for 3-month albumin, hospital-discharge albumin was not significantly associated with long-term mortality.

CONCLUSION

In older people, a low serum albumin 3 months after hospital discharge is associated with a poor long-term prognosis. It is not known whether this represents ongoing inflammation or inadequate nutrition.

The Effects of Megestrol Acetate Suspension for Elderly Patients with Reduced Appetite After Hospitalization: A Phase II Randomized Clinical Trial

OBJECTIVES

To provide preliminary evidence on the effectiveness and optimal dosage of megestrol acetate for older persons with impaired appetite after hospitalization.

DESIGN

Randomized clinical trial.

SETTING

Acute care hospital.

PARTICIPANTS

Forty-seven older persons (mean age 83) who were recently discharged from an acute care hospital and had fair or poor appetite.

INTERVENTION

Participants were randomized to placebo or megestrol acetate suspension 200 mg, 400 mg, or 800 mg daily for 9 weeks.

MEASUREMENTS

Appetite, health-related quality of life, and adverse effects were measured at baseline and 20, 42, and 63 days. Serum nutritional markers were measured at baseline and 20 and 63 days.

RESULTS

During the course of the study, there were no significant differences between treatment groups on any of the appetite questions, although participants in the 400-mg and 800-mg groups demonstrated significant improvement from baseline on some questions. At 20 days, prealbumin increased in a dose-response relationship across the four groups (by 0.4, 5.1, 7.5, and 9.0 mg/dL, respectively). Participants in the 400-mg and 800-mg groups demonstrated greater improvement in prealbumin levels at 20 days than those receiving placebo (P=.009 and P=.004, respectively) and those in the 400-mg group also demonstrated improvement at 63 days (P=.02). At 20 days, no participant taking placebo had a morning serum cortisol level less than 8 ng/mL (the lower limit of normal). In contrast, 33%, 70%, and 78% of those taking 200 mg, 400 mg and 800 mg, respectively, had values below this level; by 63 days, these percentages were 11%, 30%, 56%, and 37%, respectively. No patient reported clinical symptoms of adrenal insufficiency. Diarrhea developed in three subjects, and thromboembolism occurred in two receiving active treatment.

CONCLUSION

Megestrol acetate at doses of 400 mg and 800 mg increases prealbumin in recently hospitalized older persons. Cortisol suppression is common at higher doses and may be persistent. In this small study, the drug did not confer benefit on other nutritional or clinical outcomes.

The Effect of Megestrol Acetate on Oral Food and Fluid Intake in Nursing Home Residents: A Pilot Study

OBJECTIVES

The objective of this study was to evaluate the effect of megestrol acetate (Megace OS; Bristol-Myers Squibb, Princeton, NJ) on the oral food and fluid intake of nursing home (NH) residents under two conditions: usual NH care and optimal mealtime feeding assistance.

DESIGN AND SETTING

We conducted a prospective, preliminary trial in four NHs.

PARTICIPANTS

Participants (n = 17) were recruited from a larger study designed to assess nutritional care quality. Eligibility for the Megace OS trial required participants to consistently eat less than 75% of most meals under both usual NH care and optimal feeding assistance conditions at baseline.

INTERVENTION

Megace OS, an oral liquid suspension of megestrol acetate, was given daily in a 400-mg dose for 63 days.

MEASUREMENTS

Each participant's oral food and fluid intake was monitored weekly for 1 day (three meals) during which research staff conducted direct observations of usual NH care (weeks 1, 3, and 5 and day 63) or provided optimal feeding assistance (weeks 2, 4, and 6). Average total percent intake was compared from baseline across the assessment weeks of the trial under the two mealtime care conditions.

RESULTS

Megace OS had a significant effect on oral food and fluid intake only under the optimal mealtime feeding assistance condition, in which average total percent eaten increased from 50% (+/-15%) at baseline to 63% (+/-14%) post-63 days of the trial. There was no change in participants' oral food and fluid intake under the usual NH care condition (average total percent intake at baseline 43% +/- 12% vs. 43% +/- 20% post-63 days).

CONCLUSION

The results of this preliminary study suggest that Megace OS is not an effective nutritional intervention to increase oral intake under usual NH care conditions, which is often characterized by inadequate feeding assistance. However, Megace OS in combination with optimal mealtime feeding assistance does significantly increase oral intake in a frail NH sample at high risk for weight loss.

Individualized Feeding Assistance Care for Nursing Home Residents: Staffing Requirements to Implement Two Interventions

BACKGROUND

Recommendations have been made to increase the number of nursing home (NH) staff available to provide feeding assistance during meals and to individualize care for residents. However, there are few data reflecting the number of residents responsive to feeding assistance during meals and what alternative interventions might be appropriate for other residents. The purpose of this study was to evaluate the effects and staffing requirements of two individualized feeding assistance interventions to improve oral food and fluid intake in NH residents.

METHODS

Skilled nursing participants (n = 134) in 3 NHs received a 2-day trial of one-on-one feeding assistance during 6 meals. 68 participants who did not increase their oral intake in response to feeding assistance during meals received a 2-day intervention trial during which snacks were offered between meals 3 times daily. As part of both interventions, research staff provided adequate feeding assistance that enhanced the resident's self-feeding ability, social stimulation throughout the meal or snack period, and availability of choices for foods and fluids.

RESULTS

46% significantly increased their oral intake in response to one-on-one mealtime feeding assistance, and the staff time required to implement this intervention was 35 (+/- 8) minutes/meal per resident compared with usual NH care, which averaged 6 (+/- 9) minutes. 44% of the participants significantly increased their oral intake in response to the between-meal snack intervention, which required 12 (+/- 6) minutes of staff time per snack/resident compared with usual NH care (1 +/- 4 minutes).

CONCLUSIONS

Most participants (90%) significantly increased their daily oral food and fluid intake in response to one of two individualized interventions. The staff time necessary to implement each intervention was significantly greater than the staff time currently being spent on feeding assistance care delivery. Suggestions are made to increase the efficiency of staff time when delivering feeding assistance.

Homocysteine and disability in hospitalized geriatric patients

Elevated total homocysteine (tHcy) concentrations have been found to be associated with cardiovascular disease and dementia in old age. The present study was performed to identify the prevalence of hyperhomocysteinemia (HHcy) and to analyze the association between tHcy concentration and sociodemographic characteristics, nutritional parameters, and cognitive and functional status in this sample of hospitalized geriatric patients. A total of 214 patients (77% females) 65+ years old admitted into an acute care geriatric ward of an internal medical department in the Northern Italy were studied. tHcy concentration was measured using a high-performance liquid chromatography with fluorescence detection (HPLC-F). Information about nutrition (body mass index [BMI], serum albumin, cholesterol, and transferrin) was collected on admission. Functional status was investigated with the Basic Activities of Daily Living scale (ADL) and the Instrumental Activities of Daily Living scale (IADL); cognitive and affective status were assessed by the Mini-Mental State Evaluation (MMSE) and the Geriatric Depression Scale (GDS). The mean tHcy concentration was 18.4 +/- 13.1 micromol/L; 74.2% of males and 68.9% of females had HHcy (> 12 micromol/L). Sixty-four percent of patients with normal serum vitamin B12 and folate concentrations had HHcy. Elevated tHcy concentrations were associated with older age, male gender, increasing serum creatinine, lower MMSE score, and disability. The mean tHcy concentration depended on the occurrence of different diseases. Patients affected by atherosclerotic diseases, such as ischemic heart diseases, cerebrovascular diseases, and dementia had higher mean tHcy concentration than those without diagnosed vascular diseases. In multivariate analysis, vitamin B12, folate, serum albumin, creatinine, and disability emerged as factors associated with tHcy, adjusted for age, gender, education, MMSE score, and atherosclerotic diseases. Our results suggest that the prevalence of HHcy in hospitalized patients is very high, even in subjects with normal cobalamin and folate concentrations. High Hcy concentration can be associated with functional impairment.

Hypoalbuminemia in acute illness: is there a rationale for intervention? A meta-analysis of cohort studies and controlled trials

OBJECTIVE

To determine whether hypoalbuminemia is an independent risk factor for poor outcome in the acutely ill, and to assess the potential of exogenous albumin administration for improving outcomes in hypoalbuminemic patients.

SUMMARY BACKGROUND DATA

Hypoalbuminemia is associated with poor outcomes in acutely ill patients, but whether this association is causal has remained unclear. Trials investigating albumin therapy to correct hypoalbuminemia have proven inconclusive.

METHODS

A meta-analysis was conducted of 90 cohort studies with 291,433 total patients evaluating hypoalbuminemia as an outcome predictor by multivariate analysis and, separately, of nine prospective controlled trials with 535 total patients on correcting hypoalbuminemia.

RESULTS

Hypoalbuminemia was a potent, dose-dependent independent predictor of poor outcome. Each 10-g/L decline in serum albumin concentration significantly raised the odds of mortality by 137%, morbidity by 89%, prolonged intensive care unit and hospital stay respectively by 28% and 71%, and increased resource utilization by 66%. The association between hypoalbuminemia and poor outcome appeared to be independent of both nutritional status and inflammation. Analysis of dose-dependency in controlled trials of albumin therapy suggested that complication rates may be reduced when the serum albumin level attained during albumin administration exceeds 30 g/L.

CONCLUSIONS

Hypoalbuminemia is strongly associated with poor clinical outcomes. Further well-designed trials are needed to characterize the effects of albumin therapy in hypoalbuminemic patients. In the interim, there is no compelling basis to withhold albumin therapy if it is judged clinically appropriate.

Undernutrition in the European SENECA studies

The SENECA study, which sampled a cohort of community-dwelling persons born between 1913 and 1918 in 12 European countries in baseline (1988), follow up (1993), and final (1999) surveys, found a relatively high risk of malnutrition despite a low prevalence of actual malnourishment. The results point out the importance of monitoring nutritional status in healthy elderly adults.

Diagnosing undernutrition

Because of its wide prevalence and its grave consequences on the health of older persons, malnutrition requires immediate attention. Physicians in general have been described as being nutritionally blind in their slowness to recognize undernutrition. A high degree of suspicion, a thorough history and physical examination, and pertinent laboratory data can identify patients at risk. When a more comprehensive assessment is needed; screening tools, dietary history, and special biochemical parameter can be used.

Changes in nutritional status and postoperative outcomes in elderly CABG patients

OBJECTIVES

To systematically examine the pattern of nutritional status over time in older people undergoing elective coronary artery bypass grafting (CABG) and the extent to which nutritional status affects health outcomes postdischarge.

DESIGN

The sample consisted of 91 community-dwelling English-speaking persons > or = 65 (72.27 +/- 4.85) years of age with normal cognitive function and no active cancer. Data collected prospectively at 3 time points (preoperatively, postoperatively on day 5, and 4 to 6 weeks postdischarge) included serum albumin, transferrin, and calculated Body Mass Index (BMI). The Short-Form 36 Health Status Survey Questionnaire was administered 4 to 6 weeks postdischarge as a primary health outcome measure.

RESULTS

Nutritional status changed over time. For albumin and transferrin, the pattern of change corresponded to the phases of surgical stress (P = 0.001). The BMI decreased from preoperative to 4 to 6 weeks postdischarge (P = 0.001), and this decrease explained 13.8% of the variance in physical health 4 to 6 weeks postdischarge (P = 0.008). The change in the BMI corresponds to an average weight loss of 5% from preoperative to postdischarge.

CONCLUSIONS

Older people undergoing CABG who lose significant weight from preoperative to postdischarge are more likely to have lower self-reported physical health.

Evaluation of nutritional assessment techniques in elderly people newly admitted to municipal care

OBJECTIVES

To evaluate the Subjective Global Assessment (SGA) and the Mini Nutritional Assessment (MNA) with regard to validity using a combination of anthropometric and serum-protein measurements as standard criteria to assess protein-energy malnutrition (PEM).

DESIGN

Cross-sectional study with consecutive selection of residents aged >or=65 y.

SETTING

A municipality in the south of Sweden.

SUBJECTS

During a year, starting in October 1996, 148 females and 113 males, aged >or=65-104 y of age, newly admitted to special types of housing for the elderly, were included in the study.

RESULTS

According to SGA, 53% were assessed as malnourished or moderately malnourished on admission. The corresponding figure from MNA was 79% malnourished or at risk of malnutrition. Both tools indicated that anthropometric values and serum proteins were significantly lower in residents classified as being malnourished (P<0.05). Sensitivity in detecting PEM was in SGA 0.93 and in MNA 0.96 and specificity was 0.61 and 0.26, respectively. Using regression analysis, weight index and serum albumin were the best objective nutritional parameters in predicting the SGA- and MNA classifications. Item 'muscle wasting' in SGA and 'self-experienced health status' in MNA showed most predictive power concerning the odds of being assessed as malnourished.

CONCLUSIONS

SGA was shown to be the more useful tool in detecting residents with established malnutrition and MNA in detecting residents who need preventive nutritional measures.