Nutritional Status and Energy Intake as Predictors of Functional Status After Cardiac Rehabilitation in Elderly Inpatients With Heart Failure - A Retrospective Cohort Study

Optimal serum 25-hydroxyvitamin D level to prevent sarcopenia in patients with heart failure: Insights from a dose-response relationship

BACKGROUND AND AIMS

Low serum 25-hydroxyvitamin D (25 [OH]D) levels have been associated with sarcopenia, frailty, and risk of cardiovascular disease, whereas high levels negatively impact clinical outcomes. We determined optimal serum 25(OH)D concentrations to minimise the probability of sarcopenia in patients with heart failure (HF) by examining the dose-dependent relationship between serum 25(OH)D levels and sarcopenia.

METHODS AND RESULTS

We enrolled 461 consecutive patients with HF (mean age, 72 ± 15 years; 39% female) who underwent dual-energy X-ray absorptiometry. Serum 25(OH)D levels were measured using a chemiluminescence immunoassay. Sarcopenia was diagnosed according to the 2019 Asian Working Group for Sarcopenia criteria. Overall, 49% of enrolled patients were diagnosed with sarcopenia. Adjusted logistic regression with restricted cubic spline function revealed that the odds ratio (OR) of sarcopenia increased in patients with HF presenting serum 25(OH)D levels <14.6 ng/ml or > 31.4 ng/ml, reaching the lowest OR at ∼20 ng/ml. Multivariate logistic regression revealed that a serum 25(OH)D level below 14.6 ng/mL was independently associated with the presence of sarcopenia (adjusted OR: 2.16, 95% confidence interval [CI]: 1.24-3.78). Incorporating serum 25(OH)D levels <14.6 ng/ml, but not <20.0 ng/ml, in the baseline model improved continuous net reclassification (0.334, 95% CI: 0.122-0.546) in patients with HF.

CONCLUSION

A U-shaped relationship exists between serum 25(OH)D levels and sarcopenia probability in patients with HF. Maintaining serum 25(OH)D levels between 14.6 and 31.4 ng/ml may help prevent sarcopenia in patients with HF.

Prealbumin level is a predictor of activities of daily living at discharge in older patients with heart failure who became ADL-independent after hospitalization: - Acute and early recovery cardiac rehabilitation trials

Chiba T, Yokota J, Takahashi R, Sasaki K, Suzuki H. Prealbumin level is a predictor of activities of daily living at discharge in older patients with heart failure who became ADL-independent after hospitalization - Acute and early recovery cardiac rehabilitation trials. Jpn J Compr Rehabil Sci 2023; 14: 69-77.

Objective

To determine the relationship between prealbumin level and activities of daily living (ADL) at discharge in patients with heart failure (HF) and assess the usefulness of prealbumin measurement in predicting discharge Barthel Index (BI) in older patients with HF who become non-independent in ADL after hospital admission.

Methods

Patients with HF, aged ≥75 years, who were admitted to an acute hospital and underwent acute and early recovery cardiac rehabilitation (CR) were studied retrospectively. The exclusion criteria were non-independent ADL before admission (BI < 85 points) and independent ADL at the start of CR (BI ≥ 85 points). The usefulness of prealbumin level in predicting discharge BI was compared between four models. Albumin and Controlling Nutritional Status (CONUT) were used as comparison variables. The models and independent variables were model 1 (covariates only), model 2 (prealbumin + covariates), model 3 (albumin + covariates), and model 4 (CONUT score + covariates). Adjusted R2, a measure of model fit, was used to compare predictive ability.

Results

A total of 152 patients were included in the analysis. Prealbumin level was a significant variable for BI at discharge but not albumin or CONUT. The adjusted R2 was higher in model 2 with the addition of prealbumin than that in model 1 (0.362 vs. 0.347).

Conclusion

Prealbumin levels are useful in predicting discharge BI in older patients with HF who become non-independent in ADL after hospitalization.

Combination of low muscle strength and malnutrition is associated with longer length of hospital stay among older patients with heart failure

BACKGROUND

Muscle strength and nutritional status are associated with length of hospital stay (LOHS) in older patients with heart failure (HF).

OBJECTIVES

The purpose of the study was to examine the association of the combination of muscle strength and nutritional status on LOHS in older patients with HF.

METHODS

This retrospective cohort study included 414 older inpatients with HF (men, 57.2%; median age, 81 years; interquartile range, 75-86 years). Patients were categorized into four groups according to their muscle strength and nutritional status: group 1, high muscle strength and normal nutritional status; group 2, low muscle strength and normal nutritional status; group 3, high muscle strength and malnutrition; and group 4, low muscle strength and malnutrition. The outcome variable was the LOHS, and an LOHS of >16 days was defined as long LOHS.

RESULTS

Multivariate logistic regression analysis adjusted for baseline characteristics (reference, group 1) showed that group 4 was associated with a more significant risk of long LOHS (odds ratio [OR], 3.54 [95% confidence interval, 1.85-6.78]). In the subgroup analysis, this relationship was maintained for the first admission HF group (OR, 4.65 [2.07-10.45]) but not for the HF readmission group (OR, 2.80 [0.72-10.90]).

CONCLUSIONS

Our results suggest that the long LOHS for older patients with HF at first admission was associated with a combination of low muscle strength and malnutrition but not by either factor individually.

Barriers and Facilitators to Delivering Inpatient Cardiac Rehabilitation: A Scoping Review

Objective

The purpose of this scoping review was to summarize the literature on barriers and facilitators that influence the provision and uptake of inpatient cardiac rehabilitation (ICR).

Methods

A literature search was conducted using PsycINFO, MEDLINE, EMBASE, CINAHL and AgeLine. Studies were included if they were published in English after the year 2000 and focused on adults who were receiving some form of ICR (eg, exercise counselling and training, education for heart-healthy living). For studies meeting inclusion criteria, descriptive data on authors, year, study design, and intervention type were extracted.

Results

The literature search resulted in a total of 44,331 publications, of which 229 studies met inclusion criteria. ICR programs vary drastically and often focus on promoting physical exercises and patient education. Barriers and facilitators were categorized through patient, provider and system level factors. Individual characteristics and provider knowledge and efficacy were categorized as both barriers and facilitators to ICR delivery and uptake. Team functioning, lack of resources, program coordination, and inconsistencies in evaluation acted as key barriers to ICR delivery and uptake. Key facilitators that influence ICR implementation and engagement include accreditation and professional associations and patient and family-centred practices.

Conclusion

ICR programs can be highly effective at improving health outcomes for those living with CVDs. Our review identified several patient, provider, and system-level considerations that act as barriers and facilitators to ICR delivery and uptake. Future research should explore how to encourage health promotion knowledge amongst ICR staff and patients.

Impact of Radar Chart-Based Information Sharing in a Multidisciplinary Team on In-Hospital Outcomes and Prognosis in Older Patients With Heart Failure

Background: A multidisciplinary team (MDT) approach is crucial for managing older patients with heart failure (HF). We investigated the impact on clinical outcomes of implementation of a conference sheet (CS) with an 8-component radar chart for visualizing and sharing patient information. Methods and Results: We enrolled 395 older inpatients with HF (median age 79 years [interquartile range 72-85 years]; 47% women) and divided them into 2 groups according to CS implementation: a non-CS group (before CS implementation; n=145) and a CS group (after CS implementation; n=250). The clinical characteristics of patients in the CS group were assessed using 8 scales (physical function, functional status, comorbidities, nutritional status, medication adherence, cognitive function, HF knowledge level, and home care level). In-hospital outcomes (Short Physical Performance Battery, Barthel Index score, length of hospital stay, and hospital transfer rate) were significantly better in the CS than non-CS group. During the follow-up period, 112 patients experienced composite events (all-cause death or admission for HF). Inverse probabilities of treatment-weighted Cox proportional hazard analyses demonstrated a 39% reduction in risk of composite events in the CS group (adjusted hazard ratio 0.65; 95% confidence interval 0.43-0.97). Conclusions: Radar chart-based information sharing among MDT members is associated with superior in-hospital clinical outcomes and a favorable prognosis.

Nutritional Status in Patients Undergoing Phase II Cardiac Rehabilitation by Mini Nutritional Assessment

Background

Malnutrition impairs quality of life and prognosis of patients with cardiovascular disease. The Mini Nutritional Assessment (MNA) is a screening tool developed for the nutritional assessment of older adults. However, usefulness of MNA for patients undergoing cardiac rehabilitation (CR) has not been fully investigated.

Methods

From March 2017 to September 2019, the MNA-short form (MNA-SF) and the MNA total score in patients undergoing phase II CR at the Juntendo University Hospital were evaluated.

Results

A total of 336 patients (mean age 70.1 ± 11.4 years; males: 209) were analyzed. In the MNA-SF, 157 patients (47%) were found to be malnourished or at risk of malnutrition. In MNA total score, 168 patients (50%) were found to be malnourished or at risk of malnutrition. The MNA-SF < 12 group had significantly lower body mass index (BMI), hemoglobin level, low MNA scores for protein/water intake, self-evaluation of nutrition and health, and upper arm and calf circumferences compared to the MNA-SF ≥ 12 group. Assuming BMI < 18.5 as malnutrition, the sensitivity and specificity for malnutrition were 100% and 58.9% for MNA-SF, and 96.9% and 54.9% for MNA total score, respectively.

Conclusions

MNA is useful in screening for malnutrition in patients undergoing CR. Approximately 50% of them were determined to be malnourished or at risk of malnutrition, suggesting the need for detailed evaluation regarding their food intake and dietary intervention.

Dysphagia is an independent predictor of hospital-acquired disability in older patients with heart failure: a propensity score-matched analysis : Predictors of HAD in older HF patients

This study aims to identify the relationship between dysphagia and developing hospital-acquired disability (HAD) in older patients with heart failure (HF). This single-center retrospective cohort study included 360 patients (median age, 84 years: 58.1% female, 41.9% male) who had undergone rehabilitation and were aged 65 years and older. Patients were divided into dysphagia and non-dysphagia groups and compared based on the Functional Oral Intake Scale score. HAD was defined as a decline in the Barthel Index score (indication of daily activity levels) at discharge relative to that before admission. The relationship between dysphagia and HAD was analyzed using bivariate analysis after adjusting for age, sex, body mass index, medical history, clinical and laboratory data, short physical performance battery (SPPB), and cognitive function at the start of rehabilitation, using propensity score matching. HAD was observed in 38.1% of the patients. Patients with dysphagia were significantly older, and had lower body mass index and physical and cognitive function than those without. After propensity score matching, the prevalence of HAD was significantly higher in the dysphagia group than in the non-dysphagia group (61.9% vs. 42.9%, P = 0.032). Dysphagia at the start of rehabilitation was an independent predictor of HAD. The results of this study may contribute to risk stratification of HAD.

Loss of perceived social role, an index of social frailty, is an independent predictor of future adverse events in hospitalized patients with heart failure

Aims

Although the impact of physical frailty on prognosis and the effect of cardiac rehabilitation in HF patients has been well established, data for the prognostic impact of social frailty (SF) in HF patients are limited. In addition, the relative importance of each SF domain in clinical outcomes remains unclear. We aimed to get a new insight into the associations of SF with clinical outcomes in elderly hospitalized HF patients.

Methods

A single-center, retrospective cohort study was conducted using data from 310 in-hospital HF patients aged ≥ 65 years (mean age of 78 ± 8 years; 49% women). Makizako's five questions, a self-reported questionnaire, were used to define SF. The primary outcome was composite events defined by all-cause death and cardiovascular events.

Results

Of the 310 elderly HF patients, 188 patients (61%) had SF. Seventy-five patients (24%) had composite events during a mean follow-up period of 1.93 ± 0.91 years. Kaplan-Meier curves showed that patients with SF had a significantly higher composite event rate than patients without SF. In multivariate Cox regression analyses, SF was independently associated with a higher composite event rate after adjusting for prognostic markers [adjusted hazard ratio (HR), 2.01; 95% confidence interval (CI), 1.07-3.78; p = 0.04]. Of the 5 questions for defining SF, an answer of yes to the question about not feeling helpful toward friends or family, which indicates loss of perceived social role, was an independent predictor of composite events (adjusted HR, 2.28; 95% CI, 1.36-3.82; p < 0.01). Inclusion of loss of perceived social role into the baseline prognostic model improved both the continuous net reclassification improvement (0.562; 95% CI, 0.298-0.827; p < 0.01) and integrated discrimination improvement (0.031; 95% CI, 0.006-0.056; p = 0.02).

Conclusion

Loss of perceived social role is associated with increased adverse event risk and provides additive prognostic information in elderly HF patients.

Hospital-associated disability and hospitalization costs for acute heart failure stratified by body mass index- insight from the JROAD/JROAD-DPC database

BACKGROUND

The impact of body mass index (BMI) on hospital mortality in patients with acute heart failure has been well documented in Asian populations. However, the relationship between BMI, hospital-associated disability (HAD), and hospitalization costs in patients with heart failure is poorly understood. This study aimed to explore the impact of BMI on HAD and hospitalization costs for acute heart failure in Japan.

METHODS

From April 2012 to March 2020, the Japanese Registry of All Cardiac and Vascular Disease Diagnosis Procedure Combination (JROAD-DPC) database was used to identify patients with acute heart failure. All patients were categorized into five groups according to the World Health Organization Asian BMI criteria. The hospitalization costs and HAD were evaluated.

RESULTS

Among the 238,160 eligible patients, 15.7% were underweight, 42.2% were normal, 16.7% were overweight, 19.3% were obese I, and 6.0% were obese II, according to BMI. The prevalence of HAD was 7.43% in the total cohort, and the risk of HAD increased with a lower BMI. Restricted cubic spline analysis showed a U-shaped relationship between BMI and hospitalization costs for all ages. Furthermore, developing HAD was associated with greater costs compared with non-HAD, regardless of BMI category.

CONCLUSIONS

We found that the lower the BMI, the higher the incidence of HAD. A U-shaped association was confirmed between BMI and hospitalization costs, indicating that hospitalization costs increased for both lower and higher BMI regardless of age. BMI could be an important and informative risk stratification tool for functional outcomes and economic burdens.

A Comparative Study of Three Nutritional Risk/Screening Indices for Predicting Cardiac Events and Physical Functioning Among Patients with Acute Heart Failure

Undernutrition is very common among patients with heart failure (HF). This study evaluated the prognostic values of three nutritional risk/screening indices among patients with acute HF. We retrospectively calculated scores for 465 patients with acute HF using the Controlling Nutritional Status (CONUT) tool, the Geriatric Nutritional Risk Index (GNRI), and the Mini-Nutritional Assessment Short Form (MNA-SF). The outcomes of interest were the 1-year rate of cardiac events (cardiac-related death or HF-related readmission) and the Barthel index as an index of physical function during hospitalization. The CONUT, GNRI, and MNA-SF scores were significantly correlated, although the proportions of a normal nutritional state varied (CONUT: 18.3%, GNRI: 32.9%, and MNA-SF: 43.9%). Kaplan-Meier estimates revealed that cardiac events were more common among patients with undernutrition based on the CONUT score, and multivariable regression analysis revealed that only the CONUT score independently predicted poor outcomes. Furthermore, changes in the Barthel index during hospitalization were significantly correlated with the CONUT score but not with the GNRI and MNA-SF scores. In receiver operating characteristic analyses, the CONUT score had the most powerful predictive values on both the postdischarge incidence of cardiac events and the decline of physical function during hospitalization compared with the GNRI and the MNA-SF. These results indicate that the CONUT score might provide useful information for predicting poor outcomes in patients with acute HF.

What is the optimal nutritional assessment tool for predicting decline in the activity of daily living among older patients with heart failure?

The clinical importance of nutritional management in activities of daily living (ADL) among older inpatients with heart failure (HF) is greatly increasing. We determined the optimal nutritional assessment tool that can predict ADL decline among older inpatients with HF. We prospectively investigated 91 inpatients aged ≥ 65 years with HF in an acute hospital. We measured their nutritional status at admission using nutrition indices: the controlling nutritional status (CONUT), the geriatric nutritional risk index, the prognostic nutritional index, and the mini nutritional assessment. Logistic regression analysis was used to estimate the odds ratios (ORs) and 95% confidence intervals (CIs) of the relationships between the malnutrition status assessed by each nutritional index category and the ADL decline measured by the Barthel index (BI) in the univariate and multivariate analyses. Among the participants, 28.6% (n = 26; median age 81.5 years; 69.2% men) of the participants were included in the Reduced BI group and 71.4% (n = 65; median age 79.0 years; 67.7% men) in the Maintained BI group. The Reduced BI group showed a significantly higher CONUT value than the Maintained BI group, but there were no significant differences in other nutritional indices. In the multivariate logistic regression analysis, a higher CONUT score was associated with a significantly elevated risk of Reduced BI (adjusted OR 0.24; 95%CI 0.08-0.75; p = 0.014). We found that CONUT is an appropriate nutritional assessment tool for predicting ADL decline among older inpatients with HF in the early phase of hospitalization.

Role of frailty on cardiac rehabilitation in hospitalized older patients

BACKGROUND

Cardiovascular diseases are the leading cause of mortality, morbidity, and disability in the world, especially in the older adults. A relevant proportion of patients admitted to Cardiac Rehabilitation (CR) may suffer from frailty, a complex geriatric syndrome with multifactorial aetiology.

AIMS

The hypothesis underlying the study is that frailty complicates the management of older patients undergoing CR. The main objective is, therefore, to determine the relationship between frailty and CR outcomes in hospitalized older adults.

METHODS

The participants have been recruited among patients aged ≥ 65 years admitted at the hospital for CR. A Comprehensive Geriatric Assessment (CGA)-based Frailty Index (FI) was created following a standard procedure. The outcome was measured as the ratio between 6-min walk test (6MWT) distance at the end of CR and normal predicted values for a healthy adult of same age and gender, according to reference equations.

RESULTS

The study population consisted of 559 elderly patients, 387 males (69.2%), with age of 72 (69-76) years. The most frequent diagnosis at admission was ischaemic heart disease (231, 41.5%) and overall 6MWT ratio was 0.62 ± 0.21. At the multivariable regression analysis, gender, diagnosis and FI were significantly and independently associated with 6MWT ratio (p ≤ 0.0001, p ≤ 0.001 and p ≤ 0.0001, respectively), while no significant association emerged for age.

CONCLUSION

FI resulted independently correlated to 6MWT ratio in a population of older patients undergoing in-hospital CR programs. Frailty is a multifactorial geriatric syndrome whose assessment is essential for prognostic evaluation of older patients, also in CR clinical setting.

Association between Geriatric Nutrition Risk Index and The Presence of Sarcopenia in People with Type 2 Diabetes Mellitus: A Cross-Sectional Study

The aim of this cross-sectional study was to examine the association between the geriatric nutritional risk index (GNRI) and the prevalence of sarcopenia in people with type 2 diabetes (T2DM). Having both low handgrip strength (<28 kg for men and <18 kg for women) and low skeletal muscle mass index (<7.0 kg/m2 for men and <5.7 kg/m2 for women) was diagnosed as sarcopenia. GNRI was estimated by the formula as below: GNRI = (1.489 × serum albumin level [g/L]) + (41.7 × [current body weight (kg)/ideal body weight (kg)]). Participants were dichotomized on the basis of their GNRI scores (GNRI < 98, low; or GNRI ≥ 98, high). Among 526 people (301 men and 225 women) with T2DM, the proportions of participants with sarcopenia and low GNRI were 12.7% (n = 67/526) and 5.1% (n = 27/526), respectively. The proportion of sarcopenia in participants with low-GNRI was higher than that with high GNRI (44.4% [n = 12/27] vs. 11.0% [n = 55/499], p < 0.001). The GNRI showed positive correlations with handgrip strength (r = 0.232, p < 0.001) and skeletal muscle mass index (r = 0.514, p < 0.001). Moreover, low GNRI was related to the prevalence of sarcopenia (adjusted odds ratio, 4.88 [95% confidence interval: 1.88-12.7], p = 0.001). The GNRI, as a continuous variable, was also related to the prevalence of sarcopenia (adjusted odds ratio, 0.89 [95% confidence interval: 0.86-0.93], p < 0.001). The present study revealed that low GNRI was related to the prevalence of sarcopenia.

Barthel Index Score Predicts Mortality in Elderly Heart Failure - A Goal of Comprehensive Cardiac Rehabilitation

BACKGROUND

A strategy to predict mortality in elderly heart failure (HF) patients has not been established.Methods and Results:We retrospectively enrolled 413 HF patients aged ≥65 years (mean age 78 years) who had received comprehensive cardiac rehabilitation (CR) during hospitalization. Basic activities of daily life were assessed before discharge using the Barthel index (BI). Of 413 HF patients, 116 (28%) died during a median follow-up period of 1.90 years (interquartile range 1.20-3.23 years). An adjusted dose-dependent association analysis showed that the hazard ratio (HR) of mortality increased in an almost linear manner as the BI score decreased, and that a BI score of 85 corresponded to an HR of 1.0. Kaplan-Meier survival curves showed that the survival rate was lower for patients with a low BI (<85) than for those with a high BI (≥85; 65% vs. 74%, respectively; P=0.007). In multivariate Cox regression analyses, low BI was independently associated with higher mortality after adjusting for predictors, including B-type natriuretic peptide. Inclusion of the BI into the adjusted model improved the accuracy of the prediction of mortality.

CONCLUSIONS

A BI score <85 at the time of discharge is associated with increased mortality independent of known prognostic markers, and achieving functional status with a BI score ≥85 by comprehensive CR during hospitalization may contribute to favorable outcomes in elderly HF patients.

The Relevance of Obesity for Activities of Daily Living in Geriatric Rehabilitation Patients

The obesity pandemic has reached old age but the effect of obesity on functional recovery in geriatric rehabilitation patients has not been investigated to date. In this prospective cohort study, patients admitted into geriatric rehabilitation were consecutively included between September 2015 and September 2016, aged ≥70 years. Individual activities of daily living were documented by the Barthel index (BI, 0–100 points). Obesity was assessed by the measurement of body mass index (BMI, kg/m²), waist circumference (WC, cm) and percentage of body fat mass (%FM) based on triceps’ skinfold thickness at admission (t1), discharge (t2) and six months after discharge (t3). A total of 122 patients were included in the analysis. Prevalence of obesity according to BMI, WC and %FM was 33.6%, 83.6% and 71.3% respectively. Patients with a high WC and patients with a high BMI had lower BI values at t1, t2, t3 and the improvement in BI (t1–t2, t2–t3) was lower than in those with low WC and low BMI, but without statistical significance. In multiple regression analysis, BMI, WC and %FM were not associated with BI at t3 and improvement of BI (t2–t3). Obesity was highly prevalent in geriatric rehabilitation patients, but it was not associated with BI during the 6-month follow-up.

Dysphagia and malnutrition limit activities of daily living improvement in phase i cardiac rehabilitation: a prospective cohort study for acute phase heart failure patients

Dysphagia and malnutrition combinations in hospitalized patients with acute heart failure (AHF) may affect activities of daily living (ADL) after hospital discharge more than dysphagia or malnutrition alone. The aim of the present study to clarify the impact of the combination of dysphagia and malnutrition on ADL in hospitalized patients with acute phase heart failure who have undergone cardiac rehabilitation (CR). Prospective cohort study. Acute care hospital. Participants were 224 AHF patients undergoing CR. Barthel index (BI), functional oral intake scale (FOIS), controlling nutritional status (CONUT), short physical performance battery (SPPB), and mini-mental state examination were evaluated at baseline. We examined primary effects of predictors (CONUT) and the moderator (FOIS) and the interaction effect of FOIS and CONUT (FOIS × CONUT) using hierarchical linear regression model and simple-slope tests. The ADL independence dropped in 29.5% of the patients on hospitalization; however, 82.6% of the patients successfully regained their independence at discharge. Based on the FOIS score and nutritional status on admission, 58.5% of the patients were classified into the non-dysphagia and non-malnutrition categories, 21.0% into non-dysphagia and malnutrition, 15.2% into dysphagia and non-malnutrition, and 5.3% into dysphagia and malnutrition. Lower FOIS and SPPB scores as well as the FOIS × CONUT interaction predicted a significantly lower BI but not CONUT. Simple slope test revealed a negative association between CONUT and BI with low-level FOIS (B =  - 2.917, P < .001) but not with high-level FOIS (B = .476, P = .512). Thus, patients with dysphagia and malnutrition in combination had a greater risk of failed recovery of ADL after cardiac rehabilitation than those without this combination. In hospitalized AHF patients, FOIS and CONUT had an interactive effect on BI at hospital discharge in cases with low-level FOIS. Early detection of dysphagia might improve the accurate identification of hospitalized AHF patients at higher risk of ADL dependence at discharge.

Olfactory-cognitive index distinguishes involvement of frontal lobe shrinkage, as in sarcopenia from shrinkage of medial temporal areas, and global brain, as in Kihon Checklist frailty/dependence, in older adults with progression of normal cognition to Alzheimer's disease

Aim

Olfactory impairment as a prodromal symptom, as well as sarcopenia, frailty and dependence as geriatric syndromes, is often associated with cognitive decline in older adults with progression of Alzheimer's disease. The present study aimed to evaluate the associations of olfactory and cognitive decline with these geriatric syndromes, and with structural changes of the brain in older adults.

Methods

The participants were 135 older adults (47 men and 88 women, mean age 79.5 years), consisting of 64 with normal cognition, 23 with mild cognitive impairment and 48 with Alzheimer's disease. Olfactory function was evaluated by the Open Essence odor identification test. Shrinkage of the regional brain was determined by magnetic resonance imaging.

Results

Logistic regression analysis with Open Essence, Mini‐Mental State Examination, age and sex as covariates showed higher olfactory‐cognitive index (|coefficient for Open Essence (a) / coefficient for Mini‐Mental State Examination (b)|) in participants with sarcopenia (Asia Working Group for Sarcopenia), and lower values of (|a/b|) in participants with Barthel Index dependence, Kihon Checklist frailty, Lawton Index dependence and support/care‐need certification as objective variables. Logistic regression analysis adjusted by age and sex also showed significant shrinkage of the frontal lobe in participants with AWGS sarcopenia, especially in women, and shrinkage of the medial temporal areas and global brain in participants with Kihon Checklist frailty/dependence.

Conclusions

Olfactory‐cognitive index (|a/b|) might be a useful tool to distinguish involvement of frontal lobe shrinkage, as in sarcopenia from shrinkage of the medial temporal areas, and global brain, as in frailty/dependence, in older adults with progression of normal cognition to Alzheimer's disease. Geriatr Gerontol Int 2021; ••: ••–••.

Energy intake during hospital stay predicts all-cause mortality after discharge independently of nutritional status in elderly heart failure patients

Objective

Malnutrition is associated with an increased risk of mortality in heart failure (HF) patients. Here, we examined the hypothesis that assessment of energy intake in addition to nutritional status improves the stratification of mortality risk in elderly HF patients.

Methods

We retrospectively examined 419 HF patients aged ≥ 65 years (median 78 years, 49% female). Nutritional status was assessed by the Mini Nutritional Assessment Short Form (MNA-SF), and daily energy intake was calculated from intake during 3 consecutive days before discharge.

Results

During a median 1.52-year period (IQR 0.96–2.94 years), 110 patients (26%) died. Kaplan–Meier survival curves showed that patients with low tertile of daily energy intake had a higher mortality rate than did patients with high or middle tertile of daily energy intake. In multivariate Cox regression analyses, low daily energy intake was independently associated with higher mortality after adjustment for the model including age, sex, BNP, Charlson Comorbidity Index, history of HF hospitalization, and cachexia in addition to MNA-SF. Inclusion of both MNA-SF and energy intake into the adjustment model improved the accuracy of prediction of the mortality after discharge (continuous net reclassification improvement, 0.355, p = 0.003; integrated discrimination improvement, 0.029, p = 0.003). Results of a fully adjusted dose-dependent association analysis showed that risk of all-cause mortality was lowest among HF patients who consumed 31.5 kcal/kg/day of energy.

Conclusions

Energy intake during hospital stay is an independent predictor of the mortality in elderly HF patients, and its assessment together with established predictors improves the mortality risk stratification.

Graphic abstract

Distinct determinants of muscle wasting in nonobese heart failure patients with and without type 2 diabetes mellitus

BACKGROUND

Muscle wasting, that is, reduction in muscle mass, is frequently observed in patients with chronic heart failure (CHF) and diabetes mellitus (DM).

METHODS

We retrospectively examined 185 patients with CHF (median age of 71 years [interquartile range, 61-78 years]; 64% male) who received a dual-energy X-ray absorptiometry scan for assessment of appendicular skeletal muscle mass index (ASMI).

RESULTS

Seventy patients with CHF (38%) had DM. Patients with DM had higher prevalences of ischemic heart disease and hypertension, lower levels of estimated glomerular filtration rate (eGFR) and ASMI, and higher levels of plasma renin activity (PRA) than did patients without DM. In simple regression analyses, ASMI was positively correlated with the Mini Nutritional Assessment Short Form (MNA-SF) score and levels of hemoglobin, eGFR, and fasting plasma insulin and was negatively correlated with levels of N-terminal pro B-type natriuretic peptide, PRA, and cortisol. In multiple linear regression analyses, age, MNA-SF score, DM, fasting plasma insulin level, and PRA were independently associated with ASMI. When multiple linear regression analyses were separately performed in a non-DM group and a DM group, MNA-SF score and fasting plasma insulin level were independent variables for ASMI in both groups. PRA was independently associated with ASMI in the DM group but not in the non-DM group, whereas cortisol concentration was independently associated with ASMI only in the non-DM group.

CONCLUSIONS

In addition to malnutrition and reduction in plasma insulin, renin-angiotensin system activation may be responsible for the development of muscle wasting in CHF patients with DM.

Clinical Risk Factors and Prognostic Impact of Osteoporosis in Patients With Chronic Heart Failure

BACKGROUND

The clinical significance of osteoporosis in chronic heart failure (CHF) remains unclear.Methods and Results:A total of 303 CHF patients (75 years, [interquartile range (IQR) 66-82 years]; 41% female) were retrospectively examined. Bone mineral densities (BMDs) at the lumbar spine, femoral neck, and total femur were measured by using dual-energy X-ray absorptiometry (DEXA), and osteoporosis was diagnosed when the BMD at any of the 3 sites was <70% of the Young Adult Mean percentage (%YAM). The prevalence of osteoporosis in CHF patients was 40%. Patients with osteoporosis were older (79 [IQR, 74-86] vs. 72 [IQR, 62-80] years), included a large percentage of females, had slower gait speed and had a lower body mass index. Multivariate logistic regression analysis indicated that sex, BMI, gait speed, loop diuretics use and no use of direct oral anticoagulants (DOACs) were independently associated with osteoporosis. Kaplan-Meier survival curves showed that the rate of death and heart failure hospitalization was higher in patients with osteoporotic BMD at 2 or 3 sites than in patients without osteoporosis (hazard ratio 3.45, P<0.01). In multivariate Cox regression analyses, osteoporotic BMD at 2 or 3 sites was an independent predictor of adverse events after adjustment for prognostic markers.

CONCLUSIONS

Loop diuretics use and no DOACs use are independently associated with osteoporosis in CHF patients. Osteoporosis is a novel predictor of worse outcome in patients with CHF.

Nutritional Status Is Associated with Function, Physical Performance and Falls in Older Adults Admitted to Geriatric Rehabilitation: A Retrospective Cohort Study

Nutritional status is relevant to functional recovery in patients after an acute process requiring rehabilitation. Nevertheless, little is known about the impact of malnutrition on geriatric rehabilitation. This study aimed to determine the association between nutritional status at admission and the evolution of functional and physical outcomes, as well as the capability of nutritional status to identify fallers among patients admitted to geriatric rehabilitation for different reasons. This was a retrospective cohort study of 375 patients. Data collected included age, gender, diagnosis at admission, comorbidities, cognitive and nutritional status, functional and physical measurements, length of stay, mortality and falls. Orthogeriatric patients with worse nutritional status according to the Mini Nutritional Assessment-Short Form (MNA-SF) had a significantly lower Barthel Index at admission and discharge with worse functional gain and poorer outcomes in the Short Physical Performance Battery (SPPB). However, in hospital-deconditioned patients, the MNA-SF score was not significantly associated with functional and physical recovery. Poor nutritional status at admission increased the risk of experiencing at least one fall during rehabilitation in orthogeriatric patients. However, hospital-deconditioned patients who fell had better SPPB scores than those who did not fall. Our results demonstrate the importance of nutritional status in the clinical evolution of orthogeriatric patients throughout the rehabilitation process.

Functional status mediates the association of nutritional status with depressive symptoms in patients with heart failure

AIMS

The decline of nutritional status and depressive symptoms are pandemic in heart failure patients and functional status may play a pivotal role between these. This study aimed to determine whether nutritional status is associated with depressive symptoms and whether functional status mediates this relationship in heart failure patients.

DESIGN

This was a secondary analysis of a cross-sectional study.

METHODS

The data were collected from November 2015-April 2016. Heart failure patients (N = 254) being hospitalized were included in this secondary analysis. The Depression Sub-Scale of the Hospital Anxiety and Depression Scale and the Duke Activity Status Index were used to assess patients' depressive symptoms and functional status. The nutritional status of patients was calculated using the Geriatric Nutritional Risk Index.

RESULTS

In this study, the average scores of depressive symptoms, nutritional status and functional status were 4.91 (SD 3.12), 102.38 (SD 6.57) and 20.58 (SD 8.96) respectively. Out of the 254 patients, 46 patients (18.1%) had significant depressive symptoms (the score of Depression Sub-Scale of the Hospital Anxiety and Depression Scale ≥ 8) and 55 (21.7%) suffered from malnutrition (the score of Geriatric Nutritional Risk Index ≤ 98). In the multiple regression analyses, nutritional status was negatively associated with depressive symptoms (β = -0.142, p = .02) and functional status mediated the relationship between nutritional status and depressive symptoms.

CONCLUSIONS

Many patients with heart failure have malnutrition and depressive symptoms. Functional status plays a mediating role in the relationship between nutritional status and depressive symptoms.

IMPACT

To relieve depressive symptoms in patients with heart failure, it is of importance to improve the functional status, especially for those with poor nutritional status.

Nutritional status is associated with physical function and disability in older adults with chronic heart failure

BACKGROUND

The association between nutritional status (NS) and physical performance and disability in older adults with chronic heart failure (CHF) is not well established. We aimed at evaluating whether NS, estimated using the Mini Nutritional Assessment (MNA), is associated with gait speed (GS) and disability (ADL/IADL impairment) in this population and to assess whether energy intake (EI) and appendicular skeletal muscle mass index (ASMMI) influence this relationship.

METHODS

In this cross-sectional study we enrolled 88 older adults admitted to a cardiology outpatient clinic for CHF. MNA was analyzed both as continuous and categorical variable (risk of malnutrition [RM]/well-nourished [WN]). The association between NS and GS and disability was assessed using linear and logistic regression models, respectively, crude, adjusted firstly for age, sex, ejection fraction, and mood status, and then for EI and ASMMI.

RESULTS

Mean age was 77.8 years, 73% were men. MNA score was positively associated with GS: β adjusted = 0.022, P = 0.035; the coefficient was unaffected by adjustment for EI and ASMMI (β = 0.022, P = 0.052). Compared to WN, RM participants had a lower gait speed (0.82 vs 0.99 m/s, P = 0.006); the difference was attenuated after adjustment for potential confounders (β - = 0.138, P = 0.055). MNA score was inversely associated with ADL impairment (Adjusted OR: 0.80, 95%CI 0.64-0.98), but not with IADL impairment (Adjusted OR: 0.94, 95%CI 0.78-1.13).

CONCLUSION

Reduced MNA score is associated with poorer physical function and ADL impairment in older adults affected by CHF, independently of EI and ASMMI. Routinely evaluation of NS should be performed in this population.

Nutritional status and functionality in geriatric rehabilitation patients: a systematic review and meta-analysis

PURPOSE

Since there is only limited evidence available for geriatric rehabilitation patients, this systematic review and meta-analysis aims to characterize the nutritional status in this population and its relationship with functionality.

METHODS

Eight databases were searched for full-text articles reporting baseline nutritional intake and status of adults ≥ 60 years in rehabilitation settings. Pooled estimates were calculated for prevalence of malnutrition and risk of malnutrition based on the Mini Nutritional Assessment (MNA) and for mean body mass index (BMI). Associations between nutritional status (MNA, MNA short form and BMI) and functional status (Barthel Index and Functional Independence Measure) and prevalence of sarcopenia were reviewed.

RESULTS

62 out of 1717 references were eligible for inclusion. Pooled prevalence [95% confidence interval (CI)] of malnutrition and risk of malnutrition were 13 (5-20) % and 47 (40-54) %. Pooled estimate (95% CI) for BMI was 23.8 (23.2-24.5) kg/m². Existing data suggest a risk for low protein and energy intake and vitamin D deficiency. Functional status differed widely. Seven out of ten studies reported significant associations between reduced nutritional status and reduced functionality, whilst two out of seven studies reported significant associations between higher BMI and functionality. Prevalence of sarcopenia was high with 40-76% in this population.

CONCLUSIONS

Although geriatric rehabilitation populations and settings were heterogeneous, a relevant percentage of geriatric rehabilitation patients were affected by a reduced nutritional status. Nutritional status was associated with decreased functionality. This emphasizes the need for screening for malnutrition and targeted nutritional intervention.

Relation of Poor Nutritional Status to Mild Cognitive Impairment in Patients with Coronary Artery Disease

OBJECTIVES

Nutritional status affects cerebral circulation and cognitive function. More attention needs to be paid to nutritional status in coronary artery disease (CAD) patients, yet the relation between nutritional status or dietary intake (DI) and cognitive function or mild cognitive impairment (MCI) in CAD patients remain unclear. Thus, we examined the following relations: 1) that between nutritional status and cognitive function, and MCI and 2) that between DI and cognitive function, and MCI.

DESIGN, SETTING, AND PARTICIPANTS

We conducted a cross-sectional study of 208 patients with CAD but without dementia.

MEASUREMENTS

MCI was estimated with the Japanese version of the Montreal Cognitive Assessment (MoCA-J). Nutritional status was assessed by the Geriatric Nutritional Risk Index (GNRI), and DI was assessed by total energy intake per day. We investigated the relation between nutritional status or DI and cognitive function by Pearson correlation analysis, and that between nutritional status or DI and MCI by multivariable logistic regression analysis.

RESULTS

The GNRI and DI were positively associated with the MoCA-J score (r = 0.23, p < 0.001, and r = 0.24, p < 0.001, respectively), and both were independently associated with MCI in the multivariable logistic regression analysis (odds ratio, 0.96; p = 0.045, and odds ratio, 0.998; p = 0.020, respectively).

CONCLUSIONS

Poor nutritional status and low DI were found to be significantly associated with cognitive function and MCI in CAD patients. Our findings regarding nutritional status and DI might be useful for clinicians to prevent or intervene in the early cognitive decline of inpatients with CAD.

Possibility of Cardio-renal Protection by Long-term Cardiac Rehabilitation in Elderly Patients with Cardiovascular Diseases

Objective Cardiac rehabilitation (CR) improves the mortality in patients with cardiovascular disease (CVD). Even in elderly patients with CVD, CR may improve the activities of daily living (ADL). Methods Eighty-eight outpatients over 65 years of age at the beginning of a CR program (baseline) at Fukuoka University Hospital who had CVD and could be followed-up for up to 5 years were enrolled. CVD included ischemic heart disease, postoperative valvular heart disease, dissecting aneurysm of the aorta and peripheral artery disease. The patients were divided into 2 groups according to the average estimated glomerular filtration rate (eGFR) at baseline (55.4±14.8 mL/min/1.73 m²): high (≥55.4, n=44) and low (<55.4, n=44)-eGFR groups. The anaerobic threshold (AT) during exercise and left ventricular ejection fraction (LVEF) were measured by cardiopulmonary exercise (CPX) and ultrasound cardiography, respectively. The serum brain natriuretic protein (BNP) was also measured every year. Results The average age at baseline in all patients was 73±6 years. In all patients, the level of eGFR did not significantly change for 5 years (55±15 mL/min/1.73 m² at baseline vs. 48±14 at the end of the study). The AT (3.7±1.0 METs at baseline vs. 3.3±0.5), LVEF (57±13% vs. 64±10%) and BNP (260±452 pg/mL vs. 308±345) were also maintained for 5 years. In both the low- and high-eGFR groups, the eGFR, AT during exercise, LVEF and BNP at the end of the study were not significantly changed compared to the baseline values, although some changes were observed during the follow-up period. Conclusion Long-term CR in CVD outpatients over 65 years of age helped maintain the AT, LVEF, BNP and eGFR for 5 years. CR afforded cardio-renal protection in elderly patients with CVD.

Contraction and nutrition interaction promotes anabolism in cachectic muscle

PURPOSE OF REVIEW

Cachexia is a disease-related multifactorial syndrome characterized by inflammation, massive muscle protein catabolism and carbohydrate and lipid metabolism disorder.Several studies tried to define the impact of either nutrition or physical exercise (single approach strategy) or their combination (multimodal approach strategy) on prevention and/or treatment of muscle wasting in cachectic patients.

RECENT FINDINGS

Single approach strategies (i.e. nutrition or physical exercise) have the potential of preventing and improving features of the cachexia syndrome possibly with a differential impact according to the underlying disease. Limited information is available on the beneficial effect of multimodal approach strategies.

SUMMARY

Multimodal approaches appear to be more effective than those based on single interventions in physiological condition and in cachectic patients with COPD or chronic kidney disease. Further studies, however, are required in cachexia induced by heart failure, cancer and critical illness.